Posterior Knee Research Articles

Risk factors associated with amputation in civilian popliteal artery trauma

Popliteal artery trauma is uncommon but is associated with a high risk of limb loss depending on the scenario involving blunt or penetrating trauma as well as the severity and extent of injury that has occurred. In our setting there is a significant amount of gang and civilian warfare resulting in Vascular Trauma. There were 32 patients over a decade who sustained traumatic injury to the popliteal artery consisting of 30 males (94%) and 2 females with an age range 16–59 years with a mean of 32. There were 20 cases of penetrating trauma (63%) and 12 cases of blunt trauma (37%). Of the penetrating trauma, 18 were due to gunshot wounds (GSWs) (90%) and 2 stabs. The majority (7/12; 58%) of blunt trauma was due to falls, and 42% (5/12) secondary to motor vehicular accidents (MVAs). In terms of extent of injury, 21 of 32 patients (65%) sustained an isolated popliteal artery injury, whilst 6 (19%) had injury to both the popliteal artery and vein and another 5 (16%) had combined popliteal artery, vein and nerve injuries. There were 14 cases with associated orthopaedic injuries: 7 posterior knee dislocations, 1 fracture/dislocation of the knee, 2 femoral fractures, 2 tibial plateau fractures and 2 tibia/fibula fracture. Methods of repair included 14 reversed vein grafts, 16 polytetrafluoroethylene (PTFE) grafts and 2 primary. The overall amputation rate was 28% (9 patients). Of the penetrating trauma patients 25% required amputations composed of 5 GSWs, 33% of the blunt trauma patients required amputations. It was noted that factors associated with (but not statistically significant) poor outcomes included combined artery/vein injury, artery/vein/nerve injury, concomitant fracture/dislocation and delayed transfer to a Vascular Surgery Unit. The type of graft or repair did not affect outcome. The incidence of popliteal artery trauma was calculated at 2.46 per 100,000 population per year.

Diagnosis and surgical treatment of the posterior knee instability

Background/Aim. Posterior cruciate ligament is the primary stabilizer of the posterior tibia translation and secondary stabilizer of external tibial rotation as well as varus, valgus knee angulation. It is the strongest ligament in the knee that hurts the rarest. The aim of this study was to show the indications for surgery, present the surgical technique and give results of surgical treatment of posterior knee instability. Methods. The study icluded 12 patients who were tretaed surgically for posterior knee instabilility at the Institute for Orthopaedic Surgery ?Banjica?, Belgrade, in the period from 1st January 2010 to 1st January 2014. All of them had arthroscopically assisted anatomic reconstruction of posterior crucuate ligament done with 4-strand hamstring tendon graft. Postoperative follow-up lasted approximately 42 months and Lysholm values and International Knee Documentation Committee (IKDC) score were compared as well as the clinical status. Results. All treated patients had Grade III of posterior instability. Combined injuries of the posterolateral corner and anterior cruciat ligament (75%) were very frequent. Preoperative mean value of Lysholm score was 45.92 and postoperative 85.92 what was statistically significant improvement, the same as subjective IKDC score whose mean value was 38.58 preoperatively and 89.75 after the surgery and rehabilitation. Clinical examination showed better posterior knee stability although in 50% of patients certain level of instability remains. Conclusion. Arthroscopic reconstruction with 4-strand hamstring tendon gives satisfactory result with posterior cruciate ligament reconstruction. The result of subjective feeling of patient is much better then objective clinical examination. Although surgical procedure is technically demanding, with physically active patients having grade III of posterior instability it provides better result than non-surgical treatment.

Radiographic Morphology and Method for Localization of the Adductor Tubercle on Anterior-Posterior Knee Radiographs.

The adductor tubercle (AT) is a landmark for joint line identification in knee arthroplasty. Up to now, there has not been a dedicated study to define its morphology on an anterior-posterior (AP) radiograph. As a result, radiographic localization of the AT has been inconsistent and confusing. Ten bone specimens, each with the AT labeled with a metal marker, were radiographed to demonstrate the AT appearance on AP radiographs. Based on this knowledge, a method to locate the AT was developed. A total of 200 clinical radiographs were examined to further confirm the observed radiographic morphology with emphasis on the visibility of the AT and its association with the rotational status of the knee on radiographs. One hundred of them were used to test the reliability of this method of AT identification. Of the 200 ATs, 153 (76%) were clearly visible on radiographs as a faint pyramid-shaped shadow protruding outward from the inflexion point of the concave-convex silhouette over the femoral shaft-condylar junction, allowing direct identification. For invisible ATs (24%), this inflexion point was found to be a useful surrogate landmark for their identification. Locating the AT using this technique showed a good intra- and interobserver reliabilities. The proposed method may be valuable for the consistent use of this landmark in joint line identification on radiographs.

Degenerative changes after posterior cruciate ligament reconstruction are irrespective of posterior knee stability: MRI-based long-term results.

Posterior cruciate ligament reconstruction (PCLR) is advocated to prevent an early onset of osteoarthritis. We hypothesized that posterior instability after PCLR correlates with degenerative changes. MRIs of 42 (12 female/30 male; 39 ± 9years) patients were enrolled with a minimum 5-year follow-up (FFU) after PCLR. In addition, 25 contralateral and 15 follow-up MRIs (12months after baseline) were performed. Degenerative changes were graded using WORMS. Posterior tibial translation (PTT) was measured using posterior stress radiographs. Outcome parameters included WORMS/cartilage subscore for the whole joint, patellofemoral (PFJ), medial (MFTJ), and lateral femorotibial joint (LFTJ). Final follow-up was 101 (range 68-168) months. WORMS reached 41.5 [18.5-56.8]. Regional WORMS for PFJ was significantly higher than MFTJ and LFTJ. Cartilage subscore yielded 7 [2.8-15]. MFTJ and PFJ were significantly higher than LFTJ. Primary outcome parameters were significantly higher than the contralateral knee (P < 0.0001) and significantly increased within 12months (P = 0.0002). There was a significant correlation between the intraoperative degree of cartilage injury and WORMS (P < 0.0001 with r = 0.64) and between the number of previous surgery and the cartilage subscore (P = 0.03 with r = 0.32). Meniscal surgery led to a significantly higher WORMS (P = 0.035). Combined risk models revealed that women below the mean age had significantly lower WORMS (P = 0.001) and cartilage subscores (P = 0.003). Patients undergo degenerative changes after PCLR, which are significantly higher compared to the contralateral knee. These occur predominantly at PFJ/MFTJ and are irrespective of posterior stability. Concomitant meniscus/cartilage injuries and a high number of previous surgeries are further risk factors.

Arthroscopic medial meniscal repair with or without concurrent anterior cruciate ligament reconstruction: A subgroup analysis

BackgroundThere are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction. MethodsA total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior–posterior knee movement. ResultsMean follow-up duration was 61 (34–85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red–red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively. ConclusionConcurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red–red zone appeared to be associated with better outcomes.

Flexion Gap in the Isolated Posterior Cruciate Ligament-Injured Knee Affects Symptom Relief After Conservative Treatment: A Case-Control Study.

Background:The posterior cruciate ligament (PCL) is a primary stabilizer of the knee in the posterior direction. However, PCL deficiency presents a clinical paradox because the outcome of PCL deficiency ranges from total disability to uninterrupted participation in competitive athletics.Purpose:To investigate whether posterior laxity (PL) and the flexion gap (FG) influence the results of the conservative treatment of isolated PCL injuries.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 27 patients (23 men, 4 women; mean age, 33 ± 14 years) with isolated PCL injuries between 2007 and 2013 were included in this study. All patients had been treated conservatively for more than 6 months. Nineteen patients achieved excellent relief of their symptoms (conservative treatment [C] group). Eight patients underwent PCL reconstruction owing to their symptoms (surgical treatment [S] group). Side-to-side differences of the FG and the PL were retrospectively measured on axial radiographs and on lateral radiographs with gravity sag views, respectively, and the degree of PCL injury was graded as I (PL, <5 mm) in 7 patients and II (PL, 5 to <10 mm) in 20 patients.Results:The mean PL and FG were 6.9 ± 2.5 mm and 2.0 ± 1.8 mm, respectively. A mild positive correlation between the PL and the FG was observed (r = 0.47, P = .02). The mean PL and FG were 6.5 ± 2.9 mm and 1.2 ± 1.0 mm in the C group and 7.7 ± 1.3 mm and 3.8 ± 2.0 mm in the S group, respectively. The FG in the C group was significantly smaller than that in the S group (P < .05), although there was no significant difference between the groups for PL. All patients with grade I injury belonged to the C group, for which the FG was less than 2 mm in all cases. Eight of the patients with grade II injury were in the S group, and their FG was more than 2 mm, except in 1 patient. The FG performed better with an area under the receiver operating characteristic curve of 0.924 (95% CI, 0.000-1.000) compared with 0.599 (95% CI, 0.388-0.809) for the PL. Discrimination between the C and S groups with a cutoff set at 2.30 mm for the FG and 7.45 mm for the PL showed a sensitivity of 75.0% and 75.0% and a specificity of 89.5% and 52.6%, respectively.Conclusion:Considering that the FG affects the outcome of conservative treatment, it could be a factor in the indication for the surgical treatment of isolated PCL injuries.

Ultrasound Evaluation of the Symptomatic Popliteal Fossa

The popliteal fossa is a common site of lower extremity pain and other symptoms for which imaging evaluation frequently occurs. When the presenting clinical history includes trauma, evaluation can be straightforward; however, when there is no reported history of trauma, the cause of posterior knee symptoms may be less obvious. Ultrasound (US) usually begins the workup for cause of symptoms involving the posterior knee. When a comprehensive, straightforward scanning protocol is used, the US evaluation often will complete the patient's workup. This article reviews the anatomy that comprises the popliteal fossa. It also discusses a concise US scanning protocol that can be used for a comprehensive evaluation of popliteal fossa symptoms. Finally, it reviews the differential diagnosis of popliteal fossa symptoms, emphasizing the problem-solving ability of US with case examples.

Adding Patella Resurfacing After Circumpatellar Electrocautery Did Not Improve the Clinical Outcome in Bilateral Total Knee Arthroplasty in Chinese Population: A Prospective Randomized Study

BackgroundIn total knee arthroplasty (TKA), handling of the patella surface is still quite controversial. We carried out a prospective randomized study to compare circumpatellar electrocautery plus patella resurfacing vs circumpatellar electrocautery only in the single-staged bilateral TKA in Chinese population. MethodsOne hundred five patients diagnosed with late-staged osteoarthritis who received single-staged bilateral TKA were screened and 53 patients were included. All patients received the same posterior cruciate-stabilizing total knee prostheses. Patients were randomized to receive circumpatellar electrocautery plus patellar resurfacing or circumpatellar electrocautery only for the first TKA, and the second knee received the opposite treatment. All patients were followed for a minimum of 2 years. ResultsNo differences were found with regard to Knee Society Score, Feller score, anterior knee pain, and revision rates. Fifty-two percent of patients had no preference with regard to pain and function, 27% of patients preferred the resurfacing plus circumpatellar electrocautery knee while 21% of the patients preferred the circumpatellar electrocautery only knee. The Insall-Salvati index and the patella tilt were a little smaller in the resurfacing group. One patient (2.1%) in the circumpatellar electrocautery group underwent a patella resurfacing revision for severe anterior knee pain and patella subluxation. ConclusionEquivalent clinical results for circumpatellar electrocautery plus resurfacing and circumpatellar electrocautery alone of the patella in TKA were demonstrated in selective Chinese population with thick enough patella.

Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears

Background: Magnetic resonance imaging (MRI) of the knee is a highly sensitive and specific method for diagnosing acute posterior cruciate ligament (PCL) tears, with a reported accuracy of 96% to 100%. In chronic and revision settings, these injuries may be missed on MRI because of the apparent continuity of nonfunctional PCL fibers. Posterior tibial translation (PTT) of the medial compartment has been identified as a potential secondary finding of PCL tear on routine MRI. Purpose/Hypothesis: The purpose of this study was to evaluate the sensitivity of PTT on MRI associated with PCL injuries and compare it with the sensitivity of a radiologist’s MRI interpretation with preoperative posterior knee stress radiographs as the gold standard. Our hypothesis was that the MRI measurement of PTT of the medial compartment would improve diagnostic sensitivity as compared with the diagnosis made by the interpreting radiologist’s evaluation of the continuity of the PCL fibers for chronic and postrecostruction graft injuries. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Cases of patients who underwent a primary or revision PCL reconstruction, without anterior cruciate ligament injury, by a single surgeon between 2010 and 2016 were retrospectively analyzed. Measurements of medial and lateral compartment PTT were performed with the MRI of PCL-injured cases and controls without clinical or MRI evidence of ligamentous injury. The sensitivity of this technique was compared with the preoperative MRI diagnosis determined by review of the musculoskeletal radiologist’s report and confirmed by the gold standard of posterior knee stress radiographs. The sensitivity of medial compartment PTT was determined by receiver operator characteristic (ROC) analysis and compared with the MRI sensitivity for chronic PCL and PCL graft tears. Results: One hundred patients (80 males and 20 females) with a mean age of 31.1 years (range, 15-66 years) met the inclusion criteria: 57 acute primary tears, 32 chronic primary, and 11 PCL graft tears. MRI sensitivity was 100% for acute primary PCL tears, 62.5% for chronic primary PCL tears, and 18.1% for PCL graft tears. There were significant differences in medial compartment PTT on MRI for acute versus chronic injuries (P = .025) and acute versus graft injuries (P = .007). ROC curve analysis indicated that the most accurate cutoff point for the detection of chronic PCL tears was 2.0 mm of medial compartment PTT on MRI, with a sensitivity and specificity of 0.80 and 0.89, respectively. For PCL graft injuries, the ROC curve indicated that the most accurate medial compartment PTT cutoff for the detection of PCL graft failure was 3.6 mm (sensitivity, 0.92; specificity, 0.72). Conclusion: MRI evaluation of the PCL fibers had poor sensitivity for chronic PCL tears and PCL reconstruction graft tears. The sensitivity for diagnosing chronic PCL tears and PCL reconstruction graft failures was improved by measuring posteromedial tibial translation.

Effect of acupuncture plus thunder-fire moxibustion on MMP-3, TIMP-1 and TGF-β1 in rats with knee osteoarthritis

To observe the effect of acupuncture plus thunder-fire moxibustion on the expressions of matrix metalloproteinase-3 (MMP-3), tissue inhibitor of metalloproteinase-1 (TIMP-1) and transforming growth factor-β1 (TGF-β1) in cartilage of knee osteoarthritis (KOA) rats, and to explore the mechanism of acupuncture plus thunder-fire moxibustion in the treatment of KOA. Thirty Sprague-Dawley (SD) rats were randomly divided into a blank control group, a model group and an acupuncture-moxibustion group by random digits table, 10 rats in each group. Rats in the model group and the acupuncture-moxibustion group were injected with papain in the right posterior knee joint to prepare the models. The levels of MMP-3 and TIMP-1 in rat synovium of each group were measured by enzyme-linked immunosorbent assay (ELISA) after 2 weeks of treatment. The level of TGF-β1 was determined by Motic B5 Micro-camera system. The levels of MMP-3 and TIMP-1 in the cartilage of the model group were significantly higher than those in the blank control group (all P<0.01); the levels of MMP-3 and TIMP-1 in the acupuncture-moxibustion group were lower than those in the model group, and the between-group differences were statistically significant (all P<0.05). The levels of MMP-3 and TIMP-1 in the acupuncture-moxibustion group were higher than those in the blank control group, and the differences were statistically significant (all P<0.05). The level of TGF-β1 in cartilage tissues of the model group was significantly lower than that in the blank control group (P<0.01); the level of TGF-β1 in the acupuncture-moxibustion group was higher than that in the model group (P<0.05), but it was lower than that in the blank control group, and the between-group difference was statistically significant (P<0.05). Acupuncture plus thunder-fire moxibustion can effectively recover the abnormal expressions of MMP-3 and TIMP-1 in KOA model rats and somewhat up-regulate TGF-β1, which may be one of its mechanisms of acupuncture plus thunder-fire for KOA.

Bi-cruciate stabilized total knee arthroplasty can reduce the risk of knee instability associated with posterior tibial slope.

The purpose of this study was to evaluate the relationship between posterior tibial slope and knee kinematics in bi-cruciate stabilized (BCS) total knee arthroplasty (TKA), which has not been previously reported. This computer simulation study evaluated Journey 2 BCS components (Smith & Nephew, Inc., Memphis, TN, USA) implanted in a female patient to simulate weight-bearing stair climbing. Knee kinematics, patellofemoral contact forces, and quadriceps forces during stair climbing (from 86° to 6° of flexion) were computed in the simulation. Six different posterior tibial slope angles (0°-10°) were simulated to evaluate the effect of posterior tibial slope on knee kinematics and forces. At 65° of knee flexion, no anterior sliding of the tibial component occurred if the posterior tibial slope was less than 10°. Anterior contact between the anterior aspect of the tibial post- and the femoral component was observed if the posterior tibial slope was 6° or more. An increase of 10° in posterior tibial slope (relative to 0°) led to a 4.8% decrease in maximum patellofemoral contact force and a 1.2% decrease in maximum quadriceps force. BCS TKA has a wide acceptable range of posterior tibial slope for avoiding knee instability if the posterior tibial slope is less than 10°. Surgeons should prioritize avoiding adverse effects over trying to achieve positive effects such as decreasing patellofemoral contact force and quadriceps force by increasing posterior tibial slope. Our study helps surgeons determine the optimal posterior tibial slope during surgery with BCS TKA; posterior tibial slope should not exceed 10° in routine clinical practice.

High tibial slope correlates with increased posterior tibial translation in healthy knees.

Notwithstanding the importance of the tibial slope (TS) for anterior tibial translation, little information is available regarding the implications on posterior laxity, particularly in healthy subjects. It was hypothesized that increased TS is associated with decreased posterior tibial translation (PTT) in healthy knees. A total of 124 stress radiographs of healthy knees were enrolled in this study. Tibial slope and the posterior tibial translation were evaluated using a Telos device with a 150-N force at 90° of knee flexion. Two blinded observers reviewed independently on two different occasions. One hundred and twenty-four patients [35 females and 89 males; 41 (range 18-75) years] were enrolled in this study, with a mean PTT of 2.8mm (±1.9mm; range 0-8mm) and a mean TS of 8.6° (±2.6°; range 1°-14°). Pearson correlation showed a significant correlation between the PTT and TS in the overall patient cohort (P<0.0001) with r=0.76 and R 2=0.58. There was no statistical difference between female and male patients regarding the PTT or the TS. Subgrouping of the patient cohort (four groups with n=31) according to their TS (groups I<7°; II=7°-8.5°; III=9°-10.5°; IV≥11°) revealed significant differences between each subgroup, respectively. Furthermore, there was a weak but significant correlation between age and PTT (P=0.004, r=0.26). In addition to the substantial variance in tibial slope and posterior laxity among healthy knees, high tibial slope significantly correlates with increased posterior tibial translation. Increasing age is further associated with a greater magnitude of posterior tibial translation. Consequently, knowledge of the tibial slope facilitates simple estimation of posterior knee laxity, which is mandatory for PCL reconstruction and knee arthroplasty.

Poster 284: Deep Vein Thrombosis Presenting as Posterior Knee Pain After Playing Soccer: A Case Report

Poster 284: Deep Vein Thrombosis Presenting as Posterior Knee Pain After Playing Soccer: A Case Report

Relationship of performance on the sensory organization test to landing characteristics

ABSTRACTJump landing tasks have been used to assess landing characteristics and require significant sensorimotor feedback to maintain functional joint stability (FJS) throughout the task. Postural stability (PS) also requires significant sensorimotor feedback and control and would seemingly involve similar sensory feedback pathways. However, previous literature clarifying the relationship between these two processes, maintaining FJS and PS, is limited. 80 Special Tactics Operators. PS was assessed using the Sensory Organization Test (SOT). SOT variables included: Composite, Somatosensory, Visual, Vestibular, and Preference scores. Landing characteristics were assessed using motion analysis during a double-legged (DLSJ) and single-legged (SLSJ) stop jump task. Pearson’s correlation coefficients were calculated to assess the relationship between SOT scores and landing characteristics (α < .05). For the DLSJ, significant correlations were found between: Composite and peak posterior ground reaction forces (−.257), Vestibular and peak knee abduction moment (−.237), and Preference and initial contact hip flexion (−.297), peak hip flexion (−.249). For the SLSJ, significant correlations were found between: Somatosensory and peak vertical ground reaction forces (−.246); Preference and initial contact hip flexion (−.295), peak hip flexion (−.262). The results indicate that the SOT may not be a sensitive enough tool to assess sensorimotor control in a healthy, athletic population.

Surgical management of posterior knee dislocation associated with extensor apparatus rupture

ObjectiveThe purpose of this study was to report the clinical and functional results of patients who underwent surgical management for posterior knee dislocation associated with extensor apparatus rupture. IntroductionPosterior knee dislocations associated with extensor apparatus ruptures are defined as rare but complicated injuries, which are difficult to return to the level of activity prior to the injury. The study demonstrated a hypothesis that good knee stability and early gain of range of motion could be achieved with deliberate design of the treatment protocol and proper application of the instruments. MethodsFifteen patients with posterior knee dislocations associated with extensor apparatus ruptures were evaluated after reduction and repair of extensor apparatus. Following that, multiple-ligament reconstruction in association with use of a lateral knee-spanning external fixator was applied for at least six weeks. Ligament reconstructions were performed using allografts. Range of motion and knee stability were both measured at each follow-up evaluation at a mean time of 36months. The assessment was made using the Lysholm Knee Scoring Scale. ResultsThe mean Lysholm scale score was 87.6 (range 73–95), with excellent in 11 cases, good in two, and fair in two. In the final evaluation, the range of motion was a mean range of 123.4° (range 100–135). ConclusionThe use of a lateral knee-spanning external fixator ensured the safety of repaired vessels, knee stability after reduction, and early rehabilitation with range of motion.

Gait patterns and walking ability after training with a hybrid robotic exoskeleton compared to conventional gait training in early stroke rehabilitation

The hamstrings are often associated with the development of crouch gait, a fatiguing form of walking characterized by excessive hip flexion, knee flexion and ankle dorsiflexion during stance. However, recent studies have called into question whether abnormally active hamstrings induce the limb to move into a crouch posture. The purpose of this study was to directly measure the influence of the hamstrings on limb posture during stance. Nineteen healthy young adults walked on an instrumented treadmill at their preferred speed. A 90 ms pulse train was used to stimulate the medial hamstrings during either terminal swing or loading response of random gait cycles. Induced motion was defined as the difference in joint angle trajectories between stimulated and non-stimulated strides. A dynamic musculoskeletal simulation of normal gait was generated and similarly perturbed by increasing hamstring excitation. The experiments show that hamstring stimulation induced a significant increase in posterior pelvic tilt, knee flexion and ankle dorsiflexion during stance, while having relatively less influence on the hip angular trajectory. The induced motion patterns were similar whether the hamstrings were stimulated during late swing or early stance, and were generally consistent with the direction of induced motion predicted by gait simulation models. Hence, we conclude that overactive hamstrings have the potential to induce the limb to move toward a crouch gait posture.

Local infiltration of analgesia and sciatic nerve block provide similar pain relief after total knee arthroplasty

BackgroundAlthough femoral nerve block provides satisfactory analgesia after total knee arthroplasty (TKA), residual posterior knee pain may decrease patient satisfaction. We conducted a randomized controlled trial to clarify the efficacy of the sciatic nerve block (SNB) and local infiltration of analgesia with steroid (LIA) regarding postoperative analgesia after TKA, when administrated in addition to femoral nerve block (FNB).MethodsSeventy-eight patients were randomly allocated to the two groups: concomitant administration of FNB and SNB or FNB and LIA. The outcome measures included post-operative pain, passive knee motion, C-reactive protein level, time to achieve rehabilitation goals, the Knee Society Score at the time of discharge, patient satisfaction level with anesthesia, length of hospital stay, surgical time, and complications related to local anesthesia.ResultsThe patients in group SNB showed less pain than group LIA only on postoperative hours 0 and 3. Satisfactory postoperative analgesia after TKA was also achieved with LIA combined with FNB, while averting the risks associated with SNB. The influence on progress of rehabilitation and length of hospital stay was similar for both anesthesia techniques.ConclusionsThe LIA offers a potentially safer alternative to SNB as an adjunct to FNB, particularly for patients who have risk factors for sciatic nerve injury.

Principles of posterior knee joint instability treatment (literature review)

Damage of posterior crucial ligament postern-lateral stabiliz­ing structures is a significant injury to the knee. Incomplete diagnosis of lesions in the acute period of trauma and subse­quent inadequate treatment leads to functional instability and rapid progression of degenerative processes. Objective: based on the analysis of scientific literature to identify further direc­tion for improving surgical techniques and improving outcomes of patients with posterior instability of the knee joint. Meth­ods: keyword search on problems of diagnosis, classification and selection method for treating posterior knee instability in the english-speaking academic libraries, databases Pubmed, Medline, Cochrane library and the Russian media over the past 15 years. Results: mechanisms of posterior crucial ligament inju­ry are very diverse. Damage can be isolated or combined, have a chronic course. In recent years, increased interest in the re­construction of all the internal structures of the knee. Reports of the functional results of posterior crucial ligament surgi­cal treatment is less than anterior crucial ligament. The sig­nificance of the problem is associated with low frequency and less surgical treatment of posterior crucial ligament injuries, as well as the heterogeneity of acute, chronic and combined it with the potential damage involving posterolateral joint. Damage of posterior crucial ligament often remains unrecognized and therefore untreated. The authors analyzed the methods used to­day to treat patients with posterior instability of the knee joint, whereby defined prospects for improving surgical techniques and improving outcomes.

Double-bundle PCL Reconstruction: A Prospective Study of Two-year Patient Reported Outcomes with Stress Radiographs

Objectives:Reconstruction of grade-III posterior cruciate ligament (PCL) ruptures has historically been compromised by graft elongation and residual laxity. The purpose of this study was to report prospectively collected two-year outcomes and failure rates of double-bundle PCL reconstruction in a consecutive patient series with patient reported outcomes and quantitative stress radiographs. It was hypothesized that double bundle PCL reconstruction would result in improved subjective clinical outcomes, restoration of knee stability, and result in high patient satisfaction.Methods:A single surgeon consecutive series of patients that underwent double-bundle PCL reconstruction between June, 2010, and April, 2014, were followed prospectively. The technique is anatomically and biomechanically validated and utilizes two allografts (Achilles tendon for anterolateral bundle, tibialis anterior tendon for posteromedial bundle) in divergent femoral tunnels and a single tibial tunnel, each secured at the tibia at different knee angles to recreate the function of the two PCL bundles. Patient reported outcomes were collected preoperatively, and at a minimum two-year follow-up, including SF12, WOMAC, Tegner, Lysholm, and patient satisfaction. Posterior kneeling stress radiographs were obtained preoperatively and at the 6-month follow-up period. Failures were defined objectively as a difference of more than 3 mm in stress radiographs.Results:Sixty patients had greater than 2 year follow-up (mean 2.9 yrs). All subjective outcome measures improved except SF-12 mental component which was unchanged. The mean Lysholm score improved from 48 to 79. The mean WOMAC score improved from 39 to 11. The median SF-12 physical component score improved from 32 to 55. The median Tegner activity score improved from 2 to 5. The median patient satisfaction score was 8. Stress radiographs were available for 36 patients and improved from a preoperative side-to-side difference of 9.6 mm to 1.0 mm at 6 months follow-up. One failure occurred in a patient who had an 8 mm side-to-side difference at final follow-up and 18 mm pre-operatively.Conclusion:Double bundle PCL reconstruction results in improved patient reported outcomes and restoration of posterior knee stability. High patient satisfaction and low failure rates were found in this cohort of patients.

Outcome of posterior cruciate ligament-retaining primary total knee arthroplasty in arthritic patients

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The incidence of arthritis is rising in India due to increase in the proportion of ageing population and obesity. Cruciate retaining total knee arthroplasty (TKA) is a promising mode of treatment for end stage arthritis, with excellent functional outcome. Hence, we have evaluated the functional outcome of posterior cruciate ligament retaining TKA and the problems related to the procedure at our institute.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;This prospective study was conducted on 30 patients who underwent posterior cruciate ligament retaining primary TKA at a tertiary health care centre between December 2012 and May 2014. Patients were evaluated using Knee society score (knee score and function score) at regular follow up visits&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The study included TKA for 42 knees in 30 patients. Indications for TKA were osteoarthritis in 37 knees and rheumatoid arthritis in 5 knees. The average follow-up period was 24 weeks. All the 42 knees had poor knee score (&amp;lt;60) and poor functional score (&amp;lt;60) preoperatively. Postoperatively 37 knees had excellent (80-100) and 5 knees had good knee score (70-79) whereas 22 patients had excellent (80-100), 5 patients had good (70-79), 2 patients had fair (60-69) and 1 patient had poor functional score (&amp;lt;60). &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Our study demonstrates that posterior cruciate retaining TKA is a reliable procedure with excellent functional outcome, pain relief and early return of patients to their daily activities. Posterior cruciate retaining TKA provided excellent knee society score and functional score in majority of patients.&lt;/span&gt;&lt;/p&gt;