Incidence and severity of complications due to femoral nerve blocks performed for knee surgery

Background: While single shot femoral nerve blocks and indwelling femoral nerve catheters provide significant peri-operative analgesia, there are small but serious risks of neurovascular complications. We aimed to determine the incidence and characterise the nature of neural complications arising from femoral nerve blocks performed for knee surgery.Methods: One thousand eight hundred and two patients receiving a femoral nerve block for knee surgery during the study period were screened. Patients with possible neurological symptoms were evaluated with a detailed physical examination and self-report questionnaires. Also measures of depression, anxiety and tension/stress were collected.Results: In the patients screened, an incidence of 1.94% was found. Of the 24 patients available for testing, 4 had bilateral symptoms following bilateral nerve blocks. All had sensory abnormalities in the distribution of the femoral nerve. The incidence was significantly higher in females (females = 2.5%, males = 0.83% p = 0.01) and in patients receiving a single shot block (single shot = 2.66%, femoral catheter = 0.93, p = 0.01).Conclusions: The incidence of neurological complication after FNB was higher in this series than typically reported and the symptoms significantly influenced the quality of life in the affected cases. The decision to include a femoral nerve block in the peri-operative analgesic regimen should be made on an individual basis considering the risks and benefits.Level of evidenceTherapeutic level IV.     

Comparison of second-look arthroscopic findings and clinical results according to the amount of preserved remnant in anterior cruciate ligament reconstruction

BackgroundAlthough ACL reconstruction is prevalent, the most effective method for ACL reconstruction still remains controversial. The purpose of this study was to evaluate the effect of the preserved remnant in ACL reconstruction on graft morphology at second-look arthroscopy and clinical outcomes.Methods66 consecutive patients who underwent a second-look arthroscopy after a remnant-preserving ACL reconstruction were enrolled. The patients were divided into two groups according to whether the remnant ACL fibers could be preserved by over 50% (Group I) or not (Group II). The Lysholm score, IKDC subjective score, Tegner activity score, pivot-shift test, and KT-2000 arthrometric findings were evaluated preoperatively and just prior to the second-look arthroscopy to assess clinical outcomes. At second-look arthroscopy, graft morphology was evaluated using hypertrophy rate and synovialization.ResultsAt second-look arthroscopy, the hypertrophy rate of Group I (42.1%) was higher than Group II (25.1%), which was statistically significant (p = 0.002). In graft synovialization, there was a statistically significant difference between the two groups (p < 0.001). The IKDC subjective score improved from 42.9, 43.1 to 77.8, 75.0 for Group I and Group II, respectively (p = 0.025). For the Lysholm score, Group I and Group II improved from 55.4 and 55.7 to 87.8 and 84.9 (p = 0.031). There was also a significant difference between the pivot shift tests between the groups (p = 0.039). Other clinical tests showed no statistically significant differences.ConclusionPreserving the remnant ACL tissue during ACL reconstruction could have a positive effect on graft hypertrophy, synovialization and clinical outcomes.Level of evidenceIII, retrospective comparative study.     

The in vivo relationship between anterior neutral tibial position and loss of knee extension after transtibial ACL reconstruction

BackgroundRestoration of anterior tibial stability while avoiding knee extension deficit are a common goal of anterior cruciate ligament (ACL) reconstruction. However, achieving this goal can be challenging. The purpose of this study was to determine whether side-to-side differences in anterior tibial neutral position and laxity are correlated with knee extension deficit in subjects 2 years after ACL reconstruction.MethodsIn the reconstructed and contralateral knees of 29 subjects with transtibial reconstruction, anterior tibiofemoral neutral position was measured with MRI and three-dimensional modeling techniques; terminal knee extension at heel strike of walking and during a seated knee extension were measured via gait analysis; and anterior laxity was measured using the KT-1000.ResultsKnees that approached normal anterior stability and anterior tibial position had increased extension deficit relative to the contralateral knee. On average the reconstructed knee had significantly less (2.1 ± 4.4°) extension during active extension and during heel strike of walking (3.0 ± 4.3º), with increased anterior neutral tibial position (2.5 ± 1.7 mm) and anterior laxity (1.8 ± 1.0 mm). There was a significant correlation between side-to-side difference in anterior neutral tibial position with both measures of knee extension (walking, r = − 0.711, p < 0.001); active knee extension, r = − 0.544, p = 0.002).ConclusionThe results indicate a relationship between the loss of active knee extension and a change in anterior neutral tibial position following non-anatomic transtibial ACL reconstruction. Given the increasing evidence of a link between altered kinematics and premature osteoarthritis, these findings provide important information to improve our understanding of in vivo knee function after ACL reconstruction.     

Biomechanics of single-tunnel double-bundle anterior cruciate ligament reconstruction using fixation with a unique expandable interference screw

BackgroundSingle-tunnel double-bundle (STDB) anterior cruciate ligament (ACL) reconstruction can restore biomechanical function and anatomic structure, but existing methods of graft fixation are not adequate. The aims of this study are to examine knee biomechanics after STDB reconstruction using a unique expandable interference screw for fixation.MethodsThe biomechanical parameters of six pairs of human cadaveric knee specimens were measured with the ACL intact, after ACL removal, and after STDB reconstruction using the interference screw or single-tunnel single-bundle (STSB) reconstruction. Anterior tibial translation under 134 N anterior tibial load in a neutral position as well as in 15° and 30° internal and external knee rotation and the internal tibial rotation angle under the rotatory load (5 N · m internal tibial rotation) were measured.ResultsAnterior tibial translations at each degree of knee flexion in the STDB group were significantly less than in the STSB group (all, P < 0.05). The internal rotation angles in the STSB group at five flexion angles were significantly higher than in the ACL intact group, whereas there were significantly less than those of the ACL absent group (P < 0.05). Under rotatory loads in the neutral position, the tibial internal rotation angles of the STDB group were significantly lower than in the STSB group at all flexion angles (all, P < 0.05).ConclusionsSTDB ACL reconstruction with the expandable interference screw provides better anteroposterior and rotational stability than STSB reconstruction.Clinical relevanceThe technique provides the advantages of double-bundle reconstruction using a single-tunnel technique.     

Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block

BackgroundWe report a prospective blinded randomised trial of local infiltration versus femoral nerve block in patients undergoing primary total knee replacement (TKR), in accordance with the CONSORT statement 2010.MethodsFifty patients in a teaching hospital were consented for the study. The study arms were intraoperative local anaesthesia (150 ml 0.2% ropivacaine/1 ml 1:1000 adrenaline/30 mg ketolorac) and femoral nerve block (30 ml 0.2% ropivacaine) with a primary outcome of pain score at 4 h post operatively. Secondary outcomes were pain at 2 h, pain scores before and after physiotherapy on day one, total opiate administered, time to physiotherapy goals and length of stay. Randomisation was by sealed envelope. The assessor was blinded and the patients partially blinded to the intervention.ResultsTen patients were excluded, eight before randomisation. The trial is complete. Forty patients were analysed for the primary outcome measure. The local infiltration group had significantly lower pain scores at 4 h post-operatively; mean [SD] score 2.1 [2.6] versus 6.8 [3.2], p < 0.00001 and on post-operative day one prior to physiotherapy; mean score 2.4 [2.3] versus 4.4 [2.3], p < 0.05. Total opiate use was also significantly lower in the local infiltration group; mean total 115 [50.3] mg versus 176.5 [103.5] mg, p < 0.01. There was no difference in any other outcome. There were no harms as a result of either intervention.ConclusionIntraoperative local infiltration gives superior pain relief compared to single shot femoral nerve block over the first 24 h following primary TKR and minimises post-operative opiate use.     

Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study

PurposeTo assess post-operative pain in patients who underwent arthroscopic anterior cruciate ligament (ACL) reconstruction by the all-inside technique.MethodsA prospective randomized comparative parallel trial was performed in 2010–2011 including all patients who underwent an ACL reconstruction in an orthopaedic department in accordance with the CONSORT statement 2010. Patients were randomized to the surgical procedure, all-inside or classical, and were blinded to the surgical technique. Primary evaluation criterion was pain assessed on the Visual Analogical Scale 1 month after surgery. Secondary parameters were analgesic consumption, tunnel positioning on X-ray according to Aglietti's criteria and functional evaluation at six months with IKDC score. None of the patients was lost to follow-up.Results46 consecutive patients were included, 23 in each group, mean age 29.3 ± 9 years. Two patients were excluded due to postoperative complications that required early revision surgery. Forty-four patients were analyzed, 22 in each group. At one month, the pain level was 3.2 ± 5.5 for the all-inside group and 8.6 ± 10 for the classical group, p = 0.057 (95%CI 0.5–10.4). Postoperative analgesic consumption was similar. The position of the tibial tunnels was better with the all-inside method, p = 0.002 (95%CI 1.9–6.6%). There was no significant difference in the mean IKDC subjective score at six months, p = 0.92 (95%CI–9.7 to 9.2).ConclusionAt one month, the pain level seemed lower in the all-inside group than in the classical group, at the limit of statistical significance because the study was underpowered. The all-inside technique is a reliable procedure with very good results for pain, stability and knee function.Level of evidenceI; Therapeutic study     

Comparison of graft healing in anterior cruciate ligament reconstruction with and without a preserved remnant in rabbits

BackgroundThe remnant of the native anterior cruciate ligament (ACL) might contribute to the biological integration of the graft in ACL reconstruction. The aim of this study was to explore whether the preserved remnant enhanced graft healing in ACL reconstruction.MethodsForty New Zealand rabbits underwent bilateral anterior cruciate ligament reconstructions. One knee was treated with a 2-mm remnant preserved on the tibial side (remnant-preservation, RP group) while the contralateral knee underwent a complete removal of the remnants by cauterization (remnant-resection, RR group) in each animal. Gross observations combined with microangiography, histological evaluation, and uniaxial load testing were performed after 4, 8, and 12 weeks.ResultsThe vascular density on the graft surface was statistically higher in the RP group as compared to that of the RR group at 4 (P = 0.002) and 8 weeks (P = 0.020). Additionally, the accelerated intra-articular and intra-tunnel graft integration were histologically observed in the RP group. Histological scores in the RP group were statistically higher than the RR group at 4 weeks (P = 0.028 for the intra-articular healing and P = 0.046 for the intra-tunnel healing) and 8 weeks (P = 0.031 for the intra-articular healing and P = 0.014 for the intra-tunnel healing). The ultimate failure load (P = 0.017), yield load (P = 0.025), and stiffness (P = 0.004) were statistically higher in the RP group as compared to those of the RR group, with corresponding significant differences in the failure mode (P = 0.020) between the two groups at 8 weeks.ConclusionsThe preserved remnant enhanced ACL graft healing with improved biomechanical properties in the rabbit model.Level of evidenceLevel II.     

Reliability of a semi-automated 3D-CT measuring method for tunnel diameters after anterior cruciate ligament reconstruction: A comparison between soft-tissue single-bundle allograft vs. autograft

BackgroundPost-operative widening of tibial and/or femoral bone tunnels is a common observation after ACL reconstruction, especially with soft-tissue grafts. There are no studies comparing tunnel widening in hamstring autografts versus tibialis anterior allografts. The goal of this study was to observe the difference in tunnel widening after the use of allograft vs. autograft for ACL reconstruction, by measuring it with a novel 3-D computed tomography based method.MethodsThirty-five ACL-deficient subjects were included, underwent anatomic single-bundle ACL reconstruction and were evaluated at one year after surgery with the use of 3-D CT imaging. Three independent observers semi-automatically delineated femoral and tibial tunnel outlines, after which a best-fit cylinder was derived and the tunnel diameter was determined. Finally, intra- and inter-observer reliability of this novel measurement protocol was defined.ResultsIn femoral tunnels, the intra-observer ICC was 0.973 (95% CI: 0.922–0.991) and the inter-observer ICC was 0.992 (95% CI: 0.982–0.996). In tibial tunnels, the intra-observer ICC was 0.955 (95% CI: 0.875–0.985). The combined inter-observer ICC was 0.970 (95% CI: 0.987–0.917). Tunnel widening was significantly higher in allografts compared to autografts, in the tibial tunnels (p = 0.013) as well as in the femoral tunnels (p = 0.007).ConclusionsTo our knowledge, this novel, semi-automated 3D-computed tomography image processing method has shown to yield highly reproducible results for the measurement of bone tunnel diameter and area. This series showed a significantly higher amount of tunnel widening observed in the allograft group at one-year follow-up.Level of evidenceLevel II, Prospective comparative study.     

An evidence-based recommendation for the inclusion of specific local intrinsic factors in the study of knee osteoarthritis

ObjectiveAdequate characterization of the mechanical environment of the knee with osteoarthritis (OA) is important. These local intrinsic factors are difficult to measure and there is little evidence to guide their selection. This study makes an evidence-based recommendation for the inclusion of specific factors in the future study of knee OA.MethodForty-six subjects with knee OA were examined. Observed function was measured by the Timed Chair Rise (TCR). Self-reported function was measured by the WOMAC Function Scale and pain was measured by the WOMAC Pain Scale. Local intrinsic factors measured included varus/valgus alignment, anterior/posterior (A/P) laxity, proprioception, isometric knee extension (KE) strength, isometric knee flexion (KF) strength, and knee range of motion (ROM).ResultsFactors were recommended for inclusion in future research if they were significantly correlated with at least one measure of function or pain and if the factor made a significant unique contribution to a regression model when more than one local intrinsic factor was correlated with the same measure of function or pain. Alignment was correlated with pain (r = 0.48, p = 0.001) and WOMAC function (r = 0.38, p = 0.009). A/P laxity was correlated with pain (r = 0.30, p = 0.04) and WOMAC function (r = 0.37, p = 0.01). Knee ROM was correlated to WOMAC function (r = ? 0.35, p = 0.02). KE strength was correlated with TCR (r = 0.32, p = 0.03). Alignment made a significant contribution to prediction of pain (p = 0.003). A/P laxity (p = 0.004) and ROM (p = 0.008) made a significant contribution to WOMAC function.ConclusionWe recommend future knee OA studies include the variables varus/valgus alignment, A/P laxity, ROM, and KE strength.Level of EvidenceIII (correlational study).     

Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: A randomized,controlled study

BackgroundPain after total knee arthroplasty (TKA) is usually severe. Recently, the usefulness of local periarticular injection analgesia (PAI) and peripheral nerve block (PNB) has been reported. We report a prospective blinded randomized trial of PAI versus PNB in patients undergoing primary TKA, in accordance with the CONSORT statement 2010.MethodsA total of 210 patients undergoing TKA under spinal anesthesia were randomized to receive PNB group or PAI group. In the PNB group, femoral nerve block and sciatic nerve block were performed. In the PAI group, a special mixture containing ropivacaine, saline, epinephrine, morphine hydrochloride, and dexamethasone was injected into the periarticular soft tissue. Pain intensity at rest was assessed using a numerical rating scale (NRS: 0–10) after surgery. Use of a diclofenac sodium suppository (25 mg) was allowed for all patients at any time after surgery, and the diclofenac sodium suppository usage was assessed. The NRS for patient satisfaction at 48 hours after surgery was examined.ResultsThe average NRS for pain at rest up to 48 hours after surgery was low in both groups. Within 48 hours after surgery, the diclofenac sodium suppository usage was similar in both groups. There were no significant differences in the NRS for patient satisfaction in both groups.ConclusionsThe analgesic effects of PAI and PNB are similar. PAI may be considered superior to PNB because it is easier to perform.Level of EvidenceTherapeutic Level 1.     

Hamstring antagonist torque generated in vivo following ACL rupture and ACL reconstruction

Hamstring motor behaviour and resultant antagonist torque during knee extension has been quantified in uninjured individuals however, the effect of ACL rupture and ACL reconstruction (ACLR) on the morphology of hamstring antagonist torque generated in vivo is unknown. The purpose of this cross-sectional study was to quantify the hamstring antagonist torque generated in vivo during isokinetic knee extension in ACLD and ACLR patients relative to uninjured control subjects. Ten male ACL deficient (ACLD) subjects (18–35 years), 14 matched males who had undergone ACLR using the bone–patellar tendon–bone graft and 22 matched male control subjects participated. We used a mathematical model to estimate the opposing torque generated by the hamstrings during isokinetic knee extension in 10° intervals from 80° to 10° knee flexion. Control group hamstring antagonist torque was significantly lower at 80–70° knee flexion compared with that of the ACLD (% Diff = 40.2; p = 0.019) and ACLR (% Diff = 34.8; p = 0.036) groups. For all subject groups, hamstring antagonist torque demonstrated a descending–ascending curve; decreasing significantly from 80–70° to 50–40° knee flexion (% Diff = 40.8 to 63.3; p = < 0.001 to 0.009) but then increasing significantly from 50–40° to 20–10° knee flexion (% Diff = 37.6 to 59.0; p = < 0.001 to 0.012). ACL status and therefore, the ACL-hamstring reflex has little effect on the magnitude of hamstring antagonist torque generated during quadriceps-induced knee joint loading. Capsular afferents are thought to dictate the hamstring torque profile which decreased then increased during knee extension to maintain dynamic joint stability.     

Frontal plane knee mechanics and medial cartilage MR relaxation times in individuals with ACL reconstruction: A pilot study

BackgroundThe objective of this pilot study was to evaluate cartilage T_1ρ and T₂ relaxation times and knee mechanics during walking and drop-landing for individuals with anterior cruciate ligament reconstruction (ACL-R).MethodsNine patients (6 men and 3 women, age 35.8 ± 5.4 years, BMI 23.5 ± 2.5 kg/m²) participated 1.5 ± 0.8 years after single-bundle two-tunnel ACL reconstruction. Peak knee adduction moment (KAM), flexion moment (KFM), extension moment (KEM), and peak varus were calculated from kinematic and kinetic data obtained during walking and drop-landing tasks. T_1ρ and T₂ times were calculated for medial femur (MF), and medial tibia (MT) cartilage and compared between subjects with low KAM and high KAM. Biomechanical variables were compared between limbs.ResultsThe high KAM group had higher T_1ρ for MT (p = 0.01), central MT (p = 0.05), posterior MF (p = 0.04), posterior MT (p = 0.01); and higher T₂ for MT (p = 0.02), MF (p = 0.05), posterior MF (p = 0.002) and posterior MT (p = 0.01). During walking, ACL-R knees had greater flexion at initial contact (p = 0.04), and lower KEM (p = 0.02). During drop-landing, the ACL-R knees had lower KAM (p = 0.03) and KFM (p = 0.002).ConclusionPatients with ACL-R who have higher KAM during walking had elevated MR relaxation times in the medial knee compartments. These data suggest that those individuals who have undergone ACL-R and have higher frontal plane loading, may be at a greater risk of knee osteoarthritis.     

3D CT analysis of femoral and tibial tunnel positions after modified transtibial single bundle ACL reconstruction with varus and internal rotation of the tibia

IntroductionWe analyzed the location of femoral and tibial tunnels by three-dimensional (3D) CT reconstruction images after modified transtibial single bundle (SB) anterior cruciate ligament (ACL) reconstruction, creating a femoral tunnel with varus and internal rotation of the tibia.Material and methodsData from 50 patients (50 knees) analyzed by 3D CT after modified transtibial SB ACL reconstructions were evaluated. 3D CT images were analyzed according to the quadrant method by Bernard at the femur and the technique of Forsythe at the tibia.ResultsThe mean distance of the femoral tunnel center locations parallel to the Blumensaat's line was 29.6% ± 1.9% along line t measured from the posterior condylar surface. The mean distances perpendicular to the Blumensaat's line were 37.9% ± 2.5% along line h measured from the Blumensaat's line. At the tibia, the mean anterior-to-posterior distance for the tunnel center location was 37.8% ± 1.2% and the mean medial-to-lateral distance was 50.4% ± 0.9%.DiscussionThe femoral and tibial tunnels after modified transtibial SB ACL reconstruction creating a femoral tunnel with varus and internal rotation of the tibia (figure-of-4 position) were located between the anatomical anteromedial and posterolateral footprints.     

Effect of medial–lateral malpositioning of the femoral component in total knee arthroplasty on anterior knee pain at greater than 8 years of follow-up

BackgroundThe trochlea is often medialized after total knee arthroplasty (TKA) resulting in abnormal patellar tracking, which may lead to anterior knee pain. However, due to the difference in shape of the natural trochlea and the patellar groove of the femoral component, a medialization of the femoral component of 5 mm results in an equal patellar position at 0–30° of flexion. We tested the hypothesis that more medialization of the trochlea results in a higher VAS pain score and lower Kujala anterior knee pain score at midterm follow-up.MethodsDuring surgery a special instrument was used to measure the mediolateral position of the natural trochlea and the prosthetic groove in 61 patients between 2004 and 2005. Patient reported outcome measures were used to investigate the clinical results (NRS-pain, NRS-satisfaction, KOOS-PS and Kujala knee score).ResultsIn total 40 patients were included. The mean follow-up was 8.8 years. A medialization of ≥ 5 mm resulted in a significantly lower NRS-pain (0.2 vs. 1.4; p = 0.004) and higher NRS-satisfaction (9.6 vs. 8.2; p = 0.045). Overall clinical results were good; KOOS-PS was 33.9 and Kujala knee score was 72.1.ConclusionsThe present study showed that a more medial position may result in a better postoperative outcome, which can probably be explained by the non-physiological lateral orientation of the trochlear groove in TKA designs.Level of evidence: Level III     

Pre-operative quadriceps strength predicts IKDC2000 scores 6 months after anterior cruciate ligament reconstruction

Level of evidenceLevel II.BackgroundQuadriceps strength deficits are ubiquitous after anterior cruciate ligament (ACL) injury. Deficits prior to surgery can influence knee function post-operatively. Inhibition contributes to quadriceps strength deficits after an ACL injury. Body mass index, meniscal injury, and sex influence functional outcomes after ACL reconstruction. The purpose of this study is to examine the relationship of pre-operative quadriceps strength and post-operative knee function and to investigate how other pre-operative factors may influence this relationship.MethodsAfter an ACL injury, subjects received pre-operative rehabilitation and performed quadriceps strength testing. Subjects underwent reconstruction and post-operative rehabilitation. Six months after ACL reconstruction, subjects completed the International Knee Documentation Committee 2000 subjective form (IKDC2000). Linear regression models were developed using IKDC2000 scores at 6 months after ACL reconstruction as the dependent variable.ResultsFifty-five subjects had complete pre-operative data and IKDC2000 scores at 6 months after ACL reconstruction. Pre-operative involved quadriceps strength was a significant predictor for IKDC2000 scores 6 months after ACL reconstruction. Sex, meniscal injury, pre-operative BMI, and pre-operative involved quadriceps activation ratio were not significant predictors in the regression model.ConclusionsPre-operative quadriceps strength can predict IKDC2000 scores 6 months after ACL reconstruction. Deficits in pre-operative quadriceps strength influence self-reported function 6 months after surgery. Factors that are known to influence quadriceps strength and self-reported outcomes do not influence the relationship between pre-operative quadriceps strength and post-operative IKDC2000 scores.     

The effect of videotape augmented feedback on drop jump landing strategy: Implications for anterior cruciate ligament and patellofemoral joint injury prevention

BackgroundModification of high-risk movement strategies such as dynamic knee valgus is key to the reduction of anterior cruciate ligament (ACL) and patellofemoral joint (PFJ) injuries. Augmented feedback, which includes video and verbal feedback, could offer a quick, simple and effective alternative to training programs for altering high-risk movement patterns. It is not clear whether feedback can reduce dynamic knee valgus measured using frontal plane projection angle (FPPA).MethodsVertical ground reaction force (vGRF), two-dimensional FPPA of the knee, contact time and jump height of 20 recreationally active university students were measured during a drop jump task pre- and post- an augmented feedback intervention. A control group of eight recreationally active university students were also studied at baseline and repeat test.ResultsThere was a significant reduction in vGRF (p = 0.033), FPPA (p < 0.001) and jump height (p < 0.001) and an increase in contact time (p < 0.001) post feedback in the intervention group. No changes were evident in the control group.ConclusionAugmented feedback leads to significant decreases in vGRF, FPPA and contact time which may help to reduce ACL and PFJ injury risk. However, these changes may result in decreased performance.Clinical relevanceAugmented feedback reduces dynamic knee valgus, as measured via FPPA, and forces experienced during the drop jump task and therefore could be used as a tool for helping decrease ACL and PFJ injury risk prior to, or as part of, the implementation of injury prevention training programs.     

The predictors of outcome in total knee arthroplasty for post-traumatic arthritis

BackgroundThe outcomes of total knee arthroplasty (TKA) for post-traumatic arthritis are less reliable than for idiopathic osteoarthritis. These patients tend to be younger, present with varying degrees of deformity, and often have a history of prior surgery, resulting in a wide spectrum of pathology. We hypothesized that preoperative variables, in particular the location of deformity, would predict pain and functional outcomes.MethodsThe outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 47 knees treated at our institution. All patients were administered the Knee Society Score (KSS) preoperatively and at follow-up (mean 52 months, range 16 to 124). We classified the defects into four categories: intra-articular, metaphyseal, diaphyseal, and combined femoral and tibial deformities.ResultsThere was a significant improvement in KSS scores for pain (p < 0.0001) and a trend toward higher function (p = 0.06) comparing preoperative scores to final follow-up. The largest improvements in pain and functional scores were in patients with isolated articular deformities, while patients with combined tibial and femoral deformities did not have significant improvements in pain or function. Soft-tissue defects requiring flap coverage were associated with worsening in the pain score (p = 0.027).ConclusionsThe location of post-traumatic deformity and compromise of the soft-tissue envelope influence the pain and functional outcomes of total knee arthroplasty for post-traumatic arthritis. Specifically, isolated articular deformities have the largest improvement in pain and function while patients with combined tibial and femoral deformities as well as patients with soft-tissue compromise experience poor outcomes.Level of evidenceIV—Retrospective Case Series.     

Anatomy of the anterior cruciate ligament related to hamstring tendon grafts. A cadaveric study

BackgroundThe aim of modern techniques for anatomic reconstruction of the ACL is to reproduce ACL footprints, in order to restore anatomy and therefore normal biomechanics. Is there an oversizing of the hamstring grafts related to ACL dimensions?MethodsTwenty-two paired cadaver knees were dissected. ACL dimensions at mid-portion and ACL footprints were measured after removing the synovial membrane.Hamstrings were harvested and prepared in a quadruple strand graft in order to measure the mean circumference.ResultsThe average ACL tibial and femoral insertion site areas of the ACL were 117.9 mm² (range, 90 to 130 mm) and 96.8 mm² (range, 80 to 121 mm), respectively.The average diameter and cross sectional area of the ACL tendon at mid-portion were 6.1 mm (range, 5 to 7 mm) and 29.2 mm² (range, 20 to 38.9), respectively. The average diameter and cross-sectional area of the 4-stranded hamstring tendons were 6.7 (range, 5 to 8) and 35.3 mm² (range, 20 to 50), respectively.There was a correlation between the 4-stranded hamstring grafts and ACL dimensions (footprints, ligament at mid substance, p < 0.01). The cross sectional area of hamstring tendon was significantly larger than the ACL area at mid-portion (mean 20.9%, p < 0.05).ConclusionWith current ACL reconstruction techniques, the graft is oversized at a mean of 21%, despite a good correlation between the ACL and the hamstring tendon, especially among small subjects and women. The question arises whether the anatomic reconstruction of the ACL should fill ACL footprints or mimic the ligament itself.Clinical relevanceHamstrings grafts are significantly larger than native ACL.     

Comparison of the ceiling effect in the Lysholm score and the IKDC subjective score for assessing functional outcome after ACL reconstruction

BackgroundTo compare the ceiling effect of the Lysholm and IKDC subjective scores for assessing functional outcome after ACL reconstruction and evaluated the correlation with the one-leg hop test.MethodsA total of 134 patients who underwent ACL reconstruction between 2007 and 2011 were enrolled in this study. All patients fulfilled the postoperative 6- and 12-month evaluations. The ceiling effect of the Lysholm and IKDC subjective scores was assessed, and the correlations between two scales and one-leg hop test were analysed.ResultsFor the entire sample, the ceiling effect for the Lysholm score was 14.9% and 30.6% at 6 and 12 months postoperatively. The values for the IKDC subjective score were 5.2% and 17.2%, respectively. In all subjects, the correlation coefficients [95% confidence intervals] between the IKDC subjective score and one-leg hop test at 6 and 12 months (r = 0.492, [0.34 to 0.62]; r = 0.296, [0.12 to 0.46]) were higher than those for the Lysholm score (r = 0.355, [0.18 to 0.51]; r = 0.241, [0.06 to 0.41]), respectively.(p < 0.05).ConclusionWith regard to evaluating ACL reconstruction outcomes in patients, no significant difference between the IKDC subjective and the Lysholm scores exists in terms of the amount of ceiling effect and the correlation with the LSI. However, the concern that the ceiling effect of the Lysholm score was greater than the IKDC subjective score, should be addressed in assessing the patient's functional status postoperatively.Level of evidence: III, retrospective comparative study.     

Knee function in 10-year-old children and adults with Generalised Joint Hypermobility

PurposeKnee function is reduced in patients with Benign Joint Hypermobility Syndrome. The aim was to study knee function in children and adults with Generalised Joint Hypermobility (GJH) and Non-GJH (NGJH)).Materials and methodsIn a matched comparative study, 39 children and 36 adults (mean age children 10.2 years; adults 40.3 years) were included, comprising 19 children and 18 adults with GJH (Beighton ≥ 5/9; Beighton ≥ 4/9), minimum one hypermobile knee, no knee pain (children), and 20 children and 18 adults with NGJH (Beighton < 5; Beighton < 4). Totally, 85% of the adults were parents to these children.Knee function was determined by self-reported physical fitness (100 mm VAS), Knee injury and Osteoarthritis Outcome Score (KOOS) (only adults), measured maximum isokinetic knee strength (60°/s) and peak vertical jump displacement (PVJD), with calculated knee strength balance, Hamstring/Quadriceps (H/Q) ratio and peak rate of force development (PRFD).ResultsAdults with GJH had lower knee function (KOOS: pain, p = 0.001; symptoms, p = 0.001; Activities of Daily Living, p = 0.001; Sport/Recreation, p = 0.003; knee-related quality of life, p < 0.001), and H/Q ratio (0.46 vs. 0.54, p = 0.046) than adults with NGJH, regardless of age and knee pain. Both GJH groups had normal physical fitness, isokinetic knee strength, and (only children) H/Q ratio.ConclusionsChildren at 10 years with GJH have normal, but adults with GJH have impaired knee function. To track the risk of developing impaired knee function, children with GJH must be followed longitudinally. Meanwhile, attention to knee function may be given to children with GJH who have parents presenting GJH.