Ezio Adriani

Accelerated rehabilitation after arthroscopic meniscal repair : A clinical and magnetic resonance imaging evaluation

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Arthroscopic posterior cruciate ligament reconstruction with bone-tendon-bone patellar graft

Abstract We present a retrospective study of 24 patients with chronic injury of the posterior cruciate ligament (PCL) treated by arthroscopically assisted reconstruction with bone-tendon-bone patellar autograft. At a mean follow-up of 26.5 months (range 24–53 months) the International Knee Documentation Committee (IKDC) evaluation form, Lysholm and Tegner rating systems were used to evaluate symptoms, functional limitations during sports and daily activities, and changes in activity level. At the final IKDC evaluation we found 6 patients (25%) with grade A (normal), 13 patients (54.2%) with grade B (nearly normal), 3 patients (12.5%) with grade C (abnormal) and 2 patients (8.3%) with grade D (severely abnormal). The average side-to-side difference, as measured by the KT-2000 arthrometer, was 8.38 (± 1.95) preoperatively and 4.08 (± 2.09) mm postoperatively at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70°. The worst results significantly correlated with the time elapsed from injury to surgery (P < 0.001). The preoperative Lysholm score was 56 ± 12 (range 41–79) and at follow-up 94 ± 8 (range 76–100). The Tegner activity score improved for all patients after surgical treatment. Average preinjury score was 7.4 (range 4–9), decreasing to 3.40 (range 2–7) preoperatively and increasing to 5.4 (range 4–9) postoperatively. At follow-up, 12 patients (50%) regained to their preinjury scores after surgery. Our study suggests that this arthroscopic technique, which allows a more precise placement of tunnels, can improve the results of the PCL reconstruction with a bone-tendon-bone autograft.

Osteonecrosis after arthroscopic medial meniscectomy

Osteonecrosis of the medial femoral condyle is an uncommon complication of meniscal surgery. Whether this disease is associated with the original medial meniscus lesion or with the arthroscopic procedure is not yet known. We present two cases in which osteonecrosis has developed shortly after arthroscopy was performed for medial meniscus pathology. Magnetic resonance imaging has been the best tool to diagnose and follow up the changes in the involved area. Concerning the etiology, the authors raise the question of whether the medial compartment overloading observed in both of these cases had any significant meaning. Osteonecrosis following meniscal surgery in relatively young patients seems to have a good prognosis when correctly treated, with avoidance of weight bearing.

Technical Note Double Tibial Tunnel Using Quadriceps Tendon in Anterior Cruciate Ligament Reconstruction

To avoid complications related to the use of patellar tendon and hamstring (semitendinosus and gracilis) tendon and to create a more anatomic reconstruction, we present a new technique based on the use of quadriceps tendon placed in a single half femoral tunnel and double tibial tunnels. The graft, harvested by a central longitudinal incision, possesses the following characteristics: (1) a bone plug 20 mm long and 10 mm in diameter; (2) a tendon component 7 to 8 cm long, 10 mm wide, and 8 mm thick; and (3) division of the tendon longitudinally into 2 bundles while maintaining the patellar insertion. Every bundle has a width and thickness of approximately 5 mm and 8 mm, respectively. The total length of the graft is 9 to 10 cm. A 10-mm half femoral tunnel is drilled through a low anteromedial portal with the knee flexed at 120 degrees. A suture loop is left in place in the half tunnel. A double tibial tunnel is drilled in a convergent manner (from outside to inside) obtaining an osseous bridge between the 2 tunnels. Two suture loops are passed trough the tibial tunnels and retrieved in a plastic cannula (10 mm) positioned in the anteromedial portal to allow the passage of the 2 bundles in the tibial tunnels. The suture loop left in the half tunnel permits the transportation of the bone plug in the femoral tunnel. Fixation is achieved by an interference screw at the femoral side and by 2 absorbable interference screws (1 for each tunnel). The advantages of this technique are a more cross-sectional area (80 mm(2)), greater bone-tendon interface, and a more anatomic reconstruction. Theoretically, easier bone incorporation, decreased windshield wiper and bungee effect, fewer donor site problems, and less tunnel enlargement can also be possible.

Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect

The purpose of this study was (a) to evaluate by ultrasonography the healing of the patellar tendon after its mid-third was removed for anterior cruciate ligament (ACL) reconstruction in two randomized groups of patients in whom the tendon donor site was either left open or closed: (b) to compare clinical, radiographic, and isokinetic studies of these two groups to evaluate the incidence of patellofemoral disorders. We performed 61 ACL reconstructions (22 males, 39 females) using the arthroscopically assisted in-out technique. All operations were performed by the same surgeon, and the patients were all subjected to the same postoperative protocol. The tendon defect was left open in 25 subjects (group A) and was closed in 36 subjects (group B). Postoperative patellar tendon behavior was evaluated in these two groups by ultrasonography at 3, 6, 9, and 12 months. The vertical position of the patella was measured in the follow-up lateral view at 45° of flexion and compared to that of the untreated knee. A clinical evaluation was performed throughout the follow-up period. and patellofemoral problems (pain, stiffness, patellofemoral crepitus) were evaluated and recorded using a modified Larsen and Lauridsen rating scale. Isokinetic evaluation was carried out at 6 months, and a quadriceps index of the two groups was recorded. Ultrasonography showed that healing of the patellar tendon initially progressed with a compensatory hypertrophy in width and thickness. The width was greater in group B (P<0.01). In group A we observed in the cross-sections a characteristic image of two cords separated by a low signal bridge which we defined as a “binocular pattern”. Areas of high ultrasound signal intensities persisted after 1 year in the open group: such areas were filled with scar tissue. In the closed group the ultrasound tendon signal returned to normal at 1 year. At 6 months the clinical, radiographic and isokinetic findings did not significantly differ between the open and closed groups. We conclude that defect closure after patellar tendon harvesting does not significantly influence the extensor apparatus.

Arthroscopic treatment of bilaeral Freiberg's infraction

Freibergs disease is a relatively rare disorder with a multifactorial cause. The condition has a definite predilection for the second metatarsal head, and it is rare to find a bilateral involvement, especially of the first metatarsal head described in the literature. The results of different methods of surgical treatment have been reported, but no single procedure has produced uniformly good results. We describe a case of a 28-year-old man, a lawyer with a 4-year history of bilateral intermittent forefoot pain on weightbearing without any recollection of specific trauma to his feet. Radiographic and magnetic resonance imaging investigations were performed and the patient underwent a bilateral arthroscopic treatment with joint debridement and drilling of the metaphyseal portion of both distal metatarsal head. Three months after surgery, the patient returned to unrestricted activity without pain. At last evaluation, 2 years postoperatively, he is symptom free and new magnetic resonance examination has shown satisfactory restructuring of the lesions.

Histological and structural study of the adhesive tissue in knee fibroarthrosis: a clinical-pathological correlation.

In fibroarthrosis of the knee, it is still unknown if joint range of motion is affected by anatomopathological differences in adhesive tissue, such as tissue maturity, location, and quantity. A retrospective study of 78 patients who underwent arthoscopic arthrolysis was performed to determine a correlation between location of adhesions and preoperative range of motion (ROM). In another 17 patients, a histological and structural evaluation of adhesive tissue was performed. Based on vascularization, number and shape of cells, and collagen fiber orientation, the adhesive tissue was classified into three groups: low, medium, and high maturity. Preoperative joint ROM and the time of onset of joint stiffness was correlated with the degree of adhesion tissue maturity. A strong and statistically significant correlation between the location of adhesions and joint restriction was found. However, histological and structural evaluation showed no correlation between the degree of tissue maturity, the time of onset of joint stiffness, and the amount of joint ROM.

Arthroscopic-assisted posterior cruciate ligament reconstruction using patellar tendon autograft: a technique for graft passage

During arthroscopic posterior cruciate ligament (PCL) reconstruction, passage of the graft into the knee joint may be difficult, especially when using the patellar tendon. Because of the angle of passage, the bone block ends may become entangled or caught on the superior edge of the posterior tibial tunnel when passing the graft from the tibia to the femur. The use of a blunt trocar through the posteromedial portal avoids impingement of the bone block against the edge of the tibial tunnel. This method uses the pulley principle and permits the graft to pass freely into the knee. This method has been used successfully by the authors in more than 40 PCL arthroscopic reconstructions.

ACL reconstruction using quadriceps tendon.

Quadriceps tendon has recently become a viable graft option for primary and revision anterior cruciate ligament reconstruction. It offers excellent biomechanical strength, a large cross-sectional area, and an appropriate length. Its advantages over bone-patellar tendon-bone and semitendinosus/gracilis tendon are presented.

A prospective evaluation of a test for lateral meniscus tears

A test for diagnosing lesions to the lateral meniscus is described. Due to our inability to find its description in the literature we called it ‘dynamic test’. The accuracy of this test was assessed in 421 knees. The test was compared against arthroscopic findings in all cases. Inter-rater reliability was also estimated among three observers, who were shown to have a K coefficient ranging from 0.61 to 0.85. In a series of healthy subjects, the test was positive in eight normal knees (9.4%), but none of these false-positives was unanimously identified by more than one rater. This manipulative test was very accurate: sensitivity 85%, specificity 90.3%, positive predictive value 73.2%, negative predictive value 95% prevalence 23.7% and accuracy 89%. Thus, the test seems to be a tool that can improve the diagnostic accuracy of meniscal lesions. An important feature of this test is that it can be performed in patients with acute injuries.