Background:
Both an elevated posterior tibial slope (PTS) and high-grade anterior knee laxity are often present in patients who undergo revision anterior cruciate ligament (ACL) surgery, and these ...conditions are independent risk factors for ACL graft failure. Clinical data on slope-correction osteotomy combined with lateral extra-articular tenodesis (LET) do not yet exist.
Purpose:
To evaluate the outcomes of patients undergoing revision ACL reconstruction (ACLR) and slope-correction osteotomy combined with LET.
Study Design:
Case series; Level of evidence, 4.
Methods:
Between 2016 and 2018, we performed a 2-stage procedure: slope-correction osteotomy was performed first, and then revision ACLR in combination with LET was performed in 22 patients with ACLR failure and high-grade anterior knee laxity. Twenty patients (6 women and 14 men; mean age, 27.8 ± 8.6 years; range, 18-49 years) were evaluated, with a mean follow-up of 30.5 ± 9.3 months (range, 24-56 months), in this retrospective case series. Postoperative failure was defined as a side-to-side difference of ≥5 mm in the Rolimeter test and a pivot-shift grade of 2 or 3.
Results:
The PTS decreased from 15.3° to 8.9°, the side-to-side difference decreased from 7.2 to 1.1 mm, and the pivot shift was no longer evident in any of the patients. No patients exhibited revision ACLR failure and all patients showed good to excellent postoperative functional scores (mean ± SD: visual analog scale, 0.5 ± 0.6; Tegner, 6.1 ± 0.9; Lysholm, 90.9 ± 6.4; Knee injury and Osteoarthritis Outcome Score KOOS Symptoms, 95.2 ± 8.4; KOOS Pain, 94.7 ± 5.2; KOOS Activities of Daily Living, 98.5 ± 3.2; KOOS Function in Sport and Recreation, 86.8 ± 12.4; and KOOS Quality of Life, 65.4 ± 14.9).
Conclusion:
Slope-correction osteotomy in combination with LET is a safe and reliable procedure in patients with high-grade anterior knee laxity and a PTS of ≥12°. Normal knee joint stability was restored and good to excellent functional scores were achieved after a follow-up of at least 2 years.
Despite the growing number of studies reporting on periprosthetic joint infection (PJI), there is little information on one-stage exchange arthroplasty for the revision of infected rotating-hinge ...prostheses, which can be among the most difficult PJI presentations to treat.
After one-stage direct exchange revision for an infected rotating-hinge TKA prosthesis, and using a multimodal approach for infection control, we asked: (1) What is the survivorship free from repeat revision for infection and survivorship free from reoperation for any cause? (2) What is the clinical outcome, based on the Oxford Knee Score, of these patients at the latest follow-up?
Between January 2011 and December 2017, we treated 101 patients with infected rotating-hinge knee prostheses at our hospital. All patients who underwent a one-stage exchange using another rotating-hinge implant were potentially eligible for this retrospective study. During that period, we generally used a one-stage approach when treating PJIs. Eighty-three percent (84 of 101) of patients were treated with one-stage exchange, and the remainder were treated with two-stage exchange. Of the 84 treated with one-stage exchange, eight patients died of unrelated causes and were therefore excluded, one patient declined to participate in the study, and another eight patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, leaving 80% (67 of 84) for analysis in this study. The included study population consisted of 60% males (40 of 67) with a mean age of 64 ± 8 years and a mean (range) BMI of 30 ± 6 kg/m2 (21 to 40). The mean number of prior surgeries was 4 ± 2 (1 to 9) on the affected knee. Fifteen percent (10 of 67) of knees had a preoperative joint communicating sinus tract, and 66% (44 of 67) had experienced a prior PJI on the affected knee. The antimicrobial regimen was chosen based on the advice of our infectious disease consultant and individually adapted for the organism cultured. The mean follow-up duration was 6 ± 2 years. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from repeat revision for infection and survivorship free from all-cause revision. The functional outcome was assessed using the Oxford Knee Score (on a 12- to 60-point scale, with lower scores representing less pain and greater function), obtained by interviewing patients for this study at their most recent follow-up visit. Preoperative scores were not obtained.
The Kaplan-Meier analysis demonstrated an overall survivorship free from reoperation for any cause of 75% (95% CI 64% to 87%) at the mean follow-up of 6 years postoperatively. Survivorship free from any repeat operative procedure for infection was 90% (95% CI 83% to 97%) at 6 years. The mean postoperative Oxford Knee Score was 37 ± 11 points.
With an overall revision rate of about 25% at 6 years and the limited functional results based on the poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function level after one-stage exchange of an infected rotating-hinge arthroplasty. Nevertheless, patients may be informed about a reasonable chance of PJI eradication and might opt for this approach as a means to try to avoid high transfemoral amputation or joint arthrodesis, which in this population often is associated with the inability to ambulate at all. Regarding the relatively high number of patients with aseptic loosening, future studies might focus on implant design of revision knee systems as well. A longer course of oral antibiotics after such procedures may also be warranted to limit the chance of reinfection but requires further study.
Level IV, therapeutic study.
Purpose
Trochlear dysplasia is a significant risk factor for patellofemoral instability. The severity of trochlear dysplasia is commonly evaluated based on the Dejour classification in axial MRI ...slices. However, this often leads to heterogeneous assessments. A software to generate MRI-based 3D models of the knee was developed to ensure more standardized visualization of knee structures. The purpose of this study was to assess the intra- and interobserver agreements of 2D axial MRI slices and an MRI-based 3D software generated model in classification of trochlear dysplasia as described by Dejour.
Methods
Four investigators independently assessed 38 axial MRI scans for trochlear dysplasia. Analysis was made according to Dejour’s 4 grade classification as well as differentiating between 2 grades: low-grade (types A + B) and high-grade trochlear dysplasia (types C + D). Assessments were repeated following a one-week interval. The inter- and intraobserver agreement was determined using Cohen’s kappa (κ) and Fleiss kappa statistic (κ). In addition, the proportion of observed agreement (po) was calculated for assessment of intraobserver agreement.
Results
The assessment of the intraobserver reliability with regard to the Dejour-classification showed moderate agreement values both in the 2D (κ = 0.59 ± 0.08 SD) and in the 3D analysis (κ = 0.57 ± 0.08 SD). Considering the 2-grade classification, the 2D (κ = 0.62 ± 0.12 SD) and 3D analysis (κ = 0.61 ± 0.19 SD) each showed good intraobserver matches. The analysis of the interobserver reliability also showed moderate agreement values with differences in the subgroups (2D vs. 3D). The 2D evaluation showed correspondences of κ = 0.48 (Dejour) and κ = 0.46 (high / low). In the assessment based on the 3D models, correspondence values of κ = 0.53 (Dejour) and κ = 0.59 (high / low) were documented.
Conclusion
Overall, moderate-to-good agreement values were found in all groups. The analysis of the intraobserver reliability showed no relevant differences between 2 and 3D representation, but better agreement values were found in the 2-degree classification. In the analysis of interobserver reliability, better agreement values were found in the 3D compared to the 2D representation. The clinical relevance of this study lies in the superiority of the 3D representation in the assessment of trochlear dysplasia, which is relevant for future analytical procedures as well as surgical planning.
Level of evidence
Level II.
Introduction
Although open-surgical techniques for the reconstruction of the posterolateral corner (PLC) are well established, the use of arthroscopic procedures has recently increased. When compared ...with open surgical preparation, arthroscopic orientation in the PLC is challenging and anatomic relations may not be familiar. Nevertheless, a profound knowledge of anatomic key structures and possible structures at risk as well as technical variations of arthroscopic approaches are mandatory to allow a precise and safe surgical intervention.
Materials and methods
In a cadaveric video demonstration, an anterolateral (AL), anteromedial (AM), posteromedial (PM) and posterolateral (PL) portal, as well as a transseptal approach (TSA) were developed. Key structures of the PLC were defined and sequentially exposed during posterolateral arthroscopy. Finally, anatomic relations of all key structures were demonstrated.
Results
All key structures of the PLC can be visualized during arthroscopy. Thereby, careful portal placement is crucial in order to allow an effective exposure. Two alternatives of the TSA were described, depending on the region of interest. The peroneal nerve can be visualized dorsal to the biceps femoris tendon (BT), lateral to the soleus muscle (SM) and about 3 cm distal to the fibular styloid (FS). The distal attachment of the fibular collateral ligament (FCL) can be exposed on the lateral side of the fibular head (FH). The fibular attachment of the popliteofibular ligament (PFL) is exposed at the tip of the FS.
Conclusion
Arthroscopy of the posterolateral recessus allows full visualization of all key structures of the posterolateral corner, which provides the basis for anatomic and safe drill channel placement in PLC reconstruction. A sufficient exposure of relevant anatomic landmarks and precise portal preparation reduce the risk of iatrogenic vascular and peroneal nerve injury.
Purpose
This study aimed to compare the biomechanical properties of the popliteus bypass against the Larson technique for the reconstruction of a combined posterolateral corner and posterior cruciate ...ligament injury.
Methods
In 18 human cadaver knees, the kinematics for 134 N posterior loads, 10 Nm varus loads, and 5 Nm external rotational loads in 0°, 20°, 30°, 60,° and 90° of knee flexion were measured using a robotic and optical tracking system. The (1) posterior cruciate ligament, (2) meniscofibular/-tibial fibers, (3) popliteofibular ligament (PFL), (4) popliteotibial fascicle, (5) popliteus tendon, and (6) lateral collateral ligament were cut, and the measurements were repeated. The knees underwent posterior cruciate ligament reconstruction, and were randomized into two groups. Group PB (Popliteus Bypass;
n
= 9) underwent a lateral collateral ligament and popliteus bypass reconstruction and was compared to Group FS (Fibular Sling;
n
= 9) which underwent the Larson technique.
Results
Varus angulation, posterior translation, and external rotation increased after dissection (
p
< 0.01). The varus angulation was effectively reduced in both groups and did not significantly differ from the intact knee. No significant differences were found between the groups. Posterior translation was reduced by both techniques (
p
< 0.01), but none of the groups had restored stability to the intact state (
p
< 0.02), with the exception of group PB at 0°. No significant differences were found between the two groups. The two techniques revealed major differences in their abilities to reduce external rotational instability. Group PB had less external rotational instability compared to Group FS (
p
< 0.03). Only Group PB had restored rotational instability compared to the state of the intact knee (
p
< 0.04) at all degrees of flexion.
Conclusion
The popliteus bypass for posterolateral reconstruction has superior biomechanical properties related to external rotational stability compared to the Larson technique. Therefore, the popliteus bypass may have a positive influence on the clinical outcome. This needs to be proven through clinical trials.
Purpose
The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational ...instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee.
Methods
This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2 years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test.
Results
23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49–100); the Tegner Score changed from 6.0 (3–10) before the injury to 5.0 (0–10) at the follow-up examination (
p
= 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6–14.8) mm before the injury to 4.0 (0.2–5.7) mm postoperatively (
p
< 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0–3) mm at the follow-up examination. VAS Function 0 (0–5), VAS pain 0 (0–6).
Conclusions
The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial, for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up.
Level of evidence
IV.
Malreduction after tibial plateau fractures mainly occurs due to insufficient visualization of the articular surface. In 85% of all C-type fractures an involvement of the posterolateral-central ...segment is observed, which is the main region of malreduction. The choice of the approach is determined (1) by the articular area which needs to be visualized and (2) the positioning of the fixation material. For simple lateral plateau fractures without involvement of the posterolateral-central segment an anterolateral standard approach in supine position with a lateral plating is the treatment of choice in most cases. For complex fractures the surgeon has to consider, that the articular surface of the lateral plateau only can be completely visualized by extended approaches in supine, lateral and prone position. Anterolateral and lateral plating can also be performed in supine, lateral and prone position. A direct fixation of the posterolateral-central segment by a plate or a screw from posterior can be only achieved in prone or lateral position, not supine. The posterolateral approach includes the use of two windows for direct visualization of the fracture. If visualization is insufficient the approach can be extended by lateral epicondylar osteotomy which allows exposure of at least 83% of the lateral articular surface. Additional central subluxation of the lateral meniscus allows to expose almost 100% of the articular surface. The concept of stepwise extension of the approach is helpful and should be individually performed as needed to achieve anatomic reduction and stable fixation of tibial plateau fractures.
Background:
Concomitant lesion of the medial collateral ligament (MCL) is associated with a greater risk of anterior cruciate ligament (ACL) graft failure.
Purpose:
The aim of this study was to ...compare two medial stabilization techniques in patients with revision ACL reconstruction (ACLR) and concomitant chronic medial knee instability.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
In a retrospective study, we included 53 patients with revision ACLR and chronic grade 2 medial knee instability to compare medial surgical techniques (MCL reconstruction n = 17 vs repair n = 36). Postoperative failure of the revision ACLR (primary aim) was defined as side-to-side difference in Rolimeter testing ≥5 mm or pivot-shift grade ≥2. Clinical parameters and postoperative functional scores (secondary aim) were evaluated with a mean ± SD follow-up of 28.8 ± 9 months (range, 24-69 months).
Results:
Revision ACLR was performed in 53 patients with additional grade 2 medial instability (men, n = 33; women, n = 20; mean age, 31.3 ± 12 years). Failure occurred in 5.9% (n = 1) in the MCL reconstruction group, whereas 36.1% (n = 13) of patients with MCL repair showed a failed revision ACLR (P = .02). In the postoperative assessment, the anterior side-to-side difference in Rolimeter testing was significantly reduced (1.5 ± 1.9 mm vs 2.9 ± 2.3 mm; P = .037), and medial knee instability occurred significantly less (18% vs 50%; P = .025) in the MCL reconstruction group than in the MCL repair group. In the logistic regression, patients showed a 9-times elevated risk of failure when an MCL repair was performed (P = .043). Patient-reported outcomes were increased in the MCL reconstruction group as compared with MCL repair, but only the Lysholm score showed a significant difference (Tegner, 5.6 ± 1.9 vs 5.3 ± 1.6; International Knee Documentation Committee, 80.3 ± 16.6 vs 73.6 ± 16.4; Lysholm, 82.9 ± 13.6 vs 75.1 ± 21.1 P = .047).
Conclusion:
MCL reconstruction led to lower failure rates in patients with combined revision ACLR and chronic medial instability as compared with MCL repair. MCL reconstruction was superior to MCL repair, as lower postoperative anterior instability, an increased Lysholm score, and less medial instability were present after revision ACLR. MCL repair was associated with a 9-times greater risk of failure.
AbstractPosterolateral impression fractures of the tibial plateau are common, and open reduction and fixation can be demanding, including exposure of the peroneal nerve. Based on a patient example, ...the surgical technique of an arthroscopic controlled closed reduction and percutaneous screw fixation of a posterolateral tibia plateau impressed fracture is described. A patient sustained a posterolateral impression currently described as an “apple bite” fracture of the tibial plateau. The surgical technique includes standard arthroscopic portals and posteromedial and (transseptal) posterolateral portals. The posterolateral tibial plateau is visualized by incision of popliteomeniscal fibers, retraction of the popliteus tendon, and exposure of the posterolateral plateau. The impression area is marked with a K-wire using an anterior cruciate ligament target device. A cannulated ram is placed over the K-wire. The fracture is lifted under arthroscopic guidance and can be supported with allograft bone chips. To stabilize the reduction, 3 K-wires are positioned from anterior to posterior, and 3 cannulated screws are inserted directly under the joint surface to support the fractured area. In comparison with open surgical techniques, this procedure is exclusively performed under arthroscopic control and enables an anatomic reduction and fixation of the posterolateral tibial plateau.
Purpose
Malunions are a common complication after tibial plateau fractures (TPF), leading to stiffness, pseudo-instability and posttraumatic osteoarthritis. The purpose of this study was to analyse ...the clinical outcome after intraarticular osteotomy of malunited TPF and to perform a failure analysis.
Methods
Between 2013 and 2018, 23 patients (11 males, 12 females; 43.8 ± 12.8 years) with intraarticular osteotomy after malunited TPF were included in the retrospective study. Clinical examination and postoperative scores were collected with a minimum follow-up of 24 months. Malunion was measured on pre- and postoperative CT scans and localized according to the 10-segment classification while the leg axis in the frontal plane was measured pre- and postoperatively on long leg standing radiographs.
Results
Excellent and good clinical outcome was achieved in 73.9% (
n
= 17) of the cases and patient related outcome improved significantly (Tegner 3.3 ± 1.6–5 ± 1.8,
p
< 0.001; clinical Rasmussen 14.6 ± 3.8–24.9 ± 4.4,
p
< 0.001). Radiological parameters also improved as an intraarticular step-off was reduced from 9 ± 3.8 to 0.6 ± 0.8 mm (
p
< 0.001) and a lower limb malalignment from 7.2 ± 4.8° to 1.5 ± 1.9° (
p
= 0.003). Failure analysis showed that an impaired clinical result correlated with a postoperative extension (
n
= 3,
p
< 0.001) and flexion deficit (
n
= 4,
p
= 0.035).
Conclusion
Intraarticular osteotomy of malunited TPF lead to good clinical results with significant clinical and radiological improvement in most cases while an impaired patient outcome correlated with a limited range of motion. This study is the first failure analysis of intraarticular osteotomy after malunited TPF published up to now.
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