Meniscal repair using large diameter horizontal sutures increases fixation strength: an in vitro study

PURPOSE

the purpose of this study was to compare the mechanical characteristics of meniscal repair fixation using horizontal sutures and two different diameter sutures under submaximal cyclic and load to failure test conditions.

METHOD

a 2-cm long anteroposterior vertical longitudinal incision was created in two groups of bovine medial menisci. Lesions were repaired using either #2-0 (Group 1), or #2 (Group 2) Fiberwire suture. Following repair, the lesion was extended through the posterior and anterior meniscal horns so that no tissue secured the repair site. Specimens underwent submaximal cyclic (5-50 N at 1 Hz for 500 cycles) and load to failure testing (5 mm/min crosshead speed) in a servo hydraulic device. Specimen failure mode was verified by the primary investigator. An alpha level of P < 0.05 was selected to indicate statistical significance.

RESULTS

group 2 displayed greater load at failure (132.1 ± 54.4 N) than Group 1 (91.9 ± 26.2 N) (P = 0.02). Group 2 also displayed greater stiffness (47.1 ± 8.3 N/mm) than Group 1 (38.5 ± 10.2 N/mm) (P = 0.03). The failure mode for all specimens was suture pull-through the meniscal tissue. Larger diameter suture provided superior mechanical meniscal fixation.

CONCLUSION

if horizontal suture would be used in meniscal repair, the most suitable larger diameter suture should be used.

[Articular cartilage lesions in unstable knees]

OBJECTIVES

The purpose of this retrospective analysis was to evaluate the management of chondral defects in knees with anterior cruciate ligament (ACL) disruption.

METHODS

Twenty-seven patients (mean age 35 years; range, 20 to 48 years) were randomized to osteochondral autologous transplantation (OAT, n=14) or a microfracture (MF, n=13) procedure together with ACL reconstruction in the same session for symptomatic lesions of the articular cartilage in ACL-deficient knees. The mean follow-up period was 34 months (range 24 to 53 months) in the OAT group, and 49 months (range 24 to 97 months) in the MF group. Patients were evaluated using the Lysholm and IKDC 2000 (International Knee Documentation Committee) scores.

RESULTS

Patients undergoing OAT had a mean IKDC 2000 score of 49.2 (range 30.1 to 64.7), and Lysholm score of 43.4 (range 33.2 to 58.9) preoperatively. At the end of follow-up, these scores increased to 93.3 (range 73 to 98) and 97.5 (range 38.7 to 100), respectively. In the MF group, the mean IKDC 2000 score increased from 53.6 (range 47.1 to 64.7) to 72.3 (range 62.8 to 94), and the mean Lysholm score increased from 48 (range 38.2 to 58.9) to 81.3 (range 72.7 to 100).

CONCLUSION

Treatment of chondral lesions should be added to ACL reconstruction in unstable knees secondary to ACL deficiency.

Radiosynovectomy in Hemophilic Synovitis: Correlation of Therapeutic Response and Blood-Pool Changes

AIM

The aim of this study was to evaluate the efficacy of 90Y and 186Re radiosynovectomy in patients with hemophilic synovitis.

METHODS

Radiosynovectomy was performed in 32 joints of 20 patients with hemophilic synovitis by using 90Y citrate colloid in the knee and 186Re sulfide colloid in the elbow, shoulder, and ankle. The indication for radiosynovectomy was the continuous presence of intra-articular blood or effusion and three or more hemorrhages into the same joint within the last 6 months. Response to therapy was first assessed at the 4th month with blood-pool imaging. Patients were followed up by clinical evaluation based on assessments of joint-bleeding frequency, using range of motion measurements at 6-month intervals for an average of 1 year (range, 9-15 months).

RESULTS

A marked decrease (an 80%-100% decrease) in bleeding episodes was seen in 24 of 32 (75%) joints, a moderate decrease (51%-79% decrease) in 1 (9%) joint, and a mild decrease (30%-50%) in 3 (13%) joints. Frequency of intra-articular bleeding after treatment was unchanged in only 13% of the joints. The number of hemarthroses significantly decreased after therapy (p < 0.05). The mean bleeding frequency of the joints were 1.7 +/- 0.9 and 0.3 +/- 0.7 per month before and after therapy, respectively. The ratios of joints which had marked improvement after therapy were 86% in the ankle, 73% in the elbow, and 58% in the knee. There was no significant difference between percent joint range of motion limitations measured before and after therapy (p > 0.05). The correlation between therapeutic outcome (in terms of joint bleeding) and the difference of pre- and posttherapeutic blood-pool indices were significant (r = 0.594; p < 0.05), while the correlation between therapeutic outcome and pretherapeutic radiologic scale and pretherapeutic blood-pool indices were not significant (r = 0.095; p > 0.05; r = -0.089; p > 0.05, respectively).

CONCLUSION

Radiosynovectomy is a simple but quite effective and efficient procedure in limiting the frequency of joint hemorrhage in patients with hemophilia. Blood-pool imaging may be an objective means for monitoring therapy response in these patients.

[The effect of the tibial tunnel fixation level on the results of cyclic loading in anterior cruciate ligament reconstruction]

OBJECTIVES

This study was designed to compare the biomechanical characteristics of non-anatomic (far from joint) and anatomic (close to joint) levels of tibial tunnel fixation with soft tissue graft using a soft tissue interference screw in anterior cruciate ligament (ACL) reconstruction.

METHODS

Twelve bovine tibiae and digital extensor tendons were divided into two homogeneously equal groups after removing soft tissues. Tibial tunnels were prepared with a 7-mm drill with the use of an ACL guide adjusted to 45 degrees . Each tunnel was then dilated to 9 mm in 0.5 mm increments. Digital extensor tendons were fixed at non-anatomic (group I) or anatomic (group II) tibial tunnel levels with a soft tissue metal interference screw, 9 x 30 mm in size. All the specimens were cycled 500 times from 50 to 250 N with 1 Hz frequency in a servo-hydraulic testing machine followed by ultimate load at-failure testing at a rate of 20 mm/min. Statistical analyses were made using the Mann-Whitney U-test.

RESULTS

The mean screw insertion torque values were 8.2+/-2.4 Nm and 7.8+/-2.3 Nm in groups I and II, respectively (p=0.88). The mean values of graft displacement (1.9+/-0.75 mm versus 2.2+/-1.2 mm, p=0.63) and stiffness (132.72+/-10.93 N/mm versus 125.14+/-15.93 N/mm, p=0.63) did not differ significantly.

CONCLUSION

The biomechanical properties of ACL reconstruction with soft tissue graft fixation using a soft tissue interference screw are not influenced by the level of tibial tunnel fixation.

[Retrograde osteochondral grafting for osteochondral lesion of the talus: a new technique eliminating malleolar osteotomy]

Osteochondral grafting is one of the most effective treatment options for osteochondral lesions of the talus. However, the necessity for a medial malleolar osteotomy is the major drawback of the technique. This report presents a case treated with retrograde osteochondral grafting that eliminated the need for a medial malleolar osteotomy. An osteochondral lesion of the medial talus was detected in a 49-year-old woman. Under arthroscopic guidance, the talus was entered from the sinus tarsi region to establish a tunnel extending to the lesion. An osteochondral graft taken from the ipsilateral knee was inserted into the distal end of the tunnel and was advanced to the joint surface. Postoperative computed tomography scans showed that the graft completely filled the tunnel and provided congruency with the articular surface. Details of this technique are described.

[The effect of anterior or posterior tibial tunnel placement of a soft tissue graft with a soft tissue interference screw on fixation biomechanics]

OBJECTIVES

We investigated the biomechanical characteristics of anterior or posterior tibial tunnel placement of the soft tissue graft with a soft tissue interference screw in anterior cruciate ligament (ACL) reconstruction.

METHODS

Twelve bovine tibiae and digital extensor tendons were divided into two homogeneously equal groups after they were stripped of all soft tissues. Tibial tunnels were prepared and digital extensor tendons were fixed at nonanatomic (apart from the joint) anterior (n=6, group I) or posterior (n=6, group II) tibial tunnel positions with a soft tissue metal interference screw, 9x30 mm in size. All the specimens were cycled 500 times from 50 to 250 N at 1 Hz frequency in a servo hydraulic test device, after which ultimate load-at-failure testing was performed at a rate of 20 mm/min.

RESULTS

The mean screw insertion torque values were 8.2+/-2.4 Nm and 8.4+/-2.8 Nm in groups I and II, respectively (p=0.88). No significant differences were found between the two groups with respect to graft displacement (1.9+/-0.8 mm vs 2.3+/-0.4 mm; p=0.38) and stiffness (132.7+/-10.9 N/mm vs 126.4+/-8.5 N/mm, p=0.98) at the end of cyclic loading.

CONCLUSION

Our results show that the site of nonanatomic soft tissue graft fixation in the tibial tunnel (anterior or posterior) with a soft tissue interference screw do not affect the biomechanical parameters in ACL reconstruction.

Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport

The purposes of this multi-center study were: (a) to document the location and type of meniscal and chondral lesions that accompany anterior cruciate ligament (ACL) tears, and (b) to test for possible relationships between these lesions and patient age, time from initial injury (TFI), and sports level (i.e., recreation, amateur, professional, and national). The cases of 764 patients with ACL tears who underwent arthroscopy for the first time were retrospectively analyzed. The group included 684 males and 80 females of mean age 27 years (range 14-59 years). The mean TFI was 19.8 months (range 0.2-360 months). Eighty-seven percent of the group engaged in regular sporting activity. Thirty-seven percent had medial meniscal tears, 16% had lateral meniscal tears, and 20% had tears of both menisci. The most common tear types were longitudinal tears in the posterior and middle horns of both menisci. Tears of the lateral meniscus were more centrally located than those of the medial meniscus. Incomplete tears and radial tears were significantly more common in the lateral meniscus. Nineteen percent of the knees had one or more chondral lesions. Sixty percent of the chondral lesions were located in the medial tibio-femoral compartment. Patient age was statistically associated with presence of a medial meniscal tear, presence of a grade 3 or 4 chondral lesion, and presence of a complex tear of the medial meniscus. Sports level was not statistically related to any of the parameters studied. The odds of having a medial meniscal tear at 2 to 5 years TFI were 2.2 times higher than the odds in the first year post-injury, and the odds at >5 years were 5.9 times higher than at 0 to 12 months TFI. The frequency of lateral meniscal tear remained fairly constant at 2 years TFI. The odds of having a grade 3 or 4 chondral lesion were 2.7 times greater at 2 to 5 years TFI than they were at 1 year post-injury, and these odds increased to 4.7 when patients at >5 years TFI were compared to those in the 2 to 5 years category. Multivariate analysis demonstrated that TFI and age were equally important predictors of lateral meniscal tears and of grade 3 or 4 chondral lesions; however, TFI was the better predictor of medial meniscal tear.