Karl F. Schüttler

The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts.

The anterolateral ligament of the knee (ALL) has caused a lot of rumors in orthopaedics these days. The structure that was first described by Segond back in 1879 has experienced a long history of anatomic descriptions and speculations until its rediscovery by Claes in 2013. Its biomechanical properties and function have been examined recently, but are not yet fully understood. While the structure seems to act as a limiter of internal rotation and lateral meniscal extrusion its possible proprioceptive effect remains questionable. Its contribution to the pivot shift phenomenon has been uncovered in parts, therefore it has been recognized that a concomitant anterolateral stabilization together with ACL reconstruction may aid in prevention of postoperative instability after severe ligamentous knee damages. However, there are a lot of different methods to perform this procedure and the clinical outcome has yet to be examined. This concise review will give an overview on the present literature to outline the long history of the ALL under its different names, its anatomic variances and topography as well as on histologic examinations, imaging modalities, arthroscopic aspects and methods for a possible anterolateral stabilization of the knee joint.

Improvement in outcomes after implantation of a novel polyurethane meniscal scaffold for the treatment of medial meniscus deficiency.

Pain 47 ± 14.5 75 ± 17.7 p < 0.0001 82 ± 17.4 p < 0.0001 83 ± 18.6 p < 0.0001 Symptom 60 ± 16.2 67 ± 18.5 p = 0.0091 85 ± 9.7 p < 0.0001 81 ± 13.4 p = 0.0003 ADL 53 ± 16.0 85 ± 14.5 p < 0.0001 88 ± 13.0 p < 0.0001 91 ± 14.7 p < 0.0001 Sport/Rec 26 ± 20.5 60 ± 25.3 p = 0.0001 68 ± 24.0 p < 0.0001 66 ± 28.5 p < 0.0001 QOL 28 ± 16.6 55 ± 26.9 p = 0.0007 67 ± 20.4 p < 0.0001 63 ± 18.9 p < 0.0001 KSS Function score 61 ± 22.2 87 ± 10.2 p = 0.0001 89 ± 15.7 p = 0.0001 96 ± 7.9 p < 0.0001 Knee score 65 ± 9.4 89 ± 13.1 p < 0.0001 87 ± 14.1 p < 0.0001 88 ± 12.4 p < 0.0001 UCLA 5.4 ± 1.8 6.1 ± 1.8 n.s. 6.5 ± 2.1 n.s. 7.3 ± 1.8 p = 0.0035 VAS 5.1 ± 2.0 2.1 ± 2.4 p = 0.0004 1.8 ± 2.3 p < 0.0001 1.5 ± 2.1 p < 0.0001

Non-Anatomic Proximal Realignment for Recurrent Patellar Dislocation Does Not Sufficiently Prevent Redislocation

Several operative techniques have been described for recurrent patellar dislocation. Clinical results vary depending on the procedure and indication. The present study aimed to evaluate the clinical outcome of Insall’s proximal realignment for recurrent patellar dislocation at mid-term follow-up. Forty-five patients were reviewed with a mean follow-up period of 49 months after having undergone Insall’s procedure. Outcome measures included reports of redislocations, complications, patient-reported outcome scores (Kujala, Tegner activity scale) and subjective assessment. No statistically significant improvements (p < 0.05) in patient-reported outcome measures were noted. Sixteen patients (35%) had poor to fair results using the Kujala score. Subjective assessment revealed that 12 patients (27%) were dissatisfied with the outcome of their surgery and would not undergo the same procedure. Ten patients (22%) had suffered from redislocation at the latest follow-up. In 4 cases (9%), intra-articular knee hematoma occurred which required arthroscopic intervention. The overall mid-term outcome of the present study shows low patient satisfaction. Non-anatomic realignment for recurrent patellar dislocation does not adequately prevent redislocation.

Complications and failure of MPFL reconstruction with free tendon grafts in cases of patellofemoral instability.

BACKGROUND Reconstruction of the medial patellofemoral ligament (MPFL) using free tendon grafts has become a widespread treatment option for patellofemoral instability. As the numbers of cases gradually grow, so do the reports of possible peri- and postoperative complications following this procedure. OBJECTIVE The present review summarizes all known complications of MPFL reconstruction with regard to postoperative outcome and seeks to highlight possible pitfalls that may occur during treatment. CONCLUSIONS MPFL reconstruction generally has to be regarded as a safe procedure today due to low patellar re-dislocation rates. Complication rates however are not trivial owing to the complexity of the underlying pathology. Complications can arise from graft fixation or femoral tunnel placement. Postoperative flexion deficits and medial knee pain have been described as predominant complaints. Anatomical preconditions as the grade of trochlear dysplasia, axis or torsion of the lower extremity have to be considered in search of causes for possible graft failure as well as in the thorough preoperative planning of the procedure.

Implementation and effects of pulse-contour- automated SVV/CI guided goal directed fluid therapy algorithm for the routine management of pancreatic surgery patients

BACKGROUND Goal directed fluid management in major abdominal surgery has shown to reduce perioperative complications. The approach aims to optimize the intravascular fluid volume by use of minimally invasive devices which calculate flow-directed variables such as stroke volume (SV) and stroke volume variation (SVV). OBJECTIVE We aimed to show the feasibility of routinely implementing this type of hemodynamic monitoring during pancreatic surgery, and to evaluate its effects in terms of perioperative fluid management and postoperative outcomes. METHODS All patients undergoing pancreatic surgery at a university hospital during two successive 12 months periods were included in this retrospective cohort analysis. Twelve months after the implementation of a standard operating procedure for a goal directed therapy (GDT, N = 45) using a pulse contour automated hemodynamic device were compared with a similar period before its use (control, N = 31) regarding mortality, length of hospital and ICU stay, postoperative complications and the use of fluids and vasopressors. RESULTS Overall, 76 patients were analysed. Significantly less crystalloids were used in the GDT group. Patients receiving GDT showed significantly fewer severe complications (insufficiency of intestinal anastomosis: 0 vs. 5 (P = 0.0053) and renal failure: 0 vs. 4 (P = 0.0133). Mortality for pancreatic surgery was 1 vs. 3 patients, (P = 0.142), and length of stay (LOS) in the intensive care unit (ICU) was 4.38 ± 3.63 vs. 6.87 ± 10.02 (P= 0.0964) days. Use of blood products was significantly less within the GDT group. CONCLUSIONS Implementation of a SOP for a GDT in the daily routine using flow-related parameters is feasible and is associated with better outcomes in pancreatic surgery.

Anatomic dissection of the anterolateral ligament (ALL) in paired fresh-frozen cadaveric knee joints

IntroductionDifferent dissection studies as well as comparative studies about the anterolateral ligament of the knee (ALL) already exist and the structure’s topology and properties have been shown. However, most of the studies investigating the ligament were performed in embalmed knees, which is thought to change the structural integrity of ligaments and thus the topologic and dynamic measurements. Since the biomechanical function of the ALL is not fully understood until today and a correlation with the pivot shift phenomenon is yet speculative, further studies will have to clarify its definitive importance. Its function as a limiter of internal rotation and lateral meniscal extrusion leads to the assumption of a secondary knee stabilizer.MethodsTwenty paired fresh-frozen cadaveric knees of ten donors have been dissected in a layerwise fashion. After identification of the ALL, topologic measurements were undertaken using a digital caliper.ResultsThe ALL could be identified as a tender, pearly structure in front of the anterolateral joint capsule in only 60% of the dissected knee joints. Only 20% of donors had a bilateral ALL while 80% had an ALL only in one side. Mean length, thickness and width as well as topographic measurements were comparable to other available studies investigating fresh-frozen cadavers.ConclusionAnatomy and topography of the ALL seem to be highly variable, but consistent within certain borders. Prevalence has to be argued though as it strongly differs between studies. The impact of an ALL absence, even if only unilateral, needs to be investigated in clinical and imaging studies to finally clarify its importance.

Tissue regeneration in orthopedic surgery - do we need cells?

BACKGROUND Tissue engineering has provided the orthopedic surgeon with a vast portfolio of methods for replacement or regeneration of articular cartilage or meniscal tissue. On the one hand cell based techniques such as autologous chondrocyte transplantation (ACT) are a main focus of interest. On the other hand cell free techniques are rapidly evolving and gaining more interest. The European Union regulation of November 2007, demanding proof of efficacy in cases of autologous cell transplantation, additionally increased the interest in cell-free techniques. OBJECTIVE The aim of this review was to discuss the advantages and disadvantages of cell-based and cell-free procedures and to summarize the clinical evidence for cell-free, tissue engineering procedures in orthopedic surgery for meniscal and cartilage defects. METHODS A systematic review was performed searching for clinical human studies evaluating cell-free repair procedures for cartilage and meniscus defects. All human study reports with English or German language abstracts were included. RESULTS The search revealed 82 studies of which only 12 met the inclusion criteria. Overall good clinical results for the use of cell-free meniscal and cartilage scaffolds were reported. CONCLUSION With improved understanding of the healing process in cartilage- and meniscal-defects, acellular, off the shelf products might gain more importance.

Oxidized Zirconium Bearing Surfaces in Total Knee Arthroplasty: Lessons Learned

Polyethylene wear in total knee arthroplasty is a still unsolved problem resulting in osteolysis and long-term failure of knee joint replacement. To address the problem of polyethylene wear, research aimed for an optimal implant design and for an optimal combination of bearing surfaces. Oxidized zirconium was introduced to minimize surface wear and thus potentially increase long-term implant survival. This review comprises the current literature related to in vitro and in vivo studies evaluating performance of oxidized zirconium total knee arthroplasty and results from retrieval analyses.

Polyurethane scaffold for the treatment of medial meniscus deficiency: clinical and mri outcomes at 48 months follw-up

Aims and Objectives: The preservation of meniscal structure and function after segmental meniscal loss is of crucial importance to prevent early development of osteoarthritis. Implantation of artificial meniscal implants has been reported as a feasible treatment option. The purpose of this study was to assess the clinical and magnetic resonance imaging (MRI) results 4 years after implantation of a polyurethane scaffold for chronic segmental medial meniscus deficiency following partial medial meniscectomy. Materials and Methods: Twenty patients received arthroscopic implantation of an Actifit® polyurethane meniscal implant (Orteq S Medicine, London, UK) for deficiency of the medial meniscus. Patients were followed at 6, 12, 24 and 48 months. Clinical outcome was assessed using established patient-reported outcome scores (KOOS, KSS, UCLA activity scale, VAS for pain). Radiological outcome was quantified by MRI scans after 6, 12, 24 and 48 months evaluating scaffold morphology, tissue integration and status of the articular cartilage as well as signs of inflammation. Results: Mean patient age was 29.3 years (range 18 to 47 years) with a mean meniscal defect size of 46 mm (range 35 to 62 mm). Continuing improvement of the VAS and KSS Knee and Function Scores could be observed after 48 months compared to baseline, whereas improvement of the activity level according to UCLA continued only up to 24 months and decreased from there on. The KOOS Score showed significant improvement in all dimensions. MRI scans showed reappearance of bone bruises in 2 patients with scaffold extrusion. No significant changes of the articular cartilage could be perceived. Conclusion: Arthroscopic treatment of patients with chronic segmental meniscal loss using the a polyurethane meniscal implant can achieve sustainable mid-term results regarding pain reduction and knee function.

Back to Sports After Arthroscopic Revision Bankart Repair

Background: Recurrent instability following primary arthroscopic stabilization of the shoulder is a common complication. Young, athletic patients are at the greatest risk of recurring instability. To date, the literature contains insufficient description regarding whether return to sports is possible after revision arthroscopic Bankart repair. Hypothesis: Patients presenting with recurrent instability after primary arthroscopic stabilization should expect limitations in terms of their ability to partake in sporting activities after revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Twenty athletes who underwent arthroscopic revision stabilization of the shoulder after failed primary arthroscopic Bankart repair were included in the study after completing inclusion and exclusion criteria surveys. Athletic Shoulder Outcome Scoring System (ASOSS), Shoulder Sport Activity Score (SSAS), and the Subjective Patient Outcome for Return to Sports (SPORTS) scores were determined to assess the participants’ ability to partake in sporting activities. Furthermore, sport type and sport level were classified and recorded. To assess function and stability, Rowe, American Shoulder and Elbow Surgeons, Constant-Murley, and Walch-Duplay scores were measured and recorded. Results: Follow-up consultations were carried out after a mean of 28.7 months. The mean age at follow-up examination was 27.75 years. At the time of follow-up, 70% of the patients were able to return to their original sporting activities at the same level. However, 90% of patients described a limitation in their shoulder when participating in their sports. At 28.7 months after surgery, the mean ASOSS score was 76.8; the SSAS score decreased from 7.85 before first-time dislocation to 5.35 at follow-up (P < .005). The SPORTS score was 5.2 out of 10 at the follow-up consultation. Function- and instability-specific scores showed good to excellent results. The mean external rotational deficit for high external rotation was 9.25°, and for low external rotation it was 12°. Conclusion: Patients can return to their original type and level of sport after arthroscopic revision Bankart repair, but they must expect persistent deficits and limitations to the shoulder when put under the strains of sporting activity. Patients with shoulder injuries who partake in sports that put greater demand on the shoulder show the smallest probabilities of returning to sporting activity.