Does combined posterior cruciate ligament and posterolateral corner reconstruction for chronic posterior and posterolateral instability restore normal knee function?

SummaryIntroductionPosterior cruciate ligament (PCL) injuries are frequently associated with posterolateral corner (PLC) damages. These complex lesions are most often poorly tolerated clinically. Adherence to sound biomechanical principles treating these complex lesions entails obtaining a functional PCL and reconstructing sufficient posterolateral stability.HypothesisSurgical treatment of postero-posterolateral laxity (PPLL) re-establishes sufficient anatomical integrity to provide stability and satisfactory knee function.Material and methodsIn this retrospective, continuous, single-operator study, 21 patients were operated for chronic PPLL with combined reconstruction of the PCL and PLC and were reviewed with a minimum 1 year follow-up. The clinical and subjective outcomes were evaluated using the IKDC score. Surgical correction of posterior laxity was quantified clinically and radiologically on dynamic posterior drawer images (posterior Telos™ stress test and hamstrings contraction lateral view).ResultsThe mean subjective IKDC score was 62.8 at the last follow-up versus a preoperative score of 54.5 (NS). Preoperatively, all were classified in groups C and D. Postoperatively, 13 patients out of 21 were classified in groups A and B according to the overall clinical IKDC score. The radiological gain in laxity was 51% on the hamstring contraction films and 67% on the posterior Telos™ images (p<0.05).DiscussionThe objective of surgical treatment is to re-establish anatomical integrity to the greatest possible extent. The clinical and radiological laxity results are disappointing in terms of the objectives but are in agreement with the literature. The subjective evaluation demonstrated that this operation can provide sufficient function for standard daily activities but not sports activities.Level of evidenceLevel IV retrospective study

Comparative study of intraoperative knee flexion with three different TKR designs

SummaryIntroductionSubstantial flexion after total knee arthroplasty (TKA) is required for certain categories of patients who wish to squat or kneel in their daily life. Many factors influence this postoperative flexion, including the prosthesis design. It is therefore valuable to in vivo analyze these factors on three knee prosthesis designs through a study of their intraoperative flexion.HypothesisThe posterior-stabilized (PS) knee prostheses provide better intraoperative flexion than the ultracongruent (UC) model. Of the currently available PS models, the high-flexion ones have better intraoperative flexion than standard models. Our main focus endpoint was the intraoperative flexion achieved, before soft-tissues closure, during TKA surgical procedure.Patients and methodsThis was a controlled study. Seventy-two osteoarthritic knees requiring TKA were included to compare three selected prosthesis models: the SAL ultracongruent and two PS models (the standard LPS and the LPS Flex). This was a single-operator study, with patients divided into three homogenous, comparable groups, in which intraoperative measurement of flexion was performed using computer-assisted navigation. Statistical analysis allowed comparison of the three models.ResultsIntraoperatively, after prosthesis implantation, before soft-tissues closure, the mean flexion of the LPS-Flex was 134° versus 124° for the SAL (p=0.0004); the mean flexion of the standard LPS model was 130° versus 124° for the SAL (p=0.14); the PS Flex model showed no significant difference (p=0.26) in flexion (134°) compared to the standard model (130°). The SAL ultracongruent model seemed to be a factor reducing the intraoperative flexion by 8° compared to the PS models (p<10−4).DiscussionIn this study, the PS designs (standard or Flex) provided better intraoperative flexion than the SAL ultracongruent design. However, the LPS Prosthesis did not demonstrate superiority over the standard LPS Prosthesis.Level of evidenceLevel III, low-power prospective study

A new arthroscopic technique for lateral meniscal allograft transplantation: Cadaver feasibility study

SummaryIntroductionThe three prerequisites for a successful meniscal allograft are fixation, graft sizing and precise positioning. The goal of this study was to demonstrate that lateral meniscal allografts can be reliably positioned using a fully arthroscopic technique.HypothesisThis surgical technique is feasible and results in good positioning of the meniscal graft.Material and methodsTwelve fresh cadavers were used in the study. The meniscal graft implantation procedure was performed entirely by arthroscopy. The meniscal horns were fixed with screw-in suture anchors and the meniscal border was fixed to the capsule by arthroscopic meniscus-capsule sutures. The main outcome measure of good implant positioning was based on the distance between the implanted location of the posterior horn of the lateral meniscus (PHLM) and its original location. To accomplish this, aerial photographs of the tibial plateau were used to compare the insertion zones and to calculate the distance between them. These measurements were performed by two surgeons and then compared.ResultsEleven of the 12 procedures (92%) were performed successfully. The posterior horn of the lateral meniscus was positioned an average of 4.3mm in the medial–lateral axis and 1.7mm in the anterior–posterior axis away from its original location. Thus the position of the implanted PHLM was on average 4.6mm away from its original location.DiscussionThis fully arthroscopic technique is feasible. It offers the advantages associated with minimally-invasive surgery and results in good positioning of the posterior horn of the allograft. Two limitations of this study are that the size of the implant was not matched and the chosen fixation method was not subjected to biomechanical evaluation. The lack of a tibial tunnel will make it easier to combine this procedure with ACL reconstruction. In these conditions, the clinical application of this technique seems to be timely.Level of proofIV – Controlled experimental study

Necrotizing Fasciitis and Septic Shock Related to the Uncommon Gram-Negative Pathogen Sphingobacterium multivorum

We report the first case of necrotizing fasciitis due to the uncommon Gram-negative pathogen Sphingobacterium multivorum in an immunocompromised patient, who presented with septic shock. This case adds necrotizing fasciitis to the spectrum of S. multivorum-related infections and highlights the emergence of Gram-negative bacteria in severe soft tissue infections