Anterior cruciate ligament reconstruction with suture tape augmentation

The advent of suture tape augmentation has led to increased use in knee, elbow, and ankle ligament repairs and reconstructions. Recent biomechanical analysis of the use of suture tape augmentation have shown superior strength characteristics compared with repair or reconstruction alone. Despite its increased use in extra-articular ligament procedures, its use as an augment to anterior cruciate ligament reconstruction has not been widely described. This article details a simple technique to incorporate the use of suture tape augmentation during concurrent anterior cruciate ligament reconstruction using hamstring autograft

Evaluation of the accuracy of a patient-specific instrumentation

Patient-specific instruments (PSI) has been introduced with the aim to reduce the overall costs of the implants, minimizing the size and number of instruments required, and also reducing surgery time. The aim of this study was to perform a review of the current literature, as well as to report about our personal experience, to assess reliability and accuracy of patient specific instrument system in total knee arthroplasty (TKA). A literature review was conducted of PSI system reviewing articles related to coronal alignment, clinical knee and function scores, cost, patient satisfaction and complications. Studies have reported incidences of coronal alignment ≥3° from neutral in TKAs performed with patient-specific cutting guides ranging from 6% to 31%. PSI seem not to be able to result in the same degree of accuracy as for the CAS system, while comparing well with standard manual technique with respect to component positioning and overall lower axis, in particular in the sagittal plane. In cases in which custom-made cutting jigs were used, we recommend performing an accurate control of the alignment before and after any cuts and in any further step of the procedure, in order to avoid possible outliers

In-out versus out-in technique for ACL reconstruction. a prospective clinical and radiological comparison

Background: Several studies have recently shown better restoration of normal knee kinematics and improvement of rotator knee stability after reconstruction with higher femoral tunnel obliquity. The aim of this study is to evaluate tunnel obliquity, length, and posterior wall blowout in single-bundle anterior cruciate ligament (ACL) reconstruction, comparing the transtibial (TT) technique and the out–in (OI) technique. Materials and methods: Forty consecutive patients operated on for ACL reconstruction with hamstrings were randomly divided into two groups: group A underwent a TT technique, while group B underwent an OI technique. At mean follow-up of 10 months, clinical results and obliquity, length, and posterior wall blowout of femoral tunnels in sagittal and coronal planes using computed tomography (CT) scan were assessed. Results: In sagittal plane, femoral tunnel obliquity was 38.6 ± 10.2° in group A and 36.6 ± 11.8° in group B (p = 0.63). In coronal plane, femoral tunnel obliquity was 57.8 ± 5.8° in group A and 35.8 ± 8.2° in group B (p = 0.009). Mean tunnel length was 40.3 ± 1.2 mm in group A and 32.9 ± 2.3 mm in group B (p = 0.01). No cases of posterior wall compromise were observed in any patient of either group. Clinical results were not significantly different between the two groups. Conclusions: The OI technique provides greater obliquity of the femoral tunnel in coronal plane, along with satisfactory length of the tunnel and lack of posterior wall compromise. Level of evidence: II, prospective study

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

Anterior cruciate ligament reconstruction is associated with greater tibial tunnel widening when using a bioabsorbable screw compared to an all-inside technique with suspensory fixation

Purpose: To compare clinical outcomes and tunnel widening following anterior cruciate ligament reconstruction (ACLR) performed with an all-inside technique (Group A) or with a bioabsorbable tibial screw and suspensory femoral fixation (Group B). Methods: Tunnel widening was assessed using computed tomography (CT) and a previously validated analytical best fit cylinder technique at approximately 1-year following ACLR. Clinical follow-up comprised evaluation with IKDC, KSS, Tegner, Lysholm scores, and knee laxity assessment. Results: The study population comprised 22 patients in each group with a median clinical follow-up of 24 months (range 21–27 months). The median duration between ACLR and CT was 13 months (range 12–14 months). There were no significant differences in clinical outcome measures between groups. There were no differences between groups with respect to femoral tunnel widening. However, there was a significantly larger increase in tibial tunnel widening, at the middle portion, in Group B (2.4 ± 1.5 mm) compared to Group A (0.8 ± 0.4 mm) (p = 0.027), and also at the articular portion in Group B (1.5 ± 0.8 mm) compared to Group A (0.8 ± 0.8 mm) (p = 0.027). Conclusion: Tibial tunnel widening after ACLR using hamstring tendon autograft is significantly greater with suspensory femoral fixation and a bioabsorbable tibial interference screw when compared to an all-inside technique at a median follow-up of 2 years. The clinical relevance of this work lies in the rebuttal of concerns arising from biomechanical studies regarding the possibility of increased tunnel widening with an all-inside technique. Level of evidence: III

Surgical Anatomy in ACL Tears

Routine surgical exposure of the lateral compartment is no longer a common practice, as it was in the past. Therefore, most of the reports describing the surgical anatomy of the anterolateral capsule and ligament date back to the seventies and eighties, before the spread of arthroscopy, which dramatically changed knee ligament surgery. All these old-fashioned studies reported a prevalence of injuries in the anterolateral capsule occurring in as much as one hundred percent of all acute ACL tears. Thanks to our attitude towards acute ACL tears, which includes a comprehensive early surgical approach to either ACL or anterolateral ligament (ALL) tears, we reported a prevalence of macroscopically identifiable ALL injuries in approximately 90% of cases. Four types of tears were identified, which included stretching of the ALL, sometimes extending towards the posterolateral capsule (incomplete tears), complete ALL tears usually located below the lateral meniscus, and avulsion bony injuries (Segond’s fracture), the latter occurring in less than 10% of cases. We speculate that Segond’s fracture is only the tip of the iceberg of injuries, which usually affects the midsubstance ALL

Revision ACL Reconstructions

Failure of an ACL reconstruction may be attributed to surgical technical errors, a lack of biological incorporation of the graft, a new traumatic injury, failure to address patient anatomy or the inadequate treatment of associated injuries, including tears of secondary restraints in the anterolateral compartment of the knee. Unlike primary reconstruction, revision surgery must include careful preoperative planning, which could mainly include analysis of possible causes of failure of the previous operation to be eventually avoided in repeated surgery. Regardless of the graft used, tunnel placement and their possible expansion as well as the presence and location of the fixation devices are the most important factors to be considered. Avoiding the convergence or overlapping of the new tunnels with the previous tunnels could result in stronger fixation and faster incorporation of the graft. Fixation devices can be removed only if they actually interfere with the new tunnels, as their removal could result in significant bone loss and/or weakening of the implant site. As in primary reconstruction, the hamstrings represent our graft of choice in revision surgery. However, regardless of the selected graft, extraarticular reconstructions are strongly recommended to improve knee stability and reduce the rate of failure. Although the results of revision ACL surgery are good overall, they appear to be inferior to those of primary reconstruction in terms of patient satisfaction, knee stability, return to sports and early onset degenerative osteoarthritis

Regarding “Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model”

We read with great interest the paper “Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model” by Makhni et al.1 The surgical treatment of anterior glenohumeral insta- bility is a common worldwide issue as well as the management of failed operations. For both primary and revision cases, bone-block procedures and soft tissue repairs have been proposed. The authors have perfectly shown the social costs of these 2 operations and their cost-effectiveness. In Europe, the cost of surgical pro- cedures is even more relevant in daily practice. In Italy, all patients have the right of being assisted by the public health system due to the fact of paying taxes. The health system reimburses the hospitals and the subsi- dized private hospitals for their activity according to the diagnosis-related group (DRG). This is based on patients’ pathologies and on the interventions the physicians perform and accounts for hospitalization, implantable materials, and physicians. The reimbursement for primary or revision open stabilization is 4,303V (code 8182, DRG224) (open), whereas the reimbursement for the same procedure under arthroscopy is 1,333V (code 8182þ8021, DRG232). The same reimbursement is given for revi- sion surgeries. However, the costs for these 2 operations are completely different. The DRG of an arthroscopic Bankart repair covers 2 nights of hospitalization (as decided by the health sys- tem) (600V), implanted materials (480V for burr and shaver, 290V for a radiofrequency system, 2,000V for 4 absorbable anchors, and 88V for 2 cannulas) (data from Mitek Italy), occupation of the operating room (300V for 60 minutes), and various other costs (100V, which includes drugs, irrigation bags, sutures, surgical drapes). In case of associated remplissage, 2 additional anchors (1,080V) and 1/2 hour of operating room (150V) must be considered. The total cost is 3,858V with additional 1,230V in case of remplissage, whereas the DRG covers only 1,333V. The DRG of an open Latarjet covers implanted materials (40V for 2 malleolar screws and washers) and occupation of the operating room (225V for 45 mi- nutes). Drugs and hospitalization are the same as Bankart repair (600V). The total cost is 965V, whereas the cost that the DRG covers is 4,303V. The cost for imaging analysis (150V for a computed tomography scan), physician consultation (300V for 3 consultations), and postoperative physical therapy (400V for 10 sessions) is not included in the DRG reimbursement but has been calculated (850V) as a comparison with the study by Makhni et al. The total cost for an arthroscopic soft tissue repair varies from 4,708V to 5,938V all included (in the study by Makhni et al., it is $13,672). The total cost for an open Latarjet is 1,815V (in the study by Makhni et al., it is$15,287). The functional outcomes of both bone-block procedures (either open or arthroscopic) and soft tissue repairs are extremely satisfying.2 However, they greatly differ in terms of costs for the public health system. Open Latarjet is much more convenient in terms of costs/DRG reimbursement (all costs account for one-fourth of the expected reim- bursement) than arthroscopic soft tissue repairs (all costs exceed almost 4 times the expected reimburse- ment). The problem of expected expenses of surgical procedures has great relevance in some European countries. In fact, a policy of cost reduction has been introduced and could therefore influence surgeons’ decision making, favoring open procedures over arthroscopy