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.     

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.     

The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis

Background

In recent years, with technological advances in arthroscopy and magnetic resonance imaging and improved biomechanical studies of the meniscus, there has been some progress in the diagnosis and treatment of injuries to the roots of the meniscus. However, the biomechanical effect of posterior lateral meniscus root tears on the knee has not yet become clear. The purpose of this study was to determine the effect of a complete radial posterior lateral meniscus root tear on the knee contact mechanics and the function of the posterior meniscofemoral ligament on the knee with tear in the posterior root of lateral meniscus.

Methods

A finite element model of the knee was developed to simulate different cases for intact knee, a complete radial posterior lateral meniscus root tear, a complete radial posterior lateral meniscus root tear with posterior meniscofemoral ligament deficiency, and total meniscectomy of the lateral meniscus. A compressive load of 1000 N was applied in all cases to calculate contact areas, contact pressure, and meniscal displacements.

Results

The complete radial posterior lateral meniscus root tear decreased the contact area and increased the contact pressure on the lateral compartment under compressive load. We also found a decreased contact area and increased contact pressure in the medial compartment, but it was not obvious compared to the lateral compartment. The lateral meniscus was radially displaced by compressive load after a complete radial posterior lateral meniscus root tear, and the displacement took place mainly in the body and posterior horn of lateral meniscus. There were further decrease in contact area and increases in contact pressure and raidial displacement of the lateral meniscus in the case of the complete posterior lateral meniscus root tear in combination with posterior meniscofemoral ligament deficiency.

Conclusions

Complete radial posterior lateral meniscus root tear is not functionally equivalent to total meniscectomy. The posterior root torn lateral meniscus continues to provide some load transmission and distribution functions across the joint. The posterior meniscofemoral ligament prevents excessive radial displacement of the posterior root torn lateral meniscus and assists the torn lateral meniscus in transmitting a certain amount of stress in the lateral compartment.     

Diagnostisches Vorgehen beim Kniegelenktrauma im Kindes- und Jugendalter

Introduction

Clinical examination of acute knee injury in childhood is often difficult and therefore magnetic resonance imaging (MRI) serves as an additional diagnostic tool. The aim of the present study was to evaluate on the one hand the indications for diagnostic arthroscopy and on the other hand the indications for MRI.

Methods

Of the children treated between 1990 and 1999, 87 (group 1) underwent arthroscopy after clinical examination. Between 2000 and 2006 (group 2) 83 patients were examined using MRI after clinical examination and 53 were subsequently submitted to arthroscopy.

Results

In group 1 the clinical diagnosis was verified by arthroscopy in 79%. In group 2 the clinical and arthroscopic diagnoses were consistent in 60% of the patients. The MRI diagnosis was correctly recognized for patella dislocation in all cases, for ligament injuries in 83% and for meniscus injuries in 56%. Due to the application of MRI before arthroscopy the fraction of diagnostic arthroscopies could be reduced from 22% to 13%.

Conclusion

The number of diagnostic arthroscopies in childhood can be reduced by application of MRI.     

Concomitant ligamentous and meniscal knee injuries in femoral shaft fracture

Background

Concomitant knee injury is a common finding in femoral fractures but can be easily missed during early management of the initial trauma. Degrees of damage to the articular structures vary considerably; from only a mild effusion to complete ligamentous and meniscal tears. Since previous reports were mostly from developed societies, this study was designed to look into characteristics of associated knee injury in a sample from Iran, to represent a developing country perspective.

Materials and methods

Consecutive patients admitted to an orthopedic ward of Baqiyatallah hospital (Tehran, Iran) with diagnosis of femoral fracture were enrolled in this study between October 2008 and September 2009. In patients who met the inclusion criteria of the study, arthroscopic or open surgical examination of the knee, ADT, Lachman test, varus and valgus stress tests under anesthesia were carried out to determine the incidence of knee injury.

Results

Forty patients with ipsilateral and two patients with bilateral femoral fractures were studied. Arthroscopy revealed medial meniscus injury in 12 (27 %) knees. Three (7 %) lateral meniscus injuries, 18 (40.9 %) ACL injuries and 2 (4.5 %) PCL injuries were also found. In varus and valgus stress tests, 15 (34 %) MCL and 4 (9 %) LCL laxities were noticed. The Lachman test was positive in 3 (6 %), and ADT was positive in 2 (4.5 %) patients.

Conclusions

Based on our observations, concomitant ligamentous and meniscal knee injury is a common finding in femoral shaft fractures and rates of these injuries are generally in concert with reports from developed nations.     

Combined posterolateral corner and acute anterior cruciate ligament injuries in an adolescent cohort: a magnetic resonance imaging analysis

Purpose

Failure of a reconstructed anterior cruciate ligament (ACL) has significant morbidity in the paediatric and adolescent patient population. Untreated concomitant posterolateral corner (PLC) injury is an identified cause of failed ACL reconstruction; however, the injury pattern has yet to be defined for the paediatric population.

Methods

Magnetic resonance imaging (MRI) studies of the knee performed between 1 January 2009 and 1 January 2013 were retrospectively reviewed. Imaging reports indicating an intra-substance injury of the ACL were reviewed, and all associated injured structures were recorded. Injury patterns were categorised by age, gender, physis status and associated injuries. Logistic regression and chi-square analyses compared ACL disruptions with and without concomitant PLC injuries.

Results

One hundred and twenty-eight patients (74 boys and 54 girls, average age 15.27 years) sustained an ACL disruption. Concomitant injury to the PLC was seen in 13.3 % of injuries. Associated PLC injuries were significantly associated with lateral meniscus injury and Segond fractures. Lateral meniscus injury was predictive of PLC injury (p?=?0.05) upon logistic regression analysis.

Conclusion

Concomitant PLC injuries were found in 13.3 % of all ACL disruptions on MRI analysis. Lateral meniscus injuries associated with an ACL disruption were predictive of concomitant PLC injury. Combined injury of the ACL and lateral meniscus should prompt close scrutiny to PLC structures.

     

Biomechanical consequences of a posterior root tear of the lateral meniscus: stabilizing effect of the meniscofemoral ligament

Purpose

The purpose of this study was to evaluate the effects of different types of lateral meniscus root tears in terms of tibiofemoral contact stress.

Methods

Ten porcine knees each underwent five different testing conditions with the menisci intact, a simulated lateral posterior root tear with and without cutting the meniscofemoral ligament and with an artificial tear of the posterior root of the medial meniscus. Biomechanical testing was performed at 30° of flexion with an axial load of 100 N. A pressure sensor (st Sensor Type S2042, Novel, Munich) was used to measure the tibiofemoral contact area and the tibiofemoral contact pressure. Data were analyzed to assess the differences in contact area and tibiofemoral peak contact pressure among the five meniscal conditions.

Results

There was no significant difference in mean contact pressure between the state with the menisci intact and an isolated posterior root tear of the lateral meniscus. In case of a root tear and a tear of the meniscofemoral ligament, the contact area decreased in comparison with the intact state of the menisci. After additional cutting of the meniscofemoral ligament, the tibiofemoral contact pressure was significantly higher in comparison with the intact state and the avulsion injury. In the medial compartment, joint compression forces were significantly increased in comparison with the intact state after cutting the posterior root of the medial meniscus (P < 0.05).

Conclusions

The consequence of a medial meniscus root tear is well known and was verified by this analysis. The results of the present study show that the biomechanical consequences of a lateral meniscus root tear depend on the state of the meniscofemoral ligament. An increase in tibiofemoral contact pressure is only to be expected in combined injuries of the meniscus root and the meniscofemoral ligaments.

Clinical relevance

Posterior lateral meniscus root tear might have a better prognosis in terms of the development of osteoarthritis when the meniscofemoral ligament is intact.     

Meniscus suture provides better clinical and biomechanical results at 1-year follow-up than meniscectomy

Background

Surgery of meniscus tear results in limitation of function. The aim of study was functional assessment of knee 1 year after surgery with two techniques in cases of the medial meniscus tear followed by the same supervised rehabilitation.

Materials and methods

A total of 30 patients with good KOSS scores constituted two equal groups after partial meniscectomy or meniscus suture. Measurements of knee extensors and flexors muscles peak torques were performed with angular velocities 60, 180, 240 and 300 s^?1 using Biodex IV system. One-leg-hop and one-leg-rising tests ascertained the function of operated knee. Results of examinations were compared with reference to healthy volunteers. Results of biomechanical and clinical studies were correlated to create complex and objective method evaluating treatment.

Results

Extensors peak torque values at 60 s^?1 angular velocity and H/Q coefficient were decreased after meniscectomy more than meniscus suture in comparison to healthy volunteers (P ≤ 0.001; P ≤ 0.05). Analysis of functional tests revealed that patients after meniscectomy showed difference between operated and non-operated knee (P ≤ 0.01) while patients with meniscus suture differed the least to controls (P ≤ 0.05). Extensors peak torque values at 60 s^?1 angular velocity correlated with results of one-leg-rising test.

Conclusion

Results suggest worse functional effects when meniscectomy is applied which implies modification of the rehabilitative methods in a postoperative period.     

Mesenchymal Stem Cells in Synovial Fluid Increase After Meniscus Injury

Background

Although relatively uncommon, spontaneous healing from a meniscus injury has been observed even within the avascular area. This may be the result of the existence of mesenchymal stem cells in synovial fluid.

Questions/purposes

The purpose of this study was to investigate whether mesenchymal stem cells existed in the synovial fluid of the knee after meniscus injury.

Methods

Synovial fluid was obtained from the knees of 22 patients with meniscus injury just before meniscus surgery and from 8 volunteers who had no history of knee injury. The cellular fraction of the synovial fluid was cultured for 14 days followed by analysis for multilineage potential and presentation of surface antigens characteristic of mesenchymal stem cells. Colony-forming efficiency and proliferation potential were also compared between the two groups.

Results

Cells with characteristics of mesenchymal stem cells were observed in the synovial fluid of injured knees to a much greater degree than in uninjured knees. The colony-forming cells derived from the synovial fluid of the knee with meniscus injury had multipotentiality and surface epitopes identical to mesenchymal stem cells. The average number of colony formation, obtained from 1 mL of synovial fluid, in meniscus-injured knees was 250, higher than that from healthy volunteers, which was 0.5 (p < 0.001). Total colony number per synovial fluid volume was positively correlated with the postinjury period (r = 0.77, p < 0.001).

Conclusions

Mesenchymal stem cells were found to exist in synovial fluid from knees after meniscus injury. Mesenchymal stem cells were present in higher numbers in synovial fluid with meniscus injury than in normal knees. Total colony number per synovial fluid volume was positively correlated with the postinjury period.

Clinical Relevance

Our current human study and previous animal studies suggest the possibility that mesenchymal stem cells in synovial fluid increase after meniscus injury contributing to spontaneous meniscus healing.     

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.     

Aussagekraft der Magnetresonanztomographie bei der präoperativen Diagnostik von Rotatorenmanschetten- und Labrumläsionen der Schulter

Background

MR imaging is the method of choice in the identification of soft tissue structures. In shoulder injuries, it is widely used for the diagnosis of rotator cuff and labral lesions. In this study, the significance of MR imaging was evaluated by correlating the preoperative imaging with the results from shoulder arthroscopy.

Methods

From 8/2003 to 8/2007, 162 arthroscopic shoulder examinations in 161 patients were performed. In 146 of these patients, MR imaging was performed before surgery. Images in the transverse, paracoronal, and parasagittal planes using T1- and T2-weighting were obtained. The retrospective study included 146 patients (60 women, 86 men, mean age 52 years). MRI was performed after shoulder injury or in the case of unexplainable, persisting shoulder pain because of clinical aspects of the examination. MR imaging is compared with the arthroscopic findings. The χ² test and contingency tables were used for statistical evaluation.

Results

A transmural rotator cuff tear was diagnosed preoperatively by MRI in 76 patients. During shoulder arthroscopy, 82 transmural cuff tears were found. One tear identified by MRI could not be verified by arthroscopy. A total of 7 lesions were not identified preoperatively, which included 4 cases of subscapularis tendon and 1 of the supraspinatus tendon. Thus, sensitivity of MR imaging was 0.90 with a specificity of 0.91. A labral lesion was diagnosed by MRI in 16 patients, while during arthroscopy, 31 labral lesions were found. One MRI lesion could not be confirmed. Except for one lesion, none of the 13 SLAP lesions could be diagnosed by MRI. Thus, the sensitivity of MR imaging was 0.52 and specificity was 0.89.

Discussion

Native MR imaging is a reliable diagnostic procedure for the evaluation of transmural rotator cuff tears. Labral lesions, however, and especially SLAP lesions can not always be identified during routine native MRI. Here special scans, for instance in the ARBER position, or contrast-enhanced techniques should be taken into consideration to improve the correlation to arthroscopic results.     

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.     

The association between meniscal subluxation and cartilage degeneration

Purpose

The menisci play a critical protective role for the knee joint through shock absorption and load distribution. We hypothesized that cartilage degeneration will be abruptly progressed if meniscal subluxation exceeds a critical point.

Methods

Of 56 cases that showed medial meniscal subluxation without cartilage degeneration of ipsilateral medial femoral condyle (MFC) on initial MRI, from January 2005 to June 2007, meniscal subluxation index (MSI), the ratio of meniscal overhang to meniscal width in mid-coronal image of initial MRI, was measured. After 2 years, 40 cases were evaluated for cartilage degeneration of ipsilateral MFC on follow-up MRI. The relationship between medial MSI on initial MRI and cartilage degeneration of MFC on follow-up MRI was analyzed. Logistic regression analysis was conducted to find a critical point of meniscal subluxation related to cartilage degeneration.

Results

Abrupt progression of cartilage degeneration was observed from which MSI was 0.38. Logistic regression showed that if MSI was at the critical point, which was 0.38 in our study, then the probability of cartilage degeneration to grade 3 or 4 after 2 years was 44 %. If MSI was 0.4, then the probability was 50 %. If MSI was 0.6, then the probability was 99 %.

Conclusions

The results suggest the existence of critical point from which the protective function of the meniscus appears to be significantly altered, and the degree of cartilage degeneration of ipsilateral femoral condyle corresponding to the amount of medial meniscal subluxation may be predictable.     

Morphological evaluation and diagnosis of medial type osteoarthritis of the knee using ultrasound

Objective

The aim of this study was to diagnose osteoarthritis (OA) of the knee joint using ultrasound (US).

Methods

The study subjects included 27 males and 54 females (131 knees), who had a mean age of 62.8 years. US was used to evaluate the medial joint space of both knees in complete extension with and without weight-bearing. In each patient, the medial radial displacement of the medial meniscus (MRD), the peripheral joint space (PJS) and the number of osteophytes were evaluated. The subjects were divided into five groups based on the KL grade (0–4), and then each value was compared. Additionally, the subjects were divided into two groups: KL grade 0 and 1 (non-OA group) and KL grade 2–4 (OA group). We classified patients who met the following criteria as having OA on the US assessment: <5 mm of PJS during weight-bearing, >5 mm of MRD during weight-bearing, and >2 mm of osteophytes. Then we examined the diagnostic accuracy of the radiographic diagnosis (non-OA or OA of the knee) using US assessment.

Results

The PJS was significantly decreased and the MRD was significantly increased in the OA group compared to the non-OA group (p < 0.001). The percentage of radiographic OA of the knee that was correctly diagnosed by ultrasound was 90.8 % (sensitivity), with a specificity of 95.5 %. The positive predictive value was 97.5 % and the negative predictive value was 84.0 %.

Conclusions

Our study therefore showed that US has both a high reliability and excellent diagnostic accuracy.     

Risiko iatrogener neurovaskulärer Verletzung bei proximal dreidimensionaler Verriegelung von Tibiamarknägeln

Background

The rate of clinically relevant neurovascular injuries after proximal intramedullary nailing of the tibia remains unclear. The anatomical risk of iatrogenic damage to these structures should be estimated in a prospective MRI examination.

Material and methods

A total of 99 consecutive patients were included in the study cohort. All patients underwent an MRI examination due to suspected intra-articular lesions of the knee joint. Examinations were performed at the Institute for Radiology at the Clinic of Worms. The MRI system used was a Philips Intera 1.0 Tesla (Philips, Böblingen, Deutschland). The distance of the neurovascular bundle (GNB) to the posterior tibial cortex was measured (dTK) to estimate the risk of bicortical drilling. The position of the GNB (pGNB) in the medial (+pGNB) and lateral (?pGNB) directions was determined relative to the tibial head midline to estimate potential advantages of oblique or rotated insertion of the nail.

Results

The mean distance between the posterior tibial cortex and the GNB was 11.54 mm (range 4–21 mm standard deviation 3.42 mm). In relation to the tibia head midline, the maximal lateral position was determined as 23 mm and maximal medial position was 6 mm. In 9 cases the GNB was found medially, in 12 cases in the midline and in 69 cases laterally. The mean lateral position of the GNB was 6.03 mm.

Conclusions

Triple proximal interlocking in tibial nailing procedures can be considered a safe procedure if care is taken with the correct operation technique and careful image intensification control of drilling procedures. A rotated nail insertion to avoid a strict anterior-posterior positioning of proximal interlocking screw is not to be recommended.     

Knee sonography as a diagnostic test for medial meniscal tears in young patients

Purpose

To prospectively evaluate whether age of patient affects diagnostic accuracy of sonography and magnetic resonance imaging (MRI) in the diagnosis of medial meniscal tears.

Methods

We prospectively evaluated 74 consecutive patients (54 males and 20 females), in two different groups [group A (37 patients ≤ 30 years; mean age: 23.5 ± 5 years) and group B (37 patients > 30 years; mean age: 43.5 ± 9.35 years)] with clinical suspicion of medial meniscal tear. After inclusion, patients underwent ultrasonography and then MRI for signs of tearing. The ultrasonographic and MRI findings were compared with arthroscopic findings, which served as a gold standard for accurate detection of meniscal tearing.

Results

The sensitivity, specificity, positive and negative predictive values and accuracy of ultrasonography in detecting medial meniscal tears in group A were 100, 88.9, 96.5, 100, 97.3 % and in group B were 83.3, 71.4, 92.6, 50, 81.1 %, respectively. The sensitivity, specificity, positive and negative predictive values and accuracy of MRI in group A were 100, 88.9, 96.5, 100, 97.3 % and in group B were 96.7, 85.7, 96.7, 85.7, 94.6 %, respectively.

Conclusions

Given the fact that the sensitivity and specificity of the results of knee sonography matched that of MRI in patients who were 30 years old or less, we suggest ultrasonography as an effective initial investigation for tears of medial meniscus in this group of patients. Patients with negative ultrasonographic findings will need no further investigation.

Level of evidence

Diagnostic studies—investigating a diagnostic test, Level II.     

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.     

Rivaroxaban is as efficient and safe as bemiparin as thromboprophylaxis in knee arthroscopy

Purpose

The aim of this study is to compare effectiveness and safety profile of rivaroxaban with bemiparin in 3-week extended prophylaxis after knee arthroscopy.

Methods

Four hundred and sixty-seven patients were included in this review divided in two groups. One followed prophylaxis with rivaroxaban and the other one with bemiparin. All patients were interviewed and explored at 1 and 3 months postoperatively, looking for symptomatic signs of deep-vein thrombosis (DVT). In case of suspicion, diagnostic tests were performed. Collected data were age, sex, gender, diagnosis, time with ischemia, body mass index, concomitant diseases, concomitant therapy, DVT signs, treatment satisfaction, minor and major complications, treatment adherence and tolerability.

Results

No thromboembolic events were observed in any of the groups. In one case treated with rivaroxaban, the drug had to be withdrawn due to epistaxis.

Conclusions

Our study showed that extended prophylaxis with 10 mg of rivaroxaban once daily for 3 weeks resulted as effective as bemiparin in knee arthroscopy thromboprophylaxis.

Level of evidence

IV.