Radek Hart

Treatment of deep cartilage defects of the knee using autologous chondrograft transplantation and by abrasive techniques - a randomized controlled study

Abstract Aim of the study: To compare outcomes of surgical treatment of deep cartilage defects of the knee in a group of patients treated by autologous chondrograft transplantation versus patients treated by abrasive techniques. Materials and methods: An original method of chondrograft preparation based on cultivated autologous chondrocytes in a three-dimensional carrier-fibrin glue (Tissucol, Baxter, Austria) has been described. Preclinical tests in human cadavres and porcine models have established the possibility of chondrograft use in humans. Of the 50 patients included in the study, 25 patients (50%) underwent autologous chondrograft transplantation (group I) and 25 patients (50%) were treated using abrasive techniques according to Johnson (group II). These two groups were similar with respect to age, size of defect, depth and localization, and presence of concomitant knee injuries. The Lysholm knee and IKDC (International Knee Documentation Committee) subjective scores were used to evaluate the results. Results: The preoperative value of the Lysholm knee score for patients in group I was 47.60 points; 5 months after surgery 77.20 points; and 12 months after surgery 86.48 points. The values for the Lysholm knee score for patients in group II preoperatively, 5 months postop, and 12 months postop were 52.60, 69.20, and 74.48 respectively. Results 12 months after surgery were significantly better in group I as compared to group II (p < 0.001). The preoperative value of the IKDC subjective score in group I was 41.28 points; 5 months after surgery 67.00 points; and 12 months after surgery 76.48 points. The values for the IKDC subjective score in group II preoperatively, 5 months postop, and 12 months postop were 45.00, 62.28, and 68.08 respectively. Results 12 months after surgery were significantly better in group I when compared to group II (p < 0.05). Conclusions: The results obtained in this study have confirmed the better outcome in patients treated with autologous chondrograft transplantation. This original method was found to be just as effective as abrasive techniques. We recommend its use in clinical practice.

Outcomes After Conventional Versus Computer-Navigated Anterior Cruciate Ligament Reconstruction

PURPOSE The purpose of this prospective randomized study was to assess biomechanical, radiographic, and functional results after single-bundle anterior cruciate ligament (ACL) reconstruction by use of a navigation system. METHODS ACL reconstruction was performed by use of the OrthoPilot navigation system (B. Braun-Aesculap, Tuttlingen, Germany) in 40 patients (group 1); and in another 40 patients, surgery was done by the standard manual targeting technique (group 2). The anterior laxity was measured with a KT-1000 arthrometer (MEDmetric, San Diego, CA). Femoral and tibial tunnel position was evaluated radiologically according to the method described by Bernard and Hertel and by Harner et al., respectively. The questionnaire-based Lysholm and International Knee Documentation Committee scales were included to compare the functional state in both groups. RESULTS The knees in group 1 were as stable as those in group 2 during the arthrometer testing, with a lower value of dispersion. The postoperative Lysholm and International Knee Documentation Committee scores had the same value in both groups. Statistical differences existed with regard to anterior-posterior femoral tunnel placement when the navigated and standard techniques were compared; in the navigated group, more exact results were found. No significant complications were observed. CONCLUSIONS The only difference that we found between the navigated and standard groups was in radiographic tunnel position measurement. The computer-assisted navigation technique in our study resulted in more accurate tunnel placement in the femur (but not the tibia) than the traditional arthroscopic technique. However, the performed standard radiographic measurements are of limited precision in principle. Functional scales and stability tests gave similar results in both groups. LEVEL OF EVIDENCE Level I, therapeutic study.

Treatment of extra-articular and simple articular distal radial fractures with intramedullary nail versus volar locking plate

The purpose of this prospective, randomized and blinded study was to compare the clinical outcomes of distal radial fractures treated with either an intramedullary nail or a volar locking plate. Sixty two patients were enrolled in the study and randomized to treatment with a MICRONAILTM (Group 1, 31 patients) or an adaptive plate (Group 2, 31 patients). Fracture types included were unstable extra-articular metaphyseal distal radial fractures and simple or multifragmentary sagittal articular distal radial fractures (AO classification types A2, A3, B1.1 and B1.2). All patients were evaluated at 6 weeks, 3 months and 12 months after surgery. Outcome measures included standard radiographic parameters, active wrist range of motion, the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist scores. We concluded that treatment of this subset of distal radius fractures with minimally invasive intramedullary nailing gives better clinical outcomes at 6 weeks after surgery than treatment with a volar locking plate. By 3 and 12 months following surgery, there are no significant differences in outcome between the two treatment methods. Disadvantages of the MICRONAIL™ fixation system include risk of injury to the superficial branch of the radial nerve and a narrower spectrum of indications than volar locking plates.

AM bundle controls the anterior–posterior and rotational stability to a greater extent than the PL bundle — A cadaver study

BACKGROUND The purpose of this study was to evaluate the influence of both bundles of the anterior cruciate ligament (ACL) on knee stability, anterior-posterior translation (APT) and internal (IR) and external (ER) rotation in cadaveric knees using a computer navigation system. METHODS The APT, IR, and ER of the knees were recorded in the intact condition, the anterolateral bundle (AM) or the posterolateral bundle (PL) deficit condition and in the ACL-deficient condition. The KT-1000 arthrometer was used for APT evaluation. The measurement of rotational movements was done using a rollimeter. All tests were performed at 30°, 60° and 90° of flexion. RESULTS At 30° of flexion: In the intact knee APT was 5.8mm, IR 12.1°, ER 10.1°. After the AM was cut, the APT increased to 9.1mm, IR to 13.9° and ER to 12.6°. After the PL was cut, the APT was 6.4mm, IR 13.1° and ER 10.6°. After the AM and PL were cut, the APT was 10.8mm, IR 15.7° and the ER was 12.9° on average. CONCLUSIONS The AM has a greater impact on the APT than the PL in all knee joint flexion angles. The PL does not resist the rotational stability more than the AM. The rotational stability is better controlled by both bundles of ACL as compared to one bundle of the ACL. CLINICAL RELEVANCE This study acknowledges the fact that the both bundles of the ACL are importants for AP and rotational stability of the knee joint.

Tibiofemoral chondromalacia treated with platelet-rich plasma and hyaluronic acid

Background: The objective of the present study was to determine if platelet rich plasma (PRP) can increase tibiofemoral cartilage regeneration and improve knee function. Methods: Fourty consecutive and strictly selected patients affected by grade II or III chondromalacia underwent 1 yr of treatment (nine injections) with autologous PRP in a liquid form with 2.0 to 2.5-fold platelet concentration (20 cases) or with hyaluronic acid (HA) (20 patients). Outcome measures included the Lysholm, Tegner, International Knee Documentation Committee (IKDC), Western Ontario and McMaster (WOMAC) Osteoarthritis Index, and Short Form (SF)-36 scores. MRI arthroscopic and histologic assessment were used to evaluate cartilage thickness and degree of degeneration before and after treatment (1 yr after the primary arthroscopy). Results: The study demonstrated significant improvement in Lysholm, Tegner, IKDC, WOMAC, and SF-36 scores in both groups. Cartilage assessment revealed no significant macroscopic or microscopic structural regeneration as well as no cartilage height increase in either group. Higher content of chondrocytes and proteoglycans in cartilage was proven in both groups after treatment without a statistically significant difference between the groups. There were no adverse events observed. Conclusions: PRP and HA significantly reduced pain and improved quality of life in patients with a low degree of cartilage degeneration. MRI and arthroscopic assessment did not confirm any significant cartilage structural improvement. The content of chondrocytes and proteoglycans in cartilage was higher in the PRP group than in the HA group after the treatment but did not reach statistical significance.

Biomechanical assessment of the reconstruction of the anterolateral ligament during anterior cruciate ligament surgery

Background: Rotational instability after the anterior cruciate ligament (ACL) injury and subsequent reconstruction may be caused by the rupture of the anterolateral structures of the knee, specifically the anterolateral ligament (ALL). There are more techniques to improve the rotational stability of the knee. The objective of this randomised cohort study was: (1) To evaluate the knee rotational stability after the single-bundle ACL reconstruction (SB) with addition of the ALL reconstruction and to compare it with the double-bundle ACL reconstruction technique (DB). (2) To analyse when the ALL is necessary to reconstruct. Methods and findings: 60 patients underwent the ACL reconstruction with the average age of 29.5 years. In thirty patient’s knees the ACL was replaced with quadriceps muscle graft using the SB technique in combination with the ALL reconstruction by the gracilis graft (ALL group). With another thirty patients the ACL was reconstructed performing DB technique with the use of hamstring tendons (DB group). The rotational stability was studied before and after the reconstruction of the ACL in time “zero” using the computer navigation system. In the ALL group, the rotational stability was also analysed after the ALL reconstruction. Before the surgery, the mean internal rotational instability (IR) was 18.7° in DB group and 19.1° in ALL groups. After the DB reconstruction, IR stability improved to 10.4°. After the ACL reconstruction in the ALL group, the IR stability was 13.3°. When the ALL was added, the IR stability improved up to 9.8°. In cases where IR stability achieved 12° after the ACL reconstruction, the addition of the ALL reconstruction would not further significantly improve the IR stability. Conclusions: The SB reconstruction of the ACL using the quadriceps muscle graft in combination with the ALL reconstruction restores the IR stability of the knee to same extent as DB reconstruction does. If the IR stability after the SB reconstruction achieves 12°, the ALL reconstruction is no longer necessary

Possibilities of Computer Application in Primary Knee Replacement

The goal of this work is to share our experience with the kinematic navigation system usage in knee unicomparmental and total replacement. This manual advert to advantage and disadvantage usage of this computer system during this type of the operation and advent to importance of the digital planning of the size of components and the mechanic axis of the lower limb.