Tim Spalding

Validation of a New Technique to Determine Midbundle Femoral Tunnel Position in Anterior Cruciate Ligament Reconstruction Using 3-Dimensional Computed Tomography Analysis

PURPOSE The purpose of this study was to investigate and report on a new intraoperative measuring technique to place the anterior cruciate ligament (ACL) femoral tunnel in the center of the native ACL femoral insertion site. METHODS We investigated a novel measuring technique based on identifying the proximal border of the articular cartilage and using a specific ruler parallel to the femoral axis to locate the origin of the ACL. The accuracy of this technique was validated by measuring tunnel position on postoperative 3-dimensional computed tomography scans. Bony tunnels created by the ruler technique were compared with tunnels drilled by a traditional technique referenced from the back wall of the notch. RESULTS Fifty ACL reconstructions were performed by the novel measuring technique, with placement of the femoral tunnel at the center of the femoral insertion. The mean position for the center of the femoral tunnel measured by the ruler technique was 0.9 mm from the theoretic optimal center position but was a very distinct 5 mm from the mean position in the traditional tunnels. CONCLUSIONS The ruler technique produced femoral tunnels comparable to published radiographic criteria used for tunnel placement and is reproducible and accurate. We recommend placement of the femoral tunnel at the midpoint of the lateral femoral condyle when using the anatomic single-bundle technique. LEVEL OF EVIDENCE Level IV, case series.

Polyurethane scaffold in lateral meniscus segmental defects: Clinical outcomes at 24 months follow-up

BACKGROUND Segmental tissue loss in the lateral meniscus is associated with pain and increased risk of osteoarthritis even when indications have been carefully considered. HYPOTHESIS Repairing the defect using a novel biodegradable scaffold will reduce pain and restore the knee function. METHODS In this prospective multicenter study, a total of 54 patients (37 males/17 females; mean age: 28 years [16-50]) were enrolled. All patients presented with postmeniscectomy syndrome and segmental lateral meniscus loss, and were treated with a polyurethane biodegradable scaffold (Actifit(®), Orteq) implanted arthroscopically. Clinical outcomes were assessed at 6, 12 and 24 months using Visual Analogue Scale (VAS), International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS VAS decreased from 5.5 at baseline to 3.6 at 6 months, 3.4 at 12 months and 2.9 at 24 months. IKDC improved from 47.0 at baseline to 60.2, 67.0 and 67.0 at 6, 12 and 24 months. All KOOS subscores improved between baseline and 24 months. DISCUSSION Clinical results of this study demonstrate clinically and statistically significant improvements of pain and function scores (VAS, IKDC, and all KOOS subscales except sport), at the 6 months follow-up and on all clinical outcomes at the 2-year follow-up. The Actifit(®) scaffold is safe and effective in treating lateral meniscus defects. LEVEL OF EVIDENCE IV continuous prospective multicenter study.

Medial portal technique for single-bundle anatomical Anterior Cruciate Ligament (ACL) reconstruction

The aim of the paper is to describe the medial portal technique for anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Placement of an ACL graft within the anatomical femoral and tibial attachment sites is critical to the success and clinical outcome of ACL reconstruction. Non-anatomical ACL graft placement is the most common technical error leading to recurrent instability following ACL reconstruction. ACL reconstruction has commonly been performed using a transtibial tunnel technique in which the ACL femoral tunnel is drilled through a tibial tunnel positioned in the posterior half of the native ACL tibial attachment site. ACL reconstruction performed using a transtibial tunnel technique often results in a vertical ACL graft, which may fail to control the combined motions of anterior tibial translation and internal tibial rotation which occur during the pivot-shift phenomenon. The inability of a vertically oriented ACL graft to control these combined motions may result in the patient experiencing continued symptoms of instability due to the pivot-shift phenomenon. The medial portal technique in which the ACL femoral tunnel is drilled through an anteromedial or accessory anteromedial portal allows consistent anatomical ACL tunnel placement. This paper describes the advantages of the medial portal technique, indications for the technique, patient positioning, proper portal placement, anatomical femoral and tibial tunnel placement, graft tensioning and fixation.

Opening wedge distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee

INTRODUCTION Osteotomy aims to reduce pain and the rate of progression of arthritis by correcting deformity and offloading the affected compartment. This study reports the results of a case series of opening wedge distal femoral varus osteotomies for valgus lateral osteoarthritis of the knee. PATIENTS AND METHODS Eighteen patients underwent osteotomy surgery (21 knees) with the aim of correcting the mechanical axis to 48-50% from medial to lateral. RESULTS The mean follow-up for the study population was 4.5 years (range 1.6 to 9.2 years). Four patients underwent conversion to arthroplasty at a mean time of 3.3 years postosteotomy. Kaplan-Meier analysis demonstrates a cumulative survival of 79% at 5 years. In the remaining 17 osteotomies, all patients reported that outcome measures improved from baseline. However, only the IKDC and pain subdomain of KOOS showed a statistically significant and clinically relevant difference. Re-operation for non-arthroplasty related surgery was common. In part this was due to symptoms related to prominence of metalwork (10). Other reasons included non-union (1), loss of correction (2), infection (1), and persistent symptoms (2). CONCLUSION Cumulative survival of opening wedge DFVO is comparable with that reported in closing wedge series. Clinically relevant differences in the IKDC and KOOS pain scores suggest that opening wedge DFVO is a useful option in the management of valgus gonarthrosis. However, DFVO is a technically demanding procedure and re-operation, particularly for removal of metalwork, is common.

Meniscal allograft transplantation: rationale for treatment.

The anatomy and microstructure of the menisci allow the effective distribution of load across the knee. Meniscectomy alters the biomechanical environment and is a potent risk factor for osteoarthritis. Despite a trend towards meniscus-preserving surgery, many tears are irreparable, and many repairs fail. Meniscal allograft transplantation has principally been carried out for pain in patients who have had a meniscectomy. Numerous case series have reported a significant improvement in patient-reported outcomes after surgery, but randomised controlled trials have not been undertaken. It is scientifically plausible that meniscal allograft transplantation is protective of cartilage, but this has not been established clinically to date.

Distal Femoral Varus Osteotomy for Lateral Compartment Osteoarthritis in the Valgus Knee. A Systematic Review of the Literature

The primary objectives of this systematic review were to define the indications, functional outcomes, survivorship and complications associated with distal femoral varus osteotomy (DFVO). Cumulative survival with arthroplasty as the endpoint ranged from 64 to 82% at 10 years, and 45% at 15 years. The mean pre-operative HSS score ranged from 46 to 65 and this improved at latest follow up to means of between 72 and 88. Pooled results show an overall complication rate of 5.8% (5/86) for unanticipated re-operation due to a complication. Poor reporting of included studies and considerable heterogeneity between them precluded any statistical analysis. Further study is required to determine the precise indications for DFVO, optimum surgical technique, implant of choice and post-operative rehabilitation regimen as all of these factors may significantly affect the complication profile and outcomes of this procedure. DFVO is technically demanding and requires a significant period of rehabilitation for the patient. However, long-term survivorship and good function have been demonstrated and it remains a potential option for valgus osteoarthritis in carefully selected patients.

The role of meniscal tissue in joint protection in early osteoarthritis

It is widely accepted that partial meniscectomy leads to early onset of osteoarthritis (OA). A strong correlation exists between the amount and location of the resected meniscus and the development of degenerative changes in the knee. On the other hand, osteoarthritic changes of the joint alter the structural and functional integrity of meniscal tissue. These alterations might additionally compromise the limited healing capacity of the meniscus. In young, active patients without cartilage damage, meniscus therapy including partial meniscectomy, meniscus suture, and meniscus replacement has proven beneficial effects in long-term studies. Even in an early osteoarthritic milieu, there is a relevant regenerative potential of the meniscus and the surrounding cartilage. This potential should be taken into account, and meniscal surgery can be performed with the correct timing and the proper indication even in the presence of early OA.Level of evidence IV.

The evolution of anatomic anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction has evolved significantly since the early 1900’s, back when an emphasis was placed on repair and not reconstruction. Over the past century, the technique has evolved from intra-articular non anatomic reconstruction, to extra articular reconstruction, back to intra articular (performed arthroscopically), to now, the advent of anatomic insertion site restoration. This review will aim to illustrate the changes that have occurred, describing the rational for this process, based upon anatomical, radiological, biomechanical and clinical studies, all of which have aimed to improve patient function following ACL injury.

Factors That Predict Failure in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction:

Background: Anatomic graft placement in anterior cruciate ligament (ACL) reconstruction has become the preferred technique for many surgeons. The predictive factors for graft failure in anatomic single-bundle ACL reconstruction are relatively unknown. Purpose: To determine the risk factors for graft failure and the relative importance of those factors in anatomic single-bundle ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: All primary anatomic ACL reconstructions undertaken at a single institution over a 2-year period were evaluated for subjective and objective measures of graft failure. Risk factors evaluated included time since ACL rupture, age, sex, body mass index, intact or deficient medial and lateral meniscus, meniscal repair, hamstring graft size, and femoral and tibial tunnel position as assessed by 3D computed tomography (CT) scan. The significant factors predicting failure and the relative importance of those factors were determined. Results: At a median follow-up of 26 months, 123 patients were available for analysis. Ninety-seven patients underwent postoperative 3D CT for tunnel positions, including all 20 cases with graft failure. The significant predictors of graft failure were medial meniscal deficiency (hazard ratio [HR] 15.1; 95% CI, 4.7-48.5; P < .001), lateral meniscal deficiency (HR 9.9; 95% CI, 3-33; P < .001), shallow nonanatomic femoral tunnel positioning (HR 4.3; 95% CI, 1.6-11.6; P = .004), and younger patient age (HR 0.9; 95% CI, 0.9-1; P = .008). Conclusion: Meniscal deficiency is the most significant factor to predict graft failure in single-bundle anatomic ACL reconstruction. Shallow nonanatomic femoral tunnel positioning and younger patient age are additional risk factors for failure, but their relative importance is less.

International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation

Meniscal allograft transplantation (MAT) has become relatively commonplace in specialized sport medicine practice for the treatment of patients with a symptomatic knee after the loss of a functional meniscus. The technique has evolved since the 1980s, and long-term results continue to improve. However, there still remains significant variation in how MAT is performed, and as such, there remains opportunity for outcome and graft survivorship to be optimized. The purpose of this article was to develop a consensus statement on the practice of MAT from key opinion leaders who are members of the International Meniscus Reconstruction Experts Forum so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined with the goal of ultimately improving patient outcomes.