Usefulness of knee arthroscopy for diagnosis of knee pain in pediatric patients: comparison with preoperative clinical diagnosis

Purpose

To investigate the knee arthroscopic findings of pediatric patients with knee pain.

Subjects

Ninety-five knees of 94 patients (46 males and 48 females) aged 15 years or younger who underwent knee arthroscopy during a 4-year period from January 2007 were studied. The mean age at surgery was 13.5 (7–15) years. The mean interval from symptom onset to arthroscopic examination was 6.8 months (5 days to 2 years 10 months).

Results

The most common cause of knee pain was sports-related activities (64 knees). Other causes included falling from a moving bicycle (5 knees), while knee pain appeared with no defined reason in 14 knees. The most frequent final diagnosis based on knee arthroscopic findings was anterior cruciate ligament (ACL) injury (35 knees), followed by discoid lateral meniscus (16 knees), lateral meniscal tear (11 knees), and medial plica syndrome (9 knees), while no arthroscopic abnormality was observed in 8 of 95 knees. Among the 95 knees, the diagnosis based on preoperative physical tests and imaging findings was different from the arthroscopic diagnosis in 16 knees, 8 of which were diagnosed preoperatively as medial meniscal tear.

Conclusion

ACL injury and discoid lateral meniscus were the predominant conditions in pediatric patients who underwent knee arthroscopic surgery for knee pain. Knee arthroscopy is useful to provide a definitive diagnosis for knee pain in pediatric patients. Preoperative evaluations had a diagnostic accuracy of only 83.2 % and failed to diagnose conditions such as medial plica syndrome and chondral injury. Therefore, diagnosis before knee arthroscopy has to be interpreted with caution.     

Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft

Purpose

The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts.

Methods

From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications.

Results

Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups.

Conclusions

Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.     

Arthroscopic anatomic study of posteromedial joint capsule in knee joint associated with popliteal cyst

Purpose

The purpose of this study was to examine the arthroscopic anatomy of posteromedial capsule and magnetic resonance imaging (MRI) findings in internal derangement of the knee joint and to analyze the relationship between popliteal cysts and the posteromedial capsule.

Methods

From 2011 to 2012, a prospective study included 194 knees of consecutive arthroscopic surgeries for assorted knee problems. The anatomy of the posteromedial joint capsule was evaluated arthroscopically and divided into three types by the presence of capsular fold and opening: no capsular fold and no opening (type I), capsular fold without opening (type II), capsular fold with opening (type III). The presence and size of popliteal cyst were documented by MRI.

Results

Type I was observed in 160 knees (82.5 %), type II in 10 (5.1 %) and type III in 24 (12.4 %). Popliteal cysts were found in 25 knees (12.9 %) by MRI. Of these cases, symptomatic popliteal cysts were identified in 12 knees (6.9 %). On 160 knees demonstrated to be type I, only 3 knees (1.9 %) had popliteal cysts in MRI, 6 knees (60 %) in 10 knees of type II and 16 knees (66.7 %) in 24 knees of type III. Therefore, there was a statistically significant relationship between the type of anatomy in the posteromedial capsule and the popliteal cyst (p < 0.001).

Conclusion

An association between popliteal cyst and arthroscopic anatomy of posteromedial capsule was demonstrated. Comprehensive understanding and knowledge of the arthroscopic anatomy of posteromedial capsule would contribute to the arthroscopic approach in understanding the pathogenesis of popliteal cyst.

Study design

Development of diagnostic criteria on basis of consecutive patients.

Level of evidence

2.     

Arthroskopische Rekonstruktion des vorderen Kreuzbandes in Press-fit-Technik

Purpose

Problems related to the use of interference screws for fixation of bone-patellar tendon-bone grafts for anterior cruciate ligament (ACL) replacement have led to increasing interest in press-fit techniques. Most of the described techniques use press-fit fixation on either the femoral or tibial side. Therefore an arthroscopic technique was developed which achieves bone-patellar tendon-bone graft fixation by press-fit on both sides without the need for supplemental fixation material.

Methods

The first consecutive 40 patients were examined clinically with a KT-1000 arthrometer and radiologically after a mean of 28.7 months (range 20–40 months) postoperatively.

Results

The mean difference in side-to-side laxity was 1.3 mm (SD 2.2 mm) and the results according to the International Knee Documentation Committee (IKDC) score were as follows: 7 A, 28 B, 5 C, 0 D.

Conclusions

The presented press-fit technique avoids all complications related to the use of interference screws. It achieves primary stable fixation of the bone-patellar tendon-bone graft thereby allowing early functional rehabilitation. However, fixation strength depends on bone quality and the arthroscopic procedure is demanding. The results showed reliable stabilization of the operated knees.     

Ligament bracing – Augmentierte Primärnaht bei multiligamentären Verletzungen des Kniegelenks

Objective

Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation.

Indications

Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury.

Contraindications

Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance.

Surgical technique

Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70–90° flexion. Fixation of the ACL augmentation in 20–30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization.

Postoperative management

Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks.

Results

In total, 20 patients have been treated using the principle of “ligament bracing”. So far 8 patients (aged 18–60 years, median 33 years) have been assessed with a follow-up of 10–15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.     

Celecoxib as a pre-emptive analgesia after arthroscopic knee surgery; a triple-blinded randomized controlled trial

Background

Pre-emptive analgesia not only controls pain but also may result in the reduction of opioid consumption and related side effects following orthopedic surgeries. The purpose of the present study was to examine the therapeutic effects of celecoxib in reducing pain following the arthroscopic knee surgeries: anterior cruciate ligament (ACL) reconstruction and partial meniscectomy.

Materials and methods

In this triple-blinded, randomized, placebo-controlled clinical trial, celecoxib 400 mg and identical placebo were administered, 2 h prior to operation, to 130 patient candidates for undergoing knee arthroscopic surgery of either isolated meniscectomy or ACL reconstruction. Pain intensity, 24 h opioid consumption and the related side effects were measured at 6 and 24 h post operation.

Results

The patients in both groups were similar with regards to demographic characteristics such as age, gender and body mass index. The results of the study indicated that the pain intensity and opioid consumption were lower in both subgroups (meniscectomy and ACL-R) in celecoxib group at 6 and 24 h post operation (P < 0.0001). The side effects of analgesics such as nausea and vomiting, sedation, and dizziness were not significantly different between the two groups (P > 0.05).

Conclusion

It seems that celecoxib as a pre-emptive analgesia agent is effective in decreasing acute postoperative pain and 24 h opioid consumption in patients undergoing arthroscopic knee surgery.     

Health-related quality of life in patients with an anterior cruciate ligament injury

Introduction

We evaluated the quality of life (QOL) in patients with an anterior cruciate ligament injury through SF-36 survey, which was a global health-related QOL survey, and investigated the correlation of its results with other clinical parameters.

Patients and methods

Fifty-one patients (mean age 28.7 years) with an anterior cruciate ligament injury were studied. Clinical evaluations using SF-36 version 2 and Lysholm scoring system were conducted, and the ratio of anterior tibial translation in affected compared to unaffected knees was obtained.

Results

In SF-36 survey, scores of both physical and mental health summary measures in our subjects were lower than the national standard values. The mean ratio of anterior tibial translation was 7.8 ± 6.0, and no correlation with SF-36 scores was observed. The mean Lysholm score was 53.3 ± 17.1; which tended to be correlated with the mental health score of SF-36, but not with the physical health score.

Discussion

Our results clearly demonstrated that patients with an anterior cruciate ligament injury had a deterioration of mental health as well as physical health.     

Bioabsorbable sutures versus screw fixation of displaced tibial eminence fractures: a biomechanical study

Background

In 1995, we developed a simple and safe arthroscopic technique of anterograde stable fixation of the displaced tibial eminence fractures using a cannulated screw and washer, allowing immediate mobilisation and weight bearing. Some authors described similar end results by arthroscopic fixation of this abruption with trans-osseous sutures. We proved with the biomechanical study that the fixation with strong trans-osseous sutures provides a comparable stable fixation the same as the cannulated screw and washer. We developed a test machine for cyclic loading and a machine for measuring of the pull-out strength for this study.

Methods

A standard osteotomy of the tibial spine was performed during the cadaveric biomechanical study. We performed an arthroscopic fixation with the cannulated screw and washer in ten knees, and in another group of ten knees, arthroscopic fixation was made using two trans-osseous Orthocord? sutures. The operating time for each procedure was measured, and any possible technical complications were recorded. One thousand cycles of flexion from 0° to 90° were performed on a special loading device on all knees. The macroscopic dislocation of the fragment was measured. After the cyclic loading, all soft tissue was resected except the anterior cruciate ligament with the fixed fragment. The pull-out strength defined as translation of the tibia in anterior direction by breakage was measured with a custom-made measuring device.

Results

The average time for the screw and washer fixation was 20 min, and average time for the sutures fixation was 48 min. After cyclic loading, we did not see any dislocation of the fragment. Average pull-out strength at which fixation with a cannulated screw and washer fell was 253.42 N and mean pull-out strength at which fixation with trans-osseous sutures fell was 330.32 N. Fixation of the fragment with trans-osseous sutures was statistically significantly stronger—Wilcoxon–Mann–Whitney’s test, p = <0.00.

Conclusion

Fixation with strong trans-osseous sutures is stronger than fixation with a cannulated screw and washer on cadaveric knees. It appears that fixation with strong trans-osseous sutures allows immediate mobilisation and weight bearing like fixation with a cannulated screw and washer. Meanwhile, the time for fixation with trans-osseous sutures is significantly longer.     

„Ligament bracing“ – die augmentierte Kreuzbandnaht

Background

In the context of acute knee dislocations, suture repair of ruptured cruciate ligaments leads to good clinical results in 80% of cases. Disadvantages are low primary stability and subsequently secondary elongation of the sutured ligaments. In the present study, we compared primary stability of suture repair, reinforced by different suture augments, to cruciate ligament reconstruction.

Objective

The concept of ligament bracing with transosseous suture repair of the cruciate ligaments and additional suture augmentation is biomechanically superior to cruciate ligament reconstruction.

Material and methods

A total of 42 porcine knee joints divided into seven groups were examined. The stability of four different suture/augmentation combinations were compared to cruciate ligament reconstruction with human hamstring tendons. The investigational setup consisted of testing 1000 cycles with 20 N to 154 N load in a.-p. translation and 60° flexion. Elongation and load to failure were measured.

Results

Neither reconstruction (3.13?±?1.65 mm; 362?±?51 N) nor augmented suture repair (1.89–2.5 mm; 464–624 N) achieved the primary stability of the intact cruciate ligament (0.63?±?0.34 mm, 1012?±?91 N). In comparison to ligament reconstruction, all four augmented suture repairs showed minor elongation in the cyclic test and a higher load to failure. The isolated suture repair showed poor results (6.79?±?4.86 mm, 177?±?73 N).

Conclusion

Augmented suture repair provides significantly higher stability compared with isolated suture repair and reconstruction with hamstring tendons. The concept of ligament bracing could be a promising future treatment option in acute knee dislocations. Clinical results remain to be seen.     

The anterolateral ligament of the knee: unwrapping the enigma. Anatomical study and comparison to previous reports

Background

It has been suggested that the anterolateral ligament (ALL) of the knee may have importance in limiting rotational instability, and reconstruction may prevent a continued pivot-shift following anterior cruciate ligament surgery. However, the anatomy of this ligament has not been consistently reported in recent publications. We describe our experience of cadaveric dissection with reference to other published work.

Materials and Methods

Eleven fresh-frozen cadaveric knees were dissected using a standard technique. The ALL tissue was identified with internal rotation of the tibia and varus stress. Measurements were made using a digital caliper and details of the origin and insertion were recorded.

Results

The ALL was identified in ten of the 11 cadavers. The only specimen in which it was not identified was found to also have an anterior cruciate ligament deficiency. The mean dimensions were: length 40.1 (± 5.53) mm, width 4.63 (± 1.39) mm, thickness 0.87 (± 0.18) mm. The femoral origin was posterior and proximal to the lateral collateral ligament attachment in six knees, anterior and distal in three knees, and at the same site in one knee. The tibial insertion was a mean 17.7 (± 2.95) mm from Gerdy’s tubercle (GT) and 12.3 (± 3.55) mm from the fibula head (FH). This was 59.5 (± 5.44) % from GT to FH.

Conclusions

This anatomical data adds to previous information about the ALL. Our results support the finding that the ALL is a capsular thickening with meniscal attachment. The findings will help to guide the further work required to define the indications for reconstruction and appropriate grafts.

     

Kniegelenklaxizität beim vorderen Kreuzbandersatz

Background

The use of interference screws for femoral graft fixation in anterior cruciate ligament (ACL) reconstruction with hamstring grafts can result in rotation of the graft around the screw leading to changes in the final position of the graft within the bone tunnel.

Material and methods

In a prospective study 107 patients (54 right and 53 left knees) underwent ACL reconstruction with a hamstring tendon autograft. Femoral fixation of the graft was performed with a standard right-thread screw in all cases. Patients were assessed at 6 months postoperatively with the international knee documentation committee (IKDC) standard evaluation including instrumented laxity measurements and the results were compared between right and left knees.

Results

A significantly higher postoperative anterior laxity was observed in left knees with a negative Lachman test in only 64 % of the cases compared with 87 % in the group of right knees. Accordingly, instrumented laxity measurements of the reconstructed knee compared with the contralateral knee revealed significant differences between left and right knees (left knees 1.8±1.2 mm and right knees 1.0±1.4 mm)

Conclusions

This study demonstrates the importance of femoral graft positioning and its sensitivity to multiple influencing factors. The use of standard right-thread interference screws for femoral graft fixation in the mirrored situation of right and left knees may produce a systematic error in ACL reconstruction. Due to a possible rotation of the graft around the screw, the final position of the transplant may vary thus leading to significant changes in anterior translation of the operated knee.     

Clinical results of arthroscopic all-inside lateral meniscal repair using the Meniscal Viper Repair System

Purpose

This study examined the postoperative outcome of the all-inside arthroscopic meniscal suture repair technique using the Meniscal Viper Repair System for lateral meniscus tears.

Methods

Between January 2006 and December 2008, 57 patients (27 males and 30 females) with lateral meniscus tears who underwent meniscal repair using the Meniscal Viper Repair System were evaluated prospectively. Among them, 52 cases were tears involving the posterior third of the lateral meniscus, and most were longitudinal tears or bucket handle tears. The postoperative follow-up period ranged from 12 months to 4 years and 2 months, and averaged 19 months.

Results

Both Lysholm and Japanese Orthopaedic Association Score were significantly improved after surgery. Forty-nine of 57 patients (86.0 %) had no locking or catching, no joint line tenderness, and a negative McMurray test at the last follow-up. Of 32 patients who underwent second-look arthroscopy, 24 achieved complete healing, while four showed partial healing and required repeat repair, and four showed no healing and meniscectomy was conducted. The failure rate in all patients was thus 14.0 % (8 of 57 repairs). No major complications associated with the use of the Meniscal Viper Repair System were observed.

Conclusion

The Meniscal Viper System is a convenient and effective device for all- inside lateral meniscal suture, with high success rate and no major complications.     

Can physical examination predict the intraarticular tear pattern of the anterior cruciate ligament?

Purpose

We evaluated the correlation between physical examinations and the tear patterns of the anterior cruciate ligament (ACL).

Materials and methods

From January 2003 to May 2007, we reviewed 201 cases of ACL rupture, diagnosed by MRI. Two orthopaedic surgeons (a fellow and a senior surgeon) evaluated the instability of the knee under anaesthesia: physical examinations were the anterior draw test (AD), Lachman test (LT), and pivot shift test (PT). By describing the rupture pattern and the site of the anteromedial (AMB) and posterolateral bundle (PLB) during arthroscopic examination, we analysed the correlation between the physical examination under anaesthesia and arthroscopic findings.

Results

In terms of the arthroscopic findings, rupture of the PLB was seen in 83 cases (41.3 %), of the AMB in 24 cases (11.9 %), and of both bundles in 94 cases (46.8 %). The kappa values for the physical examinations between the examiners were 0.963 (AD), 0.92 (LT), and 0.865 (PT). AD and LT above grade 2 did not differ significantly according to the pattern of rupture, but a PT above grade 2 was significantly different in ruptured PLB versus complete rupture.

Conclusions

A PT of more than grade 2 is a reliable physical examination for prediction of ruptured PLB or complete rupture.     

Die anatomische Ersatzplastik des vorderen Kreuzbands in Einzelbündeltechnik

Objective

Restore the knee stability by ACL reconstruction of the anterior cruciate ligament.

Indication

Acute and chronic functional instability with rupture of the anterior cruciate ligament giving way phenomena, acute rupture of the anterior cruciate ligament with concomitant meniscus repair.

Contraindications

Local infection in the knee joint, local soft tissue damage, lack of cooperation of the patient.

Surgical technique

The operation begins with the examination under anesthesia. It follows an arthroscopic examination of the knee and the arthroscopic treatment of accompanying intra-articular lesions (meniscus and cartilage damage). The semitendinosus tendon is harvested via a 3 cm skin incision medial to the tibial tuberosity. A four stranded tendon graft is prepared with a minimum length of 6.5 cm. Alternetive grafts for this technique are the patellar tendon, quadriceps tendon, and allografts. The femoral tunnel for the ACL graft is drilled via a deep anteromedial portal under arthroscopic control. For precise placement of the guide wire a specific offset aimer is used. For drilling the knee must be flexed more than 110°. Landmarks are the intercondylar line and the cartilage-bone interface. The position of the guide wire is always controlled by the medial portal (medial portal view). The guide wire is overdrilled with a cannulated drill (4.5 mm when a flip tack is used). The drill diameter for the 30 mm long blind tunnel is choosen according to the graft diameter. A gentle tunnel preparation may be achieved with the use of dilators. At the tibia, the anterior horn of the lateral meniscus is used as a landmark in the absence of ACL stump. The guide wire is first overdrilled with a 6 mm drill. Slight adjustments to the tibial tunnel location can be archieved when the guide wire is overdrilled eccentrically with a larger drill. At the femur an extrakortikal fixation technique with a flip button is preferred. At the tibia, a hybrid fixation with absorbable interference screw and button is used.

Rehabilitaion

The rehabilitation program is divided into three phases. During the inflammatory phase (1st–2nd week) control of pain and swelling is recommended. The patient is lmobilized with 20 kg partial weigth bearing. During the proliferative phase (3nd–6th week), load and mobility are slowly increased. Goal of this phase is it full extension. Exercises should be performed in a closed chain. During the remodeling phase strength and coordination exercises can be started. Athletes should not return to competitive sports before the 6th to 8th month.

Results

In a prospective study, we have examined 21 patients treated with an anatomic anterior cruciate ligament reconstruction in single-bundle technique, after two years. As graft the semitendinosus was used. The postoperative MRI diagnosis showed that all tunnels were positioned anatomically. KT 1000 measurement showed that the difference of anterior translation decreased from an average of 6.4–1.7 mm. A sliding pivot shift phenomenon was detected in only one patient. The postoperative Lysholmscore was 94.2 points.     

Stadiengerechte Therapie bei Infekten nach Ersatzplastik des vorderen Kreuzbandes

Objective

Debridement and irrigation of the knee joint and the donor site to reduce the amount of bacteria and to remove bacterial enzymes and inflammatory cytokines in cases with infection after replacement of the anterior cruciate ligament (ACL).

Indications

Proven infection, suspected infection.

Contraindications

High anesthesiological risk.

Surgical technique

The therapy of infections after ACL reconstruction depends on the different stages as described by Gächter. In stage I and II, arthroscopic debridement and irrigation (about 10 l) of all compartments is performed. Several biopsies for microbiological analysis are obtained during surgery. Broad-spectrum antibiotic therapy started immediately after surgery. Once the resistance of the bacteria is known, antibiotic therapy may be changed according to the results. When pain, swelling, elevated CRP, or white blood cells persists, arthroscopic irrigation is repeated. In stage III, a complete arthroscopic synovectomy is performed. When the graft is intact, it is left in situ. Resection is performed in case of graft insufficiency, tunnel malplacement, or persistent infection. When the bone tunnels are affected, they should be debrided. In stage IV with osteolysis, an arthrotomy with open debridement may be required. The surgical therapy can be supported with the application of local antibiotics.

Rehabilitation

Redon drainage is left in situ until the next irrigation is performed, control of wound and laboratory results, passive exercises, physiotherapy, systemic antibiotic therapy.

Results

Between 2008 and 2013, we treated 13 patients with an infection after replacement of the ACL. In all cases, complete healing was achieved. In 4 cases, the graft was resected. In 2 patients, arthrofibrosis developed and arthrolysis was required.     

The Surgeon’s Role in Relative Success of PCL-Retaining and PCL-Substituting Total Knee Arthroplasty

Background

The orthopedic literature has not shown a universal and replicated difference, outside of flexion, in clinical results between posterior cruciate ligament retention and posterior cruciate ligament substitution in total knee arthroplasty.

Questions/Purposes

This study was performed to compare the restoration of flexion and knee function in a large series of cruciate-retaining and cruciate-substituting total knee arthroplasties (TKRs). In addition, we aimed to study how other variables, such as those unique to each surgeon, may have affected the results.

Patients and Methods

The current study evaluated 8,607 total knee arthroplasties in 5,594 patients performed by six surgeons, each using one of four prosthesis designs (two posterior cruciate ligament retaining, two posterior cruciate ligament substituting). Knees were compared at the level of cruciate-retaining and cruciate-substituting knees, at the level of the four prostheses, and at the level of surgeon-implant combinations. Least squared means scores were obtained through multiple linear regression, analysis of variance, and the maximum likelihood method.

Results

At the level of posterior cruciate ligament treatment, posterior cruciate ligament substitution as a whole showed 3.2° greater flexion than posterior cruciate ligament retention. At the prosthesis level, cruciate-substituting models provided greater flexion and cruciate-retaining models provided higher function scores. In the surgeon-implant combinations, surgeons provided mixed results that often did not reflect findings from other levels; one surgeon's use of a posterior cruciate ligament retaining prosthesis achieved 14.7° greater flexion than the surgeon's use of a corresponding posterior cruciate ligament substituting design.

Conclusions

Posterior cruciate ligament treatment is confounded by other variables, including the operating surgeon. The arthroplasty surgeon should choose a prosthesis based, not only on outside results, but also on personal experience and comfort.     

The effect of gentamicin in irrigating solutions on articular infection prophylaxis during arthroscopic ACL reconstruction

Purpose

The purpose of this study was to investigate whether gentamicin irrigation solutions provide a potential new tool to prevent joint infection after arthroscopic ACL reconstruction.

Methods

In this prospective randomized study, 360 consecutive ACL recondition patients were randomized in two groups alternately from Feb 2008 to March 2012. In the first group, 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9 % sodium chloride) solution. In the second group 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9 % sodium chloride solution) with added gentamicin (80 mg/L) (group 2). Three patients from group 1 and six patients from group 2 were excluded from the study due to loss of follow-up. The patients were followed for 6 months and assessed for signs of deep infection.

Results

In group 1, a total of 4 (2.2 %) postoperative septic arthritis cases were documented. In group 2, just one postoperative deep infection (septic arthritis) was documented (0.57 %). Although the rate of septic arthritis in group 1 was higher than in group 2, statistical analysis showed that the difference between using the gentamicin irrigation solution (80 mg/L) and the saline solution alone was not significant.

Conclusions

Using gentamicin in irrigating solutions during arthroscopic ACL reconstruction surgery does not statistically decrease post operation septic arthritis.

Level of evidence

Therapeutic Level II.     

Surgical management of multiple knee ligament injuries

Objectives

To summarize our experience and mid-term results of reconstruction with Iliotibial tract grafts for multiple ligament injuries.

Methods

Between July 1997 and December 2003, multiple ligament injuries of 15 patients were reconstructed with Iliotibial tract grafts in arthroscopy. There were 5 women and 10 men. The mean age at the time of the surgery was 30.5 years (range 25–43 years). There were 7 cases who were injured with combined ACL rupture and the PCL, and 8 cases were with disruption of both the ACL and the PCL, combined with damage of the medial collateral ligament.

Results

Fifteen patients were followed up for a mean of 7.5 years (range 6–12 years). The overall mean postoperative Lysholm score was 84.3 ± 5.7. At final IKDC qualification, 60.0 % of the knees were normal or nearly normal. The overall average Tegner activity score decreased significantly at the re-examination compared to the activity score before accident (3.6 ± 0.5 vs. 5.1 ± 0.6).

Conclusions

Reconstruction with Iliotibial tract grafts in arthroscopy was a reliable treatment for multiple ligament injuries.     

Long-term outcomes following single-bundle transtibial arthroscopic posterior cruciate ligament reconstruction

Purpose

Posterior cruciate ligament (PCL) injury has a reported incidence of 3–20 %. PCL reconstruction is aimed at reducing onset of premature articular degeneration and improving function. Numerous operative techniques have been described with varying degrees of result consistency.

Methods

We evaluated 15 patients treated for isolated primary posterior cruciate ligament injury with a mean follow-up of 4.1 years (range one to nine). Post-reconstruction clinical assessment included the Lysholm and Tegner knee scoring scale, international knee documentation committee (IKDC) ligament evaluation, and KT2000 arthrometer assessment.

Results

On the Lysholm knee score 11 patients (73 %) had excellent results, three patients (20 %) had good results and one patient (7 %) had a poor result. On the Tegner activity score the majority of patients scored 7–8 with a return to high level sports. At the final follow-up, the post-reconstruction IKDC score was normal or nearly normal (A and B) in 14 (93 %) patients, and abnormal (C) in one (7 %) patient. According to KT-2000 arthrometer measurements at final follow-up review, 11 patients (73 %) were rated as normal (A, 0–2 mm), and four patients (27 %) as nearly normal (B, 3–5 mm). These results were independent of age, mechanism of injury, time elapsed to surgical reconstruction, and length of follow-up.

Conclusions

Despite being a technically demanding procedure, the outcomes reported in this study show that single bundle transtibial arthroscopic PCL repair using four strands hamstring autograft provides satisfactory and consistent functional outcomes.