Science topic

Knee Injuries - Science topic

Explore the latest questions and answers in Knee Injuries, and find Knee Injuries experts.
Questions related to Knee Injuries
  • asked a question related to Knee Injuries
Question
2 answers
Knee injuries in paediatric population are increasing signifi-
cantly these past few years and become more common because
of rising sports participation and competitive sports. Anterior cru-
ciate ligament (ACL) injuries may represent 30% of all knee injuries
in young soccer players. The number of ACL ruptures in young
population increases also secondary to much more accurate diag-
nosis methods such as early magnetic resonance imaging (MRI).
Because knee injuries in children could easily evolve towards early
arthritis, it should not be mistreated.the treatment of ACL ruptures in skeletally immature patients is not consensual. Several studies reported failure of conserva-
tive management and a more stable and functional knee after
ACL reconstruction in active child.
Relevant answer
Answer
@Ganesh S Dharmshaktu sir thank you for your inputs, before the advancement of MR imaging and arthroscopy; the internal derangement of knee in children was generally managed conservatively with rest and immobilization. This has greater advantage for nondisplaced/minimally displaced avulsions of tibial eminence. The risk vs benefit of conservative
approach for ACL injury in children needs to more in attention.
  • asked a question related to Knee Injuries
Question
5 answers
Physiotherapy and exercise show short-term improvements in physical function. I would like to know particularly cycling exercise for treatment.
Relevant answer
Answer
Cycling after a total knee replacement can improve range of motion. This exercise is often included in physical therapy after TKR, as early as the first week after surgery.
Early on, the seat can be raised to limit the amount of bending required. You might only be able to do partial revolutions at first, and this is normal. As motion improves, the seat can gradually be lowered.
Cycling for range of motion is performed slowly, pausing at the top to stretch into bending, and at the bottom of the revolution to stretch into extension — a straight-knee position. During the range of motion phase, there is no added resistance on the bike.
Avid exercisers may be accustomed to moderate to high-intensity workouts. However, for patients who have recently undergone a total knee replacement, it is important not to over-exert initially.
  • asked a question related to Knee Injuries
Question
7 answers
Multi ligamentous knee injuries diagnosis and management has always been a challenging problem.
The functional and clinical outcomes differ based on the approach to treatment and post operative rehabilitation.
Need experts opinion regarding the management for optimal outcome.
Relevant answer
Answer
At first you have to be sure there is no injuries due to a luxation (you have to check the arteries, high risk of postop. compartment syndrome!).
Then I would reconstruct the MCL with internal ligament bracing (suture tapes with anchors if available). If PCL is completely instable and you have enough OR time, then I would recommend to reconstruct the PCL with Quad tendon in one session. Otherwise you can stabilize the PCL with a brace.
I do not think that full ligament repair of MCL + PCL + ACL in one session is recommended.
And what about cartilage an meniscus??
  • asked a question related to Knee Injuries
Question
8 answers
There are different reconstruction graft options that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used.
Preparation of a hamstring autograft varies depending on patient characteristics and physician preference.
There are several methods to identify hamstring tendons, graft harvest and graft preparation techniques…to obtain an individualized graft according to patients anatomy and physical activity.
Please share your own tips and tricks!
Relevant answer
Answer
The standard method by identifying semiT or gracilis on flexed knee is followed by a mini incision followed by use of tendon stripper to obtain desired tendon part. The muscles and attached soft tissue is removed manually and desired bundles are created with use of ethibond as suture material over a tendon board.
  • asked a question related to Knee Injuries
Question
7 answers
One of the most critical steps in knee ACL Reconstruction is the anatomic placement of the femoral tunnel – the so-called ACL Femoral Anatomic Footprint. This could lead to tunnel misplacement – the main reason for ACL revision surgery.
The femoral native ACL attachment site is described as an oval-shaped divided into two bundles: the anteromedial (AM) and the posterolateral (PL) bundles.
Several theories and methods have been described to a proper tunnel positioning such as 10 o’clock position (right knee) and 2 o’clock position (left knee) - in a single bundle technique or the use of intraoperative fluoroscopy.
The most accurate anatomic landmark for arthroscopic ACL reconstruction is the native ACL remnant.
The Lateral Intercondylar Ridge (LIR)/”Resident´s Ridge" defines the upper border of the ACL and the ACL femoral drilling should aim for the Lateral Bifurcate Ridge, which divides the AM and PL bundle fibers.
However, cross-sectional area of the PL and AM bundles is variable from patient-to-patient, the location of the Lateral Bifurcate Ridge, when present, does not necessarily represent the true center of the ACL femoral attachment site.
Relevant answer
Answer
AM
  • asked a question related to Knee Injuries
Question
15 answers
What is right ? To continue with pharmaceutical prophylaxis for fearing DVT or stop (reduce) it to avoid wound complications ?
Relevant answer
Answer
  • Wound complications - especially bleeding complications are 'in your face' issues while the DVT is a perceived threat. Not to counter bleeding and persisting with LMWH is counterintuitive is just wrong.
  • DVT prophylaxis can be continued with mechanical means
  • DVT chemical prophylaxis is industry driven and more from fear of legal issues , perhaps that's is obstructing clear thoughts
  • asked a question related to Knee Injuries
Question
7 answers
I have made a mini-review about CMI and I want to interact with someone who have knowledge in this area. Be free to contact me; )
Relevant answer
Answer
Thank you very much Gustavo! 
  • asked a question related to Knee Injuries
Question
3 answers
for example, if i want to examine the correlation between hamstring strength during tow different tasks and hamstring strength was normally distributed in one task but non normally distributed in the other task. what should i do in this case? should i use Spearman ?
Relevant answer
Answer
It depends on a number of factors: How non-normal is  the dataset. Are there just a few outliers? How does a plot  look like? Is it close to an oval, or a curve, or a curve With just with a few outliers? How many pairs of measuremenst do you have?
As a general rule: With a sufficient number of data, parametric methods are more informative (useful) than non-parametric.
By the way: I would consider this a question of analysing agreement, not association=correlation. Making paired subtractions would then be more appropriate? ... for example after normalizing the two sets of data.
The is a lot of erroneous use of correlation coefficients in medical papers, where paired differences should have been used.
Arne
  • asked a question related to Knee Injuries
Question
7 answers
Hello.
I am trying to define the limit or threshold of the knee varus-valgus angle (rotational range) for normal subjects. please suggest good references for me.
It seems cadaveric studies, in vitro, are best.
Best regards: Tserenchimed.
Relevant answer
Answer
I understand now.This topic is important intraop during TKA and when you explore a patient in the office ( TKA stability).I will try to read the articles above.Thank you!
  • asked a question related to Knee Injuries
Question
3 answers
Hello.
I hope that everybody knows about the curling sport. The literature search reveals there is an evidence that the curlers had severe knee pain in his/her sliding leg (deep flexed knee).
However, I could not found any information about what is the cause of that pain? where is the pain come from (for instance, from muscle or soft tissue overload) or where is the location? (anterior or posterolateral).
please advise to me, share your knowledge, and please refer related publication including unpublished study, useful websites, and injury survey.
thank you
Relevant answer
Answer
I think you would not find on curling. But nothing prevents you from seeking other similar work areas curling. As carleur who always work knee flexed. It will be in the occupational disease.
  • asked a question related to Knee Injuries
Question
3 answers
Hi everyone,
I'm currently doing a series of mechanical test in healthy porcine joints. I usually do these tests within hours after hogs are slaughtered. I'd like to quickly induce degeneration on the soft tissues (articular cartilage, tibial cartilage and menisci) by injecting chemicals on the joints.
Any suggestions regarding which chemicals can be used to induce degeneration within 48 hrs after injection?
Thanks!
Relevant answer
Answer
We used trypsin to degrade cartilage. Usually put a small sample into 0.1 mg/ml trypsin solution more than 8 hours. but you might use higher concentration trypsin.
  • asked a question related to Knee Injuries
Question
9 answers
Traditionally the patella fracture with intact extensor apparatus has been treated by cylinder cast, long knee immobilizer brace as well as percutaneous lag screw. 
But is there any evidence in the literature as to what is the best mode of treatment?
Relevant answer
Answer
In completely non-displaced patella fx's, I keep patients in a ROM brace x 3weeks locked in full extension, allowing for showers, bathing, etc.  Range of motion 0-30 at 3- 6 weeks, then progress as tolerated. 
  • asked a question related to Knee Injuries
Question
7 answers
Does anyone know what are the specific effects (adaptations) of this particular exercise called: Quadriceps Eccentric Exercise or Reverse Nordic Lower (http://s0www.utdlab.com/contents/image.do?imageKey=EM%2F100189 ) ( https://youtu.be/B6gclHMQDj8 )  on either rehabilitation or prevention of knee injuries, or perhaps on its effects on some performance parameters (RFD, VJ, COD, etc.)?
Also what are the exercise guidelines regarding the FITT-VP principle?
Please provide research articles or anecdotal evidence.
Thank you.
Relevant answer
Answer
  • asked a question related to Knee Injuries
Question
10 answers
Dear professors and colleagues,
Is it common that MRI of knee of female athletes aged 17-20 years, beside different acute injuries, shows degenerative changes? In last 6 months majority of female athletes of mentioned ages, that I needed to recover had them.
If the MRI of 17 years old female athlete shows non injured ACL but with degenerative changes, what is the risk of ACL rupture, is it drastically increased... ?
Every discussion and advice is welcome.
Regards,
Vladimir
Relevant answer
Answer
It is not surprising to find degenerative changes of ACL in young athletes. Furthermore, if such changes exist this makes ACL more vulnerable because its strength, elasticity and durability reduce. So in similar cases further training in elite sports should be seriously discussed. Perhaps, change of sports kind should be considered, i.e. from athletics to swimming. 
  • asked a question related to Knee Injuries
Question
12 answers
There may be altered joint arthrokinematics and other mechanical issue of an adjacent structure, which may contribute to lateral knee pain. So, what will be the best physiotherapy management?
Relevant answer
Answer
Hi Peter,
Very informative..... Thanks a lot.
Warm regards,
  • asked a question related to Knee Injuries
Question
5 answers
A patient had been subjected for ORIF for  supracondylar  fracture distal femur 5 months earlier, he is presenting with stiff knee to 30 degrees flexion and with no active quadriceps contraction.
Relevant answer
Answer
If we presume that no malunion with a major angle between the fragments in the sagittal plane exists, then arthrolysis (adhesions release) followed by systematic rehabilitation should yield good functional results. 
  • asked a question related to Knee Injuries
Question
11 answers
A 24 year old fell hard on her knees. A knee examination was not done. Later she complains of left sided lateral knee pain as well as hip pain and left sided low back pain. Her doctor (A GP) prescribed her an analgesic and told her she needs rest. What could be the cause of her pain? Does she need further investigation? 
Relevant answer
Answer
From the information provided it is impossible to make a proper diagnose. Yes, patient needs further examination, by both MD (to exclude structural damage such as fractures of the bone's (often gives nightly and progressiv pain, worsen in weight bearing), ligamentous tears etc.) and by an osteopath (for pain caused by e.g. fascial tention, blocked joints, compromised biomechanics etc). There are several
possibilities for the cause of the pain. Biomechanically the impact through the femour might have caused the ili to fixate postriorly, this may creates pain in both SI-joint, pelvis, buttocks and lumbar spine. Displaced/fixed sacrum can irritate e.g. the m. piriformis createing entrapments for vessels and nerves for lateral thigh --> pull on lateral knee (and others). The possibilities are many. Proper investigation is necessary.
  • asked a question related to Knee Injuries
Question
3 answers
I want to know the relation of severity with the specific clinical findings of crepitus sound.
Relevant answer
Answer
An interesting question. Years back I started my career with this question.  We tried to record the sound from the joint using a microphone attached to the knee - an experiment not entirely successful. 
Crepitus apparently has no direct relationship to knee OA. It frequently decreases when a knee becomes inflamed or has fluid in the joint, a common occupancy as knee OA becomes more severe. 
Best best in can be an early sign of OA if it is present. 
Siddharth Das 
  • asked a question related to Knee Injuries
Question
7 answers
I want to know how in evidence forces are calculated to get safe therapeutic effects of continuous traction in knee osteoarthritis.
Relevant answer
Answer
Yes, Dietrich, you are right. The idea of arthritic joint distraction is to overcome contractures. As far as knee osteoarthritis is concerned, ligamental instability is a feared effect. Especially, in frontal plane deformities.  Nevertheless, this publication by Wiegant et al (the Netherlands) (s. below) reports interestingly good results with distraction.
  • asked a question related to Knee Injuries
Question
3 answers
Does anyone know some exercises or passive techniques to restore knee extension in early acl postoperative rehabilitation without giving too much strain on the new graft? I'm a physiotherapist and in my clinical practice I often manage patients with incomplete knee extension (PROM). I'm in doubt how I can manage this problem in order to avoid potentially dangerous exercises such as active SLR or OKC extension. What do you do in your clinical practice? Is there any literature about this topic? I'm particularly interested in early rehab after acl reconstruction with semitendinosus-gracilis autograft (po weeks 1st to 5th). Thank you.
Relevant answer
Answer
After the surgery, the patient should have a knee cast in full extension, bearing according to the pain and contracting the quadriceps muscle for 10 to 12 days (until the removal of the sutures). In this period the knee get used to the new situation and we avoid excessive unpleasant inflammation. After that the patient should unblock the cast in order to start normal range of motion and should take it to realize some passive exercises of flexing and extended the knee with the help of the contralateral limb seated. In one month patient should flex more than 90º passively and actively. 
  • asked a question related to Knee Injuries
Question
3 answers
Material Chemical and Mechanical Properties.
Relevant answer
Answer
Dear Awais
Stainless steel and chrome cobalt are the routine material in orthopedic implant . but hip and knee systems for arthroplasty  had more complex structures. stems usually sprayed with Tivanium 6Al 4V for biologic osteointegration. in some designs porous coated and etc..
  • asked a question related to Knee Injuries
Question
3 answers
What is the appropriate approach for management for a neglected patella fracture of over a year with the proximal fragment at the region of the mid thigh with weakness in the extensor mechanism.
Relevant answer
Answer
I agree with Dr. Farouk. This injury lies back more than a year and the fragments are severely dislocated. The fragments are osteoporotic.  One can try to  mobilise the quadriceps muscle in an attempt to reduce the non-united fragments and fix them but in my opinon this should be difficult if possible at all.
One should then consider patellectomy, quadriceps plasty and transposition of part of the ischiocrural muscles to enhance the extension mechanism. In my practice this prosedure has worked satisfactorally.
  • asked a question related to Knee Injuries
Question
2 answers
I am trying to find out level of cartilage destroying enzymes which is associated with crepitus sound with pain.
Relevant answer
Answer
Crepitation suggests sever chondromalacia (gr II and III). I have no experience with the measuring the level of destroying enzymes.
  • asked a question related to Knee Injuries
Question
3 answers
For one of my researches here in Nepal, I needed to know the MCID of "Knee extension angle (KEA)".
KEA is a "reference standard" measure to assess the flexibility of Hamstrings. Through the literature search, I could not locate the answer. Please share if MCID is established for KEA. 
I am looking forward for your expert help. 
Regards, 
Saurab
Relevant answer
Answer
Fairly standardized calculation as soon as you identify what the gold standard of change is. 
  • asked a question related to Knee Injuries
Question
1 answer
Accidental case
Relevant answer
Answer
If you mean eversion of the patella together with the extensor apparatus at knee surgery, there seems to be some evidence, that in all these cases the postoperative flexion is diminished.
Personally I see no difference between cases, where we everted the patella and cases where we did not.
  • asked a question related to Knee Injuries
Question
10 answers
Biomaterial or scaffold for stem cells to transplant in osteo-chondral defects in rat or rabbit. There are large number of biomaterial experts are out there on RG site. My stem cells placed in osteo-chondral defects and later covered with fibrin glue is not helping much for the survival of stem cells checked after few weeks. Many thanks.
Relevant answer
Answer
Subhash,
we tested PHB/HAp scaffold for bone and UHMWPE implant for cartilage defects replacement. But the last one was not porous.
In case of PHB/HAp there were sites of neo-osteogenesis after 3 weeks of orthotopic transplantation in rats bone. Over time there was resorption of the material and replacing it with bone. 
  • asked a question related to Knee Injuries
Question
12 answers
I'd like to know if anyone have references about the influence of lumbosacral ROM on anterior knee pain, because we are conducting a study where we will compare the measuring of people with and without anterior knee pain, and I didn't have success in found this relationship   
Relevant answer
Answer
Dear all, if you want to look at what causes anterior knee pain you will need to conduct a prospective study with asymptomatic subjects that you follow over time. Looking at patients already in pain makes it impossible to determine if lumbosacral ROM is the cause or the effect of pain.
  • asked a question related to Knee Injuries
Question
4 answers
Please add any publications /evidence that may indicate it's reliability at testing quadriceps shortening .thank you 
Relevant answer
Answer
Dear Reda
This article may be useful for you
J Orthop Res. 2008 Jun;26(6):793-9. 
Reliability of the Ely's test for assessing rectus femoris muscle flexibility and joint range of motion.
Peeler J1, Anderson JE.
Abstract
Rehabilitative protocols and orthopadic research are significantly influenced by the ability to perform reliable measures of specific physical attributes or functions. The hypothesis was that the Ely's test for evaluating rectus femoris flexibility and joint range of motion (ROM) is a reliable clinical tool. Participants (n = 54) were between the ages of 18 and 45, and had no history of trauma. Three clinicians with orthopedic expertise assessed quadriceps flexibility and joint ROM using pass/fail and goniometer scoring systems. A retest session was completed 7 to 10 days later. Statistically, Kappa values for pass/fail scoring (intrarater $\bar {X}=0.52$, interrater $\bar {X}=0.46$) and ICC values (intrarater $\bar {X}=0.69$, interrater $\bar {X}=0.66$) for goniometer data both indicated that the Ely's test demonstrated only moderate levels of intra- and interrater reliability. Measurement error values (SEM = 4 degrees , ME = 4 degrees , and CV = 3%) and Bland and Altman plots (with 95% Limits of Agreement) further demonstrated the degree of intrarater variance for each examiner when executing the Ely's test in a clinical setting. Results call into question the statistical reliability of the Ely's test, and provide clinicians with important information regarding the reliability limits of the Ely's test when used to clinically evaluate flexibility and joint ROM in a physically active population. More research is required to determine the variables that may confound statistical reliability of this orthopedic technique that is commonly used in a clinical setting to assess function about the thigh region.
  • asked a question related to Knee Injuries
Question
11 answers
I usually perform distalization of tibial tubercle as the first procedure to correct the patella alta. If need be, I add MPFL reconstruction as the second staged procedure. I never had to add trochlear plasty.
Relevant answer
Answer
I do have considerable experience with trochleaplasty but feel that it is not indicated in grade 1dysplasia.  I therefore agree with a combined TT Transfer with MPFL Reconstruction in this patient. 
  • asked a question related to Knee Injuries
Question
7 answers
Hip Abductor and External Rotator Strengthening Versus Knee Extensors Strengthening
Relevant answer
Answer
Dear Khalil, In PFPS, the pattern of muscle weakness may differ patient to patient. Before comparing the intervention it is essential to identify weak group of muscle. In patients without weakness of hip abd/ ext, it may not be effective with strength training. If the aim is to correct the biomechanics I would recommend to strengthen all 3 muscle. Also finding the tight muscle group and releasing it would heighten the pain management strategy in PFPS...
  • asked a question related to Knee Injuries
Question
12 answers
We receive such patients who refuse replacement surgery and expect a 100% recovery by PT Rx in terms of pain, function, gait and even joint space and deformity. We try counseling but they keep on complaining.
Do you face such problems? What's your opinion?
Relevant answer
Answer
Dear Dhara,
The ultimate goal of exercise in OA is to prevent or delay disability. An exercise program should incorporate elements to lessen pain during activity and to
increase or at least maintain joint range of motion, periarticular muscle strength, joint stability, and aerobic capacity or level of conditioning.
Exercise in OA should be adapted according to the presence and severity of pain.
In painful episodes:
- Isometric exercise or exercise in a non weight-bearing
(e.g., biking, rowing with adapted tools) or
- In a partial weight-bearing position (e.g., aquatic ex) should be recommended.
In painless (or at least less painful) periods:
- Exercise program may include progressive muscle performance exercises.
The above exercise programs may delay disability but does not help regenerationof the cartilage. Hence, it can't recover the actual joint pathology, so the final choise of treatment will remain joint reconstruction or replacement surgery untill we get a new line of treatment.
Regards
  • asked a question related to Knee Injuries
Question
3 answers
There are three main types of bone marrow stimulation in the literature; microfracture, abrasion chondroplasty, and drilling. Can anybody tell me why microfracture is overwhelmingly more popular than the other techniques? Does anybody have any references on the results of these different techniques? Or do you use other bone marrow stimulation techniques other than microfracture?
Relevant answer
Answer
I often prefer drilling with a 2.5 mm sheath pin at low speed. The defects which are not approachable by the pin, I use microfracture awl, for example most of the tibial defects.
Although it is advocated to keep them non weight bearing for 6-8 weeks, I however, start early weight bearing. I have, although, not performed a histopathology to see the quality of cartilage, a second look arthroscopy due to some other problem, in some patients showed filling of the defects with new cartilage like tissue.
My common indications these days for this procedure is to do it as a part of arthroscopic debridement in elderly patients for osteoarthrosis who are still not the candidates for arthroplasty due to various reasons. The results are satisfactory.
  • asked a question related to Knee Injuries
Question
2 answers
I'm looking for information about the Q-Angle for my thesis.
Relevant answer
Answer
Dear Julie
Quadriceps angle (Q)
• It is the angle between the straight lines: 1) which pass through the patellar and tibial tuberosity and 2) the middle patella and the iliac crest Top Previous
• It is larger in women, since they have greater horizontal distance between iliac crest.
Limits for Men and Women
• Men: 11 to 17 degrees
• Women: 14 to 20 degrees
• Values ​​outside these limits are considered pathological burden and all structures involved joint (knee and hip).
These articles may be useful for you:
1) Biomed Tech (Berl). 2013 Sep 7
The Q-Angle and its Effect on Active Knee Joint Kinematics - a Simulation Study.
Asseln M, Eschweiler J, Zimmermann F, Radermacher K
2) J Orthop Res. 2001 Sep;19(5):834-40.
Q-angle influences tibiofemoral and patellofemoral kinematics.
Mizuno Y1, Kumagai M, Mattessich SM, Elias JJ, Ramrattan N, Cosgarea AJ, Chao EY
3) Does the change in Q angle magnitude in unilateral stance differ when comparing asymptomatic individuals to those with patellofemoral pain?
Herrington L.
Phys Ther Sport. 2013 May;14(2):94-7
4)The relationship between quadriceps angle and tibial tuberosity-trochlear groove distance in patients with patellar instability.
Cooney AD, Kazi Z, Caplan N, Newby M, St Clair Gibson A, Kader DF.
Knee Surg Sports Traumatol Arthrosc. 2012 Dec;20(12):2399-404
5) Normal Q-angle in an adult Nigerian population.
Omololu BB, Ogunlade OS, Gopaldasani VK.
Clin Orthop Relat Res. 2009 Aug;467(8):2073-6
  • asked a question related to Knee Injuries
Question
17 answers
During the anterior cruciate ligament reconstruction, my hanstring graft (STG) has fell on the floor accidently twice. I did not have option of the allograft. I only had the options of either harvesting the same side BTB or contralateral hamstring or using the same graft after cleansing it. I exercised the last option of washing the graft with 500 ml saline, soaking it in cidex for 30 minutes and again washing it with saline. I was fortunate enough that in both the patients there was no infection. Both the patients have completed 2 years and 5 years follow up and the KT assessment as well as functional assessment is good.
But is it the right way to go in this situation or we should always harvest another new graft?
Relevant answer
Answer
Dear Ravi
Below comments from Bernard R. Bach, MD, - What Do You Do If You Drop the Graft on the Floor? Healio Orthopedics.
Great care must be taken to avoid contamination during harvest and or preparation of the graft for anterior cruciate ligament (ACL) reconstruction. Our protocol emphasizes that the surgeon who harvests the graft personally walks the tissue to the back table to reduce the risk of dropping the graft. Handing off of a freshly harvested graft to other members of the surgical team for preparation simply increases the likelihood dropping the graft. With this protocol, the senior author has not dropped any grafts in over 20 years of practice, including more than 1700 knee ligament procedures. Careful attention must be paid during preparation on the back table as well. The fully prepared graft is placed in a marked kidney basin. All operative personnel are informed to prevent the graft from being inadvertently passed off the sterile field
When the graft is brought to the operative field for graft placement, if it is wrapped in a laparotomy sponge, theoretically the only contaminated portion would be the sutures extending beyond the sponge if the graft were dropped.
If the graft is dropped, the salvage falls into one of several possible categories, namely cleaning the graft, using an alternative graft (auto or allograft), or stopping the procedure and completing the surgery at another time with a different graft.
One study showed a 58% rate of positive culture when the graft was dropped and left on the operating room floor for 15 s. Molina et al have shown that a 90-s soak in chlorhexadine gluconate is the most effective method to resterilize the graft
Another report found that a 30-min soak in 4% chlorhexadine followed by a 30-min soak in triple antibiotic solution (gentamicin, clindamycin, polymixin), followed by sterile saline wash was 100% effective in sterilizing contaminated rabbit patellar tendon grafts. In that same study, 10% povidone-iodine was 100% ineffective, as was triple antibiotic soak used in isolation.
A survey of sports medicine specialists found that most would choose cleansing the graft to manage the problem of a dropped graft. Forty-three surveyed surgeons reported having cleansed a contaminated graft and none reported postoperative infections.3
Another option is choosing an alternative graft. This requires preoperative consent from the patient or intraoperative consent from a family member and may be problematic for a patient who expects one graft type but ends up with another. Some surgeons routinely consent their patients for the use of an allograft should the autograph become contaminated or otherwise compromised. Again, if this option is selected, preoperative discussion with the patient is best because cultural or religious beliefs may preclude the use of cadaveric tissue.
Our preference would be cleansing the graft using a 30-min soak in 4% chlorhexadine gluconate followed by lavage with sterile saline, then another 30-min soak in triple antibiotic solution (0.1% gentamicin, 0.1% clindamicin, 0.05% polymyxin) and another sterile saline wash. Washing the chlorhexadine is crucial because chlorhexadine-induced chondrolysis has been reported.4 While this protocol is time consuming, it has solid scientific backing and would allow one to proceed with the same graft as planned preoperatively. One could consider a course of postoperative antibiotics, although we would refrain from this as it would likely only mask an underlying infection, delaying its definitive treatment. In addition, we recommend full disclosure to the patient regarding the incident and the low likelihood of any residual difficulties.
References
1. Molina ME, Nonweiller DE, Evans JA, DeLee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373-378.
2. Goebel ME, Drez D Jr, Heck SB, Stoma MK. Contaminated rabbit patellar tendon grafts: in vivo analysis of disinfecting methods. Am J Sports Med. 1994;22:387-391.
3. Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348-1353.
4. Van Huyssteen AL, Bracey DJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81-B:995-996.
  • asked a question related to Knee Injuries
Question
18 answers
It is generally accepted that arthritis of the knee affects the entire joint including menisci, cartilage and synovia. While various studies suggest (partial) meniscectomy being the major trigger for subsequent osteoarthritis, some opinion leaders consider an initial cartilage defect being the reason for further joint degeneration and subsequent meniscus pathologies. What is your opinion regarding the relationship between cartilage injury/defect and meniscus injury and subsequent osteoarthritis?
Relevant answer
Answer
While there may be general assumptions made that the whole knee is susceptible for OA, the assumption is misleading and not well substantiated. The evolution of the OA lesion is almost always focal, beginning in a single joint compartment. The problem arises focally as a result of multiple factors which represent the imbalance between the most important mechanical factors, which are both dynamic (eg adduction moment) and static, (eg varus alignment), and biological (eg metabolic as alluded to above). Weak tissues are more susceptible, strong, well aligned limbs in slim individual are less at risk. Once the process starts all parts of the knee as joint structure become involved....the driving forces for progression are dominated by mechanical factors.
For more thoughts on this topic please visit www.oaisysmedical.com and look at 'Knee Pain; arthritis?"'
  • asked a question related to Knee Injuries
Question
8 answers
Since King, 1936 classic research:“For meniscal lesions to heal they must communicate with the peripheral vasculature of the meniscus.” a lot of things have been said. Nowadays, proper patient selection plays a key role in successful outcomes. What do you think?
Presentation Meniscal Injury
Relevant answer
Answer
Dear Gustavo
Criteria are:
1. Age of patient
2. Time of injury (Acute or Chronic)
3. Area of injury
4. How extended is the injury
5. Complexity of injury
6. Activity of patient
So young active patient with acute extended unstable tear of meniscal injury situated in the red zone mainly and without ligament injuries (or injuries that are planned to be repaired or reconstructed during surgery), would be better to have this fixed.
  • asked a question related to Knee Injuries
Question
5 answers
Limited range of motion is frequently observed following intra- or periarticular fractures of the knee. What do you consider special about this entity in comparison to other types of arthrofibrosis? What are your criteria to indicate revision surgery and how do you address arthrofibrosis? What time point following fracture treatment is best to perform revision surgery?
Relevant answer
Answer
This is a very difficult question. The "simple" answer would be that arthrolysis is rarely indicated in the era of joint replacement surgery. But the context of the question is different. It is well known that exact and perfect reduction of intraarticular fractures of the knee is not always possible. Haemarthrosis, loose bone fragments, soft-tissue damage, malunion, etc. make the recovery of optimal ROM problematic. In any case early kinesitherapy should be initiated as soon as possible. Close follow of the development of joint mobility is advisable too. In my opinion revision surgery (incl. arthrolysis) should be decided individually from case to case.Of course, haemarthrosis should be treated early on emergency base.
In any case, fracture healing should be the primary goal. When the fracture heals and the ROM is unacceptable, then there is a vast range of options including arthrolysis, arthrodesis, and last but not least TKA.
  • asked a question related to Knee Injuries
Question
6 answers
I am involved in a project reviewing contemporary clinical management of Patellofemoral Pain (PFP). Please does anyone have any rehabilitation protocols for PFP that they could share.
Relevant answer
Answer
There may be lot of reasons for patellofemoral pain,if the position of the patella is the one causing pain,corrrection of the position by taping helps a lot followed by strengthening of quadriceps,hamstrings and hip abductors will help a lot to relieve pain.
  • asked a question related to Knee Injuries
Question
2 answers
I'm trying to find quantitative measures to relate to knee stability. I've heard some gait labs use rigs specifically designed for knee stability measurements however haven't found much in the literature.
Relevant answer
Answer
Aircast has a device called the Rolimeter (see http://www.genourob.com/de/arthrometer/7-arthrometres/44-le-rolimeter-.html) that is not very expensive and is easy to use for A-P knee laxity (i.e. drawer test). I am not sure if it would work but maybe there is a way to use it (against its dedicated purpose) for M-L laxity test.