Daniel C. Wascher

Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation results using fresh-frozen nonirradiated allografts

We reviewed the results in 13 patients who underwent simultaneous allograft reconstruction of both the anterior and posterior cruciate ligaments after a knee dislocation (nine acute and four chronic injuries). Seven patients sustained related medial collateral ligament injuries and six patients had posterolateral complex injuries. Ligament reconstructions were performed using fresh-frozen Achilles or patellar tendon allografts. At follow-up evaluation (mean of 38 months), only one patient described the reconstructed knee as normal. Six patients had returned to unrestricted sports activities and four had returned to modified sports. The average extension loss was 3° (range, 0° to 10°) and average flexion loss was 5° (range, 0° to 15°). The KT-1000 arthrometer measurements at 133 N anterior-posterior tibial load showed a mean side-to-side difference of 4.5 mm (range, 0 to 10) at 20° and 5.0 mm (range, 0 to 9) at 70°. The mean Lysholm score was 88 (range, 42 to 100). International Knee Documentation Committee ratings were six nearly normal, five abnormal, and one grossly abnormal. Two patients required manipulations for knee stiffness. This study demonstrates that reconstruction of both cruciate ligaments can restore stability sufficient to allow sports activity in most patients with knee dislocations, but “normal” results are difficult to achieve.

Knee Articular Cartilage Repair and Restoration Techniques A Review of the Literature

Context: Isolated chondral and osteochondral defects of the knee are a difficult clinical challenge, particularly in younger patients for whom alternatives such as partial or total knee arthroplasty are rarely advised. Numerous surgical techniques have been developed to address focal cartilage defects. Cartilage treatment strategies are characterized as palliation (eg, chondroplasty and debridement), repair (eg, drilling and microfracture [MF]), or restoration (eg, autologous chondrocyte implantation [ACI], osteochondral autograft [OAT], and osteochondral allograft [OCA]). Evidence Acquisition: PubMed was searched for treatment articles using the keywords knee, articular cartilage, and osteochondral defect, with a focus on articles published in the past 5 years. Study Design: Clinical review. Level of Evidence: Level 4. Results: In general, smaller lesions (<2 cm2) are best treated with MF or OAT. Furthermore, OAT shows trends toward greater longevity and durability as well as improved outcomes in high-demand patients. Intermediate-size lesions (2-4 cm2) have shown fairly equivalent treatment results using either OAT or ACI options. For larger lesions (>4 cm2), ACI or OCA have shown the best results, with OCA being an option for large osteochondritis dissecans lesions and posttraumatic defects. Conclusion: These techniques may improve patient outcomes, though no single technique can reproduce normal hyaline cartilage.

Reconstruction of chronic rupture of the extensor mechanism after patellectomy.

Chronic extensor mechanism ruptures are uncommon but challenging clinical problems. Previously published procedures for treating chronic extensor mechanism ruptures assume an intact patella is available to anchor the repair. A case is presented of a patient who had a previous patellectomy, followed by rupture of the extensor mechanism. After two failed attempts at repair, an Achilles tendon allograft was used successfully to restore function of the extensor mechanism. The described technique offers an alternative for reconstruction of the extensor mechanism after patellectomy.

Absorption of Dexamethasone Sodium Phosphate in Human Connective Tissue Using Iontophoresis

Background Iontophoresis ostensibly facilitates the delivery of medications through the skin to underlying tissues using a direct electrical current. Dexamethasone is the most commonly used medication with iontophoresis to treat a variety of connective tissue disorders. Hypothesis Iontophoresis will facilitate the absorption of dexamethasone into connective tissue compared with diffusion. Study Design Controlled laboratory study. Methods Twenty-nine adults undergoing anterior cruciate ligament reconstructive surgery using the semitendinosus/gracilis autograft were randomly assigned to either a true iontophoresis (TI) or sham iontophoresis (SI). In the TI group, a 40-mA/min dose of iontophoresis using a 0.4% (4 mg/mL) solution of dexamethasone was used targeting the semitendinosus tendon just before surgery. The SI group underwent the same treatment, but the machine was not turned on. Tissue was extracted within 4 hours of treatment and analyzed for dexamethasone. In addition, 2 control samples were sent to the laboratory for analysis. Results There was a statistically significant difference in dexamethasone concentrations between the groups (P = .0216). Of the 16 samples in the TI group, 8 had measurable amounts of dexamethasone, with an average concentration of 2.906 ng/g of tendon tissue. In the SI group, 1 of the 13 samples had measurable amounts of dexamethasone with an average concentration of 0.205 ng/g of tendon tissue. The control samples contained no dexamethasone. Conclusion Iontophoresis facilitates the transmission of dexamethasone to connective tissues in humans. Clinical Relevance Iontophoresis can deliver dexamethasone to connective tissues in humans.

Knee Dislocations Lessons Learned From 20-Year Follow-up

Background: Traumatic knee dislocation is becoming more prevalent because of improved recognition and increased exposure to high-energy trauma, but long-term results are lacking. Purpose: To present 2 cases with minimum 20-year follow-up and a review of the literature to illustrate some of the fundamental principles in the management of the dislocated knee. Study Design: Review and case reports. Methods: Two patients with knee dislocations who underwent multiligamentous knee reconstruction were reviewed, with a minimum 20-year follow-up. These patients were brought back for a clinical evaluation using both subjective and objective measures. Subjective measures include the following scales: Lysholm, Tegner activity, visual analog scale (VAS), Short Form–36 (SF-36), International Knee Documentation Committee (IKDC), and a psychosocial questionnaire. Objective measures included ligamentous examination, radiographic evaluation (including Telos stress radiographs), and physical therapy assessment of function and stability. Results: The mean follow-up was 22 years. One patient had a vascular injury requiring repair prior to ligament reconstruction. The average assessment scores were as follows: SF-36 physical health, 52; SF-36 mental health, 59; Lysholm, 92; IKDC, 86.5; VAS involved, 10.5 mm; and VAS uninvolved, 2.5 mm. Both patients had excellent stability and were functioning at high levels of activity for their age (eg, hiking, skydiving). Both patients had radiographic signs of arthritis, which lowered 1 subject’s IKDC score to “C.” Conclusion: Knee dislocations have rare long-term excellent results, and most intermediate-term studies show fair to good functional results. By following fundamental principles in the management of a dislocated knee, patients can be given the opportunity to function at high levels. Hopefully, continued advances in the evaluation and treatment of knee dislocations will improve the long-term outcomes for these patients in the future.

Coccidiomycosis presenting as a popliteal cyst

Coccidiomycosis is a fungal infection that primarily causes pulmonary disease. Extrapulmonary dissemination can occur to the musculoskeletal system with the knee joint most frequently involved. This case report describes a patient with coccidiomycosis whose initial presentation was of a popliteal cyst. The need for aggressive surgical and antibiotic treatment to eradicate this infection is discussed. Coccidiomycosis should be considered in a differential diagnosis of patients with popliteal cysts without other obvious etiologies.

A Novel Posteromedial Approach for Tibial Inlay PCL Reconstruction in KDIIIM Injuries: Avoiding Prone Patient Positioning

BackgroundTreatment of traumatic knee dislocations remains controversial and challenging. Current techniques for PCL reconstruction utilize either a transtibial approach with potential risk of vascular injury from drilling toward the popliteal artery or a tibial inlay technique with prone patient positioning, which is cumbersome and adds operative time. We therefore developed a surgical technique using a supine posteromedial approach for PCL tibial inlay reconstruction for the treatment of Schenck KDIIIM (ACL/PCL/medial collateral ligament) knee dislocations. In patients undergoing this technique, we evaluated patient-reported outcome scores, ROM, stability, and complications.Description of TechniqueTibial inlay PCL reconstructions were performed through a posteromedial approach with the patient supine, knee flexed, and hip externally rotated, thus avoiding prone patient positioning. The inlay approach uses the interval between the medial head of the gastrocnemius and the pes anserinus (gracilis and semitendinosus), with release of the semimembranosus tendon approximately 1 cm from its insertion on the tibia. Retraction of the medial gastrocnemius and semimembranosus allows access to the posteromedial aspect of the proximal tibia while protecting the neurovascular bundle.MethodsAll 11 patients sustaining a KDIIIM multiligamentous knee injury treated between 2002 and 2011 with a three-ligament reconstruction received this posteromedial approach. Seven patients were available for complete evaluation, and one completed telephone followup only. Mean followup was 6.0 years (range, 2.0–11.2 years). Clinical evaluation included Lysholm and Tegner activity scores and measurements of ROM and knee laxity. We also recorded complications.ResultsMean Lysholm and Tegner activity scores were 81 and 4.9, respectively, with three patients returning to recreational or competitive sports. Mean knee flexion was 120° (range, 106°–137°); however, two patients had stiffness in flexion, lacking greater than 20° of flexion compared to the contralateral side. Five had less than 3 mm of translation. Three returned to the operating room, two for arthrofibrosis or painful hardware and a third for ACL reinjury requiring revision reconstruction; there were no vascular injuries.ConclusionsOutcome scores, stability, and complications using this surgical technique were comparable to those found in other studies. The posteromedial approach for tibial inlay avoids prone positioning and the incisions are minimized, allowing safe exposure for combined medial and posterior ligament reconstruction. Further studies are needed to compare this method with others in the treatment of KDIIIM knee dislocations.

Extra-articular procedures for the ACL-deficient knee: a state of the art review

Some patients have continued rotatory instability following intra-articular anterior cruciate ligament (ACL) reconstruction, which limits their functional abilities. Advanced surgical techniques, such as double-bundle reconstruction and anteromedial portal drilling, have not solved this problem. This has led many surgeons to revisit the use of extra-articular procedures to control rotatory laxity. Multiple anatomic studies have confirmed the presence of an anterolateral ligament (ALL) that attaches to the tibia at the site of the Segond fracture. The biomechanical importance of this ligament is still being debated. Extra-articular reconstructions decrease the forces produced by intra-articular ACL grafts. Patients likely to benefit from additional extra-articular reconstruction are: (1) those with high-grade pivot shifts; (2) patients with previous failed ACL reconstructions without an obvious cause; (3) participants in contact sports and (4) patients in subgroups that have a high risk of failure (eg, generalised laxity). A variety of extra-articular reconstructions have been developed. Those techniques that have long-term follow-up data were described before most current orthopaedic surgeons were in practice. The available evidence suggests that performing an additional extra-articular reconstruction can improve rotational stability in patients undergoing intra-articular ACL reconstructions. Newer ‘anatomic’ reconstructions of the ALL have recently been proposed but there are limited data on their effectiveness. Currently, there are no studies comparing different extra-articular procedures.

Surgical treatment of medial instability of the knee.

Medial collateral ligament (MCL) injuries are commonly seen in orthopedic practice. Most MCL injuries are isolated and can be treated nonsurgically with focus on brace protection of the ligament, range of motion, gait training, and relatively quick return to full activity. A subset of MCL injuries, however, requires operative treatment. It is critical to identify patients with medial instability and develop an operative plan that will restore stability and function to the injured knee. Many MCL reconstruction and repair techniques have been described, and improvement in outcomes with improvement of technique remains an area of great interest. This review discusses several MCL reconstruction options and outlines the authors’ preferred MCL reconstruction technique.

Management of patellar problems in skeletally mature patients with nail-patella syndrome.

AbstractPurpose Nail–patella syndrome (NPS) or hereditary onychoosteodysplasia is a rare autosomal dominant disease, characterized by a tetrad of findings, which include fingernail abnormalities, hypoplasia of the patellae, radial head dislocation and prominent iliac horns. Most of the literature on the treatment of patellar problems in NPS concerns paediatric patients, and there is no standard treatment algorithm for adult patients. MethodsWe reviewed the charts of skeletally mature patients with NPS who presented to our clinic. We reviewed the presenting complaints, the physical examination findings and the radiographic imaging.ResultsWe identified seven skeletally mature patients with NPS who presented with patellofemoral complaints. Their symptoms were instability, pain, or a combination of the two. Examination and imaging revealed a wide range of severity but included patellar instability and patellar arthritis. In our series, milder forms of the disease were treated with non-operative measures, but the majority of our patients required surgery including medial patellofemoral ligament reconstruction, tibial tuberosity transposition, patellofemoral and total knee arthroplasty. At midterm follow-up, most patients had good results.ConclusionNail–patella syndrome has a wide range of presentations and severity in skeletally mature patients. Knee surgeons should be familiar with the spectrum of clinical presentation and the range of treatment options available in order to provide optimum treatment for patients with this disorder.Level of evidenceIV.