Maria Pia Neri

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons.

Abstract Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy’s tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years’ follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3–4 months and 27.5% in 4–6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this techinque and the possibility of guaranteeing functional behaviour in the knee.

Management of Combined Anterior Cruciate Ligament–Posterolateral Corner Tears A Systematic Review

Background: A consensus on the treatment of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries is still lacking. Purpose: To review the available literature on the management of these combined lesions to investigate the influence that injuries of knee posterolateral structures play in the outcome of an ACL lesion. Study Design: Systematic review; Level of evidence, 4. Methods: A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: “posterolateral corner,” “plc,” “posterolateral instability,” “posterolateral injury,” “anterior cruciate ligament,” and “acl.” Results: A total of 6 studies involving 95 patients were included. For those with PLC lesions, 14 patients were treated nonoperatively, 9 underwent an early anatomic repair, while the remaining 72 underwent a reconstruction. In all 95 patients, an ACL reconstruction was performed. Sixty-seven of the 72 patients who underwent a PLC reconstruction were assessed for anteroposterior laxity, with a mean side-to-side difference of 1.5 ± 1.1 mm. Evaluated by the objective International Knee Documentation Committee (IKDC) Knee Form, 88% of the patients who underwent a PLC reconstruction were graded as good/excellent (A/B). The 9 patients who underwent an early surgical repair of the PLC lesion were evaluated by means of the objective IKDC score, with 3 patients (33%) graded as good/excellent (A/B), and by means of a clinical evaluation, with 5 of 9 patients (56%) graded as 1+ for varus laxity. For the 14 patients who were managed nonoperatively for PLC injuries, the only clinical score available was the subjective IKDC score, with a mean value of 80.5 (87.8 for the 6 patients with type A PLC injuries and 75.0 for type B PLC injuries). Conclusion: There is a paucity of literature focused on the management of combined ACL and PLC injuries. Combined ACL and PLC reconstruction seems to be the most effective approach to these combined lesions. However, future work is needed to explore the long-term outcome of the different treatment options.

Arthroscopic management of recurrent anterior dislocation of the shoulder: analysis of technical modifications on the Caspari procedure

Arthroscopic treatment was performed on 71 patients with recurrent shoulder dislocations; all of the patients had monoplanar anterior instability attributable to arthroscopically diagnosed Bankart lesion. Of the 71 operations, 29 were performed using the original Caspari technique (follow-up, 59 months), and 42 were performed after modifications made in the original technique (follow-up, 38 months), notably improved preparation of the capsular reinsertion zone and increase in the number of monofilament points and their anchorage directly to the bone, on the spine of the scapula. We compared the results obtained in these two differently treated groups, taking into account several factors in the patients history and clinical condition. These included the number of dislocation episodes before the operation, as well as clinical findings regarding stability, movement, function and pain (Rowe scale score), contralateral shoulder laxity, level of preoperative versus postoperative athletic activity, and postoperative recurrence rate. In the Caspari-treated group, we obtained 66% satisfactory results compared with the 90% obtained in the second group. The recurrence rate was 27% in the first group compared with 4.8% in the second group. These data were statistically significant. No correlation was found between preoperative number of dislocations and recurrence rate, nor for contralateral shoulder laxity. No significant difference was found regarding resumption of sport activity in the two groups. Our data indicate that, with accuracy in patient selection and effective surgical technique, the recurrence rate can be reduced, and results similar to those of the arthrotomic technique may be obtained.

After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis

Background Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions. Purpose The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction. Material and methods A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well. Results Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0–13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively. Conclusions In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level.

Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results

Purpose To compare patient-reported and clinician-reported outcomes, and radiographic results between patients who had had revision ACL reconstruction and those who had had primary ACL reconstruction. Design Systematic review and meta-analysis Data sources The MEDLINE, CINAHL, EMBASE and SPORTDiscus electronic databases were searched on 6 August 2015, using 3 main concepts: (1) revision ACL reconstruction, (2) primary ACL reconstruction and (3) treatment outcomes. Eligibility criteria for selecting studies Articles that compared patient-reported or clinician-reported outcomes or radiographic results between patients who had had revision ACL reconstruction and those who had had primary surgery with a minimum of 2 years follow-up were included. The outcomes evaluated were the Lysholm Knee Scoring Scale, objective International Knee Documentation Committee (IKDC) classification, Tegner Activity Scale, side-to-side difference in anterior tibial translation measured with KT-1000/2000 arthrometer, pivot shift test, tibiofemoral osteoarthritis grading on plain radiographs and subsequent knee surgeries. Results 8 studies (300 revision ACL reconstructions and 413 primary ACL reconstructions) were included in the meta-analysis. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores (mean difference: 7.8 points), had inferior clinician-reported knee function as assessed with the objective IKDC classification (IKDC category A: 27% vs 57%; IKDC category C or D: 22% vs 8%) and pivot shift test (grade II or III: 7% vs 2%), and more radiographic evidence of tibiofemoral osteoarthritis (50% vs 25%) compared with patients who had had primary surgery. Conclusions Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.

Minimally Invasive Unicompartmental Knee Arthroplasty in Varus Knee

Unicompartmental knee arthroplasty (UKA) may be considered a treatment option for selected patients with unicompartmental knee arthritis. There has been controversy and disagreement about the results reported in the literature. The major causes of failures with early implant designs were errors of surgical technique or patient selection. New instrumentation, component modularity, surgical accuracy, fixation technique, and patient selection have improved UKA results with a >90% survivorship at 10 years. The main goals of UKA are to restore the articular space of the affected compartment, fill the femoral and tibial osteochondral defect, preserve the shape and size of the femoral condyle, and restore the limb alignment as it was before pathology. It means that a varus alignment caused by osteoarthritis (OA) associated with constitutional varus angulation of the tibial plateau must be varus at the end of surgery; only the varus deformity caused by OA must be corrected; therefore, the knee alignment will be varus at the end of surgery. Therefore, in the presence of metaphyseal bowing, the cut of the medial tibial plateau should be perpendicular to the epiphyseal axis and not to the mechanical tibial axis and parallel to the intact contralateral plateau. Introduction of mini-invasive surgery and computer-assisted surgery should allow further improvement of surgical strategy and surgical accuracy with long-term results better than very satisfied today results.

Total knee arthroplasty without patellar resurfacing in active and overweight patients

Abstract Overweight patients are often considered poor candidates for total knee arthroplasty (TKA). A retrospective study of this was done on 47 osteoarthritic knees treated by TKA without patella resurfacing between March 1991 and June 1993. The Hospital for Special Surgery (HSS) rating system was used for clinical evaluation, and radiographs to study the degree of osteoarthritis and radiolucency. Correlations between overweight, range of motion (ROM) and stage of patellar damage and other measured variables (HSS score, patellar pain and radiolucency) were studied. Overweight was not correlated with HSS score, radiolucency or patellar pain. ROM was significantly correlated with patellar pain and HSS score, with better results in patients with ROM between 90° and 110°. Therefore, we believe that TKA in osteoarthritic knees can lead to successful results, even in active or overweight patients.

Arthroscopic intra and extra articular ACL reconstruction with gracilis and semitendinosus tendons with early resumption of sport. Results at minimum two years follow-up

Abstract The purpose of this study was to evaluate the results at minimum 2 years follow-up of our original hamstrings technique, with intra and extra articular ACL plasty, followed by an aggressive rehabilitation program. Forty young sports practising patients were prospectively selected. IKDC score, Lysholm scale score as well as KT 2000 and isokinetic tests with a Lido machine (Lido CA) were used for patient evaluation. Ninety percent of the patients had a negative Lachman test and 85% experienced no pivot shift. Valgus rotation was 1+ in 22.5% of the cases. KT 2000 evaluation showed a similar trend in the three tests performed, with an average injured/uninjured difference of 2.1 mm. The results confirm our original hamstrings technique efficacy and its low morbidity. Patients with residual valgus laxity in relation to partial MCL tears had significantly higher KT parameters and consequently less favourable outcome. An aggressive rehabilitation reduces sensitively the sport recovery time without affecting knee stability.