Reconstruction In Adults Research Articles

Predictors of Anterior Cruciate Ligament Tears in Adolescents and Young Adults

Background: Anterior cruciate ligament (ACL) injury in youth can lead to expensive treatment, lengthy rehabilitation, and long-term impairment. Injuries to the ACL are more common in adolescents who participate in organized sports. Purpose: To examine whether there is an association between age, physical activity patterns, pubertal timing (Tanner stage), or body mass index (obesity/overweight status) and the risk of developing an ACL injury in youth. Study Design: Cohort study; Level of evidence, 2. Methods: Data from the Growing Up Today Study (GUTS), a prospective cohort study of youth throughout the United States, were used in this study. From 1996 to 2003, questionnaires were sent to GUTS participants every 12 to 18 months to assess a variety of self-reported factors; in a related 2004 questionnaire, ACL tears and other diagnoses among the participants were reported. Cox proportional hazard models were run to determine the sex-specific association of activity patterns and pubertal timing with risk of developing an ACL tear. Results: A total of 4519 boys and 5622 girls (age: 9-15 years) were included, with 2.4% and 2.0% sustaining an ACL injury, respectively. Age was found to be a significant risk factor for ACL injury in both sexes (male: hazard ratio [HR] = 1.30 [95% CI, 1.14-1.48]; female: HR = 1.23 [95% CI, 1.10-1.38]). Mean hours per week engaged in vigorous activity was also predictive of a higher risk of ACL injury (male: HR = 1.04 [95% CI, 1.01-1.08]; female: HR = 1.10 [95% CI, 1.07-1.14]). The sports that were the most predictive of injury were running, basketball, soccer, and cheerleading/gymnastics in girls and running, football, and karate/martial arts in boys. Additionally, in boys, overweight/obese status was found to be a significant predictor of ACL injury (HR = 2.61 [95% CI, 1.60-4.26]). Furthermore, among 9- to 13-year-old girls, advanced Tanner stage was a strong predictor of injury risk (HR = 2.43 [95% CI, 1.10-5.36]). Conclusion: Age, time engaged in vigorous activity, overweight/obese status, and advanced Tanner stage were associated with an increased risk of ACL injury in young adults and adolescents. Further research with follow-up data will help complement this study and continue to highlight the risk factors associated with ACL reconstruction in adolescents and young adults.

Rising rates of anterior cruciate ligament reconstruction in Australian adults: An analysis of Australian Medicare Benefits Schedule database.

Anterior cruciate ligament (ACL) reconstruction is an evolving field, though there remains sparse epidemiological data on the treatment of ACL ruptures. The objective of this study is to analyse the trends in the rate of ACL reconstruction (ACLR) in adult patients over the past two decades in the Australian population. The incidence of ACLR between 2001 and 2020 in patients 15 years and over was analysed using the Australian Medicare Benefits Schedule (MBS) database. The data reflect patients with private health coverage (45% of the Australian population).An offset term was introduced using national population data to account for population changes over the study period. A total of 160,353 ACLRs were performed in Australia under the MBS in the 20-year period from 2001 to 2020. An annual increase in the total volume and per capita rate of ACLRs was found (p < 0.05). The annual volume of cases increased by 82%, from 5512 in 2001 to a peak of 10,011 in 2017. This increase was seen across all age groups (p < 0.05) and both sexes (p < 0.05), with a greater proportion of reconstructions performed on males (n = 102,357, 64%) than females (n = 57,996, 36%). In 2020, the rate of adult ACLRs decreased to a level last seen in 2004, likely due to the effects of COVID-19. The incidence of ACLR in adult patients has increased in Australia over the 20-year study period. The trends noted provide information that can be used to guide resource allocation and health provision in the future. Level IV.

Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes

Background: Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method: A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results: Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00–0.08] in head &amp; neck applications, 4% in the lower limb (95% CI, 0.00–0.16), 2% in the upper limb (95% CI, 0.00–0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00–0.04). Overall donor site complication rate was 4% (95% CI, 0.01–0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion: The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.

Long-term outcomes following pediatric endoscopic titanium ossiculoplasty: A single-institution experience

IntroductionEndoscopic ossicular chain reconstruction (OCR) in adults has demonstrated equivalent outcomes to the traditional microscopic approach. Less data exist on endoscopic OCR outcomes in children, who have unique considerations including a smaller transcanal corridor and variable pathology. The purpose of this study was to investigate surgical and audiometric outcomes in children undergoing fully endoscopic and endoscopic-assisted OCR in both the short and long-term. MethodsRetrospective review of all children (<17 years) who underwent endoscopic OCR at one tertiary care center between 2017 and 2021. Children undergoing primary and revision endoscopic OCR with either partial (PORP) and total ossicular reconstruction prostheses (TORP) were included. Children undergoing surgery for juvenile otosclerosis or congenital stapes fixation, or any child receiving a stapes prosthesis were excluded. Primary outcome measures were post-operative change in 4 frequency (500 Hz, 1, 2, 4 KHz) air conduction pure tone average (AC PTA) and change in air-bone gap (ABG). Secondary measures included need for readmission and/or revision surgery, complication rate, and surgery duration. ResultsSeventeen patients met inclusion criteria. Average age was 11.3 years (range, 5–17 years); 14 were male. A variety of fixed length, titanium total and partial prostheses were used. The most common prosthesis length was 2 mm (range 2–5 mm), and there were no intra- or perioperative complications. Mean long-term follow-up was 2.6 years. Most common pathology was congenital cholesteatoma (11/17, 64%), followed by chronic otitis media with tympanic membrane perforation (5/17, 29.4%), and extruded prosthesis (1/17, 5.9%). Intraoperatively, the most common finding was incus erosion (10/17, 58.8%), followed by malleus erosion (6/17, 35.3%), stapes erosion (4/17, 23.5%), and stapes absence (4/17, 23.5%). Eight children (47%) were reconstructed with PORPs, and 9 children (52.9%) were reconstructed with TORPs. Average ABG improved from 36.8 dB preoperatively to 19.9 dB postoperatively in the short-term and remained stable at 19.5 dB in the long-term. Average short-term ABG improvement was 4.2 dB for PORPs and 18 dB for TORPs. In the long-term, average ABG improved by 2.3 dB in PORPs and 13.4 dB in TORPs. PORPs had higher rates of ABG closure and lower AC PTAs than TORPs in the long-term. DiscussionEndoscopic ossiculoplasty is a viable option in children presenting with ossicular erosion from various causes. Audiometric improvement following endoscopic partial and total ossicular reconstruction remains stable over time, with a preference towards partial in the long-term, and mirrors published outcomes for microscopic surgery.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data.

Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population. Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications. A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008). Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

Revisiting bilateral bony orbital volumes comparison using 3D reconstruction in Korean adults: a reference study for orbital wall reconstruction, 3D printing, and navigation by mirroring

BackgroundOrbital wall fractures can result in changes to the bony orbital volume and soft tissue. Restoring the bony orbital and intraconal fat volumes is crucial to prevent posttraumatic enophthalmos and hypoglobus. We aimed to establish an evidence-based medical reference point for “mirroring” in orbital wall reconstruction, which incorporates three-dimensional (3D)-printing and navigation-assisted surgery, by comparing bilateral bony orbital volumes.MethodsWe retrospectively analyzed the data obtained from 100 Korean adults who did not have orbital wall fractures, categorized by age groups. The AVIEW Research software (Coreline Soft Inc., Seoul, South Korea) was used to generate 3D reformations of the bony orbital cavity, and bony orbital volumes were automatically calculated after selecting the region of interest on consecutive computed tomography slices.ResultsThe mean left and right orbital volume of males in their 20 s was 24.67 ± 2.58 mL and 24.70 ± 2.59 mL, respectively, with no significant difference in size (p = 0.98) and Pearson’s correlation coefficient of 0.977 (p < 0.001). No significant differences were found in orbital volumes in other age groups without fractures or in patients with nasal bone fractures (p = 0.84, Pearson’s correlation coefficient 0.970, p < 0.001). The interclass correlation coefficients (2,1) for inter- and intrarater reliability were 0.97 (p < 0.001) and 0.99 (p < 0.001), respectively.ConclusionsNo significant differences were found in the bilateral bony orbital volumes among males of any age. Thus, the uninjured orbit can be used as a volumetric reference point for the contralateral injured orbit during orbital wall reconstruction.

Aortic valve reconstruction in nonelderly adults: a systematic review, meta-analysis and microsimulation study

Abstract Background Aortic valve disease (AVD) calls for careful planning of treatment strategies that adheres to a patient-tailored lifetime perspective, especially in younger patients. Aortic valve reconstruction (AVr) provides an attractive option in patients with aortic valve regurgitation (AR). Purpose This study aims to provide a comprehensive overview of published outcome after AVr in nonelderly adults and to use microsimulation to obtain age-specific estimates of outcomes. Methods A systematic review of published literature reporting clinical outcome after AVr in nonelderly adults (mean age ≥18y and ≤55y) published between 1/1/1990 and 17/10/2022 was conducted. Publications reporting outcome after AVr were considered for inclusion, including publications on valve-sparing root surgery. Studies that included patients without AVD as the primary indication for AVr were excluded. Early risks (&amp;lt;30d), late event rates (&amp;gt;30d) and time-to-event data were pooled and entered into a microsimulation model. Subgroup analyses were performed for AVr for isolated AR and AVr for bicuspid aortic valves (BAV). Results Thirty-seven studies, all retrospective cohort studies, were included, yielding a total of 4,573 patients with 16,524 patient-years of follow-up (median follow-up: 4.0y; range 0.6-10.5y). Pooled mean age for all repairs, AVr for AR and AVr for BAV was 48.1±13.8, 48.3±13.8, and 42.4±12.5 years, respectively. Pooled early mortality for all repairs, AVr for AR and AVr for BAV, respectively, was 1.7% (95%CI: 1.2-2.3%), 1.5% (1.0-2.1%), and 1.0% (0.6-1.9%), and late pooled mortality rate was 1.0%/y (0.7-1.5%/y), 1.3%/y (0.8-2.1%/y), and 0.8%/y (0.5-1.4%/y), respectively. Microsimulation-based life-expectancy relative to the general population 20 years postoperatively was 92.6% (95% Credible Interval: 90.1-95.3%) after all repairs, 89.0% (85.0-93.0%) after AVr for isolated AR and 94.9% (92.0-97.4%) after AVr for BAV. Microsimulation-based 20-year risk of aortic valve reintervention for all repairs, isolated AR and BAV, respectively, was 25.0%(23.8-26.2%), 25.1%(23.5-26.9%) and 49.9%(48.2-52.0%). The main cause for reintervention was repaired valve dysfunction for all three groups, followed by endocarditis. Estimates of other late complications are shown in Figure 2. Conclusions Aortic valve reconstruction for aortic valve regurgitation effectively postpones valve replacement in nonelderly with satisfactory long-term outcomes but reintervention risks are still considerable, especially in BAV patients. Reconstructive valve surgery is associated with low risks of bleeding and thrombo-embolic events and should be considered in nonelderly adults with aortic regurgitation and carefully weighed against hazards of primary aortic valve replacement.Pooled Kaplan-Meier curves for mortalityMicrosimulation-based event risks (20y)

The Hybrid Transtibial Technique Using the LARS Device in Primary Anterior Cruciate Ligament Reconstruction

Background: The recently published hybrid transtibial technique (HTT) using the Pathfinder Guide with a flexible transtibial technique (TT) guide wire may represent a beneficial combination of both the anteromedial portal and TT technique. The HTT has been described as especially suitable for anterior cruciate ligament (ACL) reconstruction in adolescents or ACL revision. However, we also found that the HTT worked for primary ACL reconstruction in adults also using the Ligament Advanced Reinforcement System (LARS). Indications: Acute ACL rupture in active patients who are eager to return to sports quickly. Technique Description: The HTT combined with the conventional LARS reconstruction procedure improves the placement of the femoral tunnel, which involves a guiding vessel clamp through the anteromedial portal combined with a 2.0 mm Kirschner wire via the tibial tunnel. Finally, we used a metal screw for fixation of the ligament. Results: The patient experienced satisfactory reconstruction of his ACL and regained active range of motion in 1 month and a full return to sports in 6 months. Discussion/Conclusion: The HTT using the LARS for primary ACL reconstruction is easy, safe, and reproducible. This combined technique has not yet been published and it may provide good functional results that allow patients to recover quickly and return to sports as soon as possible. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The free vascularized fibula flap for long bone reconstruction in adults — a systematic review and regional centre experience

The free vascularized fibula flap for long bone reconstruction in adults — a systematic review and regional centre experience

Anatomic Double-Bundle and Single-Bundle Reconstructions Yield Similar Outcomes Following Anterior Cruciate Ligament Rupture: A Systematic Review and Meta-analysis

To evaluate outcomes of arthroscopic single-bundle (SB) versus anatomic double-bundle (ADB) anterior cruciate ligament reconstruction (ACLR) in adults through a synthesis of randomized controlled trials (RCTs). We hypothesized that SB and ADB methods would lead to similar outcomes after reconstruction of ACL rupture. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist guided our reporting. To identify RCTs that compared SB and ADB reconstructions, a thorough literature search was conducted of PubMed, Embase, Cochrane library, and Web of Science. The methodologic quality of each included study was independently assessed by 2 authors using the Cochrane Collaboration's risk of bias tool. The Anatomic ACL Reconstruction Scoring Checklist (AARSC) was used to screen the eligibility of each study's operative approaches. Twelve clinical outcomes were investigated through pooled analyses conducted using Review Manager 5.3. This meta-analysis synthesized 13 RCTs comparing postoperative outcomes between ADB and SB reconstructions of ACLs. After a minimum follow-up of 12 months, ADB and SB technique resulted in similar subjective clinical outcomes, including the International Knee Documentation Committee subjective score, Lysholm score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score sports subscale. Similarly, no statistically significant outcomes were found for objective outcomes such as International Knee Documentation Committee objective grade, pivot-shift test, Lachman test, side-to-side difference, extension deficit, flexion deficit, and osteoarthritis change. However, patients who underwent SB reconstruction had significantly greater complication rates than those that underwent ADB reconstruction. When an ACLR approach meets a minimal total AARSC score of 8, ADB and SB techniques may result in similar subjective and objective outcomes, but the ADB technique may lead to lower complication rates following surgery. We recommend that surgeons favor ADB ACLR, as guided by the AARSC. Level I, systematic review and meta-analysis of Level I randomized controlled trials.

105. Masculinizing Chest Reconstruction in Adolescents and Young Adults - A NSQIP Analysis

105. Masculinizing Chest Reconstruction in Adolescents and Young Adults - A NSQIP Analysis

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults.

Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability. A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine. Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization. Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Femoral Physeal-Sparing ACL Reconstruction With Iliotibial Band Autograft Over-the-Top With Associated Lateral Extra-Articular Tenodesis

Background: Injuries to the anterior cruciate ligament (ACL) in the pediatric population have been exponentially increasing over the years. However, surgical techniques typically employed for ACL reconstruction (ACL-R) in adults may injure the physes of skeletally immature patients, resulting in growth disturbances. Indications: Currently, ACL-R is recommended for most patients, aiming to return the patient to their previous activities as well as reduce the risk of further instability, meniscal and chondral injuries, and early osteoarthritis. Pediatric ACL-R techniques may vary widely. In this video, the technique chosen was over-the-top on the femur with a vertical tibial tunnel, in addition to a lateral extra-articular tenodesis, using the iliotibial (IT) band as the graft. Technique Description: The patient is positioned in standard supine arthroscopic position. An incision is made over the lateral epicondyle and the IT band is exposed. A 2-cm-wide graft is harvested. The proximal aspect of the graft is truncated as high as possible, and the distal aspect is left attached to Gerdy tubercle. Arthroscopic portals are established, and the remanent ACL is debrided, exposing the posterior aspect of the lateral femoral condyle. The capsule is penetrated using a Schnidt tonsil to establish the over-the-top position, which is subsequently exchanged for a cardiac clamp. The graft sutures are grasped using the clamp and pulled into the joint. The tibial tunnel is drilled at the anatomic footprint of the ACL. The graft is threaded over-the-top of the lateral femoral condyle and through the tibial tunnel. Finally, femoral graft fixation is performed on the lateral femoral condyle using interrupted sutures through the IT band and periosteum, and tibial graft fixation is performed with standard interference fixation. Results: Previous literature shows low re-rupture rates, excellent postoperative patient-reported outcomes, and high return to sport rates. Conclusion: In the pediatric population, there is still no ACL-R technique defined as the gold standard. The described technique is a valuable option for ACL-R in skeletally immature patients, with low revision rates and excellent postoperative outcomes. In addition, this technique minimizes the risk of growth disturbances and effectively stabilizes the knee, allowing patients to return to previous activities. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis

Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.

Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect

Bone–patellar tendon–bone (BPTB) autograft is a popular graft choice for anterior cruciate ligament reconstruction (ACLR) in active young adults. In case of BPTB ACLR failure, the 3 most popular autograft choices for a revision surgery include contralateral BPTB, contralateral or ipsilateral hamstrings autograft, and contralateral or ipsilateral quadriceps tendon autograft. Quadriceps tendon autograft has been gaining increasing popularity in recent years in this respect, but using quadriceps tendon–bone autograft in the setup of a previous use of ipsilateral BPTB autograft deserves special technical considerations, with emphasis on preserving patellar bone integrity. We describe a technique for performing revision ACLR after failed primary BPTB ACLR by using ipsilateral quadriceps tendon–bone autograft in the setup of persistent distal patellar bone defect. Using this autograft benefits the advantages of highly resilient graft tissue in addition to fast bone-to-bone healing on the femoral side, and it can be an excellent choice in revision reconstruction for surgeons who prefer tendon-bone autograft for highly active young adults and specifically when the patients underwent bilateral primary autologous BPTB ACLRs.

Muscle activation for targeted elbow force production following surgical reconstruction in adults with brachial plexus injury.

Nerve transfer or grafting surgery to restore elbow flexion in peripheral nerve injuries has been an effective technique, but alters neuromuscular control compared with healthy individuals. This study compared neuromuscular control in the elbow flexors of 11 unimpaired control subjects and 11 adult patients with traumatic brachial plexus injury who underwent a nerve transfer or grafting procedure to the biceps motor branch to restore elbow flexion. The subjects performed a series of trials to generate a specific percentage of their maximum elbow torque. Each trial had an increasing and decreasing stairstep torque pattern that the subjects were asked to match. The amount of time that the subject's elbow torque was maintained within 5% of the target torque was calculated. The hypothesis was that there was a significant difference in the neuromuscular control between the two groups during elbow isometric torque generation. A secondary hypothesis was that a relationship existed between the neuromuscular control and the torque level for each group. The results demonstrated that neuromuscular control was different between the groups and there were significant differences in how torque levels are generated. The control group more easily modulated their myoelectric activation and achieved greater neuromuscular control variability with varying torque demand. The nerve transfer or grafting group could not modulate their myoelectric activation with changing torque demands. Further studies focusing on the improvement of neuromuscular control are needed to optimize functional outcomes in nerve injury patients.

Abdominal Wall Reconstruction in Adults With Exstrophy of the Bladder.

Abdominal wall reconstruction in an adult patient with exstrophy bladder is challenging. A variety of local and regional flaps are described. We describe our experience with a 3-layer technique with the differential reconstruction of the fascial and cutaneous layer. Three adult patients with untreated bladder exstrophy were included in the study period from 2017 and 2019. The surgical technique involved 3-layer abdominal reconstruction involving closure with unilateral anterior rectus sheath turnover and a pedicled anterolateral thigh flap for skin cover reinforced with a mesh between the two. All three were male patients with an average age of 22.3 years. The average size of the defect was 10 × 9 cm. The mean period of follow-up was 6 months (range, 2-18 months). In all 3 patients, the flaps settled well with no complications. Although rare as they may be, the management of untreated bladder exstrophy presenting in adulthood has evolved over the years. The goals of the management have changed from simple defect closure to the dynamic reconstruction of the abdominal wall covering a continent neobladder. Our technique of a 3-layer closure can provide good functional integrity to the abdominal wall even in large defects.

Daily Life Impact of Brachial Plexus Reconstruction in Adults: 10 Years Follow-Up

Reconstructive surgery of brachial plexus injury in adults remains a challenge. Short- and midterm follow-up results have been described in terms of impairments, such as muscle strength grading. However, psychologic management has been shown to be a major contributor in long-term results. A new, specific brachial plexus injury scale, including functional and psychologic components, was described. Objectives of this study were: (1) to assess functional long-term brachial plexus reconstruction outcomes; and (2) to validate the Mancuso scale at 10 years of follow-up. Twenty patients with at least 10 years of follow-up were included in the study. Four patients had C5-C6 palsy and 16 had a C5-T1 injury. Shoulder abduction and elbow flexion were assessed with Medical Research Council grades. Shoulder function was evaluated with a Constant score. The 36-item short-form survey (SF36) was used to assess quality of life, and the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) was used for patient reports of disability. The Mancuso scale was assessed and correlated to the different scores used. At the last follow-up, the Medical Research Council grade was at least grade 3 in 10 cases (50%) of shoulder abduction and in 12 cases (60%) of elbow flexion. The Constant score was 31.4 (SD, 15.1). The SF36 score was 67.5 (SD, 4.25) and the QuickDASH was 50 (SD, 15.9). We found a correlation between the symptom score (Mancuso score) and the different quality-of-life scores (QuickDASH: coefficient, 0.491; SF36: coefficient,-0.565; limitations score: coefficient, 0.445). This study reported results from the Mancuso scale at a minimum of 10 years of follow-up of reconstructive surgery for brachial plexus injury in adults. Correlations between this composite scale and the SF36 and QuickDASH scores suggest construct validity. Therapeutic IV.

ACL Graft Growth in Pediatric Patients After ACL Reconstruction

Background:The native anterior cruciate ligament (ACL) changes in diameter and cross-sectional area throughout growth and up until age 18. The size and morphology of the native ACL continues to change throughout skeletal maturation. While ACL autografts have been shown to increase in size following ACL reconstruction in adults, there have been no similar studies to evaluate the change in ACL autografts in skeletally immature patients.Purpose:The primary aim of this study was to measure changes in ACL graft diameter in pediatric patients based on subsequent magnetic resonance imaging (MRI) after ACL reconstruction surgery. The second aim was to determine if there is evidence of ACL autograft growth after ACL reconstruction in skeletally immature patients.Methods:This was a retrospective review of 21 skeletally immature patients (mean age 14 years, range 12-16 years, 76% female) who underwent ACL reconstruction from January 2009 to July 2020 and had a subsequent MRI following surgery. We excluded patients who were treated with an allograft or underwent subsequent MRI for ACL re-injury. We measured the mid-substance ACL cross-sectional area and the post-operative graft diameter on subjects’ subsequent MRI. The recorded intra-operative graft diameter was compared to the post-operative graft diameter to determine the change in graft size.Results:76% (n=16) of subjects were treated with a quadriceps autograft. Follow-up MRIs were performed at a mean of 1.7 years (range 0.3 – 3.8 years) post-operative. Post-operative grafts increased 2.2mm (p<0.001, 95% CI = 1.8-2.7) in diameter compared to the intra-operative graft diameter (Figure 1).Conclusions:In our study population, there was a significant increase of 2.2mm in ACL graft diameter an average of 1.7 years after ACL reconstruction in skeletally immature patients. Our results are similar to previous studies demonstrating an increase in graft size post-operatively in adults. These results suggest that it may be useful for surgeons to take the likely changes in graft size into account when determining appropriate autograft size in skeletally immature patients.Figure 1.Comparison between initial mid graft diameter measurement size and follow-up MRI graft diameter size. The line within the box defines the median value. The range of the box defines the 25th and 75th percentile, and whiskers extending from the box plots define the range of measurements obtained.

Older Age and Surgical Delay May Affect Medial Meniscus Repairability During Anterior Cruciate Ligament Reconstruction in Adolescents and Young Adults

Background:In the setting of meniscus pathology, earlier treatment of meniscus tears may increase the likelihood of repair in young patients. Moreover, delayed anterior cruciate ligament reconstruction (ACLR) has been associated with an increased risk of meniscus injury. There is, however, limited data on the relationship between surgical delay and meniscus repairability in the setting of an ACLR in young patients.Purpose:The purpose of this study was to examine meniscus tear patterns and the likelihood of repair at the time of ACLR in young athletes, and specifically, to determine whether age and time from injury to surgery are correlated with tear patterns or meniscus repairability.Methods:Records were retrospectively reviewed on patients aged 13-25 years who underwent primary ACLR from January 2017 through December 2017. Patients with multi-ligament knee injuries were excluded. Demographic data were collected including age, sex, BMI, race/ethnicity, insurance status, primary sport, mechanism of injury, and time from injury to surgery. Operative reports were reviewed to document meniscus tear type/pattern and all concomitant pathology/procedures. Univariate and logistic regression analyses were used to determine factors associated with meniscus repair.Results:89 eligible patients underwent ACLR during the study period. 59 (51% females) with mean age 19.3 ± 3.4 years had concomitant meniscus pathology and were included for analysis. The mean time to surgery was 5.2 ± 7.4 months. Combined medial and lateral meniscus tears accounted for 37% of tears, followed by lateral (32%) and medial (31%) tears. For tear type, medial and lateral tears were most commonly vertical (57.5%) and complex (34%), respectively. Surgical repair was performed in 67.5% of medial tears but only 34% of lateral tears. Univariate analyses demonstrated a statistically significant correlation between medial meniscus repair and time to surgery (p=0.01) and age (p=0.01), with repair less likely with a surgical delay >3 months and age >18 years. However, time to surgery was not significant after adjusting for age. There was a statistically significant difference in age between those with a surgical delay > 3 months (20.6 ± 3.4 vs.18.3 ± 3.0; p=0.01). Age and time to surgery did not affect the location or type of meniscus tear. There was no correlation between other demographic or surgical variables and time to surgery.Conclusion:In the setting of concomitant ACL and medial meniscus injury, age >18 years and surgical delay >3 months may decrease the likelihood of medial meniscus repair in young athletes.