Christos D. Papageorgiou

Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking.

Background It is possible that gait abnormalities may play a role in the pathogenesis of meniscal or chondral injury as well as osteoarthritis of the knee in patients with anterior cruciate ligament deficiency. Hypothesis The three-dimensional kinematics of anterior cruciate ligament-deficient knees are changed even during low-stress activities, such as walking, but can be restored by reconstruction. Study Design Case control study. Methods Using a three-dimensional optoelectronic gait analysis system, we examined 13 patients with anterior cruciate ligament-deficient knees, 21 patients with anterior cruciate ligament-reconstructed knees, and 10 control subjects with uninjured knees during walking. Results Normal patterns of knee flexion-extension, abduction-adduction, and internal-external rotation during the gait cycle were maintained by all subjects. A significant difference in tibial rotation angle during the initial swing phase was found in anterior cruciate ligament-deficient knees compared with reconstructed and control knees. The patients with anterior cruciate ligament-deficient knees rotated the tibia internally during the initial swing phase, whereas the others rotated externally. Conclusions Patients with anterior cruciate ligament-deficient knees experienced repeated episodes of rotational instability during walking, whereas patients with reconstruction experienced tibial rotation that is closer to normal. Clinical Relevance Repeated episodes of knee rotational instability may play a role in the development of pathologic knee conditions.

The effects of anterior cruciate ligament reconstruction on tibial rotation during pivoting after descending stairs.

Recent in vitro research suggests that ACL reconstruction does not restore tibial rotation. This study investigated rotational knee joint stability in vivo during a combined descending and pivoting movement that applies a high rotational load to the knee joint. We studied 20 ACL reconstructed patients (bone–patellar tendon–bone graft) and 15 matched controls with a six-camera optoelectronic system performing the examined movement. In the control group the results showed no significant differences in the amount of tibial rotation between the two sides. No significant differences were also found between the contralateral intact leg of the ACL group and the healthy control. However, a significant difference was found within the ACL reconstructed group and between the reconstructed and the contralateral intact leg. Therefore ACL reconstruction may not restore tibial rotation even though anterior tibial translation has been reestablished.

Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: a clinically relevant anatomic study.

Abstract Based on our clinical experience and an anatomical study, we examined the conditions under which injury to the popliteal artery, tibial nerve or peroneal nerve and its branches may occur during high tibial osteotomy. In 250 high tibial osteotomies performed in our department, we observed the following intraoperative complications. (1) The popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique. (2) A tibial nerve paresis also occurred in 1 patient. (3) In 3 patients, temporary palsy of the anterior tibialis muscle was documented. (4) In 4 other patients, palsy of the extensor hallucis longus occurred. To investigate the causes of these complications in the popliteal artery, tibial nerve and branches of the peroneal nerve, we dissected the neurovascular structures surrounding the area of the osteotomy in 10 cadaveric knees and performed a high tibial osteotomy in another 13 cadaveric knees. We concluded the following. (1) The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles. Damage can occur only by placing the Hohman retractor behind the muscles. The insertion of the muscles is very close to the periosteum and can be separated only with a scalpel. (2) The tibialis anterior muscle is innervated by a group of branches arising from the deep branch of the peroneal nerve. In two-thirds of the dissected knees, we found a main branch close to the periosteum, which can be damaged by dividing the muscle improperly or due to improper placement and pressure of the Hohman retractor. This may explain the partially reversible muscle palsy. (3) The extensor hallucis longus is also innervated by 2–3 thin branches, arising from the deep branch of the peroneal nerve, but in 25% of the specimens, only one large branch was found. This branch is placed under tension by manipulating the distal tibia forward. Thus, it may be damaged by the Hohman retractor during distal screw fixation, tensioned by hyperextension or directly injured during midshaft fibular osteotomy.

Anterior cruciate ligament reconstruction with the press-fit technique : 2-5 years followed-up of 42 patients

42 patients underwent anterior cruciate ligament (ACL) reconstruction with the press-fit technique. The ACL was reconstructed with a bone-tendon-bone graft from the medial third of the patellar tendon. The graft was stabilized without screws in the femur and tibia by press-fit. To imitate the anatomical functioning of the ACL, the femoral bone block was placed with the tendon close to the over-the-top position. The tibial block was then placed in a trough on the tibia, so that the ligament fibres were parallel and tight during extension and slightly inverted during flexion. At evaluation mean 41 (25-61) months postoperatively, the mean Lysholm score was 93 (80-100) points, the mean activity level was 6 (3-10) points, and the mean translation of the tibia head, measured by the KT-1000 arthrometer (side-to-side difference), was 2 (0-7) mm. Only 3 of the patients suffered loss of extension (5 degrees). Patients who underwent reconstruction at least 4 months after the injury had better results than those who were operated earlier. The press-fit method allowed for anatomic substitution of the ACL with a stable graft without the disadvantages associated with screws. This method gave early postoperative functioning of the knee and good mid-term results.

Simultaneous bicompartmental bucket-handle meniscal tears with intact anterior cruciate ligament: a case report

IntroductionBucket handle tear of the menisci is a common type of lesion resulting from injury to the knee joint. Bucket handle injury of both menisci in almost all cases is associated with a lesion to either the anterior or the posterior cruciate ligament of the knee joint. We describe a case of acute bucket-handle tear of the medial and lateral menisci with intact anterior and posterior cruciate ligaments in a dancer. To the best of our knowledge, there are no previous reports of this type of injury in the literature.Case presentationA 28-year-old Caucasian Greek woman presented to the emergency department after sustaining an injury to her right knee during dancing. An MRI evaluation demonstrated tears in both menisci of the right knee, while the anterior and posterior cruciate ligaments were found to be intact. A partial medial and lateral meniscectomy was then performed. At a follow-up examination six months after her injury, clinical tests demonstrated that our patients right knee was stable, had a full range of motion and had no tenderness. She was satisfied with the outcome of the operation and returned to her pre-injury activities.ConclusionWe present the first case in the literature that describes a combined bucket-handle injury of both the medial and lateral menisci with an intact anterior cruciate ligament. The clinical examination of the anterior cruciate ligament was unremarkable, with no signs of deficiency or rupture. The posterior cruciate ligament was also intact. On magnetic resonance imaging, the ligaments were visualised as intact in all their length. These findings were confirmed by arthroscopic evaluation.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques

BackgroundTo compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator.MethodsSeventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel.ResultsAll fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant.ConclusionProximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Difficulties and early results of the endoscopic carpal tunnel release using the modified Chow technique

Abstract In reporting on the preliminary results of our series of 76 patients, this paper aims to identify potentially complicating aspects of endoscopic carpal tunnel release (ECTR) using the two-portal Chow technique, and to recommend solutions, based on our early experience, which enhance the ease and safety of this minimally invasive technique. Of the first 24 patients, 16 cases required conversion to an open procedure. Based on these initial cases, we developed certain modifications of the Chow technique which precluded any need for open conversion in the 60 remaining cases. During a follow-up interval ranging from 4 to 24 months, there was no recurrence of carpal tunnel symptoms, and the average time to resumption of work activity was 14 days. The complication rate was 5% and included one case of transient hypesthesia, one case of extended hematoma, and one hypersensitive scar. All complications resolved at subsequent follow-up. In our experience, correct positioning of the hand, proper injection of local anesthetic, use of magnifying loupes, and correct use of instruments are essential for a safe and successful procedure.

Application of silicon tissue expanders for the direct or indirect coverage of soft tissue defects in the extremities

In a 2 year prospective study, 17 tissue expanders were placed on the extremities of 17 patients. The aim was to cover soft tissue defects in the forearm of 8 patients after chinese flap dissection, which was used either as a free or reversed flap. In 8 of the remaining patients, the expanded skin was placed directly on the affected region as a local fasciocutaneous flap. In 1 patient it was determined intra-operatively that the prepared extended skin was not necessary to treat the patient. The tissue expander was successfully used to cover skin defects, both directly and indirectly, in the lower extremity (7 cases) and in the upper extremity (9 cases). Neither infection nor necrosis was observed in the flaps and the cosmetic results, particularly in the forearm, were satisfactory.

Allografts in PCL Reconstruction

Posterior cruciate ligament (PCL) is a major stabilizer of the knee joint. It has been currently accepted that PCL insufficiency may lead in early knee degeneration and it has been widely suggested that grade III injuries should treated with surgical reconstruction of the ligament. Both autografts and allografts have been used in PCL reconstruction. Although allografts have been reported to present risks of immune reaction, disease transmission, increased cost, delayed incorporation and remodeling, and inferior structural properties, most surgeons are currently using them in PCL reconstruction considering the advantages: Decreased tourniquet and surgical time, lack of donor-site morbidity, increased size of the graft, and availability in double-bundle reconstruction and in combined multiligament injuries.

Meniscus Allograft Transplantation

Meniscal allotransplantation is considered a salvage procedure for symptomatic meniscal deficiency in a young patient. Although various contraindications have been described, including diffuse subchondral bone exposure, axial malalignment, and instability, a knee may be rendered suitable for meniscus transplantation if combined with chondral resurfacing, osteotomy, and/or ligament reconstruction. In the present manuscript, meniscus anatomy and function and exact preoperative size matching techniques are analyzed in detail. The most common arthroscopic methods involving double bone plug technique for medial meniscal transplantation, trough or “keyhole” techniques for lateral meniscal transplantation, and simultaneous anterior cruciate ligament reconstruction and meniscal transplantation are described. Possible complications after meniscus allotransplantation, surgical outcomes, and future directions are also discussed in this article.