Pier Paolo Mariani

Knee ligament injuries in volleyball players

The authors report a series of 52 cases of serious knee ligament injuries in volleyball players. The most frequent mechanism of injury was landing from a jump in the attack zone. Women were more affected than men. Injuries were more frequent during games than training. Volleyball must then be considered among high-risk sports according to the frequency and gravity of our surgical findings. Results are similar to those obtained in athletes in other sports who underwent the same surgical procedure.

Stress radiography for quantifying posterior cruciate ligament deficiency

PURPOSE The objective of this study was to evaluate the efficacy of different stress radiography techniques in quantifying a posterior cruciate ligament (PCL) lesion. TYPE OF STUDY Prospective serial study. METHODS Sixty patients with subacute or chronic PCL injuries, confirmed using magnetic resonance imaging (MRI) or arthroscopic evaluation, were enrolled in this study. The patients underwent a KT-2000 (Medmetric, San Diego, CA) examination and a series of stress radiographs that included a radiographic posterior drawer test with Telos (Telos, Weterstadt, Germany) at 90 degrees and 25 degrees of knee flexion, an active radiograph at 90 degrees of knee flexion, and an axial view radiograph. RESULTS Stress radiography performed with Telos showed an average posterior tibial displacement of 11.54 +/- 4.93 mm and 7.97 +/- 3.16 mm at 90 degrees and 25 degrees, respectively. The active radiographs showed an average posterior tibial displacement of 11.48 +/- 5.14 mm. CONCLUSIONS Stress radiographs were shown to be superior to arthrometric evaluation in quantifying posterior tibial translation. The techniques performed with the knee at 90 degrees of knee flexion allowed for greater posterior tibial displacement and, consequently, an easier quantification of the degree of ligament insufficiency. Stress radiographs performed through hamstring contraction gave the same results as those performed with Telos at 90 degrees of knee flexion.

Accelerated rehabilitation after arthroscopic meniscal repair : A clinical and magnetic resonance imaging evaluation

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Arthroscopic posterior cruciate ligament reconstruction with bone-tendon-bone patellar graft

Abstract We present a retrospective study of 24 patients with chronic injury of the posterior cruciate ligament (PCL) treated by arthroscopically assisted reconstruction with bone-tendon-bone patellar autograft. At a mean follow-up of 26.5 months (range 24–53 months) the International Knee Documentation Committee (IKDC) evaluation form, Lysholm and Tegner rating systems were used to evaluate symptoms, functional limitations during sports and daily activities, and changes in activity level. At the final IKDC evaluation we found 6 patients (25%) with grade A (normal), 13 patients (54.2%) with grade B (nearly normal), 3 patients (12.5%) with grade C (abnormal) and 2 patients (8.3%) with grade D (severely abnormal). The average side-to-side difference, as measured by the KT-2000 arthrometer, was 8.38 (± 1.95) preoperatively and 4.08 (± 2.09) mm postoperatively at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70°. The worst results significantly correlated with the time elapsed from injury to surgery (P < 0.001). The preoperative Lysholm score was 56 ± 12 (range 41–79) and at follow-up 94 ± 8 (range 76–100). The Tegner activity score improved for all patients after surgical treatment. Average preinjury score was 7.4 (range 4–9), decreasing to 3.40 (range 2–7) preoperatively and increasing to 5.4 (range 4–9) postoperatively. At follow-up, 12 patients (50%) regained to their preinjury scores after surgery. Our study suggests that this arthroscopic technique, which allows a more precise placement of tunnels, can improve the results of the PCL reconstruction with a bone-tendon-bone autograft.

Jumper's knee: An epidemiological study of volleyball players

In brief: We studied 407 volleyball players to investigate the factors that cause patellar or quadriceps tendinitis (jumpers knee). Athletes from 30 teams in various divisions of the Italian Volleyball Federation championship were interviewed personally or by questionnaire. Factors investigated included age and sex, years of play, frequency of training sessions and games, type of playing surface, and type of training. The results showed that symptoms occurred most often among athletes playing five times a week or more and among those playing on hard surfaces, such as cement. Age, sex, years of play, and type of training were less significant factors.

Osteonecrosis after arthroscopic medial meniscectomy

Osteonecrosis of the medial femoral condyle is an uncommon complication of meniscal surgery. Whether this disease is associated with the original medial meniscus lesion or with the arthroscopic procedure is not yet known. We present two cases in which osteonecrosis has developed shortly after arthroscopy was performed for medial meniscus pathology. Magnetic resonance imaging has been the best tool to diagnose and follow up the changes in the involved area. Concerning the etiology, the authors raise the question of whether the medial compartment overloading observed in both of these cases had any significant meaning. Osteonecrosis following meniscal surgery in relatively young patients seems to have a good prognosis when correctly treated, with avoidance of weight bearing.

Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect

The purpose of this study was (a) to evaluate by ultrasonography the healing of the patellar tendon after its mid-third was removed for anterior cruciate ligament (ACL) reconstruction in two randomized groups of patients in whom the tendon donor site was either left open or closed: (b) to compare clinical, radiographic, and isokinetic studies of these two groups to evaluate the incidence of patellofemoral disorders. We performed 61 ACL reconstructions (22 males, 39 females) using the arthroscopically assisted in-out technique. All operations were performed by the same surgeon, and the patients were all subjected to the same postoperative protocol. The tendon defect was left open in 25 subjects (group A) and was closed in 36 subjects (group B). Postoperative patellar tendon behavior was evaluated in these two groups by ultrasonography at 3, 6, 9, and 12 months. The vertical position of the patella was measured in the follow-up lateral view at 45° of flexion and compared to that of the untreated knee. A clinical evaluation was performed throughout the follow-up period. and patellofemoral problems (pain, stiffness, patellofemoral crepitus) were evaluated and recorded using a modified Larsen and Lauridsen rating scale. Isokinetic evaluation was carried out at 6 months, and a quadriceps index of the two groups was recorded. Ultrasonography showed that healing of the patellar tendon initially progressed with a compensatory hypertrophy in width and thickness. The width was greater in group B (P<0.01). In group A we observed in the cross-sections a characteristic image of two cords separated by a low signal bridge which we defined as a “binocular pattern”. Areas of high ultrasound signal intensities persisted after 1 year in the open group: such areas were filled with scar tissue. In the closed group the ultrasound tendon signal returned to normal at 1 year. At 6 months the clinical, radiographic and isokinetic findings did not significantly differ between the open and closed groups. We conclude that defect closure after patellar tendon harvesting does not significantly influence the extensor apparatus.

Posterior cruciate ligament injuries in the athlete: an anatomical, biomechanical and clinical review.

AbstractRecently, the posterior cruciate ligament (PCL) has become an increasingly popular subject of orthopaedic research and debate. In the past several years, anatomic and biomechanical studies have provided invaluable information concerning the structure and function of the PCL. However, many aspects of PCL injury are still not fully understood. Diagnosis of the injury is often missed because of subtlety of symptoms and clinical findings, and current management strategies of PCL injury have experienced relatively poor clinical outcomes. Controversy exists concerning the most appropriate treatment, especially in cases of isolated PCL injury. The purpose of this review is to present a complete overview of the current knowledge regarding the basic science and clinical aspects of PCL injuries, with a specific focus on the athletic population.

C-reactive protein and erythrocyte sedimentation rate changes following arthroscopically assisted anterior cruciate ligament reconstruction

Abstract. We studied changes in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to establish normal values after uncomplicated anterior cruciate ligament (ACL) reconstruction. The levels of CRP and ESR were determined by serial measurements in 45 consecutively treated patients. Blood samples were collected before surgery and on postoperative days 1, 3, 7, 15, and 30. Both ESR and CRP showed a marked increase postoperatively, peaking between the 3rd and 7th postoperative days, the latter showing a faster return to normal (P=0.286). These data show that CRP can be used as a more accurate predictor than ESR of postoperative complications if the blood level remains elevated or unexpectedly rises.

Arthroscopic treatment of bilaeral Freiberg's infraction

Freibergs disease is a relatively rare disorder with a multifactorial cause. The condition has a definite predilection for the second metatarsal head, and it is rare to find a bilateral involvement, especially of the first metatarsal head described in the literature. The results of different methods of surgical treatment have been reported, but no single procedure has produced uniformly good results. We describe a case of a 28-year-old man, a lawyer with a 4-year history of bilateral intermittent forefoot pain on weightbearing without any recollection of specific trauma to his feet. Radiographic and magnetic resonance imaging investigations were performed and the patient underwent a bilateral arthroscopic treatment with joint debridement and drilling of the metaphyseal portion of both distal metatarsal head. Three months after surgery, the patient returned to unrestricted activity without pain. At last evaluation, 2 years postoperatively, he is symptom free and new magnetic resonance examination has shown satisfactory restructuring of the lesions.