A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-ligament injured athlete

Knee dislocations with multi-ligamentous involvement are potentially limb-threatening injuries that require extensive surgical and rehabilitative intervention. These knee injuries, such as combined anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and/or lateral collateral ligament injuries, are devastating injuries with results that vary from total disability to nearly full recovery of function. Recent surgical advances, including the use of allograft tissues, have increased the efficacy of these procedures while posing new challenges. By combining scientifically based surgical and rehabilitative approaches, improved outcomes in these difficult cases are being reported in the orthopaedic literature.This review details the epidemiology and biomechanics of these serious knee ligament injuries. In addition, state-of-the-art surgical and rehabilitative techniques will be outlined. Clinical and diagnostic imaging evaluation of these knee injuries is reviewed in order to plan and execute the surgical and rehabilitative practices. We review the basic science, surgical and rehabilitative theories and practices associated with bringing patients with these serious knee injury injuries to full recovery, and detail the development of strategies for developing protocols to address these complicated cases.     

Arthroscopic reconstruction of a ruptured patellar tendon: a technical note

A traumatic patellar tendon rupture of a 35-year-old, otherwise healthy male was reconstructed with semi-tendinosus and gracillis tendons. Tendon grafts were harvested with an open-ended tendon stripper without dissecting them free from their tibial insertion. A transpatellar tunnel was drilled appropriate to the tendon size and a passing pin was used across the length of the patella. Graft bundles were passed in a standard fashion, traversing through the midst of the distal part of the patellar tendon via a beath pin with a loaded looped suture. The endo-button device was then flipped and fixed as an anchor. The patella was positioned at the original placement under arthroscopic visualization and the free ends of the hamstring tendons were attached to a post-fixation screw through the Krackow sutures. Tendon grafts were gathered on the tuberositas tibia and fixed with two additional staples. The patient could flex his knee up to 130 deg at the 3-month follow-up. It was demonstrated that arthroscopic reconstruction of a ruptured patellar tendon may be the optimal surgical choice to minimize trauma and begin early rehabilitation.     

Knee laxity after ACL reconstruction with a BPTB graft

The objective of the study was to compare prospectively short-term and mid-term results after ACL reconstruction with special focus on changes in instrumented knee laxity. METHODS: The original study group included prospectively 58 patients who underwent arthroscopically assisted ACL reconstruction with BPTB graft in a two-tunnel technique between 1991 and 1993. Seven patients were lost to follow-up, leaving 51 patients for a first follow-up at 6 months and a second follow-up at 3-6 years (mean 4.3 years). Clinical results were evaluated by means of the Lysholm score and the IKDC score. Laxity was assessed using a KT-1000 arthrometer applying an 89 N anterior load in 20 degrees of flexion. Increased laxity was defined as a 3 mm increase in AP translation between the first and the second follow-up. RESULTS: At mid-term follow-up pivot shift was negative in 86% of cases. IKDC score: normal = 28%, nearly normal = 44%, abnormal = 24%, severely abnormal = 4%. KT-1000: < 3 mm = 68%, 3-5 mm = 24%, > 5 mm = 8%. The mean KT-1000 side-to-side difference was 1.08 (0.17) mm at 6 months and 2.01 (0.29) mm at 3-6 years. The difference was statistically significant (P < 0.005). According to the defined criteria, seven patients had increased laxity at the second follow-up, suggesting a malfunction of the graft due to stretch-out or injury. In this subgroup the mean KT-1000 measurements were 0.86 (0.26) mm at the first follow-up and 5.93 (0.54) mm at the second follow-up. In five of these patients, a malposition of the tunnels was identified as a possible cause. In the remaining group, KT-1000 measurements did not differ significantly between the first and the second follow-up [1.12 (0.20) mm versus 1.37 (0.21) mm]. CONCLUSIONS: Increase in AP laxity occurred in 14% of our cases between the first and the second follow-up. In most of these cases increased laxity was due to inadequate surgical technique, especially malposition of bony tunnels. If tunnel position was correct, there was no evidence for elongation of grafts over time as a general principle.     

Knee bracing after ACL reconstruction: effects on postural control and proprioception

PURPOSE: To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control. METHODS: Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop. RESULTS: The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50). CONCLUSIONS: In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.     

Radiographic landmarks for tunnel placement in reconstruction of the medial patellofemoral ligament

Purpose

To verify the findings of previous studies in confirming radiographic landmarks for the femoral attachment of the medial patellofemoral ligament (MPFL), but also to define radiographic landmarks for the patellar attachment. Assess the effect of limb rotation upon these radiographic landmarks.

Methods

The medial patellofemoral ligament was identified in ten fresh-frozen human cadaveric knees. A headed pin was used to mark the centre of the femoral and patellar attachments. True lateral radiographs were performed followed by lateral radiographs in 10° and 20° of internal and external rotation. Posterior-anterior and proximal?Cdistal position of the headed pin was evaluated.

Results

The femoral attachment averaged 3.8?±?5.0?mm anterior to the posterior femoral cortical line and 0.9?±?2.4?mm distal to the perpendicular line intersecting the posterior aspect of Blumensaat??s line. The patellar attachment averaged 7.4?±?3.5?mm anterior to the posterior patellar cortical line, 5.4?±?2.6?mm distal to the perpendicular line intersecting the proximal margin of the patellar articular surface. There was a significant relationship between limb rotation and distance of femoral and patellar attachment from the posterior cortical line (P?<?0.0001 and P?<?0.0002 respectively).

Conclusion

Radiographic landmarks for the femoral attachment of the MPFL identified in this study are comparable with other recent work. This study describes new radiographic landmarks for the patellar attachment of the MPFL and highlights that it is essential to acquire true lateral radiographs if these radiographic landmarks are to be interpreted accurately.     

Arthroscopic posterior cruciate ligament reconstruction using bioabsorbable cross-pin femoral fixation: a technical note

There are many methods for fixation of the posterior cruciate ligament grafts. We introduce a new surgical technique that provides more secure femoral and tibial fixation of a tibialis posterior allograft. The tendon was prepared as a four-stranded graft. The tibial tunnel was made using a standard trans-tibial technique. A femoral tunnel was prepared through a low anterolateral portal. The graft was inserted into the femoral tunnel through the anterolateral portal and TransFix (Arthrex, Naples, FL) was fixed at the femur. Four stands of the graft were passed through the tibial tunnel and IntraFix (DePuy Mitek, Raynham, MA) was fixed at the tibia.     

Ultrasound of the elbow: a systematic approach using bony landmarks

The use of bony landmarks can be helpful in performing an ultrasound study of the elbow. We discuss bony landmarks that can be used for evaluation of the common extensor tendon, ulnar collateral ligament and common flexor tendon, coronoid and olecranon fossa, ulnar nerve, and biceps tendon. We discuss bony landmarks for each of these structures.     

Double-bundle anterior cruciate ligament reconstruction using two different suspensory femoral fixation: a technical note

We describe a novel double-bundle reconstruction method for ACL deficient knee. Grafts are tibialis allograft for AMB (anteromedial bundle) and semitendinosus autograft for PLB (posterolateral bundle). Femoral fixations are done by Bio-TransFix for AMB and EndoButton for PLB. Tibial fixations are done by Bio-interference screw for AMB at 60–70° knee flexion and secure the PLB and remnant AMB graft simultaneously onto anteromedial aspect of tibia at 10–20° knee flexion with spiked washer and screw. With our technique, graft lengths are not restricted and we provide strong femoral and tibial fixation if it is compared with previous techniques.     

Imaging the gallbladder: a historical perspective

After Wilhelm Conrad Roentgen's discovery of the X-ray in 1895, it was initially thought that gallstones could not be visualized. Surgeons relied solely on the clinical examination to detect biliary disease. Today, no evaluation of the gallbladder would be complete without the performance of an imaging study. Radiology has gone through several eras in the imaging of gallstones. The plain film era, 1895-1924, was characterized by techniques that improved soft-tissue detail, allowing better detection of radiopaque stones. The contrast media era, 1924-1960, was initiated by the invention of IV cholecystography. In 1925, oral cholecystography was developed. During the era of expanding technology, 1960-1979, percutaneous transhepatic cholangiography, scintigraphy, and sonography came into use. The therapeutic era began in the 1980s.     

Knee performance and self-efficacy trajectory curves after ACL reconstruction: A longitudinal study

ObjectivesTo examine knee flexion range-of-motion, quadriceps strength, and knee self-efficacy trajectory curves over 6 months after anterior cruciate ligament reconstruction (ACLR), stratified by patients’ Month-6 sports activity level.DesignProspective longitudinal study.SettingHospital outpatient physiotherapy department.Participants595 individuals after unilateral ACLR (mean age, 27 years).Main outcome measuresAt 2-, 3-, and 6-months post-surgery, knee flexion range-of-motion, quadriceps strength, and self-efficacy were quantified. Flexion range-of-motion was additionally measured at 2- and 4-weeks post-surgery. Sports activity levels were assessed using the Tegner Activity Score at 6-months post ACLR.ResultsThe various measures improved nonlinearly over time, with substantial improvements observed in the first 2–4 months post-surgery. In multivariable generalized least squares models, greater knee flexion range-of-motion, quadriceps strength, and self-efficacy over time were significantly associated with higher Month-6 Tegner levels (all P values < 0.01). Additionally, receiving a bone-patellar-tendon-bone graft or meniscal repair was associated with lower quadriceps strength trajectories (P-values<0.001) while female sex was associated with lower knee self-efficacy trajectories (P = 0.02).ConclusionsGreater knee flexion range-of-motion, quadriceps strength, and self-efficacy were associated with higher Month-6 Tegner levels. The derived trajectory curves may be useful for effective management decision making and adequate results interpretation during the rehabilitation process.     

Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes

Purpose

Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes.

Methods

A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination.

Results

Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL.

Conclusions

The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.

Level of evidence

Therapeutic case series, Level IV.     

A mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note

Patellar dislocations are associated with injuries to the medial patellofemoral ligament (MPFL). Several techniques for MPFL reconstruction have been recently published with some disadvantages involved, including large skin incisions and donor site morbidity. Arthroscopic stabilizing techniques carry the potential of inadequate restoration of MPFL function. We present a minimally invasive technique for MPFL reconstruction using adductor magnus tendon autograft. This technique is easily performed, safe, and provides a stabilizing effect equal to current MPFL reconstructions. Skin incision of only 3–4 cm is located at the level of the proximal half of the patella. After identifying the distal insertion of the adductor magnus tendon, a tendon harvester is introduced to harvest the medial two-thirds of the tendon, while the distal insertion is left intact. The adductor magnus tendon is cut at 12–14 cm from its distal insertion and transferred into the patellar medial margin. Two suture anchors are inserted through the same incision at the superomedial aspect of the patella in the anatomic MPFL origin. The graft is tightened at 30° knee flexion. Aftercare includes 4 weeks of brace treatment with restricted range of motion.