Fabio Conteduca

Knee ligament injuries in volleyball players

The authors report a series of 52 cases of serious knee ligament injuries in volleyball players. The most frequent mechanism of injury was landing from a jump in the attack zone. Women were more affected than men. Injuries were more frequent during games than training. Volleyball must then be considered among high-risk sports according to the frequency and gravity of our surgical findings. Results are similar to those obtained in athletes in other sports who underwent the same surgical procedure.

Regeneration of the Semitendinosus Tendon after Its Use in Anterior Cruciate Ligament Reconstruction A Histologic Study of Three Cases

We describe the histologic course of regenerated tissue simulating the semitendinosus tendon in three patients after anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons. Specimens were retrieved during revision surgery for removal of tibial hardware at 6, 24, and 27 months, respectively. Resisted flexion during physical examination in all patients revealed a “string” on the posteromedial aspect of the knee that was quite evident, suggesting the presence of a regenerated semitendinosus tendon. At surgery, a well-defined fibrous band was identified about 3 cm proximal and medial to the pes anserinus, reproducing the pathway of the native semitendinosus tendon. In the specimen retrieved 6 months postoperatively, a prominent fibroblastic proliferation was observed together with a few vessels surrounded by fibrous tissue; only a few bundles of well-oriented collagen fibers were present, together with scattered rows of spindle-shaped cells. In both of the specimens retrieved 2 years postoperatively, all of the central, thicker portion of each specimen was occupied by well-oriented tendon-like fibers together with uniformly distributed spindle-shaped cells that had the appearance of mature tenocytes arranged in orderly rows. These findings help us to understand the progression of the healing process at the harvest site and the nature of the regenerated semitendinosus tendon, which has previously been investigated only by studies of clinical and functional outcomes and by imaging studies.

Regeneration of the Semitendinosus Tendon Harvested for Anterior Cruciate Ligament Reconstruction: Evaluation Using Ultrasonography*:

In a prospective study, 40 consecutive patients who underwent anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon autografts were examined pre- and postoperatively by ultrasound to investigate the anatomy of the donor site before and after the harvest of the tendons. The patients underwent ultrasonography at 2 weeks and 1, 2, 3, 6, 12, 18, and 24 months postoperatively. A total of 298 postoperative sonographic evaluations were performed. The semitendinosus tendon was imaged in the sagittal and axial planes: structure and margins were evaluated with the sagittal views; thickness and width were measured with the axial views. In all cases the following sequence of healing was documented: 2 weeks after surgery the semitendinosus tendon site was occupied by an area of increased thickness and decreased echogenicity, suggesting the presence of traumatic edema of the soft tissue surrounding the tenotomy. At 1 month, an irregular hypoechoic structure appeared in a near-anatomic position; at 2 months after surgery, thickness, width, and cross-sectional area of this structure were significantly greater than preoperatively. The amount of regenerated tissue increased up to that seen in the tissue of the 6-month examinations, which also showed a more uniform echostructure. The scans performed at 1 year showed distinct edges and reduction in thickness and width. At 18 and 24 months the echogenicity of the structure occupying the donor site was very similar to that of the normal semitendinosus tendon. However, this structure was clearly identified about 4 cm proximal to the pes anserinus, revealing a more proximal insertion of the regenerated semitendinosus tendon.

Knee Injuries in Volleyball

SummaryThe knee is the most frequent site of injury in volleyball players. More than 40% of high level players suffer overuse injuries during this activity; this particularly painful syndrome is caused by the amount of jumping typical in volleyball play, and in its training which aims at strengthening the quadriceps muscle. In volleyball players the extensor apparatus is subject to continuously high stress and the bone tendon junction, being the weakest point, is susceptible to lesion.The prevention and treatment of ‘jumper’s knee’ requires a high degree of cooperation among trainers, doctors and athletes. Although volleyball is a sport without contact between players, traumatic acute injuries are more frequent and more serious than would be expected. It is therefore important to emphasise that volleyball must be considered among the high risk sports that expose the knee not only to twisting, but also to contact with other players.Generally, the lesions are caused by frequent jumps with loss of balance and a consequent ‘one-footed’ landing.There is no specific method of preventing knee instability. Accurate diagnoses, rest and rapid surgical treatment after the first injury are recommended in order to avoid chronic knee instability with subsequent meniscal lesions and post-traumatic osteoarth-ritis.

Revision Anterior Cruciate Ligament Reconstruction with Doubled Semitendinosus and Gracilis Tendons and Lateral Extra-Articular Reconstruction

BACKGROUND The outcome of revision anterior cruciate ligament reconstruction has only rarely been reported. The purpose of this study was to evaluate the results of revision anterior cruciate ligament surgery with use of an autogenous doubled semitendinosus and gracilis graft in association with an extra-articular procedure. METHODS Between 1997 and 2003, thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament with use of a doubled semitendinosus and gracilis graft combined with an extra-articular reconstruction. Primary reconstruction had been done with an autogenous patellar tendon graft in twenty-six patients and with a prosthetic ligament in four patients; the average time from the primary reconstruction to the revision was five years. Functional outcomes, graft survival, and radiographic outcomes were evaluated at a mean of five years. A graft was considered to have failed when a revision was done or when the side-to-side difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift test grade was greater than a trace. RESULTS One patient underwent another revision reconstruction because of graft failure at three years postoperatively. The mean International Knee Documentation Committee (IKDC) subjective knee score for the remaining twenty-nine patients was 84 +/- 12 points, and the mean Lysholm knee score was 90 +/- 10 points. The side-to-side difference as measured with the KT-1000 arthrometer with maximum manual force was <3 mm in twenty patients (of the twenty-eight who returned for follow-up), between 3 and 5 mm in six patients, and >5 mm in two patients. The result of the pivot shift examination was normal in fifteen patients, slightly positive in eleven patients, and positive in two patients. Twenty-five percent of the patients showed no radiographic signs of degenerative joint disease. CONCLUSIONS Revision anterior cruciate ligament reconstruction with use of an autogenous doubled semitendinosus and gracilis graft combined with an extra-articular procedure provided satisfactory functional outcomes, with a failure rate of 10%.

Double-Bundle Anterior Cruciate Ligament Reconstruction A Computer-Assisted Orthopaedic Surgery Study

Background The biomechanical function of single-bundle anterior cruciate ligament reconstruction, in cadaveric studies, is successful in limiting anterior tibial translation in response to an anterior tibial load but seems to be insufficient to control a combined rotator load of internal and valgus torque. Anatomical double-bundle anterior cruciate ligament reconstruction might produce a better biomechanical outcome. Hypothesis The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce internal rotation of the tibia at 30° of knee flexion, compared with a standard single-bundle reconstruction. Study Design Controlled laboratory study. Methods Twenty consecutive anterior cruciate ligament reconstructions were performed in male patients in April and May 2006 with double-bundle gracilis and semitendinosus tendon grafts using the 2.0 OrthoPilot navigation system. Group A (10 patients) underwent standard single-bundle anterior cruciate ligament reconstruction with doubled gracilis and semitendinosus tendon graft; group B (10 patients) underwent double-bundle reconstruction with doubled gracilis and semitendinosus tendon graft. Anteroposterior displacement and internal and external rotation at 30° of knee flexion were evaluated before and after reconstruction, using manual maximum force. Results Both techniques significantly reduced anteroposterior displacement and internal and external rotation of the tibia with respect to preoperative anterior cruciate ligament–deficient condition (P < .05). Comparing groups, no differences in anteroposterior tibial displacement and internal and external rotation of the tibia were found (anteroposterior, 3.7 mm and 5.2 mm; internal rotation, 16.3° and 16.6°; external rotation, 15.7° and 15.1°, respectively) in group A and B (P = .06, .90, and .72, respectively). Conclusion The hypothesis that addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia at 30° of knee flexion is not confirmed. Clinical Relevance The effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model.

Patellar Tendinosis: A Follow-up Study Of Surgical Treatment

Background: Patellar tendinopathy (jumpers knee) is an overuse syndrome that frequently affects athletes. A retrospective study was done to analyze the results at a minimum of five years after the performance of a surgical technique in competitive athletes.Methods: From 1985 to 1995, thirty-two patients (thirty-eight knees) affected by patellar tendinopathy were treated surgically after failure of nonoperative treatment. All knees were operated on by the same surgeon using the same surgical technique: longitudinal splitting of the tendon, excision of any abnormal tissue that was identified, and resection and drilling of the inferior pole of the patella. The results in twenty-seven patients (thirty-three knees), including twenty-two athletes (twenty-seven knees) who were still involved in sports activities (or wished to still be involved) at a competitive level at the time of final follow-up, were reviewed at a mean of eight years postoperatively. The results were evaluated according to symptoms and the ability to return to full sports activities.Results: The result was excellent in twenty-three knees (70%), good in five, fair in one, and poor in four at the time of the long-term follow-up. Eighty-two percent of the patients who tried to pursue sports at their preinjury level were able to do so, and 63% of those knees were totally symptom-free.Conclusions: The outcome of the described surgical treatment appears to be satisfactory; however, the results are less predictable in volleyball players.

Double-Bundle Anterior Cruciate Ligament Reconstruction: A Comprehensive Kinematic Study Using Navigation

Background Single-bundle anterior cruciate ligament reconstruction seems to be insufficient to control a combined rotatory load of internal and valgus torque, whereas anatomical double-bundle reconstruction might produce a better biomechanical outcome, especially during rotatory loads. Hypothesis The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce the internal rotation of the tibia at different degrees of flexion. Study Design Controlled laboratory study. Methods Ten consecutive anterior cruciate ligament reconstruction procedures were performed in male patients using double-bundle gracilis and semitendinosus tendon graft with the 2.0 OrthoPilot anterior cruciate ligament navigation system. Anteroposterior displacement at 30°, 60°, and 90° as well as internal and external rotation at 0°, 15°, 30°, 45°, 60°, and 90° of knee flexion were evaluated before reconstruction, after fixation of the anteromedial bundle, and then after fixation of the posterolateral bundle. Results Fixation of the anteromedial bundle significantly (P <. 05) reduced the anteroposterior displacement at 30°, 60°, and 90° of knee flexion; the internal rotation at 15°, 30°, 45°, and 60°; and the external rotation at 0°, 30°, 60°, and 90°. The addition of the posterolateral bundle to the anteromedial bundle did not significantly reduce internal and external rotation of the tibia at degrees of flexion measured (P >. 05). Conclusion The hypothesis that the addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia, minimizing the pivot-shift phenomenon, was not confirmed. Clinical Relevance The effective role of the anatomical double-bundle procedure in better restoring knee kinematics and allowing better clinical outcomes should be questioned in an in vivo model of anterior cruciate ligament reconstruction using doubled semitendinosus and gracilis graft.

Extra-articular ACL reconstruction and pivot shift: In vivo dynamic evaluation with navigation

Background: The pivot-shift test is considered a reliable examination to evaluate the results of anterior cruciate ligament (ACL) reconstruction, as it strongly correlates with patient satisfaction, giving-way episodes, and activity level. The addition of lateral tenodesis (LT) to current techniques of intra-articular reconstruction with a hamstring graft could potentially improve knee laxity in cases of severe rotational instability. Purpose: To biomechanically investigate the effect of intra- and extra-articular ACL reconstructions on knee laxity and the pivot-shift phenomenon. Study Design: Controlled laboratory study. Methods: Twenty patients underwent anatomic single-bundle ACL reconstruction with doubled semitendinosus and gracilis tendons with the addition of extra-articular reconstruction. In patients in group A, intra-articular reconstruction was performed first and LT thereafter; in patients in group B, LT was performed first and intra-articular reconstruction thereafter. A navigator equipped with software designed for both static and dynamic evaluations was used to measure maximum anterior tibial translation (ATT) and axial tibial rotation (ATR) at 30° of flexion (static evaluation) and during the pivot-shift test (dynamic evaluation). Measurements were performed before reconstruction, after the first procedure, and after the second procedure. Results: For the static evaluation, in group A, the mean ATT significantly decreased from 14.1 ± 3.7 mm in the preoperative (ACL-deficient) condition to 6.0 ± 1.9 mm after ACL reconstruction and to 5.3 ± 1.6 mm after LT. The mean ATR at 30° of knee flexion significantly decreased from 35.7° ± 4.8° to 28.9° ± 4.1° and to 20.9° ± 4.8°, respectively. In group B, the mean ATT significantly decreased from 13.5 ± 6.5 mm in the preoperative (ACL-deficient) condition to 10.2 ± 3.2 mm after LT and to 4.0 ± 1.6 mm after ACL reconstruction. The mean ATR at 30° of knee flexion significantly decreased from 36.7° ± 4.8° to 26.2° ± 6.2° and to 23.5° ± 4.9°, respectively. For the dynamic evaluation (pivot-shift test), in group A, the mean ATT significantly decreased from 15.0 ± 6.8 mm in the preoperative (ACL-deficient) condition to 9.4 ± 6.4 mm after ACL reconstruction and to 8.5 ± 5.4 mm after LT. The mean ATR significantly decreased from 16.9° ± 4.7° to 11.6° ± 4.1° and to 6.1° ± 2.2°, respectively. In group B, the mean ATT significantly decreased from 12.5 ± 3.3 mm in the preoperative (ACL-deficient) condition to 9.1 ± 5.9 mm after LT and to 8.1 ± 5.4 mm after ACL reconstruction. The mean ATR significantly decreased from 16.0° ± 4.5° to 9.2° ± 4.3° and to 7.5° ± 4.0°, respectively. Conclusion/Clinical Relevance: Extra-articular reconstruction had little effect in reducing the anterior displacement of the tibia at 30° of flexion, but it was more effective than intra-articular reconstruction in reducing ATR. Anatomic ACL reconstruction and LT were synergic in controlling the pivot-shift phenomenon.

Are MRI-based, patient matched cutting jigs as accurate as the tibial guides?

PurposeThe aim of this study is to evaluate the accuracy of VISIONAIRE (Smith & Nephew Inc., Memphis, TN, USA) Patient Matched cutting tibial jigs in comparison with extramedullary (EM) tibial instrumentation by analysing data as detected by intra-operative use of VectorVision knee navigation software from BrainLAB (Redwood City, CA, USA).MethodsTwelve patients were selected for unilateral total knee replacement (TKR). They underwent a full-length weight-bearing anteroposterior (AP) radiograph and magnetic resonance imaging (MRI). During surgery, once the EM guides were placed and fixed on the tibia, the orientation in the coronal and sagittal planes was checked by the navigator and then compared with the data obtained by measuring the orientation of VISIONAIRE Patient Matched cutting tibial jigs. An unsatisfactory result was considered an error ≥2° in both coronal and sagittal planes for the tibial component as a possible error of 4° could result.ResultsIn the coronal plane the mean deviation of the EM tibial guides from the ideal alignment (0°) was 0.7 ± 0.39° and of the VISIONAIRE was 129 ± 1.55° (P = 0.22). In the sagittal plane the mean deviation of the EM tibial guides from 3° of posterior slope was −1.62 ± 1.78° and of the VISIONAIRE was +1.16 ± 4.29° (P < 0.05). Negative values indicate a more posterior slope from the ideal and positive values an anterior slope.ConclusionsThis preliminary study documented only a fair accuracy of the method with a consistent risk of error of more of 3° especially in the sagittal plane. We could speculate that the problem in the sagittal plane was due to the fact that the pre-operative protocol does not include a lateral X-ray projection of the knee and only includes an AP standing X-ray of the straight leg and MRI.