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The optimal treatment of partial anterior cruciate ligament (ACL) tears continues to be debatable. Short-term results of selective bundle reconstruction have already been widely shown. The purpose of this study was to assess functional outcomes, subjective satisfaction and the failure rate of selective bundle reconstructions for partial ACL tears over a five to nine year follow-up period.Patients who underwent ACL selective bundle reconstruction between October 2008 and October 2012 were studied. Functional assessment was performed with the objective International Knee Documentation Committee (IKDC) ligament evaluation form, the Lysholm knee scale and the Tegner activity level scale. Cumulative failure and level of satisfaction have also been investigated.Seventy-six patients were included. The average follow-up period was 85 months (range 65-110). Thirty-four had AMB tear and 42 had PLB tears. An overall statistically significant improvement (p 0.001) was obtained in terms of the subjective IKDC and the Lysholm questionnaire between preoperative and last follow-up. The same or no more than one level lower Tegner score was restored in 97.3% of the cases. Cumulative failure was observed in two patients (2.6%). Dissatisfied patient percentage was 15% (4/76).Selective bundle reconstruction in partial ACL tears leads to excellent long-term functional outcomes, a low percentage of failures and a high degree of subjective satisfaction in patients.Therapeutic case series; level 4.

Objective: The aim of this study was to evaluate whether the establishment of a preoperative screening and decolonization protocol for Staphylococcus aureus carriers undergoing total knee arthroplasty (TKA) could decrease the incidence of periprosthetic joint infection (PJI) caused by this microorganism. Methods: We conducted a retrospective study comparing a control group comprising 400 patients (134 men, and 266 women; mean age: 72.2 ± 6.8 years) who went through surgery between January 2009 and December 2013, with a second intervention group of 403 patients (125 men, and 278 women; mean age: 72.4 ± 6.9 years) in which the protocol of screening and decolonization of S. aureus nasal carriers was applied between January 2014 and December 2016. During this latter period patients were preoperatively screened and, if positive, treated with mupirocin nasal ointment and chlorhexidine soap, for 5 days prior to surgery. Results: In the control group, 17 of 400 patients (4.2%) had a SSI, 8 (2%) of them caused by S. aureus and 9 (2.2%) by other microorganisms. In the intervention group 20.6% of patients had a positive S. aureus nasal swab and were treated according to the protocol. 5 of 403 patients (1.2%) in this group had a SSI, 1 (0.2%) due to S. aureus and 4 (1%) to other microorganisms. When comparing surgical-site infection (SSI) rates between the two groups, we found a statistically significant reduction in both global SSI (p = 0.009) and specifically S. aureus SSI (p = 0.02), in the intervention group. No decolonized S. aureus nasal carrier presented a SSI. Discussion: In patients undergoing TKA a preoperative screening and decolonization protocol for S. aureus nasal carriers, using mupirocin nasal ointment and chlorhexidine soap, is an effective measure to reduce the rate of SSI caused by this microorganism. Level of Evidence: Level III; Therapeutic Study. Keywords: S. aureus, TKA infection, Screening protocol, Decolonization protocol, TKR infection

Author(s): Pogorzelski, David; Nguyen, Uyen; McKay, Paula; Thabane, Lehana; Camara, Megan; Ramsey, Lolita; Seymour, Rachel; Goodman, J Brett; McGee, Sheketha; Fraifogl, Joanne; Hudgins, Andrea; Tanner, Stephanie L; Bhandari, Mohit; Slobogean, Gerard P; Sprague, Sheila; PREP-IT Investigators Executive Committee:; Steering Committee; Adjudication Committee; Data and Safety Monitoring Committee; Research Methodology Core; Patient Centred Outcomes Core; Orthopaedic Surgery Core; Operating Room Core; Infectious Disease Core; Military Core; McMaster University Methods Center; University of Maryland School of Medicine Administrative Center; University of Maryland School of Pharmacy, The PATIENTS Program; PREP-IT Clinical Sites: Lead Clinical Site (Aqueous-PREP and PREPARE); Aqueous-PREP and PREPARE; Aqueous-PREP; PREPARE; PREP-IT Investigators Executive Committee | Abstract: IntroductionPragmatic trials in comparative effectiveness research assess the effects of different treatment, therapeutic, or healthcare options in clinical practice. They are characterized by broad eligibility criteria and large sample sizes, which can lead to an unmanageable number of participants, increasing the risk of bias and affecting the integrity of the trial. We describe the development of a sampling strategy tool and its use in the PREPARE trial to circumvent the challenge of unmanageable work flow.MethodsGiven the broad eligibility criteria and high fracture volume at participating clinical sites in the PREPARE trial, a pragmatic sampling strategy was needed. Using data from PREPARE, descriptive statistics were used to describe the use of the sampling strategy across clinical sites. A Chi-square test was performed to explore whether use of the sampling strategy was associated with a reduction in the number of missed eligible patients.Results7 of 20 clinical sites (35%) elected to adopt a sampling strategy. There were 1539 patients excluded due to the use of the sampling strategy, which represents 30% of all excluded patients and 20% of all patients screened for participation. Use of the sampling strategy was associated with lower odds of missed eligible patients (297/4545 (6.5%) versus 341/3200 (10.7%) p l 0.001).ConclusionsImplementing a sampling strategy in the PREPARE trial has helped to limit the number of missed eligible patients. This sampling strategy represents a simple, easy to use tool for managing work flow at clinical sites and maintaining the integrity of a large trial.

UDTAULÍ The incidence of anterior cruciate ligament (ACL) lesions with Tanner stage ≤4 has been increasing in children. To stabilize the knee, different surgical techniques have been developed for ACL reconstruction in the pediatric population. The use of a hybrid anatomic technique, intra-epiphyseal in the femur and transphysis in the tibia, has been recommended as the technique of choice to reconstruct the ACL in these patients. Despite the favorable results, this technique is not exempt from complications. The aim of this study was to present a simple and reproducible modification of the hybrid anatomic technique for ACL reconstruction in pediatric patients.

The aim of the study was to translate and validate the English version of the 'Knee Society Knee Scoring System' developed in 2011 (2011 KSS) into Spanish. This new KSS version considers patient satisfaction and expectations before and after knee arthroplasty. Moreover, the questionnaire allows a better characterization of a younger and more diverse population.A cross-cultural adaptation process was carried out to obtain the Spanish version of the questionnaire. After that, patients undergoing primary knee arthroplasty answered the translated questionnaire before and 6 months after surgery. Psychometric properties including feasibility, validity, reliability, and sensitivity to change were then assessed, and the questionnaire was compared with prior KSS, as well as with SF-12 and WOMAC, all of them already validated to Spanish.In the cross-cultural adaptation process, alternative translations of some items in 'Patient Expectative' and 'Functional Activities' sections were suggested. One hundred and seventy-six patients answered the resulting 1.0 version. Feasibility: 'Charnley Functional Classification', 'Deduction for flexion contracture and extensor lag', the question 'Do you use these aids because of your knees?', and 'Advanced activities (total)' obtained a high number of missing items. Eighty-eight patients (50%) in the preoperative visit and 141 patients (86.5%) after surgery had at least one missing answer. Internal validity: although the analysis suggests the presence of more than one dimension, there was a dimension that explained a higher percentage of variance, which was more noticeable in the postoperative visit. Convergent validity: correlation coefficients with prior KSS, SF-12, and WOMAC confirm the questionnaire's validity. Reliability: Cronbach's alpha for the new KSS was 0.841 and 0.861 in visit 1 and 2, respectively, and higher than that for prior KSS. Sensitivity to change: statistically, significant differences were found between the mean scores between both visits.The proposed Spanish version of 2011 KSS is valid, reliable, and sensible to change in patients undergoing primary knee arthroplasty. Moreover, it has higher internal consistency (reliability) than the prior KSS. It should be emphasized its correct filling by both health professional and patients LEVEL OF EVIDENCE: II.

PURPOSE: To compare the radiographic results (in terms of graft extrusion) and the functional results of lateral meniscus allograft transplantations (MAT) performed with a bony fixation technique or with a soft tissue fixation technique after capsulodesis. METHODS: A prospective series of 29 consecutive lateral MAT was analyzed. The inclusion criterion for MAT was lateral joint line pain due to a previous meniscectomy. Malalignment, patients who had an Ahlback grade greater than II, and patients with a body mass index over 30 were considered as the exclusion criterion to prevent confounding results. Fifteen of the grafts were fixed with a bony fixation technique (group A). The remaining 14 cases (group B) were fixed with sutures through bone tunnels after lateral capsular fixation (capsulodesis). All patients were studied with magnetic resonance imaging to determine the degree of meniscal extrusion at an average of 18 months of surgery (range, 12-48 months). Meniscal extrusion was measured on coronal magnetic resonance imaging. To standardize the results, the percentage of meniscus extruded for each group was also calculated and compared. The functional results were analyzed by means of standard knee scores (Lysholm, Tegner, and visual analog scale). RESULTS: If we consider the first 4 cases of group B as the learning curve of the new technique, we observe that group A had 8 cases (53.3%) of major extrusion, whereas group B had 1 case (7.1%) (P = .02). When comparing the degree of meniscal extrusion with the type of fixation employed, an even lower percentage of extruded menisci was found in group B (P = .01). The final follow-up Lysholm score in group A was 94.33 ± 5.96 (P < .001) and 91.43 ± 6.19 (P < .001) in group B. The median follow-up Tegner score significantly improved from 4 (range, 2-5) to 7 (range, 6-9) in group A (P < .001) and from 4 (range, 3-5) to 7 (range, 6-8) in group B (P < .001). The average visual analog scale score dropped down 5.87 and 7.29 points in groups A and B, respectively (P < .001). The Knee Injury and Osteoarthritis Outcome Score improved from 51.98 ± 2.84 to 90.88 ± 7.53 in group A (P < .001) and from 50.44 ± 2.32 to 92.01 ± 6.71 in group B (P < .001). Patient satisfaction with regard to the procedure stood at a mean of 3.6 ± 0.2 points out of a maximum of 4 in group A and 3.8 ± 0.4 in group B. There were no complications in this series. CONCLUSIONS: The capsulodesis technique in lateral MAT proved not to be statistically different at decreasing the degree of meniscal extrusion with respect to the bone-bridge fixation. If the first 4 cases using the new capsulodesis technique had not included in the results, the capsulodesis technique would have effectively presented better results relative to the degree of meniscal extrusion compared with the bone-bridge fixation technique. In addition, the functional results were similar. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The purpose of this study was to analyze postoperative computed tomography (CT) scan evaluations of patients who had undergone a combined anterior cruciate ligament (ACL) reconstruction and modified Lemaire anterolateral tenodesis (ALT) with femoral fixation through a bony tunnel.Postoperative CT scans of 52 patients who had undergone combined ACL and ALT were prospectively evaluated. ACL femoral tunnels were drilled through an anteromedial portal in the center of the native footprint. An ALT fixation tunnel was drilled 5 mm proximal to the lateral epicondyle, aiming at an inclination of 30° proximally and 30° anteriorly. Two independent observers evaluated the CT scans measuring any degree of collision, the shortest distance between the tunnels, and the inclination of the ALT tunnels. Measurements were carried out at both the cortical level and on a plane passing 1 cm deeper in the lateral condyle.At the level of the cortex, no convergence of the tunnels was identified. In 14 of 52 cases (26.9%), the shortest distance between the tunnels was less than 5 mm. Tunnel collision occurred in 8 of 52 cases (15.4%), and the bone bridge between the tunnels was less than 5 mm in 11 cases (21.1%) when the measurements were made on the deeper plane. When the inclination on the axial plane was less than 15°, a collision always (P.001) occurs. When it was more than 20°, no collision occurred (P.001). No correlation between convergence and the inclination of the ALT tunnel on the coronal plane was detected.To fix a modified Lemaire ALT through a femoral tunnel avoiding any interference with an anatomic femoral ACL tunnel, we recommend that the femoral tunnel be drilled with an inclination of at least 20° anteriorly.IV, therapeutic case series.

PURPOSE: To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics. METHODS: Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols. RESULTS: A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 ± 1.5 vs. 1.7 ± 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups. CONCLUSION: Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used.

Purpose: To report the magnetic resonance imaging (MRI) and clinical outcomes at a minimum 5-year follow-up in a series of patients with postmeniscectomy syndrome and treated with a polyurethane scaffold. Methods: All consecutive patients operated on from September 2008 to February 2011 for either persistent medial or lateral joint line compartmental pain receiving a polyurethane scaffold due to a previous partial meniscus resection with a minimum 5-year followup were included. Functional scores (Knee Injury and Osteoarthritis Outcomes Score, International Knee Documentation Committee, Lysholm, and Tegner) were assessed preoperatively and at the last follow-up. The state of the scaffold as well as postoperative scaffold extrusion and the total remaining meniscal volume was also evaluated in MRI. Results: Thirty-two patients were included. The mean follow-up was 70.8 +/- 7.5 months. The functionality of the knees improved in all the scores used (P < .001) except for the Tegner score that stayed steady. Most of meniscal implants showed extrusion of 2.4 mm (95% confidence interval [ CI], 1.1-3.7) were smaller and a hyperintensity signal was seen in the MRI. Three scaffolds were resorbed at the last follow-up. The meniscal volume, determined by MRI, was 1.14 cm(3) (95% CI, 0.96-1.31) preoperatively and 1.61 cm(3) (95% CI, 1.43-1.7) at the last follow-up. No differences were presented. Conclusions: The use of a polyurethane meniscal scaffold in patients with a symptomatic meniscus deficit had a good functional outcome at 5 years after surgery. However, the implanted scaffolds did not present normal meniscal tissue with MRI, and the implant volume was considerably less than expected. The fact that most of patients included received different concomitant procedures during scaffold implantation introduces a degree of performance bias into the results.

Introduction Pigmented villonodular synovitis (PVS) is a synovial proliferation disorder of uncertain aetiology, with some controversy as regards its proper treatment. The purpose of the study was to evaluate the functional outcome and recurrence rate in a series of patients diagnosed with both the diffuse and the localised types of PVS and treated by arthroscopic resection. Material and methods Twenty-four patients diagnosed with PVS were retrospectively assessed. There were 11 cases with the diffuse type, and 13 cases with the localised type of PVS. They were followed-up for a median of 60 months (range, 34–204). They underwent arthroscopic synovectomy, and were functionally evaluated with IKDC, WOMET, and Kujala scores. Results There was recurrence in 8 out of 13 (61.5%) cases with the diffuse type of PVS. Two of these patients were treated with radiation. One patient underwent surgical resection with an open procedure due to extra-articular involvement. The remaining 5 patients underwent a second arthroscopic resection, and no recurrence was subsequently observed. Cases with localised PVS did not recur after a single arthroscopic resection. IKDC, WOMET and Kujala scores improved by 30.6, 37.4 and 34.03 points, respectively. Discussion Pigmented villonodular synovitis treated by arthroscopic resection showed good functional results at mid-term follow-up. A single arthroscopic resection was sufficient to treat the localised PVS, whereas the diffuse type of PVS required a second arthroscopic resection in most cases, due to its high rate of recurrence.

Purpose To evaluate the association of anterior cruciate ligament (ACL) injuries with the intercondylar notch angle and notch width in male patients. The secondary purpose was to evaluate the association of these injuries with other novel morphologic parameters. Methods Male patients undergoing primary ACL reconstruction between 2010 and 2013 for injury through noncontact mechanisms with preoperative magnetic resonance imaging were compared with an age-matched control group of male patients (patients who underwent knee operations other than ACL reconstruction) regarding the following magnetic resonance imaging–assessed parameters: intercondylar notch angle, width, and depth; condylar width; medial/lateral condylar widths; medial/lateral posterior tibial plateau slopes; anterior sagittal tibial slope (corresponding to the level of the tibial ACL footprint); coronal tibial slope; and angle between the Blumensaat line and anterior tibial slope. Results In both the coronal and axial planes, patients with ACL injury had a significantly lower intercondylar notch angle ( P P = .008, respectively) than the control group, but there were no significant between-group differences for intercondylar notch width ( P = .9 and P = .97, respectively). In the sagittal plane, patients with ACL injury had significantly higher medial ( P P = .02) posterior tibial slopes, a significantly lower anterior tibial slope ( P = .01), and a significantly higher angle between the Blumensaat line and anterior tibial slope ( P = .02) than the control group. Conclusions Narrowing of the intercondylar notch may be associated with ACL injury in male patients. However, the intercondylar notch angle may be a better parameter to evaluate notch narrowing and its potential association with ACL injuries compared with the notch width. The association between the angle formed by the Blumensaat line and anterior tibial slope and ACL injuries in male patients needs more investigation. This study further suggests that increased posterior tibial slope may be associated with ACL injury in male patients. Level of Evidence Level III, case-control study.

Microfracture, the current standard of care for the treatment of non-degenerative chondral lesions in the hip joint, is limited by the poor quality of the filling fibrocartilaginous tissue. BST-CarGel (Piramal Life Sciences, Laval, Quebec, Canada) is a chitosan-based biopolymer that, when mixed with fresh, autologous whole blood and placed over the previously microfractured area, stabilizes the blood clot and enhances marrow-triggered wound-healing repair processes. BST-CarGel has been previously applied in the knee, with statistically significant greater lesion filling and superior repair tissue quality compared with microfracture treatment alone. In this report we describe the application of BST-CarGel for the arthroscopic treatment of hip chondral lesions. Our preliminary data suggest that our BST-CarGel procedure provides high-quality repair tissue and therefore may be considered a safe, cost-efficient therapeutic choice for the treatment of hip chondral defects.

Why anterior cruciate ligament (ACL) autograft soaking in a 5 mg/ml vancomycin solution decreases the rate of infection has not been well-explained. One hypothesis is that grafts can be contaminated during harvesting and vancomycin eradicates the bacteria. The purpose of the present study is to assess how the vancomycin solution acts against ACL graft contamination during graft harvesting and preparation. The study was carried out in three university hospitals over a period of 6 months. After sample size calculation, 50 patients were included in the study. Three samples were taken from each ACL graft. Sample 1 was obtained immediately after graft harvesting. After graft manipulation and preparation, the remaining tissue was divided into two parts. The raw sample was denominated sample 2 and sample 3 consisted of the rest of the remaining tissue that had been soaked in the vancomycin solution. All the cultures were incubated at 37 °C with 5% CO2 in agar plates for 7 days (aerobically) or 14 days (anaerobically) and inspected daily for microbial growth. Any bacterial growth and the number of colony forming units were reported. In seven cases (14%), either sample 1 or sample 2 was positive. In five of the cases (10%), only the sample after graft preparation was positive (sample 2). In two cases (4%), sample 1 and sample 2 were positive for the same bacteria. Isolated microorganisms corresponded to coagulase-negative staphylococci (CNS) and Propionibacterium acnes. No bacterial growth was observed in sample 3 (p

Although several surgical techniques have been described to perform meniscal allograft transplantation with good clinical results and although different methods of capsular stabilization can be found in the literature, there is no standard surgical technique to prevent a common complication in the most of series: the tendency to a radial displacement or extrusion of the transplanted menisci. We present a simple, reproducible, and implant-free technique to perform a lateral capsular fixation (capsulodesis) at the time of only the soft-tissue fixation technique of meniscal allograft transplantation in an effort to reduce or prevent the risk of graft extrusion. Using a minimum of two 2.4-mm tunnels drilled from the contralateral side of the tibia with the help of a regular tibial anterior cruciate ligament guide, a capsular attachment to the lateral tibial plateau is obtained.

Background Sealing of the femoral canal, usually with autologous bone, is a surgical procedure that is often performed during TKA surgery to decrease blood loss in the postoperative period. However, evidence as to the effectiveness of this surgical procedure is not conclusive. The objective of this study was to assess the effectiveness of this surgical action in reducing postoperative blood loss and the blood transfusion rate. Methods A randomized prospective study that included 201 TKAs divided into three groups (67 in each one) was carried out. The three groups were; A) bone graft sealing, B) cement sealing and C) unsealed canal. All groups were comparable with regard to pre and intra-operative data. The haemoglobin decrease at 2, 24 and 72 h was compared to the preoperative haemoglobin value. Subsequently, blood drainage at 12 and 24 h and the rate of blood transfusion were also assessed. The different complications that arose were reported. Results No statistical differences were obtained with regard to blood drainage at 12 h (p = 0.102) and 24 h (p = 0.542), the haemoglobin value decrease at 72 h (p = 0.95) and the number of blood transfusions (p = 0.597) in the three groups studied. Conclusion There was no significant difference, whether sealing the femoral canal with a bone graft, cement or when it was left unsealed, in decreasing blood loss or blood transfusion requirements in the postoperative period. Level of evidence Therapeutic type I.

Objectives To study the relationship between the appearance of end-of-stem pain with a preoperative decrease in local bone strength by using the bone microindentation technique. The potential usefulness of pressure algometry in the diagnosis and monitoring of this group of patients is also determined. Materials and methods A preliminary intra- and inter-rater correlation study was performed in a group of 50 healthy volunteers in order to validate the algometry technique. A prospective study was then conducted on 20 patients with a mean age of 74 years (range 57–84) undergoing knee prosthetic surgery with use of a cementless tibial stem. Bone microindentation and pressure algometry measurements were made preoperatively, and after one year of follow-up. The statistical analysis was performed using the Intraclass correlation coefficient and the Student's t-test for paired data. Results The intra- and inter-rater correlation values were excellent; 0.91 (0.84–0.95) and 0.86 (0.74–0.92), respectively. No significant variations were found in the microindentation (P = 0.11) or in the pressure algometry (P = 0.6) values after one year of follow-up. Nevertheless, a significant correlation was observed between the values for pressure algometry and the EVA (P = 0.002) and functional scale (P = 0.02) at the end of follow-up. Conclusions Pressure Algometry is a useful tool to evaluate this group of patients. Bone microindentation does not seem to be useful in identifying patients with increased risk of developing tibial end-of-stem pain.

Background: Hamstring tendon grafts may have an unacceptable size for use in anterior cruciate ligament (ACL) reconstruction. Magnetic resonance imaging (MRI) has been proposed to predict the diameters of hamstring tendon grafts. Hypothesis: Preoperative ultrasonography (US) might reliably anticipate intraoperative 4-strand semitendinosus and gracilis tendon (4ST-GT) graft sizes similarly to MRI. An MRI evaluation of the hamstring tendons with a higher magnification may improve the accuracy of the method. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 33 patients undergoing ACL reconstruction with a 4ST-GT graft and MRI performed at our institution were included. The cross-sectional area (CSA) of each semitendinosus tendon (ST) and gracilis tendon (GT) was calculated preoperatively with US and with MRI under 2× and 4× magnification. Intraoperative measurement of the final diameter of the 4ST-GT using a closed-hole sizing block with 0.5-mm increments was made. Pearson correlation coefficients were calculated to determine the relationship between the final intraoperative graft diameter of the 4ST-GT and the CSA of the ST and GT measured with US and MRI with 2× and 4× magnification. Simple linear regression was also calculated to attempt to predict the graft diameter based on given measurements. Results: There were statistically significant correlations between the measured CSA with US and both MRI magnifications with the 4ST-GT diameter. However, MRI under 4× magnification showed a much higer correlation (0.86) than MRI under 2× magnification (0.54) or US (0.51). Final graft diameters ≥8 mm were observed in 80.8% of patients with a CSA >14 mm2, in 76.9% of patients with a CSA >25 mm2, and in 96.2% of patients with a CSA >17 mm2 measured with US, 2× magnification of MRI, and 4× magnification of MRI, respectively. Conclusion: Preoperative calculation of the CSA of the hamstring tendons with MRI and US can help to reliably estimate 4ST-GT grafts. In terms of correlation of the CSA with graft diameter, US was comparable to 2× MRI, but 4× MRI showed a much greater accuracy. Threshold values of the CSA of the ST and GT of 25 mm2, 17 mm2, and 14 mm2 with the 2× MRI, 4× MRI, and US methods, respectively, are needed to reliably predict a 4ST-GT graft with a minimum diameter of 8 mm.

OBJECTIVES Supracondylar femoral fracture is a complex complication after total knee arthroplasty (TKA). One potential complication of retrograde locked nailing is malunion in extension of the femoral prosthetic component--produced by an overly posterior nail entry point in the intercondylar notch. The aim of this study was to determine the repercussion of this deformity on the midterm radiological and functional outcomes of TKA. DESIGN Retrospective review. METHODS From 2001 to 2006, 30 patients were treated for supracondylar femoral fracture above TKA with a retrograde locked nail. In 7 patients (6 women and 1 man) with a mean age of 78.8 years (range, 74-84 years), more than 10 degrees of hyperextension (mean of 18.5 degrees) of the femoral component on the sagittal plane was observed without any significant misalignment on the coronal plane. Functional outcomes were assessed using the Knee Society Score. RESULTS After a mean follow-up of 68.5 months (range, 48-111 months), all patients' fractures with a hyperextension of the femoral component had consolidated with no clinical or radiological signs of TKA loosening. These patients presented "good" functional outcomes at final follow-up. CONCLUSIONS These results should be interpreted with caution. However, isolated hyperextension of the femoral component of a TKA after placing a retrograde nail for a periprosthetic fracture does not seem to significantly affect the functional or radiological outcomes at ∼6-years follow-up. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to compare the diagnostic accuracy for the detection of infection between the culture of fluid obtained by sonication (SFC) and the culture of peri-implant tissues (PITC) in patients with early and delayed implant failure, and those with unsuspected and suspected septic failure. It was hypothesised that SFC increases the diagnostic accuracy for infection in delayed, but not early, implant failure, and in unsuspected septic failure. The diagnostic accuracy for infection of all consecutive implants (hardware or prostheses) that were removed for failure was compared between SFC and PITC. This prospective study included 317 patients with a mean age of 62.7 years (9 to 97). The sensitivity for detection of infection using SFC was higher than using PITC in an overall comparison (89.9% versus 67%, respectively; p < 0.001), in unsuspected septic failure (100% versus 48.5%, respectively; p < 0.001), and in delayed implant failure (88% versus 58%, respectively; p < 0.001). PITC sensitivity dropped significantly in unsuspected compared with suspected septic failure (p = 0.007), and in delayed compared with early failure (p = 0.013). There were no differences in specificity. Sonication is mainly recommended when there is implant failure with no clear signs of infection and in patients with delayed implant failure. In early failure, SFC is not superior to PITC for the diagnosis of infection and, therefore, is not recommended as a routine diagnostic test in these patients. Cite this article: Bone Joint J 2013;95-B:244–9.

Objective To evaluate whether an alteration of the lower limb axis is associated with meniscal extrusion. Materials and Methods: Ninety-four patients who had complained of knee pain with good knee function and had a knee magnetic resonance image (MRI) and a full-length X-ray taken of the lower limb were included in the study. Meniscal extrusion was measured in the coronal MRI. Subluxation of the meniscus was considered minor or physiological if ≤3 mm, and major if >3 mm. The extrusion as a percentage of meniscus size was also calculated. Knee alignment (varus, negative value; valgus, positive value) was correlated with the presence of minor and major extrusion. Results There were varus knees in 61 cases (58.7%), with a mean measured deviation of −2.63°. Valgus knees were observed in 27 knees (26%) and had a mean deviation of 2.22°. The medial meniscus showed major extrusion in 18 cases (17.3%). It corresponded to 44.7% of the meniscus size. The lateral menisci showed no subluxation in most cases. There was no correlation between alignment and meniscal extrusion in this series, either for the medial meniscus (p = 0.760) or for the lateral meniscus (p = 0.381). Conclusions In patients complaining of knee pain with good knee function, there is no relationship between mild malalignment and the degree of meniscus extrusion.

The main objective of this study was to compare the functional results and the impact on quality of life after a single-radius or a multiradius TKA implantation. The secondary objectives were to compare range of motion, satisfaction and the ability to perform daily life activities with both types of implant. It was hypothesized that the single-radius TKA would lead to better functional results and better quality of life than the multiradius TKA. This is a prospective non-randomized study that included 250 cases of a single-radius TKA and 224 of a multiradius posterior-stabilized TKA implanted with the same surgical and rehabilitation protocol. In the 1- and 5-year follow-up, we found similar knee KSS scores (89.7 ± 12.1 in the multiradius group and 90.3 ± 11.7 in the single-radius group) and functional KSS scores (78.6 ± 21.4 in the multiradius group and 75.8 ± 20.9 in the single-radius group). The pain and the Physical SF-36 scores were also similar. Range of motion (112° ± 12° in the multiradius group and 112 ± 12° in the single-radius group), patients’ satisfaction and the ability to perform daily life activities were also similar in both groups. The use of a single-radius or a multiradius posterior-stabilized knee prosthesis can improve the function of the knee and the patients’ quality of life in a similar way at the short-term and midterm follow-up. Moreover, range of motion, patient satisfaction and the ability to perform daily life activities are similar with both types of prosthesis. As both types of prosthesis can improve the function and quality of life of the patients in a similar way, the sagittal radius of the femoral component should not be considered the main factor when choosing the model of TKA. Therapeutic study: Prospective comparative study, Level II

Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes.A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination.Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL.The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.

Meniscal tissue's ability to heal has been shown to be limited. Until recently, orthopedic surgeons treating patients who had undergone a meniscectomy had few options available to treat the persistent pain sometimes associated with it and the subsequent early joint degeneration. This was true except

Objective The aim of this study was to know what were the preferences of the Spanish surgeons about different aspects of anterior cruciate ligament (ACL) reconstruction. Material and methods In February 2009, 910 surveys regarding some technical aspects of ACL reconstruction was mailed to surgeons who perform this kind of surgery in Spain. The survey had 8 questions: number of ACL reconstructions per year, two clinical cases, what kind of graft was preferred, the use of simple or double bundle reconstruction, the time and the amount of tension to apply to the hamstrings during ACL reconstruction and finally, some aspects about the creation of the femoral tunnel. Results A total of 102 responses were received. Most of them (66%) had between 5–20 years of experience. A 60.3% of them performed between 10–50 procedures per year. The first choice graft in both clinical cases was autologous hamstring tendons (62% and 64%). The transtibial technique (71.8%) and the single bundle technique (79.1%) were preferred. Discussion The management of the ACL injuries remains unclear. Like in other countries with available ACL registries, autologous hamstrings have increased their use for ACL reconstruction. However, there is not consensus in some aspects of the technique. Conclusion The preferred technique for ACL reconstruction in this group was the transtibial technique with single bundle and using autologous hamstring tendons.

The purpose of this work was to describe the posterior ankle impingement syndrome related to the posterolateral tubercle of the talus bone and to present a retrospective analysis of our results after arthroscopic plasty of the tubercle in 15 ankles with a mean 3-year follow-up. Fifteen cases of posterior ankle impingement (PAI) underwent arthroscopic excision of an impinging bone spur. All the patients (13) were retrospectively evaluated at an average of 36 months after index surgery. There were seven women (bilateral in two of them) and six men. Ten were involved in different kinds of sport and three were professional ballet dancers. Preoperative symptoms included pain localized in the posterior ankle, limitation of motion, weakness and swelling. All patients had failed a course of conservative therapies. Surgery was performed through posterolateral and posteromedial portals as described by van Dijk. After soft tissue debridement, partial resection of the posterolateral process was performed until there was complete plantar flexion without bone impingement. Postoperatively, all patients followed the same rehabilitation protocol. Improvement in their impingement symptoms was recorded in all of them according to AOFAS score. One of them (7%) still had occasional discomfort. The results suggest that arthroscopic bone decompression of the posterolateral tubercle in cases of PAI resistant to non-surgical therapies is an effective treatment.

Joint infection after anterior cruciate ligament (ACL) reconstruction is uncommon but has potentially serious consequences for the graft and articular cartilage. Most recently published series are in agreement that an urgent arthroscopic washout and antibiotic treatment are mandatory to preserve both graft and cartilage. However, several questions have not as yet been touched upon. We performed a literature review to assess the most interesting series published about this issue. In this review, a management protocol is first presented that discusses the different diagnostic parameters to consider and surgical and antibiotic treatment suggested according to the literature. Outcomes published in different series are also discussed.

PURPOSE: To determine the best angle to drill the femoral tunnels of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with concomitant posterior cruciate ligament (PCL) reconstruction to avoid either short tunnels or tunnel collisions. METHODS: Eight cadaveric knees were studied. Double-bundle PCL femoral tunnels were arthroscopically drilled. Drilling of the sMCL and POL tunnels was performed in 4 different combinations of 0° and 30° axial (anteriorly directed) and coronal (proximally directed) angulations. Specimens were scanned with computed tomography to document the relations of the sMCL and POL tunnels to the intercondylar notch and PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS: When the sMCL femoral tunnel was drilled at 0° axial and 30° coronal (proximally directed) angulations or 30° axial (anteriorly directed) and 0° coronal angulations, the risk of tunnel collision with the PCL tunnels increased in comparison with the remaining evaluated angulations (P < .001). No POL tunnels collided with either PCL tunnel bundle with the exception of tunnels drilled at 0° axial and 30° coronal (proximally directed) angulations, which did so in 3 of 8 cases (P < .001). The minimum required tunnel length was obtained in all the sMCL and POL tunnels (P < .001 and P = .02, respectively). However, some of those angled at 0° on the axial plane violated the intercondylar notch. CONCLUSIONS: When one is performing posteromedial reconstructions with concomitant PCL procedures, the sMCL and POL femoral tunnels should be drilled anteriorly and proximally at both 30° axial and 30° coronal angulations. The POL femoral tunnel may also be angled 0° in the coronal plane. Tunnels at 0° axial angulations showed a shorter distance to the intercondylar notch and a higher risk of collision with the PCL tunnels. CLINICAL RELEVANCE: Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when sMCL and POL femoral tunnels are placed with concomitant PCL reconstruction.

Introduction: The addition tibial valgus osteotomy (ovat) is a common treatment of symptomatic genu varus. This frequently is accompanied by considerable loss of medial meniscal tissue. The aim was to evaluate, in the context of performing a ovat, restoring the functional impact of this lack of medial meniscal tissue with Actifit® compared with the simple meniscectomy. Material and Methods: Sixty patients with symptomatic genu varo operated with ovat were studied prospectively. In 30 patients we have left a medial meniscal defect> 25 mm (M) and in 30 a medial Actifit® was implanted(A). The evaluations were performed using Womet, IKDC, Kujala, EVA and satisfaction (0-4). Results: Both groups were statistically comparable preoperatively, including follow-up time (31.2 months; range, 24-47.5; p = 0.35). 53.4 ± 8.4 Womet improved and 42.4 ± 17.2 points in M and A (p = 0.002), improved IKDC 56.7 ± 12 and 50.3 ± 15.6 points in M and A (p = 0.107), 50.4 ± 14.7 Kujala improved to 38.9 ± 21.6 points M and A (p = 0.02) and VAS decreased 6.9 ± 2.1 and 4.7 ± 2.8 points in M and A (p = 0.006). The satisfaction was 3.3 ± 0.8 and 3.3 ± 1 in M and A (p = 0.84). Conclusions: The symptomatic genu varus treated with OVAT associated to medial meniscectomy led, compared to when it was associated with the implantation of a medial Actifit®, to a marked improvement in most of the scales tested. There was no difference in the degree of satisfaction. Based on short-term results of this study, restitution replacement with polyurethane substitute can not be recommended to perform a ovat.

Introduction: The surface medial collateral ligament (LCMs) and the posterior oblique ligament (POL) are sometimes concomitantly reconstructed with the posterior cruciate ligament (PCL). The objective was to determine the most appropriate angle of the femoral tunnel. Material and Methods: 8 cadaveric knees. Bifascicular LCP tunneling performed arthroscopically. Tunnels LCMs and LOP at 0 ° and 30 ° in axial / coronal planes (0A / 30A // 0C / 0C). Were studied by CT and valued intercondylar relationship, PCL ,and tunnels. A 25mm tunnel was the least considered sufficient Results: The LCMs tunnels 30A / 30C and 30A / 0C measured 31.8 ± 3.2 and 32.2 ± 2.8 mm, respectively, without encroaching on the LCP and 17.4 ± 4 and 17.67 ± 3.8mm intercondylar ceiling. The LCMs 0A / 0C and 0A / 30C tunnels were 5.8 ± 5.2 and 7.2 ± 4.7 of intercondilo respectively, without invasion of the PCL. The LCMs tunnels 0A / 30C in 4 cases ended intraarticulararmente. The LOP 30A / 0C and 30A / 30C measured 33 ± 2.7 and 32.3 ± 3mm, without invasion of the PCL and 16.2 ± 5.7 and 19.3 ± 4.6mm of intercondilo. The LOP 0A / 0C and 0A / 30C tunnels were 6.50 ± 3.9 and 2.9 ± 5.3mm of intercondilo. The LOP tunneled 0A / 30C invaded in 3 cases the PCL tunnels and ended intraarticularly on 7 occasions. Conclusions: The angulation of the femoral tunnels LCMs and POL have versatility although the LCP is rebuild concomitantly. LCMs tunnels and POL axially oriented at 0° and 30° in coronal planes have high risk of puncturing the joint and in the case of POL also invade LCP tunnels.

The existence of meniscal extrusion is well known in the natural history of the osteoarthritic knee. However, extruded menisci are also seen in non-pathologic knees. To ascertain the prevalence of meniscal extrusion in non-arthritic patients, the MRIs of 100 knees were prospectively studied. The data were correlated both with clinical and operative arthroscopic findings. The results showed 68.5% of the medial menisci to have some degree of extrusion, averaging at 28% of the meniscal size. While the lateral meniscus were extruded in 18.8% of cases at an average of 15% of the meniscal size. Furthermore, a relationship between the anterior insertion variant of the anterior medial meniscus and meniscal extrusion was found (P=0.001) in this series. The results suggest meniscal extrusion to be much more common in non-arthritic knees than previously estimated. The results also suggest that when the anterior horn of the medial meniscus inserts anteriorly in the tibial plateau, the meniscus tends to be extruded. It must be kept in mind that one of the limitations of this work is that the MRIs are taken in a non-weightbearing position.

To determine whether the bathing of an anterior cruciate ligament (ACL) autograft in vancomycin reduces the rate of infection following an ACL reconstruction.Retrospective analysis of all ACL reconstructions over an 8-year period in two University Hospitals. In the initial 4-year period, all patients were operated on under classical antibiotic intravenous prophylaxis (group 1). Over the last 4-year period, this prophylaxis was supplemented with presoaking of the autograft (group 2). Presoaking was performed with sterile gauze previously saturated with a vancomycin solution (5 mg/ml).There were 810 and 734 patients in group 1 and 2, respectively. Fifteen cases of knee joint infections were identified in the series (0.97 %). All of these infections occurred in group 1, representing a rate of infection of 1.85 % in comparison with 0 % in group 2 (p 0.001).Autograft presoaking with vancomycin in combination with classical intravenous antibiotic prophylaxis reduced the rate of knee joint infection following an ACLR in comparison with antibiotic prophylaxis alone. This technique could be of relevance in daily clinical practice to prevent infection after ACLR.Case control study, retrospective comparative study, Level III.

The relevance of wound complications in association with acute prosthetic joint infection (PJI) is well known. However, whether a successfully treated superficial infection can result in a chronic deep infection remains unclear. The aim of this study was to determine the prevalence, treatment and late complications of superficial wound infections following TKA. In a 3000 TKA prospective cohort, 45 superficial infections were diagnosed and treated successfully with antibiotic therapy along with or without surgical debridement. None of the cases developed deep chronic PJI at 70 months of follow-up. Three cases were in need of a TKA exchange due to aseptic loosening. A successfully treated superficial wound infection does not result in a chronic deep TKA infection.

The aim of the study was to determine whether medial meniscal substitution with a polyurethane scaffold (Actifit(®)) improves the outcome of medial meniscal-deficient varus knees undergoing open-wedge high tibial osteotomy.Sixty patients with symptomatic varus knees those who underwent open-wedge high tibial osteotomies were prospectively studied. In 30 patients, the medial meniscus was left with a defect larger than 25 mm (Group M). An Actifit(®) device was implanted (Group A) in the remaining 30 patients. Patients were functionally evaluated with WOMET, IKDC and VAS. Patient satisfaction was graded from 0 (not satisfied) to 4 (very satisfied).Both groups were comparable preoperatively. They had similar follow-up periods (31.2 months; range 24-47.5; n.s.). WOMET improved a mean of 53.4 ± 8.4 and 42.4 ± 17.2 points in Groups M and A, respectively (p = 0.002). IKDC improved a mean of 56.7 ± 12 and 50.3 ± 15.6 points in Groups M and A, respectively (n.s.). VAS dropped 5.9 ± 2.1 and 4.7 ± 2.8 points in Groups M and A, respectively (p = 0.006). Patient satisfaction averaged 3.3 ± 0.8 and 3.3 ± 1 in Groups M and A, respectively (n.s.).Patients with symptomatic varus knees were treated with open-wedge high tibial osteotomies, and a meniscectomy was improved more at short-term follow-up in most of the evaluated functional scores than those patients with concomitant implantation of a medial Actifit(®) implant. However, there was no difference in terms of patient satisfaction with the procedure. Based on the short-term functional results of this study, no data were provided to support medial meniscal substitution with a polyurethane scaffold when an open-wedge high tibial osteotomy is being performed.Prospective comparative study, Level II.

The purpose of this article is to report the treatment and short-term results of a combined fracture of the talus treated arthroscopically. A 29-year-old man sustained an anterolateral osteochondral grade III fracture of the talus dome associated with a coronal fracture of the body of the talus. This injury was reduced and fixed arthroscopically using cannulated screws. The patient returned to his daily style of living after 3 months time. One year later, the patient remains asymptomatic. Radiography showed neither signs of osteonecrosis nor osteoarthritis of the talus at the 1-year follow-up. Therefore, arthroscopic surgery could be an alternative treatment for this kind of talus fracture.

Melorheostosis is a rare non-hereditary bone disease characterized by a radiographic pattern of flowing hyperostosis along the cortex with sclerotomal distribution. We report a case of a patient with severe knee contracture and a restricted range of motion caused by intraarticular bone fragment and hyperostotic bone lesions secondary to melorheostosis. An arthroscopically assisted approach was used successfully in order to remove free bone fragments and to release the hyperostotic lesions in the bone cortex of the distal femur.

Background: The use of antibiotic-loaded cement is believed to prevent infection in primary total knee arthroplasty, but there is a lack of randomized studies to support this concept. The aim of this study was to evaluate the use of an antibiotic-loaded cement to reduce the infection rate in primary total knee arthroplasty. Methods: This is a prospective randomized study with 2948 cemented total knee arthroplasties, in which bone cement without antibiotic was used in 1465 knees (the control group) and a bone cement loaded with erythromycin and colistin was used in 1483 knees (the study group). All patients received the same systemic prophylactic antibiotics. The patients were followed for a minimum of twelve months. The rate of infection was analyzed according to the criteria of the Centers for Disease Control and Prevention. Results: The rate of deep infection (1.4% in the control group and 1.35% in the study group; p = 0.96) and the rate of superficial infection (1.2% and 1.8%, respectively; p = 0.53) were similar in both groups. The factors related to a higher rate of deep infection in a multivariate analysis were male sex and an operating time of >125 minutes. Conclusions: The use of erythromycin and colistin-loaded bone cement in total knee arthroplasty did not lead to a decrease in the rate of infection when systemic prophylactic antibiotics were used, a finding that suggests that the use of antibiotic-loaded bone cement would not be indicated in the general population. Further research is needed to assess whether its use is recommended for patients with a higher risk of infection. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to compare the short-term changes in quality of life for patients younger than 80 years with those 80 years and older undergoing total knee arthroplasty (TKA). It was hypothesized that patients 80 years and older had a similar quality of life after TKA compared with those younger than 80 years. All consecutive patients undergoing primary TKA were enrolled in this prospective, comparative, prognostic (level I evidence) study and were stratified into 2 groups based on their age (younger than 80 years and 80 years and older). Data on quality of life assessed using the Short Form 36 health survey were obtained preoperatively and 1 year postoperatively (short-term follow-up) and were compared between groups. A total of 328 (83.89%) patients younger than 80 years (mean age, 70.7 years) and 63 (16.11%) patients 80 years and older (mean age, 82.1 years) were included. No significant differences in preoperative quality of life were observed between groups. Postoperative physical function, vitality, social function, and physical component summary were lower in patients 80 years and older. Older patients had a lower difference between pre- and postoperative values in Short Form 36 physical function and role–emotional scores. Patients 80 years and older had a similar improvement in quality of life 1 year after TKA compared with patients younger than 80 years. Therefore, changes in quality of life justify TKA as a treatment option for elderly patients with end-stage knee osteoarthritis.

Cervicocephalic screw medialization is a rare complication after intertrochanteric fracture synthesis with a Gamma3-type intramedullary nail. Only 6 cases of intrapelvic penetration by Gamma3 lag screw have been described. We now describe 2 additional cases and a review of the literature.

It is not clear whether indicating TKA-surgery is advisable in depressed patients. A prospective cohort of 716 patients undergoing TKA was designed. SF36, KSS, WOMAC and VAS plus 2 satisfaction questions were evaluated. There were 2 groups: 200 patients were depressed and 516 were not. Preoperative/postoperative results show better scores for non-depressed patients on almost every sub-scale. Nevertheless, net change results (improvement) were quite similar: 65.74 improvement in depressed-KSS and 74.58 in non-depressed (P = 0.049); 8.93 net change in depressed-Physical Composite Score and 11.84 in non-depressed (P = 0.003); 2.38 in depressed-Mental Composite Score and − 0.61 in non-depressed (P = 0.024). Depressed patients obtained great improvement from preoperative at one-year follow-up and even greater than non-depressed patients in some domains. Moreover, satisfaction was similar. Therefore, TKA can be recommended to depressed patients.

The different functions of the two anterior cruciate ligament (ACL) bundles have increased interest in tears of only one of these two bundles. The purpose of this study was to assess the outcome of selective reconstruction of an injured bundle of isolated anteromedial bundle (AMB) or posterolateral bundle (PLB) tears.Consecutive series of 147 ACL reconstructions was prospectively analyzed. Patients with partial ACL tears who underwent selective bundle reconstructions were studied. Stability was assessed with the Lachman, anterior-drawer and pivot-shift tests and KT-1000. Functional assessment was performed with Lysholm and Tegner questionnaires. The preoperative MRI was analyzed to detect differences from arthroscopic findings.Twenty-eight patients (19%) were included. The minimum follow-up period was 30months. Eighteen had AMB and 10 PLB tears. Only 19% of their MRI's were categorized as partial ACL tears. The Lysholm score improved from 66.1/65.5 to 96.6/95.2 in the AMB/PLB groups, respectively (p0.001). The same or no more than one level lower Tegner score was restored. The pivot-shift, Lachman and anterior-drawer tests were negative in all cases (p0.001). Two reconstructed AMBs developed extension loss due to Cyclops lesions and were resolved surgically.The technique provided excellent functional scores with normalized stability and a return to previous level of activity with a low rate of minor complications at a minimum 2.5years' follow-up. Arthroscopic examination was the most reliable tool for properly diagnosing and treating a condition observed in almost one out of every five ACL reconstructed knee in this series.Therapeutic case series; level 4.

Surgical procedures for reconstruction of a torn anterior cruciate ligament (ACL) have changed considerably over the last 30 years. They have evolved from open surgery to advanced all-inside endoscopic techniques. Arthroscopic transtibial ACL reconstructions have been largely used in recent decades. However, a trend toward more anatomic ACL reconstructions has started in recent years due to the high rates of persistent rotatory instability observed after vertically oriented graft. Placing a single femoral tunnel at the center of the anatomic insertions of the ACL may restore the rotational stability of the knee as well as a double-bundle technique. A thorough knowledge of the anatomical attachment sites of the ACL is required for precise anatomic ACL reconstruction.

Interest in isolated tears of one of the two bundles of the anterior cruciate ligament has increased over recent years. It is thought that by only reconstructing the ruptured bundle while preserving the uninjured bundle contributes to faster graft healing, a better proprioceptive outcome as well as faster recovery. However, this is still to be proven. This chapter describes the difficulty in assessing and confirming partial anterior cruciate ligament injuries. Attention to clinical examination and imaging must also be done. The main purpose of this section is to detail the arthroscopic examination and reconstruction of isolated anterior cruciate ligament bundle ruptures.

Both the meniscus and ACL are frequently injured in sports-related trauma. Regardless of the knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes. Although the ability of the meniscal tissue to heal is known to be limited, its repair at the time of ACL reconstruction has the best chance of healing and so it is currently done by most knee surgeons. ACL-deficient patients with a significant meniscal defect, particularly on the medial side, might benefit from the increase in stability provided by a meniscal transplantation carried out at the time of ACL reconstruction.

The etiology of the patellar instability involves multiple factors and it can often be successfully managed with conservative treatment. This is particularly so in cases of primary dislocation. If there is no clinical improvement with nonoperative management, surgery may be considered especially in cases of recurrent patellar dislocation. In these patients, a complete physical examination and some imaging studies are mandatory.

Background:Most of the published series of transplanted menisci have consistently shown some degree of allograft extrusion. The speculation is that this meniscal extrusion may be caused by the soft tissue technique used to fix the allograft.Hypothesis:The percentage of extruded meniscal graft would be higher if the allograft were only fixed with sutures rather than with associated bony fixation.Study Design:Cohort study; Level of evidence, 2.Methods:We performed a prospective series of 88 meniscal allograft transplantations. Thirty-three of the grafts were fixed with the suture-only technique (group A). The remaining 55 cases were performed with the bone plug method (group B). All patients were studied with magnetic resonance imaging (MRI) at a minimum 3 years’ follow-up to determine the degree of meniscal extrusion. The time between surgery and MRI evaluation was 40 months (range, 36-48 months) in both groups. Meniscal extrusion was measured on coronal MRI. The percentage of the meniscal body width that was extruded was calculated. The average percentage of extrusion for each group was compared. The Lysholm score was analyzed in relation to the fixation method and degree of meniscal extrusion. Tears of the allograft that required surgical intervention were also reported.Results:The average percentage of meniscal tissue extruded in group A was 36.3% ± 13.7% without differences between the medial (35.9% ± 18.1%) and lateral (38.3% ± 14.4%) compartments ( P = .84). Group B had a mean 28.13% ± 12.2% of the meniscal body extruded without differences between the medial (25.8% ± 16.2%) and lateral (30.14% ± 13.5%) compartments. A higher percentage of extruded meniscal tissue was found in group A than in group B ( P < .001). No association between the degree of meniscal extrusion and the functional score was observed ( P = .4). Graft tears were observed in 21.4% of the cases in group A and in 7.3% of the cases in group B ( P = .09).Conclusion:A meniscal allograft fixed with the suture-only technique showed a significantly higher degree of extruded meniscal body than that fixed with the bony fixation method, with no influence on the functional outcome. There was also a considerably higher rate of graft tears observed in those menisci fixed only with sutures, although this difference was not statistically significant with the numbers available.

The aim of this study was to determine whether it is necessary to use the KSS, WOMAC and SF-36 scales in a Spanish speaking population. These 3 questionnaires were administered to 1000 consecutive patients in the TKA preoperative period. Pearson's correlation coefficient and coefficient of determination were obtained. 196 patients were excluded. A poor correlation was obtained comparing the different items of the different scores with each other. Only in 3 out of different comparisons performed was a Pearson's correlation r>0.5 obtained. The worst results were obtained comparing the two knee specific tests (SF-36 vs WOMAC) and the best ones comparing SF-36 and WOMAC scores. Based on these results, the use of the three tests in the TKA preoperative period is recommended in a Spanish speaking population.

The acetabular labrum augments femoral head coverage within the acetabulum and contributes to hip joint stability. This has led to an increasing interest in procedures dedicated to preservation of the labrum. An allogenic labral transplantation performed in a patient who had previously undergone a partial labral resection is presented.

Purpose: The aim of the study was to evaluate the clinical outcome of a collagen meniscus graft implanted in an injured medial meniscus after a minimum of 10 years' follow-up. Methods: Twenty-five patients underwent arthroscopic implantation of the collagen meniscus device. They had either persistent compartmental joint line pain due to a previous medial meniscus resection (5 cases) or a large irreparable meniscus tear at arthroscopy (20 cases). Implant failure was defined as infection due to the implant or mechanical failure of the device. Twenty-two patients returned for clinical, functional, and radiographic evaluation. Magnetic resonance imaging was also performed and was analyzed with the criteria of Genovese et al. (where type 3 indicates normal and type 1 indicates completely abnormal). All the aforementioned evaluations were carried out at a minimum of 10 years (range, 10.1 to 12.5 years) after the procedure. Results: The mean Lysholm score improved from 59.9 preoperatively to 89.6 at 1 year (P < .001), and it was 87.5 at final follow-up (P < .001). The results were good or excellent in 83% of the population. No differences were observed when we compared the Lysholm score at 1 year of follow-up with the score at final follow-up (P > .05). The mean pain score on a visual analog scale improved by 3.5 points at final follow-up. Patient satisfaction with the procedure was 3.4 of 4 points. Radiographic evaluation showed either minimal or no narrowing of the joint line. Magnetic resonance imaging showed type 2 in 64% of cases and type 3 in 21%. All cases showed less volume than expected (size type 2 in 89%). The failure rate in the patient population was 8% (2 of 25). There were no complications related to the device. Conclusions: Although there were several different types of patients and acute and chronic tears were treated in a limited number of patients, meniscal substitution with the collagen meniscal implant provides significant pain relief and functional improvement after a minimum of 10 years' follow-up. The implant generally diminished in size, but the procedure proved to be safe and had a low rate of implant failure on a long-term basis. No development or progression of degenerative knee joint disease was observed in most cases. Level of Evidence: Level IV, therapeutic case series.

Purpose: To compare drilling the femoral tunnel with an offset aimer and BullsEye guide (ConMed Linvatec, Largo, FL) to perform an anatomic single-bundle reconstruction of the anterior cruciate ligament (ACL) through the anteromedial portal. Methods: Seven matched pairs of cadaveric knees were studied. The intent was to drill the femoral tunnel anatomically in all cases. In group A the femoral tunnel was drilled arthroscopically with an offset aimer. In group B the femoral tunnel was drilled arthroscopically with the BullsEye guide. Two tunnels were drilled through the same entry point in each knee. One was done at 110 degrees of knee flexion and the other at 130 degrees. They were scanned by computed tomography and reconstructed 3-dimensionally. Volume-rendering software was used to document relations of the drilled tunnel to the bony anatomy and tunnel length. Results: In group B the femoral tunnel was placed at the center of the femoral insertion site. The center of the tunnel was 9.4 mm from the high cartilage margin and 8.6 mm from the low cartilage margin. In group A the tunnels were placed deeper (5.4 mm and 12.6 mm, respectively) (P = .018). There were no differences in tunnel length for either knee flexion degree. Three of the tunnels drilled at 110 degrees in group A compromised the posterior tunnel wall and measured less than 25 mm in length. Conclusions: Accurate placement in the center of the femoral footprint of the ACL is better accomplished with the BullsEye guide rather than 5-mm offset aimers. Five-millimeter offset aimers might cause posterior tunnel blowout and present the risk of obtaining short tunnels when performing oblique femoral tunnel placement through the anteromedial portal at 110 degrees of knee flexion. Clinical Relevance: The BullsEye guide might be better than standard offset aimers in the performance of anatomic single-bundle ACL reconstruction.