Ferran Abat

Suture-Only Fixation Technique Leads to a Higher Degree of Extrusion Than Bony Fixation in Meniscal Allograft Transplantation

Background: Most of the published series of transplanted menisci have consistently shown some degree of allograft extrusion. The speculation is that this meniscal extrusion may be caused by the soft tissue technique used to fix the allograft. Hypothesis: The percentage of extruded meniscal graft would be higher if the allograft were only fixed with sutures rather than with associated bony fixation. Study Design: Cohort study; Level of evidence, 2. Methods: We performed a prospective series of 88 meniscal allograft transplantations. Thirty-three of the grafts were fixed with the suture-only technique (group A). The remaining 55 cases were performed with the bone plug method (group B). All patients were studied with magnetic resonance imaging (MRI) at a minimum 3 years’ follow-up to determine the degree of meniscal extrusion. The time between surgery and MRI evaluation was 40 months (range, 36-48 months) in both groups. Meniscal extrusion was measured on coronal MRI. The percentage of the meniscal body width that was extruded was calculated. The average percentage of extrusion for each group was compared. The Lysholm score was analyzed in relation to the fixation method and degree of meniscal extrusion. Tears of the allograft that required surgical intervention were also reported. Results: The average percentage of meniscal tissue extruded in group A was 36.3% ± 13.7% without differences between the medial (35.9% ± 18.1%) and lateral (38.3% ± 14.4%) compartments (P = .84). Group B had a mean 28.13% ± 12.2% of the meniscal body extruded without differences between the medial (25.8% ± 16.2%) and lateral (30.14% ± 13.5%) compartments. A higher percentage of extruded meniscal tissue was found in group A than in group B (P < .001). No association between the degree of meniscal extrusion and the functional score was observed (P = .4). Graft tears were observed in 21.4% of the cases in group A and in 7.3% of the cases in group B (P = .09). Conclusion: A meniscal allograft fixed with the suture-only technique showed a significantly higher degree of extruded meniscal body than that fixed with the bony fixation method, with no influence on the functional outcome. There was also a considerably higher rate of graft tears observed in those menisci fixed only with sutures, although this difference was not statistically significant with the numbers available.

Effectiveness of a Footprint Guide to Establish an Anatomic Femoral Tunnel in Anterior Cruciate Ligament Reconstruction: Computed Tomography Evaluation in a Cadaveric Model

PURPOSE To compare drilling the femoral tunnel with an offset aimer and BullsEye guide (ConMed Linvatec, Largo, FL) to perform an anatomic single-bundle reconstruction of the anterior cruciate ligament (ACL) through the anteromedial portal. METHODS Seven matched pairs of cadaveric knees were studied. The intent was to drill the femoral tunnel anatomically in all cases. In group A the femoral tunnel was drilled arthroscopically with an offset aimer. In group B the femoral tunnel was drilled arthroscopically with the BullsEye guide. Two tunnels were drilled through the same entry point in each knee. One was done at 110° of knee flexion and the other at 130°. They were scanned by computed tomography and reconstructed 3-dimensionally. Volume-rendering software was used to document relations of the drilled tunnel to the bony anatomy and tunnel length. RESULTS In group B the femoral tunnel was placed at the center of the femoral insertion site. The center of the tunnel was 9.4 mm from the high cartilage margin and 8.6 mm from the low cartilage margin. In group A the tunnels were placed deeper (5.4 mm and 12.6 mm, respectively) (P = .018). There were no differences in tunnel length for either knee flexion degree. Three of the tunnels drilled at 110° in group A compromised the posterior tunnel wall and measured less than 25 mm in length. CONCLUSIONS Accurate placement in the center of the femoral footprint of the ACL is better accomplished with the BullsEye guide rather than 5-mm offset aimers. Five-millimeter offset aimers might cause posterior tunnel blowout and present the risk of obtaining short tunnels when performing oblique femoral tunnel placement through the anteromedial portal at 110° of knee flexion. CLINICAL RELEVANCE The BullsEye guide might be better than standard offset aimers in the performance of anatomic single-bundle ACL reconstruction.

An experimental study of muscular injury repair in a mouse model of notexin-induced lesion with EPI® technique

BackgroundThe mechanisms of muscle injury repair after EPI® technique, a treatment based on electrical stimulation, have not been described. This study determines whether EPI® therapy could improve muscle damage.MethodsTwenty-four rats were divided into a control group, Notexin group (7 and 14 days) and a Notexin + EPI group. To induce muscle injury, Notexin was injected in the quadriceps of the left extremity of rats. Pro-inflammatory interleukin 1-beta (IL-1beta) and tumoral necrosis factor-alpha (TNF-alpha) were determined by ELISA. The expression of receptor peroxisome gamma proliferator activator (PPAR-gamma), vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-1 (VEGF-R1) were determined by western-blot.ResultsThe plasma levels of TNF-alpha and IL-1beta in Notexin-injured rats showed a significant increase compared with the control group. EPI® produced a return of TNF-alpha and IL-1beta values to control levels. PPAR-gamma expression diminished injured quadriceps muscle in rats. EPI® increased PPAR-gamma, VEGF and VEGF-R1 expressions. EPI® decreased plasma levels of pro-inflammatory TNF-alpha and IL-1beta and increased anti-inflammatory PPAR-gamma and proangiogenic factors as well as VEGF and VEGF-R1 expressions.ConclusionThe EPI® technique may affect inflammatory mediators in damaged muscle tissue and influences the new vascularization of the injured area. These results suggest that EPI® might represent a useful new therapy for the treatment of muscle injuries. Although our study in rats may represent a valid approach to evaluate EPI® treatment, studies designed to determine how the EPI® treatment may affect recovery of injury in humans are needed.

Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee

PURPOSE To determine the best angle to drill the femoral tunnels of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with concomitant posterior cruciate ligament (PCL) reconstruction to avoid either short tunnels or tunnel collisions. METHODS Eight cadaveric knees were studied. Double-bundle PCL femoral tunnels were arthroscopically drilled. Drilling of the sMCL and POL tunnels was performed in 4 different combinations of 0° and 30° axial (anteriorly directed) and coronal (proximally directed) angulations. Specimens were scanned with computed tomography to document the relations of the sMCL and POL tunnels to the intercondylar notch and PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS When the sMCL femoral tunnel was drilled at 0° axial and 30° coronal (proximally directed) angulations or 30° axial (anteriorly directed) and 0° coronal angulations, the risk of tunnel collision with the PCL tunnels increased in comparison with the remaining evaluated angulations (P < .001). No POL tunnels collided with either PCL tunnel bundle with the exception of tunnels drilled at 0° axial and 30° coronal (proximally directed) angulations, which did so in 3 of 8 cases (P < .001). The minimum required tunnel length was obtained in all the sMCL and POL tunnels (P < .001 and P = .02, respectively). However, some of those angled at 0° on the axial plane violated the intercondylar notch. CONCLUSIONS When one is performing posteromedial reconstructions with concomitant PCL procedures, the sMCL and POL femoral tunnels should be drilled anteriorly and proximally at both 30° axial and 30° coronal angulations. The POL femoral tunnel may also be angled 0° in the coronal plane. Tunnels at 0° axial angulations showed a shorter distance to the intercondylar notch and a higher risk of collision with the PCL tunnels. CLINICAL RELEVANCE Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when sMCL and POL femoral tunnels are placed with concomitant PCL reconstruction.

Reliability of preoperative measurement with standardized templating in Total Knee Arthroplasty

AIM To investigate the correlation between preoperative measurement in total knee arthroplasty and the prosthetic size implanted. METHODS A prospective double-blind study of 50 arthroplasties was performed. Firstly, the reliability and correspondence between the size of said measurement and the actual implant utilized was determined. Secondly, the existing correlation between the intra- and interobserver determinations with the intraclass correlation coefficient was analyzed. RESULTS An overall correspondence of 54%, improving up to 92% when the measured size admitted a difference of one size, was found. Good intra- and interobserver reliability with an intraclass correlation coefficient greater than 0.90 (P < 0.001) was also discovered. CONCLUSION Agreement between the preoperative measurement with standardized acetate templates and the prosthetic size implanted can be considered satisfactory. We thus conclude it is a reproducible technique.

All-Suture Repair for Compressive Rotator Cuff Tears: Reducing the Traction of the Tissue

Tears of the rotator cuff are a frequent pathology, but the best surgical procedure remains unclear. The arthroscopic approach has become the gold standard, but there are many different suture configurations that can be used. We describe an all-suture repair system with which the anatomical reduction of the rotator cuff is achieved performing traction from the anchor of the lateral row to subsequently performing a suture bridge suture from the medial row. The major advantage of this technique is that it creates compression forces and minimizing tensioning of the tissue.

The MRI appearance of a polyurethane meniscal substitute worsens if it matches articular cartilage lesions of the knee

Objectives: To evaluate the influence of chondral lesions of the knee in function and appearance on magnetic resonance imaging (MRI) of the meniscal implant Polyurethane (Actifit®). Material and Methods: 48 patients were implanted with Actifit® by postmeniscectomía syndrome. The chondral status of their respective compartment was graded at arthroscopy with ICRS scale. Were evaluated functionally Womet, IKDC, Kujala, EVA and satisfaction (0-4). The implant characteristics were evaluated with MRI scale Genovese, assessing its correlation with the degree of chondral damage and functional outcome Results: Mean follow-up of 38 months (25-75). 16 patients had no chondral lesion, 14 had lesion grade II, 10 grade III and IV grade 9. Womet, Kujala improved IKDC and 36.2 ± 7.6, 32.3 ± 13.5 and 39.2 ± 8.1 to 75.8 ± 12.9 (p = 0.02), 75.5 ± 15.4 (p = 0.03) and 85.6 ± 13.4 (0.042), respectively. No relationship between the degree of chondral damage and functional outcome was observed. The shape and size of the implant in RM was worse with higher levels of chondral lesion (p = 0.023). A post-hoc analysis showed that this was only due to the difference between patients without chondral injury versus those with ICRS II-IV. The satisfaction was 3.6 ± 0.8 points. Conclusion: Implementing a Actifit® led to significant pain and functional improvement after a minimum follow-up of 2 years. The size and morphological MRI appearance of meniscal replacement polyurethane was better in patients without chondral lesions. No relationship between the degree of chondral damage and functional outcome was observed.

Right angle to make posteromedial corner tunnels with concomitant posterior cruciate ligament reconstruction. CT evaluation in a cadaveric model

Introduction: The surface medial collateral ligament (LCMs) and the posterior oblique ligament (POL) are sometimes concomitantly reconstructed with the posterior cruciate ligament (PCL). The objective was to determine the most appropriate angle of the femoral tunnel. Material and Methods: 8 cadaveric knees. Bifascicular LCP tunneling performed arthroscopically. Tunnels LCMs and LOP at 0 ° and 30 ° in axial / coronal planes (0A / 30A // 0C / 0C). Were studied by CT and valued intercondylar relationship, PCL ,and tunnels. A 25mm tunnel was the least considered sufficient Results: The LCMs tunnels 30A / 30C and 30A / 0C measured 31.8 ± 3.2 and 32.2 ± 2.8 mm, respectively, without encroaching on the LCP and 17.4 ± 4 and 17.67 ± 3.8mm intercondylar ceiling. The LCMs 0A / 0C and 0A / 30C tunnels were 5.8 ± 5.2 and 7.2 ± 4.7 of intercondilo respectively, without invasion of the PCL. The LCMs tunnels 0A / 30C in 4 cases ended intraarticulararmente. The LOP 30A / 0C and 30A / 30C measured 33 ± 2.7 and 32.3 ± 3mm, without invasion of the PCL and 16.2 ± 5.7 and 19.3 ± 4.6mm of intercondilo. The LOP 0A / 0C and 0A / 30C tunnels were 6.50 ± 3.9 and 2.9 ± 5.3mm of intercondilo. The LOP tunneled 0A / 30C invaded in 3 cases the PCL tunnels and ended intraarticularly on 7 occasions. Conclusions: The angulation of the femoral tunnels LCMs and POL have versatility although the LCP is rebuild concomitantly. LCMs tunnels and POL axially oriented at 0° and 30° in coronal planes have high risk of puncturing the joint and in the case of POL also invade LCP tunnels.

Worth replacing a loss of medial meniscal tissue with a polyurethane substitute (Actifit®) when performing a valgus tibial osteotomy addition

Introduction: The addition tibial valgus osteotomy (ovat) is a common treatment of symptomatic genu varus. This frequently is accompanied by considerable loss of medial meniscal tissue. The aim was to evaluate, in the context of performing a ovat, restoring the functional impact of this lack of medial meniscal tissue with Actifit® compared with the simple meniscectomy. Material and Methods: Sixty patients with symptomatic genu varo operated with ovat were studied prospectively. In 30 patients we have left a medial meniscal defect> 25 mm (M) and in 30 a medial Actifit® was implanted(A). The evaluations were performed using Womet, IKDC, Kujala, EVA and satisfaction (0-4). Results: Both groups were statistically comparable preoperatively, including follow-up time (31.2 months; range, 24-47.5; p = 0.35). 53.4 ± 8.4 Womet improved and 42.4 ± 17.2 points in M and A (p = 0.002), improved IKDC 56.7 ± 12 and 50.3 ± 15.6 points in M and A (p = 0.107), 50.4 ± 14.7 Kujala improved to 38.9 ± 21.6 points M and A (p = 0.02) and VAS decreased 6.9 ± 2.1 and 4.7 ± 2.8 points in M and A (p = 0.006). The satisfaction was 3.3 ± 0.8 and 3.3 ± 1 in M and A (p = 0.84). Conclusions: The symptomatic genu varus treated with OVAT associated to medial meniscectomy led, compared to when it was associated with the implantation of a medial Actifit®, to a marked improvement in most of the scales tested. There was no difference in the degree of satisfaction. Based on short-term results of this study, restitution replacement with polyurethane substitute can not be recommended to perform a ovat.

1 Clinical Results After EPI® and Eccentric Exercise in Patellar Tendinopathy at 10 Years Follow-Up

Aims To investigate the outcome of ultrasound-guided Intratissue percutaneous electrolysis (EPI®) [Abat, 2014] and eccentric exercise [Romero-Rodriguez, 2011; Malliaras, 2013; Larsson, 2012] in the treatment of patellar tendinopathy during a long-term follow-up. Methods Forty patients with patellar tendinopathy [Maffulli, 1998] were prospectively evaluated over a 10-year follow-up period. Pain and function were evaluated before treatment and at 3 months and 2, 5 and 10 years with the Victorian Institute of Sport Assessment–Patella (VISA-P) score [Visentini, 1998], the Tegner score and Blazina’s classification. According to VISA-P score at baseline, patients were also dichotomized into Group 1 (<50 points) and Group 2 (≥50 points). There were 21 patients in Group 1 and 19 in Group 2. Patient satisfaction was measured according to the Roles and Maudsley score. Results The VISA-P score improved globally by 41.2 points (p < 0.01) after a mean 4.1 procedures. In Group 1, VISA-P score improved from 33.1 ± 13 to 78.9 ± 14.4 at 3 months and to 88.8 ± 10.1 at 10 years follow-up (p < 0.001). In Group 2, VISA-P score improved from 69.3 ± 10.5 to 84.9 ± 9 at 3 months and to 96.0 ± 4.3 at 10 years follow-up (p < 0.001). After 10 years, 91.2% of the patients had a VISA-P score > 80 points. The same level (80% of patients) or a Tegner score at no more than one level lower (20% of patients) was restored and 97.5% of the patients were satisfied with the procedure. Conclusion Treatment with the US-guided EPI® technique and eccentric exercises in patellar tendinopathy resulted in a great improvement in knee function and a rapid return to the previous level of activity after few sessions. The procedure has proven to be safe with no recurrences on a long-term basis. Abstract 1 Table 1 Patients’ characteristics at baseline Abstract 1 Table 2 Victorian Institute of Sport Assessment-Patella (VISA-P) values during follow-up References Abat F, et al. Rev Esp Cir Ortop Traumatol. 2014;58(4):201–5 Abat F, et al. Ligaments Tendons J. 2014;4(2):188–93 Larsson ME, et al. Knee Surg Sports Traumatol Arthrosc. 2012;20:1632–1646 Maffulli N, et al. Arthroscopy. 1998;14:840–843 Malliaras P, et al. Sports Med. 2013;43:267–86 Romero-Rodriguez D, et al. Phys Ther Sport. 2011;12:43–48 Visentini PJ, et al. J Sci Med Sport. 1998;1:22–28