Reliability of preoperative measurement with standardized templating in Total Knee Arthroplasty

AIM: To investigate the correlation between preoperative measurement in total knee arthroplasty and the prosthetic size implanted. METHODS: A prospective double-blind study of 50 arthroplasties was performed. Firstly, the reliability and correspondence between the size of said measurement and the actual implant utilized was determined. Secondly, the existing correlation between the intra- and interobserver determinations with the intraclass correlation coefficient was analyzed. RESULTS: An overall correspondence of 54%, improving up to 92% when the measured size admitted a difference of one size, was found. Good intra- and interobserver reliability with an intraclass correlation coefficient greater than 0.90 (P < 0.001) was also discovered. CONCLUSION: Agreement between the preoperative measurement with standardized acetate templates and the prosthetic size implanted can be considered satisfactory. We thus conclude it is a reproducible technique

Comparison of ultrasound-guided versus blind interventions for supraspinatus tendinopathy : A cadaveric study

Background. The treatment of supraspinatus tendinopathy remains a challenge for the health professional. This study aims to analyze the precision of needle interventions in lesions of the supraspinatus tendon when conducting them in an ultrasound-guided or non-ultrasound guided (blind) manner. Methods. Study on cadaver with infiltrations performed under ultrasound control or blind after randomization of the parts and participants. Twenty fresh cadaveric shoulders and 30 practitioners with experience using musculoskeletal ultrasound and doing needle interventions. Each practitioner performed 4 ultrasound-guided and 4 unguided punctures. This provided 240 punctures that were analyzed in 3 different anatomical cuts, thus providing a database of 720 measurements for statistical analysis. Results. Statistically significant differences were observed (p<0.0001) in the distance to the bullet point between the ultrasound-guided and the non-guided infiltrations. It was estimated that the unguided punctures were performed on average 10mm farther from the bullet point than the 'ultrasound-guided' punctures. The ultrasound-guided punctures demonstrated 95% precision while the unguided punctures had a precision rate of 12.5% (p <0.0001). Conclusion. Interventions of the supraspinatus tendon should be performed in an ultrasound-guided manner to facilitate administration of the treatment in the proper area

Trasplante Meniscal Alogénico Artroscópico: Resultados Clínicos y Viabilidad Celular

La resección meniscal o meniscectomía fue el tratamiento de elección de las lesiones meniscales durante mucho tiempo. Desde que la literatura reportó reiteradamente los cambios articulares degenerativos tras este gesto quirúrgico a largo plazo, la forma de tratar estas lesiones ha ido cambiando hacia un proceder cada vez más conservador. Además, la resección meniscal conlleva en muchos casos al dolor compartimental a medio o largo plazo, denominado como síndrome postmeniscectomía. En un intento de paliar de forma biológica este dolor y de potencialmente prevenir la degeneración articular debida a una disminución de tejido meniscal, a mediados de los años 80’ se planteó el trasplante meniscal alogénico (TMA) como una posible solución. Esta alternativa terapéutica ha reportado buenos resultados a medio y largo plazo. Si bien el efecto positivo del TMA sobre el síndrome postmeniscectomía es ya incuestionable, el efecto condroprotector a largo plazo del TMA no ha sido claramente demostrado. Dentro de las técnicas de fijación del implante, si bien la fijación mediante suturas representa una menor dificultad técnica, estudios en cadáver han demostrado una mejor transmisión en las fuerzas de presión cuando la fijación se realiza con tejido óseo conservado en el menisco trasplantado. Sin embargo, la superioridad clínica de una técnica de fijación sobre la otra no ha sido demostrada. El término extrusión meniscal hace referencia a la situación en la que el tejido meniscal se encuentra al menos en un 25% desplazado por fuera del margen tibial. Es evidente y así se ha sugerido, que este “desnudamiento” de la superficie tibial atenta contra el normal funcionamiento biomecánico del menisco. Trasladando esta situación de extrusión meniscal al contexto del TMA podría limitar los potenciales beneficios de ésta técnica. Incluso se ha especulado sobre si el método de fijación del injerto puede afectar la mecánica articular. Otro tema de controversia alrededor del TMA, es el método de preservación del injerto. Mientras que la liofilización se ha dejado de usar dado que se ha demostrado que altera la ultraestructura del injerto conllevando a pobres resultados funcionales, la congelación ha resultado ser un método simple y con buenas resultados funcionales. Sin embargo, aunque para algunos autores con la congelación simple el injerto seguiría mantenimiento sus características biomecánicas, recientemente Gelber et al. han demostrado que esta congelación afecta la ultraestructura de la red colágena. Esto puede evitarse con la criopreservación del tejido que incluso parece mantener la estructura celular, aunque este último punto también está en debate. Finalmente, el injerto fresco se presentaría como la opción más idónea, ya que no produce destrucción celular e incluso preserva la capacidad de producir proteoglicanos y fibras de colágeno por dichas células. La principal limitación de esta técnica de preservación meniscal es la dificultad logística y la necesidad de incubar previamente al injerto a trasplantarse con el suero del receptor, aunque esto último se podría evitar si se utilizasen medios de cultivo genéricos como el Insulin-Transferrin-Selenio (ITS). Sin embargo, no se ha reportado hasta la fecha su utilización en el terreno de la conservación meniscal.Meniscectomy or meniscal resection was the treatment of choice for meniscal injuries for a long time. Once the literature repeatedly reported degenerative joint changes after this surgical action, the way to treat these injuries has shifted towards increasingly conservative procedures. Furthermore, meniscal resection often provokes medium to long term compartmental pain, which is called postmeniscectomy syndrome. In an attempt to alleviate this pain by biological means and potentially prevent joint degeneration due to decreased meniscal tissue, meniscal allograft transplantation (MAT) was put forth as a possible solution in the mid-80's. This alternative therapy has reported good results in the medium and long term. While the positive effect of TMA on the postmeniscectomy syndrome is unquestionable, the long-term chondroprotective effect of TMA has not been clearly demonstrated. Within the area of implant fixation techniques, while fixation with sutures has shown less technical difficulty in cadaver studies, it has shown a better transmission of the pressure forces when the fixing is done with the bone tissue in the preserved transplanted meniscus. However, the clinical superiority of one technique over another has not been demonstrated. The term meniscal extrusion refers to the situation in which the meniscal tissue is displaced by at least 25% outside the tibial margin. It is obvious and as has been suggested that this "stripping" of the tibial surface undermines the normal biomechanical functioning of the meniscus. Transferring this situation of meniscal extrusion to the context TMA may limit the potential benefits of this technique. It has even been speculated that the graft fixation method can affect joint mechanics. Another topic of controversy surrounding the TMA is the graft preservation method. While lyophilization is no longer used as it has been shown to alter graft ultrastructure and so lead to poor functional results, freezing has proven to be a simple method with good functional results. Although for some authors the graft would continue maintaining its biomechanical characteristics with simple freezing, Gelber et al. have recently shown that this freezing affects the ultrastructure of the collagen network. This can be avoided with tissue cryopreservation that even appears to maintain cellular structure, although the latter is also being debated. Finally, the fresh graft is presented as the most suitable option as it does not produce cellular destruction and even preserves the ability of said cells to produce proteoglycans and collagen fibers. The main limitation of this meniscal preservation technique is the logistical difficulty and the need to previously incubate the graft to be transplanted in serum from the recipient, even though the latter could be avoided if generic culture media such as Insulin-Transferrin-Selenium (ITS) is used. However, its use in this field of meniscal conservation has not been reported, to date

Trasplante meniscal alogénico artroscópico : resultados clínicos y viabilidad celular /

La resección meniscal o meniscectomía fue el tratamiento de elección de las lesiones meniscales durante mucho tiempo. Desde que la literatura reportó reiteradamente los cambios articulares degenerativos tras este gesto quirúrgico a largo plazo, la forma de tratar estas lesiones ha ido cambiando hacia un proceder cada vez más conservador. Además, la resección meniscal conlleva en muchos casos al dolor compartimental a medio o largo plazo, denominado como síndrome postmeniscectomía. En un intento de paliar de forma biológica este dolor y de potencialmente prevenir la degeneración articular debida a una disminución de tejido meniscal, a mediados de los años 80' se planteó el trasplante meniscal alogénico (TMA) como una posible solución. Esta alternativa terapéutica ha reportado buenos resultados a medio y largo plazo. Si bien el efecto positivo del TMA sobre el síndrome postmeniscectomía es ya incuestionable, el efecto condroprotector a largo plazo del TMA no ha sido claramente demostrado. Dentro de las técnicas de fijación del implante, si bien la fijación mediante suturas representa una menor dificultad técnica, estudios en cadáver han demostrado una mejor transmisión en las fuerzas de presión cuando la fijación se realiza con tejido óseo conservado en el menisco trasplantado. Sin embargo, la superioridad clínica de una técnica de fijación sobre la otra no ha sido demostrada. El término extrusión meniscal hace referencia a la situación en la que el tejido meniscal se encuentra al menos en un 25% desplazado por fuera del margen tibial. Es evidente y así se ha sugerido, que este "desnudamiento" de la superficie tibial atenta contra el normal funcionamiento biomecánico del menisco. Trasladando esta situación de extrusión meniscal al contexto del TMA podría limitar los potenciales beneficios de ésta técnica. Incluso se ha especulado sobre si el método de fijación del injerto puede afectar la mecánica articular. Otro tema de controversia alrededor del TMA, es el método de preservación del injerto. Mientras que la liofilización se ha dejado de usar dado que se ha demostrado que altera la ultraestructura del injerto conllevando a pobres resultados funcionales, la congelación ha resultado ser un método simple y con buenas resultados funcionales. Sin embargo, aunque para algunos autores con la congelación simple el injerto seguiría mantenimiento sus características biomecánicas, recientemente Gelber et al. han demostrado que esta congelación afecta la ultraestructura de la red colágena. Esto puede evitarse con la criopreservación del tejido que incluso parece mantener la estructura celular, aunque este último punto también está en debate. Finalmente, el injerto fresco se presentaría como la opción más idónea, ya que no produce destrucción celular e incluso preserva la capacidad de producir proteoglicanos y fibras de colágeno por dichas células. La principal limitación de esta técnica de preservación meniscal es la dificultad logística y la necesidad de incubar previamente al injerto a trasplantarse con el suero del receptor, aunque esto último se podría evitar si se utilizasen medios de cultivo genéricos como el Insulin-Transferrin-Selenio (ITS). Sin embargo, no se ha reportado hasta la fecha su utilización en el terreno de la conservación meniscal.Meniscectomy or meniscal resection was the treatment of choice for meniscal injuries for a long time. Once the literature repeatedly reported degenerative joint changes after this surgical action, the way to treat these injuries has shifted towards increasingly conservative procedures. Furthermore, meniscal resection often provokes medium to long term compartmental pain, which is called postmeniscectomy syndrome. In an attempt to alleviate this pain by biological means and potentially prevent joint degeneration due to decreased meniscal tissue, meniscal allograft transplantation (MAT) was put forth as a possible solution in the mid-80's. This alternative therapy has reported good results in the medium and long term. While the positive effect of TMA on the postmeniscectomy syndrome is unquestionable, the long-term chondroprotective effect of TMA has not been clearly demonstrated. Within the area of implant fixation techniques, while fixation with sutures has shown less technical difficulty in cadaver studies, it has shown a better transmission of the pressure forces when the fixing is done with the bone tissue in the preserved transplanted meniscus. However, the clinical superiority of one technique over another has not been demonstrated. The term meniscal extrusion refers to the situation in which the meniscal tissue is displaced by at least 25% outside the tibial margin. It is obvious and as has been suggested that this "stripping" of the tibial surface undermines the normal biomechanical functioning of the meniscus. Transferring this situation of meniscal extrusion to the context TMA may limit the potential benefits of this technique. It has even been speculated that the graft fixation method can affect joint mechanics. Another topic of controversy surrounding the TMA is the graft preservation method. While lyophilization is no longer used as it has been shown to alter graft ultrastructure and so lead to poor functional results, freezing has proven to be a simple method with good functional results. Although for some authors the graft would continue maintaining its biomechanical characteristics with simple freezing, Gelber et al. have recently shown that this freezing affects the ultrastructure of the collagen network. This can be avoided with tissue cryopreservation that even appears to maintain cellular structure, although the latter is also being debated. Finally, the fresh graft is presented as the most suitable option as it does not produce cellular destruction and even preserves the ability of said cells to produce proteoglycans and collagen fibers. The main limitation of this meniscal preservation technique is the logistical difficulty and the need to previously incubate the graft to be transplanted in serum from the recipient, even though the latter could be avoided if generic culture media such as Insulin-Transferrin-Selenium (ITS) is used. However, its use in this field of meniscal conservation has not been reported, to date

Anatomic Reconstruction of Chronic Coracoclavicular Ligament Tears: Arthroscopic-Assisted Approach With Nonrigid Mechanical Fixation and Graft Augmentation

It has recently been suggested that all coracoclavicular ligament tears could be considered for surgery because nonoperative management might result in irreversible changes in the scapular position that could lead to muscle kinematic alterations that would perturb the shoulder girdle function and result in pain. In this technical note we describe an anatomic technique for the treatment of chronic coracoclavicular ligament tears that overcomes the issues related to open surgery, metal hardware, the inferior resistance to secondary displacement of only grafting and nonanatomic techniques, and the saw effect and anterior loop translation that can be seen in systems that surround the base of the coracoid. Our technique incorporates the use of a tendon graft and a nonrigid mechanical stabilizer that protects the graft from stretching during the process of healing and integration into bone, guaranteeing the maintenance of a reduced acromioclavicular joint

All-Suture Repair for Compressive Rotator Cuff Tears: Reducing the Traction of the Tissue

Tears of the rotator cuff are a frequent pathology, but the best surgical procedure remains unclear. The arthroscopic approach has become the gold standard, but there are many different suture configurations that can be used. We describe an all-suture repair system with which the anatomical reduction of the rotator cuff is achieved performing traction from the anchor of the lateral row to subsequently performing a suture bridge suture from the medial row. The major advantage of this technique is that it creates compression forces and minimizing tensioning of the tissue

Effectiveness of the Intratissue Percutaneous Electrolysis (EPI®) technique and isoinertial eccentric exercise in the treatment of patellar tendinopathy at two years follow-up

Aim: to show the effect of Intratissue Percutaneous Electrolysis (EPI®) combined with eccentric programme in the treatment of patellar tendinopathy. Methods: prospective study of 33 athlete-patients consecutively treated for insertional tendinopathy with Intratissue Percutaneous Electrolysis (EPI®) and followed for 2 years. Functional assessment was performed at the first visit, at three months and two years with the Tegner scale and VISA-P. Results: an average improvement in the VISA-P of 35 points was obtained. The mean duration of treatment was 4.5 weeks. Some 78.8% of the patients returned to the same level of physical activity as before the injury by the end of treatment, reaching 100% at two years. Conclusions: intratissue percutaneous electrolysis (EPI®) combined with an eccentric-based rehab program offers excellent results in terms of the clinical and functional improvement of the patellar tendon with low morbidity in a short-term period. Level of Evidence: Therapy, level 4

Confirmatory factor analysis of VISA-P scale and measurement invariance across sexes in athletes with patellar tendinopathy

Background The Victorian Institute of Sport Assessment–Patella (VISA-P) scale is the most condition-specific patient-reported outcome measure used to assess symptom severity in athletes with patellar tendinopathy. Previous exploratory factor analyses have been conducted to evaluate the scale's dimensionality, with inconsistent results, and the factor structure of the scale remains unclear. The aims of the present study were to determine the factorial structure of the VISA-P scale using confirmatory factor analysis (CFA) and test measurement invariance across sexes. Methods The study included a convenience sample of 249 Spanish athletes with patellar tendinopathy. CFA was performed to assess factorial validity. Hypothesized 1- and 2-factor models were tested. Measurement invariance across sexes was evaluated via multi-group CFA with several fit indices using EQS 6.1 software. Results The internal consistency coefficient was 0.74. Several CFA models were examined and the 1-factor model in which errors for Items 7 and 8 were correlated showed acceptable fit in terms of comparative fit index (CFI) and goodness-of-fit index (GFI) statistics (CFI = 0.93; GFI = 0.94; standardized root mean square residual = 0.06; root mean square error of approximation = 0.10; 90% confidence interval: 0.08–0.13). This model was invariant across sexes. Conclusion The 1-factor model of the Spanish version of the VISA-P scale (VISA-P-Sp) in which errors for Items 7 and 8 were correlated demonstrated relative fit in CFA. Scores obtained via VISA-P-Sp can be compared between men and women without sexes bias. Further studies should examine the VISA-P scale and other single-score patient-reported outcome measures concurrently

Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee

PURPOSE: To determine the best angle to drill the femoral tunnels of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with concomitant posterior cruciate ligament (PCL) reconstruction to avoid either short tunnels or tunnel collisions. METHODS: Eight cadaveric knees were studied. Double-bundle PCL femoral tunnels were arthroscopically drilled. Drilling of the sMCL and POL tunnels was performed in 4 different combinations of 0° and 30° axial (anteriorly directed) and coronal (proximally directed) angulations. Specimens were scanned with computed tomography to document the relations of the sMCL and POL tunnels to the intercondylar notch and PCL tunnels. A minimum tunnel length of 25 mm was required. RESULTS: When the sMCL femoral tunnel was drilled at 0° axial and 30° coronal (proximally directed) angulations or 30° axial (anteriorly directed) and 0° coronal angulations, the risk of tunnel collision with the PCL tunnels increased in comparison with the remaining evaluated angulations (P < .001). No POL tunnels collided with either PCL tunnel bundle with the exception of tunnels drilled at 0° axial and 30° coronal (proximally directed) angulations, which did so in 3 of 8 cases (P < .001). The minimum required tunnel length was obtained in all the sMCL and POL tunnels (P < .001 and P = .02, respectively). However, some of those angled at 0° on the axial plane violated the intercondylar notch. CONCLUSIONS: When one is performing posteromedial reconstructions with concomitant PCL procedures, the sMCL and POL femoral tunnels should be drilled anteriorly and proximally at both 30° axial and 30° coronal angulations. The POL femoral tunnel may also be angled 0° in the coronal plane. Tunnels at 0° axial angulations showed a shorter distance to the intercondylar notch and a higher risk of collision with the PCL tunnels. CLINICAL RELEVANCE: Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when sMCL and POL femoral tunnels are placed with concomitant PCL reconstruction

An experimental study of muscular injury repair in a mouse model of notexin-induced lesion with EPI® technique

BACKGROUND: The mechanisms of muscle injury repair after EPI® technique, a treatment based on electrical stimulation, have not been described. This study determines whether EPI® therapy could improve muscle damage. METHODS: Twenty-four rats were divided into a control group, Notexin group (7 and 14 days) and a Notexin + EPI group. To induce muscle injury, Notexin was injected in the quadriceps of the left extremity of rats. Pro-inflammatory interleukin 1-beta (IL-1beta) and tumoral necrosis factor-alpha (TNF-alpha) were determined by ELISA. The expression of receptor peroxisome gamma proliferator activator (PPAR-gamma), vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-1 (VEGF-R1) were determined by western-blot. RESULTS: The plasma levels of TNF-alpha and IL-1beta in Notexin-injured rats showed a significant increase compared with the control group. EPI® produced a return of TNF-alpha and IL-1beta values to control levels. PPAR-gamma expression diminished injured quadriceps muscle in rats. EPI® increased PPAR-gamma, VEGF and VEGF-R1 expressions. EPI® decreased plasma levels of pro-inflammatory TNF-alpha and IL-1beta and increased anti-inflammatory PPAR-gamma and proangiogenic factors as well as VEGF and VEGF-R1 expressions. CONCLUSION: The EPI® technique may affect inflammatory mediators in damaged muscle tissue and influences the new vascularization of the injured area. These results suggest that EPI® might represent a useful new therapy for the treatment of muscle injuries. Although our study in rats may represent a valid approach to evaluate EPI® treatment, studies designed to determine how the EPI® treatment may affect recovery of injury in humans are needed