Danilo Bruni

Prospective Long-Term Outcomes of the Medial Collagen Meniscus Implant Versus Partial Medial Meniscectomy: A Minimum 10-Year Follow-Up Study

Background: Loss of meniscal tissue can be responsible for increased pain and decreased function. Hypothesis: At a minimum 10-year follow-up, patients receiving a medial collagen meniscus implant (MCMI) would show better clinical, radiological, and magnetic resonance imaging (MRI) outcomes than patients treated with partial medial meniscectomy (PMM). Study Design: Cohort study; Level of evidence 2. Methods: Thirty-three nonconsecutive patients (men; mean age, 40 years) with meniscal injuries were enrolled in the study to receive MCMI or to serve as a control patient treated with PMM. The choice of treatment was decided by the patient. All patients were clinically evaluated at time 0 and at 5 years and a minimum of 10 years after surgery (mean follow-up, 133 months) by Lysholm, visual analog scale (VAS) for pain, objective International Knee Documentation Committee (IKDC) knee form, and Tegner activity level scores. The SF-36 score was performed preoperatively and at final follow-up. Bilateral weightbearing radiographs were completed before the index surgery and at final follow-up. Minimum 10-year follow-up MRI images were compared with preoperative MRI images by means of the Yulish score. The Genovese score was also used to evalute MCMI MRI survivorship. Results: The MCMI group, compared with the PMM one, showed significantly lower VAS for pain (1.2 ± 0.9 vs 3.3 ± 1.8; P = .004) and higher objective IKDC (7A and 10B for MCMI, 4B and 12C for PMM; P = .0001), Teger index (75 ± 27.5 vs 50 ± 11.67; P = .026), and SF-36 (53.9 ± 4.0 vs 44.1 ± 9.2; P = .026 for Physical Health Index; 54.7 ± 3.8 vs 43.8 ± 6.5; P = .004 for Mental Health Index) scores. Radiographic evaluation showed significantly less medial joint space narrowing in the MCMI group than in the PMM group (0.48 ± 0.63 mm vs 2.13 ± 0.79 mm; P = .0003). No significant differences between groups were reported regarding Lysholm (P = .062) and Yulish (P = .122) scores. Genovese score remained constant between 5 and 10 years after surgery (P = .5). The MRI evaluation of the MCMI patients revealed 11 cases of myxoid degeneration signal: 4 had a normal signal with reduced size, and 2 had no recognizable implant. Conclusion: Pain, activity level, and radiological outcomes are significantly improved with use of the MCMI at a minimum 10-year follow-up compared with PMM alone. Randomized controlled trials on a larger population are necessary to confirm MCMI benefits at long term.

ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up

Several investigators have reported the presence of biomechanical, kinematic, anatomic, fiber orientation patterns and biological differences between the anteromedial bundle and the posterolateral bundle of ACL. The purpose of this prospective randomized study was to compare the clinical, instrumental and X‐ray outcome of two ACL reconstruction techniques with hamstring tendons: one with a single intra‐articular bundle associated to an extra‐articular sling, the second with a more anatomic double‐bundle technique that reproduces better the native ACL function. From an initial group of 100 patients who underwent ACL reconstruction, 72 patients (35 single bundle plus lateral plasty and 37 double bundle) were evaluated with IKDC, Tegner score, KT2000 arthrometer, Activity Rating Scale, Psychovitality Questionnaire and Ahlback radiographic score at a mean 3 years follow‐up. Double‐bundle group showed significantly better results regarding IKDC, ROM, Activity Rating Scale and time to return to sport. Also KT 2000 showed significant differences in objective stability. The double‐bundle technique for ACL reconstruction described in this paper has demonstrated significantly better subjective, objective and functional results compared with a double‐stranded hamstrings plus extra‐articular sling at a minimum 3‐year follow‐up.

Double-bundle ACL reconstruction: influence of femoral tunnel orientation in knee laxity analysed with a navigation system - an in-vitro biomechanical study.

BackgroundThis paper reports an in-vitro study for evaluating the influence of the femoral tunnel orientation in anterior cruciate ligament (ACL) double-bundle reconstructions.MethodsThis work describes the experimental protocol and results obtained for six cadaver knees using the FlashPoint optical system (Image Guided, Boulder, Colorado, USA) and a computer-assisted technique for the elaboration of anatomical and kinematic data. Each specimen was examined by the same surgeon in the following steps: (1) intact knee stability was evaluated by performing antero-posterior displacement and internal-external rotation test at 90°; (2) the ACL was resected and the knee evaluated again; (3) the ACL was reconstructed using the gracilis semi-tendinous tendon (through horizontal tunnels in femur), and the new kinematics recorded; (4) the ACL was reconstructed again with the same tendon, but with a more vertical orientation of the femoral tunnel (vertical tunnel) and kinematics was once more recorded; (5) finally the knee was dissected to digitise the anatomical structures.ResultsOff-line computer analysis of the acquired anatomical and kinematic data showed that there was a significant statistical difference (Wilcoxon test with the Montecarlo method for small samples – p = 0.035) between horizontal tunnel (HT) and vertical tunnel (VT) reconstruction both in the antero-posterior test (median antero-posterior displacement in horizontal tunnel was 0.8 mm less than in vertical tunnel reconstruction) and in the internal-external (IE) rotation test (median internal-external rotation in horizontal tunnel reconstruction was 5° less than in vertical tunnel reconstruction).ConclusionThe analysis of graft behavior in reconstructed knees compared with normal and ACL-deficient knees suggests that the most horizontal tunnel performed better than the vertical tunnel, thus constraining optimally both antero-posterior and internal-external rotations. This finding suggests that femoral tunnel direction may be an important issue in ACL surgery.

Knee arthrodesis with a press-fit modular intramedullary nail without bone-on-bone fusion after an infected revision TKA

INTRODUCTION Knee arthrodesis can be an effective treatment after an infected revision Total Knee Arthroplasty (TKA). The main hypothesis of this study is that a two-stage arthrodesis of the knee using a press-fit, modular intramedullary nail and antibiotic loaded cement, to fill the residual gap between the bone surfaces, prevents an excessive limb shortening, providing satisfactory clinical and functional results even without direct bone-on-bone fusion. MATERIAL AND METHODS The study included 22 patients who underwent knee arthrodesis between 2004 and 2009 because of recurrent infection following revision-TKA (R-TKA). Clinical and functional evaluations were performed using the Visual Analogue Scale (VAS) and the Lequesne Algofunctional Score. A postoperative clinical and radiographical evaluation of the residual limb-length discrepancy was conducted by three independent observers. RESULTS VAS and LAS results showed a significant improvement with respect to the preoperative condition. The mean leg length discrepancy was less than 1cm. There were three recurrent infections that needed further surgical treatment. DISCUSSION This study demonstrated that reinfection after Revision of total knee Arthroplasty can be effectively treated with arthrodesis using a modular intramedullary nail, along with an antibiotic loaded cement spacer and that satisfactory results can be obtained without direct bone-on-bone fusion.

Does chronic medial collateral ligament laxity influence the outcome of anterior cruciate ligament reconstruction? A prospective evaluation with a minimum three-year follow-up

We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (SD 0.9) versus 0.9 mm (SD 0.7), respectively, p = 0.013), while no statistically significant difference was found between the AP laxity and the other clinical parameters. Our results show that the residual valgus laxity does not affect AP laxity significantly at a minimum follow up of three years, suggesting that no additional surgical procedure is needed for the medial collateral ligament in combined lesions.

Over-the-top double-bundle revision ACL reconstruction.

Revision ACL presents many technical issues that are not seen in the primary ACL reconstruction. A variety of surgical techniques for revising ACL reconstruction have been described in the literature to address these concerns. The purpose of this article is to present a novel technique consisting in a non-anatomic double-bundle ACL revision reconstruction, using a fresh-frozen Achilles tendon allograft with soft tissue fixation. This technique is a valid treatment option when faced with a complex scenario such as ACL revision surgery.

Synthetic meniscal scaffolds

Arthroscopic partial meniscectomies showed better clinical results with respect to complete meniscus removal, but at long-term follow-up a substantial number of patients suffer the effect of a lost meniscus cartilage. It is extremely important to preserve the meniscus as much as possible to avoid degenerative knee joint progression. During the 1980s Stone, Steadman and Rodkey developed a new collagen I scaffold to replace meniscus in the case of irreparable major tears: the CMI (Collagen Meniscus Implant). After 13 years of good results in implanting ReGen, Medial CMI, in 2006 we started a postmarketing study to evaluate the efficacy and effectiveness of an equivalent meniscal scaffold specifically designed to repair the lateral meniscal defect (ReGen, Lateral CMI). In this study, we describe indications for the implantation of a CMI device, the evolution of the surgical technique (from in-out arthroscopic suturing technique to all-inside arthroscopic scaffold implantation) in these 13 years of experience, and a short report of our clinical results.

Does total knee arthroplasty modify flexion axis of the knee

PurposeTo prospectively investigate whether preoperative functional flexion axis in patients with osteoarthritis- and varus-alignment changes after total knee arthroplasty and whether a correlation exists both between preoperative functional flexion axis and native limb deformity.MethodsA navigated total knee arthroplasty was performed in 108 patients using a specific software to acquire passive joint kinematics before and after implant positioning. The knee was cycled through three passive range of motions, from 0° to 120°. Functional flexion axis was computed using the mean helical axis algorithm. The angle between the functional flexion axis and the surgical transepicondylar axis was determined on frontal (αF) and axial (αA) plane. The pre- and postoperative hip-knee-ankle angle, related to femur mechanical axis, was determined.ResultsPostoperative functional flexion axis was different from preoperative only on frontal plane, while no differences were found on axial plane. No correlation was found between preoperative αA and native limb deformity, while a poor correlation was found in frontal plane, between αF and preoperative hip-knee-ankle angle.ConclusionsTotal knee arthroplasty affects functional flexion axis only on frontal plane while has no effect on axial plane. Preoperative functional flexion axis is in a more varus position respect to the transepicondylar axis both in pre- and postoperative conditions. Moreover, the position of the functional axis on frontal plane in preoperative conditions is dependent on native limb alignment, while on axial plane is not dependent on the amount of preoperative varus deformity.Level of evidenceIV.

Pathophysiology of Lateral Patellar Dislocation

Patellofemoral disorders represent 20–40% of all knee problems and can be one of the most common complaints in sports related injuries. These disorders are a major cause of disability, particularly in females, and in extreme cases may contribute to termination of athlete’s career and could lead to degenerative arthritic changes of the knee joint. For these reasons, disorders and in particular patellar instability often pose a diagnostic and therapeutic dilemma for the orthopedic surgeon. This dilemma implies that usually no single pathophysiology or therapeutic approach can fully explain and solve patellofemoral instability. In fact the patellofemoral joint is biomechanically one of the most complex human articulations with different anatomical components like bone shape, capsuloligament structures, and muscle that could alone or in combination be responsible for patellar instability. These factors are often present in combination in one patient, but the severity of each pathology can be different resulting in variable patterns of instability and pain that determine that each patient is almost unique; thus the characterization in a classification is a simplification of a very complex issue. Moreover the multifactoriality and variability of pathogenesis has determined in the past numerous misunderstanding. These misconceptions have been responsible for the high variety of surgical procedures proposed to treat patellofemoral instability, leading to less than completely satisfactory clinical results also related to iatrogenic cause.

MPTL (Medial Patellotibial Ligament) Reconstruction

The surgical treatment for patellar subluxation and related pathology described in this chapter is based on dynamic distal extensor mechanism reconstruction rather than a static correction of distal attachments. It is extremely rare for us to proceed with surgical treatment if the patient has not undergone an intensive specific customized rehabilitation program. The rehabilitation period should finish with functional tests to verify the patient’s ability to perform normal unrestricted sports activities. We believe that is not acceptable to adjust the performance to knee symptoms. Only in cases of failure of nonoperative program do we proceed with surgical treatment.