Claudio Legnani

Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature

Anterior cruciate ligament (ACL) rupture, one of the most common knee injuries in sports, results in anteroposterior laxity, which often leads to an unstable knee. Traditional ACL reconstruction is performed with autograft; disadvantages of this technique are donor site morbidity and a long rehabilitation period. In the 1980s, artificial ligaments became an attractive alternative to biological grafts. The initial enthusiasm surrounding their introduction stemmed from their lack of donor morbidity, their abundant supply and significant strength, immediate loading and reduced postoperative rehabilitation. Synthetic grafts made of different materials such as carbon fibers, polypropylene, Dacron and polyester have been utilised either as a prosthesis or as an augmentation for a biological ACL graft substitute. Nevertheless, every material presented serious drawbacks: cross-infections, immunological responses, breakage, debris dispersion leading to synovitis, chronic effusions, recurrent instability and knee osteoarthritis. Recently, a resurgence of interest in the use of synthetic prostheses has occurred and studies regarding new artificial grafts have been reported. Although many experimental studies have been made and much effort has been put forth, currently no ideal prosthesis mimicking natural human tissue has been found.

Synthetic grafts for anterior cruciate ligament rupture : 19-year outcome study

Artificial ligaments for ACL replacement have been widely used in the 1980s and early 1990s in orthopaedic surgery. Synthetic devices have been utilized either as a prosthetic material or as an augmentation for a biological ACL graft substitute. The initial enthusiasm surrounding the introduction of synthetic graft materials stemmed from their lack of donor morbidity, their abundant supply and significant strength of these devices. The disadvantages in long-term follow-up were found to be cross-infections, immunological responses, tunnels osteolysis, femural and tibial fractures, foreign-body synovitis and knee osteoarthritis. A total of 126 patients were treated with artificial ACL substitution with polyethylene terephthalate (PET) synthetic ligaments in our Institute between 1986 and 1990. Of the original group, 51 sportsmen aged 15 to 40 were followed-up at a mean of 19years (range 17.5 to 20.6years) after surgery. Assessment was made with KOOS and IKDC score, Tegner activity scale, clinical examination, KT-1000 arthrometer, and X-ray evaluation. Of the 51 patients followed-up, 27.5% were found to have ruptured their PET ligaments and 100% presented degenerative osteoarthritis at the X-ray evaluation according to Ahlbäck radiological classification of arthritis. The objective evaluation showed functional impairment in 29.4% with an average reduction of 3 points in the Tegner activity scale. The osteoarthritis observed in all patients prompted us to avoid the diffusion of this surgical technique. Although in theory well-conceived, studies have yet to substantiate the function of these augmentation devices or to show clinical better results than those achieved with isolated autograft or allograft ACL substitutes.

Arthroscopic four-step treatment for chronic ankle instability.

Background: Chronic lateral ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. Open reconstructive procedures carry the disadvantages of subtalar joint stiffness and potential morbidity at the harvesting site. Recently, arthroscopic treatment of chronic lateral ankle instability has been proposed in order to minimize invasiveness, reduce operating time, and allow a faster rehabilitation period. The purpose of our paper was to assess the outcomes in terms of postoperative recovery and return to sport following arthroscopic reconstruction of lateral ankle instability. Methods: Ninety patients with chronic lateral ankle instability were treated at our Department from 2004 to 2009. Mean age was 32.4 (range, 17 to 56) years. All patients underwent a four-step operative procedure, including: synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Results: Followup examination at an average of 4 years after surgery showed significant improvement of mean AOFAS scale (preoperative, 63.5; postoperative, 92.3; p < 0.001) and average Karlsson score (preoperative, 61.8; postoperative, 88.4; p < 0.001). Mean Tegner rating changed from 3.6 preoperatively to 4.9 at followup (p < 0.001). Articular stability as assessed by Sefton scale significantly improved from a preoperative value of 4.0 to 1.8 (p < 0.001). Most patients (96.6%) rated the success of their surgery as good to excellent. Conclusion: Based on our results, we propose arthroscopic treatment as a suitable option for moderate chronic ankle joint laxity in patients with a complete ATFL lesion. Level of Evidence: IV, Retrospective Cohort Study

Single- and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years.

PURPOSE The purpose of our study was to retrospectively evaluate the outcomes after anterior cruciate ligament (ACL) reconstruction with hamstring in patients aged 50 years or older. In addition, we present, for the first time, the outcomes of a subgroup of middle-aged patients treated with double-bundle (DB) reconstruction. METHODS Fifty patients aged 50 years or older underwent primary ACL reconstruction with hamstring. Inclusion criteria were primary ACL reconstruction in active patients. Exclusion criteria were multiligamentous injuries and a contralateral ACL-deficient knee. The mean age at surgery was 54.4 years (range, 50 to 65 years). The mean period from the initial injury to surgery was 32.6 months (range, 3 to 125 months). Of the patients, 36 underwent single-bundle (SB) ACL reconstruction and 14 underwent DB reconstruction. Patients were assessed preoperatively with physical examination (including range of motion, pivot-shift test, and instrumented knee laxity measurement), the Lysholm score, the International Knee Documentation Committee scoring system, and the Tegner activity scale. Standard radiographs were taken, and degenerative changes were graded according to the Ahlbäck radiologic classification of arthritis. RESULTS Patients were evaluated at a mean of 4.4 years (range, 2 to 7 years) after surgery. A significant improvement in knee function and symptoms was reported in most patients, with increased Lysholm, International Knee Documentation Committee, and Tegner scores (P < .001). The outcomes of clinical assessment and instrumented laxity testing were clearly improved when compared with preoperative status (P < .001). The level of osteoarthritis did not statistically increase at follow-up. No statistically significant difference could be observed between the SB and DB groups (P = not significant). CONCLUSIONS Operative treatment showed favorable outcomes in most of the ACL-reconstructed patients with regard to knee stability, osteoarthritis progression, and patient satisfaction in a cohort of subjects aged 50 years or older. Our subgroup of patients undergoing DB ACL reconstruction reported average satisfactory outcomes, which did not significantly differ from the SB group. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Conservative treatment of a femoral neck fracture following nail removal.

With increased longevity, the management of fragility fractures in the elderly is becoming more frequent. In particular, hip fractures have considerable importance due to the significant morbidity and mortality. A 67-year-old woman underwent intramedullary nail (IMN) removal inserted for a pertrochanteric fracture that had occurred 20 months earlier. This was indicated due to continuous discomfort related to the protruding apex of the implant over the great trochanter. Due to pain persistence two days after surgery, a computed tomography (CT) scan was performed, documenting a minimally displaced impacted subcapital femoral neck fracture. Conservative management with close radiographic follow-up was conducted. After six months, the patient had returned to previous daily activities and a satisfactory range of motion was achieved without pain on walking. The purpose of our paper is to discuss the decision of removing hardware in the elderly osteoporotic patient and to analyze the possibility to conservatively treat an impacted minimally displaced subcapital fracture occurring after the removal of an IMN inserted previously for the treatment of a trochanteric fracture. In the elderly population with decreased bone quality, the removal of intramedullary implants of the proximal femur should be carefully evaluated, and osteoporotic patients undergoing reduction and fixation of femoral fractures should be encouraged to start antiosteoporotic therapy (bisphosphonate, teriparatide) to reduce the risk of further bone loss. Conservative treatment should be considered for the management of lesser symptomatic minimally displaced impacted fractures, where the inherent stability of the fracture allows rapid healing without further surgical attempts.

Revision Anterior Cruciate Ligament Reconstruction with Contralateral Hamstring Tendon Grafts: 6 Years Follow-Up

Purpose  The purpose of this study was to retrospectively evaluate the clinical outcome of revision anterior cruciate ligament (ACL) reconstruction with contralateral hamstring tendon autografts, specifically with regard to patient satisfaction, return to preinjury activity level, and postoperative functional outcomes. Methods  Between 2004 and 2011, 23 patients underwent revision ACL reconstruction with contralateral autogenous hamstring tendon grafts and were retrospectively reviewed at an average follow-up of 6.3 years. Subjective and functional evaluations were performed. The Tegner score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachman test, pivot-shift test, and KT-1000 instrumented laxity testing. Wilcoxon test was used to compare the preoperative and follow-up status. Differences with a p -value of <0.05 were considered statistically significant. Results  No major complications were reported. The mean KOOS significantly increased from a preoperative mean of 62.8 ± 8.3 to 85.8 ± 6.9 ( p < 0.001). IKDC subjective score significantly improved from 29.2 ± 10.4 to 72.8 ± 5.2 ( p < 0.001). The median Tegner activity score significantly improved from a preoperative mean of 6.5 (range: 4–10) to 7.5 (range: 7–10) ( p  < 0.001). Most of the patients increased or returned to the same activity level, with 61% of the patients returning to cutting and pivoting sports. Conclusion  The use of contralateral hamstring tendon autografts for ACL revision surgery represents a valid option following a failed primary ACL reconstruction and confirms subjective and objective clinical improvement 6 years after surgery. Level of Evidence  Level IV, therapeutic case series.

Chronic Ankle Instability

Chronic ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. In the case of severe joint laxity, surgical treatment is recommended with either direct repair or external ligamentoplasty. Direct repair has been advocated to provide long-term stability. However, in the case of severe joint laxity, reconstruction of the lateral ligamental complex is recommended. According to a recent meta-analysis, there is insufficient evidence to support one form of treatment over the other in the management of chronic ankle instability, and the best surgical option for the treatment of lateral ankle instability has yet to be determined.