Roland P. Jakob

Autologous osteochondral grafting in the knee: indication, results, and reflections.

The use of multiple autologous osteochondral plugs (mosaicplasty) for repair of articular cartilage defects is a well-accepted technique. Since 1995, the authors have used mosaicplasty to treat more than 110 patients with cartilage defects of the knee, hip, and ankle. The first 52 consecutive patients who had mosaicplasty of the knee and have an average followup of 37 months (range, 24–56 months) were examined. Indications for surgical treatment were osteochondritis dissecans, acute trauma, and posttraumatic lesions of the femorotibial joint, femoropatellar maltracking with recurrent episodes of patella dislocations, and distinct femoropatellar arthrosis. Preoperatively, cartilage defects were classified as International Cartilage Repair Society Grade III lesions in 23 patients and Grade IV lesions in 29 patients. Two years after surgery, an increased level of knee function was found in 86% of the patients. At the latest followup, improved knee function was observed in 92% of the patients. In four patients, reoperation was necessary because of graft failure. Complications and reoperation rate were related to large surface lesions. Autologous osteochondral transplantation is a valid option for the treatment of full-thickness osteochondral defects. However, the method is limited by the defect size and the number of plugs to be taken at the donor site.

Four-part valgus impacted fractures of the proximal humerus

There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury.

Long-term Results of Arthroscopic Meniscal Repair An Analysis of Isolated Tears

From 1984 through 1986 we performed 54 arthroscopic meniscal repairs on patients with anterior cruciate ligament-stable knees. We evaluated the repair results of 52 of these patients at an average followup of 7.5 years. In 40 patients the meniscal repairs had not failed and these patients were examined clinically and radio- graphically ; in 25 cases, magnetic resonance imaging was also performed. Significantly more failures (P ≤ 0.05) occurred when the rim width of the tear was greater than 3 mm and when the tear was repaired with resorbable sutures. Conversely, the following factors were found to favorably influence meniscal healing (P > 0.05): time from injury to surgery less than 8 weeks, patient age less than 30 years, tear length less than 2.5 cm, and tear in the lateral meniscus. The overall failure rate after 7.5 years was 27% (14 of 52); 64% (9 of 14) of the failures occurred in the first 6 months after repair. The clinical and radiographic evaluation of the success fully repaired knees showed that 90% (36 of 40) had normal knee function; the remaining 10% (4 patients) had nearly normal knee function. Magnetic resonance imaging, however, showed a persisting grade 3 or 4 lesion in 96% (24 of 25) of the successfully repaired menisci and is therefore not reliable in assessing me niscal healing.

The arthroscopic meniscal repair Techniques and clinical experience

Conservative meniscal repair should limit resection to only pathologic portions of the meniscus. The periphery of the meniscus is well vascularized, enabling healing of longitudinal tears. Sutures that perforate the menis cus vertically usually lead to stable healing. In arthros copic meniscal surgery, isolated tears are sutured from within the joint, usually using techniques related to specially developed instrumentation. Our system uses three curved cannulas of various radii and a specific needle of 1.2 mm thickness, and can be operated by one hand while the joint is distracted with an AO/ASIF femoral distractor. In our series of 54 arthroscopic meniscal repairs, 42 (78%) healed without reinjury. Retears occurred in 12 patients, and were refixed again using the same techniques. Our experience has led us to conclude that the type of meniscal tear most suitable for arthroscopic repair is a vertical longitudinal lesion that involves the vascular ized zone; abrading the synovial surfaces is helpful, as is positioning the sutures tightly together; the repair should be checked at 4 months by arthroscopy or by arthrogram; and a combination of nonabsorbable and resorbable sutures is most satisfactory. We believe that with experience arthroscopic meniscal repair becomes a less involved procedure than open repair, and that in the future such repair will be successfully extended to the more centrally located lesions.

Anterior knee motion analysis Measurement and simultaneous radiography

Sixteen patients with a clinically diagnosed chronic ACL deficient knee on one side and a contralateral ACL intact knee were evaluated by arthrometry and simul taneous radiography after epidural anesthesia was in duced. The posterior cruciate ligament was intact in all knees. This paper reports only the anterior position of the tibia at the 89 N anterior force level of the KT-1000 arthrometer (as read from the dial) and the anterior tibial position recorded simultaneously by radiography at the 89 N dial tone. A 3 mm difference in anterior tibial position between the two knees of the same patient was considered diagnostic for ACL deficiency. Arthro metrically, 13 of the 16 patients were diagnosed accu rately ; radiographically, 13 of the 16 met the criterion. Moderately high significant positive correlation of paired values was obtained in ACL deficient knees by the two methods (correlation, 0.58 and two-tail probability, 0.02). In ACL intact knees there was no correlation of paired values (correlation, 0.01 and two-tail probability, 0.98). We found no numerical equivalency between the measurements obtained by the KT-1000 and simulta neous radiography. Neither did we find an apparent pattern to the differences, or formula we could use to interpolate findings of anterior tibial position from one measurement system to the other. We conclude that an examiner can substantiate a clinical diagnosis of chronic ACL deficiency with both methods. Arthrometry alone may be used to repeatedly follow conservatively treated ACL deficient knees without exposing the pa tient to radiation. Radiographs obtained under known anterior force levels provide a retrievable record to document the exact tibial position in relation to the femur.

Treatment of proximal humerus fracture using multiple intramedullary flexible nails.

Abstract A total of 61 patients with a proximal humeral fracture was treated between January 1996 and March 1998 by closed reduction and fracture fixation with intramedullary Prévot (or Nancy) nails. Of these, 28 female and 25 male patients with a mean age of 52 years (range 3–¶91 years) were reviewed clinically and radiologically with a mean follow-up of 17 months (range 4–30 months). The mean Constant score was 63, the mean Neer score 74 and the mean visual analogue scale (VAS) 73. The 14 patients under 24 years old achieved a Constant score of 86, a Neer score of 99 and a VAS of 97, while 13 patients aged between 25 and 60 years had a Constant score of 67, a Neer score of 75 and a VAS of 71. The 26 patients older than ¶61 years had a Constant score of 48, a Neer score of 61 and a VAS of 61. One patient with total and 6 with partial humeral head necrosis as well as 5 pseudarthroses were noted. Proximal nail perforation of the humeral head due to fracture collapse was seen in 22 cases. Complications were more frequently observed in the elderly. End results were not related to the type of fracture. This minimally invasive technique decreases the rate of occurrence of avascular necrosis of the humeral head. However, fractures are not sufficiently stabilised, mainly because of bone loss induced by impaction and osteoporosis. Bone loss remains an unsolved problem, and alternative methods such as the use of bone substitute combined with minimally invasive techniques should be studied.

A New Mechanical Testing Device for Measuring Anteroposterior Knee Laxity

Background The authors assessed a new instrument, the Rolimeter, for the measurement of anteroposterior translation in the knee; it was compared to the KT-1000 arthrometer. Purpose To determine if the Rolimeter offers a valid method for the measurement of anteroposterior translation that is as reproducible and reliable as the KT-1000 arthrometer. Methods Two of 3 observers examined 16 normal subjects (32 knees) and 36 patients (72 knees) with ligament ruptures twice, using both the Rolimeter and the KT-1000 arthrometers, 30 minutes apart. Total anteroposterior translation (manual maximal Lachman test) was recorded at 20° and 80° of knee flexion. Results On average, the Rolimeter measured approximately 1 mm less anteroposterior displacement than the KT-1000 arthrometer at manual maximum stress. Rolimeter measurements were more consistent than the KT-1000 measurements as measured by our observers. Specificity and sensitivity were equivalent between the Rolimeter and the KT-1000 arthrometer. Conclusions The Rolimeter is as reproducible and reliable as the KT-1000 arthrometer. It offers a valid method for the measurement of anteroposterior translation in the knee. Higher accuracy was obtained at 20° of flexion for the KT-1000 arthrometer and at 80° of flexion for the Rolimeter.

Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: A PRELIMINARY REPORT

We investigated the role of a functional brace worn for four months in the treatment of patients with an acute isolated tear of the posterior cruciate ligament to determine whether reduction of the posterior tibial translation during the healing period would give an improved final position of the tibia. The initial and follow-up stability was tested by Rolimeter arthrometry and radiography. The clinical outcome was evaluated using the Lysholm score, the Tegner score and the International Knee Documentation Committee scoring system at follow-up at one and two years. In all, 21 patients were studied, 21 of whom had completed one-year and 17 a two-year follow-up. The initial mean posterior sag (Rolimeter measurement) of 7.1 mm (5 to 10) was significantly reduced after 12 months to a mean of 2.3 mm (0 to 6, p < 0.001) and to a mean of 3.2 mm (2 to 7, p = 0.001) after 24 months. Radiological measurement gave similar results. The mean pre-injury Lysholm score was normal at 98 (95 to 100). At follow-up, a slight decrease in the mean values was observed to 94.0 (79 to 100, p = 0.001) at one year and 94.0 (88 to 100, p = 0.027, at two years). We concluded that the posterior cruciate ligament has an intrinsic healing capacity and, if the posteriorly translated tibia is reduced to a physiological position, it can heal with less attentuation. The applied treatment produces a good to excellent functional result.

Association Between Mechanical Axis of the Leg and Osteochondritis Dissecans of the Knee Radiographic Study on 103 Knees

Background: The cause of osteochondritis dissecans (OCD) is unknown, but mechanical factors seem to play a role. Purpose: To identify a relationship between localization of OCD and mechanical axis of the leg. Study Design: Case series; Level of evidence, 4. Methods: Using bilateral full-leg standing radiographs, we analyzed the position of the mechanical axis of the leg in a group of 93 adolescent and adult patients (103 knees) with OCD of the medial or lateral femoral condyle. Results: The location of OCD and the position of the mechanical axis in the same knee compartment was significantly correlated for both knees with medial (P < .001) as well as lateral (P < .012) compartment OCD. In the medial OCD group, the mean mechanical axis was located in the medial knee compartment (28% medial ± 2.8%; range, 100% medial to 14% lateral) with a statistically insignificant medial shift with respect to the unaffected side. In lateral OCD, the mean mechanical axis was located laterally (13% lateral ± 3.9%; range, 13% medial to 60% lateral) with a significant shift from the medial into the lateral knee compartment when comparing unaffected with affected knees. No significant difference was observed between adolescents with open growth plates compared with adults with closed growth plates (P > .05). Conclusion: We found an association between medial condyle OCD and varus axis and between lateral condyle OCD and valgus axis. This evokes higher loading of the affected than of the unaffected knee compartment, and therefore, axial alignment may be a cofactor in OCD of the femoral condyles.

Avoiding intraoperative complications in open-wedge high tibial valgus osteotomy: technical advancement

Open-wedge high tibial osteotomy for varus osteoarthritis of the knee is a successful treatment option, but is associated with potential intraoperative complications, jeopardizing outcome. We describe four technical hints avoiding complications as tibia plateau fracture, lateral hinge dislocation, over- and undercorrection, and unwanted increase of the posterior tibial slope and axial malrotation. The technique, which is primarily based on placing five Kirschner-wires (one for the osteotomy direction, two for the external fixator, and two for rotational and slope control) is simple, reproducible, inexpensive, and readily available.