Knee
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High tibial osteotomy (HTO) is a relatively conservative surgical option in the management of medial knee pain. Thus far, the outcomes have been variable, and apparently worse than the arthroplasty alternatives when judged using conventional metrics, owing in large part to uncertainty around the extent of the correction planned and achieved.
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This review paper introduces the concept of detailed 3D planning of the procedure, and describes the 3D printing technology that enables the plan to be performed.
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The different ways that the osteotomy can be undertaken, and the varying guide designs that enable accurate registration are discussed and described. The system accuracy is reported.
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In keeping with other assistive technologies, 3D printing enables the surgeon to achieve a preoperative plan with a degree of accuracy that is not possible using conventional instruments. With the advent of low dose CT, it has been possible to confirm that the procedure has been undertaken accurately too.
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HTO is the ‘ultimate’ personal intervention: the amount of correction needed for optimal offloading is not yet completely understood.
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For the athletic person with early medial joint line overload who still runs and enjoys life, HTO using 3D printing is an attractive option. The clinical effectiveness remains unproven.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170075.
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In suitable patients, unicompartmental knee arthroplasty (UKA) offers a number of advantages compared with total knee arthroplasty. However, the procedure is technically demanding, with a small tolerance for error. Assistive technology has the potential to improve the accuracy of implant positioning.
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This review paper describes the concept of detailed UKA planning in 3D, and the 3D printing technology that enables a plan to be delivered intraoperatively using patient-specific instrumentation (PSI).
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The varying guide designs that enable accurate registration are discussed and described. The system accuracy is reported.
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Future studies need to ascertain whether accuracy for low-volume surgeons can be delivered in the operating theatre using PSI, and reflected in improved patient reported outcome measures, and lower revision rates.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180001
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Recurrent patellar dislocation is a disabling condition, which can lead to articular cartilage injuries, osteochondral fractures, recurrent instability, pain, decreased activity and patellofemoral osteoarthritis. Trochlear dysplasia represents an important component of patellar dislocation.
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Imaging provides an objective basis for the morphological abnormalities and thus allows determination of the surgical strategy according to the concept of ‘à la carte’ surgery.
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The main surgical techniques of trochleoplasty are the sulcus deepening trochleoplasty, the ‘Bereiter’ trochleoplasty and the recession trochleoplasty.
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At mid-term, all techniques have shown a postoperative improvement in clinical scores, with a low rate of recurrence of dislocation and a possible return to sport. But these techniques do not halt the progression of patellofemoral arthritis.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170058
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This is a review of the recent literature of the various factors that affect patellar tracking following total knee arthroplasty (TKA).
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Patellar tracking principally depends on the pre-existing patellar tracking and the rotational alignment of the femoral and tibial implants, but the detailed movements depend on the patellar shape. The latter means that the patellar kinematics of any implanted TKA does not return to normal.
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Laboratory cadaveric studies use normal knees and non-activity-based testing conditions and so may not translate into clinical findings.
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The recent literature has not added anything significant to change established clinical practice in achieving satisfactory patellar tracking following TKA.
Cite this article: EFORT Open Rev 2018;3:106-113. DOI: 10.1302/2058-5241.3.170036.
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Twenty randomized controlled trials comprising 1893 primary total knee replacements were included in this review.
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The subvastus approach conferred superior results for mean difference (MD) in time to regain an active straight leg raise (1.7 days, 95% confidence interval [CI] 1.0 to 2.3), visual analogue score for pain on day one (0.8 points on a scale out of 10, 95% CI 0.2 to 1.4) and total range of knee movement at one week (7°, 95% CI 3.2 to 10.7). The subvastus approach also resulted in fewer lateral releases (odds ratio 0.4, 95% CI 0.2 to 0.7) and less peri-operative blood loss (MD 57 mL, 95% CI 10.5 to 106.4) but prolonged surgical times (MD 9.7 min, 95% CI 3.9 to 15.6).
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There was no difference in Knee Society Score at six weeks or one year, or the rate of adverse events including superficial or deep infection, deep vein thrombosis or knee stiffness requiring manipulation under anaesthesia.
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This review demonstrates evidence of early post-operative benefits following the subvastus approach with equivalence between approaches thereafter.
Cite this article: EFORT Open Rev 2018;3:78-84. DOI: 10.1302/2058-5241.3.170030.
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Almost all athletes who have suffered an anterior cruciate ligament (ACL) injury expect a full return to sports at the same pre-injury level after ACL reconstruction (ACLR). Detailed patient information on the reasonable outcomes of the surgery may be essential to improve patient satisfaction.
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Pre-operative rehabilitation before ACLR should be considered as an addition to the standard of care to maximise functional outcomes after ACLR.
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We propose an optimised criterion-based rehabilitation programme within a biopsychosocial framework.
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No benchmark exists for evaluating return-to-sport (RTS) readiness after ACLR. Therefore, the authors propose a multi-factorial RTS test battery. A combination of both physical and psychological elements should be included in the RTS test battery.
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There is need for shared decision-making regarding RTS.
Cite this article: EFORT Open Rev 2017;2:410-420. DOI: 10.1302/2058-5241.2.170011
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Meniscectomy is one of the most popular orthopaedic procedures, but long-term results are not entirely satisfactory and the concept of meniscal preservation has therefore progressed over the years. However, the meniscectomy rate remains too high even though robust scientific publications indicate the value of meniscal repair or non-removal in traumatic tears and non-operative treatment rather than meniscectomy in degenerative meniscal lesions
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In traumatic tears, the first-line choice is repair or non-removal. Longitudinal vertical tears are a proper indication for repair, especially in the red-white or red-red zones. Success rate is high and cartilage preservation has been proven. Non-removal can be discussed for stable asymptomatic lateral meniscal tears in conjunction with anterior cruciate ligament (ACL) reconstruction. Extended indications are now recommended for some specific conditions: horizontal cleavage tears in young athletes, hidden posterior capsulo-meniscal tears in ACL injuries, radial tears and root tears.
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Degenerative meniscal lesions are very common findings which can be considered as an early stage of osteoarthritis in middle-aged patients. Recent randomised studies found that arthroscopic partial meniscectomy (APM) has no superiority over non-operative treatment. Thus, non-operative treatment should be the first-line choice and APM should be considered in case of failure: three months has been accepted as a threshold in the ESSKA Meniscus Consensus Project presented in 2016. Earlier indications may be proposed in cases with considerable mechanical symptoms.
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The main message remains: save the meniscus!
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160056. Originally published online at www.efortopenreviews.org
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Alignment and stability are two key factors for success in total knee arthroplasty (TKA). Several techniques have been advocated, the two best known being measured resection and tensioned gaps.
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Dogma and fuzzy wording have cast an obscure shadow on the dualistic discussion between proponents of both techniques.
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This review is an attempt to clarify definitions, analyse the flaws and pitfalls in the different techniques and make some suggestions for improvement.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170001. Originally published online at www.efortopenreviews.org
Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
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Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
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Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy
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Patellofemoral dysplasia is a major predisposing factor for instability of the patellofemoral joint. However, there is no consensus as to whether patellofemoral dysplasia is genetic in origin, caused by imbalanced forces producing maltracking and remodelling of the trochlea during infancy and growth, or due to other unknown and unexplored factors.
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The biomechanical effects of patellofemoral dysplasia on patellar stability and on surgical procedures have not been fully investigated. Also, different anatomical and demographic risk factors have been suggested, in an attempt to identify the recurrent dislocators. Therefore, a comprehensive evaluation of all the radiographic, MRI and CT parameters can help the clinician to assess patients with primary and recurrent patellar dislocation and guide management.
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Patellofemoral dysplasia still represents an extremely challenging condition to manage. Its controversial aetiology and its complex biomechanical behaviour continue to pose more questions than answers to the research community, which reflects the lack of universally accepted guidelines for the correct treatment. However, due to the complexity of this condition, an extremely personalised approach should be reserved for each patient, in considering and addressing the anatomical abnormalities responsible for the symptoms.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160081. Originally published online at www.efortopenreviews.org
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Isolated posterior cruciate ligament (PCL) tears are much less frequent than anterior cruciate ligament (ACL) tears.
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Abrupt posterior tibial translation (such as dashboard impact), falls in hyperflexion and direct hyperextension trauma are the most frequent mechanisms of production.
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The anterolateral bundle represents two-thirds of PCL mass and is reconstructed in single-bundle techniques.
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The PCL has an intrinsic capability for healing. This is the reason why, nowadays, the majority of isolated PCL tears are managed non-operatively, with rehabilitation and bracing.
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Recent studies have focused on double-bundle reconstruction techniques, as they seem to restore knee kinematics.
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No significant clinical differences have been established between single versus double-bundle techniques, autograft versus allograft, transtibial tunnel versus tibial inlay techniques or remnant-preserving versus remnant-release techniques.
Cite this article: EFORT Open Rev 2017;2:89-96. DOI: 10.1302/2058-5241.2.160009
