Patella infera following arthroscopic anterior cruciate ligament reconstruction

Fifty patients who had an arthroscopic anterior cruciate ligament reconstruction for chronic insufficiency were reviewed at an average of 13.6 months following surgery. Among these patients, 32% complained of anterior knee pain that interfered with daily activities. Radiographic patella infera was present in 12% of patients using the Insall-Salvati ratio and in 16% using the Blackburne-Peel ratio. Radiographic patella infera did not correlate with the clinical problem of postoperative anterior knee pain. However, loss of knee extension of greater than 5 degrees correlated highly with pain (p=0.002).     

Unsuccessful arthroscopic treatment of pyarthrosis following anterior cruciate ligament reconstruction

Postoperative purulent infection developed in the knee of a patient who had undergone anterior cruciate ligament reconstruction. Initially, arthroscopic lavage and debridement was performed, but was unsuccessful because the infection had spread into the soft tissues of the former surgical wound. Open debridement had to be performed to control the periarticular infection. It is important to stress that the extent of the infection has to be considered when instituting a method of treatment. It should be possible to clinically diagnose this extraarticular infection.     

Intraarticular viscosupplementation following arthroscopic anterior cruciate ligament reconstruction: A systematic review

BackgroundPain, swelling and joint stiffness are the major problems following arthroscopic ACL reconstruction (ACLR) surgery that restrict early return to sports and athletic activities. The patients often receive prolonged analgesic medications to control the inflammatory response and resume the pre-injury activities. This systematic review aims to evaluate the safety and efficacy of intraarticular (IA) hyaluronic acid (HA) injection following ACLR.Material and methodsA literature search of electronic databases and a manual search of studies reporting clinical effectiveness of IA HA following ACLR was performed on 1^st November 2020. The quality of the methodology and risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool and Newcastle-Ottawa scale for randomized-controlled trial and prospective cohort studies, respectively.ResultsOf 324 studies retrieved, four studies (3 RCTs and one prospective cohort study) were found to be suitable for inclusion in this review. These studies had a low to moderate risk of bias. There were 182 patients in the HA group and 121 patients in the control group. The demographic characteristics of the patients were similar in all studies. The pooled analysis of studies evaluating pain at different follow up periods (2-week, 4–6 weeks, 8–12 weeks) after ACLR revealed no significant difference between the HA and control groups (p > 0.05). The knee swelling was significantly less in the HA group at two weeks (MD -7.85, 95% CI: [-15.03, −0.68], p = 0.03, I2 = 0%), but no such difference was noted after 4–6 weeks and 8–12 weeks. The functional outcome score was not significantly different between the groups (SMD 0.00, 95% CI: 0.38 to 0.38, p = 0.99, I² = 0%).ConclusionsAlthough the individual study demonstrated a short-term positive response regarding pain control and swelling reduction, the pooled analysis did not find any clinical benefit of IA HA injection following ACLR surgery.Level of evidenceII.     

Rehabilitation after arthroscopic anterior cruciate ligament reconstruction

Rehabilitation is an important part of therapy in patients who have had arthroscopic anterior cruciate ligament reconstruction. A well-designed rehabilitation program avoids potential graft damage and speeds up patients' return to their full function level. The course of rehabilitation depends on the type of surgery, mode of fixation and possible co-existing injury to the knee's soft tissues. The rehabilitation program presented here is based on the present-day knowledge of neurophysiological and biomechanical principles and is divided into five phases. In the pre-operative phase (I), the main objective is to prepare patients for surgery in terms of maximum muscle strength and range of motion. It also includes providing full information on the procedure. In the early post-operative phase (II) we are concerned with pain alleviation and reduction of knee edema. After suture removal we begin with soft techniques for the patella and post-operative physical therapy to reduce scarring. In the next post-operative phase (III) patients are able to walk with their full weight on the extremity operated on, and we continue doing exercises that improve flexor/extensor co-contraction. In this phase we also begin with exercises improving the patient's proprioceptive and sensorimotor functions. In the late post-operative phase (IV) we go on with exercises promoting proprioception of both lower extremities with the aim of increasing muscle control of the knee joints. In the convalescent phase (V) patients gradually return to their sports activities.     

The fate of intra-articular debris following arthroscopic anterior cruciate ligament reconstruction

The debris generated during arthroscopic anterior cruciate ligament (ACL) reconstruction may be seen on postoperative radiographs. The purpose of this study was to evaluate the incidence, effects, and natural history of intraarticular debris following ACL reconstruction. This retrospective review included 99 ACL reconstructed knees in 96 patients. Radiographically visible debris was present in 63% of knees (bone in 59% and metal in 4%), and 37% of knees had no visible debris. Bone was most commonly seen in the posterior compartment (95%), and metal within the intercondylar notch. There were no differences in the incidence of debris between reaming techniques, single and dual incision techniques, or between graft types. Metal debris was always associated with retrograde reaming. Complete disappearance of bone debris was noted in 71% (3 to 6 months). Of the 25% of knees that showed persistent bone debris, in 79% it had decreased in size. There was no change in the appearance of metal debris (4%). No patient experienced mechanical symptoms directly related to debris. No secondary surgeries for debridement of debris or loose body removal were required. Bone debris produced during arthroscopic ACL reconstruction appears clinically benign, and is likely to disappear by 6 months. Long-term effects are unknown. Metal debris is persistent, but not problematic over the short-term.     

关节镜下前交叉韧带重建的手术时机

[目的]比较不同手术时机行关节镜重建治疗前交叉韧带损伤(ACL)的临床疗效及安全性。[方法]2016年1月～2018年1月本院收治的84例ACL损伤患者,根据手术距受伤时间不同进行分组,其中<4周组48例,4～12周组36例。比较末次随访时两组膝关节功能评分、稳定性应力试验结果和运动能力试验结果。[结果]两组患者随访13～37个月,平均(25.20±6.16)个月。术前两组IKDC评分、Lysholm评分、Tegner评分比较差异均无统计学意义(P>0.05)。末次随访时,两组上述评分均较术前显著增加(P<0.05),<4周组的IKDC评分、Lysholm评分和Tegner评分均大于4～12周组,但是差异无统计学意义(P>0.05)。合并半月板损伤者,<4周组Lysholm评分显著高于4～12周组(P<0.05),而未合并半月板损伤者,两组评分差异无统计学意义(P>0.05)。末次随访时,两组Lachman及ADT试验结果相比术前均明显改善,差异有统计学意义(P<0.05),两组间Lachman及ADT试验差异无统计学意义(P>0.05)。两组间膝关节屈曲受限程度和伸膝受限程度的差异亦均无统计学意义(P>0.05),两组间大腿周径差值、单脚跳、侧边单脚跳和交叉单脚跳距离的差异均无统计学意义(P>0.05)。<4周组并发症发生率明显低于4～12周组(P<0.05)。[结论]早期与晚期行关节镜重建治疗ACL损伤的疗效相当,但早期并发症风险低,且对于合并半月板损伤的患者,早期手术有利于膝关节功能恢复。     

计算机导航关节镜下前十字韧带重建术

目的介绍计算机导航技术辅助关节镜下前十字韧带重建术的术前规划和手术方法,比较导航技术辅助与单纯关节镜技术中股骨、胫骨隧道位置的优良率。方法根据术前标准正侧位X线片设计股骨、胫骨隧道的理想位置。术中“C”型臂X线机获得正侧位影像后输入计算机,形成虚拟工作界面。膝关节周围分别于股骨、胫骨侧安置“患者追踪器”。前十字韧带胫骨及股骨导向器上分别装配“工具追踪器”。经过注册及校准后,导航系统识别并捕获上述追踪器发射的信号,确定膝关节的位置,实时跟踪手术工具的位置和方向,并将隧道的虚拟路径叠加在工作界面上,供术者实时调整导向器的位置与方向,直至达到术前规划的要求。临床上完成计算机导航关节镜下前十字韧带重建术46例。对其中40例进行术后X线片测量,确定胫骨及股骨隧道的位置,并与同期进行的40例单纯关节镜下重建术隧道位置的测量结果进行比较。结果导航组胫骨隧道位置平均为45.35%±3.827%(37%￣53%),股骨隧道位置平均为62.25%±5.610%(52%￣73%);关节镜组胫骨隧道位置平均为41.05%±6.008%(25%～54%),股骨隧道位置平均为56.62%±7.316%(46%￣77%)。导航组的股骨及胫骨隧道位置较关节镜组偏后,差异有统计学意义(P<0.05),导航组的标准差小于关节镜组。结论计算机导航技术可以使关节镜下前十字韧带重建手术中胫骨及股骨隧道的位置更偏后,提高了手术准确性及可重复性。     

Single versus two-incision arthroscopic anterior cruciate ligament reconstruction

The purpose of this study was to compare single (endoscopic) versus two-incision arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone in a population of young athletes. All patients followed a similar postoperative rehabilitation program. The Lysholm knee score, the International Knee Documentation Committee Score, KT-1000 arthrometric measurements, Lachman tests, pivot shift tests, isokinetic and functional testing, and perioperative complications were used to compare the two techniques. Anteroposterior and lateral radiographs were also evaluated and compared. Group I comprised 51 patients who underwent two-incision arthroscopic ACL reconstruction. The average age was 19.8 years, with a range of 18 to 22. The average follow-up in this group was 31 months (range, 24 to 43 months). Group II, the endoscopic group, consisted of 31 patients with an average age of 19.4 years (range, 18 to 22). The average follow-up was 25 months (range, 24 to 31 months). There were no significant differences between the two groups using subjective, objective, and functional criteria. There did appear to be a trend toward a residual pivot glide in the endoscopic group, but this did not achieve statistical significance. Radiographic analysis demonstrated an increased incidence of screw divergence in the endoscopic group. Intraoperative complications were more common with the endoscopic method.     

Graft selection in arthroscopic anterior cruciate ligament reconstruction

Background  

Anterior cruciate ligament (ACL) surgical reconstruction is performed with the use of an autogenic, allogenic or synthetic graft. The document issued by the Italian National Guidelines System (SNLG, Sistema Nazionale Linee Guida) at the National Institute of Health aims to guide orthopaedic surgeons in selecting the optimal graft for ACL reconstruction using an evidence-based approach.     

Posttraumatic cartilage degradation progresses following anterior cruciate ligament reconstruction: A second-look arthroscopic evaluation

BackgroundSeveral studies have demonstrated that posttraumatic knee osteoarthritis progresses even after anterior cruciate ligament reconstruction. Few reports described zone-specific cartilaginous damages after anterior cruciate ligament reconstruction. This study aimed to compare the status of articular cartilage at anterior cruciate ligament reconstruction with that at second-look arthroscopy.MethodsThis study included 20 patients (20 knees, 10 males and 10 females, mean age 22.4 years, Body mass index 24.4 kg/m²) that underwent arthroscopic anatomic double-bundle anterior cruciate ligament reconstruction and second-look arthroscopy. Mean periods from injury to reconstruction and from reconstruction to second-look arthroscopy were 3.4 and 15.3 months, respectively. Cartilage lesions were evaluated arthroscopically in the 6 articular surfaces and 40 articular subcompartments independently, and these features were graded with the International Cartilage Repair Society articular cartilage injury classification; comparisons were made between the grades at reconstruction and at second-look arthroscopy. Furthermore, clinical outcomes were assessed at reconstruction and at second-look arthroscopy, using the Lysholm knee score, Tegner activity scale, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, side-to-side difference of the KT-2000 arthrometer, and pivot shift test.ResultsEach compartment showed a deteriorated condition at second-look arthroscopy compared with the pre-reconstruction period. A significant worsening of the articular cartilage was noted in all compartments except the lateral tibial plateau and was also observed in the central region of the medial femoral condyle and trochlea after reconstruction. However, each clinical outcome was significantly improved postoperatively.ConclusionsGood cartilage conditions were restored in most subcompartments at second-look arthroscopy. Furthermore, posttraumatic osteoarthritic changes in the patellofemoral and medial compartments progressed even in the early postoperative period, although good knee stability and clinical outcomes were obtained. Care is necessary regarding the progression of osteoarthritis and the appearance of knee symptoms in patients undergoing anterior cruciate ligament reconstruction.     

Periarticular heterotopic ossification: A complication of arthroscopic anterior cruciate ligament reconstruction using a two-incision technique

Extra-articular heterotopic bone formation was recognized as a postoperative complication of arthroscopic anterior cruciate ligament reconstructions in four knees around the femoral drill hole. Although laxity of the reconstructed anterior cruciate ligament was not observed in these patients, local pain, swelling, and deformity at the site of heterotopic ossification required surgical intervention. The ectopic bone can be successfully excised with restoration of function. The incidence rate of this complication is less than 1%.     

Pretibial cyst formation after arthroscopic anterior cruciate ligament reconstruction

Pretibial cyst formation is a rare occurrence after anterior cruciate ligament (ACL) reconstruction. We report this complication after ACL reconstruction using a hamstring autograft. Bone grafting of the original tibial tunnels during revision surgeries after failed ACL reconstruction could prevent this rare complication.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp E5–E5     

前交叉韧带损伤关节镜下重建治疗的临床研究进展

前交叉韧带（anterior cruciate ligament,ACL）是保持膝关节稳定的重要结构,断裂后可导致膝关节不稳,引起膝关节继发损害而严重影响膝关节功能。目前,ACL重建已成为治疗其损伤的有效方法。国内有关ACL的临床研究已较广泛和深入,但仍有许多新的课题有待研究。现结合本期刊登的几篇相关领域的论文予以评述,讨论有关ACL重建治疗中的热点问题。     

关节镜下前交叉韧带袖套状保残重建的临床效果

目的:观察袖套状保留残端的关节镜下前交叉韧带重建的临床效果。方法:收集2012年1月至2014年12月于骨科就诊的42例前交叉韧带损伤患者,其中男17例,女25例,平均年龄28.4岁,平均受伤时间5.5周(2~12周)。采用关节镜下重建前交叉韧带,同时保留胫骨侧韧带残端,通过滑膜袖套恢复残端张力。治疗前及治疗后2、6、12个月采用Lachman试验、前抽屉试验对稳定性进行评价,术后12个月采用Lysholm评分和Tegner运动分级评价膝关节功能。治疗前和治疗后12个月行膝关节MRI检查。结果:术后2、6、12个月Lachman试验、前抽屉试验均为阴性。术前Lysholm评分37.8±7.1,Tegner评分2.1±0.4;术后12个月的Lysholm评分96.8±6.1,Tegner评分6.2±0.9,均高于术前。术后12个月复查MRI显示前交叉韧带显影良好。结论:关节镜下前交叉韧带袖套状保残重建可以获得良好的临床效果。     

关节镜下前十字韧带重建术后并发致死性肺栓塞一例报告

男,30岁,因"左膝外伤后关节不稳伴疼痛感3个月"入院.入院查体:身高180 cm,体重100 kg,血压127/85mmHg(1 mm Hg=0.133 kPa);左膝关节无明显肿胀,左股四头肌轻度萎缩,左膝外侧间隙压痛,内外翻试验阴性,麦氏征阳性,前抽屉试验阳性,Lachman试验阳性,末梢血运良好,左足趾屈伸活动良好.     

前交叉韧带重建术后感染的诊断分型与分期治疗

目的 探讨前交叉韧带(ACL)重建术后感染的诊断分型与分期治疗的有效性. 方法 2002年10月至2010年12月共收治11例ACL重建术后感染患者,男8例,女3例;平均年龄为28.8岁(18 ～45岁).感染确诊时间为术后1～ 64周,平均7.7周.结合国内外文献,我们根据全身症状、局部是否有红肿渗出及是否累及关节腔等特点将感染分为3型:Ⅰ型,急性感染性滑膜炎型(5例);Ⅱ型,关节外型(3例);Ⅲ型,感染性关节炎型[3例,其中关节穿刺培养阳性者为ⅢA型(2例),阴性者为ⅢB型(1例)].根据分型和病程不同,早期应用广谱抗生素治疗,必要时行早期清创和关节内置管冲洗,病程长并有窦道形成者采用开放手术清创,取出移植肌腱和内固定物. 结果 11例患者术后获2.5 ～8.0年(平均5.2年)随访.11例患者感染均获痊愈,但3例(Ⅰ型1例,ⅢA型2例)遗留关节伸直受限.11例患者未次随访时膝关节Lysholm评分为76 ～93分,平均82分.KT-1000检查评估20°前句松弛度对比健侧＜2 mm者2例,对比健侧为3 mm者6例,＞3mm者3例. 结论 对于ACL重建术后感染,根据临床表现应早期进行诊断分型,根据我们的诊断分型实施分期治疗可取得良好疗效.     

计算机导航辅助关节镜下重建前交叉韧带

目的通过与传统关节镜下重建前交叉韧带(ACL)手术进行比较,说明基于X线影像的计算机导航系统辅助关节镜下重建ACL的手术方法隧道定位更精确。方法2005年12月-2006年3月共完成40例计算机导航系统辅助关节镜下ACL重建手术。选择2005年6月-2006年3月40例传统关节镜下ACL重建手术作为对照组,在X线片上分别测量胫骨隧道和股骨隧道的位置,对两组患者测量结果进行统计学分析。结果计算机导航系统辅助关节镜下ACL重建手术组测量股骨隧道位置平均值为62．3％±5．6％(52％-73％),传统手术组测量股骨隧道位置平均值为56．6％±7．3％(46％-77％)。胫骨隧道位置测量,导航辅助手术组平均值为45．4％±3．8％(37％-53％),传统手术组平均值为41．1％±6．0％(25％-54％)。两组患者的股骨隧道和胫骨隧道位置分别做统计学分析,差异均有显著性意义(P< 0．05)。导航辅助手术组数据更接近解剖重建ACL位置。计算机导航系统辅助关节镜下ACL重建的平均手术时间较传统手术延长20 min,透视次数为4次。结论基于X线影像的计算机导航系统辅助关节镜下ACL重建手术是安全、可行的,可以使股骨、胫骨隧道位置更精确。