Medial Arthrotomy Research Articles

Osteochondral Allograft Transplantation: A Technical Note

Background: Chondral injuries in the knee are commonly discovered during knee arthroscopy procedures. Due to the poor restoration potential and avascular nature of cartilage, large defects are commonly treated with such surgical procedures. Treatment utilizing an osteochondral allograft (OCA) transplant for symptomatic focal cartilage defects in the patellofemoral joint has demonstrated strong, lasting clinical and radiographic outcomes. Indications: Active and otherwise healthy patients are indicated for surgery when presenting with significant joint-line pain and a large focal chondral defect verified on advanced imaging after an extensive course of nonoperative management. Technique Description: Beginning with diagnostic arthroscopy to confirm the large defect of the medial femoral condyle, we proceeded with OCA transplantation. A small medial peripatellar arthrotomy is performed. The fat pad is removed for visualization and retractors are placed both medially and laterally to appropriately visualize the defect. The defect is then sized according to the appropriate sizing guide. The guide is then placed perpendicular to the defect, and a central guide pin is drilled. A scoring reamer is used to carefully cut the size of the defect followed by a central reamer to prepare the defect. Any debris is removed, and the incision is thoroughly irrigated. The defect is then carefully measured in all four quadrants to match the donor. Any underlying bone is impacted for a stable base. A drill is then used for appropriate marrow venting underneath the defect. The corresponding donor site is selected and reamed with continuous irrigation to prevent thermal necrosis. The plug is removed and carefully measured to match the recipient site. The plug is thoroughly irrigated with pulse lavage to remove marrow elements. The graft is carefully inserted with gentle manual pressure until it is seated perfectly flush with the surrounding cartilage. Results: Clinical research has demonstrated good-to-excellent long-term survivorship of OCA transplantation. Long-term return to sport rates for recreational and competitive athletes are upward of 75%. Discussion/Conclusion: As surgical techniques continue to develop, surgeons should consider utilizing OCA transplants to treat large chondral defects in the patellofemoral joint. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Poster 269: 4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

Poster 269: 4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

Mosaicplasty for osteochondritis dissecans of the knee: About 4 cases

Osteochondritis dissecans (OCD) of the femoral condyles is a subchondral bone necrosis, resulting in osteochondral fragmentation that causes joint dysfunction. Mosaic grafting consists of harvesting osteochondral grafts from a donor site and transferring them to the osteochondral defect. The objective of our study was to evaluate the results of mosaicplasty as a treatment for osteochondritis dissecans of the knee. This is a retrospective study of 04 cases of osteochondritis dissecans of the knee in the department of traumatology and orthopedics at the University Hospital Oujda, Morocco. The average preoperative IKDC functional score was 43. The lesions were classified according to Cahill's classification in zone 2 and 3, and according to Harding's classification in zone B and C. According to Bedeouelle's classification, the evolutionary stage was divided into one stage IIb case, two stages III, and one stage IV.MRI revealed two stage II cases and one case for each of the stages IV and V according to Hefti's classification. Our surgical treatment consisted of osteochondral reconstruction of the injured area by mosaicplasty. A first arthroscopic step allows us to evaluate the size and depth of the cartilage defect. The 4 patients had an OCD grade 4 ICRS. All our mosaicplasties were performed open after a medial arthrotomy. Progressive rehabilitation was started the next day, and weight-bearing was not allowed until the sixth week. The IKDC score was 84.5. The arthroscopic "second look" showed the integration of the grafts with the edges of the healthy hyaline cartilage, creating a "golf ball" appearance. The mosaic graft is a validated cartilage restoration technique 14. Garretson et al 15 demonstrated that the optimal and least constrained site was the margins of the superomedial trochlea. Hangody et al 18 reported in a heterogeneous series of more than 1,000 mosaic grafts: 3% morbidity, four infections and 36 hemarthroses. Gudas et al 22 compared 29 mosaic grafts an

Arthroscopic meniscus transplantation without bone blocks

Replacement of the lateral or medial meniscus with an allogeneic graft. Complete loss of inner or outer meniscus. Grade 3 to 4 cartilage damage in the corresponding compartment, uncorrected varus or valgus deformities > 5°, symptomatic instabilities. Knee joint arthroscopy via the high anterolateral standard portal and checking the indication. Thaw the allogeneic meniscus graft in NaCl at room temperature and incubate in vancomycin solution. Refreshment of the capsule and resection of remnants of the meniscus. Search for the insertion zones on the tibial plateau, debridement, insert atranstibial targeting device and drill target wires in the middle of the insertion zones. Overdrill the target wires with a4.5 mm drill. Short medial or lateral arthrotomy (approx. 2 cm). Reinforcement of the anterior and posterior horns of the meniscus graft with nonresorbable suture material (e.g. "fiber wire" size5). Insertion of K‑wires with thread loops into the tibial bone tunnel. The reinforcement threads of the meniscus transplant are drawn into the bone tunnel via the thread loops, and the meniscus transplant is drawn into the joint. Reduction of the meniscus base to the capsule and refixation of the meniscus to the capsule with "inside out" or "all inside" sutures. Six weeks partial weight-bearing using ahinged brace, then gradually increased load. Range of motion: 4weeks 0‑0-60°, then 2weeks 0‑0-90°, followed by no restrictions. In our hospital, 15patients (6 × medial, 9 × lateral) were treated using the described surgical technique. After aminimum period of 1year (mean = 14.2months), meniscus extrusion-measured in the MRI-averaged 2.7 mm. The Lysholm score rose from an average of70.2 (±7.4) to 90.1points (±10.6). In one case, due to an early reruption, revision with renewed meniscus refixation had to be performed 10days after the operation. In another case, meniscus resection was performed 6months after the meniscus transplant due to areruption. Thrombosis, infection and arthrofibrosis were not observed.

An optimized medial parapatellar approach to the goat medial femoral condyle.

Goats or sheep are the preferred animal model for the preclinical evaluation of cartilage repair techniques due to the similarity of the goat stifle joint to the human knee. The medial femoral condyle of the stifle joint is the preferred site for the assessment of articular cartilage repair, as this is the primary location for this type of lesion in the human knee. Proper surgical exposure of the medial femoral condyle is paramount to obtain reproducible results without surgical error. When applying the standard human medial arthrotomy technique on the goat stifle joint, there are some key aspects to consider in order to prevent destabilization of the extensor apparatus and subsequent postoperative patellar dislocations with associated animal discomfort. This paper describes a modified surgical technique to approach the medial femoral condyle of the caprine stifle joint. The modified technique led to satisfactory exposure without postoperative incidence of patellar luxations and no long‐term adverse effects on the joint.

Patient-specific cruciate-retaining total knee replacement with individualized implants and instruments (iTotal™ CR G2).

Treatment of tricompartimental osteoarthritis (OA) using customized instruments and implants for cruciate-retaining total knee arthroplasty. Use of patient-specific instruments and implants (ConforMIS iTotalTM CR G2) together with a 3D-planning protocol (iView®). Retropatellar resurfacing is optional. Symptomatic tricompartmental OA of the knee (Kellgren-Lawrence stageIV) with preserved posterior cruciate ligament (PCL) after unsuccessful conservative or joint-preserving surgical treatment. Knee ligament instabilities of the posterior cruciate or collateral ligaments. Infection. Relative contraindication: knee deformities >15° (varus, valgus, flexion); prior partial knee replacement. Midline or parapatellar medial skin incision, medial arthrotomy; distal femoral resection with patient-specific cutting block; tibial resection using either acutting jig for the anatomic slope or afixed 5° slope. Balancing the knee in extension and flexion gap using patient-specific spacer.The final tibial preparation achieved with gap-balanced placement of the femoral cutting jigs. Kinematic testing using anatomic trial components. Final implant components are cemented in extension. Wound layers are sutured. Drainage is optional. Sterile wound dressing; compressive bandage. No limitation of the active and passive range of motion. Optional partial weight bearing during the first 2weeks, then transition to full weight bearing. Follow-up directly after surgery, at 12 and 52weeks, then every 1-2years. Overall 60patients with tricompartmental knee OA and preserved PCL were treated. Mean age was 66 (range 45-76) years. Minimum follow-up was 12months. There was 1septic revision after alow-grade infection, 1reoperation to replace the patellar due to patellar osteoarthritis and 3manipulations under anesthesia (MUAs) to increase range of motion. Radiographic analyses demonstrated an ideal implant fit with less than 2 mm subsidence or overhang. The WOMAC score improved from 154.8points preoperatively to 83.5points at 1 year and 59.3points at 2years postoperatively. The EuroQol-5D Score also improved from 11.1points preoperatively to 7.7points at 1year postoperatively.

Frequency of infrapatellar neuropathy post-total knee replacement and arthroscopic surgery in Egyptian patients

BackgroundThe infrapatellar branch of the saphenous nerve (IPBSN) contains only sensory fibers that innervate the knee regarding its anteromedial aspect and the anterior-inferior portion of its capsule. IPBSN damage has been recorded as a postoperative complication of surgery about the knee, which is manifested by pain, numbness and reflex sympathetic dystrophy. The incisions made for arthroscopy, medial arthrotomy, and anterior cruciate ligament surgery also, can causes IPBSN damage in about 0.5 to 30% of cases. We aimed to study the frequency of infrapatellar branches of the saphenous nerve entrapment/injured in Egyptian patients to find the incidence of its affection in post-operative knee surgeries and to increase the awareness of this condition.ResultsNinety patients complaining pain at the antero-medial aspect of the knee were collected and divided into 3 groups: G1 included 30 patients with a history of total knee replacement, G2 included 30 patients with a history of knee arthroscopy and G3 included 30 patients with non-specific knee pain. All patients went to clinical, electrophysiological study and laboratory measures.There was a significant statically differences of sensory nerve conduction study regarding latency and amplitude of infrapatellar nerve between the three groups and significant statically differences of clinical signs among patients of the studied groups regarding Hofmann-Tinel sign and pain provocation test.ConclusionThe entrapment/injury of IPBSN is an underestimated sometimes unrecognized cause of post-operative knee pain to many clinicians. Awareness of this condition would probably help in managing these cases to decrease post-operative pain and disability as the frequency of infrapatellar neuropathy post total knee replacement was 56.6% and post arthroscopic surgery was 63.3% in cohort of Egyptian patients.

Revision arthroplasty with rotating hinge systems for total knee arthroplasty instability.

Restoring stability after total knee arthroplasty (TKA) and improving joint function using acemented rotating hinge system. Ligament instability and/or osseous defects (including Anderson Orthopaedic Research Institute [AORI] classification typeII defects) after primary TKA or TKA revision surgery. Distal femoral or proximal tibial bowing requiring implant systems that provide femoral or tibial offset stems. Persistent periprosthetic infection. Poor therapeutic compliance. AORI typeIII defects. Medial arthrotomy. Femoral and tibial component removal with small saw blades and chisels. Intramedullary alignment for the tibial and femoral cuts. Debridement and removal of membranes and cement remnants. Reconstruction of joint line and correct TKA alignment. Trial reduction. Cement fixation. Unrestricted range of motion, partial weight bearing for 4weeks. Between 2012 and 2013, 18patients suffering from ligament insufficiency after TKA were revised using the described system and included in aprospective study protocol. The mean follow-up was 37months (range 30-46months). There was asignificant improvement of the Oxford Knee Score (OKS) from 19 (range 7-29) preoperatively to 29 (range 10-45) postoperatively (p = 0.004). The Knee Society Score (KSS) knee assessment subscore improved from 35 (range 9-70) to 67 (range 35-97) (p = 0.002) and the pain score from 7 (range 0-50) to 24 (range 0-50) (p = 0.008).

Synovial inflammation in anterior cruciate ligament injury knees in mice: surgical vs non-surgical models

Purpose: Anterior-cruciate-ligament (ACL) rupture is one of the most common knee injuries, resulting in pain, disability, and increased risk of developing OA. However, only ∼50% of individuals with ACL rupture develop OA, and the factors underlying this variable risk remain unclear. Changes in joint stability as a result of ACL deficiency drive mechanobiological dysfunction and the development of OA. However, specific factors are known to increase OA risk such as concurrent injury to the meniscus, cartilage, and subchondral bone. Also, the degree of initial joint inflammation and its resolution are implicated in long-term outcomes. Surgical and nonsurgical models of ACL rupture in mice result in similar joint instability but distinct risks or trajectories of OA. We used these two models to investigate if differences in synovial inflammatory response are associated with this risk of OA disease progression Methods: Ten-week-old, male C57BL/6 mice were randomly assigned to ACL transection (ACLT), ACL rupture (ACLR), sham-surgery or uninjured groups. Mice in the ACLT and sham-operated groups were subjected to anaesthesia, right unilateral medial arthrotomy, patella luxation, and fat-pad elevation to visualise the ACL, at which time the surgeon was informed to transect or spare the ACL before joint closure. Uninjured and ACLR animals were anaesthetised, the latter having a single compressive load (9-12N) to posteriorly displace the femur and traumatically rupture the ACL. Animals were housed in mixed injury groups (up to 5/cage) and allowed unrestricted activity. At 1, 2, 4 and 8 weeks post-injury, mice were euthanised and joints harvested for fixation, paraffin embedding, sectioning and OA histopathology scoring (n=7/group/timepoint); or synovial tissue (en bloc fat-pad, synovial lining and joint capsule anterior to the collateral ligaments) isolation for RNA extraction and quantitative RT-PCR analysis of cytokines (IL1, IL6, TNF), inflammatory cell markers (CD11b, CD4, CD8), and enzymes implicated in OA pathophysiology (ADAMTS4, ADAMTS5, MMP3, MMP9, MMP13) (n=6/group/time point). Results: ACL injury resulted in progressive OA pathology with cartilage pathology significantly greater in ACLR compared with ACLT at 2 and 4 weeks (p<0.001), but by 8 weeks was equivalent in the two models; posterior osteochondral erosion significantly worse in ACLR than ACLT at 4 and 8 weeks (p<0.01); and osteophyte size (p<0.001) and maturity (p<0.01) greater at 1 and 2 weels in ACLR compared with ACLT. Synovitis was increased acutely in both ACL-injuries and then decreased with time, with ACLT>ACLR (p=0.003) at week-1 but similar thereafter; both still greater than uninjured joints through to week 8 (p<0.001). Sham and ACLT had similar synovitis scores until week 8 when the latter was more severe. Despite histomorphological similarities in synovitis in ACLT and ACLR, there were differences in gene expression patterns. Synovial expression of TNF, CD11b and CD8 was unchanged at any time when comparing between groups. Surgery alone (ACLT and Sham) increased synovial IL6 (week-1: ACLT p=0.02, Sham p<0.001 vs uninjured) while ACLR did not. While CD4 was also increased by surgery (week-1 and -2: ACLT p<0.01, Sham p<0.05 vs uninjured), it was also increased in ACLR versus uninjured at these times (p<0.05; Figure 1). ADAMTS5 expression was not detected in synovial tissue, and MMP9 mRNA did not differ between groups. In contrast, ADAMTS4, MMP3, and MMP13 expression were increased by surgery (ACLT/Sham) and ACLR at week-1 and -2 compared with uninjured joint, although both surgeries>ACLR (Table 1). Conclusions: While both models caused joint instability, OA trajectory and ultimate severity were greater in ACLR. In contrast, surgery induced greater histo-pathological synovitis acutely but was similar in both injuries thereafter. There was a difference in the “phenotype” of the synovial inflammation in the two injury models. In ACLT there was upregulation of IL6 not evident in ACLR but similar to Sham, suggesting this was a response to surgery and wound healing. While helper T-cell (CD4) increase was greater in ACLT and Sham, this also occurred in ACLR suggesting a role of adaptive immunity in OA after nonsurgical injury. Expression of ADAMTS4, MMP3 and MMP13 were similarly increased acutely in both injury models, suggesting synovial tissues as a source of these enzymes implicated in the structural pathology of OA. While their expression was not correlated with ultimate pathological severity they may be broad-spectrum target across varying phenotypes of post-traumatic OA. Our data suggest that synovitis severity per se was not associated with differential OA risk with ACL injury; it likely still contributes to long-term OA structural pathology.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Luxação lateral de patela em um Poodle toy

Background: Luxating patella is one of the most frequent conditions of the stifle joint in dogs and it can evolve into a degenerative joint disease. The occurrence of the condition can be medial or lateral, unilateral or bilateral. Its origin can be traumatic or congenital and, additionally, it may undergo genetic and environmental influence. Lateral luxation is more common in large breed dogs, and it can rarely affect medium and small breeds, whilst medial luxation is more common in small breed dogs. The classification of patellar luxation comprises four grades, according to the patellar position, clinical signs and seriousness of the bone deformities found. The diagnosis is made based on the clinical evaluation, associated with a radiographic evaluation. The present study aims at describing a case of bilateral grade 3 lateral luxating patella in a Toy Poodle dog. Case: A five-month-old female Toy Poodle dog was presented for difficulty standing and claudication of hind limbs. Orthopedic evaluation revealed internal rotation of the stifle, claudication of hind limbs during walking and “jumps” during trotting, in addition to a lateral grade 3 luxating patella and slight restriction of the joint motion upon extension of the right and left hind limbs. Radiographic evaluation of both stifles evidenced an ectopic (lateral) position of the right and left patellas. The animal was referred to the surgery department, where it was submitted to surgical intervention of both stifles. A reduction of luxation in both stifles was achieved through medial arthrotomy, wedge recession trochleoplasty, lateral desmotomy and medial imbrication of the articular capsule techniques. Tramadol hydrochloride, dipyrone and meloxicam were prescribed as postoperative medication. Daily wound care, resting and mild walks using a lead were recommended for the animal. On the tenth postoperative day, the stitches were removed from the skin and the animal seemed to be in a good general state, using adequately its hind limbs when walking and trotting. Discussion: The medial form of the congenital patellar luxation is common both in large and small breeds. However, the lateral form is more common in large or giant breeds, differently to the findings of the present case, in which luxation occurred in a Toy Poodle. Surgery is recommended in animals with a luxating patella grade starting from 2, as even the smallest luxation grades may evolve into higher grades, causing functional inability of the limb and degenerative joint disease. Surgery was justified in this case, because the animal presented a grade 3 luxating patella. The decision on which technique should be used will depend on the luxating patella grade and on soft tissue compromise. The most recommended procedure is a combination of various techniques in the same articulation. In this case, the use of wedge recession trochleoplasty and medial imbrication of the articular capsule techniques was successful, as a few days after surgery the animal was able to walk adequately without presenting any instability of the patellas, thus improving its quality of life. Moreover, upon reaching adulthood, the animal maintained an adequate gait, without excessive patellar motion.

Lateral Meniscal Allograft Transplant via a Medial Approach Leads to Less Extrusion

Background: Accurate positioning of the bony bridge is crucial to prevent extrusion of meniscal allografts after transplant. However, oblique or lateralized placement of the bony bridge of the lateral meniscal allograft may occur due to technical error or a limited visual field. The patellar tendon may be an obstacle to approaching the anterior horn of the lateral meniscus, resulting in a laterally placed allograft. Therefore, lateral meniscal transplant through a medial arthrotomy would be an alternative approach. However, no report exists regarding allograft extrusion when comparing medial and lateral arthrotomy techniques in lateral meniscal transplants. Hypothesis: Extrusion of the midbody of the allograft is less severe and the rotation of the bony bridge is less oblique in lateral meniscal allograft transplants through the medial parapatellar approach than those through the lateral approach. Study Design: Cohort study; Level of evidence, 3. Methods: A bony bridge was used to perform 55 lateral meniscal transplants through either a medial or a lateral arthrotomy. Thirty-two allografts were transplanted through a medial arthrotomy and 23 were transplanted through a lateral arthrotomy, not randomly. Because correct positioning of the bony trough through the medial arthrotomy was easier than that through the lateral arthrotomy, the method of the arthrotomy was changed for the latter. The procedure for both groups was identical except for the arthrotomy technique, and rehabilitation was identical for both groups. Follow-up magnetic resonance imaging was conducted for all patients to measure the postoperative extrusion and obliquity of the bony bridge of the allograft. On the coronal view, extrusion was measured as the distance between the outer edge of the articular cartilage of the lateral tibial plateau and the outer edge of the meniscal allograft. On the axial view, a line (line B) was drawn along the longitudinal axis of the bony bridge. The posterior tibial condylar tangential line was drawn between the medial and lateral posterior tibial condylar cortices. A line (line T) was drawn perpendicular to the posterior tibial condylar tangential line. The angle (trough angle) between lines B and T was measured. Postoperative extrusion and the trough angle were compared between the medial and lateral arthrotomy groups. Results: The median extrusion of the midbody of the allograft was 2.2 mm (interquartile range [IQR], 2.4 mm; range, 0-4.6 mm) in the medial arthrotomy group and 3.1 mm (IQR, 1.5 mm; range, 0-5.3 mm) in the lateral arthrotomy group (P = .001). Seven (21.9%) patients demonstrated extrusion in the medial arthrotomy group, and 15 (65.2%) patients had extrusion in the lateral group (P = .002). The median trough angle was 0.9° (IQR, 9.3°; range, -8.8-15.8°) in the medial arthrotomy group and 11.6° (IQR, 2.8°; range, 3-19.8°) in the lateral arthrotomy group (P < .001). Conclusion: Based on this experience, lateral meniscal allograft transplant through a medial arthrotomy is preferred to decrease postoperative extrusion of the allograft.

Short-term effects of arthrotomy with and without infrapatellar fat pad resection on the normal canine stifle.

To investigate the short-term effects of infrapatellar fat pad (IFP) resection in normal dogs. Experimental in vivo study. Five normal adult female beagle dogs. The IFP was resected via arthrotomy in the left stifle joint (experimental side) while the right stifle underwent arthrotomy alone (sham side). An orthopedic examination was performed every week for 4 weeks and synovial fluid was analyzed before and 4 weeks after the procedure. The ratio of the length of the patellar ligament to the patellar length (L:P) was calculated on a lateral radiograph of the stifle before, 2 and 4 weeks after the procedure. Patellar depth (PD) and the contact area (CA) between the femur and patella were calculated from computed tomographic images taken at 3 different stifle angles (extended, flexed, hyperflexed) before, immediately after, and 4 weeks following the procedure. The dogs were euthanatized 4 weeks after the procedure for macroscopic and microscopic evaluation of the patellofemoral joint. No difference was found between treatment groups throughout the study. No evidence of postoperative osteoarthritis was detected in any of the dogs. Orthopedic examinations, radiographs, and synovial fluid analyses remained within normal limits. Most PD, but not CA measurements, increased with time in both joints and at all stifle angles. Excision of the IFP subsequent to medial arthrotomy did not result in any measurable changes in the canine patellofemoral joint when compared with medial arthrotomy alone after 4 weeks of follow-up.

A prospective randomized study in 20 patients undergoing bilateral TKA comparing midline incision to anterolateral incision

BackgroundLateral flap numbness is a known side-effect of midline skin incision in total knee arthroplasty (TKA) and a cause of patient dissatisfaction. Anterolateral incision is an alternative approach which preserves the infrapatellar branches of the saphenous nerve and avoids numbness. Studies have compared both incisions, but in different patients. However, different patients may assess the same sensory deficit dissimilarly, because of individual variations in anatomy and healing responses. We compared the two incisions in the same patient at the same time, using an anterolateral incision on one knee and a midline incision on the other knee in simultaneous bilateral TKA. Other surgical steps including medial arthrotomy were idential. We also correlated subjective and objective findings.Materials and methodsTwenty patients were prospectively randomized. Sensory loss and skin healing were assessed at 6, 12 and 52 weeks. Subjective preference for the knee with less numbness was charted on Wald’s Sequential Probability Ratio Test. Sensation scores for touch, vibration, static and moving two-point discrimination were measured. Scar healing was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). Functional scores were measured.ResultsA statistically significant difference favoring knees with anterolateral incision was observed in patient preference at all assessment points and this correlated with sensation scores. A statistically significant difference was observed in POSAS score favoring knees with anterolateral incision at 6 and 12 weeks which became statistically insignificant at 1 year. Functional scores remained comparable.ConclusionWe recommend anterolateral incision as a safe and effective method to circumvent the problem of lateral flap numbness with midline incision.Level of evidenceI.

Effect of Soft Tissue Releases on Joint Space Opening in Total Knee Arthroplasty

BackgroundThe purpose of this study was to determine the gap achieved to the medial and lateral compartments following sectioning and release of the relevant soft tissues in preparation for a total knee arthroplasty. MethodsA custom-designed knee tensioner allowed the application of forces to the medial and lateral compartments of 12 cadaveric knee specimens. Loads of 100 N and 200 N were applied to each compartment, and the resulting displacement was measured in the following conditions: (1) All soft tissues intact, (2) an arthrotomy, (3) anterior cruciate ligament (ACL) sectioned, (4) posterior cruciate ligament (PCL) sectioned, and (5) release of the anterior aspect of the deep medial collateral ligament (MCL) fibers. Tensions were applied for all conditions from 90° to 0° of knee flexion in 30° increments. ResultsNo differences were found in medial or lateral displacement after the arthrotomy or releasing the ACL or PCL at either 100 N or 200 N. At the 100 N load application, there was a significant increase in gap width when the anterior portion of the deep MCL was released (7.49 mm) compared to the intact (5.28 mm) and arthrotomy (5.75 mm) conditions. With respect to the 200 N load application, there were statistically significant differences detected between the deep MCL fiber release (11.09 mm) and intact conditions (8.05 mm) and release of the deep MCL and arthrotomy conditions (8.77 mm). ConclusionThe medial parapetellar arthrotomy, ACL and PCL sectioning did not result in medial or lateral displacement changes. The release of the anterior fibers of the deep MCL as part of the surgical exposure increased the medial gap magnitude.

Osteotendinous Suturing for Anchorage of Medial Arthrotomy in Total Knee Arthroplasty

Aim: To develop a method for closure of the arthrotomy wound and approximation of the medial periosteum at the level of tibial tuberosity after total knee arthroplasty in severe varus deformity. Method: We describe a technique of osteotendinous suturing through the tibial tuberosity for suturing of the medially elevated periosteum. Result: This is an easily reproducible technique which results in very early mobilisation and no additional complications and has several advantages over other methods of closure. Conclusion: The osteotendinous technique can be used for medial arthrotomy closure after correction of severe varus deformities and also after partial patellar tendon avulsions in total knee arthroplasty surgeries.

Conventional over-the-top-aiming devices with short offset fail to hit the center of the human femoral ACL footprint in medial portal technique, whereas medial-portal-aiming devices with larger offset hit the center reliably.

Aim of this study was to investigate the accuracy of a conventional over-the-top-guide (OTG) with a typically short offset to hit the center of the native femoral ACL footprint through the anteromedial portal in comparison to a specific medial-portal-aimer (MPA) with larger offset. In 20 matched human cadaveric knees, insertion sites of the ACL were marked in medial arthrotomy. An OTG with an offset of 5.5mm, respectively, the MPA with 9mm offset was used in a medial portal approach to locate the center of a single bundle ACL reconstruction tunnel with k-wires. Distances from the footprint center, the OTG drilling and the MPA drilling to the roof of the intercondylar notch and to the deep cartilage margin were determined. After positioning of radiological markers, radiographic analysis was performed according to the quadrant technique as described by Bernard and Hertel. The distance from ACL origin to the roof of the notch was 10.3 (±2.1) mm, in the OTG group 6.7 (±1.5) mm and in the MPA group 9.6 (±1.9) mm. The distance to the deep cartilage margin was 9.5 (±1.7) mm from ACL origin, 4.8 (±1.3) mm with OTG and 8.7 (±1.4) mm with MPA. There were statistically significant differences between the distances of the footprint center and the OTG group after measuring and also after radiographic analysis (p<0.0001). Using the MPA, no significant different distances in comparison to the anatomical ACL center were found (p>0.0001). There was an increased risk for femoral blow (9/10 vs. 0/10) in the OTG group after overdrilling with a 9mm drill. Short (5.5mm) offset femoral aiming devices fail to locate the native ACL footprint center in medial portal approach with an increased risk for femoral blowout when overdrilling. The special medial-portal-aiming device with 9mm offset hit the center reliably.

Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus

Autologous osteochondral transplantation is used in the management of osteochondral lesions of the talus that are not responsive or amenable to arthroscopic debridement or bone marrow stimulation. Therefore, the technique is indicated for large (>100-150mm 2 ) or cystic lesions. Technical success of the procedure is predicated on the ability to achieve perpendicular access to the lesion. Several methods exist to achieve this, including alterations in foot positioning with medial or lateral arthrotomy, as well as malleolar or tibial osteotomy. Graft implantation should be flush with the native articular surface. Good outcomes have been demonstrated in the short to medium term, and the results do not appear to depreciate over time. These results can be expected in patients with focal disease in which the lesion is contained. Donor cartilage is obtained from the lateral femoral condyle, intercondylar notch, or trochlea of the knee. Donor site knee pain and postoperative cyst formation have been reported in some series, and these risks should be weighed against the indications and clinical outcomes in the literature.

A neglected case of congenital dislocation of knee: Case report

In this case report, we describe a 1 and ½-year-old girl who presented with the full clinical and radiographic features of congenital dislocation of knee (CDK). The knee deformity in our patient was compatible with a complete grade 3 anterior dislocation of the tibia on the femur. The classic surgical approach to true CDK has been a V-Y quadricepsplasty combined with medial and lateral arthrotomies of the knee, which allow mobilization of the ligamentous structures that are anteriorly displaced is performed. CDK is a rare congenital disorder. The results of treatment are favorable if started before age 3 months, or sometimes before age 1 year, but there is no effective treatment for older, neglected cases; therefore, we believe this case report demonstrates a novel surgical approach.

The effect of partial fibulectomy on contact pressure of the knee: a cadaveric study

The fibula is a valuable source of bone graft and partial or total fibulectomy is done in some procedures, such as upper tibial osteotomy and treatment of tibial nonunion. Previous studies emphasized donor-site morbidity after fibulectomy. The aim of our study was to quantitatively survey joint reaction forces in the medial and lateral compartments of the ipsilateral knee, after partial fibulectomy. Using left knees of six cadavers, after medial and lateral arthrotomy and total meniscectomy, Fuji pressure-sensitive film was inserted to both lateral and medial knee compartments. Weight bearing was simulated using a novel device that allowed a defined axial force to be applied to the left lower limbs of supine cadavers. The axial force of half the body weight of each specimen was applied to the plantar surface of the foot. After removing the films, fibulectomy was done 12 cm proximal to lateral malleolus and 2 cm of fibula harvested. The examination was repeated again in the same manner with new films. The resulting Fuji films were scanned using HP Scanjet (G3110) with resolution of 4,800 × 9,600 dpi. Films interpreted using software for Fuji pressure-sensitive film analysis. Joint reaction force was decreased in the medial compartment (P = 0.028) and increased in the lateral compartment (P = 0.027) after partial fibulectomy. Our study also showed that pressure changes over the medial and lateral compartments of the knee were not dependent on body weight (P = 0.787 for the medial compartment and P = 0.872 for the lateral compartment) and decreasing pressure in medial compartment was not depended on increasing pressure in lateral compartment (P = 0.208 and correlation coefficient were 0.6). The current study demonstrated partial fibulectomy at 12 cm above lateral malleolus results in decreasing pressure in knee medial compartment and increasing pressure in knee lateral compartment. Further studies are needed to evaluate the clinical importance of partial fibulectomy.

A modified Maquet technique for management of cranial cruciate avulsion in a cat

This case report describes the management of cranial cruciate ligament avulsion from the femur of a four-year-old Norwegian Forest cat that presented with a history of lameness which had not improved with conservative treatment. During medial arthrotomy, avulsion of the cranial cruciate ligament from the caudomedial aspect of the lateral femoral condyle was suspected and the torn portion resected. A modified Maquet technique was performed on the left tibia resulting in a rapid improvement in lameness postoperatively. Histopathology of the resected cranial cruciate ligament confirmed avulsion. To the authors' knowledge this is the first reported use of this technique in the cat, and the first of stifle instability due to cranial cruciate ligament avulsion from the femur in the cat.