David Figueroa

Magnetic Resonance Imaging Evaluation of the Integration and Maturation of Semitendinosus-Gracilis Graft in Anterior Cruciate Ligament Reconstruction Using Autologous Platelet Concentrate

PURPOSE To evaluate integration and maturation of semitendinosus-gracilis (STG) grafts in anterior cruciate ligament (ACL) reconstruction with magnetic resonance imaging (MRI) in patients who underwent ACL reconstruction with STG with and without autologous platelet concentrate (APC). METHODS A randomized single-blinded evaluator prospective study was performed in 2 consecutive series of patients who underwent reconstruction over a 14-month period: 30 with APC use (group A) and 20 as control subjects (group B). At 6 months, an MRI evaluation was performed, with observation of the grafts maturation and presence or absence of synovial fluid at the tunnel-graft interface. To facilitate interpretation, a scoring scale was designed to evaluate graft integration and maturation. RESULTS Regarding the presence of synovial fluid at the bone-graft interface, the test was negative in 86.84% of patients in group A and 94.74% in group B. A disorganized autograft signal pattern was found in 2.63% in group A and 5.26% in group B. Signal intensity was considered hypointense in 63.16% in group A and 42.11% in group B, isointense in 34.21% in group A and 52.63% in group B, and hyperintense in 0% in both groups. The final mean score was 4.45 points in group A and 4.2 points in group B (P ≥ .05). Poor integration was found in 2.63% in group A and 5.26% in group B (P = .214). Good integration was found in 97.37% in group A and 94.74% in group B (P = .784). CONCLUSIONS In our consecutive series of patients who underwent ACL reconstruction with STG grafts, 1 group with intraoperative APC use versus a control group, followed up by MRI at 6 months after reconstruction, we did not find any statistically significant benefit in the APC group in terms of integration assessment and graft maturation (ligamentization). LEVEL OF EVIDENCE Level III, case-control study.

Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: Clinical and electrophysiological study

The incidence of IBSN injury to the infrapatellar branch of the saphenous nerve (IBSN) in ACL surgery using the hamstrings technique has been reported to be between 30 and 59%. The purpose of this study was to evaluate the incidence of IBSN injury in ACL surgery with the hamstrings technique through clinical and electrophysiological evaluation, and also to evaluate potential risk factors of IBSN injury related to the surgical incision. Between November 2003-September 2004, 21 consecutive patients (22 knees) with an acute ACL rupture suitable for reconstruction were included. Patients with previous surgeries or scars around the knee and those with any degree of osteoarthritis were excluded. Clinical and electrophysiological evaluations were performed in all the cases. Hypoesthesia of the IBSN territory was found in 17 knees (77%) with an average area of 36 cm(2) (1-120 cm(2)). Injury to the IBSN was electrophysiologically detected in 15 knees (68%). Two patients also had an injury to the saphenous nerve (9%). The presence of sensory loss associated with damage to the IBSN did not correlate with the size of the incision or the distance to the tibial tubercle. This injury probably occurs during tendon harvesting as found by an injury to the saphenous nerve in two of our patients. However the sensory loss does not impair normal daily activities in these patients.

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes 10-Year Follow-up Study

Background: The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. Current evidence supports the view that surgical techniques restore knee stability and prevent progressive articular damage. However, most of the studies on this topic are small case series or they have short- or medium-term follow-up times. Purpose: To determine the long-term functional outcomes and secondary complications of transphyseal intra-articular ACL reconstruction with hamstring graft in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: Transphyseal ACL reconstruction with autograft hamstrings was performed in 27 skeletally immature patients. The average age at surgery was 13 years (range, 12-16 years), and the average follow-up time was 10.6 years (range, 10-13 years). Clinical outcomes were assessed with preoperative and final follow-up Tegner, International Knee Documentation Committee (IKDC) subjective, and Lysholm scores. Surgery details, return to sports, and ACL reconstruction failures were collected. The anteroposterior knee laxity was assessed by arthrometry, and the presence of deformities and lower limb length discrepancies were evaluated by radiographs. The presence of degenerative signs on anteroposterior and lateral knee radiographs at final follow-up was also evaluated. Results: Transphyseal ACL reconstruction was performed with vertically oriented tunnels, 7 to 10 mm in diameter, using semitendinosus-gracilis autograft. The average preoperative Tegner, IKDC, and Lysholm scores were 7, 55, and 40, respectively. Significant differences in these scores were observed at the time of the final assessment (Tegner, 6 [P = .026]; IKDC, 94 [P < .001]; Lysholm, 92 [P < .001]). Two patients reported instability during sports activity. Three patients had a rupture of the ACL graft. No leg length discrepancy, axis malalignment, or degenerative changes were observed. Conclusion: The transphyseal ACL reconstruction in skeletally immature patients is a safe option, with high functional and satisfaction results, without significant growth plate damage in this series of patients.

Platelet-Rich Plasma Use in Anterior Cruciate Ligament Surgery: Systematic Review of the Literature

PURPOSE To systematically review the current literature for evidence that would substantiate the use of platelet-rich plasma (PRP) in the treatment of anterior cruciate ligament (ACL) ruptures. METHODS We performed a systematic search in PubMed and Embase of studies written in the English and Spanish languages that compared the use of PRP with a control group in patients with ACL injuries assessing graft-to-bone healing, graft maturation, and/or clinical outcomes and were randomized controlled trials or prospective cohort studies. RESULTS Eleven studies fulfilled the inclusion criteria, comprising 516 patients (266 ACL reconstructions using PRP and 250 ACL reconstructions without PRP). Six studies reported a statistically significant difference (4 studies) or tendency toward faster graft maturation in the platelet group (2 studies). One study found no differences. Regarding tunnel healing/widening, 1 study showed faster healing in the PRP group and 5 studies showed no differences between the 2 groups. Considering clinical outcomes, 1 study showed better clinical outcomes with PRP use and 5 studies showed no benefits with the use of PRP. CONCLUSIONS Concerning ACL graft maturation, there is promising evidence that the addition of PRP could be a synergic factor in acquiring maturity more quickly than grafts with no PRP, with the clinical implication of this remaining unclear. Regarding tunnel healing, it appears that there is not an improvement with the addition of PRP. There is no proof that clinical outcomes of ACL surgery are enhanced by the use of PRP. LEVEL OF EVIDENCE Level III, systematic review of Level I through III studies.

Septic arthritis in ACL reconstruction surgery with hamstring autografts. Eleven years of experience

BACKGROUND Knee joint infection after ACL reconstruction is a rare complication with a low reported incidence, but the consequences can be devastating. The purpose of the study was to determine the incidence of septic arthritis after primary ACL reconstruction with hamstring auto-graft and the risk factors that may be associated. METHOD A retrospective study of all primary ACL reconstruction from January 2000 to May 2011. Electronic medical records were reviewed to determine the number of infections, operating time, associated procedure, time of presentation after surgery, infection treatment, microbiological cultures and graft retention. At the end of the follow-up (18-108months) a functional assessment of all the infected patients was performed using the Lysholm score with the Lysholm score. RESULTS We analyzed 1564 cases of primary ACL reconstruction with hamstring autograft, of which seven cases were diagnosed with postoperative joint infection (incidence rate of 0.45%). The infectious agent most frequently isolated was a coagulase-negative Staphylococcus. Neither intraoperative factors nor age correlated with the development of the infection. The average Lysholm score was 95 points (range 89-100 points). All but two patients retained their reconstructed ACL. The results of the five patients in which the graft was preserved were significantly better than the two patients that had their grafts removed (p=0.03). CONCLUSION We conclude that septic arthritis post ACL reconstruction has a low incidence rate, which if handled at an early stage allows the patients a satisfactory return to their previous activities. Graft retention is important to obtain better functional results. LEVEL OF EVIDENCE IV.

Clinical outcomes after arthroscopic treatment of knee osteoarthritis.

PURPOSE The aim of this study was to describe the clinical outcomes of patients with knee osteoarthritis (OA) treated with arthroscopic surgery, documenting the associated injuries and defining the type of treatment selected for OA patients with different symptoms. HYPOTHESIS Knee arthroscopy is effective for treating patients with symptomatic OA and mechanical symptoms. METHODS This was a prospective, consecutive series of 100 patients with a clinical and radiological diagnosis of OA who were treated with knee arthroscopy. The average follow-up time was 35.9months (25-71), and the average age was 60.1years (50-83). INCLUSION CRITERIA >50years of age, a clinical imaging diagnosis of knee OA with an Ahlbäck I-III classification. EXCLUSION CRITERIA <50years of age, Ahlbäck IV, pathologic lower limb mechanical axis and inflammatory joint diseases. The IKDC and Lysholm scores were assessed before and after surgery. RESULTS The preoperative average scores were as follows: Lysholm, 56.9±13.5 points (22-71); IKDC, 59.4±21.7 points (45-80). The postoperative average scores were as follows: Lysholm, 86.9 points (22-87); IKDC, 79.5 points (45-100). Regarding the Lysholm scores, 76% were good and excellent results and 24% were moderate (p=0.045). The associated injuries included 48% of chondral and 36% of unstable meniscal injuries. Good or excellent results were observed in 76% of the meniscal injury cases according to the Lysholm scores, while only 84.6% of the cases with unstable chondral lesions had good or excellent results (p=0.035). CONCLUSION Most patients with knee OA associated with unstable cartilage or meniscal injuries reported good-to-excellent symptomatic results at the short- and mid-term follow-ups. LEVEL OF EVIDENCE III.

Osteochondral autografts in full thickness patella cartilage lesions

The purpose of this study was to evaluate clinical, functional and imaging results of full thickness patella cartilage lesions treated with osteochondral autografts (OCA). We studied a consecutive case series of 10 patients. At follow-up, Lysholm and International Knee Documentation Committee (IKDC) scores were obtained. Magnetic resonance imaging (MRI) evaluation was performed at an average of 8 months post-op. The average cartilage lesion area was 1.2 cm(2). An average of 1.9 grafts was used per patient. The average Lysholm scores were: pre-op 73.8±8.36; post-op 95±4.47 points (p<0.05). The average IKDC post-op score was 95±1.74 points. No postoperative complications were registered. In the MRI analysis we found that in all cases, OCA presented flush characteristics when compared with adjacent cartilage. The majority of cases presented no fissures in the graft-receptor interface (60%). In 80% we observed mild bone marrow edema around the graft. According to the International Cartilage Research Society (ICRS) cartilage lesions classification, all grafts were considered 1A; in the periphery cartilage was classified as 1A in 60%. We conclude that patellar OCA is a good alternative for the treatment of full thickness patellar cartilage lesions, offering good clinical, functional and imaging results at midterm follow-up.

Aloinjertos óseos y la función del banco de huesos

The use of bone grafts is a common practice in musculoskeletal surgery to provide mechanical stability where there is a defect and it allows skeletal reconstruction. Classically auto and allografts have been used. The latter are the choice in large, complex defects. Allografts can be transplanted despite cell death, have osteoconduction and osteoinduction capacity, low antigenicity and biomechanical properties similar to the original bone. They can be obtained from living and death donors. They are stored by cryopreservation and lyophilization in entities called bone banks. This is a review about bone allografts and the organization and function of the bone banks.

Effect of tendon tensioning: An in vitro study in porcine extensor tendons

Graft tensioning is a controversial issue in anterior cruciate ligament reconstruction (ACLR) that has not achieved consensus between peers. The purpose of this study is to determine if after tensioning tendon length and resistance to maximal load changes. We performed an in vitro study with 50 porcine extensors tendons. The first group (P=25) was tensioned with 80 N (19.97 lb) for 10 min, using an ACL graft preparation board. The second group (C=25) was used as control and was not tensioned. The average initial (groups P and C) and post tensioning tendon length (group C) were measured; the average initial and post tensioning tendon diameter were measured as well. All samples were fixated in a tube-clamp system connected to a tension sensor. The samples were stressed with continuous and progressive tension until ultimate failure at maximum load (UFML) occurs. The initial mean length was: P before tensioning=13.4 mm+/-1.4 mm (range 10.5-16.5); P after tensioning=13.8 mm+/-1.4 mm (range 11.5-16.5); C=13 mm+/-1.35 mm (p=0.005). The mean diameter was: P=5.6 mm (4.5-6); C=5.5 mm (range 4.5-6) (p>0.05). The UFML was: P=189.7 N (114-336); C=229.9 N (143-365) (p=0.029). Tendon tensioning with 80 N for 10 min produced 3% average elongation. These could be beneficial in ACLR since tendon tensioning decreases elongation of the graft after fixation. Regardless, tendon tensioning is not innocuous since it diminishes their resistance when continuously stressed until complete failure occurs.

Steroids and Platelet-Rich Plasma as Coadjuvants to Microfracture for the Treatment of Chondral Lesions in an Animal Model Can the Healing Be Enhanced?

Objective: The aim of this study was to evaluate the contribution to hyaline cartilage regeneration of the microfracture (MFx) technique plus intraarticular betamethasone (BMS) or platelet-rich plasma (PRP). Design: Full-thickness chondral defects of 3 × 6 mm2 were surgically performed in both femoral condyles of each knee in 13 New Zealand rabbits and then treated with MFx associated with intraarticular BMS or PRP. At 12 weeks postimplantation, the animals were killed and the condyles were characterized macroscopically, molecularly according to collagen type II and I gene expression (quantitative reverse transcriptase–polymerase chain reaction), and histologically (hematoxylin–eosin staining). For the latter, samples were scored using the International Cartilage Repair Society visual histological scale. Data of MFx/BMS-treated and MFx/PRP-treated condyles were compared against untreated, MFx-treated, or normal condyles without lesions. Results: Our macroscopic findings showed that in MFx/BMS-treated and MFx/PRP-treated groups, the defects were filled with an irregular, partially rough tissue similar to the MFx-treated group. No differences in the ratio between collagen type II versus collagen type I expression were observed among groups. Histological changes were observed between MFx/BMS-treated and MFx/PRP-treated groups versus untreated defects mainly in surface regularity and cell distribution. However, International Cartilage Repair Society score analysis did not support statistical differences between MFx/BMS-treated and MFx/PRP-treated groups versus MFx-treated group. Conclusions: These results provide evidence that the use of intraarticular BMS or PRP as coadjuvants to the microfracture technique in the treatment of acute chondral lesions is not associated with a significant improvement of hyaline cartilage regeneration.