Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players

PURPOSE: The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players. METHODS: Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker-Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing. RESULTS: At a mean follow-up of 72.6 ± 8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture. DISCUSSION: The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain. CONCLUSIONS: The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity

Can the outside-in half-tunnel technique reduce femoral tunnel widening in anterior cruciate ligament reconstruction? A CT study

There are different techniques for drilling the femoral tunnel in the anterior cruciate ligament reconstruction (ACLR), but their influence in the bone tunnel enlargement in unknown. The purpose of this study was to compare two different surgical techniques for evaluating femoral tunnel enlargement in ACLR. The hypothesis was that tunnel placement using the outside-in technique leads to less tunnel enlargement compared to the transtibial technique. METHODS: Forty-four patients treated for ACLR between March 2013 and March 2014 were prospectively enrolled in this study. According to the surgical technique, subjects were assigned to Group A (Out-in) or Group B (Transtibial). All patients underwent CT examination in order to evaluate the femoral tunnel enlargement at four different levels. Moreover, all patients were evaluated with the Lachman test and pivot shift test, and the KT1000 arthrometer was used to measure the anterior laxity of the knee. A subjective evaluation was performed using the 2000 International Knee Documentation Committee Subjective Knee score, Lysholm knee score and Tegner activity scale. All patients were assessed after 24 months of follow-up. RESULTS: At the final follow-up, there were statistically significant differences (p 0.05). CONCLUSIONS: In ACLR with a suspension system, the outside-in technique leads to less enlargement of the femoral tunnel lower than the transtibial technique. KEYWORDS: Anterior cruciate ligament reconstruction; CT imaging; Drilling technique; Femoral tunnel enlargement PMID: 28389757 DOI: 10.1007/s00590-017-1950-8 Share on FacebookShare on TwitterShare on Google+ LinkOut - more resource

Single harvesting in the all-inside graft-link technique. is the graft length crucial for success? A biomechanical study

Background: The all-inside graft-link technique for anterior cruciate ligament reconstruction is performed with two cortical suspension devices with adjustable loops on both femur and tibia. This technique requires meticulous graft preparation. The aim of this study was to biomechanically test three different graft configurations resulting from differences in initial graft length. Materials and methods: Thirty bovine digital extensor tendons were arranged in three different ways: “half-quadrupled”, “tripled” and “quadrupled”. The final graft length was 65–75 mm. The specimens were fixed vertical to the loading axis of a tensile testing machine. After a static pre-conditioning of 50 N for 5 min, a load to failure test was performed and data regarding the ultimate failure load (UFL), the stiffness and mode of failure were recorded. Results: The evaluation of UFL showed a significant differences between group means as determined by one-way analysis of variance (F = 21.92, p = 0.002). Post hoc comparisons showed a significantly better UFL of “tripled” (p = 0.007) and “quadrupled” preparations (p = 0.014) compared to the “half-quadrupled” configuration, with no significant differences between “tripled” and “quadrupled” grafts (p = 0.061). No significant differences were found when evaluating the stiffness between the groups. Failure occurred by tendon slippage across the suture in all specimens. Conclusion: The “quadrupled” tendon achieved the best UFL, with even the “tripled” configuration having sufficient biomechanical characteristics to withstand the loads experienced during early rehabilitation. For this reason, with a total semitendinosus length of less than 260 mm it could be better to “triple” instead of “half-quadruple” it to achieve better performance of the graft

Functional evaluation of professional athletes treated with a mini-open technique for achilles tendon rupture

Introduction: in this study we report the functional results of 36 professional athletes treated with a combined percutaneous and mini-open technique. Methods: patients were evaluated with Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the objective 100-points Hannover scale and the Ergo-jump Bosco System device. Results: at a mean 28- month follow-up no re-rupture cases were observed. Six patients had minor complications. The Ergo-jump Bosco System device showed no significant differences in the side-to-side evaluation in regard to strength (-0.94%) and elasticity (+2.44%), while a significant post-operative loss was detected in the endurance trials (-6.78%). The Hannover scale showed an average score of 94.5, while the VISAA had an average of 93.1. Thirty-one patients resumed their pre-perative sports activity level within five months from surgery. Conclusions: our results showed that the combined mini-open and percutaneous repair is an effective treatment for professional athletes, with satisfactory clinical and functional results, lack of major complications and a quick return to professional sports activity

Reverse total shoulder arthroplasty demonstrates better outcomes than angular stable plate in the treatment of three-part and four-part proximal humerus fractures in patients older than 70 years

Background: Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear. Questions/purposes: (1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA? Methods: Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31%(73 patients) were excluded because 18%(13 of 73 patients) did notmeet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 6 2.9 years in the RTSA group and 73 6 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROMmeasurements.Asurgical complicationwas defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only. Results: Compared with patients treatedwithORIF, patients treated with RTSA had superior improvements in Constant (85.0 6 7.0 versus 53.06 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 6 3.7 versus 30.0 6 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 6 4.2 versus 30.5 6 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° 7° for patients with RTSA and 100° 6° for patients with ORIF (mean difference 35o [95% CI 33 to 37]; p < 0.01). The mean abductionwas 131° 7° for patients with RTSA and 104° 6° for those with ORIF (mean difference 27o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85°5° for patients with RTSA and 64° 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° 6° for patients with RTSA and 40° 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0%[0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07). Conclusion In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete

Biomechanical comparison of four coupled fixation systems for ACL reconstruction with bone socket or full-tunnel on the tibial side

Background To compare in an animal model the biomechanical properties of four coupled fixation devices currently used in ACL reconstruction. Three out of four devices used a full tibial tunnel with an interference screw, while the other one system used a tibial socket and an adjustable loop suspension device. The null hypothesis is that there are no biomechanical differences between all the techniques tested. Methods Thirty two femur–graft–tibia complexes were mounted on a tensile machine using bovine digital extensor tendons, porcine knees and four different fixation device combinations: – Group A: EndoButton CL and BioRCI– Group B: Rigidfix and Intrafix– Group C: Transfix and Deltascrew– Group D: TightRope-RT with the All-inside GraftLink technique.After a preconditioning with a tensile load of 90 N for five minutes, 1000 cycles between 0 and 150 N were applied to the complex before the final pulled to failure. Stiffness and strength were evaluated at the final pullout, as was the displacement (slippage) at one, 100, 500, and 1000 cycles. Results The multiple mean comparison led to a significant difference for the case of stiffness, with worse results in group C compared to group A (p = 0.037). Conversely, no differences were found in UFL and slippage between all groups (p > 0.05). Conclusion All the tested systems demonstrated in an animal model sufficient properties for a safe postoperative rehabilitation both for strength and for stiffness and slippage under cyclic loading