Giovanni Giordano

Anterior Cruciate Ligament Reconstruction Associated With Extra-articular Tenodesis A Prospective Clinical and Radiographic Evaluation With 10- to 13-Year Follow-up

Background This study was undertaken to prospectively analyze, at a mean 11-year follow-up, the clinical and radiographic outcomes in patients undergoing the authors’ intra-articular anterior cruciate ligament reconstructive procedure with extraarticular augmentation, and to compare these data with those at 5-year follow-up. Purpose The clinical and radiographic outcomes in patients undergoing anterior cruciate ligament reconstruction were analyzed at a mean 11-year follow-up. Study Design Case series; Level of evidence, 4. Methods The authors studied 54 of 60 consecutive high-level sports patients who underwent their anterior cruciate ligament reconstruction technique between 1993 and 1995. The surgical technique uses the hamstring tendons with intact tibial insertions for intra-articular double-stranded reconstruction plus an extra-articular plasty (augmentation) performed with the remnant part of the tendons. Clinical and radiographic evaluations were performed. Results After 11 years, the International Knee Documentation Committee score demonstrated good or excellent results (A and B) in 90.7% of patients. Ligament arthrometry using the KT-2000 arthrometer demonstrated that only 2 patients had >5 mm manual maximum side-to-side difference in laxity. The mean Tegner activity score was 4.5, while the mean Lysholm score was 97.3 and the mean subjective score was 90.0%. Radiographic evaluation demonstrated progressive joint narrowing only for the 20 patients having concomitant medial meniscal surgery. Conclusion The original technique demonstrates highly satisfactory results. Factors negatively affecting the outcomes are meniscectomy and laxity. In this series, anterior cruciate ligament reconstruction with lateral plasty shows maintenance of knee stability at long-term follow-up. Knee osteoarthritis after anterior cruciate ligament reconstruction with extra-articular tenodesis does not appear to be greater than after anterior cruciate ligament reconstructions without extra-articular augmentation as reported in historical controls.

Prospective Long-Term Outcomes of the Medial Collagen Meniscus Implant Versus Partial Medial Meniscectomy: A Minimum 10-Year Follow-Up Study

Background: Loss of meniscal tissue can be responsible for increased pain and decreased function. Hypothesis: At a minimum 10-year follow-up, patients receiving a medial collagen meniscus implant (MCMI) would show better clinical, radiological, and magnetic resonance imaging (MRI) outcomes than patients treated with partial medial meniscectomy (PMM). Study Design: Cohort study; Level of evidence 2. Methods: Thirty-three nonconsecutive patients (men; mean age, 40 years) with meniscal injuries were enrolled in the study to receive MCMI or to serve as a control patient treated with PMM. The choice of treatment was decided by the patient. All patients were clinically evaluated at time 0 and at 5 years and a minimum of 10 years after surgery (mean follow-up, 133 months) by Lysholm, visual analog scale (VAS) for pain, objective International Knee Documentation Committee (IKDC) knee form, and Tegner activity level scores. The SF-36 score was performed preoperatively and at final follow-up. Bilateral weightbearing radiographs were completed before the index surgery and at final follow-up. Minimum 10-year follow-up MRI images were compared with preoperative MRI images by means of the Yulish score. The Genovese score was also used to evalute MCMI MRI survivorship. Results: The MCMI group, compared with the PMM one, showed significantly lower VAS for pain (1.2 ± 0.9 vs 3.3 ± 1.8; P = .004) and higher objective IKDC (7A and 10B for MCMI, 4B and 12C for PMM; P = .0001), Teger index (75 ± 27.5 vs 50 ± 11.67; P = .026), and SF-36 (53.9 ± 4.0 vs 44.1 ± 9.2; P = .026 for Physical Health Index; 54.7 ± 3.8 vs 43.8 ± 6.5; P = .004 for Mental Health Index) scores. Radiographic evaluation showed significantly less medial joint space narrowing in the MCMI group than in the PMM group (0.48 ± 0.63 mm vs 2.13 ± 0.79 mm; P = .0003). No significant differences between groups were reported regarding Lysholm (P = .062) and Yulish (P = .122) scores. Genovese score remained constant between 5 and 10 years after surgery (P = .5). The MRI evaluation of the MCMI patients revealed 11 cases of myxoid degeneration signal: 4 had a normal signal with reduced size, and 2 had no recognizable implant. Conclusion: Pain, activity level, and radiological outcomes are significantly improved with use of the MCMI at a minimum 10-year follow-up compared with PMM alone. Randomized controlled trials on a larger population are necessary to confirm MCMI benefits at long term.

ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up

Several investigators have reported the presence of biomechanical, kinematic, anatomic, fiber orientation patterns and biological differences between the anteromedial bundle and the posterolateral bundle of ACL. The purpose of this prospective randomized study was to compare the clinical, instrumental and X‐ray outcome of two ACL reconstruction techniques with hamstring tendons: one with a single intra‐articular bundle associated to an extra‐articular sling, the second with a more anatomic double‐bundle technique that reproduces better the native ACL function. From an initial group of 100 patients who underwent ACL reconstruction, 72 patients (35 single bundle plus lateral plasty and 37 double bundle) were evaluated with IKDC, Tegner score, KT2000 arthrometer, Activity Rating Scale, Psychovitality Questionnaire and Ahlback radiographic score at a mean 3 years follow‐up. Double‐bundle group showed significantly better results regarding IKDC, ROM, Activity Rating Scale and time to return to sport. Also KT 2000 showed significant differences in objective stability. The double‐bundle technique for ACL reconstruction described in this paper has demonstrated significantly better subjective, objective and functional results compared with a double‐stranded hamstrings plus extra‐articular sling at a minimum 3‐year follow‐up.

An original clinical methodology for non-invasive assessment of pivot-shift test

Even if pivot-shift (PS) test has been clinically used to specifically detect anterior cruciate ligament (ACL) injury, the main problem in using this combined test has been yet associated with the difficulty of clearly quantifying its outcome. The goal of this study was to describe an original non-invasive methodology used to quantify PS test, highlighting its possible clinical reliability. The method was validated on 66 consecutive unilateral ACL-injured patients. A commercial triaxial accelerometer was non-invasively mounted on patients tibia, the corresponding 3D acceleration was acquired during PS test execution and a set of specific parameters were automatically identified on the signal to quantify the test. PS test was repeated three times on both injured and controlateral limbs. Reliability of the method was found to be good (mean intra-rater intraclass correlation coefficient was 0.79); moreover, we found that ACL-deficient knees presented statistically higher values for the identified parameters – than the controlateral healthy limbs, averagely reporting also large effect size.

Strains across the Acetabular Labrum during Hip Motion: A Cadaveric Model

Background Labral tears commonly cause disabling intra-articular hip pain and are commonly treated with hip arthroscopy. However, the function and role of the labrum are still unclear. Hypotheses (1) Flexion, adduction, and internal rotation (a position clinically defined as the position for physical examination known as the impingement test) places greatest circumferential strain on the anterolateral labrum and posterior labrum; (2) extension with external rotation (a position clinically utilized during physical examination to assess for posterior impingement and for anterior instability) places significant circumferential strains on the anterior labrum; (3) abduction with external rotation during neutral flexion-extension (the position the extremity rests in when a patient lies supine) places the greatest load on the lateral labrum. Study Design Descriptive laboratory study. Methods Twelve cadaveric hips (age, 79 years) without labral tears or arthritis were studied. Hips were dissected free of soft tissues, except the capsuloligamentous structures. Differential variable reluctance transducers were placed in the labrum anteriorly, anterolaterally, laterally, and posteriorly to record circumferential strains in all 4 regions as the hip was placed in 36 different positions. Results The posterior labrum had the greatest circumferential strains identified; the peak was in the flexed position, in adduction or neutral abduction-adduction. The greatest strains anteriorly were in flexion with adduction. The greatest strains anterolaterally were in full extension. External rotation had greater strains than neutral rotation and internal rotation. The greatest strains laterally were at 90° of flexion with abduction, and external or neutral rotation. In the impingement position, the anterolateral strain increased the most, while the posterior labrum showed decreased strain (greatest magnitude of strain change). When the hip is externally rotated and in neutral flexion-extension or fully extended, the posterior labrum has significantly increased strain, while the anterolateral labrum strain is decreased. Conclusion These are the first comprehensive strain data (of circumferential strain) analyzing the whole hip labrum. For the intact labrum, the greatest strain change was at the posterior acetabulum, whereas clinically, acetabular labral tears occur most frequently anterolaterally or anteriorly. The results are consistent with the impingement test as an assessment of anterolateral acetabular labral stress. The hyperextension-rotation test, often used clinically to assess anterior hip instability and posterior impingement, did not show a change in strain anteriorly, but did reveal an increase in strain posteriorly. Clinical Relevance Although this study does not include muscular forces across the hip joint, it does provide a clue as to the stresses about the labrum through the complete range of motions of the hip, which may help in providing a better understanding of the cause of labral tears and in the protection of labral repairs.

Evaluation of formal methods in hip joint center assessment: An in vitro analysis

BACKGROUND The hip joint center is a fundamental landmark in the identification of lower limb mechanical axis; errors in its location lead to substantial inaccuracies both in joint reconstruction and in gait analysis. Actually in Computer Aided Surgery functional non-invasive procedures have been tested in identifying this landmark, but an anatomical validation is scarcely discussed. METHODS A navigation system was used to acquire data on eight cadaveric hips. Pivoting functional maneuver and hip joint anatomy were analyzed. Two functional methods - both with and without using the pelvic tracker - were evaluated: specifically a sphere fit method and a transformation techniques. The positions of the estimated centers with respect to the anatomical center of the femoral head, the influence of this deviation on the kinematic assessment and on the identification of femoral mechanical axis were analyzed. FINDINGS We found that the implemented transformation technique was the most reliable estimation of hip joint center, introducing a - Mean (SD) - difference of 1.6 (2.7) mm from the anatomical center with the pelvic tracker, whereas sphere fit method without it demonstrated the lowest accuracy with 25.2 (18.9) mm of deviation. Otherwise both the methods reported similar accuracy (<3mm of deviation). INTERPRETATION The functional estimations resulted in the best case to be in an average of less than 2mm from the anatomical center, which corresponds to angular deviations of the femoral mechanical axis smaller than 1.7 (1.3) degrees and negligible errors in kinematic assessment of angular displacements.

Does chronic medial collateral ligament laxity influence the outcome of anterior cruciate ligament reconstruction? A prospective evaluation with a minimum three-year follow-up

We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (SD 0.9) versus 0.9 mm (SD 0.7), respectively, p = 0.013), while no statistically significant difference was found between the AP laxity and the other clinical parameters. Our results show that the residual valgus laxity does not affect AP laxity significantly at a minimum follow up of three years, suggesting that no additional surgical procedure is needed for the medial collateral ligament in combined lesions.

A new hinged dynamic distractor, for immediate mobilization after knee dislocations: Technical note

Knee dislocation is always a difficult topic mainly with regard to the structures that have been damaged and the best treatment option. The purpose of this study is to describe a new dynamic external fixator (EF) to be applied after knee dislocation, in combination with posterior cruciate ligament (PCL) reconstruction. This approach permits an immediate postoperative mobilization of the joint, with the possibility to perform a delayed ACL reconstruction and eventually reducing the complication rate related to multiple ligament surgery

Synthetic meniscal scaffolds

Arthroscopic partial meniscectomies showed better clinical results with respect to complete meniscus removal, but at long-term follow-up a substantial number of patients suffer the effect of a lost meniscus cartilage. It is extremely important to preserve the meniscus as much as possible to avoid degenerative knee joint progression. During the 1980s Stone, Steadman and Rodkey developed a new collagen I scaffold to replace meniscus in the case of irreparable major tears: the CMI (Collagen Meniscus Implant). After 13 years of good results in implanting ReGen, Medial CMI, in 2006 we started a postmarketing study to evaluate the efficacy and effectiveness of an equivalent meniscal scaffold specifically designed to repair the lateral meniscal defect (ReGen, Lateral CMI). In this study, we describe indications for the implantation of a CMI device, the evolution of the surgical technique (from in-out arthroscopic suturing technique to all-inside arthroscopic scaffold implantation) in these 13 years of experience, and a short report of our clinical results.

Pathophysiology of Lateral Patellar Dislocation

Patellofemoral disorders represent 20–40% of all knee problems and can be one of the most common complaints in sports related injuries. These disorders are a major cause of disability, particularly in females, and in extreme cases may contribute to termination of athlete’s career and could lead to degenerative arthritic changes of the knee joint. For these reasons, disorders and in particular patellar instability often pose a diagnostic and therapeutic dilemma for the orthopedic surgeon. This dilemma implies that usually no single pathophysiology or therapeutic approach can fully explain and solve patellofemoral instability. In fact the patellofemoral joint is biomechanically one of the most complex human articulations with different anatomical components like bone shape, capsuloligament structures, and muscle that could alone or in combination be responsible for patellar instability. These factors are often present in combination in one patient, but the severity of each pathology can be different resulting in variable patterns of instability and pain that determine that each patient is almost unique; thus the characterization in a classification is a simplification of a very complex issue. Moreover the multifactoriality and variability of pathogenesis has determined in the past numerous misunderstanding. These misconceptions have been responsible for the high variety of surgical procedures proposed to treat patellofemoral instability, leading to less than completely satisfactory clinical results also related to iatrogenic cause.