Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

The study sought to determine the results of labral restoration among patients over age 60 compared to a cohort of younger adults.

21 consecutive patients over age 60 undergoing labral repair with minimum one-year follow-up were compared to a contemporaneous group of 21 patients age 18–55 matched for gender, degree of chondral damage, and associated FAI or dysplasia.

Follow-up averaged 18.9 months (12 to 24 months). The study group averaged 63.2 years (61 to 71); with 20 FAI and one dysplasia. 19 had acetabular articular damage (2 grade IV, 11 grade III, 5 grade II, 1 grade I) and 6 had femoral changes (1 grade IV, 5 grade 3). The control group averaged 35.8 years (20 to 54).

Average improvement among the study group was 28.1 points modified Harris Hip Score (mHHS) and 37.5 points iHOT; and among the control group, 21.2 points mHHS and 37.1 points iHOT. There was no statistically significant difference between the two groups in the amount of improvement, with statistically and clinically significant improvement noted in both. Two study group patients underwent total hip arthroplasty (THA) at average 10 months with one control group THA at 11 months. All three converted to THA had combined grade IV acetabular and grade III femoral damage. There were no repeat arthroscopies and no complications in either group.

We conclude that patients over age 60 can benefit from arthroscopic labral repair with improved outcomes, modest rates of conversion to THA, and small risk of complication. Results are comparable to younger adults. Combined bipolar grade IV or grade III articular damage is a harbinger of conversion to THA, regardless of age.

Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown.

The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL.

Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded.

Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05).

Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05).

Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee.

Over the last two decades, anatomic anterior cruciate ligament (ACL) reconstructions have gained popularity, while the use of extraarticular reconstructions has decreased. However, the biomechanical rationale behind the lateral extraarticular sling has not been adequately studied. By understanding its effect on knee stability, it may be possible to identify specific situations in which lateral extraarticular tenodesis may be advantageous. The primary objective of this study was to quantify the ability of a lateral extraarticular sling to restore native kinematics to the ACL deficient knee, with and without combined intraarticular anatomic ACL reconstruction. Additionally, we aimed to characterise the isometry of four possible femoral tunnel positions for the lateral extraarticular sling.

Eight fresh frozen hip-to-toe cadavers were used in this study. Navigated Lachman and mechanised pivot shift examinations were performed on ACL itact and deficient knees. Three reconstruction strategies were evaluated: Single bundle anatomic intraarticular ACL reconstruction, Lateral extraarticular sling, Combined intraarticular ACL reconstruction and lateral extraarticular sling. After all stability tests were completed, we quantified the isometry of four possible femoral tunnel positions for the lateral extraarticular sling using the Surgetics navigation system. A single tibial tunnel position was identified and digitised over Gerdy's tubercle. Four possible graft positions were identified on the lateral femoral condyle: the top of the lateral collateral ligament (LCL); the top of the septum; the ideal tunnel position, as defined by the navigation system's own algorithm; and the actual tunnel position used during testing, described in the literature as the intersection of the linear projections of the LCL and the septum over the lateral femoral condyle. For each of the four tunnel positions, the knee was cycled from 0 to 90® of flexion and fiber length was recorded at 30® intervals, therefore quantiying the magnitude of anisometry for each tunnel position.

Stability testing: Sectioning of the ACL resulted in an increase in Lachman (15mm, p = 0.01) and mechanised pivot shift examination (6.75mm, p = 0.04) in all specimens compared with the intact knee. Anatomic intraarticular ACL reconstruction restored the Lachman (6.7mm, p = 3.76) and pivot shift (−3.5mm, p = 0.85) to the intact state. With lateral extraarticular sling alone, there was a trend towards increased anterior translation with the Lachman test (9.2mm, p = 0.50). This reconstruction restored the pivot shift to the intact state. (1.25mm, p = 0.73). Combined intraarticular and extraarticular reconstruction restored the Lachman (6.2mm, p = 2.11) and pivot shift (−3.75mm, p = 0.41) to the intact state. There was no significant difference between intraarticular alone and combined intraarticular and extraarticular reconstruction. (p = 1.88)

Isometry: The ideal tunnel position calculated by the navigation system was identified over the lateral femoral condyle, beneath the mid-portion of the LCL. The anisometry for the ideal tunnel position was significantly lower (5.9mm; SD = 1.8mm; P<0.05) than the anisometry of the actual graft position (14.9mm; SD = 4mm), the top of the LCL (13.9mm; SD = 4.3mm) and the top of the septum (12mm; SD = 2.4mm).

In the isolated acute ACL deficient knee, the addition of a lateral extraarticular sling to anatomic intraarticular ACL reconstruction provides little biomechanical advantage and is not routinely recommended. Isolated lateral extraarticular sling does control the pivot shift, and may be an option in the revision setting or in the lower demand patient with functional instability. Additionally, the location of the femoral tunnel traditionally used results in a significantly more anisometric graft than the navigation's system mathematical ideal location. However, the location of this ideal tunnel placement lies beneath mid-portion of the fibers of the LCL, which would not be clinically feasible.

Controversies about the management of injuries to the soft tissue structures of the posteromedial corner of the knee and the contribution of such peripheral structures on rotational stability of the knee are of increasing interest and currently remain inadequately characterised. The posterior oblique ligament (POL) is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule. The POL is reported to be a primary restraint to internal rotation and a secondary restraint to valgus translation and external rotation. Although its role as a static stabiliser to the medial knee has been previously described, the effect of the posterior oblique ligament (POL) injuries on tibiofemoral stability during Lachman and pivot shift examination in the setting of ACL injury is unknown.

The objective of this study was to quantify the magnitude of tibiofemoral translation during the Lachman and pivot shift tests after serial sectioning of the ACL and POL.

Eight knees were used for this study. Ligamentous constraints were sequentially sectioned in the following order: ACL first, followed by the POL. Navigated mechanised pivot shift and Lachman examinations were performed before and after each structure was sectioned, and tibiofemoral translation was recorded.

Lachman test: There was a mean 6.0 mm of lateral compartment translation in the intact knee (SD = 3.3 mm). After sectioning the ACL, translation increased to 13.8 mm (SD = 4.6; P<0.05). There was a nonsignificant 0.7 mm increase in translation after sectioning the POL (mean = 14.5 mm; SD = 3.9 P>0.05).

Mechanised pivot shift: Mean lateral compartment translation in the intact knee was −1.2 mm (SD = 3.2 mm). Sectioning the ACL caused an increase in anterior tibial translation (mean = 6.7 mm; SD = 3.0 mm; P<0.05). No significant change in translation was seen after sectioning the POL (mean = 7.0 mm, SD = 4.0 mm; P>0.05).

Sectioning the POL did not significantly alter tibiofemoral translation in the ACL deficient knee during the Lachman and pivot shift tests. This study brings into question whether injuries to the POL require reconstruction in conjunction with ACL reconstruction. More studies are needed to further characterise the role of the injured POL in knee stability and its clinical relevance in the ACL deficient and reconstructed knee.

Purpose: Waterproof casts have been shown to be a safe and effective means of immobilization in children with minimally displaced fractures. The purpose of this study was to determine if waterproof Gore-Tex-lined casts are as effective as traditional cotton-lined casts in the immediate postoperative period after closed reduction of displaced distal radius fractures in children.

Method: We performed a retrospective review of distal radius fractures that underwent closed reduction and application of a long-arm cast between June 2004 and December 2006. A total of 124 cases were included (55 Gore-Tex; 69 traditional cotton-lined). The primary outcome measure was redisplacement in the cast. The cast index was also used to assess the quality of cast molding. Data was analyzed using repeated measures ANOVA. Power analyses were also conducted.

Results: There were no significant differences between the two groups with regards to translation of the radius or angulation of the radius on anterior-posterior (AP) and lateral radiographs at the time of injury, postreduction, or cast removal. Redisplacement as measured by the change in translation of the radius and angulation of the radius on AP and lateral radiographs from the time of reduction to cast removal was also not significantly different between the two groups. The mean cast index for the Gore-Tex and traditional cotton-lined groups was 0.882 and 0.873 respectively, which was not a significant difference.

Conclusion: A waterproof Gore-Tex-lined cast will maintain fracture reduction as well as a cotton-lined cast for closed reductions of distal radius fractures in children in the immediate postreduction period. Waterproof casts also provide extensive benefits to the patient with regards to bathing, hygiene, and participation in aquatic activities