Extra-articular Procedures Research Articles

Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET).

Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra-articular tenodesis (LET). Yet, few series evaluating these procedures are published. To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra-articular procedure. Systematic review. A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra-articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot-shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system. Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8years (range 16-68years) and a weighted mean follow-up of 4.9years (range 1-10years). The mean time from primary ACL reconstruction to revision was 5.3years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6mm mean side-to-side arthrometric difference and 80% negative pivot-shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty-nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32-72). Good mid-term results were obtained for combined revision ACL reconstruction and lateral extra-articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high-level studies supporting this technique. IV.

Combined Anatomic Anterior Cruciate and Anterolateral Ligament Reconstruction With Quadriceps Tendon Autograft and Gracilis Allograft Through a Single Femoral Tunnel

Despite technical advances in anterior cruciate ligament (ACL) reconstruction surgery, there remains a need to improve postoperative outcomes with respect to graft failure rates. Recently, it has been shown that combined ACL–anterolateral ligament (ALL) reconstruction (using a graft composed of a tripled semitendinosus and single-strand gracilis tendon) is associated with a significant reduction in graft rupture rates compared with isolated ACL reconstruction. It is recognized that the hamstring tendons are not always available (revision scenario) or are not always the primary ACL graft choice. Some surgeons prefer to use quadriceps tendon ACL grafts because of the suggestion that these grafts may be associated with equal or better functional scores. However, if surgeons wish to try to reduce the risk of graft failure by performing an ALL reconstruction, either a combined reconstruction or the use of an independent ALL graft, with a separate femoral socket, could be considered. The disadvantage of an independently performed extra-articular procedure is the risk of femoral socket collision with the femoral ACL tunnel. This Technical Note therefore describes the use of a combined ACL-ALL reconstruction using quadriceps tendon autograft (ACL graft), gracilis allograft (ALL graft), and a single femoral tunnel.

Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up

The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria. A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2years. Stratified variable analysis of the groups was also performed. There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52months and 27months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P < 0.001) favoured ACL reconstruction with LEAT compared to ACL reconstruction alone. Sports with frequent change of direction maneuvers and higher rates of ACL injury (rugby, soccer, skiing) favoured ACL reconstruction with LEAT versus ACL reconstruction alone (P = 0.001). No significant difference in re-operation rate or type of surgery was found between the two surgical groups after propensity matching but 13 patients in the ACL reconstruction-only group re-injured their ACL, 8 of whom required supplementary LEAT at the time of revision surgery. Patient-reported outcomes and return to multi-directional sports after ACL reconstruction favour LEAT at the time of ACL reconstruction when narrow inclusion criteria are applied.

Biomechanical Assessment of a Distally Fixed Lateral Extra-articular Augmentation Procedure in the Treatment of Anterolateral Rotational Laxity of the Knee

Background: Most lateral extra-articular tenodesis (LET) procedures rely on passing a strip of the iliotibial band (ITB) under the fibular (lateral) collateral ligament and fixing it proximally to the femur. The Ellison procedure is a distally fixed lateral extra-articular augmentation procedure with no proximal fixation of the ITB. It has the potential advantages of maintaining a dynamic element of control of knee rotation and avoiding the possibility of overconstraint. Hypothesis: The modified Ellison procedure would restore native knee kinematics after sectioning of the anterolateral capsule, and closure of the ITB defect would decrease rotational laxity of the knee. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees were tested in a 6 degrees of freedom robotic system through 0° to 90° of knee flexion to assess anteroposterior, internal rotation (IR), and external rotation laxities. A simulated pivot shift (SPS) was performed at 0°, 15°, 30°, and 45° of flexion. Kinematic testing was performed in the intact knee and anterolateral capsule–injured knee and after the modified Ellison procedure, with and without closure of the ITB defect. A novel pulley system was used to load the ITB at 30 N for all testing states. Statistical analysis used repeated measures analyses of variance and paired t tests with Bonferroni adjustments. Results: Sectioning of the anterolateral capsule increased anterior drawer and IR during isolated displacement and with the SPS (mean increase, 2° of IR; P < .05). The modified Ellison procedure reduced both isolated and coupled IR as compared with the sectioned state (P < .05). During isolated testing, IR was reduced close to that of the intact state with the modified Ellison procedure, except at 30° of knee flexion, when it was slightly overconstrained. During the SPS, IR with the closed modified Ellison was less than that in the intact state at 15° and 30° of flexion. No significant differences in knee kinematics were seen between the ITB defect open and closed. Conclusion: A distally fixed lateral augmentation procedure can closely restore knee laxities to native values in an anterolateral capsule–sectioned knee. Although the modified Ellison did result in overconstraint to isolated IR and coupled IR during SPS, this occurred only in the early range of knee flexion. Closure of the ITB defect had no effect on knee kinematics. Clinical Relevance: A distally fixed lateral extra-articular augmentation procedure provides an alternative to a proximally fixed LET and can reduce anterolateral laxity in the anterolateral capsule–injured knee and restore kinematics close to the intact state.

Functional outcomes following contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery.

Lateral extra-articular procedure in association with ACL reconstruction can act as a protection against undesired load occurring during early postoperative phases, thus making it useful in revision ACL surgery. The purpose of the present study is to retrospectively review the clinical outcome of contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery, specifically with regard to patient satisfaction, return to preinjury activity level, and postoperative functional outcomes. The hypothesis was that this combined procedure leads to improved stability and functional outcome in patients affected by ACL re-tear. Twelve patients who underwent ACL revision surgery using contralateral hamstring tendon autografts and extra-articular tenodesis were retrospectively reviewed at an average follow-up of 4.1 years (range, 2 to 7 years). All the operations were performed by a single senior surgeon. The Tegner, Lysholm, International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachmann test, pivot-shift test and KT-1000 instrumented laxity testing. Wilcoxon test was utilized to compare the preoperative and follow-up status. Differences with a P value <0.05 were considered statistically significant. Lysholm knee score as well as IKDC score significantly improved at follow-up (P<0.05). No significant differences concerning Tegner activity level were reported (P=0.9). In terms of knee stability, anterior tibial translation according to manual laxity testing and as measured with KT-1000 arthrometer significantly improved after surgery (P<0.05). The present study shows favorable results for revision ACL reconstruction with contralateral hamstrings and associated extra-articular tenodesis concerning subjective knee function and knee stability as well as ability to resume sport activities.

Ultrasound-guided Musculoskeletal Interventions for the Most Common Hip and Pelvis Conditions: A Step-by-Step Approach.

Pain around the hip and pelvis is a very common condition. Pain may be generated within the joint space (i.e. the hip joint itself, the sacroiliac joints or the pubic symphysis) or from surrounding myotendinous, bursal, or nerve structures. Over the years, percutaneous musculoskeletal procedures have become increasingly popular to diagnose and treat painful conditions around the hip and the pelvis. Most intra- and extra-articular procedures are performed under ultrasound guidance. This article reviews the most common diagnostic and therapeutic procedures that can be performed around the hip and the pelvis under ultrasound guidance.

Hip Arthroscopy: extra-articular Procedures.

Hip preservation is one of the fastest growing fields in orthopaedics and indications of intra-articular procedures are well established. In the last decade, extra-articular procedures have gained momentum and arthroscopic solutions to peri-articular hip pathologies have been offered. It should be noted that many of these pathologies are well-treated conservatively and only those who fail conservative management should be treated operatively. These indications can be divided into 5 categories: greater trochanteric pain syndrome; internal hip snapping; anterior inferior iliac spine/sub-spine impingement; sciatic nerve entrapment; and proximal hamstring injuries. This article reviews the anatomy, patient history and physical examination, imaging, non-operative treatment, endoscopic operative treatment and outcomes of each category. While indications for hip arthroscopy, specifically extra-articular procedures, are rising steadily, there is not enough data to support its superiority over open procedures. Current literature consists of case studies, case reports, and expert opinions and lacks large, randomised control studies.

A residual intra-articular varus after medial opening wedge high tibial osteotomy (HTO) for varus osteoarthritis of the knee.

Varus deformity of knee osteoarthritis was formed by both intra-articular and extra-articular pathologies. Such intra-articular deformities could not be fully corrected by a medial open-wedge high tibial osteotomy (HTO), which was performed as an extra-articular procedure. Therefore, the purpose of this study was to investigate whether any residual varus was left inside the joint after HTO in the patients with knee osteoarthritis, and a correlation of the residual varus could be traced. This study involved 66 patients (66 knees) undergoing HTO for medial knee osteoarthritis. The percentage of mechanical axis (%MA), mechanical femorotibial angle (mFTA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and joint line convergence angle (JLCA) were measured on radiographs of the full-length legs preoperatively and 6 months postoperatively. The relationship between changes in the JLCA and alignment correction was assessed. The postoperative residual JLCA was categorized as the optimal (postoperative JLCA ≤ 2°), the acceptable (2° < postoperative JLCA ≤ 5°), and the unacceptable (postoperative JLCA > 5°) to analyze its correlation with pre- or intra-operative factors. Average %MA and mFTA were improved from 5.5 to 60% and from 190.2° to 176.4°, respectively. There was no change in mLDFA, whereas mMPTA changed from 80.3° to 91.8°. JLCA changed from 4.2° to 2.7°. The analyses of multiple linear regression showed that the preoperative JLCA and postoperative changes in mechanical alignment (%MA, mFTA and mMPTA) were two important variables dependently associated with differences in JLCAs postoperatively. However, postoperative JLCAs showed a stronger correlation to preoperative JLCAs than to changes in mechanical alignment postoperatively. A Chi-square analysis showed a significantly higher percentage of patients achieved acceptable postoperative JLCAs in the preoperative JLCA ≤ 6° group (78.8%) compared to the preoperative JLCA > 6° group (6.1%). Therefore, 6° of JLCA was suggested to be a tipping point. The capability of HTO to correct intra-articular varus deformities, which was represented by JLCAs, is limited. Postoperative residual JLCAs were correlated primarily to preoperative JLCA values and total alignment correction, while the former accounted for most. A preoperative JLCA of 6° was suggested to be a tipping point, and a larger value indicated more than 5° residual JLCA after the HTO.

Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

Background: Although the cause of rotational instability after revision anterior cruciate ligament reconstruction (ACLR) is multifactorial, the rationale of adding an extra-articular procedure is based on its ability to restrict rotational instability. Purpose: To assess the effect of anterolateral ligament (ALL) reconstruction on revision ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 87 patients who underwent revision ACLR between March 2011 and July 2014 with a follow-up of more than 3 years were included in this retrospective study. Patients were divided into the isolated revision ACLR group (group I, n = 45, from March 2011 to January 2013) or the revision ACLR in combination with ALL reconstruction group (group C, n = 42, from February 2013 to July 2014). Subjective knee assessments including the subjective International Knee Documentation Committee (IKDC) form, Lysholm score, Tegner activity scale, and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale were used. Clinical and functional tests were performed before surgery and at ≥6 months after surgery. All tests were usually completed at 36 months of follow-up. Results: The mean follow-up duration for groups I and C were 41.5 ± 8.2 and 38.2 ± 6.9 months, respectively (P = .451). The subjective IKDC score, Tegner score, and ACL-RSI score were significantly better in group C compared with those in group I at the last follow-up (84.3 ± 18.5 vs 75.9 ± 19.2, 7.0 ± 0.8 vs 6.3 ± 0.7, and 69.5 ± 25.4 vs 51.9 ± 23.1, respectively), although they were not significantly different between the 2 groups at 12 months after surgery (79.2 ± 18.8 vs 76.7 ± 17.2, 6.7 ± 0.7 vs 6.5 ± 0.9, and 50.2 ± 24.6 vs 49.9 ± 25.1, respectively). There were no significant differences in KT-2000 arthrometer, isokinetic extensor strength, single-legged hop for distance, co-contraction test, or carioca test results between the 2 groups at the last follow-up (P = .304, .068, .125, .056, and .066, respectively). Preoperatively, 43 (95.6%) patients in group I and 40 (95.2%) patients in group C had a grade 2 or 3 pivot shift (P = .387). Postoperatively, 23 (53.5%) patients in group I and 38 (90.5%) patients in group C had a negative pivot shift (P < .001). Group C showed a higher rate of return to the same level of sports activity than group I (57.1% vs 25.6%, respectively; P = .008), although there was no significant difference in the rate of return to any sports activity at the last follow-up (88.4% in group I vs 88.1% in group C; P = .713). Conclusion: Revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the 2 groups.

Rotational stability after ACL reconstruction using anatomic double bundle technique versus anatomic single bundle technique plus anterolateral ligament augmentation

BackgroundA residual pivot shift seen in up to quarter of ACL reconstructions using anatomic single bundle (ASB) technique. Light has been thrown on the importance of the Posterolateral (PL) bundle and its role in rotational stability, hence the concept of anatomic double bundle (ADB) reconstruction. Anterolateral ligament (ALL) reconstruction; an added extra-articular procedure, is proposed to be responsible for rotational knee stability. The aim of this study was to assess functional outcomes and rotational stability of the knee after ADB versus ASB reconstruction plus ALL augmentation. Patients and methodsBetween January 2015 and December 2015, a randomized controlled trial (RCT) was conducted on 40 patients suffering from chronic ACL injuries or acute injuries with high grade knee jerk or are high demand athletes. Twenty patients (group A) were treated with ASB ACL reconstruction and ALL augmentation. The other 20 patients (group B) underwent ADB ACL reconstructions. All patients were assessed pre and post-operatively using the Lysholm and IKDC (international knee documentation committee) scores and KT-1000 arthrometer. At the final follow-up, internal rotation kinematics of the knee was assessed using motion analysis in a gait lab. ResultsAll were followed-up for a mean of two years. At the final follow-up, there was no statistically significant difference regarding the total Lysholm score, IKDC score and KT-1000 side to side difference; P-values 0.821, 0.732, 0.533 respectively. Group ‘A’ demonstrated better rotational stability than group ‘B’ as measured from internal tibial rotation angle with a p-value of 0.001. ConclusionALL augmentation is an added extra-articular procedure that superseded ADB reconstruction in achieveing better knee internal rotation kinematics. Level of evidence: II.

EXTRA-ARTICULAR RECONSTRUCTION ASSOCIATED WITH THE ANTERIOR CRUCIATE LIGAMENT IN BRAZIL.

ABSTRACTObjective:To assess the knowledge and technical preferences of Brazilian knee surgeons in relation to the treatment of Anterior Cruciate Ligament (ACL) injuries using intra-articular reconstruction in combination with extra-articular reconstruction.Methods:A questionnaire consisting of 16 questions about intra-articular ACL reconstruction in combination with extra-articular procedures and about the Anterolateral Ligament (ALL) was applied at the 48th Brazilian Congress of Orthopedics.Results:One hundred thirty-seven surgeons answered the questionnaire. Most surgeons perform 10-30 ACL reconstructions per year, with the transtibial technique appearing as the most common. Most surgeons find some percentage of residual pivot-shift after reconstructions, but the minority performs extra-articular procedures on a routine basis. The main indications for extra-articular reconstruction are revision and profuse pivot-shift cases. Most surgeons consider the ALL a true ligament, but 46.7% with less biomechanical importance and 32.3% with greater importance in knee stability. However, 91.4% had a positive perception of the reconstruction of this structure.Conclusion:Although the preferred technique is still the transtibial procedure, combined anatomical reconstructions already make up more than 50% of cases. Extra-articular reconstructions associated with the ACL are still performed by the minority of Brazilian surgeons, but 91.4% of them report having had a positive perception with their reconstruction. Level of Evidence III, Descriptive Study.

Revision Surgery for Metal Component Failure in Total Ankle Arthroplasty.

Background:Metal component failure in total ankle arthroplasty (TAA) is difficult to treat. Traditionally, conversion to an arthrodesis has been advocated. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. The goal of this study was to analyze the clinical results and patient-reported outcomes for patients undergoing revision total ankle arthroplasty.Methods:We retrospectively reviewed prospectively collected data on 52 patients with a mean age of 63.5 ± 9.6 years who had developed loosening or collapse of major metal components following primary TAA. These patients were compared to a case-matched control group of 52 primary TAAs performed at the host institution with a minimum of 2 years’ follow-up. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA), and pain scores were prospectively collected. Clinical data was collected through review of the electronic medical record to identify reasons for clinical failure, where clinical failure was defined as second revision or conversion to arthrodesis or amputation.Results:The identified causes of failure of primary TAA were aseptic loosening of both components (42%), talar component subsidence/loosening (36%), coronal talar subluxation (12%), tibial loosening (8%), and talar malrotation (2%). Thirty-one patients (59.5%) underwent revision of all components, 20 (38.5%) just the talar and polyethylene components, and one (2%) the tibial and polyethylene components. The average time to revision was 5.5 years ± 5.4 with a follow-up of 3.1 years ± 1.5 after revision. Eleven (21.2%) revision arthroplasties required further surgery: 6 required conversion to arthrodesis and 5 required second revision TAA. Pain scores, SF-36 scores, SMFA scores, and AOFAS Hindfoot scores all improved after revision surgery but never reached the same degree of improvement seen after primary TAA.Conclusions:Clinical and patient-reported outcomes of revision ankle arthroplasty after metal component failure significantly improved after surgery, although the recovery time was longer. In this series, 21.2% of revision TAAs required a second revision TAA or arthrodesis surgery. Various prostheses performed similarly when used for revision surgery. Revision TAA can offer significant improvements postoperatively.Level of Evidence:Level III, therapeutic.

Anatomic Study and Reanalysis of the Nomenclature of the Anterolateral Complex of the Knee Focusing on the Distal Iliotibial Band: Identification and Description of the Condylar Strap.

Background:The capsulo-osseous layer (COL), short lateral ligament, mid–third lateral capsular ligament, lateral capsular ligament, and anterolateral ligament (ALL) are terms that have been used interchangeably to describe what is probably the same structure. This has resulted in confusion regarding the anatomy and function of the anterolateral complex of the knee and its relation to the distal iliotibial band (ITB).Purpose:To characterize the macroscopic anatomy of the anterolateral complex of the knee, in particular the femoral condylar attachment of the distal ITB. We identified a specific and consistent anatomic structure that has not been accurately described previously; it connects the deep surface of the ITB to the condylar area and is distinct from the ALL, COL, and Kaplan fibers.Study Design:Descriptive laboratory study.Methods:Sixteen fresh-frozen human cadaveric knees were used to study the anterolateral complex of the knee. Standardized dissections were performed that included qualitative and quantitative assessments of the anatomy through both anterior (n = 5) and posterior (n = 11) approaches.Results:The femoral condylar attachment of the distal ITB was not reliably identified by anterior dissection but was in all posterior dissections. A distinct anatomic structure, hereafter termed the “condylar strap” (CS), was identified between the femur and the lateral gastrocnemius on one side and the deep surface of the ITB on the other, in all posteriorly dissected specimens. The structure had a mean thickness of 0.88 mm, and its femoral insertion was located between the distal Kaplan fibers and the epicondyle. The proximal femoral attachment of the structure had a mean width of 15.82 mm, and the width of the distal insertion of the structure on the ITB was 13.27 mm. The mean length of the structure was 26.33 mm on its distal border and 21.88 mm on its proximal border. The qualitative evaluation of behavior in internal rotation revealed that this anatomic structure became tensioned and created a tenodesis effect on the ITB.Conclusion:There is a consistent structure that attaches to the deep ITB and the femoral epicondylar area. The orientation of fibers suggests that it may have a role in anterolateral knee stability.Clinical Relevance:This new anatomic description may help surgeons to optimize technical aspects of lateral extra-articular procedures in cases of anterolateral knee laxity.

Similar results for revision ACL with and without a lateral extra-articular reconstruction. A prospective evaluation

ObjectivesLateral extra-articular augmentation procedure (LEAP) has been proposed as an additional technique in the setting of revision ACL Reconstruction (ACLR). Few case series have been reported. The purpose of this study was to compare the clinical results and return to sports of a consecutive series of patients treated for revision ACLR with and without a LEAP.MethodsWe prospectively evaluated a series of patients treated for isolated revision ACL between 2014 and 2015 (group 1) and revision ACL associated with a LEAP from 2015 to 2016 (group 2). We analyzed the surgical technique and graft used for primary and revision ACL and for the LEAP. All patients were evaluated at one-year follow-up with Lysholm score and IKDC evaluation, return to sports and MRI evaluation.ResultsThirty-six patients were evaluated, eighteen patients in each group. For the revision ACL procedures, 14 autografts and 4 allografts were used in group 1 and 16 autografts and 2 allografts in group 2. For the LEAP, in 13 cases we performed a lateral tenodesis using ilio-tibial band and in 5 patients we used allograft.The mean age was 32 years (SD 8,5) for group 1 and 28,4 (SD 6,5) for group 2. In group 1, the median Lysholm and IKDC scale was 90 (IQR 27) and 80 (IQR 40) respectively, and in group 2 the median was 90 (IQR 48) and 67,5 (IQR 33) respectively. The difference for IKDC was statistically significant (p=0,000).Eight patients return to sports in group 1 and seven in group 2.The MRI shown and homogeneous neoligament in 66% of patients in group 1 and 61% in group 2.ConclusionDespite there was a statistically significant difference in IKDC results in favor of group 2, we found no differences in return to sports, Lysholm score and MRI imaging when a LEAP was associated at one year follow-up.

Clinical outcomes and return to sport after repeat-revision ACL reconstruction: 2-year minimum follow-up

ObjectivesAnterior cruciate ligament reconstruction (ACLR) is one of the most common procedures performed by orthopaedic surgeons to date. As the number of ACL reconstructions continues to increase, revision and multiple revision scenarios will become more frequent. The purpose of our study was to retrospectively analyze functional outcomes, return-to-sports and concomitant procedures in a series of patients who had undergone repeat revision surgery.MethodsWe retrospectively evaluated a consecutive series of patients operated between 2011 and 2016 with a minimum follow-up of 2 years. Surgical procedure, type of graft and fixation were recorded. IKDC evaluation, Lysholm score, KOOS score, Tegner scale, return-to-sports and a radiographic evaluation were performed.ResultsSeven patients were included for analysis with an average age at the second revision of 34 years (range 22-49). The contralateral knee was intact in 5 cases while in the remaining 2 an ACLR had been performed. The average follow-up was 35 months (SD 17; median 27 [IQR 24-39 months]).The graft used for ACLR was: 1 ipsilateral BTB autograft and 6 allografts. In three cases, an associated lateral extra-articular procedure was performed. Three (43%) patients had a meniscal tear; two required partial meniscectomy and 1 was sutured. Three (43%) patients had grade III chondral lesion and we performed microfracture.All patients had a side-to-side difference of less than 5 mm in the arthrometric evaluation and none had residual rotational laxity.The median pre and postoperative IKDC score was 60 (IQR 45-68) and 89 (IQR, 65-94) respectively (p 0.021). The median pre and postoperative Lysholm score was 69 (IQR, 55-80) and 91 (IQR, 86-100) respectively (p 0.S007). The median postoperative KOOS score was: Pain 93, Symptoms 94, ADL 100, Sports 90, QOL 56. Three (43%) patients returned to their previous sports activity level at final follow-up. Three switched to a less demanding activity, whereas 1 discontinued contact sports.No significant osteoarthritic changes were observed. The mean posterior tibial slope was 8° (SD 2.7; median 7 [IQR 10-6]).ConclusionRepeat revision ACLR was effective in restoring knee stability and improving functional outcomes in our patients when compared to their preoperative state. However, only 43% returned to their pre-injury level of sports activity.

Anatomic and Histological Study of the Anterolateral Aspect of the Knee: A SANTI Group Investigation.

Background:The structure and function of the anterolateral aspect of the knee have been significantly debated, with renewed interest in this topic since the description of the anterolateral ligament (ALL).Purpose:To define and describe the distinct structures of the lateral knee and to correlate the macroscopic and histologic anatomic features.Study Design:Descriptive laboratory study.Methods:Twelve fresh-frozen human cadavers were used for anatomic analysis. In the left knee, a layer-by-layer dissection and macroscopic analysis were performed. In the right knee, an en bloc specimen was obtained encompassing an area from the Gerdy tubercle to the posterior fibular head and extending proximally from the anterior aspect to the posterior aspect of the lateral femoral epicondyle. The en bloc resection was then frozen, sliced at the level of the joint line, and reviewed by a musculoskeletal pathologist.Results:Macroscopically, the lateral knee has 4 main layers overlying the capsule of the knee: the aponeurotic layer, the superficial layer including the iliotibial band (ITB), the deep fascial layer, and the ALL. Histologically, 8 of 12 specimens demonstrated 4 consistent, distinct structures: the ITB, the ALL, the lateral collateral ligament, and the meniscus.Conclusion:The lateral knee has a complex orientation of layers and fibers. The ALL is a distinct structure from the ITB and is synonymous to the previously described capsulo-osseous layer of the ITB.Clinical Relevance:Increasingly, lateral extra-articular procedures are performed at the time of anterior cruciate ligament reconstruction. Understanding the anatomic features of the anterolateral aspect of the knee is necessary to understand the biomechanics and function of the structures present and allows surgeons to attempt to replicate those anatomic characteristics when performing extra-articular reconstruction.

Outcome after Combined Lateral Extra-articular Tenodesis and Anterior Cruciate Ligament Revision in Professional Soccer Players.

We report the functional outcome after combined anterior cruciate ligament (ACL) reconstruction and lateral extra-articular tenodesis (LET) for ACL re-rupture and high-grade pivot shift in professional soccer players. For this retrospective review, the medical records of 24 professional soccer players were analyzed. The mean age at surgery was 23.8 ± 4.2 years and the mean follow-up was 42.2 ± 16.9 months. Pre- and postoperative assessment included the KT-1000 Lachman test, pivot shift test, International Knee Documentation Committee (IKDC) subjective knee evaluation, Tegner activity scale (TAS), and Lysholm score. The rate of return to sports and the level of play at final follow-up were recorded. ACL revision was performed with an autologous bone-patellar tendon-bone autograft or a hamstring graft. LET was performed using an extra-articular MacIntosh procedure as modified by Arnold-Coker. Anterior-posterior laxity was significantly reduced at the final clinical assessment (p < 0.0001): 22 patients (91.7%) had a negative pivot shift and 2 (8.3%) had residual glide (+), with significant improvement (p < 0.0001). The mean subjective IKDC and Lysholm score improved from 69.5 ± 11.1 (range: 56-90) to 88.4 ± 8.9 (range: 62.1-100) and from 58.1 ± 11.7 (range: 33-72) to 97.4 ± 3.2 (range: 88-100), respectively, with significant improvement (p < 0.0001) over preoperative values. The overall failure rate was 8.3%. There were no differences between mean preinjury and final TAS scores (p > 0.05). The rate of return to sports at the same level was 91.7% and the mean time to return to sports was 9.2 ± 2.2 months. Mid-term functional outcome after combined extra-articular reconstruction and ACL revision surgery was satisfactory, with a reduction in residual postoperative rotatory instability and degree of pivot shift.

Die Korrektur intraartikulärer Fehlstellungen am distalen Radius auf der Basis computergestützter virtueller Planungen

Computer-assisted 3D-virtual planning of extraarticular corrective procedures at the distal radius and transfer of the virtually planned procedure to the radius in vivo has been recently described. In contrast to this analogue studies on intraarticular corrective procedures are still lacking. With regard to the difficulties of the technique and the potential risks a similar technique would be valuable, that overcomes the problems of the limited access and the difficulties of reposition and fixation. This study presents a technique for intraarticular corrective procedures at the distal radius based on computer assisted 3D- virtual planning and custom made patient specific instruments. Between 2013 and 2016, 6 patients (1 female and 5 male) underwent intraarticular corrective osteotomy of the distal radius. The average age was 48 (38-60) years, the interval between injury and correction 10 (4-13) months. All patients had been previously operated externally. The computer-assisted planning was performed in cooperation with an external industrial partner ((Materialise NV, 15 Technologielaan, 3001 Leuven, Belgium). Therefore CT-scans of both wrists and forearms were performed at our institution following a special protocol from which both distal radii were virtually reconstructed. The mirror-image of the 3-D-model of the uninjured radius was superposed over the 3-D-image of the malunited radius so that the malunion was exactly visualized. The correction as well as the desired position of the implants was planned step by step via an online-conference. The stabilisation of the fragments was simulated by introducing plates and screws into the 3-D-images. Based on this plan for every step of the procedure patient-specific drilling and sawing guides were produced (Fa. Materialise) and supplied to our institution. The operative strategy and technique is demonstrated by a typical example and will vary with the individual situation of the patient. No complications occurred. All patients gained bony union. No additional procedures were required. Postoperative CT-scans confirmed that step offs were regularly well corrected but gaps often persisted.

Patient-Reported Outcomes Before and After Primary and Revision Total Ankle Arthroplasty.

Studies examining the clinical outcomes of revision total ankle arthroplasty (TAA) are sparse. Revision TAA surgery has become more common with availability of revision implants and refinement of bone-conserving primary implants. In this study, patient-reported results and clinical outcomes were analyzed for a cohort of patients who underwent both primary and revision TAA at a single high-volume institution. We retrospectively reviewed prospectively collected data on 29 patients with failed primary total ankle arthroplasty. Cases of isolated polyethylene exchange, infection, or extra-articular realignment procedures were excluded. Patient-reported outcome (PRO) measures and clinical results were reviewed in this longitudinal study. Fifteen patients (51.7%) underwent revision of just the talar and polyethylene components while 13 patients (44.8%) underwent revision of all components. The most common cause was talar subsidence (51.7%). The average time to revision was 3.9 years with a follow-up of 3.2 years after revision, and 3 (10.3%) revision arthroplasties required further surgery; 2 required conversion to arthrodesis and 1 required second revision TAA. Improvements in PROs were better after primary than revision TAA. Clinical and patient-reported results of revision ankle arthroplasty after metal component failure improved significantly but never reached the improvements seen after primary ankle arthroplasty. In our series, 10.3% of revision TAAs required a second revision TAA or arthrodesis surgery. Therapeutic Level III, comparative series.

Reverdin-Isham procedure for mild or moderate hallux valgus: clinical and radiographic outcomes.

In the last decade, interests in minimal incision surgery have been growing. Theoretically, this kind of procedure could decrease time to recovery and rehabilitation, with a reduction in morbidity. The present study assessed clinical and radiological outcomes and complications of percutaneous surgery for mild-to-moderate hallux valgus using Reverdin-Isham and Akin osteotomies without fixation after 60months of follow-up. A series of 48 patients (57 cases) with medium-to-moderate hallux valgus underwent the same percutaneous surgery, between 2003 and 2011. Data collection involved preoperative dorsal flexion, plantar flexion, M1P1, M1M2, DMAA angles, AOFAS scale score, and subjective satisfaction. AOFAS scale score rose from a preoperative median of 55.9-89.2/100 postoperatively (p < 0.001); 51 surgical procedures (89.5%) were considered as satisfactory or very satisfactory by patients at the end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (29.3° and 14.1°-15.4° and 7.7°, p < 0.001, respectively). There was a significant increase in MTPJ 1 stiffness (p < 0.001). Percutaneous correction by Reverdin-Isham and Akin osteotomies seems to be effective in isolated medium-to-moderate hallux valgus. Stiffness observed is comparable to other percutaneous and open procedures but needs to be compared in a randomized controlled clinical trial to extra-articular percutaneous procedures without capsule detachment in association with an internal fixation which allows an early mobilization. IV.