Stanislav I. Spiridonov

An In Vitro Analysis of an Anatomical Medial Knee Reconstruction

Background An anatomical medial knee reconstruction has not been described in the literature. Hypothesis Knee stability and ligamentous load distribution would be restored to the native state with an anatomical medial knee reconstruction. Study Design Controlled laboratory study. Methods Ten nonpaired cadaveric knees were tested in the intact, superficial medial collateral ligament and posterior oblique ligament—sectioned, and anatomically reconstructed states. Each knee was tested at 0°, 20°, 30°, 60°, and 90° of knee flexion with a 10-N·m valgus load, 5-N·m external and internal rotation torques, and 88-N anterior and posterior drawer loads. A 6 degrees of freedom electromagnetic motion tracking system measured angulation and displacement changes of the tibia with respect to the femur. Buckle transducers measured the loads on the intact and reconstructed proximal and distal divisions of the superficial medial collateral ligament and the posterior oblique ligament. Results A significant increase was found in valgus angulation and external rotation after sectioning the medial knee structures at all tested knee flexion angles. This was restored after an anatomical medial knee reconstruction. The authors also found a significant increase in internal rotation at 0°, 20°, 30°, and 60° of knee flexion after sectioning the medial knee structures, which was restored after the reconstruction. A significant increase in anterior translation was observed after sectioning the medial knee structures at 20°, 30°, 60°, and 90° of knee flexion. This increase in anterior translation was restored following the reconstruction at 20° and 30° of knee flexion, but was not restored at 60° and 90°. A small, but significant, increase in posterior translation was found after sectioning the medial knee structures at 0° and 30° of knee flexion, but this was not restored after the reconstruction. Overall, there were no clinically important differences in observed load on the ligaments when comparing the intact with the reconstructed states for valgus, external and internal rotation, and anterior and posterior drawer loads. Conclusion An anatomical medial knee reconstruction restores near-normal stability to a knee with a complete superficial medial collateral ligament and posterior oblique ligament injury, while avoiding overconstraint of the reconstructed ligament grafts. Clinical Significance This anatomical medial knee reconstruction technique provides native stability and ligament load distribution in patients with chronic or severe acute medial knee injuries.

Isolated and Combined Grade-III Posterior Cruciate Ligament Tears Treated with Double-Bundle Reconstruction with Use of Endoscopically Placed Femoral Tunnels and Grafts Operative Technique and Clinical Outcomes

BACKGROUND A variety of techniques have been developed to improve clinical outcomes and objective knee stability following posterior cruciate ligament (PCL) reconstruction. Additional refinements in surgical and rehabilitation techniques are necessary for improvement of both subjective and objective outcomes. METHODS All patients studied underwent endoscopic PCL reconstruction with a double-bundle allograft. All of the allografts were placed into the femoral tunnel through a lateral arthroscopic portal, secured by an all-inside method, and were passed distally through a transtibial tunnel. Modified Cincinnati subjective and International Knee Documentation Committee (IKDC) subjective and objective outcome scores and posterior stress radiographs of the knee were made preoperatively and at the time of final follow-up. RESULTS There were a total of thirty-nine patients, including thirty-three male and six female patients, with an average age of thirty-three years. There were seven isolated PCL reconstructions and thirty-two combined reconstructions of the knee. Eight patients were not available for follow-up at a minimum of two years, leaving a cohort of thirty-one patients. Preoperative Cincinnati and IKDC subjective scores averaged 34.5 and 39.3, respectively. These scores improved significantly to 73.2 and 74.3, respectively, at an average of 2.5 years postoperatively. On posterior stress radiographs, the average posterior tibial translation of the knees was 15 mm preoperatively and improved significantly to 0.9 mm postoperatively. CONCLUSIONS Patients undergoing double-bundle PCL reconstruction with use of endoscopic placement of femoral tunnels had significant improvements in subjective and objective outcome scores and with objective knee stability.

Medial Knee Injury Part 2, Load Sharing Between the Posterior Oblique Ligament and Superficial Medial Collateral Ligament

Background There is limited information regarding directly measured load responses of the posterior oblique and superficial medial collateral ligaments in isolated and multiple medial knee ligament injury states. Hypotheses Tensile load responses from both the superficial medial collateral ligament and the posterior oblique ligament would be measurable and reproducible, and the native load-sharing relationships between these ligaments would be altered after sectioning of medial knee structures. Study Design Descriptive laboratory study. Methods Twenty-four nonpaired, fresh-frozen adult cadaveric knees were distributed into 3 sequential sectioning sequences. Buckle transducers were applied to the posterior oblique ligament and the proximal and distal divisions of the superficial medial collateral ligament; 10 N·m valgus moments and 5 N·m internal and external rotation torques were applied at 0°, 20°, 30°, 60°, and 90° of knee flexion. Results With an applied valgus and external rotation moment, there was a significant load increase on the posterior oblique ligament compared with the intact state after sectioning all other medial knee structures. With an applied external rotation torque, there was a significant load decrease on the proximal division of the superficial medial collateral ligament from the intact state after sectioning all other medial knee structures. With an applied external rotation torque, the distal division of the superficial medial collateral ligament experienced a significant load increase from the intact state after sectioning the posterior oblique ligament and the meniscofemoral division of the deep medial collateral ligament. Conclusion This study found alterations in the native load-sharing relationships of the medial knee structures after injury. Sectioning both the primary and secondary restraints to valgus and internal/external rotation of the knee alters the intricate load-sharing relationships that exist between the medial knee structures. Clinical Significance In cases in which surgical repair or reconstruction is indicated, consideration should be placed on repairing or reconstructing all injured medial knee structures to restore the native load-sharing relationships among these medial knee structures.

A Prospective Outcomes Study of Meniscal Allograft Transplantation

Background: Symptomatic early-onset chondromalacia often develops after a meniscectomy in the affected knee compartment. The role of meniscal transplantation in reducing pain and improving function in patients with prior ipsilateral meniscectomy is still being defined. Hypothesis: Patients with symptomatic early-onset chondromalacia of the knee after ipsilateral meniscectomy will have improved clinical outcomes after meniscal transplantation. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent meniscal allograft transplantation between July 2003 and December 2006 were prospectively followed. The indications for surgery were unicompartmental knee pain and postactivity effusions after total or near-total meniscectomy in patients with closed physes. High-field magnetic resonance imaging (1.5-T or 3-T magnets) was used to assess the articular cartilage of the affected compartment. The meniscal transplantations were performed with an arthroscopically assisted technique. Modified Cincinnati knee and International Knee Documentation Committee (IKDC) subjective and IKDC objective outcome scores were obtained on all patients preoperatively and postoperatively to evaluate patients’ outcomes. Results: Forty patients with an average age of 25 years and a body mass index of 25.4 were included. After an average final follow-up of 2.5 years, IKDC subjective scores increased significantly from 54.5 to 72.0 (P < .001). Modified Cincinnati knee scores increased from 55.2 to 75.3 (P < .001). The preoperative IKDC objective scores measuring effusion improved significantly from 6 A (normal), 29 B (nearly normal), and 5 C (abnormal), when compared with the postoperative scores of 33 A (normal) and 1 B (nearly normal) (P < .01). Five patients sustained tears of their meniscal transplants and underwent partial meniscectomies of the transplant graft. Conclusion: The results confirm that meniscal transplantation significantly reduces pain, decreases activity-related effusions, and improves function in patients with prior meniscectomy; however, the long-term chondroprotective effects remain unknown.

Fibular collateral ligament anatomical reconstructions: a prospective outcomes study.

Background After the development and biomechanical validation of an anatomical fibular collateral ligament reconstruction using a semitendinosus graft, this technique has subsequently been applied clinically. Hypothesis An anatomical reconstruction of a grade III fibular collateral ligament tear using a semitendinosus graft restores the knee to near-normal lateral compartment stability and results in improved patient outcomes. Study Design Case series; Level of evidence, 4. Methods A prospective study of 20 patients with an average age of 24 years (range, 16-45 years) who had an anatomical reconstruction of the fibular collateral ligament using a semitendinosus graft was performed. All patients were preoperatively and postoperatively evaluated with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scoring systems, with the IKDC objective subscores for lateral and posterolateral knee stability and with varus stress radiographs. The patients were followed for an average of 2 years. Results Sixteen patients were available for follow-up. Six of the patients had an isolated fibular collateral ligament reconstruction. The average preoperative modified Cincinnati score was 28.2, and the average IKDC subjective score was 34.7. Postoperatively, there was a significant improvement of both the modified Cincinnati score (to 88.5) and the IKDC subjective outcome score (to 88.1). The Cincinnati component symptom and functional subscores were also evaluated. The average preoperative symptom subscore was 9.1 and the functional subscore was 19.1. Postoperatively, there was a significant improvement in both scores; symptom subscores improved to 43.0 and functional subscores improved to 45.5. Preoperative varus stress radiographs demonstrated an average differential of 3.9 mm (range, 2.5-6.2 mm) of lateral compartment gapping between the injured and noninjured knee. At an average of 2 years postoperatively, varus stress radiographs demonstrated an average side-to-side lateral compartment gap differential of —0.4 mm. Conclusion An anatomical fibular collateral ligament reconstruction using a semitendinosus graft results in improved patient outcomes and near-normal lateral compartment stability in patients with grade III injuries of the fibular collateral ligament.

Intra-articular lateral femoral condyle fracture following an ACL revision reconstruction

Lateral femoral condyle fractures following an ACL reconstruction are rare. To our knowledge, this is the first case report of a lateral femoral condyle fracture following a revision ACL reconstruction. The patient’s fracture was intra-articular, had a significant amount of soft tissue damage, and was further complicated by a large defect involving the bone tunnel from the ACL revision reconstruction. The patient was treated with an open reduction and internal fixation and recovered well.

A prospective study of injuries in NCAA intercollegiate ice-hockey goaltenders.

While relatively well protected and padded, ice-hockey goaltenders are at risk for impact injuries. There is little information regarding the incidence and mechanism of intercollegiate ice-hockey goaltender injuries. We prospectively studied all NCAA ice-hockey goaltender injuries through the Injury Surveillance System. We analyzed the seasons prospectively starting in 2000–2001 and through 2006–2007. Injury rates were calculated per 1000 player games. The overall rate of NCAA men’s ice-hockey goaltender injuries was 0.5/1000 player games. Fifty-six men’s ice-hockey goaltender injuries resulted in further time loss from practices or games. Thirteen injuries resulted in time loss of 1 to 2 days, 18 resulted in time loss of 3–5 days, 10 injuries resulted in time loss of 6–9 days, and 10 injuries resulted in 10 or more days of time loss from competition. The overall rate of NCAA women’s ice-hockey goaltender injuries was 0.72/1000 player games. The most common injuries were nine knee ligament injuries, five on-ice concussions, and four shoulder injuries. Overall, women sustained 23 time-loss game injuries. Five of these resulted in further loss of on-ice practice/game times of 1 day, eight resulted in 3–5 days of time loss, two resulted in 6–9 days of time loss, and seven injuries resulted in 10 or more days of time loss. Further understanding of the etiology of these on-ice goaltender-player contact injuries should assist in the development of possible interventions to reduce the incidence of NCAA ice-hockey goaltender injuries. The current Injury Surveillance System has shortcomings and does not provide us with enough information to evaluate the effectiveness of goalie equipment and the impact that possible rule changes would have on the game. This paper is the first step in analyzing all participants in hockey with anticipation for future rule and equipment optimization and subsequent injury reduction.

MR Imaging with T2*- mapping for improved acetabular cartilage assessment in FAI-a case report with arthroscopic correlation.

UNLABELLED Articular cartilage assessment in femoroacetabular impingement (FAI) is challenging. Recent studies on T2* relaxation time mapping suggest the technique may be useful in diagnosing cartilage damage. The purpose of this case report is to describe how quantitative T2*-mapping may improve cartilage assessment of the acetabulum in patients with FAI. MR arthrography was performed at 3 Tesla (T) using intra-articular Gadolinium and a T2* mapping protocol. Data from the acetabular cartilage was separated from femoral head cartilage data and then superimposed on a flattened, map projection representation of the patients acetabulum. The areas of unhealthy cartilage observed at the time of arthroscopy - including debonding and delamination - were seen preoperatively at the same anatomic locations as areas of decreased T2* values. T2* mapping values provided a non-invasive assessment of the acetabular articular cartilage. A flattened acetabular map projection allowed for anatomic visualization of areas of unhealthy cartilage. LEVEL OF EVIDENCE Level IV.

A prospective study of injuries in ncaa intercollegiate ice-hockey goaltenders

Background While relatively well protected and padded, ice-hockey goaltenders are at risk for impact injuries. Objective To study incidence and mechanism of intercollegiate ice-hockey goaltender injuries. Design Analyzed seasons prospectively starting in 2000–01 through 2006–07. Setting All National Collegiate Athletic Association (NCAA) ice-hockey goaltender injuries through the Injury Surveillance System. Participants NCAA ice-hockey goaltenders. Assessment of risk factors Injury rates were calculated per 1000 player games. Main outcome measurements Injury rates. Results The overall rate of NCAA men9s ice-hockey goaltender injuries was 0.5/1000 player games. 56 men9s ice-hockey goaltender injuries resulted in further time loss from practices or games. 13 injuries resulted in time loss of 1–2 days, 18 resulted in time loss of 3–5 days, 10 injuries resulted in time loss of 6–9 days, and 10 injuries resulted in 10 or more days of time loss from competition. The overall rate of NCAA women9s ice-hockey goaltender injuries was 0.72/1000 player games. Overall, women sustained 23 time-loss game injuries. Five of these resulted in further loss of on-ice practice/game times of 1 day, eight resulted in 3–5 days of time loss, two resulted in 6–9 days of time loss, and seven injuries resulted in 10 or more days of time loss. Conclusions Further understanding of the aetiology of these on-ice goaltender-player contact injuries could assist in the development of possible interventions to reduce the incidence of NCAA ice-hockey goaltender injuries. The current Injury Surveillance System has shortcomings and does not provide us with enough information to evaluate the effectiveness of goalie equipment and the impact that possible rule changes would have on the game. This study is the first step in analyzing all participants in hockey with anticipation for future rule and equipment optimisation and subsequent injury reduction.