Aims

Patients with midcarpal instability are difficult to manage. It is a rare condition, and few studies have reported the outcomes of surgical treatment. No prospective or retrospective study has reported the results of arthroscopic palmar capsuloligamentous suturing. Our aim was to report the results of a prospective study of arthroscopic suture of this ligament complex in patients with midcarpal instability.

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

The objective of this study was to analyze the biomechanical effect of an implanted ACL graft by determining the tunnel position according to the aspect ratio (ASR) of the distal femur during flexion-extension motion. To analyze biomechanical characteristics according to the ASR of the knee joint, only male samples were selected to exclude the effects of gender and 89 samples were selected for measurement. The mean age was 50.73 years, and the mean height was 165.22 cm. We analyzed tunnel length, graft bending angle, and stress of the graft according to tunnel entry position and aspect ratio (ratio of antero-posterior depth to medio-lateral width) of the articular surface for the distal femur during single-bundle outside-in anterior cruciate ligament reconstruction surgery. We performed multi-flexible-body dynamic analyses with wherein four ASR (98, 105, 111, and 117%) knee models. The various ASRs were associated with approximately 1-mm changes in tunnel length. The graft bending angle increased when the entry point was far from the lateral epicondyle and was larger when the ASR was smaller. The graft was at maximum stress, 117% ASR, when the tunnel entry point was near the lateral epicondyle. The maximum stress value at a 5-mm distance from the lateral epicondyle was 3.5 times higher than the 15-mm entry position and, the cases set to 111% and 105% ASR, showed 1.9 times higher stress values when at a 5-mm distance compared with a 15-mm distance. In the case set at 98% ASR, the low-stress value showed a without-distance difference from the lateral epicondyle. Our results suggest that there is no relationship between the ASR and femoral tunnel length, A smaller ASR causes a higher graft bending angle, and a larger ASR causes greater stress in the graft

Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.

Aims

To investigate the risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament (ACL) reconstruction.

Total knee replacement (TKR) smart tibial trials have load-bearing sensors which will show quantitative compartment pressure values and femoral-tibial tracking patterns. Without smart trials, surgeons rely on feel and visual estimation of imbalance to determine if the knee is optimally balanced. Corrective soft-tissue releases are performed with minimal feedback as to what and how much should be released. The smart tibial trials demonstrate graphically where and how much imbalance is present, so that incremental releases can be performed. The smart tibial trials now also incorporate accelerometers which demonstrate the axial alignment. This now allows the surgeon the option to perform a slight recut of the tibia or femur to provide soft-tissue balance without performing soft-tissue releases. Using a smart tibial trial to assist with soft-tissue releases or bone re-cuts, improved patient outcomes have been demonstrated at one year in a multicentre study of 135 patients (135 knees).

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):78–83.

We used immediate post-operative in vivo three-dimensional computed tomography to compare graft bending angles and femoral tunnel lengths in 155 patients who had undergone single-bundle reconstruction of the anterior cruciate ligament using the transtibial (n = 37), anteromedial portal (n = 72) and outside-in (n = 46) techniques. The bending angles in the sagittal and axial planes were significantly greater but the coronal-bending angle was significantly less in the transtibial group than in the anteromedial portal and outside-in groups (p < 0.001 each). The mean length of the femoral tunnel in all three planes was significantly greater in the transtibial group than the anteromedial portal and outside-in groups (p < 0.001 each), but all mean tunnel lengths in the three groups exceeded 30 mm. The only significant difference was the coronal graft- bending angle in the anteromedial portal and outside-in groups (23.5° vs 29.8°, p = 0.012). Compared with the transtibial technique, the anteromedial portal and outside-in techniques may reduce the graft-bending stress at the opening of the femoral tunnel. Despite the femoral tunnel length being shorter in the anteromedial portal and outside-in techniques than in the transtibial technique, a femoral tunnel length of more than 30 mm in the anteromedial portal and outside-in techniques may be sufficient for the graft to heal. . Cite this article: Bone Joint J 2014;96-B:743–51

The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Cite this article: Bone Joint J 2013;95-B:436–44.

Slipped capital femoral epiphysis (SCFE) is relatively common in adolescents and results in a complex deformity of the hip that can lead to femoroacetabular impingement (FAI). FAI may be symptomatic and lead to the premature development of osteoarthritis (OA) of the hip. Current techniques for managing the deformity include arthroscopic femoral neck osteochondroplasty, an arthroscopically assisted limited anterior approach to the hip, surgical dislocation, and proximal femoral osteotomy. Although not a routine procedure to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy has been successfully used to treat FAI caused by acetabular over-coverage. These procedures should be considered for patients with symptoms due to a deformity of the hip secondary to SCFE.

Cite this article: Bone Joint J 2013;95-B:445–51.

The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible. We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision. With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used. An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe. A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear. Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue. It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis

Advanced MRI cartilage imaging such as T₁-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (sd 9.95) and 36.71 ms (sd 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028).

These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (sd 3.5) pre-operatively to a mean of 87.3 (sd 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover’s classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston’s rating scale, where 19 knees were rated as good, four as fair and five as poor.

We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory.

Arthroscopic controlled retrograde drilling of femoral and tibial sockets and tunnels using a specially designed cannulated drill pin and retrocutter (Arthrex Inc, Naples FL.) provides greater flexibility for anatomical graft placement and in revision cases avoids previous tunnels and intra osseus hardware. Inside out drilling of femoral and tibial sockets minimises incisions and eliminates intra articular cortical bone fragmentation of tunnels rims common to conventional antegrade methods. This technique is also ideal for skeletally immature patients since drilling and graft fixation through growth plates may be avoided. Initial tunnel-referencing cannulated drill guide pin placement is carried out from outside-in. This technique (out-in/in-out) combines the advantages of the two-incision and the one-incision technique. In fact it permits us, as in the two-incision technique, to drill a pin guide from outside to inside in order to obtain the correct anatomical insertion of the ACL, otherwise not reproducible from inside-out. Since November 2004 our preferred technique for hamstring (autogenous quadrupled semitendinosis/ gracilis) ACL reconstruction incorporates the above mentioned femoral socket creation. In recent years, arthroscopically assisted ACL reconstruction has become the procedure of choice. Initially, arthroscopic techniques required two incisions for outside-in drilling of bone tunnels, but there has been a trend toward using a single incision with inside-out of the femoral tunnel. Those who advocate the two-incision technique state that they do so primarily because they believe that the two-incision procedures makes accurate femoral tunnel placement easier. Harner found no difference in tunnel placement using the two techniques, while Schiavone found that the inside-out femoral tunnels were significantly more vertical in the one-incision procedure. We have performed two-incision ACL reconstruction routinely since 1977, with very favourable results. The recent variation in our technique affords a reduction in morbidity, associated with improved cosmesis and quicker post-operative recovery. One factor related to our success appears to be a more anatomically positioned femoral tunnel, which in our hands, is difficult to accomplish with the single incision trans-tibial femoral socket creation. The retro-drill technique allows preparation of the correct anatomical femoral and tibial socket or tunnel, either with a very small lateral skin incision or without any skin incisions if the surgeon is using an allograft, and appears to represent a promising future technique in ACL reconstruction

Introduction : The purpose of the study is to compare in a randomised clinical double blind trial two methods of hamstring ACL reconstruction, the SIngle Bundle (SB) and the Double Bundle (DB). Materials and methods: Seventy patients, with a chronic ACL insufficiency, were randomized to receive a unilateral single or double bundle ACL reconstruction. All the operations were performed by the same surgeon using the same two incision outside-in technique. The tibial guide wire was introduced with a 65 degrees Howell guide in extension to avoid impingment. To introduce the second tibial wire (posterolateral wire) a prototype guide that lets you place the wire with a fixed angulation and a fixed distance (9 mm) from the first was used. On the femoral side we used a modified Rear Entry guide. In a SB reconstruction the 10.00 o’clock position (right knee), intermediate between the two anatomic bundles, was used. In a DB reconstruction the first wire was placed in the anteromedial insertion area, close to the “over the top” position on the lateral wall and for the second wire the same prototype guide that gives you the correct angulation and distance with the first (10 mm) was used. The direction was chosen in order to exit 5 mm close to the posterior cartilage. The graft was prepared and pretensioned as to have two arms of the same diameter. It was fixed on the cortex of the tibia by means of a titanium ring bridge when doing a SB and looped around a cortical bony bridge when doing a DB. Tensioning and femoral fixation of the SB was done at 20 degrees, while in the DB tensioning and fixation of the PL bundle was achieved first after cycling at 10–15 degrees and of the AM bundle at 40–45 degrees. Femoral fixation was obtained via RCI titanium interference screws and one additional cortical titanium staple. The same moderately aggressive rehabilitation was utilized in both groups. Outcome assessment was performed by an indipendent observer, blinded to the involved leg and type of reconstruction, using the new IKDC form, the KOOS score, the KT-1000 arthrometer. Results: All patients reached a minimum follow-up of one year. No difference was found in terms of overall KOOS and IKDC subjective scores. A significant difference was found (p< .001) in KT data and in IKDC final ojective scores (Excellent-A-result: 73% SB and 95% DB). he DB group showed a tred to less pivot shift (glide). Conclusion: In the short period the DB reconstruction offered better knee stability and better objective results than the 10.00 o’clock SB. Longer follow up and accurate instrumented in vivo rotational stability assessment is probably needed to further disclose small but important differences

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient’s pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.