Mark Watts

Meniscal Repair in the Elite Athlete Results of 45 Repairs With a Minimum 5-Year Follow-up

Background The preservation of meniscal tissue is important to protect joint surfaces. Purpose We have an aggressive approach to meniscal repair, including repairing tears other than those classically suited to repair. Here we present the medium- to long-term outcome of meniscal repair (inside-out) in elite athletes. Study Design Case series; Level of evidence, 4. Methods Forty-two elite athletes underwent 45 meniscal repairs. All repairs were performed using an arthroscopically assisted inside-out technique. Eighty-three percent of these athletes had ACL reconstruction at the same time. Patients returned a completed questionnaire (including Lysholm and International Knee Documentation Committee [IKDC] scores). Mean follow-up was 8.5 years. Failure was defined by patients developing symptoms of joint line pain and/or locking or swelling requiring repeat arthroscopy and partial meniscectomy. Results The average Lysholm and subjective IKDC scores were 89.6 and 85.4, respectively. Eighty-one percent of patients returned to their main sport and most to a similar level at a mean time of 10.4 months after repair, reflecting the high level of ACL reconstruction in this group. We identified 11 definite failures, 10 medial and 1 lateral meniscus, that required excision; this represents a 24% failure rate. We identified 1 further patient who had possible failed repairs, giving a worst-case failure rate of 26.7% at a mean of 42 months after surgery. However, 7 of these failures were associated with a further injury. Therefore, the atraumatic failure rate was 11%. Age and size and location of the tears were not associated with a higher failure rate. Medial meniscal repairs were significantly more likely to fail than lateral meniscal repairs, with a failure rate of 36.4% and 5.6%, respectively (P < .05). Conclusion Meniscal repair and healing are possible, and most elite athletes can return to their preinjury level of activity.

Repair of Radial Tears and Posterior Horn Detachments of the Lateral Meniscus: Minimum 2-Year Follow-Up

PURPOSE The aim of this study was to show that repair of posterior radial tears and horn detachments of the lateral meniscus is possible and to assess the outcomes. METHODS A retrospective review of 24 patients who had repair of a posterior defunctioning tear of the lateral meniscus combined with anterior cruciate ligament reconstruction was undertaken. Patients completed a follow-up postal questionnaire that included Lysholm, subjective International Knee Documentation Committee (IKDC), and Tegner scoring systems. RESULTS Eight patients had suture repair of a lateral meniscal radial tear. The mean Lysholm, IKDC, and Tegner scores were 86.9 (SD, 11.6), 81.6 (SD, 13.9), and 5.8 (SD, 2.7), respectively, at a mean follow-up of 70.5 months (range, 29.0 to 168.0 months). Subsequent arthroscopy in 2 patients confirmed meniscal healing. Sixteen patients underwent a posterior horn reattachment. The mean Lysholm, subjective IKDC, and Tegner scores were 86.1 (SD, 13.3), 84.3 (SD, 17.0), and 6.5 (SD, 2.1), respectively, at a mean follow-up of 53.6 months (range, 26.0 to 116.0 months). Three patients had subsequent magnetic resonance imaging and/or arthroscopy that indicated meniscal healing. Two further patients had reinjury, and magnetic resonance imaging and/or arthroscopy showed that their repairs had failed. CONCLUSIONS Posterior radial tears that extend to the capsule and posterior horn detachments of the lateral meniscus are frequently amenable to repair. In this study 22 of 24 repairs functioned successfully over a mean follow-up of 58.6 months (range, 26.0 to 168.0 months). LEVEL OF EVIDENCE Level IV, therapeutic case series.

Bioabsorbable versus titanium interference screws with hamstring autograft in anterior cruciate ligament reconstruction: a prospective randomized trial with 2-year follow-up.

PURPOSE The purpose of this study was to prospectively assess the outcome of hamstring autograft anterior cruciate ligament (ACL) reconstruction by use of identically shaped bioabsorbable and titanium interference screws in a randomized trial. METHODS One hundred patients were randomized to have either bioabsorbable or titanium interference screws used for graft tunnel fixation in hamstring autograft ACL reconstruction. Patients were objectively and subjectively assessed preoperatively and 3, 6, 12, and 24 months postoperatively. Radiographs at 12 months postoperatively were also assessed for tunnel width. RESULTS There were no differences in clinical outcome by use of Lysholm and International Knee Documentation Committee scores between the 2 groups at any stage of follow-up to 2 years. Tibial tunnel widths were the same between the 2 groups. There was slightly more tunnel widening in the femur when bioabsorbable interference screws were used. CONCLUSIONS Identically shaped bioabsorbable interference screws and titanium interference screws used for hamstring autograft ACL reconstruction are equally successful up to 2 years postoperatively. LEVEL OF EVIDENCE Level I, prospective randomized trial with more than 80% follow-up.

Impairment and disability following limb salvage procedures for bone sarcoma.

Bone sarcomas are the fourth most common cancer in individuals under 25 years. Limb salvage procedures are popular for the treatment of osteosarcomas as they have functional and physiological benefits over traditional amputative procedures. The objective of this study was to apply disease specific measures to a group of intra-articular knee osteosarcoma patients and to evaluate structural and treatment variables predictive of the functional outcome scores. Twenty patients (10 female, 10 male) treated with tumour resection and endoprosthetic knee arthroplasty took part in the study. The Musculoskeletal Tumour Society (MSTS) rating scale and the Toronto Extremity Salvage Score (TESS) were used to assess impairment and disability respectively. Impairment was recorded as 83% and disability was recorded as 86% suggesting moderate to high function following limb salvage surgery. Task difficulty was shown to increase for activities requiring large knee flexion angles, presumably due to increased patellofemoral forces. Bivariate correlations revealed that loss of quadriceps musculature, knee extension strength and knee flexion range of motion were parameters moderately associated with the assessment instruments. ANOVA revealed no significant differences in impairment (P=0.962) or disability (P=0.411) between the differing types of prostheses. In conclusion clinicians and therapists should emphasise restoration of post-surgical range of motion and strength in order to enhance functional recovery.

Knee arthroplasty: a cross-sectional study assessing energy expenditure and activity.

Background:  What has been missing from current assessment tools post knee arthroplasty is a means by which a patients mobility and activity levels can be objectively measured over time in a real world setting. The Intelligent Device for Energy Expenditure and Activity (Minisun, Fresno, USA) (IDEEA) is one such device that meets these criteria. It quantifies activity by measuring energy expenditure and records the type of activity performed. The purposes of this study were to (i) determine if there were differences in energy expenditure in different groups of patients at various time points pre‐ and post‐surgery and (ii) determine the correlations between energy expenditure and each of the subjective International Knee Documentation Committee (IKDC), Oxford and Tegner scoring systems.

78 Tibial interference screw position in soft tissue ACL graft fixation: biomechanical considerations

Introduction Concentric interference screw placement has been proposed as having potentially better biological graft integration than eccentric interference screw placement during soft tissue ACL reconstruction. The purpose of this study was to determine whether a wedge shaped concentric screw was at least equivalent to an eccentric screw in stiffness, yield load, ultimate load and mode of failure. Methods Seven matched pairs of human cadaveric tendon in porcine tibia with titanium wedge shaped screws were randomly allocated to either the eccentric or concentric groups. Bone tunnels were drilled 45° to the long axis of the tibia, akin to standard ACL reconstruction. Tendon diameter was matched to tunnel diameter and a screw one millimetre larger than tunnel diameter was inserted. An Instrom machine was used to pull in the line of the tendon. Tendons were inspected after construct disassembly. Results The concentric screw configuration showed significantly higher stiffness (p Conclusions Concentric interference screw fixation of soft tissue graft offers superior fixation in single pullout mode when compared to eccentric interference screw fixation.