Background: It is unknown whether popliteal tendon reconstruction is necessary in anatomic posterolateral corner reconstruction, although the tendon has function in the varus and rotatory stability of the knee joint.
Hypothesis: Anatomic reconstructions of the posterolateral corner with the popliteal tendon reconstructed will present better clinical and radiographic results than cases with the popliteal tendon not reconstructed.
Study Design: Cohort study; Level of evidence, 3.
Methods: The authors retrospectively analyzed 32 cases of anatomic posterolateral corner reconstruction with a minimum 2-year follow-up. There were 17 cases of anatomic reconstruction with popliteal tendon reconstruction and 15 cases without popliteal tendon reconstruction. The authors compared preoperative and postoperative range of motion, varus instability by varus stress test, lateral joint opening on varus stress radiographs, posterolateral rotatory instability by dial test, Tegner activity score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee evaluation form and knee examination form between the 2 groups. They also compared posterior translation on posterior stress radiographs in cases with posterior cruciate ligament reconstruction.
Results: There was no difference in range of motion, varus stress test, dial test, Tegner score, Lysholm score, or the score by IKDC subjective knee evaluation form. The side-to-side difference in lateral joint opening on the varus stress radiographs significantly improved after anatomic reconstruction in both groups (P < .001, P = .001), but there was no preoperative or postoperative differences between the groups. No difference was found in the grade distribution on the IKDC examination form. In the cases with posterior cruciate ligament reconstruction, there was also no difference in posterior translation between the groups on posterior stress radiographs at the last follow-up.
Conclusion: No effect of popliteal tendon reconstruction was found in anatomic posterolateral corner reconstruction on the stability and clinical results.
Background: High tibial osteotomy (HTO) is a common treatment for medial compartment arthritis of the knee in younger, more active patients. An HTO also potentially affects leg length. Mathematical models predict that the osteotomy type (medial opening-wedge vs lateral closing-wedge) and the magnitude of the correction determine the change in leg length, but no in vivo studies have been published.
Purpose: This study was undertaken to quantify and compare leg-length change after opening-wedge and closing-wedge HTO.
Study Design: Cohort study; Level of evidence, 3.
Methods: Thirty-two medial opening-wedge and 32 lateral closing-wedge HTOs were selected from patients treated at the authors’ institution. Preoperative and postoperative coronal plane alignment and leg length were measured and surgical details were collected.
Results: The 64 osteotomies were performed at an average age of 57 years. The mean opening wedge was 9.3 mm and the mean closing wedge was 8.0 mm. Mean knee alignment changed from 174° preoperatively to 183° postoperatively in both groups. In the medial opening-wedge group, entire leg length changed from 836.3 ± 63.5 mm to 841.8 ± 64.1 mm, an increase of 5.5 ± 4.4 mm (P < .0001). Tibia length changed from 368 ± 30.9 mm to 372.3 ± 31.2 mm, an increase of 4.3 ± 2.3 mm (P < .0001). In the lateral closing-wedge group, entire leg length changed from 840.6 ± 51.5 mm preoperatively to 837.9 ± 52.0 mm postoperatively, a decrease of 2.7 ± 4.0 mm (P = .0008). Tibia length changed from 365.1 ± 23.2 mm to 361 ± 22.9 mm, a decrease of 4.1 ± 2.9 mm (P < .0001). The difference in mean leg-length change between opening-wedge and closing-wedge osteotomies was 8.2 ± 5.9 mm (P < .0001).
Conclusion: Both medial opening-wedge and lateral closing-wedge HTO can result in significant leg-length change, but changes are generally less than mathematical models predict.
Background: The authors devised a double-bundle posterior cruciate ligament reconstruction technique in combination with a single-sling method. However, the double-bundle technique needs more simplicity and a decreased possibility of failure.
Hypothesis: A novel surgical technique of transtibial double-bundle posterior cruciate ligament reconstruction using a single-sling method with a tibialis anterior allograft, previously introduced, produces satisfactory results.
Study Design: Case series; Level of evidence, 4.
Methods: Twenty-one patients who underwent double-bundle transtibial isolated posterior cruciate ligament reconstruction using a single-sling method between July 2003 and September 2007 were enrolled in this study. The exclusion criteria applied were (1) a multiligamentous injury, (2) posterior cruciate ligament reconstruction previously performed using another technique, and (3) the presence of any additional injury capable of affecting knee stability. The Lysholm and International Knee Documentation Committee (IKDC) knee scales were used for the clinical outcome evaluation. Stability was evaluated using a KT-2000 arthrometer. The evaluation was performed by comparing preoperative and last follow-up results.
Results: Nineteen men and 2 women were enrolled, with a mean follow-up of 49.2 months (range, 25-73 months). The mean Lysholm score was 53 ± 5.3 (range, 34-68) preoperatively and improved to 83.5 ± 13 (range, 61-97) at the last follow-up after surgery (P < .001). The IKDC score also improved from preoperative (0 A, 0 B, 7 C, 14 D) to final follow-up (8 A, 9 B, 3 C, 1 D; P < .001). Mean side-to-side difference in posterior translation, measured using the KT-2000 arthrometer, was 13.5 ± 1.2 mm preoperatively and 3.4 ± 0.8 mm at last follow-up evaluations (mean 51.7 months postoperatively).
Conclusion: After follow-up for longer than 24 months, the transtibial double-bundle posterior cruciate ligament reconstruction with a single sling was found to produce satisfactory clinical and stability results, which indicates that the described technique should be viewed as a viable alternative.
Background: A posterior root tear of the medial meniscus disrupts hoop tension and causes extrusion of the meniscus, which results in progressive cartilage degeneration.
Purpose: To identify the structural integrity of healing after arthroscopic repair of a posterior root tear of the medial meniscus by second-look arthroscopy and to determine the clinical relevance of the findings.
Study Design: Case series; Level of evidence, 4.
Methods: From December 2006 to August 2008, 21 consecutive patients underwent arthroscopic pullout suture repair for a posterior root tear of the medial meniscus. Eleven were available for second-look arthroscopy evaluation (mean, 13.4 months; range, 10 to 22 months). The healing status of the repaired meniscus was classified as complete healing, lax healing, scar tissue healing, and failed healing. Chondral lesions were reviewed using arthroscopic photographs, and clinical evaluation was based on the Lysholm knee scores and the Hospital for Special Surgery scores.
Results: There was no case with complete healing. Five knees had lax healing (symptomatic in 2 and asymptomatic in 3); 4, scar tissue healing (asymptomatic in all 4); and 2, failed healing (symptomatic in 1 and asymptomatic in 1). Progression of the chondral lesion was found in 1 case. Mean Lysholm scores improved from 56.1 preoperatively (range, 41 to 71) to 83.0 at follow-up (range, 69 to 91; P = .003); mean Hospital for Special Surgery score also significantly increased, from 64.1 (range, 50 to 76) to 87.4 (range, 77 to 95; P = .003).
Conclusion: Complete healing was not observed in this retrospective case series of posterior horn meniscus repairs performed by 2 surgeons using a single technique. Further research is needed to clarify why all patients showed clinical improvement despite findings of incomplete or failed healing on second-look arthroscopy. Treatment modalities for managing posterior root tears of the medial meniscus require further investigation to determine their efficacy.
Background:
Autologous chondrocyte implantation is indicated as a second-line treatment of large, irregularly shaped chondral defects after failure of first-line surgical intervention. This study examines the clinical results of a patient cohort undergoing autologous chondrocyte implantation and elucidates factors associated with subjective improvement after implantation.
Hypothesis:
Autologous chondrocyte implantation will result in long-term functional and symptomatic improvement.
Study Design:
Case series; Level of evidence, 4.
Methods:
The cohort included 137 subjects (140 knees) who underwent autologous chondrocyte implantation of the knee. Mean defect size per patient was 5.2 ± 3.5 cm2 (range, 0.8–26.6 cm2). Patients averaged 30.3 ± 9.1 years of age (range, 13.9–49.9 years) and were followed for 4.3 ± 1.8 years (range, 2.0–9.7 years). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm scale, International Knee Documentation Committee scale, and Short Form-12.
Results:
A significant improvement after surgery was observed in all outcome assessments including the Lysholm (41 to 69; P < .001) and International Knee Documentation Committee (34 to 64; P < .001) scales. Subjectively, 75% of patients indicated they were completely or mostly satisfied with the outcome and 83% would have the procedure again. Preoperatively, 32% of patients had a Tegner score of 6 or greater, compared with 82% before injury and 65% at most recent follow-up. Multivariate analysis identified age (P < .021) and receiving workers’ compensation (P < .018) as independent predictors of follow-up Lysholm score. Twenty-one patients (16%) required debridement of the autologous chondrocyte implantation site secondary to persistent symptoms, whereas 9 knees (6.4%) clinically failed and underwent a revision procedure.
Conclusion:
Autologous chondrocyte implantation is a viable treatment option for chondral defects of the knee, resulting in durable functional and symptomatic improvement. Age and workers’ compensation status are independent predictors of outcome.
Background
The Lysholm score and Tegner activity scale are commonly used to document outcomes after arthroscopic knee surgery. These outcomes measurements are subjective in nature and evaluate performance and activity restrictions both before and after surgery, making them a valuable research tool when judging the effectiveness of surgical treatment.
Purpose
To establish a normal knee data set for the Lysholm and Tegner rating systems, as well as to show how these scores are affected by age and gender.
Study Design
Cross-sectional study; Level of evidence, 3.
Methods
A subjective questionnaire that included both the Lysholm score and Tegner activity grading scale was completed by 488 subjects in the community who considered their knee function normal. Any subject reporting a history of injury or surgery was excluded from the study. The average age was 41 years (range, 18–85), with 244 men and 244 women qualifying for statistical analysis.
Results
The average Lysholm score was 94 (range, 43–100), and the average Tegner activity level was 5.7 (range, 1–10). The Lysholm score and age demonstrated no correlation. The Tegner activity level was inversely correlated with age. The average Tegner activity level for men was 6.0, and the average activity scale for women was 5.4. There was no significant difference in the Lysholm score between men and women.
Conclusion
These data acquired from a normal, healthy population provide a standard point of reference for the injured or postsurgical knee. These data also serve as ideal tools when counseling patients about realistic expectations after surgery, based on age and gender.
Background
Surgical treatment of patellofemoral instability can successfully diminish episodes of subluxation and dislocation, as well as symptoms of pain and instability.
Hypothesis
Surgical treatment of lateral patellar instability in a strictly athletic population will facilitate return to sports.
Study Design
Case series; Level of evidence, 4.
Methods
From 1999 to 2004, 41 Fulkerson osteotomies combined with an arthroscopic lateral release were performed in 34 athletes for patellofemoral instability. Three patients were lost to follow-up. All patients participated in sports at least 3 times per week in at least one sport for 4 months of the year. There were 4 male and 30 female patients; 7 patients underwent bilateral, staged procedures. There were 14 high school, 12 collegiate, and 8 recreational athletes. Results were obtained by an independent examiner.
Results
The mean age was 20.05 years (range, 14–54 years) with a mean follow-up of 46 months (range, 22–71 months). Patients averaged 1.3 dislocations before reconstruction (range, 0–6). The average Lysholm score was 91.8 (range, 67–100) at follow-up. The International Knee Documentation Committee (IKDC) scores were A (normal) in 27 knees, B (near normal) in 12, and C (abnormal) in 2. Seventeen patients had symptomatic hardware removed at an average of 8 months. There were 2 complications: one saphenous neuroma that resolved, and one recurrent dislocation in a patient later diagnosed with Ehlers-Danlos syndrome.
Conclusion
This series is the largest to date documenting the successful treatment of patellofemoral instability in athletes with concomitant Fulkerson osteotomy and arthroscopic lateral release. Forty-nine percent of patients in our series required removal of screws from the osteotomy site.
Background: A traumatic knee dislocation represents a serious injury, particularly for athletes who have the highest demands on their knee function.
Purpose: Our aim was to analyze the long-term outcome and return to sports after traumatic knee dislocation in elite athletes treated surgically according to a standardized treatment protocol and to identify predictive factors for a successful outcome.
Study Design: Case series; Level of evidence, 4.
Methods: A review of hospital medical records yielded 26 elite athletes with a knee dislocation (torn bicruciate ligaments and at least one torn collateral ligament), who had undergone an open complete single-stage reconstruction/primary repair of the cruciates and collateral ligaments including the posterolateral corner from January 1983 to August 2006. Return to sport (start of sport-specific training) was recorded. Return to the former level of sports activity was assessed. At a median follow-up of 8 years (range, 1-23 years), 24 patients (92%) were evaluated for instrumented anterior-posterior laxity (KT-1000 arthrometer) and scored on the visual analog scale (VAS pain, satisfaction), International Knee Documentation Committee form (IKDC), American Knee Society score, and Lysholm and Tegner score. Standard weightbearing and stress radiographs were taken.
Results: Seventy-nine percent of patients (n = 19) returned to their previous sport after a median time of 5.5 months (range, 1.5-36 months), with 8 of them returning to preinjury levels. Eight percent had a VAS pain score >3. Thirteen percent of patients showed a flexion deficit >15°, and 8% showed an extension deficit >10°. The mean side-to-side differences for anterior and posterior laxity were 2.3 mm (range, 1-5 mm) and 2.0 mm (range, 2-7 mm), respectively. The total IKDC score was normal in 4, nearly normal in 12, abnormal in 6, and severely abnormal in 2 patients. The median Lysholm score was 91.8 (range, 37-100). The median Tegner score decreased from 9 (range, 7-10) to 7 (range, 2-10). The median American Knee Society score was 190 (range, 162-200). The median radiological anterior-posterior side-to-side differences in 30° and 90° flexion were 1 mm (range, 1-6 mm)/1 mm (range, 0-11 mm) and 1 mm (range, 0-7 mm)/3 mm (range, 0-11 mm), respectively. Patients treated more than 40 days after injury had a poorer outcomeon the satisfaction and relative Tegner scores. This group was also less successful in returning to sport compared with patients treated earlier.
Conclusion: Athletes treated by early, open, complete single-stage reconstruction within 40 days of injury had better outcomes. Although 19 of 24 patients returned to sports with good functional outcomes and ligamentous stability, only 8 of 24 athletes reached their preinjury sports activity level.
Background: Active patients with arthritic malalignment of the knee are difficult to manage. Arthroplasty, unicompartmental or total knee replacement, may not be appropriate in patients who desire to remain highly active. High tibial osteotomy has been recommended for the treatment of varus osteoarthritis to decrease pressure on the damaged medial compartment.
Purpose: To determine the length of time patients with varus gonarthrosis can avoid knee arthroplasty with chondral resurfacing (microfracture) and medial opening wedge high tibial osteotomy (HTO).
Study Design: Case series; Level of evidence, 4.
Methods: From 1995 to 2001, the senior authors performed a medial opening wedge HTO/microfracture in 106 knees (mean age, 52 years; range, 30-71 years). Survivorship was defined as not requiring knee arthroplasty after microfracture and HTO.
Results: At 5 years, survivorship was 97%. At 7 years, survivorship was 91%. Twelve patients proceeded to arthroplasty at a mean of 81 months (range, 19-116 months). Follow-up was obtained for 90% of patients. At most recent follow-up, the mean Lysholm score was 71 (range, 5-100). At 3 years, the mean Lysholm score was 73, Tegner score was 2.8, and patient satisfaction was 7.9. At 5 years, the mean Lysholm score was 73, Tegner score was 3.8, and patient satisfaction was 7.5. At 9 years, the mean Lysholm score was 67, Tegner score was 3.1, and patient satisfaction was 7.5. Patients with medial meniscus injury at surgery were 9.2 times more likely to undergo arthroplasty than patients without (95% confidence interval [CI], 1.4-13.5; P = .015).
Conclusion: With 91% survivorship at 7 years, microfracture/HTO seems to contribute to a delay of knee replacement in active patients with varus gonarthrosis. Patients who proceeded to knee arthroplasty after combined HTO/microfracture had a mean delay of 81.3 months.
