In anterior cruciate ligament (ACL) injury, conventional adult reconstruction techniques have to face the potential risk of growth disturbance or angular deformities in skeletally immature patients. The aim of this study was to evaluate the clinical outcomes of ACL reconstruction by conventional transphyseal tunnel technique.
Materials and Methods
On a retrospective basis, we reviewed 25 skeletally immature patients; all the patients showed skeletal maturity at last follow-up, and the mean age was 16.4 years. The average injury to surgery interval was 12.6 months. Clinical outcomes were assessed at a mean of 74.4 months postoperatively using the Lysholm Knee Scoring Scale, the Tegner activity level, the International Knee Documentation Committee (IKDC), and plain radiographs.
All the patients had undergone transphyseal reconstruction of ACL. The mean Lysholm score was 48.36 points preoperatively and 93.32 points postoperatively; the mean Tegner activity level was changed from 3.0 points to 5.6 points. The mean IKDC level was categorized as C preoperatively and changed to A postoperatively.
Our midterm outcome at an average 6 years after surgery was satisfactory without significant leg length discrepancies or abnormal alignment of the knee joint. Transphyseal reconstruction of ACL is a good treatment modality in the skeletally immature patient.
Anterior cruciate ligament; Skeletally immature; Adolescent
The purpose of our study was to analyze the clinical and radiological long-term outcomes of surgically treated traumatic knee dislocations and determine prognostic factors for outcome.
Retrospective consecutive series of patients treated surgically for traumatic knee dislocation with reconstruction/refixation of the anterior (ACL) and posterior cruciate ligaments (PCL) and primary complete repair of collaterals and posteromedial and posteromedial corner structures. 68 patients were evaluated clinically (IKDC score, SF36 health survey, Lysholm score, Knee Society score, Tegner score, visual analogue scale - VAS pain and satisfaction, Cooper test) and radiologically (weight bearing and stress radiographs) with a mean follow up of 12 ± 8 years. Instrumented anterior-posterior translation was measured (Rolimeter, KT-1000). Pearson correlation and stepwise regression analysis was used.
82% of patients (n = 56) returned to their previous work. At final follow-up 6 patients (9%) suffered from pain VAS > 3. The mean side-to-side difference of anterior/posterior translation (KT-1000, 134N) was 1.6 ± 1.6 mm and 2.6 ± 1.4 mm. Valgus and varus stress testing in 30° flexion was <3 mm (normal) in 57 patients (86%). The IKDC score was normal/nearly normal in 38 (58%) patients and the mean Lysholm score 83 ± 17 (intact 98 ± 7). The median Tegner score decreased from 7 preinjury (range 3-10) to 5 at follow-up (range 0-10). The mean Knee Society score was 187 ± 15 (out of maximum 200). In 7 patients (10%) a secondary ligament reconstruction was performed. Three patients (4%) underwent a high tibial osteotomy and four (6%) received a primary unconstrained total knee replacement. According to the Kellgren Lawrence osteoarthritis score only mild degenerative changes were present. The stress radiographs showed stable results for anteroposterior translation. Injury of the lateral collateral ligament, refixation of the ACL/PCL and delayed surgery >40 days were significantly associated with worse outcome (p < 0.05).
Early complete reconstruction can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity. Negative predictive factors for outcome were injury pattern, type of surgical procedure and timing of surgery.
Eleven skeletally immature adolescents underwent anterior cruciate ligament reconstruction using a transphyseal tibial and femoral tunnel. An autologous quadrupled hamstring tendon was used in all cases and the average follow-up was 77.7 months. Clinical results were evaluated using Lysholm knee scores and a return to pre-injury sports activities. Radiological results were evaluated using side-to-side differences of instrumented laxities and growth disturbances compared with the uninjured side on final follow-up orthoroentgenograms. The mean Lysholm score was 97.8 (range 94-100) and mean side-to-side laxity difference was 2.4 mm (range 1-4). Ten of 11 patients returned to pre-injury sports activity. No patient had a leg length discrepancy of over 1 cm or a significant abnormal angular deformity of the knee joint. Therefore, anterior cruciate ligament reconstruction using the transphyseal tunnel and hamstring autograft in skeletally immature adolescents is believed to be a reliable treatment method, which is not associated with significant leg length discrepancy or abnormal angular deformity of the knee joint.
Adolescent; Anterior Cruciate Ligament; Reconstructive Surgical Procedures
Compared to knees, hips have more bony constraint and soft tissue coverage. Thus, repair of focal cartilage defects in hips requires more invasive and technically complex surgeries than simple arthroscopy or arthrotomy. Autologous matrix-induced chondrogenesis (AMIC) is a second-generation bone marrow stimulation technique. Improvement in Tegner, Lysholm, International Cartilage Repair Society (ICRS), and Cincinnati scores has been reported at 1 and 2 years after AMIC in knees. AMIC is potentially useful to repair defects in hips, but it is unknown whether it relieves symptoms or results in a durable construct.
Description of Technique
A surgical hip dislocation is used to access the defect. This is débrided to stable cartilage shoulders, necrotic bone is removed, and the lesion base is drilled. Autogenous bone graft is used for lesions with bony defects to create a level surface. Fibrin gel and a collagen membrane are placed to stabilize the superclot for fibrocartilage formation.
We treated six patients with AMIC in the hip between 2009 and 2010. We obtained Oxford Hip and UCLA Activity Scores. Repair quality was assessed on 6-month postoperative MRI using the modified magnetic resonance observation of cartilage repair tissue (MOCART) system. Minimum 1-year followup data were available for four patients (range, 1–2.5 years).
Postoperative Oxford Hip Scores ranged from 13 to 17, UCLA Activity Scores ranged from 5 to 10, and MOCART scores ranged from 55 to 75. No complications occurred.
We describe AMIC in the hip. Although these patients had pain relief and improved function, long-term followup is necessary to assess the duration of improvement, durability of repair, and potential for arthrosis.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
The objective of this study was to evaluate the incidence of radiographic osteoarthritis in the operated knee in comparison with the contralateral knee ten years after a bone-tendon bone patellar autograft ACL-reconstruction and to evaluate to which level patients regain activity ten years after reconstruction.
Fifty-three patients with ACL instability were operated arthroscopically using the central third of the patellar tendon as a bone-tendon-bone autograft. At a minimum of 10 year follow up 28/44 patients matched the inclusion criteria and could be reached for follow-up. Evaluation included a patient satisfaction evaluation using a Visual Analog Scale, physical examination (International Knee Documentation Committee score, Tegner score, Lysholm score, KT-1000 stabilometry) and a radiological evaluation (Kellgren and Fairbanks classification).
The patients' satisfaction, at a mean of 10,3 year follow-up, measured with a VAS score (0–10) was high with a mean of 8.5 (range 4 to 10). The KT 1000 arthrometer laxity measurements revealed in 55% of the patients an A rating (1–2 mm), in 29% a B rating (3–5 mm) and in 16% a C rating (6–10 mm). According to the Tegner score 54% of the patients were able to perform at the same activity level as pre-operatively. The mean pre-operative Tegner score was 6.8 and the mean post-operative Tegner score was 6.0 at final follow up. The Lysholm score showed satisfactory results with a mean of 91 points (range 56 to 100). According to the Kellgren and Fairbank classifications, there is a significant difference (p < 0.05) in development of OA between the ACL injured and subsequently operated knee in comparison to the contralateral knee.
The patellar BTB ACL reconstruction does not prevent the occurrence of radiological OA after 10 years but does help the patient to regain the pre-operative level of activity.
Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean: 7.3). Reconstruction was performed using either the gracilis or semitendinosus tendon autograft. The Tegner activity score improved overall from 3 to 4.4 at follow-up and the mean follow-up Kujala score was 87 (range: 55–100). No patella redislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft using a longitudinal tunnel technique provided good post-operative stability restoring the primary soft tissue restraint to pathological lateral patellar displacement with no complications of post-operative patellar fracture.
The aim of the present study was to evaluate incidence, degree and impact of tibial tunnel widening (TW) on patient-reported long-term clinical outcome, knee joint stability and prevalence of osteoarthritis (OA) after isolated anterior cruciate ligament (ACL) reconstruction. On average, 13.5 years after ACL reconstruction via patella-bone-tendon-bone autograft, 73 patients have been re-evaluated. Inclusion criteria consisted of an isolated anterior cruciate ligament rupture and reconstruction, a minimum of 10-year follow-up and no previous anterior cruciate ligament repair or associated intra-articular lesions. Clinical evaluation was performed via the International Knee Documentation Committee (IKDC) score and the Tegner and Lysholm scores. Instrumental anterior laxity testing was carried out with the KT-1000™ arthrometer. The degree of degenerative changes and the prevalence of osteoarthritis were assessed with the Kellgren-Lawrence score. Tibial tunnel enlargement was radiographically evaluated on both antero-posterior and lateral views under establishment of 4 degrees of tibial tunnel widening by measuring the actual tunnel diameters in mm on the sclerotic margins of the inserted tunnels on 3 different points (T1–T3). Afterwards, a conversion of the absolute values in mm into a 4 staged ratio, based on the comparison to the results of the initial drill-width, should provide a better quantification and statistical analysis. Evaluation was performed postoperatively as well as on 2 year follow-up and 13 years after ACL reconstruction. Minimum follow-up was 10 years. 75% of patients were graded A or B according to IKDC score. The mean Lysholm score was 90.2±4.8 (25–100). Radiological assessment on long-term follow-up showed in 45% a grade I, in 24% a grade II, in 17% a grade III and in additional 12% a grade IV enlargement of the tibial tunnel. No evident progression of TW was found in comparison to the 2 year results. Radiological evaluation revealed degenerative changes in sense of a grade II OA in 54% of patients. Prevalence of a grade III or grade IV OA was found in 20%. Correlation analysis showed no significant relationship between the amount of tibial tunnel enlargement (P>0.05), long-term clinical results, anterior joint laxity or prevalence of osteoarthritis. Tunnel widening remains a radiological phenomenon which is most commonly observed within the short to midterm intervals after anterior cruciate ligament reconstruction and subsequently stabilises on mid and long- term follow-up. It does not adversely affect long-term clinical outcome and stability. Furthermore, tunnel widening doesn't constitute an increasing prevalence of osteoarthritis.
anterior cruciate ligament reconstruction; long-term follow-up; IKDC-score; tibial tunnel widening; osteoarthritis; long-term anterior laxity.
A new reconstruction of the patellar tendon was performed in a 43-year-old patient who lost tendon and tibial tuberosity after a wide tumor resection for low-grade myofibroblastic sarcoma of the parapatellar tendon. In this technique, the patellar tendon was anatomically reconstructed using a fascia lata attached to the iliac bone. The iliac bone was fixed to the tibial bony trough with absorbable screws, and the fascia lata was fashioned into three branches: the central branch was folded through the tunnel in the patella, and the medial and lateral branches were tagged to the medial and lateral retinaculum, respectively, around the patella. The skin defect was covered by the bilateral head of the gastrocnemius flap and a split-thickness skin graft. At the 3-year follow-up, the active range of motion of the knee joint was 0 to 110 degrees. The functional result according to the Musculoskeletal Tumor Society scoring system was 97%. Radiographs showed that the grafted bone was united well to the tibial bone, and the grafted fascia was confirmed as a dark band on MRI. There was no evidence of disease and no complaint of the donor site. This procedure allows for the reconstruction of the patellar tendon in the original location. To our knowledge, this reconstructive procedure of the patellar tendon using the fascia lata attached to the iliac bone has never been reported in English literature.
Fascia lata; patellar tendon; reconstruction; soft tissue sarcoma
Multiple epiphyseal dysplasia (MED) is one of the more common generalised skeletal dysplasias. Due to its clinical heterogeneity diagnosis may be difficult. Mutations of at least six separate genes can cause MED. Joint deformities, joint pain and gait disorders are common symptoms.
We report on a 27-year-old male patient suffering from clinical symptoms of autosomal recessive MED with habitual dislocation of a multilayered patella on both sides, on the surgical treatment and on short-term clinical outcome. Clinical findings were: bilateral hip and knee pain, instability of femorotibial and patellofemoral joints with habitual patella dislocation on both sides, contractures of hip, elbow and second metacarpophalangeal joints. Main radiographic findings were: bilateral dislocated multilayered patella, dysplastic medial tibial plateaus, deformity of both femoral heads and osteoarthritis of the hip joints, and deformity of both radial heads. In the molecular genetic analysis, the DTDST mutation g.1984T > A (p.C653S) was found at the homozygote state. Carrier status was confirmed in the DNA of the patient's parents. The mutation could be considered to be the reason for the patient's disease. Surgical treatment of habitual patella dislocation with medialisation of the tibial tuberosity led to an excellent clinical outcome.
The knowledge of different phenotypes of skeletal dysplasias helps to select genes for genetic analysis. Compared to other DTDST mutations, this is a rather mild phenotype. Molecular diagnosis is important for genetic counselling and for an accurate prognosis. Even in case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity.
If anterior cruciate ligament (ACL) reconstruction is to be performed, decision regarding graft choice and its fixation remains one of the most controversial. Multiple techniques for ACL reconstruction are available. To avoid disadvantages related to fixation devices, a hardware-free, press-fit ACL reconstruction technique was developed.
The aim of this study was to evaluate clinical outcome and osteoarthritis progression in long term after ACL reconstruction with central third patellar-tendon autograft fixed to femur by press-fit technique.
Fifty two patients met inclusion/excusion criteria for this study. The patients were assessed preoperatively and at 15 years after surgery with International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, Tegner activity scale and radiographs.
Good overall clinical outcomes and self-reported assessments were documented, and remained good at 15 years. The mean Lysholm and Tegner scores improved from 59.7 ± 18.5 and 4.2 ± 1.0 preoperatively to 86.4 ± 5.6 (p = 0.004) and 6.9 ± 1.4 (p = 0.005) respectively at follow-up. The IKDC subjective score improved from 60.1 ± 9.2 to 80.2 ± 8.1 (p = 0.003).
According to IKDC objective score, 75% of patients had normal or nearly normal knee joints at follow-up. Grade 0 or 1 results were seen in 85% of patients on laxity testing. Degenerative changes were found in 67% of patients. There was no correlation between arthritic changes and stability of knee and subjective evaluation (p > 0.05).
ACL reconstruction with patellar tendon autograft fixed to femur with press-fit technique allows to achieve good self-reported assessments and clinical ligament evaluation up to 15 years. Advantages of the bone-patellar-tendon-bone (BPTB) press-fit fixation include unlimited bone-to-bone healing, cost effectiveness, avoidance of disadvantages associated with hardware, and ease for revision surgery. BPTB femoral press-fit fixation technique can be safely applied in clinical practice and enables patients to return to preinjury activities including high-risk sports.
Paralysis of quadriceps muscle leads to severe disability as the knee is unstable and cannot be fully extended and locked in extension, which results in giving way of the knee joint. Because of this, the patient tries to get stability of the knee by various means like hand to knee gait, extreme internal or external rotation of the affected limb to stabilize knee by support of medial or lateral collateral ligament, respectively, or by tilting pelvis. When there is concomitant weakness of gluteus maximus quadriceps and hamstrings (MRC muscle power less than grade III), patient may develop compensatory hyperlordosis of spine. Hamstring (H) transfer is a well-accepted procedure for patients with quadriceps (Q) weakness. For hamstring transfer, we have used a modified technique of anchoring of biceps femoris and semitendinosus tendon to patella. Instead of cutting the periosteum over the patella in an I-shaped manner, an osteoperisoteal flap was raised after two parallel incisions over the patella and both tendons were sutured under the flap with each other. We conducted a retrospective evaluation of the results of modified hamstring transfer in 267 patients of post polio residual paralysis with residual quadriceps paralysis.
Materials and Methods:
Two hundred and fifty young patients (100 male and 150 female patients) who had quadriceps paralysis due to polio were managed by hamstring transfer at a single center between 1984 and 1996 and were followed for a mean of 5 years (range 4–12 years). Age of patients ranged from 7 to 18 years in 238 patients and 12 patients were above the age of 18 years. All cases were followed periodically, and assessment of knee extension, extension lag, knee flexion, elimination of calliper, and avoidance of hand to knee gait was done.
One hundred and sixty two patients (65%) showed excellent results, 38 patients (15%) had good results, and 50 patients (20%) showed poor results. Ninety three patients had major complications like genu recurvatum, restricted knee flexion, and extension lag. Ten patients had minor complications like superficial infection and epidermal edge necrosis.
H to Q transfer in the presence of quadriceps paralysis with good power in hamstring is a better alternative than supracondylar osteotomy because it is a dynamic correction and it produces some degree of recurvatum with increasing stability of knee in extension while walking. While inserting hamstring over patella the periosteum is not cut in an I-shaped fashion to create a flap which gives additional strength to new insertion and also patella act as a fulcrum during the extension of knee by producing the bowstring effect.
Hamstring transfer; post polio residual paralysis; quadriceps paralysis
Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.
This retrospective study assessed the results of 71 patients with knee dislocations who underwent acute combined repair and reconstruction using Ligament Advancement Reinforcement System (LARS) artificial ligaments between June 1996 and May 2008 with a follow-up between two and eight years. The outcome measures used were the Lysholm score, the International Knee Documentation Committee form (IKDC 2000), the Tegner activity level score, the Meyers ratings, Telos stress radiography, range of motion and clinical knee stability testing. When comparing high- versus low-energy dislocations and knee dislocation (KD) II/III versus KD IV injuries, a better Lysholm score for the knee dislocation (KD) II/III group was found compared with the KD IV group. The subjective and objective findings from our study are satisfactory and comparable with the results of other studies of knee dislocations. Our findings suggest that with a mean follow-up of 54 months, acute combined repair and reconstruction with LARS ligaments is a valid alternative for treating knee dislocations.
Residual laxity remains after ACL reconstruction in patients with combined chronic ACL and medial instability. The question arises whether to correct medial capsular and ligament injuries when Grade II and III medial laxity is present.
Description of Technique
We developed a mini-invasive medial ligament plasty to repair the medial collateral ligament to correct residual medial valgus and rotatory laxity after ACL reconstruction.
Patients and Methods
We prospectively followed 36 patients with an ACL deficiency combined with chronic Grade II or III valgus and rotatory medial instability. The mean age was 37 years (range, 15–70 years). For all patients, we obtained preoperative and postoperative Knee Injury and Osteoarthritis Outcome, International Knee Documentation Committee, Lysholm, and Tegner Activity Level Scores. The minimum followup was 2 years (median, 3 years; range, 2–7 years).
The mean subjective International Knee Documentation Committee score improved from 36 preoperatively to 94 at the last followup. While all patients had an International Knee Documentation Committee score of Grade C or D preoperatively, no patient did postoperatively. The mean Knee Injury and Osteoarthritis Outcome Score improved from 45 preoperatively to 93 postoperatively. Valgus and external rotatory tests were negative in all patients. The mean Tegner activity level decreased from 7 preinjury to 6 postoperatively, and the mean Lysholm score improved from 40 preoperatively to 93 at last followup.
This simple technique restored medial stability and knee function to normal or nearly normal in all patients.
Level of Evidence
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
This retrospective study compared the results after anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (4SHG) versus Ligament Advanced Reinforcement System (LARS) artificial ligament in 60 patients between January 2003 and July 2004 with a minimum four-year follow-up. The KT-1000 examination, the International Knee Documentation Committee (IKDC) scoring systems and Lysholm knee scoring scale were used to evaluate the clinical results. The mean side-to-side difference was 2.4 ± 0.5 mm and 1.2 ± 0.3 mm in the 4SHG group and LARS group, respectively (P = 0.013). Although other results of ACL reconstruction, measured by IKDC evaluation, Lysholm scores and Tegner scores, showed using a LARS graft clinically tended to be superior to using a 4SHG, there were no significant differences calculated. Our results suggest that four years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group.
Background and purpose Several mechanisms are responsible for patellar dislocation. We investigated how the primary pathomechanism relates to patient characteristics and the outcome.
Methods 126 patients (81 females) with primary patellar dislocation reported the knee position before the episode, the movement during it, and whether the patella was locked in dislocation. The median age was 20 (9–47) years. The subjective outcome and Kujala, Hughston VAS, and Tegner scores were evaluated after an average of 7 years.
Results 102 patients moved to flexion during the dislocation, 98 from a straight start and 4 from a well-bent start. 10 extended the knee from a well-bent start; they were older (mean 25 vs. 19 years) and more often had low trauma energy (5/10 vs. 15/102) and a locked dislocation (10/10 vs. 50/102). 4 had a direct hit to the knee and 1 only rotated it while stretching. 24 of 60 patients with open growth line of the tibial tubercle and 43 of 66 with closed tubercle had locked primary dislocation (p = 0.005). 33% of girls, 52% of boys, 57% of women, and 71% of men had locked primary dislocation. There was no correlation between trauma mechanism and outcome.
Interpretation Movement to flexion occurred in 84% of primary patellar dislocations and movement to extension in 8%. Spontaneous patellar relocation is common in skeletally immature girls and locked dislocation is common in skeletally mature men.
The objective of this work was firstly to evaluate the long-term results of medial opening wedge high tibial osteotomy (HTO) and secondly to evaluate the tolerance and integration of a Biosorb® wedge (β Tricalcium Phosphate, SBM Company, Lourdes, France). The series consisted of 124 knees in 110 patients, 74 men and 36 women, with mean age of 53.23±10.68 years (range 32–74) and treated between June 1995 and November 2000 for medial compartment knee osteoarthritis by the senior author. The mean preoperative Lysholm and Tegner functional score was 65.44±13.32 (range 27–80) and the preoperative HKA angle was 172.51°±3.8° (range 162–179°). According to the modified Ahlbäck classification there were 27 stage I, 42 stage II, 44 stage III and 11 stage IV knees. All patients were reviewed clinically and radiologically with a mean follow-up of 10.39±1.98 years (range 8–14 years). Immediate postoperative complications consisted of nine undisplaced lateral tibial plateau fractures of no clinical significance, two deep vein thromboses and three pulmonary emboli which resolved with appropriate treatment. At a later stage, there were seven delayed unions without development of pseudarthrosis, and three screw breakages when the AO T-plate was used, leading to a secondary angulation in one case, requiring revision by femoral osteotomy. Postoperative mean weightbearing HKA angle was 182°±1.8° (range 178–186°) and 73.4% of axes were 184°±2°. Fifteen knees (12.1%) underwent total knee arthroplasty (TKA) after a mean delay of 8.87±3.04 years and were excluded from the final analysis. Concerning the long-term results (n = 107 knees), the mean Lysholm-Tegner score was 88±12.7 points (51–100) and the KOOS score was 86±14.6 points (25–100) with 94 patients satisfied or very satisfied (87.85%). In terms of the HTO survivorship curve, with failure consisting of revision to TKA or another operation, survival was 88.8% at five years and 74% at ten years. Concerning Biosorb®, this was completely integrated in 100% of cases and there was complete resorption in 12.1% of cases and greater than 50% resorption in 52.3% of cases.
Acute patellar dislocation or subluxation is a common cause for knee injuries in the United States and accounts for 2% to 3% of all injuries. Up to 49% of patients will have recurrent subluxations or dislocations. Importance of both soft tissue (predominantly, the medial patellofemoral ligament, MPFL, which is responsible for 60% of the resistance to lateral dislocation) and bony constraint of femoral trochlea in preventing subluxation and dislocation is well documented. Acute patella dislocation will require closed reduction and management typically consist of conservative or surgical treatment depending on the symptoms and recurrence of instability. Most patients are diagnosed and treated in a timely manner. We present a 15 years old male with a missed traumatic lateral patella dislocation during childhood. The patient presented as an adolescent with a chronically fixed lateral patella dislocation and was management with surgery. The key steps in the surgical reconstruction of this patient required first mobilizing the patella with a lateral retinacular release and V-Y lengthening of the shortened or contracted quadriceps tendon. Then a combination of MPFL reconstruction using the semitendinosis autograft, tibial tubercle osteotomy with anterio-medialization, and lateral facetectomy was performed. At the one-year follow-up, our patient had improved knee range of motion and decrease in pain. Chronically fixed lateral dislocated patella is a rare and complex problem to manage in older patients that will require a thorough work-up and appropriate surgical planning along with reconstruction.
pediatric orthopedics; patella dislocation; Faulkerson procedure; MPFL reconstruction
Many surgical techniques, including microfracture, periosteal and perichondral grafts, chondrocyte transplantation, and osteochondral grafts, have been studied in an attempt to restore damaged articular cartilage. However, there is no consensus regarding the best method to repair isolated articular cartilage defects of the knee.
We compared postoperative functional outcomes, followup MRI appearance, and arthroscopic examination after microfracture (MF), osteochondral autograft transplantation (OAT), or autologous chondrocyte implantation (ACI).
We prospectively investigated 30 knees with MF, 22 with OAT, and 18 with ACI. Minimum followup was 3 years (mean, 5 years; range, 3–10 years). We included only patients with isolated cartilage defects and without other knee injuries. The three procedures were compared in terms of function using the Lysholm knee evaluation scale, Tegner activity scale, and Hospital for Special Surgery (HSS) score; modified Outerbridge cartilage grades using MRI; and International Cartilage Repair Society (ICRS) repair grade using arthroscopy.
All three procedures showed improvement in functional scores. There were no differences in functional scores and postoperative MRI grades among the groups. Arthroscopy at 1 year showed excellent or good results in 80% after MF, 82% after OAT, and 80% after ACI. Our study did not show a clear benefit of either ACI or OAT over MF.
Owing to a lack of superiority of any one treatment, we believe MF is a reasonable option as a first-line therapy given its ease and affordability relative to ACI or OAT.
Level of Evidence
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Unstable meniscal tears are rare injuries in skeletally immature patients. Loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. This study deals with the outcome of intraarticular meniscal repair and factors that affect healing. Parameters of interest were type and location of the tear and also the influence of simultaneous reconstruction of a ruptured ACL.
We investigated the outcome of 25 patients (29 menisci) aged 15 (4–17) years who underwent surgery for full thickness meniscal tears, either as isolated lesions or in combination with ACL ruptures. Intraoperative documentation followed the IKDC 2000 standard. Outcome measurements were the Tegner score (pre- and postoperatively) and the Lysholm score (postoperatively) after an average follow-up period of 2.3 years, with postoperative arthroscopy and MRT in some cases.
24 of the 29 meniscal lesions healed (defined as giving an asymptomatic patient) regardless of location or type. 4 patients re-ruptured their menisci (all in the pars intermedia) at an average of 15 months after surgery following a new injury. Mean Lysholm score at follow-up was 95, the Tegner score deteriorated, mean preoperative score: 7.8 (4–10); mean postoperative score: 7.2 (4–10). Patients with simultaneous ACL reconstruction had a better outcome.
All meniscal tears in the skeletally immature patient are amenable to repair. All recurrent meniscal tears in our patients were located in the pars intermedia; the poorer blood supply in this region may give a higher risk of re-rupture. Simultaneous ACL reconstruction appears to benefit the results of meniscal repair.
The aim of this prospective study was to compare two arthroscopic techniques for reconstructing the anterior cruciate ligament, the "outside-in" (two incisions) and the "all-inside" (one incision) techniques. The results obtained for 30 patients operated on using the "outside-in" technique (group I) were compared with those for 29 patients operated on using the "all-inside" technique (group II). Before surgery, there were no significant differences between the groups in terms of Lysholm score, Tegner activity level, patellofemoral pain score, or knee laxity. Both groups displayed significant improvements in Lysholm score after 24 months, from 69 (16) to 91 (9) in group I and from 70 (17) to 90 (15) in group II (means (SD)). There were also significant improvements in patellofemoral pain scores in both groups, from 13 (6) to 18 (5) in group I and from 14 (6) to 18 (4) in group II after 24 months. No difference was found between the groups in knee stability at the 24 month follow up. The IKDC score was identical in both groups at follow up. The operation took significantly longer for patients in group I (mean 94 (15)) than for those in group II (mean 86 (20)) (p = 0.03). The mean sick leave was 7.7 (6.2) weeks in group I and 12.3 (9.7) weeks in group II (p = 0.026), indicating that there may be a higher morbidity associated with the "all-inside" technique. It can be concluded that there were no significant differences between the two different techniques in terms of functional results, knee laxity, or postoperative complications. The results were satisfactory and the outcome was similar in both treatment groups.
Although many options exist for ligament reconstruction in knee dislocations, the optimal treatment remains controversial. Allografts and autografts have both been used to reconstruct the cruciate ligaments. We present the results of reconstruction using artificial ligaments at Hôpital du Sacré-Coeur in Montréal.
We reviewed the treatment of all patients with knee dislocations seen between June 1996 and October 1999. The Lysholm score, ACL-quality of life (QoL) questionnaire, physical examination and Telos instrumented laxity measurement were used to evaluate the results.
Twenty patients (21 knees) participated in the study. The mean (and standard deviation [SD]) Lysholm score was 71.7 (18). Results from the ACL-QoL questionnaire showed a global impairment in QoL. Mean (and SD) range of motion and flexion were 118° (10.9°) and 2° (2.9°) respectively. Mean (and SD) radiologic laxity evaluated with Telos for the anterior and posterior cruciate ligaments were 6.1 (5.7) mm and 7.3 (4.5) mm respectively.
Knee reconstruction with artificial ligaments shows promise, but further studies are necessary before it can be recommended for widespread use. This is the first study to show specifically a severe impairment in QoL in this patient population.
Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.
Materials and Methods:
Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.
The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.
MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.
Hamstring tendon; medial patellofemoral ligament; patellofemoral instability
Previous approaches for medial collateral ligament (MCL) reconstruction have been associated with extensive exposure, risk of donor site morbidity with autografts, loss of motion, nonanatomic graft placement, and technical complexity with double-bundle constructs. Therefore, we implemented a technique that uses Achilles allograft, small incisions, and anatomic insertions to reconstruct the MCL.
Description of Technique
The MCL femoral insertion was identified, and a socket reamed over a guide pin. The Achilles bone plug was fixed in the socket and the tendon passed distally under the skin and fixed on the tibia, creating isometric reconstruction.
Patients and Methods
We evaluated 14 patients who had this MCL reconstruction. We determined range of knee motion, knee ligament laxity, functional outcome scores (International Knee Documentation Committee [IKDC]-subjective, Lysholm, Knee injury and Osteoarthritis Outcome Score [KOOS]), and activity level scores (Tegner, Marx). Followup range was 24 to 61 months.
Knee motion was maintained in 12 cases. Grade 0-1 + valgus stability was obtained in all 14 cases. In cases of MCL with primary ACL reconstruction, IKDC-subjective, Lysholm, and KOOS-sports scores were 91 ± 6, 92 ± 6, and 93 ± 12, respectively, and return to preinjury activity levels was achieved. In cases of MCL with revision ACL reconstruction, function was inferior, and patients did not return to their preinjury activity levels.
This technique uses allograft that provides bone-to-bone healing on the femur, requires small incisions, and creates isometric reconstruction. When performed with a cruciate reconstruction, knee stability can be restored at 2 to 5 years followup. In patients with MCL with primary ACL reconstruction, return to preinjury activity level in recreational athletes can be achieved.
Ninety-one patients were assessed 5–9 years after an anterior cruciate ligament reconstruction (bone patella-tendon bone autograft). Forty-eight patients had been treated within 6 weeks of the injury (Group I) and 43 patients more than 3 months after the injury (Group II). 73 patients had either a normal or nearly normal final outcome. The mean Lysholm score was 82 and the mean Marshall score was 42. Eighty nine patients had normal or nearly normal stability in the operated knee when compared to the contralateral joint. In none of these results was there any significant difference between the groups. Results of functional and of isokinetic strength tests, as well as the presence of anterior knee pain, were also similar in both groups. However, patients with early reconstruction had fewer degenerative changes in the tibio-femoral joint and were more satisfied with the result. They also returned to their pre-injury level of sports activity more often than those patients in the late reconstruction group.