Indian Journal of Orthopaedics最新文献

Introduction: Multi-ligament knee injuries present in various combinations of structures around the knee joint, with or without involvement of neurovascular structures, posing significant challenges to the treating physician and therapists. Accurate diagnosis with appropriate surgical intervention and comprehensive rehabilitation to restore function and stability is, therefore, paramount. This article looks at the recent advancements in technology that are aiding in the management of these injuries.

Method: An extensive search of literature was done in PubMed, SCOPUS, and Google Scholar on this topic and the necessary information was derived from the relevant articles for this review. The progress made in the field of diagnosis, surgical management, rehabilitation and patient education tools were explored.

Discussion: A wide variety of diagnostic tools exists that are providing a more accurate evaluation of multi-ligament knee injuries both pre-operatively and post operatively. Advances in technology and techniques have aided in transforming their surgical management to a more minimally invasive approach. Patient-specific instrumentation, computer navigation and robotic-assisted surgery are in various stages of development offering enhanced precision and accuracy during ligament reconstruction procedures along with developments in digital technology and artificial intelligence.

Conclusion: Advancements in technology have transformed the management of multi-ligament knee injuries, offering new tools and techniques that enhance diagnostic accuracy, surgical precision, and rehabilitation effectiveness. Artificial intelligence and its utility have widened the horizons, while at the same time bringing in the need for regulations necessary to monitor and develop these technologies.

Background: Anatomic single-bundle ACL reconstruction (ACLR) produces good results when the graft and tunnel are positioned in the anatomic footprint on the femoral and tibial insertion sites in a more oblique orientation. The Anterolateral Complex of the knee and its biomechanical role in controlling rotational laxity, internal rotation, and pivot shift has led to adding adjunctive procedures like extra-articular augmentation and lateral extra-articular tenodesis (LET) to decrease rotational laxity. We prospectively analyzed young adults with rotational instability and generalized laxity undergoing an arthroscopic single bundle ACLR with an additional LET procedure.

Methods: 42 patients, aged between 20 and 50, undergoing all-inside ACLR augmented with concomitant lateral extra-articular tenodesis between November 2020 and October 2021 were included. All patients were followed up for one year and functional assessment comprised of the International Knee Documentation Committee [IKDC] score, visual analogue score [VAS], and Lysholm Knee Scoring Scale at 6 months and 1 year. Return to activity was assessed using the Tegner Activity Score.

Results: The Lysholm score, IKDC score, and VAS showed significant improvements at 6 months after ACLR + LET (p < 0.0001) and further improved significantly at 1 year. The patients had a significant decline in the Tegner Activity Scale at 6 months but returned to the near pre-injury level (5.98 ± 0.924) at 1 year (5.67 ± 0.816) which was insignificant (p = 0.1067). Three patients sustained mild complications. 93% were satisfied with the surgery, 66% returned to sports and no patient underwent re-operation.

Conclusions: Combination of LET with ACLR produces good functional outcomes, high rates of return to sports activities, and no graft failure in young patients at high risk of failure.

Introduction: Cruciate retaining and posterior stabilizing knee systems are frequently used in total knee replacements. Most researchers compare the results of Cruciate Retaining (CR) and Posterior Stabilizing (PS) knees with those of a control group. The results of using both knee systems in a single patient in simultaneous Total Knee Arthroplasty (TKA) have been studied less.

Methodology: A total of 50 patients with primary bilateral osteoarthritis with varus which is not fixed and valgus deformity of not more than 10 degrees, age between 55 and 85 years, BMI < 35 kg/m², ASA I or II, and non-inflammatory arthritis were taken up for simultaneous bilateral TKR with one-side CR and other-sided PS surgeries. Patients were followed up periodically at 6 weeks, 3 months, 6 months, and 1 year with Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Differences in scores were tested with the help of an independent sample Student's t test. A p value of less than 0.05 was considered statistically significant.

Results: During the first 6 weeks after surgery, mean KSS was lower in PS knees, though statistically not significant, this difference reduced considerably over a while. By the end of the 1-year post-surgical intervention, KSS was similar among both knees. WOMAC score was similar between CR and PS preoperatively as well as during the entire post-operative follow-up period.

Conclusion: Functional outcomes, patient-reported outcomes, and objective knee indicators in one-sided cruciate-retaining and other-sided posterior stabilizing total replacement in bilateral simultaneous two-team surgery were similar between both knees.

Total hip arthroplasty stands as a milestone in surgical success for alleviating hip arthritis-related pain and enhancing patients' quality of life. While complications persist, advancements like dual-mobility articulation aims to mitigate risks. This manuscript presents an unprecedented unique complication in a 60-year-old woman with a revision dual mobility THA. The metal liner displaced from its original position causing impingement at the medial aspect of the femoral neck and deformation of the acetabular shell. Radiographic evidence revealed the displaced liner cutting into the femoral neck. This unusual complication prompted a re-revision, revealing severe damage to the acetabular cup and femoral neck. While intra-prosthetic dislocations in dual-mobility articulations are recognized, this case deviates from conventional types, emphasizing the need for ongoing vigilance in prosthesis design and patient follow-up. This case report highlights a new variant of intra-prosthetic dislocations to the existing literature on dual-mobility THA complications.

Background: Multiligament knee injuries (MLKIs) are complex and heterogeneous, often associated with concomitant injuries, and necessitates precise treatment strategies.

Preoperative management: Effective preoperative management in MLKIs requires comprehensive evaluation, starting with a detailed patient history to identify the mechanisms of injury and prior treatments. Physical examination assesses for knee stability, while imaging techniques including magnetic resonance imaging (MRI) and radiographs detail ligament, cartilage, and meniscal injuries to identify all injured structures. Vascular evaluations are critical given the high risk of concomitant neurovascular injuries especially in dislocated knees, bicruciate injuries, and lateral-sided injuries.

Avoiding tunnel convergence: Anatomic reconstruction of the torn ligaments has been biomechanically and clinically validated to improve knee stability and function. When performing multiple anatomic reconstructions, the risk of tunnel convergence is high. Therefore, surgical intervention aimed at optimizing outcomes necessitates careful planning to avoid tunnel convergence. This involves strategic tunnel placement, orientation, and techniques, such as adjusting tunnel angulation and using intraoperative imaging. These measures are vital for restoring knee functionality and minimizing future complications. Managing tunnel convergence is vital in treating MLKIs. Avoiding convergence on the medial side of the femur and tibia is more challenging due to the number of tunnels. In an MLKI involving all ligaments, 4 femoral tunnels and 4 tibial tunnels are required on the medial side, compared to 3 on the femur and 1 on the tibia for the lateral side, respectively.

Conclusion: The success of a multiligament knee reconstruction depends on a precise diagnosis, thorough preoperative management, and strategic tunnel placement. A multidisciplinary approach not only enhances surgical outcomes, but also ensures long-term improvement in knee function, effectively addressing the complexities and risks associated with these injuries.

Adjustable Loop Fixation devices (ALD) were introduced to allow tensioning and re-tensioning while increasing flexibility of graft length in the bone tunnel. ALDs have shown comparable clinical and biomechanical results when used for anterior cruciate ligament reconstructions. We routinely use ALDs in multi-ligament knee reconstructions. In double bundle posterior cruciate ligament reconstruction, using an ALD, we can achieve differential tensioning of the anterolateral and posteromedial bundles utilizing two femoral and one tibial tunnel. When performing an anatomic posterolateral corner reconstruction using our modification of the anatomical LaPrade technique, an ALD permits differential tensioning of the fibular collateral ligament and popliteus tendon/popliteofibular ligaments with a single graft. In anatomic superficial medial collateral ligament reconstructions, ALD allows for tensioning from the femoral side, subsequent cycling, followed by re-tensioning to achieve a stable reconstruction. In conclusion, ALDs provide numerous benefits when performing multi-ligament knee reconstructions. ALDs allow for appropriate tensioning and re-tensioning which is helpful in removing creep from the graft to prevent postoperative laxity. Additionally, it permits differential tensioning which helps achieve accurate tensioning of individual bundles to help restore native knee kinematics.

Background: The medial collateral ligament (MCL) is frequently involved in injuries around the knee but is uncommonly treated surgically. There are various techniques to reconstruct the medial side of the knee, which have varying outcomes.

Purpose/hypothesis: The purpose of the present systematic review and meta-analysis is to describe the clinical results of surgical management of acute and chronic isolated grade III MCL injury using various functional scores, such as IKDC, Lysholm, and VAS, and to ascertain complication rates associated with these interventions.

Methods: A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, and two independent authors (L.F and A.M) conducted a comprehensive search across multiple databases (PubMed, Web of Science, and Scopus). They reviewed each article's title and abstract for studies available until April 2024. The search terms used were "((MCL) OR (Medial collateral ligament)) AND (injuries) AND (treatment)". The full texts of the studies were evaluated when eligibility could not be assessed from the title and abstract.

Results: The pooled proportion (percentage) of complications from the three studies reporting data on surgery for the MCL acute stage was 15.3% with 95% CI [6.1% to 24.6%]. No complications were reported in studies reporting surgery in the chronic stage. Marked resolution of pain was observed with the mean VAS Score for pain at the final follow-up after surgery for MCL injury in the acute stage was 0.4 with 95% CI [-0.04 to 0.84]. The mean IKDC score at the final follow-up in the three studies reporting data on surgery for the MCL in the acute stage was 79.39 with 95% CI [67.96 to 90.82], and in the chronic stage, was 85 with 95% CI [83.02 to 86.98]. The mean Lysholm Score at the final follow-up after surgery for MCL injury in the chronic stage was 83.04 with 95% CI [75.24 to 94.84], and in the acute stage was 95 with 95% CI [91.76 to 98.24].

Conclusion: This systematic review found that functional outcomes regarding IKDC and LYSHOLM scores were comparable for surgeries performed in acute and chronic MCL tears. There was a marginally increased risk of complication in surgeries performed for acute MCL tears. Compared to the acute phase, a marked resolution of pain was observed at the final follow-up after surgery for MCL injury.

Study design: Systematic review; level of evidence, 4..

Background: Multiple ligament knee injuries (MLKI) are a complex group of injuries ideally treated in the acute phase, though delayed presentation is common. Chronic MLKI varies in presentation, requiring individualized management strategies. This review aims to differentiate chronic MLKI types and propose an algorithm that facilitates a tailored treatment plan.

Methods: Chronic MLKI is classified into three types based on knee joint status and limb alignment. Type 1 involves ligament deficiency in a reduced knee with normal alignment, treated with soft-tissue ligament reconstruction. Type 2 includes ligament deficiency with malalignment, where deformity correction precedes ligament surgery. Type 3 entails chronic unreduced knee dislocations, necessitating open reduction and extensive release prior to reconstruction.

Results: Treatment depends on classification, emphasizing realignment for Type 2 and reduction for Type 3 before soft-tissue procedures. Individualized approaches are critical due to the complexity and variability of chronic MLKI.

Conclusion: A treatment algorithm is essential to manage chronic MLKI. Joint reduction, limb realignment, and ligament reconstruction are important to ensure optimal functional outcomes.