Anterior cruciate ligament reconstruction: A multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method

To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels. DESIGN: Multicenter prospective cohort study (level of evidence II). SETTING: Departments of Orthopedic Surgery of Centro Medico Teknon (Barcelona, Spain) Clinica Universitaria de Navarra (Navarra, Spain), and Clinica FREMAP (Gijon, Spain). PATIENTS: All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study. INTERVENTION: Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months. MAIN OUTCOME MEASURES: Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength. RESULTS: There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5. CONCLUSIONS: The selection of the surgical technique for ACL reconstruction may be based on the surgeon's preference

A lower starting point for the medial cut increases the posterior slope in opening-wedge high tibial osteotomy : a cadaveric study

The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. Results: Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an opening-wedge high tibial osteotomy. Controlled laboratory study

A lower starting point for the medial cut increases the posterior slope in opening‑wedge high tibial osteotomy: a cadaveric study

Abstract Purpose: The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. Methods: A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. Results: Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. Conclusion: Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an openingwedge high tibial osteotomy. Level of evidence: Controlled laboratory study. Keywords: Anterior cruciate ligament, Cadaveric study, Lateral knee X-ray, Medial starting point, Posterior tibial slope, Opening-wedge high tibial osteotomy, Osteotomy, Proximal anatomical axi

Bone Cut Accuracy in Total Knee Arthroplasty: Do Conventional Cutting Guides Stay True to the Planned Coronal Orientation of the Components?

Background: Total knee arthroplasty (TKA) has become the gold standard for the definitive treatment of knee osteoarthritis. One crucial aspect in the implantation of a TKA is the precise orientation of the femoral and tibial components. The main purpose of the present study is to assess, in patients undergoing total knee replacement, whether the difference between the planned angulation in the distal femoral cut and the angulation obtained in the postoperative radiological control is low enough to consider the conventional bone-cutting guides reliable. Methods: A retrospective study was designed with a consecutive series of patients who had undergone primary total knee arthroplasty using conventional instrumentation over one year. The authors analysed the main variable (bone cuts) while considering different variables (age, gender, surgeon, prosthesis, laterality, constraint, body mass index and alignment) to identify different patient patterns that justify the results in the main variable. Descriptive variables were analysed using the Mann–Whitney U and Kruskal–Wallis tests. Additionally, the correlation between continuous variables was explored in accordance with the Spearman correlation. Results: A total of 340 patients with a mean age of 75 ± 9.16 years were finally included in the present study. The mean absolute error of the main variable for the femoral coronal bone cut was 1.89° (SD 1.53). For the tibial coronal bone cut, it was 1.31° (SD 2.54). These values correspond to what remains after subtracting the radiological angulation obtained in the postoperative period from the planned intraoperative angulation of the distal femoral cut. No associations were observed between the main variable (the angulation of the proximal tibial cut and distal femoral cut) and the rest of variables for either the femur or tibia. Conclusion: A discrepancy between the planned angulation and the final radiological measure on the coronal plane of the femur and tibia using conventional cutting guides has been demonstrated. The degree of deviation is low enough that it probably does not affect clinical outcomes. Therefore, the use of conventional cutting guides will continue to be an appropriate tool to perform bone cuts in knee replacement surgery

Influència del suport audiovisual sobre les expectatives preoperatòries del malalt candidat a una artroplàstia total de genoll

La prevalencia de las enfermedades del aparato locomotor,y, en concreto, la artrosis ha ido en aumento con el paso de los años. Esta situación condiciona una problemática socio-económica creciente.En el tratamiento de de esta enfermedad se hace necesario obtener la máxima satisfacción por parte del paciente. Esta satisfacció irá ligada a la calidad de la información que se proporciona al enfermo y, en este sentido, el enfermo puede modificar sus expectativas y por lo tanto incrementar su satisfacción final.Según se observa en la literatura el hecho de adaptar las expectativas del paciente al resultado estándar final condiciona la máxima satisfacción por parte del enfermo.En este trabajo de tesis doctoral se plante un estudio prospectivo, randomizado y comparativo con un nivel de evidencia I segun los criterios descritos en el Journal of Bone and Joint Surgery en el año 2005.Se describen una serie de factores de inclusión y exclusión obteniendo un grupo estudio con 42 pacientes y un grupo control con 50 pacientes. El diseño del estudio se plantea iniciandose en el momento de la indicación quirúrgica, pasando por la administración de un soportye audiovisual en el grupo estudio añadido a la información verbal clásica. Se utilizan diversos intrumentos de medida, siendo el elemento clave el test de expectativas que se administra a ambos grupos antes y después de la administración del soporte audiovisual.A nivel global no se observan diferencias estadísticamente significativas en los dos grupos.Encontramos un perfil de paciente con cierta tendencia a mejorar sus expectativas con la visualización del soporte audiovisual, sin encontrar diferencias estadísticamente significativas.Finalment se observa que en determinados aspectos del test de expectativas existen diferencias esytadísticamente significativas entre los dos grupos. Estos aspectos hacen referencia básicamente a los ítems de función de la articulación que contempla dicho test.La conclusión de este trabajo es que a nivel global el soporte audiovisual en las expectativas del paciente no provoca ninguna modificación significativa. No obstante se observa que existe un cierto perfil de paciente y ciertos aspectos de la información que se da al enfermo en los que el soporte audiovisual actua de forma que las expectativas se ven modificadas para adaptarse al resultado estándar final.Objective: Disparities in expectations about surgical outcomes may be responsible for low good results rates relative to total knee replacement (TKR) surgery in patients deemed suitable for it. The primary goal of this study was to test, in a randomized prospective clinical trial, the efficacy of an educational videodisc and how it influenced patient's expectations. Another objective of the study was to determine the approximate profile of the most apt videodisc pre-surgery viewing patient.Design: Randomized prospective comparative trial. Evidence: Level I, therapeutic study.Methods: Ninety-two patients from 50 to 90 years of age with moderate to severe knee osteoarthritis (OA) were recruited. Forty-two patients (study group) viewed a videodisc on the total knee arthroplasty (TKA) implantation process and fifty patients didn't view it (control group). Both groups were comparable with regard to all the studied variables. The videodisc included the first visit to the orthopaedic surgeon, all aspects of the hospital stay, the surgical intervention and the post-operative clinical situation at two, six and twelve months. Patients completed baseline and post-videodisc session questionnaires with regard to their expectations (Hospital for Special Surgery Knee Replacement Expectation Survey questionnaire). The same surgical technique and controlled rehabilitation were carried out on both groups. Results: After the videodisc session, all patients in both groups improved their overall expectations. There were significant differences relative to three aspects of the HSS questionnaire in patients who visualised the videodisc. Expectations in terms of climbing and lowering stairs and the range of motion were the items that had a significant modification in the study group. After analysing all the variables, the ideal profile was encountered in a male less than seventy-five years of age without signs of depression, less radiological observed deformity, cited pain in WOMAC scale and a punctuation under 50 points in the mental domain of SF-36 scale. Discusion: The information that we give to the patient before surgery is very important in order to reach a better satisfaction at the end of the surgical process. When the expectations before surgery are similar to the final result, the satisfaction is high. As better is the congruence between both aspects, higher is satisfaction. If the information we give to the patient can modify the expectations before surgery, in order to adapt them to the final result, the satisfaction can be modified in the way to improve it. The results of our study show that the application of an educational videodisk support, for the pre-operative information, can be a good tool in order to increase the patient satisfaction. Conclusion: TKR expectations may be enhanced with the combined educational videodisc and the classical information interview

Influència del suport audiovisual sobre les expectatives peroperatòries del malalt candidat a una artroplàstia total de genoll

Descripció del recurs: 13 gener 2011La prevalencia de las enfermedades del aparato locomotor,y, en concreto, la artrosis ha ido en aumento con el paso de los años. Esta situación condiciona una problemática socio-económica creciente. En el tratamiento de de esta enfermedad se hace necesario obtener la máxima satisfacción por parte del paciente. Esta satisfacció irá ligada a la calidad de la información que se proporciona al enfermo y, en este sentido, el enfermo puede modificar sus expectativas y por lo tanto incrementar su satisfacción final. Según se observa en la literatura el hecho de adaptar las expectativas del paciente al resultado estándar final condiciona la máxima satisfacción por parte del enfermo. En este trabajo de tesis doctoral se plante un estudio prospectivo, randomizado y comparativo con un nivel de evidencia I segun los criterios descritos en el Journal of Bone and Joint Surgery en el año 2005. Se describen una serie de factores de inclusión y exclusión obteniendo un grupo estudio con 42 pacientes y un grupo control con 50 pacientes. El diseño del estudio se plantea iniciandose en el momento de la indicación quirúrgica, pasando por la administración de un soportye audiovisual en el grupo estudio añadido a la información verbal clásica. Se utilizan diversos intrumentos de medida, siendo el elemento clave el test de expectativas que se administra a ambos grupos antes y después de la administración del soporte audiovisual. A nivel global no se observan diferencias estadísticamente significativas en los dos grupos. Encontramos un perfil de paciente con cierta tendencia a mejorar sus expectativas con la visualización del soporte audiovisual, sin encontrar diferencias estadísticamente significativas. Finalment se observa que en determinados aspectos del test de expectativas existen diferencias esytadísticamente significativas entre los dos grupos. Estos aspectos hacen referencia básicamente a los ítems de función de la articulación que contempla dicho test. La conclusión de este trabajo es que a nivel global el soporte audiovisual en las expectativas del paciente no provoca ninguna modificación significativa. No obstante se observa que existe un cierto perfil de paciente y ciertos aspectos de la información que se da al enfermo en los que el soporte audiovisual actua de forma que las expectativas se ven modificadas para adaptarse al resultado estándar final.Objective: Disparities in expectations about surgical outcomes may be responsible for low good results rates relative to total knee replacement (TKR) surgery in patients deemed suitable for it. The primary goal of this study was to test, in a randomized prospective clinical trial, the efficacy of an educational videodisc and how it influenced patient's expectations. Another objective of the study was to determine the approximate profile of the most apt videodisc pre-surgery viewing patient. Design: Randomized prospective comparative trial. Evidence: Level I, therapeutic study. Methods: Ninety-two patients from 50 to 90 years of age with moderate to severe knee osteoarthritis (OA) were recruited. Forty-two patients (study group) viewed a videodisc on the total knee arthroplasty (TKA) implantation process and fifty patients didn't view it (control group). Both groups were comparable with regard to all the studied variables. The videodisc included the first visit to the orthopaedic surgeon, all aspects of the hospital stay, the surgical intervention and the post-operative clinical situation at two, six and twelve months. Patients completed baseline and post-videodisc session questionnaires with regard to their expectations (Hospital for Special Surgery Knee Replacement Expectation Survey questionnaire). The same surgical technique and controlled rehabilitation were carried out on both groups. Results: After the videodisc session, all patients in both groups improved their overall expectations. There were significant differences relative to three aspects of the HSS questionnaire in patients who visualised the videodisc. Expectations in terms of climbing and lowering stairs and the range of motion were the items that had a significant modification in the study group. After analysing all the variables, the ideal profile was encountered in a male less than seventy-five years of age without signs of depression, less radiological observed deformity, cited pain in WOMAC scale and a punctuation under 50 points in the mental domain of SF-36 scale. Discusion: The information that we give to the patient before surgery is very important in order to reach a better satisfaction at the end of the surgical process. When the expectations before surgery are similar to the final result, the satisfaction is high. As better is the congruence between both aspects, higher is satisfaction. If the information we give to the patient can modify the expectations before surgery, in order to adapt them to the final result, the satisfaction can be modified in the way to improve it. The results of our study show that the application of an educational videodisk support, for the pre-operative information, can be a good tool in order to increase the patient satisfaction. Conclusion: TKR expectations may be enhanced with the combined educational videodisc and the classical information interview

Failed medial patellofemoral ligament reconstruction : Causes and surgical strategies

Patellar instability is a common clinical problem encountered by orthopedic surgeons specializing in the knee. For patients with chronic lateral patellar instability, the standard surgical approach is to stabilize the patella through a medial patellofemoral ligament (MPFL) reconstruction. Foreseeably, an increasing number of revision surgeries of the reconstructed MPFL will be seen in upcoming years. In this paper, the causes of failed MPFL reconstruction are analyzed: (1) incorrect surgical indication or inappropriate surgical technique/patient selection; (2) a technical error and (3) an incorrect assessment of the concomitant risk factors for instability. An understanding of the anatomy and biomechanics of the MPFL and cautiousness with the imaging techniques while favoring clinical over radiological findings and the use of common sense to determine the adequate surgical technique for each particular case, are critical to minimizing MPFL surgery failure. Additionally, our approach to dealing with failure after primary MPFL reconstruction is also presented

A new score assessing the surgical wound of a TKA and its relation with pain, infection and functional outcomes.

The aim of this study was to describe a new score to measure the aspect of the TKA surgical wound and to correlate it with postoperative pain, infection and functional outcomes at 1 year of follow-up. This score, ranging from 0 to 10, assessed 5 parameters; swelling, haematoma, erythema, blood draining and blisters. 159 consecutive TKA were prospectively evaluated.             Intra and inter-rate reliability was superior to 0.9. No differences were obtained comparing the aspect of the surgical wound with postoperative pain or functional outcomes. Incidence of deep infection is directly related with an increased score (p=0.0025).

A lower starting point for the medial cut increases the posterior slope in opening-wedge high tibial osteotomy: a cadaveric study

Abstract Purpose The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. Methods A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. Results: Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. Conclusion Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an opening-wedge high tibial osteotomy. Level of evidence Controlled laboratory study