RESUMEN

Necrotizing fasciitis is a rare, life-threatening and rapidly spreading soft-tissue infection that results in necrosis of the muscle, fascia and surrounding tissue. It can be result of a polymicrobial synergistic infection or a streptococcal infection. The authors report a case of necrotizing fasciitis occurring in the knee of a 65-year-old woman following an uneventful primary total knee arthroplasty and resulting in above-the-knee amputation. Having in mind severe infections like necrotising fasciitis, one should be aware of the possibility of such postoperative complications especially in patients with risk factors even in routine procedures like a total knee arthroplasty.

Asunto(s)

RESUMEN

We retrospectively reviewed the records of 21 patients (23 shoulders) who underwent surgical treatment for septic arthritis of the shoulder joint, between 2000 and 2007. Patients were on average 63.7 (41-85) years old; they were treated either by arthroscopic debridement (12 shoulders) or by combined arthroscopic and open procedures (11 shoulders). The mean duration of symptoms prior to surgery was 16 (5-76) days. The mean Constant score recorded at the last follow-up - on average 353 months (25-43) after surgery - was 73 (46-82) points. Patients with symptoms for two weeks or less prior to surgery had better results and a lower re-operation rate than those with symptoms longer than two weeks. Early infection can be managed arthroscopically, and satisfactory results can be expected. In advanced infection, a more radical approach is more appropriate.

Asunto(s)

RESUMEN

The aim of this radiographic study was to visualize the femoral insertion sites of the anteromedial (AM) and posterolateral (PL) bundle of the anterior cruciate ligament (ACL) on lateral radiographs in different angles of knee flexion to gain better understanding for arthroscopic femoral tunnel placement in ACL double bundle reconstruction. Four fresh cadaveric knees with an intact ACL were dissected to isolate the AM and PL bundle of the ACL. We obtained lateral radiographs of each knee over the range of 0 degrees -90 degrees flexion in 30 degrees increments after painting the bundles with a radiopaque tantalum powder. The center of the radiographically marked femoral insertion was defined for each bundle on the lateral roentgenogram. We analyzed the relationship of knee flexion and the projection of the relative position of the femoral insertion sites of both bundles of the ACL on the lateral roentgenogram. The centre of the PL bundle visualized more anterior and distal than the centre of the AM bundle with the knee held in 90 degrees flexion. The centers of the AM and PL bundle were horizontally aligned when the knee was flexed over 90 degrees . The resulting images allow a radiographic description of the femoral insertion sites of both bundles in different angles of knee flexion. It is essential to be aware of the degree of knee flexion when drilling the femoral tunnels.

Asunto(s)

RESUMEN

In order to describe the arthroscopic presence of the double bundle structure and to evaluate the value of different portals in knee arthroscopy, we assessed the AM and PL bundle anatomy. We prospectively examined the knees of 60 patients undergoing arthroscopic surgery for pathology unrelated to the ACL. Arthroscopy was performed in a two portal technique using an anterolateral (ALP) and an anteromedial (AMP) portal. With the arthroscope in the ALP, we could distinguish an AM and PL bundle in 28%. Switching the arthroscope to the AMP, differentiation of the bundles was possible in 67%. In all remaining cases visualization of the PL bundle was possible after retraction of the AM bundle. Use of AMP increased visualization of the PL bundle. It seems reasonable to perform arthroscopy for ACL reconstruction with the arthroscope in the AMP and to establish an additional medial working portal to increase the visualization of the femoral ACL insertion sites for optimal femoral tunnel placement.

Asunto(s)

RESUMEN

BACKGROUND: Double bundle ACL reconstruction has been demonstrated to decrease rotational knee laxity. However, there is no simple, commercially-available device to measure knee rotation. The investigators developed a simple, non-invasive device to measure knee rotation. In conjunction with a rigid boot to rotate the tibia and a force/moment sensor to allow precise determination of torque about the knee, a magnetic tracking system measures the axial rotation of the tibia with respect to the femur. This device has been shown to have acceptable levels of test re-test reliability to measure knee rotation in cadaveric knees. METHODS: The objective of this study was to determine reliability of the device in measuring knee rotation of human subjects. Specifically, the intra-tester reliability within a single testing session, test-retest reliability between two testing sessions, and inter-tester reliability were assessed for 11 male subjects with normal knees. RESULTS: The 95% confidence interval for rotation was less than 5 degrees for intra-tester, test-retest, and inter-tester reliability, and the standard error of measurement for the differences between left and right knees was found to be less than 3 degrees . CONCLUSION: It was found that the knee rotation measurements obtained with this device have acceptable limits of reliability for clinical use and interpretation.

Asunto(s)

RESUMEN

Current clinical and instrumented outcome measurements of knee instability lack accuracy, especially when multiplanar instability is considered. The aim of our cadaveric study was to describe the kinematics in the intact, double bundle, and anteromedial bundle reconstructed anterior cruciate ligament knee by applying a protocol for computer-assisted evaluation of knee kinematics. An optical navigation system was used to acquire knee motion (n = 5) during clinical evaluations by tracking markers rigidly attached to the bones. The protocol included acquisition of anteroposterior translations and internal-external rotations and evaluation of three clinical knee laxity tests (anterior drawer, manual, and instrumented Lachman). Our anteroposterior translation data showed the double-bundle technique and anteromedial bundle technique could restore anteroposterior stability comparable to the intact state. For internal-external laxity, the double-bundle technique demonstrated overcorrection at 15 degrees, 60 degrees, 75 degrees, and 90 degrees. The anterior drawer and manual Lachman knee laxity tests showed improved stability for the double-bundle compared to the anteromedial bundle technique. This pilot study suggests the computation of knee laxity with a high precision method might be a step toward a more precise kinematic test of knee stability for evaluating different reconstruction methods.

Asunto(s)

RESUMEN

The aim of this cadaveric study was to describe the kinematics of the anterior cruciate ligament (ACL)-intact, posterolateral (PL) bundle-deficient and ACL-deficient knee by applying a protocol for computer-assisted evaluation of knee kinematics. The hypothesis that the PL bundle functions mainly at low knee flexion angles was tested. An optical tracking system was used to acquire knee joint motion on 10 knees during clinical evaluations by tracking markers rigidly attached to the bones. The protocol included acquisition of anterior-posterior (AP) translations and internal-external (IE) rotations, and evaluation of three clinical knee laxity tests (anterior drawer, manual and instrumented Lachman). The data demonstrated no significant contribution to AP translation and IE laxity from the PL bundle over the entire range of motion. The clinical knee laxity tests showed no significant differences between the ACL-intact and PL bundle-deficient states. The hypothesis could not be proven. Current clinical knee laxity measurements may not be suited for detecting subtle changes such as PL bundle deficiency in the ACL anatomy. The computation of knee laxity might be a step towards a more precise kinematic test of knee stability not only in the native and torn ACL state of the knee but also in the reconstructed knee.

Asunto(s)

RESUMEN

BACKGROUND: Despite its highly specialized nature, articular cartilage has a poor reparative capability. Treatment of symptomatic osteochondral defects of the talus has been especially difficult until now. METHODS: We performed autologous chondrocyte transplantation in twelve patients with a focal deep cartilage lesion of the talus. There were seven female and five male patients with a mean age of 29.7 years. The mean size of the lesion was 2.3 cm(2). All patients were studied prospectively. Evaluation was performed with use of the Hannover ankle rating score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a visual analog scale for pain, and magnetic resonance imaging. RESULTS: All patients were available for follow-up at a mean of sixty-three months. There was a significant improvement in the Hannover score, from 40.4 points preoperatively to 85.5 points at the follow-up examination, with seven excellent results, four good results, and one satisfactory result. The AOFAS mean score was 88.4 points compared with 43.5 points preoperatively. Magnetic resonance imaging showed a nearly congruent joint surface in seven patients, discrete irregularities in four, and an incongruent surface in one. The patients who had been involved in competitive sports were able to return to their full activity level. CONCLUSIONS: The promising clinical results of this study suggest that autologous chondrocyte transplantation is an effective and safe way to treat symptomatic osteochondral defects of the talus in appropriately selected patients.

RESUMEN

Magnetic resonance imaging (MRI) is the most commonly used diagnostic imaging procedure for suspected injuries to the anterior cruciate ligament (ACL). However, MRI has less utility for the evaluation of partial ACL tears. The goal of this study was to evaluate the possibility of distinguishing partial ACL tears applying the double bundle concept by dividing the ACL anatomy in the anteromedial (AM) and posterolateral bundle (PL). Six human cadaver knees were used in this laboratory study. The protocol consisted of sagittal, oblique coronal, and oblique sagittal proton-density-weighted fast spin echo sequences. After MRI the AM and the PL bundle were severed to mimic different partial ACL rupture patterns. MRI scanning of each knee was repeated, to record the quantitative parameters tilt and ACL angles and discontinuity as a nonquantitative parameter. Three orthopaedic surgeons and two radiologists were enlisted as blinded observers to evaluate the images. The transection patterns could be differentiated by evaluating discontinuity both in the paracoronal and in the sagittal plane. Evaluating the transection patterns, the AM bundle reached a better result in both planes compared to the PL bundle and the paracoronal plane had a better result in assessing the transection patterns compared to the sagittal plane for the PL bundle. Partial ACL transections could predictably be recognized on oblique sagittal and oblique coronal planes utilizing 3-T MRI technology. This concept allows a more precise description of ACL rupture patterns and might lead to a more distinctive approach for reconstructive surgery. The presurgical planning could be improved by applying a treatment algorithm based on a description of each bundle as intact or ruptured, leading to a reconstruction of the torn and a preservation of the intact bundle.

Asunto(s)

RESUMEN

BACKGROUND: In recent studies objective evaluations have demonstrated that arthroscopic rotator cuff repairs can have higher failure rates than open repairs. Thus, there is a need for a stronger tissue-holding stitch for arthroscopical repair. The purpose of this study was to compare the biomechanical properties of traditional open transosseous suture technique and modified Mason-Allen stitches versus double-loaded suture anchors and arthroscopic Mason-Allen stitches in rotator cuff repair. METHODS: In 20 sheep shoulders the infraspinatus tendons were dissected from their insertion and were randomized to 2 repair groups: (1) repair with transosseous suture and modified Mason-Allen stitches, (2) repair with double loaded bioabsorbable suture anchors and arthroscopic Mason-Allen stitches: Both groups were coupled with braided, nonabsorbable polyester (Ethibond) suture sized USP No. 2. All repairs were cyclically loaded from 10 to 180N with the use of a materials testing machine. The number of cycles to gap formation of 5 and 10mm at the repair site and the mode of failure were recorded. RESULTS: The number of cycles to 5-mm gap was mean 634 (SD 106) for group 1 and mean 750 (SD 107) for group 2 (P<0.026). The corresponding values to 10-mm gap were mean 1573 (SD 161) for group 1, and mean 1789 (SD 183 cycles) for group 2 (P<0.012). In group 2 the mode of failure occurred by tissue pull-out, whereas in group 1 the failure occurred by a mixture of suture breakage and pull-out. CONCLUSIONS: This time-zero study demonstrates that the combination of bioabsorbable suture anchors and arthroscopic Mason-Allen stitches provides strength superior to that of the modified Mason-Allen transosseous suture technique under isometric cyclic loading conditions. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.

Asunto(s)

RESUMEN

For anterior cruciate ligament (ACL) surgery using the anatomic approach of the double bundle concept it is helpful to describe the anteromedial (AM) and posterolateral (PL) bundle using Magnetic Resonance Imaging (MRI), since this is the most important preoperative parameter next to the physical examination. The aim of this study was to distinguish both bundles in MRI. In a prospective study we evaluated the double bundle structure in ACL anatomy with a 3-T ultra-high-field strength MR imaging of cadaver knees, which allows faster imaging times, increased resolution and increased signal-to-noise ratio. Using oblique sagittal and oblique coronal planes, we were able to distinguish the double bundle structure in each knee. The following arthroscopic evaluation of the knees confirmed our MRI findings. Our study demonstrates the possibility of distinguishing the two bundles in the native ACL with 3T MRI. Following examinations must study the value for clinical application by describing different rupture patterns of the bundles and correlating this to arthroscopy. It would be advantageous to know the rupture pattern in advance. Presurgical planning could be improved by reconstructing only the torn and preserving the intact bundle.

Asunto(s)

RESUMEN

INTRODUCTION: The purpose of this study was to identify the factors that may lead to poor outcomes after arthroscopic debridement in massive rotator cuff tears. MATERIALS AND METHODS: Thirty-three patients (10 women and 23 men) with massive, irreparable rotator cuff tears underwent arthroscopy by a single surgeon. The preoperative diagnosis was based on the clinical examination and MRI. Their mean age was 69 years (range 62-79 years), and the average follow-up was 31 months (range 24-46 months). If indicated, the performed arthroscopic debridement included acromioplasty, debridement of the cuff, resection of the distal part of the clavicle or tenotomy of the long head of the biceps. In 28 cases (85%) acromioplasties and in 6 cases (18%) biceps tenotomies were performed, 2 of which were a single tenotomy without any associated acromioplasty. One patient had been managed with concomitant resection of the distal part of the clavicle. RESULTS: The Constant and Murley Score improved by a mean of 30 points, from a mean of 37 points (range 21-52) preoperatively to a mean of 67 points (range 31-82) at the time of follow-up. Some 82% of the patients were satisfied with the procedure. The result was considered unsatisfactory because of inadequate pain relief in 4 shoulders, because of limited active abduction in 1 and because of limited external rotation in 1. A poor outcome was associated with a complete tear of the subscapularis tendon in 6 patients. The radiological study showed no significant narrowing of the subacromial space. CONCLUSION: Our early results suggest that arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands. However, its long-term consequences remain to be evaluated by studies with lengthy follow-up. Prognostic factors that may lead to a negative outcome are preoperative superior migration of the humeral head, presence of subscapularis tear, presence of glenohumeral arthritis and decreased range of motion.

Asunto(s)

RESUMEN

The purpose of this prospective study was to evaluate the results of simultaneous anterior cruciate ligament (ACL) reconstruction and osteochondral autograft transplantation performed in patients suffering an anterior instability associated with symptomatic full-thickness cartilage defects. Our clinical report includes the first 21 patients (six women, 15 men) who have been followed up for 32 months or longer. The average patient age was 29 years (range 22-44 years), and mean time from injury to the combined reconstructive surgery was 10 months (range 4-27 months). The cartilage defects had a mean area of 3.5 cm2 (range 2.0-5.0 cm2). All patients were evaluated according to the IKDC, Lysholm and Tegner scoring scales by an independent observer. A visual analogue scale (VAS) reflecting patient pain was evaluated. Assessment using the IKDC knee scoring scale revealed 81% of the patients with a normal or nearly normal knee joint. There was a significant improvement in subjective discomfort, and the KT-1000 arthrometric evaluation showed a reduction of the ventral tibial translation (5.9 to 1.9 mm). All but two patients had returned to full activities without restriction and were asymptomatic. The results of this study suggest that symptomatic full-thickness articular cartilage defects associated with ACL instability can be effectively treated by performing ACL reconstruction and osteochondral autologous grafts in one procedure. However, only the years which follow will show the long-term outcome of the patients.

Asunto(s)