Francisco 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.

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.

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.

Role of a Limited Transarticular Release in Severe Hallux Valgus Correction

Background: Hallux valgus (HV) treatment is continuously evolving, and no definitive treatment can be recommended. Osteotomies are the main surgical choice for these deformities, but no clear role for soft tissue procedures is available. Objective: To perform a retrospective comparison of the radiographic and clinical outcomes of 2 groups of patients with severe HV operated with the same osteotomy technique but differing on the type of lateral release. Methods: Two groups of patients with symptomatic moderate to severe HV deformities were operated with the same proximal metatarsal osteotomy, which differed on the type of lateral release: group 1 had limited transarticular lateral capsule release (n = 62), and group 2 complete lateral release, including capsule, adductor tendon, and intermetatarsal (IM) ligament (n = 57). We recorded the American Orthopaedic Foot & Ankle Society (AOFAS) score, HV and IM angles, first metatarsal shortening, concomitant metatarsal shortening osteotomies (Weil), Akin osteotomies, and complications. Results: The postoperative AOFAS score in group 1 was similar to that of group 2. The HV and IM angles improved in both groups with no significant difference. The multivariate analysis showed no influence of any variable analyzed on HV or IM angle improvement. Regarding AOFAS score improvement, a limited lateral release was associated with a higher increase in AOFAS score (P = .019). Conclusion: No studies are available to identify which soft tissue structures are involved in HV deformities nor which have to be released, if any. A limited transarticular release can provide similar clinical and radiologic outcomes when compared with a classic open lateral release. Level of Evidence: Level IV, case series.

Single time angular deformity correction and treatment of knee instability in congenital fibular hemimelia. A case report.

BACKGROUND Fibular hemimelia is the most frequently occurring congenital anomaly of long bones. These patients, among other deficiencies, have a poor development of the anterior cruciate ligament (ACL). Unless it causes clinically assessed instability of the knee, nonsurgical treatment is given. When surgical treatment is required, correction of angular limb deformity must be realized prior to ACL reconstruction. METHODS We present the case of a 16-year old patient with congenital fibular hemimelia. Physical examination showed genu valgum, anteromedial rotatory instability and recurvatum of the right knee. We decided to perform surgical correction of the angular deformities and ACL reconstruction in the same surgical time. RESULTS Twelve months after surgery, the patient had no evidence of clinical instability, with a range of motion from -5°-110° of the right knee. No claudication or gait instability was found. The KT-1000 arthrometer showed a difference of 2mm between both knees. CONCLUSION The ACL reconstruction and corrective osteotomies of angular deformities performed in a single surgical procedure had a good clinical result in a 12 month follow up-period, restoring stability of the knee and allowing a normal gait cycle.

Hamstring autograft size importance in anterior cruciate ligament repair surgery

Graft size in hamstring autograft anterior cruciate ligament (ACL) surgery is an important factor directly related to failure. Most of the evidence in the field suggests that the size of the graft in hamstring autograft ACL reconstruction matters when the surgeon is trying to avoid failures. The exact graft diameter needed to avoid failures is not absolutely clear and could depend on other factors, but newer studies suggest than even increases of 0.5 mm up to a graft size of 10 mm are beneficial for the patient. There is still no evidence to recommend the use of grafts > 10 mm. Several methods – e.g. folding the graft in more strands – that are simple and reproducible have been published lately to address the problem of having an insufficient graft size when performing an ACL reconstruction. Due to the evidence presented, we think it is necessary for the surgeon to have them in his or her arsenal before performing an ACL reconstruction. There are obviously other factors that should be considered, especially age. Therefore, a larger graft size should not be taken as the only goal in ACL reconstruction. Cite this article: EFORT Open Rev 2018;3:93-97. DOI: 10.1302/2058-5241.3.170038

Graft Preparation Technique to Optimize Hamstring Graft Diameter for Anterior Cruciate Ligament Reconstruction

Hamstring autografts are frequently used for anterior cruciate ligament reconstruction. The inherent variability in graft diameter has been stated as a disadvantage in its use because the presence of smaller graft diameters has been correlated with increased risk of re-rupture. Several techniques have been described to address this concern. Modifications of the basic Graftlink technique allows for increased control over final graft diameter using a standard harvest of the semitendinosus tendon with or without the gracilis tendon, and results in a graft of adequate length and diameter in all patients with rigid cortical fixation on the femur and tibia.

Clinical and arthrometric outcomes of an anatomic outside-in single-bundle anterior cruciate ligament reconstruction using a retrodrill

BACKGROUND The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill. METHODS Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test. RESULTS 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported. CONCLUSION OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique.

Symptomatic relief in medial opening wedge high tibial osteotomies for the treatment of knee osteoarthritis is influenced by concurrent procedures and preoperative pain level

Objectives Medial compartment osteoarthritis (OA) in the younger patient is technically challenging to treat. Medial opening wedge high tibial osteotomy (MOWHTO) is an option for surgical treatment; however, there remains a lack of evidence to establish the procedure as the preferred treatment option. The literature remains inconsistent with regard to patient characteristics and surgical factors that determine patient outcomes, particularly with respect to procedure survival and pain relief. The purpose of this study is to (i) describe the patient demographics and surgical outcomes of a consecutive series of MOWHTOs for treatment of medial knee OA; (ii) determine the procedure survivorship up to 10 years postsurgery and (iii) identify patient and surgery-related factors associated with pain relief following MOWHTO. Methods A cohort of 210 patients was identified that underwent MOWHTO between 2002 and 2013. Patient demographics and complications were extracted from the clinical research database. Procedure survival analysis was conducted using a Kaplan-Meier analysis. All patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire preoperatively and postoperatively with pain relief identified as the difference between pre- and postoperative KOOS-pain subscale. A partial least square regression model was fitted to identify predictors of pain relief. Results Males comprised 84% of the cohort, which had a median age of 51 years (95% CI 42 to 57 years). Patients were overweight on average, with a median BMI of 28.9 kg/m2 (95% CI 23 to 36 kg/m2) and 36% of patients underwent concomitant procedures. A complication rate of 3.8% was observed. Survivorship was 97.7% at 5 years and 80% at 10 years, with median time to conversion in those requiring total knee replacement of 7 years (95% CI 5 to 8). Patients undergoing cartilage treatment and bilateral procedures experienced increased pain relief compared with average, while there was reduced pain relief in patients with lower preoperative pain. Conclusion MOWHTO is an effective procedure for relief of pain associated with medial knee OA, even in older and heavier patients. Patients and clinicians can expect an average procedure survival of 12.5 years and a maximum of 21 years, with effective pain relief influence by cartilage treatment and preoperative pain score. Level of evidence IV. Case series.

New and evolving technologies for knee arthroplasty—computer navigation and robotics: state of the art

Computer-assisted navigation was introduced as an adjunct to total knee arthroplasty (TKA) with the potential of improving positioning and alignment of TKA implants. Computer-assisted surgery (CAS) can be divided into: passive (navigated TKA) or semiactive and active (robotic TKA). Passive CAS has shown improved results regarding alignment in TKA compared with conventional instrumentation but it has several possible complications such as registration errors, pin site complications, increased surgical time and a potentially longer learning curve. Robotic TKA has been developed to eliminate the possible error in the preparation of bone surfaces by the surgeon. There is still little evidence on these systems but the early results are encouraging. Despite better results in accuracy with both CAS systems, clinical benefits are still subject of debate. Additional research is required to fully define the costs and benefits of robotics in regular medical practice.