Preinjury Activity Level Research Articles

Usefulness of Suture-Tape Augmentation Based on Intraoperative Ankle Stress Radiographs During Anatomical Ligament Repair for Chronic Lateral Ankle Instability.

During the modified Broström procedure for chronic ankle instability, surgeons often experience cases with insufficiently restored mechanical stability even after anatomical ligament repair. In these cases, longer postoperative immobilization and delayed rehabilitation can be required, and a risk for recurrence of instability may persist. This study aimed to evaluate the clinical usefulness of suture-tape augmentation based on intraoperative stress radiographs during anatomical ligament repair for chronic ankle instability. Twenty-four patients who underwent additional suture-tape reinforcement because of residual mechanical instability on intraoperative stress radiographs were followed up ≥3 years. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Changes in mechanical stability were analyzed through periodic stress radiographs, and postural control ability was evaluated with the modified Romberg test. FAOS and FAAM scores improved significantly from preoperative mean 55.1 and 52.4 points to 92.3 and 90.2 points at final follow-up, respectively (P < .001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 15.8 degrees and 13.6 mm to 2.9 degrees and 4.2 mm, respectively (P < .001). Balance retention time improved significantly from preoperative mean 3.6 to 6.4 seconds (P < .001). Although 9 patients experienced sprain injury after surgery, no patient showed recurrence of mechanical and subjective instability, and 21 patients (87.5%) were able to return to preinjury level of sports activity. Evaluation of residual mechanical instability through intraoperative stress view and additional suture-tape augmentation showed satisfactory clinical outcomes at midterm follow-up. Suture-tape augmentation based on intraoperative stress radiographs seems to be a useful surgical option for patients with insufficiently restored mechanical stability even after anatomical ligament repair. This combined procedure can provide a reliable mechanical stability that can be performed after recognition of residual instability during the index surgery.

Anterior Cruciate Ligament Allograft Reconstruction in Females Can Produce Outcomes Comparable to Those of Autografts in Male Counterparts.

There are unique anatomic and geometric risk factors that contribute to higher injury rates of the anterior cruciate ligament (ACL) in women. Allografts are an important alternative option for female patients. Patients who underwent primary ACL reconstruction were retrospectively evaluated. The case group comprised female patients with ACL allograft reconstruction, and the control group comprised male patients with ACL reconstruction. Functional and clinical evaluations were based on the pre- and postoperative Cybex test, Lysholm score, International Knee Documentation Committee subjective and objective measurement criteria, and Tegner Activity Scale questionnaires. Radiological comparisons were performed using the femorotibial angle (FTA), posterior tibial slope (PTS), and intercondylar notch width (INW). The roof inclination angle (RIA) was assessed using magnetic resonance imaging. The two groups [female (44) and male (88)] had an average follow-up period of 57.9±19.3 months and average ages of 36.5±10.9 and 35.2±11.7 years, respectively. Functional and clinical outcomes showed no differences between the groups, except that the return to the pre-injury activity level was higher in the female group (95% vs. 77%, P<0.001). The female group showed larger FTA and PTS and smaller INW and RIA than those of the male group (P<0.001, 0.008, <0.001 and 0.035, respectively). Female ACL allograft reconstruction showed comparable outcomes to those of their male counterparts, and the return to pre-injury activity levels was significantly higher in women. However, women showed lower activity levels and were more vulnerable to geometric risk factors than their male counterparts.

Arthroscopic Fixation of Posterior Cruciate Ligament Tibial Bony Avulsion Fractures: The Double Suture Bridge Technique and Evaluation of Results

Background: Surgical fixation is required for displaced posterior cruciate ligament (PCL) tibial bony avulsion fractures or with fractures having grade 2 or more posterior instability. The purpose of this study is to evaluate the results of arthroscopic fixation of PCL tibial bony avulsion fractures using the double suture bridge technique. Methods: A retrospective study was done involving 24 patients having displaced PCL tibial bony avulsion fractures. The arthroscopic double suture bridge technique was used to fix these fractures. Patients were followed up for three years and assessed for knee-related symptoms, signs, Lysholm Knee Score, and satisfaction. Results: The study group consisted of 21 men and three women. Fracture union was achieved in all cases two months postoperatively. The mean Lysholm Knee Score at follow-ups of three months, six months, one year, two years, and three years was 86.6, 96.5, 98.8, 99.1, and 99.4, respectively. At the latest follow-up, all the patients were satisfied with their knee function with respect to pain, range of motion (ROM), stability, and resumption of pre-injury activity level. Conclusion: The arthroscopic double suture bridge technique is an effective method for the fixation of PCL tibial bony avulsion fractures with respect to knee stability, ROM, and resumption of pre-injury activity level.

Anterior Opening-Wedge Proximal Tibial Osteotomy for Symptomatic Genu Recurvatum and Osteochondral Autograft Transfer for Osteochondral Defect

Acute knee hyperextension injuries are more frequently sustained during athletic trauma and can cause symptomatic pain, soft-tissue laxity of the knee, malalignment, and ligament strain. Decreased posterior tibial slope is correlated with a higher degree of knee hyperextension, and although not the only cause, it can contribute to symptomatic genu recurvatum. In the context of acute knee hyperextension, chondral lesions may occur secondarily but are more often caused by limb malalignment and overuse. In the setting of symptomatic genu recurvatum and an osteochondral defect, it is vital to restore the native joint biomechanics. We describe the use of anterior opening-wedge proximal tibial osteotomy to correct symptomatic genu recurvatum and osteochondral autograft transfer to repair a full-thickness chondral defect. Past studies have shown long-term successful functional outcomes for both anterior opening-wedge proximal tibial osteotomy and osteochondral autograft transfer procedures, with most patients returning to their preinjury activity levels.

Intra-articular anterior inferior iliac spine avulsion with hip instability: A retrospective study

BackgroundIntraarticular anteroinferior iliac spine (AIIS) avulsion fractures combined with hip dislocation are infrequently reported in medical literature. This study aims to present the outcomes of surgical treatment for this rare type of injury. MethodsWe retrospectively analyzed six cases of AIIS avulsion fracture with hip dislocation treated surgically. All patients underwent emergency hip reduction under sedation followed by open reduction and internal fixation using 4 mm cannulated screws through the iliofemoral approach. ResultsAfter an average follow-up period of 50 months, all fractures healed. Clinically, four patients were rated as having an excellent outcome and two as good, according to the Harris Hip Score. Radiological assessment using Matta's grading system showed excellent results in five patients and good in one. All patients were able to resume their pre-injury activity levels within six months post-surgery. ConclusionSurgical fixation of AIIS avulsion fractures with associated hip instability demonstrates favourable outcomes, ranging from good to excellent, in both clinical and radiological assessments at medium-term follow-up. This suggests that surgical intervention is a viable option for managing such injuries.

Anatomic physeal-sparing MPFL reconstruction in skeletally immature patients shows favourable outcomes at a minimum of 24-month follow-up.

Recurrent patellar dislocation is a prevalent orthopaedic issue among active paediatric and adolescent populations. Bony surgical procedures are not recommended in growing patients; therefore, the focus of surgery is on restoring the medial patellar ligaments, with different reconstructive techniques available. This retrospective case series focuses on the 2-year outcomes of medial patellofemoral ligament (MPFL) reconstruction in skeletally immature patients with open physis. Twenty-four consecutive patients with patellofemoral instability and open growth plates underwent anatomic MPFL reconstruction with a physeal-sparing technique. All subjects have had more than three episodes of true patellar dislocations. Preoperative radiographic examination included anteroposterior and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle-trochlear groove (TT-TG) distance. The patients were questioned regarding complications and clinical outcomes using the visual analogue scale (VAS), Kujala and Paediatric International Knee Documentation Committee (Pedi-IKDC) score. Variables were evaluated using paired t test with significance at p < 0.05. The mean age at the time of operation was 13.04 years (9-16 years). The cohort was followed for a mean duration of 38.66 months (24-86 months). The mean time from injury to surgery was 50.45 days (16-80 days). No growth arrest, limb-length discrepancies or angular deformities were observed post-operatively during the whole follow-up period. No patellar re-dislocations were recorded throughout the study period. The VAS score improved significantly from 5.67 (4-8) to 1.88 (0-4) (p < 0.01). The Kujala score improved significantly from 64.67 (44-81) preoperatively to 87.58 (77-100) post-operatively (p < 0.01). The Pedi-IKDC also increased significantly from 58.81 (34.80-77.70) preoperatively to 90.64 (70.70-100) post-operatively (p < 0.01). The vast majority of patients (87.5%) returned to their pre-injury activity level. Boys scored better than girls in VAS, Pedi-IKDC and Kujala score post-operatively, but these differences were not statistically significant. Physeal-sparing MPFL reconstruction in children and adolescents yields excellent midterm results and allows patients to return to sports without redislocation of the patella. Boys scored better than girls in VAS, Pedi-IKDC and Kujala score post-operatively, but these differences were not statistically significant. IV: case series with no comparative group.

Predictive factors to return to sport after surgical management of ankle fractures

Achieving Return to Sport (RTS) is crucial in managing ankle fractures for athletes. This study aimed to identify RTS factors post-surgical fixation of ankle fractures. A retrospective analysis was conducted on 93 active patients with surgically treated displaced or unstable ankle fractures from January 2020 to January 2021. The median follow-up was 2.12 years. Clinical, functional, and radiographic aspects were evaluated. Among the athletes, 82.8% resumed sports post-surgery, with 26.9% returning within 3 months and 75.3% at 1 year. At 1 year, 40.9% regained their pre-injury activity level. There was a significant association between RTS and AO/OTA fracture subtype (p = 0.038). Unimalleolar fractures had the best outcomes, with 100% achieving RTS in a median of 4 months. Bimalleolar fractures had 80.77% RTS in 6 months, and trimalleolar fractures had 65.22% RTS in 8 months. AO/OTA subtypes B and C predicted lower RTS to pre-injury levels, with delayed recovery for bimalleolar and trimalleolar fractures. These findings underscore the impact of fracture severity on RTS, with more complex fractures leading to poorer and delayed recovery outcomes.Level of evidence: III

Atypical Multi-ligamentous Knee Injury (MLKI): Binary Injury with Avulsion of One Cruciate and Tear of the Other, or Bi-cruciates Avulsion with or Without Collateral Ligament Injury Following Road Traffic Accidents (RTA).

Multi-ligamentous knee injuries (MLKI) fall within a narrow spectrum, accounting for around 11% of all knee injuries. Atypical MLKI involve binary injury: avulsion of one cruciate and tear of the other, or both cruciates avulsion with or without collateral ligament injury. The purpose of this study is to analyse the clinical and radiological outcomes of patients diagnosed with atypical MLKI, and to assess the differences in outcomes between patients with collateral injury and those without. 66 patients with atypical MLKI were studied and compared in this retrospective cohort. 32 of these patients did not have collateral injuries, while the remaining 34 patients did have collateral injuries. The duration of the study was from 2010 to 2022. Reconstruction forthe cruciate tearsand open or arthroscopic reduction and fixation (ORIF/ARIF) of the cruciate avulsion were performed. In earlier years (2010-2015), posterior cruciate ligament avulsions were open reduced andfixed using the double draping approach. However, in later years (2016-2022), the double draping method was replaced by the single draping technique. Conservative or surgical management of the collateral ligaments was determined based on factors such as intraoperative laxity, tissue quality, injury site, and chronicity.Group 1 comprised of atypical MLKI patients without collateral ligament injuries, while Group 2 included atypical MLKI patients with collateral ligament injuries and subgroup was based on the various combinations of cruciate avulsions, tears and collateral injuries.A comparative statistical analysis was conducted on the International Knee Documentation Committee (IKDC) score, Lysholm score, knee flexion range of motion (ROM), and laxity on stress radiographs. The male:female ratio were 54:12 patients. The average follow-up was 26.48months (range 23-30months). The average age of the patients is 37.66 (range 20-50years). All patients had significant improvement from pre-operative scores to final follow-up scores (P < 0.001). There was no significant difference between the atypical MLKI with collateral and atypical MLKI without collateral injury in terms of the postoperative IKDC score (P = 0.154), Lysholm score (P = 0.387), knee flexion ROM (P = 0.314), and laxity on radiographs with anterior stress (P = 0.108) and posterior stress (P = 0.272). The intergroup analysis was not statistically significant. There was no significant difference in patients' functional outcomes at final follow-up based on fixation modality. Patients recovered to their pre-injury activity levels without knee joint giving way on daily activities. None of the patients in our series had infections. The incidence of atypical MLKI in multi-ligamentous injury was 9.53% (66/692). Atypical MLKI with cruciate avulsion can be treated with ARIF and cruciate tears with reconstruction in single-stage single draping method with good clinical and radiographic results. Atypical MLKI with or without collateral ligament injury had similar outcomes when appropriate techniques are instituted to address collateral ligaments.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years.

The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. Level II, prospective comparative cohort study, before and after intervention.

Distal Triceps Tendon Repair in Strength Athletes Leads to Satisfactory Return to Sports: A Retrospective Analysis of 22 Cases.

Background: Distal triceps brachii tendon rupture (DTTR) is a relatively rare injury that is common in bodybuilding and high-intensity contact sports and can lead to significant functional impairment of the elbow joint. This study was conducted to evaluate clinical outcomes and the rate of return to sports among competitive bodybuilders and high-demand strength athletes after surgical repair of DTTR. Methods: This retrospective case series was performed in an institutional setting in tertiary health care. Return to sports of 22 competing or high-demand strength athletes (meaning three or more exercises per week) were analyzed pre- and postoperatively after surgical repair of DTTR using a hybrid technique of transosseous sutures and anchor fixation. Descriptive statistics were used to analyze demographic variables, and independent and paired t-tests were used to assess clinical outcomes. Results: The follow-up showed that from pre- to postoperatively, there was no deterioration in the number of sports disciplines (2.4 and 2.5 sporting activities per person, respectively; p = 0.540) or in the frequency of weekly training (4.1 and 4.1 times per person, respectively; p = 0.329). The postoperative visual analog scale for pain (from 6.0 to 1.6, p < 0.001), level of fitness (from 5.1 to 2.6, p = 0.002), and ability to train (from 5.2 to 1.3, p < 0.001) improved significantly. The time of return to sports was 1.5-3 months and 4-6 months after the surgery for ten patients each. The overall rate of return to sports was 95%, whereas 86% returned to the preinjury level of sporting activity. Conclusions: Repair of DTTR leads to high rates of return to sports in competitive athletes.

Assessment of Function in Patients after Calcaneal Fracture Treatment with the Ilizarov Method.

Background: Up to 75% of calcaneal fractures are intra-articular fractures, which may severely impair foot function and lead to disability. Methods: We retrospectively analyzed 21 patients with intra-articular calcaneal fractures who had been treated with the Ilizarov method in the period 2021-2022. The mean patient age was 47 years (range 25-67 years). We analyzed the following functional parameters: foot function with a revised foot function index (FFI-R) questionnaire and the level of physical activity, with the University of California Los Angeles (UCLA) activity scale, a visual analog scale (VAS), and a Grimby physical activity level scale; and ankle range of motion. Results: We observed a significant improvement in the UCLA activity scores and Grimby activity score at long-term follow-up. Functional outcomes based on the FFI-R questionnaires showed an improvement, from 292 points prior to surgery to 127 points at follow-up, p = 0.013. The post-treatment follow-up measurements revealed a median dorsiflexion at the treated ankle joint of 20 degrees, whereas that at the intact ankle was 40 degrees, p = 0.007. The plantar flexion showed asymmetry, with a median 15 degrees at the treated ankle and 30 degrees at the intact ankle, p = 0.007. The median range of inversion at the ankle joint was 5 degrees in the treated limb and 15 degrees in the intact limb, p = 0.039. Conclusions: Patients with calcaneal fractures treated with the Ilizarov method are recommended to have a longer and more intensive rehabilitation. The range of ankle motion in the treated limb was limited in comparison with that in the intact limb; however, this did not greatly affect the patients' return to their earlier, pre-injury level of physical activity.

Returning to pre-injury level of sports before 9 months after medial patellofemoral ligament reconstruction increases the incidence of anterior knee pain in young patients.

This study aimed to identify the risk factors for anterior knee pain (AKP) after medial patellofemoral ligament reconstruction (MPFLR). Patients aged 15-35 years who underwent isolated MPFLR between 2012 and 2022 were included in the study. These patients were divided into two groups (AKP and control group). Patient demographics and preoperativeand postoperative clinical outcomes between the two groups were assessed and compared. Univariate logistic regression analysis was performed to explore the potential risk factors associated with postoperative AKP. Subgroup analysis stratified the results based on the time to return to sports (RTS) (>9 and ≤9 months). Furthermore, Spearman correlation analysis was performed to investigate the association between Kujala score and time to RTS. A total of 206 patients were included (AKP, n = 59; control, n = 147). At the 2-year follow-up, patients with AKP demonstrated a shorter duration in returning to their pre-injury activity level compared to those without AKP (9.0 ± 3.6 vs. 10.3 ± 2.7 months, p < 0.05). RTS earlier than 9 months after MPFLR was the only significant risk factor associated with postoperative AKP (odds ratio, 2.13, 95% confidence interval, 1.03-4.39; p < 0.05). Further subgroup analysis revealed that patientRTS earlier than 9 months exhibited worse patient-reported outcomes in both the total cohort and control group (p < 0.05). Furthermore, among patientRTS within 9 months, a longer recovery duration before RTS strongly correlated with a higher Kujala score (R = 0.670, p < 0.001). Young patients who RTS at their pre-injury levels before 9 months after MPFLR have a higher incidence of postoperative AKP and poorer functional outcomes compared to those who delay their return. Specifically, within the first 9 months after MPFLR, the earlier the RTS, the more severe the AKP symptoms. Careful consideration of the timing for RTS may help reduce the incidence of postoperative AKP. Level III.

Single-plug osteochondral autograft transplantation for knee osteochondritis dissecans: Clinical improvement and long-term survivorship at a minimum ten year follow-up.

Osteochondritis dissecans (OCD) can lead to detrimental effects in the affected joints. Osteochondral autologous transplantation (OAT) allows to restore the articular surface with an autologous osteochondral unit. While short-term results are documented, there is a lack of long-term data. Aim of this study was to analyze the long-term clinical results of single-plug OAT for the treatment of knee OCD. Twenty patients (14 men, 6 women) were treated with single plug-OAT. Mean age was 23.6 ± 9.9 years and BMI was 23.3 ± 3.6kg/m2. Lesion size was 2.3 ± 1.6 cm2 and defects included 14 medial femoral condyles (MFC) and 6 lateral femoral condyles (LFC). Patients were followed up prospectively at baseline, 24 months, 60 months, and at minimum ten years (12.6 ± 2.0 years) using the IKDC subjective score and through an overall judgment on treatment satisfaction. The activity level was evaluated with the Tegner score and adverse events and failures were also recorded. Factors influencing the clinical outcomes, including age, sex, BMI, lesions size, and lesion location were also investigated. No severe adverse events and no surgical failures were reported and 85.0% of patients were satisfied at a minimum ten year follow-up. Subjective IKDC showed a significant and stable improvement at all follow-ups, passing from 45.3 ± 16.5 at baseline to 73.7 ± 16.6 at 24 months (p < 0.0005), to 72.9 ± 16.6 at 60 months (p < 0.0005), and to 74.1 ± 20.8 at long-term follow-up (p < 0.0005). Patients with OCD lesions localized on the LFC obtained lower results compared to those with MFC lesions at two years and five years (p = 0.034 and p = 0.023). The highest long-term scores were obtained in patients with lesion size lower than 2 cm2 (89.1 ± 8.8) compared to patients with lesion size between 2 and 4 cm2 (69.2 ± 15.7), and patients with lesion size larger than 4 cm2 (63.8 ± 34.6). OAT is a suitable technique to treat knee OCD in young patients and offers a high patient satisfaction and a significant improvement in terms of clinical subjective scores, with results remaining stable over time, although without reaching the pre-injury activity level. No severe adverse events and no surgical failures have been documented confirming OAT as a valid treatment option, although the best long-term results for lesions smaller than 2 cm2 and for MFC lesions should be considered when choosing this procedure to address knee OCD lesions.

Navigating Post-operative Challenges: A Comprehensive Review of Complications Following Anterior Cruciate Ligament (ACL) Tear Surgery.

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating sports-related injuries, often necessitating surgical intervention to restore knee stability and function. ACL reconstruction surgery, which has evolved significantly over the years, aims to enable patients, particularly those who are young and physically active, to return to their pre-injury activity levels. However, despite advancements in surgical techniques and rehabilitation protocols, post-operative complications remain a significant concern that can adversely affect patient outcomes. This comprehensive review explores the spectrum of complications that can arise following ACL tear surgery, ranging from common issues such as infection, graft failure, and knee stiffness to less frequent but clinically significant complications like osteoarthritis and neurological injuries. The review also delves into the various factors influencing the likelihood of these complications, including patient-related variables, surgical techniques, and the effectiveness of rehabilitation protocols. By providing an in-depth analysis of these post-operative challenges, this review aims to enhance the understanding of ACL reconstruction outcomes and guide healthcare professionals in implementing preventive strategies and optimizing patient care. Through a multidisciplinary approach, the goal is to minimize the risk of complications, improve surgical outcomes, and ultimately enhance the quality of life for patients undergoing ACL reconstruction.

No Clinical Advantage of Harvesting a Patellar Bone Block Compared With All Soft-Tissue Graft in Primary Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

PurposeTo compare patient-reported outcomes measurements (PROMs) and subsequent surgical interventions in patients treated with anterior cruciate ligament reconstruction (ACLR) using either quadriceps tendon autograft with a patellar bone block (bQT) or soft tissue only (sQT). MethodsAll ACLRs performed between 01.2010 and 03.2022 were prospectively followed for 24 months and retrospectively evaluated. All primary ACLRs with full 24 months of follow-up data, without any previous surgery or any additional ligamentous interventions, were matched for major ACL risk factors, including gender, age, Tegner activity level (TAL), pivoting sports, and concomitant injuries. PROMs (Lysholm score, Visual Analog Scale (VAS) for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperative. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, gender, pivoting sports and concomitant interventions on the need to undergo subsequent surgery. ResultsAfter matching, 246 patients were included in the final analysis. Both groups did not differ regarding any preoperative patient demographics or intraoperative details. At final follow-up, no significant difference in mean Lysholm score (sQT: 90.8±10.6, bQT: 91.8±10.6, p= .46), median TAL (sQT: 6 [1-10], bQT: 6 [1-10], p= .53) and VAS for pain (sQT: 0.7±1.1, bQT: 0.7±1.2, p= .70) was reported between both groups. 70.3% (sQT-A: 70.7%, bQT: 69.9%, p= .89) of patients returned to or exceeded their preinjury activity level. In terms of revision ACLR, there was no statistically significant difference between bQT (3.3%) and sQT (4.1%). Similarly, no difference was observed in contralateral ACLR (bQT: 7.3% sQT: 11.4%). Regression analysis indicated that none of the studied factors, including the use of a patellar bone block, influenced subsequent surgery, revision ACLR, or contralateral ACLR. ConclusionHarvesting an additional patellar bone block in quadriceps tendon ACL reconstruction does not seem to impact postoperative patient-reported outcomes, ACL revision- or contralateral ACL reconstruction rates. Level of EvidenceLevel 3 – Cohort Study

The option of transosseous distal suture placement during minimally invasive Achilles tendon repair for high-risk patients can improve outcomes, however does not prevent re-rupture

PurposeAchilles tendon ruptures (ATRs) close to the insertion, in high-level athletes, and in patients at high risk of re-rupture, may be better suited to operative repair. Minimally Invasive Repair (MIR) of the Achilles tendon has excellent outcome and low complication rates. Traditionally MIR has showed lower repair strength, failing due to suture pull-out from the distal tendon stump. The aim of this study was to describe the outcome of ATR patients who received transosseous distal suture placement using a standard technique as a reference.MethodsFollowing ATR, patients were evaluated for pre-injury activity level, body weight, location of the tear and size of the distal Achilles tendon stump. Patients considered to be at high-risk of re-rupture: Tegner level ≥ 8, body weight ≥ 105Kg and distal ATR, received transosseous (TO) distal suture placement (n = 20) rather than the usual transtendinous (TT) technique (n = 55). Patient reported outcome measures and functional evaluation was performed at 12 months following repair.ResultsAt 12 months follow up both methods resulted in good median (IQR) Achilles tendon Total Rupture Score TO 83.8 (74-88.3) vs. TT 90 (79–94), low increased relative Achilles Tendon Resting Angle TO -3.5˚ (3.6) vs. TT -3.5˚ (3.3) and mean (SD) Single leg Heel-Rise Height Index TO 88.2% (9.9) vs. TT 85.6% (9.9) (n.s.). There were 4 re-ruptures in the high-risk group and 2 in the group receiving TT distal suture placement. All but one of these were traumatic in nature. The mode of failure following TO distal suture placement was proximal suture pull out.ConclusionsTo distal suture placement during minimally-invasive Achilles tendon repair for higher-risk patients can lead to results equivalent to those in lower-risk patients treated with a standard TT MIR technique, except for the re-rupture rate which remained higher. There may be factors that have greater influence on outcome other than suture placement following ATR.

Which patients need anterior cruciate ligament reconstruction after initial treatment with rehabilitation? A scoping review.

Some patients with anterior cruciate ligament (ACL) injury initially treated with rehabilitation need ACL reconstruction (ACLR); yet, it is unclear what characterizes these patients. This review aimed to describe predictors for ACLR in patients initially treated with rehabilitation. A systematic literature search was performed in the Cochrane, Embase, Medline, SportsDiscus and Web of Science databases from inception to 21 February 2023. Articles describing characteristics in adult patients with ACL injury undergoing ACLR after a minimum of 5 weeks rehabilitation were included. It was a priori chosen that characteristics described in at least three articles were considered more certain and could be defined as a predictor for ACLR, and those described in less than three articles were considered less certain and therefore defined as possible predictors. Articles were screened by two independent reviewers. The study was originally intended as a systematic review with meta-analysis, but in case of limited data, we would convert it to a scoping review, as was the case for this review. There were 22,836 studies identified, and 181 full texts were screened, of which 10 papers were finally included. Only lower age and higher preinjury activity level were identified as predictors for ACLR. Another 12 possible predictors were identified in single studies. Through an iterative process, potential predictors were categorized into four groups: patient demographics, knee function, patient-reported outcome measures and anatomical structures. Lower age and higher preinjury activity level were the only predictors for ACLR after initial treatment with rehabilitation. While younger and highly active patients show a higher need for ACLR, more studies focussing on predictors and reasons for delayed ACLR are warranted. Level II.

Enhanced Surgical Techniques in Orthopedics: A Comprehensive Guide for Surgeons Based on Modification of the McFarland and Osborne Approach to the Hip.

The implementation of various approaches in hip arthroplasties introduces distinct advantages and complications. Notably, widely adopted methods such as the posterior approach have been linked to elevated rates of posterior hip dislocations and iatrogenic sciatic nerve injuries, while the lateral approach has been associated with superior gluteal nerve injuries. In this study, we propose a refined modification of the McFarland and Osborne approach, aiming to amalgamate the most favorable aspects of prior modifications of the lateral approach to the hip. Additionally, our contribution extends to providing a comprehensive stepwise guide for the exposure and closure processes in cases of bipolar hemiarthroplasty or total hip replacement. This modification not only offers potential advantages to seasoned orthopedic surgeons but also serves as a valuable resource for young Turks venturing into hip surgeries. 14 patients with femoral neck fractures underwent surgery using the modified McFarland and Osborne approach and were followed up for a period of six months. The functional outcome was analyzed by the Modified Mobility and Aids Scoring Matrix. Seven of the 14 patients attained pre-injury status with respect to the Mobility and Aids scoring matrix. six patients had a fall of 1, and one patient had a fall of 2, as compared to pre-injury status. Our research suggests that this method serves as a superior alternative to conventional approaches, demonstrating notable advantages in terms of dissection difficulty, reduced risk to neurovascular structures, and minimized post-operative hip dislocations. Additionally, it exhibits a favorable outcome, enabling a return to pre-injury levels of activity.

Fixation Vs Arthroplasty for Management of Geriatric Distal Femur Fractures

Abstract Background Distal femur fractures are considered challenging to manage, particularly in geriatric patients. Double plating (DP) is a technique that helps with earlier rehabilitation and return to pre-injury level of activity. Distal femoral replacement (DFR) is an alternative technique in the management of these fractures that may help to solve problems like associated knee osteoarthritis, osteoporosis, and severely comminuted condyles. The current study compares the functional and radiological outcomes of DFR and DP in the management of these fracture among geriatric patients. Methods This randomized, comparative, interventional study was performed at a university hospital. A total of 30 patients who underwent DFR or DP after distal femur fractures (AO/OTA 33 A3, 33 C) were analyzed. The primary outcome was Knee Society Score (KSS), whereas secondary outcomes included postoperative complications rate, knee range of motion (ROM), reoperation rate, and operative time. Results No significant difference was observed between DFR and DP except for the knee component of the KSS at 12-month interval (p = 0.03), and knee ROM at 12-month interval (p = 0.001), both of which were in favor of DP. No significant difference in postoperative complications (p = 0.06), reoperation rate (p = 1.00), or operative time (p = 0.06) were noted. Conclusion DFR and DP had comparable functional (KSS) and radiological outcomes with no significant difference in postoperative complications, reoperation rate, or operative time.

Paper 31: Patient Reported and Clinical Outcomes of High Tibial Osteotomy and Distal Femoral Osteotomy in High Level Athletes

Objectives: High Tibial Osteotomy (HTO) and Distal Femoral Osteotomy (DFO) have long been utilized in the treatment of symptomatic osteoarthritis as well as malalignment with instability, meniscal deficiency or chondral defects. There remains a paucity of literature on the clinical and patient reported outcomes following HTO and DFO procedures in high level athletes. The purpose of this study is to present the outcomes in high-level athletes following HTO and DFO surgery at a large academic institution. Methods: High-level athletic patients (defined as Tegner score over 5) undergoing HTO/DFO from January 2010 to August 2023 were eligible for inclusion. Patients were excluded if they were less than 18 years old, had a Tegner score below 5 prior to symptom onset or had less than 2 years of follow-up. Demographic data including sex, age at time of surgery, and body mass index (BMI) at time of surgery was obtained from the EMR. Outcomes were assessed using follow-up questionnaires that consisted of symptom resolution, patient satisfaction, Tegner Activity Scale, IKDC, KOOS, Lysholm, and return to sports. Patients with concomitant meniscus allograft transplantation, osteochondral allograft transplantation and anterior cruciate ligament reconstruction were included. Results: There were 52 patients that met inclusion criteria, with 39 (75.0%) of patients undergoing HTO and 13 (25.0%) patients undergoing DFO. The mean age at the time of surgery was 39.5 ± 11.1 years, mean follow-up was 5.6 ± 3.1 years (2.0-12.2 years). The cohort was 71.2% male with average BMI of 26.8 ±4.1 Complete symptomatic resolution was reported by 46.2% of patients. When asked about their overall physical ability after surgery, 41.2% patients said they were “much better”, with 27.5% patients saying they were “better”. The mean VAS satisfaction score at final follow-up was 73.7 and 64.7% patients would choose to undergo the operation again if given the option. There was a significant decrease in the value of VAS pain score from the patient’s pre-operative level after knee injury versus their current pain level (73.6 vs. 29.5, p&lt;0.0001). Furthermore, 3/51 (5.9%) patients eventually underwent total knee arthroplasty with an average time of 2.9 ± 0.2 years form HTO/DFO procedure. The mean Tegner score before injury was 6.4, before surgery was 2.7 and a significant increase to 4.3 (p&lt;0.0001) after the procedure at follow up. Following surgery 82.7% of patients met the threshold for patient acceptable symptom state (PASS) for IKDC. 44 percent returned to sports after surgery and only 12 (25.0%) were able to return to sport to the same level from before their injury. The average time to return to sport was 47.3 ±27.0 weeks. There was a significant difference between male and female patients undergoing HTO/DFO procedures with respect to IKDC (p=0.027), KOOS symptom (p=0.048), KOOS activities of daily living (p=0.050), KOOS pain (p=0.050), KOOS QoL (p=0.039) and KOOS sports (p=0.016). Additionally, there was no significant difference in any of the clinical or patient reported outcomes studied between patients who underwent HTO/DFO procedures for degenerative joint disease versus instability aside from IKDC (72.8 vs. 61.1, p=0.046) and KOOS ADL (92.1 vs. 81.0, p=0.037). Conclusions: In high level-athletes, HTO and DFO procedures lead to high satisfaction rates and significant increases in Tegner scores following surgery compared to their symptomatic baseline, with low conversion rates to total knee arthroplasty at mid-term follow up, with male patients having better outcomes. The majority of patients did not return to sport following these procedures and even fewer were able to return to sport at their pre-injury activity level. Surgeons can use the findings from this study to educate high-level athletes that HTO/DFO procedures provide reliable improvements in clinical and patient reported outcomes with high patient satisfaction but may not allow them to return to sport at their pre-injury level.