Paolo Aglietti

A comparison of four models of total knee-replacement prostheses

Twenty-nine knees with unicondylar, sixty-four with duocondylar, fifty with Guepar, and fifty with geometric prostheses were studied. The follow-up ranged from two to three and one-half years. The unicondylar prosthesis was used in the mildest cases and gave the least complications, but the quality of results was not superior to that achieved with the other prostheses. The duocondylar model was best suited for knees with rheumatoid arthritis and mild deformity. The geometric prosthesis was the best condylar prosthesis for osteoarthritis with moderate to severe deformity, but gave the worst results in knees with rheumatoid arthritis. The Guepar prosthesis was used in the worst knees and gave the best results, but it had the highest infection rate and was the most difficult to salvage. A radiolucency was observed in about 60 per cent of the condylar replacements around the tibial component and in 45 per cent of the Geupar replacements around the femoral component. The significance of this cannot yet be determined but it suggest that the fixation may not be ideal. In all types, residual pain was most frequently attributed to the patellar compartment. Patellectomy was not a solution.

Patellar Tendon Versus Doubled Semitendinosus and Gracilis Tendons for Anterior Cruciate Ligament Reconstruction

The results of intraarticular anterior cruciate ligament reconstruction with either the patellar tendon or the semitendinosus and gracilis tendons (four strands) were prospectively compared in a consecutive series of 60 patients with chronic injuries. A single surgeon per formed arthroscopically assisted reconstructions in an alternating sequence. Preoperative and operative data revealed no significant differences between the two groups. After 28 months of followup there were no sig nificant differences in the incidence of symptoms, and recurrent giving way was present in only one knee with semitendinosus and gracilis tendon graft. Return to sport participation was more frequent in the patellar ten don group (80% versus 43%, P < 0.01 ). A minor ex tension loss (≤3°) was more frequent in the patellar tendon group (47% versus 3%, P < 0.001 ). Other dif ferences between the two groups were not significant. KT-2000 arthrometer side-to-side difference of anterior displacement >5 mm at 30 pounds was present in 13% of the knees with patellar tendon grafts and in 20% of those with semitendinosus and gracilis; a patellofemo ral crepitation developed in 17% and 3% of the two groups, respectively. Based on these data we routinely use patellar tendon grafts. Semitendinosus and gracilis tendons are preferred in selected cases: older patients, patients with preexisting patellofemoral problems, and those with failed patellar tendon grafts.

Anterior Cruciate Ligament Reconstruction: Bone-Patellar Tendon-Bone Compared with Double Semitendinosus and Gracilis Tendon Grafts

Background: The choice of graft for anterior cruciate ligament reconstruction is a matter of debate, with patellar and hamstring tendons being the two most popular autologous graft options. The objective of this study was to determine in a prospective, randomized clinical trial whether two grafts (bone-patellar tendon-bone or doubled hamstring tendons) fixed with modern devices affect the two-year minimum clinical and radiographic outcomes of anterior cruciate ligament reconstruction. Methods: One hundred and twenty patients with a chronic unilateral rupture of the anterior cruciate ligament underwent arthroscopically assisted reconstruction with use of either autologous bone-patellar tendon-bone or doubled hamstring tendon grafts, in a strictly alternating manner. Both groups were comparable with regard to demographic data, preoperative activity level, mechanism of injury, interval between the injury and the operation, and the amount of knee laxity present preoperatively. The same well-proven surgical technique and aggressive controlled rehabilitation was used. An independent observer, who was blinded with regard to the involved leg and the type of graft, performed the outcome assessment with use of a visual analog scale, the new International Knee Documentation Committee form, the Knee Injury and Osteoarthritis Outcome Score, the Functional Knee Score for Anterior Knee Pain, and an arthrometric and an isokinetic dynamometric evaluation. Radiographs were also made. Results: At the two-year follow-up evaluation, no differences were found in terms of the visual analog score, the Knee Injury and Osteoarthritis Outcome Score, the new International Knee Documentation Committee subjective and objective evaluation scores, the KT-1000 side-to-side laxity measurements, the Functional Knee Score for Anterior Knee Pain, muscle strength recovery, or return to sports activities. In the bone-patellar tendon-bone group, we found a higher prevalence of postoperative kneeling discomfort (p < 0.01) and an increased area of decreased skin sensitivity (p < 0.001). In the hamstring tendon group, we recorded a higher prevalence of femoral tunnel widening (p < 0.01). In this group, a correlation was also found between medial meniscectomy and an increased prevalence of pivot-shift glide (p = 0.035). Conclusions: We believe that, with use of accurate and proven surgical and rehabilitation techniques, both grafts are an equivalent option for anterior cruciate ligament reconstruction. Level of Evidence: Therapeutic study, Level I-1b (randomized controlled trial [no significant difference but narrow confidence intervals]). See Instructions to Authors for a complete description of levels of evidence.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon A 5–8-year follow-up

Abstract We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3°– 5° extension loss compared with the normal side was present in 20 knees (22%) and 6°–10° in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5°. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible.

Patellofemoral problems after intraarticular anterior cruciate ligament reconstruction

A series of 226 anterior cruciate ligament (ACL) reconstructions were reviewed to determine the incidence of patellofemoral (PF) problems and the associated prognostic factors. Patients were divided into four groups according to the type of injury (acute or chronic) and operation (through an arthrotomy or arthroscopic assisted). The average follow-up period was 39 months. Overall there was a 5% incidence of PF crepitus with pain and/or swelling, and a further 20% of clear PF crepitus without pain. The change from open surgery and cast to arthroscopic surgery and early motion allowed a decrease of PF problems from 40% to 21% in acute injuries, but the difference was less marked in chronic knees. A deficit greater than 10% at the one-leg hop test was present in 75% of the knees with PF crepitus and pain. The height of the patella was increased in 5% and decreased in 17% of the knees. Patients with rehabilitation difficulties had the largest decrease in patella height, whereas a patella alta was more frequent after patellar tendon reconstruction. A significant correlation was found between PF problems and female gender, positive congruence angle, preoperative PF crepitation, rehabilitation difficulties, flexion loss greater than 10 degrees, extension loss greater than 5 degrees, and variation in the height of the patella. The importance of avoiding immobilization, rehabilitation difficulties, and permanent flexion or extension loss is emphasized.

Comparison Between Single-and Double-Bundle Anterior Cruciate Ligament Reconstruction A Prospective, Randomized, Single-Blinded Clinical Trial

Background Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published. Purpose The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation. Results All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more “normal knees” in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08). Conclusion In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.

Patellar Pain and Incongruence: II

In 150 normal asymptomatic knees, the average Q angle was 15%. The patellar length was equal to the patellar ligament length, and the average congruence angle was-8%. In 53 knees with recurrent subluxation, the patella was high-riding (TP, 1.23), the sulcus angle was shallow (147%), and the average

Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis

Forty-four patients with symptomatic chronic anterior cruciate ligament instabilities that had been recon structed with the central one-third patellar tendon and a lateral extraarticular iliotibial band tenodesis were studied at an average followup of 7 years (range, 4 to 10). The cases with associated medial, lateral, or pos terior laxity were not included, nor were the cases with more than minimal preoperative degenerative changes. The average age at surgery was 21 years (range, 16 to 33). A postoperative cast was used for 4 weeks. Satisfactory objective stability, which was defined as a KT-1000 side-to-side difference of up to 5 mm at the manual maximum test, was obtained in 37 (84%) of the patients. In 25 patients (57%), stability was restored within normal limits (≤3 mm). No deterioration of the KT-1000 stability was noted at two follow-up visits performed by the same examiner (at an average of 4 and 7 years). A return to high-risk sports was possible in 27 (62%) of the patients. Difficulties in regaining a complete range of motion were recorded in 5 (11 %) of the patients. A flexion contracture of 5° to 7° was also found in 5 patients. Significant patellofemoral symptoms were present in 4 patients (9%). A 5% to 11% shortening of the patella tendon was observed in 14 (32%) of the knees, but did not correlate with patellar problems. Moderate radio graphic changes were noted in eight patients (18%) at followup and correlated with meniscectomy and pain. Overall satisfactory results were obtained in this initial experience in 29 (66%) of the patients. We believe that the operation gives reliable stability in the majority of the cases, but the results may be improved with more attention to isometry, earlier postoperative mobilization with complete extension, and a faster rehabilitation course.

Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment

This is a prospective study of 105 knees in 91 patients with idiopathic osteonecrosis of the femoral condyles, with an average follow-up of five years in 101 knees. Forty-eight of the 75 patients in whom the body weight was studied were obese and four of the 33 patients in whom a densitometry study was done showed decreased bone density. Prognosis is unfavourable if the lesion is larger than five square centimetres and if its width is more than 40 per cent of that of the condyle. Of the 22 patients followed up after conservative treatment 80 per cent were satisfactory. Of the 11 knees treated by arthrotomy alone 55 per cent were satisfactory. Of the 31 knees treated by osteotomy (21 with associated arthrotomy) 87 per cent were satisfactory. Arthrotomy did not significantly improve the results of osteotomies. The ideal correction was to 10 degrees of valgus. Of the 37 knees treated with replacement 95 per cent were satisfactory, and the best results were obtained with the total-condylar prosthesis.

Patellofemoral functional results and complications with the posterior stabilized total condylar knee prosthesis

The authors reviewed 73 knee arthoplasties performed with the Posterior Stabilized Total Condylar prosthesis, with an average follow-up period of 5.5 years. The function of the patellofemoral articulation was specifically analyzed. Patients with documented or suspected tibiofemoral problems were excluded. Using the Hospital for Special Surgery knee rating system, 48 knees (66%) had excellent, 20 had good (27%), and 5 (7%) had fair results. Patients with unilateral disease were able to negotiate stairs and transfer normally in 64% and 100% of the cases, respectively. The most frequent patellofemoral problem was impingement (21%), but reoperation was needed in only one patient. Stress fracture of the patella and subluxation were rare. A medial tilt of the patella on the axial view had no apparent ill effect. The patella was lowered 12 mm on average as a consequence of the standard bone resection sequence and insertion of the tibial component. The patella was significantly lower in patients with impingement than in normal joints. Routine complete patellofemoral resurfacing is advised in total knee joint arthroplasty. Complications are infrequent with appropriate prosthetic design and due technical care.