Julian A. Feller

Synthetic Devices for Reconstructive Surgery of the Cruciate Ligaments: A Systematic Review

PURPOSE The role of synthetic devices in the management of the cruciate ligament-injured knee remains controversial. The aim of this systematic review was to assess the safety and efficacy of synthetic devices in cruciate ligament surgery. METHODS A systematic review of the electronic databases Medline, Embase, and The Cochrane Library (issue 1, 2014) on January 13, 2014, was performed to identify controlled and uncontrolled trials. Trials that assessed the safety and efficacy of synthetic devices for cruciate ligament surgery were included. The main variables assessed included rates of failure, revision, and noninfective effusion and synovitis. Patient-reported outcome assessments and complications were also assessed where reported. RESULTS From 511 records screened, we included 85 articles published between 1985 and 2013 reporting on 6 synthetic devices (ligament augmentation and reconstruction system [Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France)]; Leeds-Keio [Xiros (formerly Neoligaments), Leeds, England]; Kennedy ligament augmentation device [3M, St Paul, MN]; Dacron [Stryker, Kalamazoo, MI]; Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ]; and Trevira [Telos (limited liability company), Marburg, Germany]). The heterogeneity of the included studies precluded meta-analysis. The results were analyzed by device and then type of reconstruction (anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]/combined ACL and PCL). The lowest cumulative rates of failure were seen with the LARS device (2.6% for ACL and 1% for PCL surgery). The highest failure rate was seen in the Dacron ACL group (cumulative rate, 33.6%). Rates of noninfective synovitis and effusion ranged from 0.2% in the LARS ACL group to 27.6% in the Gore-Tex ACL group. Revision rates ranged from 2.6% (LARS) to 11.8% (Trevira-Hochfest; Telos). Recent designs, specifically the LARS, showed good improvement in the outcome scores. The mean preoperative and postoperative Lysholm knee scores were 54 and 88, respectively; the mean preoperative and postoperative Tegner activity scale scores were 3.3 and 6, respectively. CONCLUSIONS Preliminary results for newer-generation devices, specifically the LARS, show lower reported rates of failure, revision, and sterile effusion/synovitis when compared with older devices. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.

Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery

BACKGROUND Computer-assisted navigation in total knee arthroplasty (TKA) reduces variability and may improve accuracy in the postoperative static alignment. The effect of navigation on alignment and biomechanics during more dynamic movements has not been investigated. METHODS This study compared knee biomechanics during level walking of 121 participants: 39 with conventional TKA, 42 with computer-assisted navigation TKA and 40 unimpaired control participants. RESULTS Standing lower-limb alignment was significantly closer to ideal in participants with navigation TKA. During gait, when differences in walking speed were accounted for, participants with conventional TKA had less knee flexion during stance and swing than controls (P<0.01), but there were no differences between participants with navigation TKA and controls for the same variables. Both groups of participants with TKA had lower knee adduction moments than controls (P<0.01). CONCLUSIONS In summary, there were fewer differences in the biomechanics of computer-assisted navigation TKA patients compared to controls than for patients with conventional TKA. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA.

Standing balance and inter-limb balance asymmetry at one year post primary anterior cruciate ligament reconstruction: Sex differences in a cohort study of 414 patients

BACKGROUND Static standing balance can be safely assessed early following anterior cruciate ligament reconstruction (ACLR), and deficits may have important implications for long-term outcomes. This study includes a large cohort of people post-ACLR and has the primary aim of establishing whether inter-limb and sex differences exist, with a secondary aim of assessing the association between static balance variables and other outcome measures. METHODS A total of 414 patients with a primary ACLR performed a 30-s static single leg balance test. Centre of pressure (COP) path length, antero-posterior (AP) and medio-lateral (ML) sway range and slow and fast speed COP path-length were examined. Additional measures included single and triple hop distance and symmetry, knee flexion range of motion, ligament laxity and the International Knee Documentation Committee (IKDC) subjective knee evaluation form. RESULTS No significant inter-limb balance differences were present in females. Significant, yet small to negligible effect size (ES) differences were present in males for ML range (ES=0.19), and AP and ML axis slow speed path length (ES=0.11 and 0.23 respectively). Significant, negligible to moderate effect size (ES range=<0.01 to 0.60) sex differences were observed, with females showing reduced sway compared to males. No balance variables had associations with any other variable that were greater than weak. DISCUSSION Our findings provide evidence that primary ACLR does not appear to negatively impact single leg standing balance on the operated limb more than the non-operated side. The lack of association with other outcome measures warrants further longitudinal examination into the utility of static standing balance assessment.

Quality assessment of radiological measurements of trochlear dysplasia; a literature review

PurposeTo make a systematic review with quality assessments of the known measurements used to describe trochlear dysplasia.MethodsA systematic literature search was conducted in the databases PubMed and Embase using the search string “trochlea dysplasia OR trochlear dysplasia”. Papers were screened for their relevance based on predefined parameters, and all measurements showing a statistical association between trochlear dysplasia and patellar instability were presented. Four experts evaluated the quality of the measures using a purpose-made quality scale.ResultsThe search generated 600 papers of which eight were chosen for review. Thirty-three unique measurements were identified and described in order of their date of publication. The lateral trochlea inclination was rated highest by the expert panel. The crossing sign, the trochlea bump, the TT–TG distance, the trochlea depth and the ventral trochlea prominence also had high ratings.ConclusionThirty-three unique measurements were identified with the lateral trochlea inclination as the highest rated measurement by the expert panel, and it is recommended for use in assessment of trochlear dysplasia. The crossing sign, the trochlea bump, the TT–TG, the trochlea depth and the ventral trochlea prominence were also rated well and can be recommended for use.Level of evidenceV.

Factors Related to Return to Sport After ACL Reconstruction: When Is It Safe?

Current clinical practice permits patients to return to sport at between 6 and 12 months postoperatively. There is high-quality evidence to indicate that most patients (93 %) do attempt some form of sport after surgery. However, it appears that, at best, only approximately 60 % return to their pre-injury level of sports participation. There are many factors that may influence when it is safe to return to sport, and many criteria have been used to guide the patient and treating health professional. However, the validity of such criteria remains to be established. Similarly, there may be aspects of graft healing that influence safety in return to sport, but these are yet to be fully explored in vivo. The health of other structures in the knee must also be considered when making return-to-play decisions. The clinician should ask the following: Is it safe for the ACL graft, and is it safe for the health of the whole knee for the patient to return to sport at this time?

Anterior Cruciate Ligament Reconstruction Outcomes as a Function of Age

The age of a patient undergoing ACL reconstruction has an influence on some of the outcomes.

Psychological Factors Influencing Return to Sport After Anterior Cruciate Ligament Reconstruction

Despite having good knee function, many athletes do not return to their previous level of preinjury sport following anterior cruciate ligament (ACL) reconstruction. This suggests that there are other factors which influence return to sport after this surgery. Recent reviews and meta-analyses have demonstrated that a range of contextual factors affect the return-to-sport rate after ACL reconstruction including age, sex, sport participation level and psychological factors. In terms of psychological factors, there is convincing evidence that a lower fear of reinjury and greater psychological readiness are associated with higher return-to-sport rates. A number of measurement tools are now available which aim to measure such constructs, one of which is specific to ACL injury, the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale. This scale has shown clear associations between psychological readiness and return to sport, even when used before athletes undergo surgery. Clinical cut-off scores have been proposed, which may guide both the athlete and clinician in the return-to-sport process. This chapter provides a summary of the evidence of the psychological aspects related to injury recovery and returning to sport following ACL reconstruction injury and surgery.

Graft Rupture and Failure After ACL Reconstruction

ACL graft failure includes graft rupture, graft insufficiency that may or may not be symptomatic and failure of the ACL reconstruction to provide the desired level of function. Graft failure is often multifactorial in aetiology.