Daniel J. Liechti

Opening- and Closing-Wedge Distal Femoral Osteotomy A Systematic Review of Outcomes for Isolated Lateral Compartment Osteoarthritis

Background: Lateral compartment osteoarthritis of the knee can be a challenging pathology in the younger, active population due to limited treatment options and high patient expectations. Distal femoral osteotomy (DFO) has been reported to be a potential treatment option. Purpose: To perform a systematic review on the survival, outcomes, and complications of DFO for treatment of genu valgum with concomitant lateral compartment osteoarthritis of the knee. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, PubMed, and MEDLINE from 1980 to present. Inclusion criteria were as follows: outcomes of opening- and closing-wedge DFOs performed for treatment of genu valgum with concomitant lateral compartment osteoarthritis of the knee, English language, minimum 2-year follow-up, and human studies. Data abstracted from the selected studies included type of osteotomy (opening vs closing), survival rate, patient-reported and radiographic outcomes, and complications. Results: Fourteen studies met the inclusion criteria and were considered for the review. A total of 9 closing-wedge and 5 opening-wedge DFO studies were included. All were retrospective studies and reported good to excellent patient-reported outcomes after DFO. Survival decreased with increasing time from surgery, with 1 study reporting a 100% survival rate at 6.5 years, compared with 21.5% at 20 years in another study. A low rate of complications was reported throughout the review. Conclusion: Highly heterogeneous literature exists for both opening- and closing-wedge DFOs for the treatment of isolated lateral compartment osteoarthritis with valgus malalignment. A mean survival rate of 80% at 10-year follow-up was reported, supporting that this procedure can be a viable treatment option to delay or reduce the need for joint arthroplasty. A low complication rate was observed, with symptomatic hardware being the most prevalent postoperative complication.

Clinical Outcomes of High Tibial Osteotomy for Knee Instability A Systematic Review

Background: In recent years there has been an increasing interest in high tibial osteotomy (HTO) to treat patients with chronic knee instability due to posterolateral corner (PLC), posterior cruciate ligament (PCL), and anterior cruciate ligament (ACL) insufficiencies with concurrent malalignment in the coronal and/or sagittal plane. Purpose: To perform a systematic review of the use of HTO for the treatment of knee ligament instability with concurrent malalignment. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was conducted for the treatment of combined knee ligament instability and malalignment with HTO using the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE (1980 to present); the queries were performed in July 2015. Terms searched included the following: high or proximal tibial osteotomy, unstable, instability, laxity, subluxation, tibial slope, and malalignment, in the knee joint. Inclusion criteria were as follows: HTO to treat instability of the knee joint in the sagittal and/or coronal plane, minimum 2-year follow-up with reported outcomes measures, English language, and human studies. Animal, basic science, and cadaveric studies were excluded as well as editorials, reviews, expert opinions, surveys, special topics, letters to the editor, and correspondence. Results: The search resulted in 460 studies. After applying exclusion criteria and removing duplicates, 13 studies were considered. Of the studies reviewed, knee ligament pathologies, previous surgeries, and measurement of knee stability were heterogeneous. However, all studies reported an improvement in knee stability after HTO. Most studies reported improvement in outcome scores. However, other studies did not provide preoperative scores for comparison. Reported complication rates ranged from 0% to 47%. Conclusion: Although HTO has been highly advocated and used in treating patients with ligamentous knee instability, there remains a paucity of high-quality studies. Included studies report improvement of instability as well as relatively high patient satisfaction and rate of return to sports. The heterogeneity of the pathology treated, follow-up time, and outcome measures limit comparison between studies.

Biomechanical Analysis of the Individual Ligament Contributions to Syndesmotic Stability

Background: Biomechanical data and contributions to ankle joint stability have been previously reported for the individual distal tibiofibular ligaments. These results have not yet been validated based on recent anatomic descriptions or using current biomechanical testing devices. Methods: Eight matched-pair, lower leg specimens were tested using a dynamic, biaxial testing machine. The proximal tibiofibular joint and the medial and lateral ankle ligaments were left intact. After fixation, specimens were preconditioned and then biomechanically tested following sequential cutting of the tibiofibular ligaments to assess the individual ligamentous contributions to syndesmotic stability. Matched paired specimens were randomly divided into 1 of 2 cutting sequences: (1) anterior-to-posterior: intact, anterior inferior tibiofibular ligament (AITFL), interosseous tibiofibular ligament (ITFL), deep posterior inferior tibiofibular ligament (PITFL), superficial PITFL, and complete interosseous membrane; (2) posterior-to-anterior: intact, superficial PITFL, deep PITFL, ITFL, AITFL, and complete interosseous membrane. While under a 750-N axial compressive load, the foot was rotated to 15 degrees of external rotation and 10 degrees of internal rotation for each sectioned state. Torque (Nm), rotational position (degrees), and 3-dimensional data were recorded continuously throughout testing. Results: Testing of the intact ankle syndesmosis under simulated physiologic conditions revealed 4.3 degrees of fibular rotation in the axial plane and 3.3 mm of fibular translation in the sagittal plane. Significant increases in fibular sagittal translation and axial rotation were observed after syndesmotic injury, particularly after sectioning of the AITFL and superficial PITFL. Sequential sectioning of the syndesmotic ligaments resulted in significant reductions in resistance to both internal and external rotation. Isolated injuries to the AITFL resulted in the most substantial reduction of resistance to external rotation (average of 24%). However, resistance to internal rotation was not significantly diminished until the majority of the syndesmotic structures had been sectioned. Conclusion: The ligaments of the syndesmosis provide significant contributions to rotary stability of the distal tibiofibular joint within the physiologic range of motion. Clinical Relevance: This study defined normal motion of the syndesmosis and the biomechanical consequences of injury. The degree of instability was increased with each additional injured structure; however, isolated injuries to the AITFL alone may lead to significant external rotary instability.

Activity Level and Function After Lateral Ankle Ligament Repair Versus Reconstruction

Background: Few studies have compared outcomes of Broström-Gould repair and allograft reconstruction. Hypothesis/Purpose: The purpose of this study was to compare outcomes and revision rates after Broström-Gould lateral ankle ligament repair versus anatomic allograft reconstruction in patients with lateral ankle instability. The hypothesis was that patients who underwent lateral ankle ligament repair would have outcomes and revision rates similar to those of patients who underwent anatomic allograft reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent surgical repair or reconstruction of the anterior talofibular ligament and/or the calcaneofibular ligament by a single surgeon between September 2009 and February 2013 were included in this study. Patients completed a subjective questionnaire at minimum 2 years after ankle surgery. Outcomes measures included the Foot and Ankle Disability Index (FADI), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Lysholm score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form–12 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Tegner activity scale, and patient satisfaction with outcome. Detailed surgical data and intraoperative findings were documented at the time of surgery. All data were collected prospectively and reviewed retrospectively. Results: A total of 86 patients were included in this study: 45 men and 41 women (mean age, 38 years; range, 19-68 years) with a mean body mass index of 26.5 (range, 17.5-47.1). There were 61 (71%) patients in the repair cohort and 25 (29%) in the reconstruction cohort. There was no significant difference in age or sex between cohorts. Seventy-six (88%) patients had minimum 2-year follow-up (mean follow-up, 3.0 years; range, 2.0-5.3 years). There was no significant difference in FADI (87 vs 91; P = .553), AOFAS (77 vs 82; P = .372), Lysholm score (83 vs 87; P = .110), Tegner activity scale (6 vs 4; P = .271), patient satisfaction (9 vs 10; P = .058), WOMAC (8 vs 5; P = .264), or Short Form–12 PCS (51.3 vs 54.6; P = .169) or MCS (54.8 vs 51.5; P = .239) score between the repair cohort and the reconstruction cohort, respectively. No patient in either cohort underwent revision lateral ligament surgery. Conclusion: When compared with lateral ankle repair, anatomic allograft reconstruction produced similarly favorable outcomes, including high patient satisfaction, high function and activity levels, and no revision surgeries in either cohort.

Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques.

Background: Significant debate exists regarding optimal repair for unstable syndesmosis injuries. Techniques range from screw fixation, suture-button fixation, or a combination of the two. In this study, 3 common repairs were compared using a simulated weightbearing protocol with internal and external rotation of the foot. Methods: Twenty-four lower leg specimens with mean age 54 years (range, 38-68 years) were used for testing. Following creation of a complete syndesmotic injury (AITFL, ITFL, PITFL, interosseous membrane), specimens were repaired using 1 of 3 randomly assigned techniques: (1) one 3.5-mm syndesmotic screw, (2) 1 suture-button construct, and (3) 2 divergent suture-button constructs. Repairs were cycled for 500 cycles between 7.5 Nm of internal/external rotation torque under a constant 750 N axial compressive load in a neutral dorsiflexion position. At 0, 10, 100, and 500 cycles, torsional cyclic loading was interrupted to assess torsional resistance to rotation within a physiologic range of motion (15 degrees external rotation to 10 degrees internal rotation). Torque (Nm), rotational position (degrees), and 3-dimensional data were collected throughout the testing to characterize relative spatial relationships of the tibiofibular articulation. Results: There were no significant differences between repair techniques in resistance to internal and external rotation with respect to the intact syndesmosis. Three-dimensional analysis revealed significant differences between repair techniques for sagittal fibular translation with external rotation of the foot. Screw fixation had the smallest magnitude of posterior sagittal translation (2.5 mm), and a single suture-button construct demonstrated the largest magnitude of posterior sagittal translation (4.6 mm). Screw fixation also allowed for significantly less anterior sagittal translation with internal rotation of the foot (0.1 mm) when compared to both 1 (2.7 mm) and 2 (2.9 mm) suture-button constructs. Conclusion: All repairs provided comparable rotational stability to the syndesmosis; however, no repair technique completely restored rotational stability and tibiofibular anatomic relationships of the preinjury state. Clinical Relevance: Constructs were comparable across most conditions; however, when repairing injuries with a suture-button construct, a single suture-button construct may not provide sufficient resistance to sagittal translation of the fibula.

Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes

BackgroundThe goal of this perform a systematic review on the outcomes of bone marrow aspirate concentrate (BMAC) for the treatment of chondral defects and osteoarthritis (OA) of the talus.ResultsThe systematic search performed identified 47 studies after duplicates were removed. After inclusion criteria were applied four studies were considered for insightful analysis for the treatment of focal chondral defects in the foot and ankle with the use of BMAC. Three studies were retrospective and one study was prospective in nature. One study was a comparative cohort study and three studies were case series.ConclusionsThis review denotes that there exists an overwhelming paucity of long-term data and high-level evidence supporting BMAC for the treatment of chondral defects. Nonetheless, the evidence available showed varying degrees of beneficial results of BMAC for the treatment of ankle cartilage defects. The limited literature presented in this review demonstrates the need for more advanced, comparative studies to further investigate the efficacy, safety and techniques for BMAC in the treatment of OLTs. The authors recommend that BMAC therapy should be performed with careful consideration until the application and target population for this treatment are established.

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up

HYPOTHESIS We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature. METHODS In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score. RESULTS A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4). CONCLUSION Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.

A Transosseous Bone Bridge Repair for Posterior Horn Meniscal Root Tears During Anterior Cruciate Ligament Reconstruction

Meniscal root tears occur in isolation or concurrently with ligamentous knee injury and cause significantly altered knee mechanics with the loss of normal meniscus hoop stress. This loss of normal meniscus function can result in abnormal knee kinematics and, subsequently, more rapid degenerative changes of the knee articular surface. In the setting of anterior cruciate ligament tear, the posterolateral meniscus root is most commonly damaged. Several techniques exist for meniscus root repair; however, none have been shown to be clearly superior. We present a safe, effective, and reproducible arthroscopic transtibial technique for posterior horn lateral meniscal root tears.

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.

Repair of the Ankle Syndesmosis A Biomechanical of Analysis of Three Current Repair Techniques

Objectives: Significant debate exists regarding the optimal repair techniques for unstable syndesmosis injuries. Techniques range from one to multiple screw fixation, suture-button fixation devices, or a combination of the two. The purpose of the current investigation was to biomechanically compare three common syndesmotic repair techniques using a simulated weight-bearing protocol with internal and external rotation of the foot. Methods: Twenty-four, lower leg specimens with mean age 54.25 years (range, 38 to 68 years) were utilized for testing. Following the creation of a complete syndesmotic injury (AITFL, ITFL, PITFL, interosseous membrane) specimens were repaired using one of three randomly assigned repair techniques: (1) one 3.5 mm syndesmotic screw, (2) one suture-button construct, and (3) two divergent suture-button constructs. For testing, specimens were oriented in neutral plantar/dorsiflexion and neutral internal/external rotation with the respect to the vertical tibia. Repairs were then cycled for 500 cycles between 7.5 Nm of internal/external rotation torque under a constant 750 N axial compressive load. At 0, 10, 100, and 500 cycles, torsional cyclic loading was interrupted to assess torsional stiffness and resistance to rotation within a physiologic range of motion. While axially loaded to 750 N, the foot was externally rotated to 15° and then rotated to 10° of internal rotation. Torsional cyclic loading was then resumed. Torque (Nm) and rotational position (degrees) were recorded continuously throughout testing. Three-dimensional data was also collected throughout testing to characterize the relative spatial relationships of the tibiofibular articulation. Results: Biomechanically, there were no significant differences between techniques when repairs were compared to the intact syndesmosis. Three-dimensional analysis revealed significant differences between all repair techniques for sagittal fibular translation with external rotation of the foot. Screw fixation had the smallest magnitude in sagittal translation (-2.5 mm), and a single suture-button construct demonstrated the largest magnitude of sagittal translation (-4.6 mm). Screw fixation also allowed for significantly lower sagittal translation with internal rotation of the foot (0.1 mm) when compared to both one (2.7 mm) and two (2.9 mm) suture-button repair constructs. Conclusion: All repairs provided a significant resistance to internal and external rotation, and only demonstrated mild reductions in strength and torsional stiffness throughout torsional cyclic testing.