Posterior Horn Repair Augmented With the Central Portion of Thickened Meniscus for Large Posterolateral Corner Loss Type of Discoid Lateral Meniscus.

Large posterolateral corner loss type of discoid lateral meniscus tear is unsalvageable. Therefore, subtotal meniscectomy has been the only treatment option in this case. However, long-term results of subtotal or total meniscectomy have shown a high prevalence of early degenerative changes. Persistent symptoms, such as increased pain, snapping, giving way, locking, and limited extension, can be attributed to progressive loss of posterior tibial meniscal attachment and meniscal degeneration, especially in the posterior horn. The purpose of this technique-based article is to describe a partial repair, posterior horn repair augmented with the central portion of the discoid lateral meniscus that would have been removed if a subtotal meniscectomy were performed and bone marrow stimulation in the intercondylar notch to improve meniscal healing.

Clinical comparisons of the anatomical reconstruction and modified biceps rerouting technique for chronic posterolateral instability combined with posterior cruciate ligament reconstruction.

BACKGROUND: The purpose of this study was to describe a one-stage operation for posterior cruciate ligament reconstruction with use of an Achilles tendon-bone allograft and a posterolateral corner reconstruction with use of two different methods, with a comparison of clinical outcomes in the two groups. METHODS: Our study included forty-six patients who had undergone posterior cruciate ligament reconstruction with use of an Achilles tendon-bone allograft and posterolateral corner reconstruction with either anatomical reconstruction of the lateral collateral ligament and popliteus tendon with use of a tibialis posterior tendon allograft (twenty-one patients; Group A) or the modified biceps rerouting tenodesis (twenty-five patients; Group B) in an alternating fashion. Patients were assessed for knee instability with use of the dial test at 30° and 90°, together with varus and posterior stress radiography. RESULTS: At the two-year follow-up evaluation, although no significant difference was found on posterior stress radiography (mean and standard error, 5.7 ± 0.4 mm for Group A compared with 4.8 ± 0.4 mm for Group B), Group A showed more improvement than Group B on the dial test (16° ± 1° vs. 13° ± 1° at 30° and 17° ± 1° vs. 14° ± 1° at 90°; p = 0.001 for both) and varus stress radiography (3.6 ± 0.3 mm vs. 2.6 ± 0.3 mm; p = 0.024), in the Lysholm (29.5 ± 2.4 vs. 22.3 ± 2.3; p = 0.037) and the International Knee Documentation Committee knee scores (p = 0.041), and less terminal flexion loss (4.0° ± 1.2° vs. 8.8° ± 1.3°; p = 0.013). CONCLUSIONS: Combined with posterior cruciate ligament reconstruction, anatomical posterolateral corner reconstruction of the popliteus tendon and lateral collateral ligament showed better outcomes compared with the modified biceps rerouting tenodesis, although the mean differences of varus and external rotatory stability between the groups were relatively small. However, the overall difference might have been reduced by the negative value caused by overcorrection in Group B. This study demonstrated that anatomical posterolateral corner reconstruction is a reliable alternative method in addressing posterolateral corner and posterior cruciate ligament insufficiency of the knee, a finding that ideally should be tested in a randomized controlled trial.

Is correctional osteotomy crucial in primary varus knees undergoing anterior cruciate ligament reconstruction?

BACKGROUND: Valgus high tibial osteotomy (HTO) has been recommended for ligament stability and enhanced function after anterior cruciate ligament (ACL) reconstruction in varus-angulated knees. However, it is not clear whether HTO should be performed in patients undergoing ACL reconstruction who have primary varus knees without medial compartment arthrosis. QUESTIONS/PURPOSES: We therefore asked whether stability and function differed in patients having ACL reconstruction with differing degrees of preoperative alignment. PATIENTS AND METHODS: We retrospectively reviewed 201 patients who had primary, single-bundle ACL reconstructions with primary varus knees based on the preoperative mechanical axis deviation (MAD) on preoperative standing hip-knee-ankle radiographs. Patients were categorized into four groups according to the MAD: Group 1: 0 mm to 4 mm, Group 2: 5 mm to 9 mm, Group 3: 10 mm to 14 mm, and Group 4: greater than 15 mm. A total of 201 patients, 67 in Group 1, 53 in Group 2, 38 in Group 3, and 43 in Group 4, were assessed. Ligament stability was determined with the Lachman test, pivot shift test, and KT 2000™ arthrometer. Functional scores were assessed using the Lysholm score and the International Knee Documentation Committee (IKDC) score. The minimum followup was 24 months (mean, 45 months; range, 24-96 months). RESULTS: We observed no differences in the side-to-side KT 2000™ measurements, Lysholm score, or IKDC functional scores based on the preoperative MAD. CONCLUSIONS: The stability and functional scores after ACL reconstruction were not adversely altered by primary varus alignment. Thus, if there is no medial compartment arthritis or varus thrust, we do not believe a correctional tibial osteotomy is crucial in primary varus knees undergoing ACL reconstruction.

Anterolateral transtibial posterior cruciate ligament reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction over a 2- to 6-year follow-up.

BACKGROUND: There is a paucity of clinical studies comparing single- and double-bundle posterior cruciate ligament (PCL) reconstruction combined with a posterolateral corner reconstruction. PURPOSE: To compare the clinical outcomes of single- and double-bundle transtibial PCL reconstruction combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. STUDY DESIGN: Cohort study; Level of evidence 3. METHODS: The study population consisted of 42 patients for whom a minimum of 2 years of follow-up data were available. The authors compared the clinical outcomes of 2 surgical techniques: a single-bundle technique (23 patients) and a double-bundle technique (19 patients), each combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. RESULTS: There was no significant difference between the single- and double-bundle groups in mean side-to-side difference of posterior translation as measured with Telos stress radiography (4.2 ± 1.7 vs 3.9 ± 1.6 mm; P = .628). Rates of residual increased laxity greater than 5 mm were 22% in the single-bundle group and 21% in the double-bundle group. Regarding posterolateral rotatory instability, there were no differences between the 2 groups in mean side-to-side difference in the dial test (5.3° ± 2.7° vs 5.1° ± 2.4° at 30° of flexion [P = .800]; 6.7° ± 2.7° vs 6.7° ± 2.4° at 90° of flexion [P = .917]) or in varus stress radiography (1.2 ± 1.2 vs 1.3 ± 1.4 mm; P = .722). The Lysholm knee scores were 85.7 ± 7.6 in the single-bundle group and 87.7 ± 7.3 in the double-bundle group, and there was no significant difference between them (P = .392). There was also no difference between the groups in International Knee Documentation Committee knee score (P = .969); from this, the rates of abnormal and severely abnormal were 30% in the single-bundle group and 26% in the double-bundle group. CONCLUSION: In this series, double-bundle PCL reconstruction combined with posterolateral corner reconstruction did not appear to have advantages over single-bundle PCL reconstruction combined with posterolateral corner reconstruction with respect to the clinical outcomes or posterior knee stability.

Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques: surgical technique.

BACKGROUND: Despite its technical complexity, arthroscopic tibial inlay reconstruction of the posterior cruciate ligament has biomechanical advantages over transtibial procedures. The purpose of this study was to compare the clinical results of arthroscopic tibial inlay single-bundle and double-bundle techniques with those of the conventional transtibial single-bundle technique. METHODS: We evaluated twenty-nine patients treated with primary posterior cruciate ligament reconstruction and followed for longer than two years. Eight patients were treated with a transtibial single-bundle procedure; eleven, with an arthroscopic inlay single-bundle procedure; and ten, with an arthroscopic inlay double-bundle procedure. An Achilles tendon allograft was used in all cases. Each patient was evaluated on the basis of the Lysholm knee score, the mean side-to-side difference in tibial translation as measured on Telos stress radiographs, and the side-to-side difference in the range of motion of the knee. RESULTS: The mean side-to-side difference (and standard deviation) in posterior tibial translation differed significantly between the arthroscopic tibial inlay double-bundle group (3.6 ± 1.43 mm) and the transtibial single-bundle group (5.6 ± 2.0 mm) (p = 0.023), although there was no significant difference between the arthroscopic inlay single-bundle group (4.7 ± 1.62 mm) and the transtibial group (p = 0.374). The mean range of motion and Lysholm scores were similar among the three groups. CONCLUSIONS: Despite its technical difficulty, the arthroscopic tibial inlay double-bundle technique is our preferred method of reconstruction of the posterior cruciate ligament because it stabilizes posterior tibial translation better than do the other two methods.

Anterior cruciate ligament reconstruction improves activity-induced pain in comparison with pain at rest in middle-aged patients with significant cartilage degeneration.

BACKGROUND: Recent reports revealed that outcomes of anterior cruciate ligament (ACL) reconstruction in middle- or old-age patients are comparable with those of young patients. However, in case of concomitant arthrosis in the affected knee, there has been a paucity of literature regarding the outcomes of ACL reconstruction. We studied the level of improvement in pain originating from significant cartilage degeneration in middle-aged ACL-deficient patients after ACL reconstruction. We divided the pain into pain at rest and activity-induced pain. HYPOTHESIS: The activity-induced pain would be more improved by ACL reconstruction than the pain at rest. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We studied 36 patients who had undergone arthroscopic isolated ACL reconstruction for functional instability with significant cartilage degeneration grade III or IV without mensical injury. All patients had activity-induced pain; 20 of these patients also had pain at rest. To assess the pain level, the visual analog scale (VAS) was employed, in addition to radiologic and clinical evaluations such as the Lachman test, KT-2000 arthrometer, and pivot shift test. The mean age of the patients was 48.6 years (range, 41-61 years); mean follow-up was 46.7 months (range, 27-74 months). RESULTS: The preoperative mean VAS of the activity-induced pain (4.1 +/- 1.0; range, 2-6) showed significant improvement at the most recent follow-up (2.0 +/- 1.0; range, 0-4; P < .0001). However, the preoperative mean VAS of the pain at rest (2.9 +/- 0.9; range, 2-5) did not improve significantly at the most recent follow-up (2.5 +/- 0.8; range, 1-4; P = .149). The Lachman test, KT-2000 arthrometer, andpivot shift test showed significant improvement compared with preoperative outcomes (P < .0001). There was no significant difference in radiologic assessment between preoperative and postoperative outcomes (P = .082). CONCLUSION: Anterior cruciate ligament reconstruction in middle-aged patients with significant cartilage degeneration is effective in reducing activity-induced pain and instability. Even though all patients had less than severe arthritic changes on preoperative radiographs, the pain at rest did not improve after ACL reconstruction.

Peel-off injury at the tibial attachment of the posterior cruciate ligament in children.

BACKGROUND: Careful review of the literature seldom reveals peel-off-type injuries at the tibial attachment of the posterior cruciate ligament in children. PURPOSE: The purpose of this research is to describe the diagnosis and treatment of peel-off injuries at the tibial ligament-osseous junction of the posterior cruciate ligament in children. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between February 2001 and May 2007, 6 patients with diagnosed peel-off injuries at the tibial attachment of the posterior cruciate ligament were surgically treated. All patients were boys from 12 to 13 years of age (mean, 12.3 years). Plain radiographs were normal, but magnetic resonance imaging and arthroscopic findings revealed complete avulsion of the posterior cruciate ligament at the tibial attachment without an osseous fragment. The authors retrospectively reviewed the clinical presentations, diagnostic tests, surgical procedures, and the results of the treatment. The mean follow-up was 37.3 months (range, 25-53 months). RESULTS: Five of the 6 patients had returned to their preinjury levels of activities. The mean side-to-side difference in posterior translation as measured with the KT-2000 arthrometer and stress radiographs was 2.3 mm (range, 0.7-5.2 mm) and 2.9 mm (range, 0.3-6.4 mm), respectively. The mean Lysholm score was 95 points (range, 90-100 points). According to the assessment with the International Knee Documentation Committee form, 2 patients were classified as A, 3 as B, and 1 as C. CONCLUSION: The authors could diagnose peel-off injuries at the tibial attachment of the posterior cruciate ligament in children by careful examinations and arthroscopic surgeries. Satisfactory outcomes without any complications were obtained through the arthroscopic reattachment and fixation using multiple sutures in the case of the avulsed stump that was not split.

A biomechanical comparison of 3 reconstruction techniques for posterolateral instability of the knee in a cadaveric model.

PURPOSE: The objective of this study was to compare the varus and external rotatory laxity of reconstructed knees by use of 3 different reconstruction techniques that address posterolateral instability of the knee: popliteus tendon (PT) and lateral collateral ligament (LCL) reconstruction, PT and popliteofibular ligament (PFL) reconstruction, and PFL and LCL reconstruction. METHODS: We divided 36 fresh-frozen cadaveric knees into 3 groups of 12, and each group was assigned to a reconstruction technique: PT-LCL reconstruction with the posterior tibialis tendon, PT-PFL reconstruction with the patellar tendon and bone (Warren technique), and PFL-LCL reconstruction with the semitendinosus tendon (Larson technique). Each specimen was fixed with an Ilizarov external fixator and mounted on a custom-designed apparatus that was made to measure posterolateral instability of the knee, that is, external rotatory and varus laxity in the intact state, after cutting, and in the postoperative state at every 30 degrees from 0 degrees to 90 degrees . RESULTS: There were no significant differences between the 3 techniques with external rotation and varus laxity in all specimens. CONCLUSIONS: PT-LCL reconstruction was comparable to the other 2 established techniques: PT-PFL reconstruction (Warren technique) and PFL-LCL reconstruction (Larson technique). However, the original strength of the native knee could not be achieved with any of the techniques. CLINICAL RELEVANCE: All techniques restored the posterolateral stability of the knee to near normal, with none of them being superior.

The treatment of nonisthmal femoral shaft nonunions with im nail exchange versus augmentation plating.

OBJECTIVES: The purpose of this study was to compare the results between exchange nailing (EN) and augmentation plating (AP) with a nail left in situ for nonisthmal femoral shaft nonunion after femoral nailing. DESIGN: : Retrospective data analysis, November 1996-March 2006. SETTING: A level I trauma center. PATIENTS: Eighteen patients with 18 nonisthmal femoral nonunions. INTERVENTION: Seven patients with 7 fractures treated for nonisthmal femoral shaft nonunions after femoral nailing with EN and 11 patients with 11 fractures treated for nonisthmal femoral shaft nonunions after nailing with AP combined with bone grafting. MAIN OUTCOME MEASURE: Union and complications. RESULTS: Five nonunions in the EN group failed to achieve union (72% failure rate), whereas all 11 pseudarthroses in the AP group obtained osseous union. Fisher exact test showed a higher nonunion rate of EN compared with AP for nonisthmal femoral shaft nonunion (odds ratio, 6.5; P = 0.002). CONCLUSIONS: AP with autogenous bone grafting may be a better option than EN for nonisthmal femoral nonunions.

Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction?

UNLABELLED: It generally is believed generalized joint laxity is one of the risk factors for failure of anterior cruciate ligament (ACL) reconstruction. However, no consensus exists regarding whether adverse effects on ACL reconstruction are attributable to joint-specific laxity or are related to the severity of generalized joint laxity. We therefore asked whether knee stability and functional outcomes would be related to joint-specific laxity and would differ according to the severity of generalized joint laxity. The Beighton and Horan criteria were used to assess joint laxity in 272 subjects. All elements are added to give an overall joint laxity score ranging from 0 to 5. Knee translation did not increase in proportion to the severity of the generalized joint laxity. Patients with scores less than 4 showed similar knee stability. When all variables, including the severity of generalized joint laxity, were considered, only hyperextension of the knee independently predicted knee stability and function. In patients with knee hyperextension, a bone-patellar tendon-bone autograft provided superior stability and function compared with a hamstring tendon autograft. Our data suggest knee hyperextension predicts postoperative stability and function regardless whether patients have severe generalized joint laxity. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Is the transglenoid suture technique recommendable for recurrent shoulder dislocation? A minimum 5-year follow-up in 59 non-athletic shoulders.

The aim of this retrospective study is to compare the clinical outcomes following arthroscopic Bankart repair employing the transglenoid technique versus suture anchors in non-athletic shoulders of patients 30 years or older at the time of surgery. Fifty-nine consecutive patients who were available for a minimum of 5 years follow-up after arthroscopic Bankart repair were included. The transglenoid technique was employed in 27 patients whose age and follow-up period were 37 years (range 30-58) and 82 (range 61-109) months. Suture anchor was used in 32 patients whose age and follow-up period were 38 years (range 30-62) and 72 months (range 65-89). The Rowe scores of the transglenoid and suture anchor groups were 90 (range 35-100) and 90 (range 35-100), respectively, and there was no statistically significant difference between the two groups (p > 0.05). The Constant score of both groups was 92 (range 64-100) and 95 (range 62-100) without a significant difference (p > 0.05). Moreover, there were no significant differences between the recurrence rates (7%-transglenoid, 6%-suture anchor) (p > 0.05) and positive apprehension signs (7%-transglenoid, 3%-suture anchor) (p > 0.05). In non-athletes over 30-years-old, the results of the transglenoid technique in arthroscopic Bankart repair were comparable to those of the suture anchor. We suggest that the transglenoid technique is a viable alternative for older, non-athletic shoulder if the suture anchors are not available.

Risk factors associated with the halo phenomenon after lumbar fusion surgery and its clinical significance.

STUDY DESIGN: Retrospective study. PURPOSE: First, to examine the association between bone mineral density (BMD) and the halo phenomenon, and second, to investigate risk factors predisposing to the halo phenomenon and its correlation with clinical outcomes. OVERVIEW OF LITERATURE: The few in vivo studies regarding the relationship between pedicle screw stability and BMD have shown conflicting results. METHODS: Forty-four female patients who underwent spine fusion surgery due to spinal stenosis were included in this study. The halo phenomenon and fusion state were evaluated through plain radiographs performed immediately after surgery and through the final outpatient follow-up examination. BMD, osteoarthritis grade in the hip and knee joints, and surgical outcome were also evaluated. RESULTS: BMD was not related to the halo phenomenon, but age, absence of osteoarthritis in the knee, and non-union state were found to be significant risk factors for the halo phenomenon. However, the radiological halo phenomenon did not correlate with clinical outcome (visual analogue scale for back pain and leg pain). CONCLUSIONS: The halo phenomenon is a simple phenomenon that can develop during follow-up after pedicle screw fixation. It does not influence clinical outcomes, and thus it is thought that hydroxyapatite coating screws, expandable screws, cement augmentation, and additional surgeries are not required, if their purpose is to prevent the halo phenomenon.