Knee Reconstruction Research Articles

Post-operative outcomes associated with posterolateral tibial plateau impaction fractures in the setting of primary ACL tear

Objectives:The primary objective was to assess the effect of impaction fractures of the posterolateral tibial plateau on patient reported post-operative outcomes following primary ACL surgery.Methods:Patients with available MRI images who underwent surgery for primary ACL tears by a single surgeon between April 2010 and September 2017 were identified. A prospectively and consecutively enrolled clinical outcomes database was queried for all patients within this cohort who had 2-year or greater post-operative patient reported outcomes available. Patient reported outcomes included the 12-item Short Form Health Survery (SF-12) Physical Composite Scale (PCS) and Mental Health Composite Scale (MCS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), International Knee Documentation Committee Questionnaire (IKDC), Lysholm Knee Questionnaire, Tegner Activity Scale and patient satisfaction. For patients without existing 2-year outcomes, additional inclusion criteria included English-speaking and current age greater than or equal to 18. Patients meeting these criteria were sent electronic surveys to collect patient reported outcomes. MRI images were reviewed for all patients with denotation of displaced posterolateral tibial impaction fractures. Posterolateral tibial impactions were classified based on morphology using the following classification: (Type I) posterior cortical buckle not involving the articular surface, (Type II) posterior impaction fracture involving the articular surface [(with subtype based on (A) tibial plateau depth bone loss <10% and (B) bone loss >10%)], and (III) displaced osteochondral fragment [(with subtypes for (A) shear or (B) depressed fragment)]. All tibial impaction fractures were measured to determine amount of tibial plateau bone loss in the sagittal plane. Pre-operative and 2-year or greater post-operative patient reported outcome scales were compared based on posterolateral tibial impaction fracture classification using Kruskal-Wallis non-parametric ANOVA with Nemenyi post-hoc test. Pearson’s correlations were used to assess for correlations between post-operative patient reported outcomes and amount of tibial plateau sagittal plane bone loss present.Results:There were 638 knees identified with primary ACL tears who underwent surgery between April 2010 and September 2017. Thirty-nine patients met exclusion criteria, leaving 599 total patients. Of these, 2-year outcomes were available for 416 patients for a 69.4% follow-up rate at a mean time of 158 weeks (range: 90-422). There were statistically significant improvements in all PROs from pre-op to 2-year post-op (p < 0.001). Kruskal-Wallis non-parametric ANOVA showed no difference in all PROs based upon posterolateral impaction fracture classification type, except for Tegner Activity Scale which showed difference in outcomes based on impaction fracture type (p < .002) (Table 1). Specifically, diminished post-operative activity level was observed in patients with type 2B, type 3A, and type 3B fractures. Pearson correlation testing showed weak but statistically significant correlations between tibial plateau impaction fracture sagittal bone loss amount and SF-12 PCS (PCC: -0.156, p = 0.023), WOMAC Total Score (PCC: 0.159, p = 0.02), Lysholm (PCC: -0.203, p = .003), and Tegner Activity Scale (PCC: -0.151, p = 0.032). Independent T-testing showed no difference in any patient reported outcome scores at 2-year follow-up when all posterolateral tibial impaction fractures were grouped together compared to those without impaction fracture.Conclusion:Displaced posterolateral tibial plateau impaction fractures occurring in the setting of ACL tear are associated with diminished 2-year post-operative outcomes after ACL reconstruction. When classified based on fracture morphology, posterolateral tibial plateau impaction fracture types 2B, 3A, and 3B are associated with decreased post-operative activity level as assessed by Tegner Activity Scale. When comparing patients with posterolateral impaction fractures, greater amounts sagittal plane tibial plateau bone loss at the posterior rim showed weak but significant correlations with worse scores on SF-12 PCS, WOMAC, Lysholm, and Tegner patient reported outcome measures.Figure 1.

Anatomic Lateral Collateral Ligament Reconstruction Graft Options: Clinical and Radiographic Outcomes of Autograft versus Allograft

Objectives:As awareness of lateral knee pathology has increased, surgical outcomes for lateral collateral ligament (LCL) reconstruction and posterolateral corner reconstructions have improved. Despite reliable improvement in results, no study to date has compared the radiographic or clinical outcome of lateral knee reconstruction procedures when comparing autograft versus allograft reconstruction options. To evaluate patient reported outcomes and radiographic outcomes following anterior cruciate ligament (ACL) reconstruction with isolated LCL anatomic reconstruction, comparing the use of autografts versus allografts for LCL reconstruction. The null hypothesis was that there would be no significant differences in clinical outcomes at 2-year follow up and no differences in LCL insufficiency as defined by a side-to-side difference of greater than 2.1mm in varus stress radiographs at minimum of 6-month follow up.Methods:All patients who underwent primary ACLR with concomitant isolated LCL reconstruction from 2010 to 2017 by a single surgeon were retrospectively identified; clinical characteristics and graft choice for LCL reconstruction was collected. Patients with minimum 2-year follow up clinical outcome scores and 6-month bilateral varus stress radiographs were included. Patients with any other ligamentous procedure or revision ACL reconstruction were excluded. An a priori power analysis demonstrated a minimum group size of 18 patients per group to detect a difference in LCL insufficiency.Results:There were 58 primary ACLR with concomitant LCL reconstruction patients identified that met inclusion criteria. Thirty-nine patients underwent LCL reconstruction with semitendinosus autograft compared to 19 patients with allograft (16 semitendinosus and 3 tibialis anterior). At a minimum 6-month radiographic varus stress x-ray follow-up, there was no significant difference in LCL graft reconstruction failure (>2.1 mm) between autograft and allograft (autograft 0/39 vs allograft 0/19). There was also no absolute side-to-side difference of stress x-ray gapping between the two cohorts (allograft= 0.49 mm and autograft= 0.15 mm, p= 0.22). Furthermore, there was no difference when comparing the autograft to allograft group at minimum 2-year clinical outcome follow-up for SF-12 Mental Component Score (MCS) and Physical Component Score (PCS), WOMAC (Total, pain, stiffness, activity), Tegner, and Lysholm scores. Lastly, patient satisfaction between allograft and autograft groups showed no significant difference at average follow-up of 3.6 years. There were no significant differences in clinical knee stability between groups at final follow-up (p >0.05).Conclusion:In the largest reported series comparing autograft and allograft lateral collateral ligament reconstructions, we found that both autograft and allograft LCL reconstructions offer reliable and similar radiographic and clinical results. As a result, surgeons may discuss the risks and benefits of both graft options with the patient and come to a decision through a shared decision-making process knowing that both grafts will provide reliable outcomes.

Anterior cruciate ligament – to repair or not to repair?

Anterior cruciate ligament injuries are one of the most frequent knee joint injuries, leading to instability which limits return to sport activity, and is one of osteoarthritis risk factors. Treatment issues are present since 1895, when Mayo Robertson performed first documented open ACL repair. Positive short-term results of open suturing led to rising popularity of this method, which in 70’s and 80’s became golden standard of ACL injury treatment. Feagin in his longterm observations noticed that nearly half of patients after open ACL repair, during first 5 years suffered from reappearing ACL tear. Since then, for many years reconstruction techniques with graft use became most popular technique. Increasing knowledge of ligament healing biology, creation of Sherman’s ACL injury location classification, development of arthroscopic techniques, connected with growing tendency for biological treatment caused increase in repair techniques interest. Most important potential benefits of this techniques are: limitation of perioperative trauma – no need to harvest graft, drill large tunnels, possible retention of additional ACL proprioceptive feeling, easier eventual reoperation. Effort to save patient’s ACL is especially indicated in case of acute trauma (depending on source up to 3-14 weeks from injury), with proximal tear (type I in Sherman classification) with good remnant quality. Most popular techniques of ACL repair are: proximal ACL attachment reinsertion, IBLA – Internal Bracing Ligament Augmentation and DIS – Dynamic Intraligamentary Stabilization. The aim of this study was to present actual state of knowledge concerning options of primary ACL repair, it’s results, indications, and sharing authors own experiences in this treatment methods. Preliminary, available in literature, results of studies concerning methods mentioned above are good and very good, comparable, and sometimes even superior to results of classical ACL reconstruction. However, there is lack of long-term studies, that might confirm increase in survivorship rate of repaired ACLs comparing to previous open suturing technique.

Hamstrings substitution via anteromedial portal with optional anterolateral ligament reconstruction is the preferred surgical technique for anterior cruciate ligament reconstruction: a survey among ESSKA members

The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures. All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods. Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500-66%), while a compression system was preferred on the tibial side by 537 (71% of the sample). This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community. III.

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury.

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

Correction to: Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.

Authors would like to update the full author names.

Resolution of Pain and Predictors of Postoperative Opioid use after Bridge-Enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction

PurposeTo compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription.MethodsA nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined.ResultsThe total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not.ConclusionsTotal overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients.Level of EvidenceLevel III, case control study (therapeutic).

Assessment of fixation for anterior cruciate ligament reconstruction using oversized suspensory devices on full-length femoral tunnels

BackgroundIn ACL repair, full-length single-diameter tunnels facilitate anatomic femoral fixation with suspensory devices, especially with outside-in techniques, and are required after accidental cortical perforation. With tunnel diameters over 6 mm, fixation resistance using regular suspensory devices may not suffice. Oversized cortical footprint devices could be a solution to guarantee fixation performance in larger tunnel diameters. This study aims to assess the biomechanical properties of ACL femoral fixation provided by two enlarged suspensory devices of similar characteristics, a fixed loop (G-Lok™ with G-Lok-XL™) and an adjustable loop (ProCinch™ with G-Lok-XL™), resting on a full-length 9 mm diameter tunnel compared to the widely accepted regular fixed-loop device (G-Lok™) on a socket tunnel. MethodsTwenty-seven fresh frozen porcine femurs and flexor digitorum profundus tendons were randomly assigned to a study group depending on the fixation method used (N = 9). Graft-femur constructs were subjected to a traction cyclic test (5000 cycles, [50–250]N load, 1 Hz) followed by a load-to-failure test (v = 1 mm/s). Residual displacement during the cyclic test and stiffness, displacements at physiological loads, ultimate load and corresponding displacement during the load-to-failure test were determined. FindingsNo significant differences could be established for any parameter measured in the comparison between the control with the socket tunnel and the oversized fixations with full-length tunnels. InterpretationACL femoral fixation achieved in full-length single diameter tunnels by using an enlarged suspension device, both with a fixed or an adjustable loop, provide similar biomechanical properties to the gold-standard fixed-loop device in a socket tunnel. Therefore, its clinical use may be safe.

Repair vs. Reconstruction for Acute Isolated ACL Tears- 2-Year Results of a Prospective Randomized Study

Aims and Objectives:Recently, due to the development of new techniques, ACL repair has returned back into focus of experimental and clinical research. Newer studies highlight the fact that ACL repair can lead to satisfying functional results and healing rates. Aim of the present study was to compare the functional results after ACL repair in comparison to primary ACL reconstruction for acute isolated ACL tears. It was hypothesized, that functional results and knee joint stability after ACL repair are comparable to those after ACLR.Materials and Methods:A prospective randomized study (Level of evidence 1) including a total of 85 patients with acute ACL tears was performed. Patients were randomized to undergo either ACL repair or primary ACL reconstruction with a semitendinosus autograft. The preinjury activity level and function were recorded. Follow-up examinations were performed at six weeks, six, twelve and 24 months postoperatively. At each follow up, the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score and the Lysholm score were acquired. Furthermore, anterior tibial translation (ATT) was evaluated by Rolimeter testing. The rate of recurrent instability and other complications were recorded.Results:79 patients could be re-evaluated (follow-up rate 93%). No significant differences between ACL repair and ACLR were found for the Tegner, IKDC and Lysholm score at any time of the follow-up. ATT was increased in the ACL repair group (& ATT 1.9 vs. 0.9). This difference was statistically significant (p=0.0086). Seven patients (17%) of the ACL repair group presented with recurrent instability and underwent single-stage revision reconstruction with hamstring autografts. Another three patients showed increased laxity with insufficient healing after ACL repair but did not require revision. In the ACLR group, five patients (13%) sustained a re-tear after return to their previous activity level. However, in three cases, a two-staged revision was required. Recurrent instability was associated with young age and higher Tegner scores in both groups.Conclusion:Functional results after ACL repair for acute tears are comparable to those after ACLR. However, the rate of ACL insufficiency seems to be slightly increased after ACL repair. In the revision situation, single-stage revision was possible in all cases following primary repair, whereas after primary reconstruction, a two-staged revision had to be performed in three of five cases. The current study supports the use of ACL repair as an option to treat acute ACL tears.

Challenging Knee Reconstruction After Resection of Cavernous Hemangioma in Young Patient – A case Report

Background:One of the most challenging problem of limb salvage is a large tumour involving knee joint. Large aggressive hemangioma could disrupt soft tissue and bone surrounding. Meticulous wide surgical resection was mandatory perfomed to ensure adequate resection in order to minimized recurrence. Reconstructive procedure should be individualized and aiming functional restoration. Knee Reconstruction using arthroplasty should considered Stability, Range of Motion and Longlive survival.Method:We are presenting a case 19 years girl who had pain, unable to extent the knee and dislocated patella laterally. Valgus knee deformity 30 ֯ with Range of motion limited extension 30֯ and flexion 45֯ Wide resection was done 2 years ago with clinical large of mass at harmstring muscle, pushed patella to lateral and large of cartilage erosions. The patients was prepared second operation for knee reconstruction. Knee reconstruction using standard Posterior Stabilized implant (Implancast) Approach anterior of knee, osteotomy and anteromedialisation tibial tubercle ( Fulkerson procedure) with lateral retincular release to restore patellar tracking. Exposing Joint line very narrow and fully filled with arthrofibrosis, was identified and did osteotomy . Mostly femoral and tibial cartilage has been damaged. Post operation protocol using long leg cast and delayed weight bearing for 3 weeks. Isometric exercise on the bed to maintance and regain muscle power. During 3 – 6 weeks cast was removed and patient was allowed to partial weight bearing using 2 crutches. Extensor muscle strengthening was performed gradually. Followed up until 6 months post operation.Results:After 6 months we evaluate no pain at full weight bearing, x ray no sign of loosening nor progressive deformity, good stability with varus valgus test. Range of motion full extension and 90֯ flexion. Knee Society Score was significantly increase from poor to good.Conclusion:Knee Reconstruction following tumor resection using standard implant Posterior Stabilized (PS) is possible to perfomed as long as using meticulous technique combined with selective procedures as needed to regain functional restoration.

Metanalysis of Qualitative and Quantitative improvement in Active Rehabilitation of Post ACL Repair or Reconstruction

Background: Physiotherapy regimen is important in both Pre-Surgery and Post-Surgery phases. However, Despite its widespread knowledge of importance of physiotherapy in both pre and post operation phases and during conventional therapy, the efficacy of early active intervention of physiotherapy in post-operative ACL repair/reconstruction is limited on the basis of quantitative and qualitative analysis. Purpose: The aim of this meta-analysis was to analyze the randomized controlled trials having quantitative and qualitative improvement in parameters after active rehabilitation in subjects with post-repair/ reconstruction of Anterior Cruciate Ligament. Methods: The authors searched Google Scholar and PubMed from 2014 to 2019. Only downloadable randomized controlled trials were included in the study. Main results: Twelve trials were included in the study with. The schedule of treatments varied greatly from certain days to 6 weeks or even follow up of 12 weeks. Subgroup analysis performed on Qualitative and quantitative assessment of pre-operative and post-operative active physiotherapy regimen showed significant statistical difference. Conclusion: The result of the present study shows strong evidence to support the active physiotherapeutic treatment pre-operative as well as post-operative in subjects with ACL repair/reconstruction, which helps in improving both qualitative and quantitative parameters.

Survival and complications in hinged knee reconstruction prostheses after distal femoral or proximal tibial tumor resection: A retrospective study of 161 cases

IntroductionHinged knee megaprostheses are mainly used for reconstruction after tumor resection. They may incur complications, but this has not been assessed in the French literature, except in small series at short follow-up. We therefore conducted a large-scale nationwide multicenter retrospective study with a minimum 5 years’ follow-up. The objectives were (1) to compare survival between distal femoral and proximal tibial reconstruction prostheses, and (2) to analyze complications and failure. HypothesisDistal femoral hinged reconstruction prostheses show longer survival with fewer complications than proximal tibial prostheses. Material and methodsOne hundred sixty-one patients were included: 118 in the distal femoral group, and 43 in the proximal tibial group. Tumors were mostly osteosarcomas (90 cases) or chondrosarcomas (31 cases). Mean age was 37 years (range, 12-86 years). Complications were assessed on the Henderson classification. Failure was defined by prosthesis anchor exchange or amputation. ResultsAt a mean 9 years’ follow-up (range, 5-23 years), implant survival was longer in the distal femoral group: 5- and 10-year survival, 84% [95% CI, 75-89] and 70% [95% CI, 59-79] versus 74% [95% CI, 69-85] and 43% [95% CI, 23-61] (p=0.02). Revision surgery for complications mainly concerned aseptic loosening (19%, 30 cases) or deep infection (16%, 25 cases) and more often involved the proximal tibia (65% vs. 43%, 28 vs. 51 cases; OR 2.4 [95% CI, 1.2-5.1]; p=0.02). DiscussionHinged knee reconstruction prosthesis is a solution in tumoral pathology, but with a high risk of complications (loosening and infection) and a higher failure rate in the proximal tibial reconstruction prosthesis. Level of evidenceIV, case series.

FEMORAL NERVE CATHETER IS ASSOCIATED WITH PERSISTENT STRENGTH DEFICITS AT 6 MONTHS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN PEDIATRIC PATIENTS

Background:The long-term outcomes of femoral nerve blockade following ACL reconstruction are not well defined. Femoral nerve blocks are typically administered as either a single-injection nerve block (FNB) or a continuous femoral nerve catheter (FNC). Prior work among pediatric patients found knee extension and flexion strength deficits 6 months postoperatively using FNB. However, this work was limited by the use of multiple graft choices and orthopedic surgeons.Purpose/Hypothesis:The purpose of this study was to investigate functional recovery after primary ACL surgery with quadriceps tendon-patellar autograft (QPA) in patients receiving a sciatic nerve block and either FNB or FNC. Our hypothesis was that short-term functional performance would be worse among those who underwent FNC compared to FNB.Methods:We conducted a retrospective chart review of pediatric patients 10-19 years of age who underwent ACL reconstruction with QPA by a single orthopedic surgeon. Surgery was performed at two locations: one of which administered FNB and the other FNC. Both were combined with sciatic nerve block. A physical therapist performed functional asymmetry assessments at approximately 6 months postoperative. We compared single-leg squat symmetry between groups using independent samples t-tests. We compared the proportion of patients in each group who achieved 80% symmetry on single-leg squat and Y-Balance tests, had initiated ballistics and running programs, and demonstrated functional symmetry at the 6-month post-operative appointment using Chi-square analyses.Results:Demographics were similar between groups (Table 1). Single leg percent symmetry of the operative limb was significantly greater in the FNB group compared to the FNC group (Table 2). In addition, a greater proportion of those in the FNB group demonstrated functional symmetry compared to the FNC group during the 6-month assessment (Table 2). There were no proportional differences between the groups for the number of patients who demonstrated 80% symmetry during single-leg squat or Y-Balance test, or had initiated a ballistics or running program at the time of assessment.Conclusion:Pediatric patients in the FNC group demonstrated poorer single-leg squat symmetry and functional symmetry compared to those in the FNB group at 7 months following ACL reconstruction with QPA. These preliminary findings may relate to increased concentration and duration of local anesthetic in the FNC group postoperatively. Providers should be cognizant of the implications of FNC on long-term outcomes of ACL reconstruction.Table 1.Patient demographic and surgery characteristics between those who received a femoral nerve catheter compared to those who received a femoral nerve block single shot.VariableFemoral nerve single shot block(n=31)Femoral nerve catheter(n=57)P valueFemale sex30 (53%)16 (52%)0.93Age (years)15.6 (1.8)15.6 (1.7)0.88Height (cm)167.4 (9.5)164.8 (18.2)0.48Weight (kg)66.5 (11.5)67.2 (20.1)0.87Tourniquet time (minutes)90.3 (22.7)93.7 (15.2)0.43Concomitant meniscus injury20 (65%)31 (54%)0.36Non-contact mechanism of injury20 (65%)38 (57%)0.91Time of follow-up assessment (months post-surgery)6.1 (0.6)6.1 (0.5)0.82Table 2.Functional outcomes at the follow-up assessment. Data are presented as the number in each group / total number of patients who had data for that variable (corresponding percentage), or as mean (sd).VariableFemoral nerve single shot blockFemoral nerve catheterP valueAchieved 80% symmetry on the single-leg squat15/18 (83%)16/27 (59%)0.09Single-leg squat symmetry95.5 (6.7)88.3 (9.3)0.02*Initiated ballistics at follow-up assessment time28/31 (90%)43/56 (77%)0.12Initiated running program at follow-up assessment time17/25 (68%)38/56 (68%)0.99Achieved 80% symmetry on the Y-Balance test10/10 (100%)15/18 (83%)0.17Demonstrated functional symmetry at follow-up assessment7/19 (37%)2/24 (8%)0.02*

Analgesic efficacy of a single-dose, intraoperative, intra-articular morphine application in ACL reconstruction

BackgroundAnterior cruciate ligament (ACL) reconstruction is the mainstay treatment for the symptomatic anterior cruciate ligament insufficiency. Postoperative rehabilitation is the key main factor in successful surgical outcome but, the postoperative pain is a major obstacle to achieve good postoperative rehabilitation. The purpose of this study is to compare the effects of intra-articular morphine (IAMO) with normal saline [control group (C)] for postoperative pain control in the ACL reconstruction knees. MethodsPatients who underwent ACL reconstruction during 2017-2019 were included, prospectively, from Khon Kaen hospital and randomized into 2 groups: IAMO group and the control group (C). After surgery, all patients received the same rehabilitation protocols. The results were assessed using the visual analogue scale (VAS), following the spinal block anesthesia at 6, 12,18 and 24 hours. Time to first analgesic request, range of motion and adverse effects were recorded. ResultsForty patients were included and twenty were designated to the IAMO group. The mean age was 25.3±7.6 years and 80 percent of the patients were males. The IAMO group had lower VAS scores at the 12 and 24 hour postoperative periods [greatest variance at 12 hours (4.7±1.7 vs 5.8±1.6)]. In the IAMO group, time to first analgesic request was longer and morphine consumption was less, but these were not statistically significant. No complications were observed in both groups. ConclusionsThe trend of VAS in the IAMO group was lower than in the control group, especially at 12 hours after surgery with no statistically significant differences. From this study and with the advantages of IAMO after ACL reconstruction, IAMO is useful in ACL reconstruction patients without complications.

Technique of all arthroscopic autologous chondrocyte implantation (ACI) for the treatment of cartilage defects in the knee

All arthroscopic treatment of deep cartilage defects in the knee for reconstruction of the articular surface. Focal cartilage defects of the knee (ICRS ≥ grade3) from asize of 2.5 cm2 and more. Osteoarthritis (Kellgren-Lawrence > grade2), osseus defect situation, cartilage lesion of the opposing articular surfaces (ICRS > grade2), instability, malalignment (>3-4°), inflammatory joint diseases. First procedure (cell harvesting): Treatment of additional pathologies, preparation of the cartilage defect, harvesting of osteochondral cylinders for cell culture. Second procedure (cell implantation): Dry arthroscopy, cleaning and drying of the already prepared defect, implantation of the in situ crosslinking cartilage cell suspension. First procedure (cell harvesting): Early functional treatment with weight bearing as tolerated. Second procedure (cell implantation): No drains, extension brace for 4days, then free range of motion, partial weight bearing for 4weeks in patellofemoral implantation and for 8weeks in tibiofemoral implantation, continuous passive motion beginning in postoperative week2, cycling from postoperative week9. In the literature, results for ACI in the knee are reported to be good, especially for larger cartilage defects. Arthroscopic techniques should lead to adecrease of complications and perioperative morbidity. No technique-specific complications occurred in our cohort. From 2012-2015, 98patients were treated using the above mentioned technique, whereby 62patients were retrospectively evaluated after 31.0 ± 14.8 (12.5-61.4) months. In 15patients (28%) additional procedures were performed (7anterior cruciate ligament reconstructions, 3correction osteotomies and 5medial patellofemoral ligament reconstructions). Average cartilage defect size was 4.7 ± 2.8 cm2, in 18patients (29%) more than one cartilage defect was treated. The subjective IKDC and total KOOS scores resulted in 66 ± 10 and 73 ± 19points.

Computed tomography (CT), X-ray, and MRI evaluation of two anterolateral knee reconstruction techniques: lateral extra-articular tenodesis (LET) and the anterolateral ligament (ALL) reconstruction.

The anterolateral ligament (ALL) and capsule of the knee are anatomical structures involved in rotational stability and pivot-shift control. As such, it has been demonstrated that the extra-articular anterolateral procedures improve clinical outcome when performed as an augmentation of the anterior cruciate ligament (ACL) reconstruction in specific groups of patients. This review describes the postoperative imaging findings of two techniques used to perform these procedures, using magnetic resonance imaging (MRI), computed tomography (CT), and radiography. The first technique described is the lateral extra-articular tenodesis (LET), which uses a strip of the iliotibial band that is harvested, passed underneath the lateral collateral ligament (LCL) and fixed posterior, and proximal to the lateral femoral epicondyle (LFE), preserving ITB insertion on Gerdy's tubercle. The second technique described is the ALL reconstruction, a procedure that attempts to recreate the anatomy of the ALL, using most often a gracilis autograft. In this procedure, femoral fixation is performed proximal and posterior to the LFE, and tibial fixation is slightly distal to the joint line, halfway from Gerdy's tubercle to the fibular head. The main objective of this review is to provide an overview of the postoperative imaging aspects of these two procedures with MRI, CT, and radiography and to describe possible complications. As they become more common, it is important for the radiologist and the orthopedic surgeon to understand their particularities in combination with the already well-known ACL reconstruction.

National trends, 90-day readmission and subsequent knee surgery following multi-ligament knee reconstruction

Introduction/backgroundGiven the uncommon nature of the multi-ligament injured knee, a better understanding of its outcomes may be achieved by contemporary evaluation of a national administrative database. We aim to identify risk factors for 90-day major complications, 90-day readmissions, and subsequent knee surgery after a multi-ligament knee reconstruction. MethodsThe Humana Claims Database was queried for all patients undergoing a multi-ligament knee reconstruction procedure from 2007 to 2016 using International Classification of Diseases (ICD)-9 procedure codes and Current Procedural Terminology (CPT) codes. Outcomes of interest included Center of Medicaid and Medicare Services (CMS)- reportable 90-day complications, 90-day readmission and subsequent ligament reconstruction or total knee arthroplasty. Predictive factors studied included demographics (ie. age, sex, tobacco use) comorbidity burden and operative factors (ie. surgical setting, diagnosis of knee dislocation, concomitant meniscal repair or meniscectomy). Results588 multi-ligament knee reconstruction procedures were identified. The 90-day readmission rate 8.3%. The rate of subsequent ligament surgery was 7.1%. On multivariate regression analysis, a diagnosis of knee dislocation was associated with a four times greater likelihood of readmission and a two and a half greater likelihood of subsequent ligament surgery. Concomitant meniscectomy was associated with higher likelihood of subsequent total knee arthroplasty (9.1, 1.4–67.0) and outpatient setting of surgery compared to inpatient hospital setting was associated with reduced likelihood of readmission. ConclusionWhile uncommon, the patient population undergoing multi-ligament knee surgery is relatively diverse. Understanding common factors predisposing this population to adverse events following surgery may assist in improved outcomes.

CT scan of the placement of the femoral tunnel in combined anterior cruciate ligament and anterior lateral ligament reconstruction by a single femoral tunnel using the outside-in technique

Background:The main difficulty with this ALL reconstruction method is the placement of the femoral tunnel as isometrically as possible. The femoral insertion of the ALL is usually located one centimeter posteriorly and proximal to the lateral epicondyle, at the level of the Lemaire vessels. The purpose of our study was to evaluate the placement of the femoral tunnel in ligament reconstruction by combined ACL and ALL reconstruction with a single femoral tunnel using the outside-in technique. Our hypothesis was that a single femoral tunnel by outside-in technique would allow satisfactory placement of the femoral insertion of the ALL..Methods:We conducted a retrospective bi-centric study of all patients who underwent combined ACL and ALL reconstruction surgery with a common outside-in femoral technique. A postoperative low-dose knee CT scan with multiplane reconstructions was performed after patient consent. After locating the top of the epicondyle on three-dimensional CT scan reconstructions, the distances between the top of the lateral epicondyle and the center of the femoral tunnel in the frontal and sagittal planes were measured. These measurements were taken by a surgeon and a radiologist.Results:45 patients were included and the average age was 29 years (17-39). 30 patients had a CT scan. Analysis of the placement of the femoral tunnel showed that 10 tunnels were placed posteriorly and proximal to the top of the lateral epicondyle.Conclusion:This study did not confirm our hypothesis. Combined ACL and ALL reconstruction by a single tunnel did not provide access to the isometric point of the femoral insertion of the ALL in a reproducible manner, despite open intra-operative identification of this point. This study highlights the difficulty of locating the femoral isometric point with a standard outside-in femoral guide. Developing a specific femoral guide might be useful.

A biomechanical study after combined reconstruction of the anterior cruciate and anterolateral ligaments: Comparison between anatomic anterolateral ligament reconstruction and lateral tenodesis using the modified Lemaire technique

Objectives:To determine the stabilizing role of the anterolateral ligament reconstruction (ALLR) and the modified Lemaire lateral extraarticular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine if one of these two procedures was superior to the other.Methods:Six non paired cadaveric knees were tested with a 6 degrees of freedom robotic system (KUKA Robotics). Internal rotation and anterior tibial translation were measured between 0 and 90° knee flexion after applying 5 N-m Torque and a 134-N anterior load, respectively. A full kinematics assessment was performed in each following conditions: intact knee, after section of the anterior cruciate ligament (ACL), after section of the ACL and anterolateral ligament (ALL) and Kaplan fibers, after isolated ACLR, after combined ACLR+LET and ACLR+ALLR. ALLR was performed using Gracilis tendon while central strip of the ilio-tibial band was used for the modified Lemaire procedure.These different states were compared using a Tukey paired comparison test.Results:In combined ACL and anterolateral deficient knee, anterior translation and internal rotation remained significantly increased after isolated ACLR compared to intact knee (+2.33 ± 1.44 mm and +1.98 ± 1.06°; p > 0.01). On the other hand, the addition of an ALLR or a modified Lemaire LET to the ACLR allowed to restore anterior translation and internal rotation to values similar to the intact knee. Finally, the two anterolateral procedures had not significantly different values in both tests. This difference was 0.67 ± 1.46 mm for anterior translation (p=0.79) and 0.11 ± 1.11° for internal rotation (p=0.99).Conclusion:In ACL and anterolateral deficient knee, combined ACLR and anterolateral reconstruction allowed restoration of native stability of the knee in anterior translation and internal rotation contrary to isolated ACLR.Additionally, both types of extra-articular reconstruction, ALLR or modified Lemaire procedure, were similar in terms of restoring knee kinematics and neither overconstrained the knee.

MULTI-LIGAMENT KNEE RECONSTRUCTION AND NOVEL MENISCUS RADIAL REPAIR TECHNIQUE, WITH RETURN TO OLYMPIC LEVEL SKIING: A CASE REPORT

Multi-ligament knee injuries (MLKI) can be debilitating and often career ending injuries for athletes. Current literature reports on outcomes following these injuries for return to activities of daily life; however, there is a paucity of evidence evaluating the return to sport following a MLKI. The purpose of this case report is to describe the treatment and outcome following a MLKI and novel meniscus radial repair technique in which the athlete returned to compete in the 2018 Winter Olympic Games 14 months postoperatively. Case Report. A healthy 28-year-old female Olympic alpine skier who sustained a deep knee flexion with varus force injury to her right knee during a competitive skiing event. Examination and imaging revealed a completely torn anterior cruciate ligament (ACL) and lateral collateral ligament (LCL), complex radial tear of the lateral meniscus, medial meniscus tear, popliteofibular ligament tear, proximal tibiofibular joint ligament tear, and a common peroneal nerve neuropraxia. The athlete underwent an anatomic single-stage, multi-ligament knee reconstruction surgery which consisted of a novel meniscus radial repair technique. A return to snow progression was initiated at seven months postoperatively. At 10 months postoperatively, a physical exam revealed trace effusion, no joint line tenderness, and negative stability tests. A repeat MRI revealed adequate healing of the lateral meniscus radial repair. The athlete passed a functional sports test at 10-months postoperatively and was cleared to return to ski with no restrictions. At 12 months postoperatively, the athlete placed in an Olympic qualifying ski race. At 14 months postoperatively, the athlete competed in the 2018 Olympic Winter Games. This case report highlights the ability of an athlete to return to elite level of competition following an anatomic single-stage, multi-ligament knee reconstruction with a novel meniscus radial repair in a safe but timely manner. 4.