Knee Reconstruction Research Articles

Lateral genicular artery flap for reconstruction of defects around the knee: a series of 5 cases

The lateral genicular artery flap is a fasciocutaneous flap used for knee reconstruction with low donor site morbidity. It is raised from the lower lateral thigh and is based upon the cutaneous termination of superior lateral genicular artery. This flap showed constant anatomy and is reliable for coverage of defects at superior and lateral portions of the knee and the proximal part of the lower leg. The study period was from January 2016 to June 2017 where we operated on 5 patients, 3 for post-traumatic and 2 were post burn contracture excision. The flap was used as a pedicled fasciocutanous and was based on the superior lateral genicular artery. Five cases underwent lateral genicular artery flap of which 4 were males and 1 was a female. Mean defect size was 12 cm×10 cm. All the donor sites were closed with a split skin graft. One patient had distal necrosis which was managed conservatively. The lateral genicular artery flap is a thin, versatile, reliable and easy to harvest flap for reconstructing defects around the knee, with good cosmetic and functional outcome.

Analysis of Hip and Knee Reconstruction Questions on the Orthopedic In-Training Examination

BackgroundIt is vital for orthopedic residents and residency programs to have a current understanding of the materials and resources utilized on the Orthopedic In-Training Examination (OITE) to tailor resident educational curricula accordingly. This study presents an updated analysis of the hip and knee section of the OITE. MethodsAll OITE questions related to hip and knee reconstruction over six examinations between 2014 and 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, resident performance, and references. ResultsThere were 166 hip and knee reconstruction questions of 1600 OITE questions (10.4%) over a six-year period. The most commonly tested topics include mechanical properties of total knee and hip implants (10.8%), instability after THA (10.8%), periprosthetic fracture (10.2%), and prosthetic joint infection (10.2%). A total of 362 references were cited from 68 different sources. The most common sources were JOA, JBJS, JAAOS, and CORR, which were collectively responsible for 68% of all citations. There was an average publication lag of 7.1 years, with 75% of all citations falling within 10 years of the question date. Compared with a prior analysis from 2005 and 2009, there were significantly more complex multistep questions regarding treatment and fewer one-step knowledge recall questions (P = .003). Similarly, recent tests had significantly more questions involving interpretation of radiographs (55%, P < .001) and advanced imaging (9.6%, P < .001), compared with a decade ago. ConclusionsThe OITE continues to evolve over time, incorporating recent literature and topics. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE hip and knee section.

Multi-ligament reconstructions as a risk factor for adverse outcomes in arthroscopic surgery.

Multi-ligament knee injuries are a serious consequence of knee dislocation with a poorly evaluated post-operative complication profile due to low incidence. The aim of this study is to assess the risk of adverse post-operative events associated with operative management of multi-ligament knee injuries. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing surgical procedures for multi-ligament knee injuries from 2006 to 2016 using Current Procedural Terminology codes. We evaluated data on patient demographics and used a propensity score algorithm to adjust for baseline differences in these patients and developed univariate and multivariate logistic regression models to assess effects on minor and severe 30-day post-operative complications. We identified 444 patients in this database who underwent multi-ligament knee reconstructions between 2006 and 2016. After propensity matching, minor and major adverse post-operative events were more frequent in patients with multi-ligament knee injuries (1.4% vs 0.2%, p < 0.001 and 2.7% vs 1.1%, p = 0.002, respectively). Patients with multi-ligament knee injuries experienced a 55-fold increase risk of need for transfusion (p < 0.001) and a fivefold increased risk of pulmonary embolism (p = 0.025), with most occurring in bicruciate reconstructions (Schenck Classification KD-III and KD-IV injuries). The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse event over arthroscopic ACL reconstruction. These patients are most at risk for post-operative blood transfusion requirement, and pulmonary embolism, with patient's undergoing surgery for bicruciate ligament injuries at particularly high risk of complication. IV.

Single leg aerobic capacity and strength in individuals with surgically repaired anterior cruciate ligaments

ObjectivesCompare single-leg aerobic capacity and strength differences between the surgically repaired ACL leg (injured) and the uninjured leg. DesignCross-sectional study. SettingLaboratory. ParticipantsEight participants (5 female, 3 male, age = 23 ± 3.5 y, mass = 72.3 ± 17.3 kg, height = 169.7 ± 9.4 cm) that returned to play from ACL surgery between six and 18 months. Main outcome measuresParticipants performed an aerobically-based, single-leg cycling protocol to determine maximum oxygen consumption, ventilatory threshold, heart rate, rating of perceived exertion, and maximal watts cycled. Participants also performed isokinetic knee flexion and extension on a dynamometer to assess peak torque, total work, work fatigue, and power. ResultsThere were no statistical differences in single-leg aerobic capacity or strength outcomes between the injured and uninjured legs. ConclusionsIndividuals who have had an ACL surgically repaired six to 18 months after return to play do not appear to have aerobic capacity or strength deficits between the injured leg and uninjured leg.

Length change pattern of the medial structures of the knee and related reconstructions

Introduction:Aim of the study was to investigate the length changes of the medial structures and related reconstructions. It was assumed that the three fibre sections (anterior/middle/posterior) of the superficial medial collateral ligament (sMCL) have different length change patterns, which cannot be imitated by current reconstructions.Hypotheses:The three fibre sections (anterior/middle/posterior) of the superficial medial collateral ligament (sMCL) cannot be imitated by current reconstructions.Methods:Measurements were made on eight cadaveric knees. The knee joints were clamped in a custom-made open chain extension structure. For this purpose, the portions of the quadriceps and the iliotibial tract were aligned according to their fibre direction and statically loaded using hanging weights. The respective tibial and femoral insertion points of the sMCL anterior/middle/posterior fibres were marked by small pins. Similarly, pins were inserted at the tibial and femoral attachment sites of the posterior oblique ligament (POL). In order to imitate the Lind reconstruction, a pin was additionally inserted on the tibial semitendinosus insertion site. Pin combinations accounting for the anterior/middle/posterior sMCL, the POL, and the Lind reconstruction were connected using a high resistant suture. Then the length change patterns were measured using a rotary encoder from 0-120° knee flexion. Statistical analysis was performed using 2-way repeated-measures ANOVA and a post-hoc Bonferroni correction (p <0.05).Results:The anterior and posterior fibres of the sMCL showed a reciprocal behaviour (p< 0.001). The anterior fibres showed a length reduction (2%) up to a flexion of 20°, followed by an elongation of 5% at 120° flexion, which means that the anterior fibres are tight in knee flexion. Conversely, the posterior fibres of the MCL showed an initial length reduction of 4% at 20° flexion. This was followed by an isometric range (20° - 80°) and a further length reduction of 8% in deep flexion (120°). Thus, the posterior fibres of the MCL were tight in extension.The three parts of the POL showed a constant reduction of 25% between 0° and 120°. The Lind reconstruction with the tibial pin at the semitendinosus insertion site showed similar length changes compared to the sMCL (n.s.). Furthermore, the Lind reconstruction was dependent on the femoral placement of the pins (p <.001). The tibial placement had no significant influence.Conclusion:The anterior portion of the sMCL was tight in flexion, whereas the posterior portion was tight in extension. This reciprocal behavior could not be imitated by a single point to point reconstruction. When surgically applying these reconstructions, special attention should be paid to the femoral insertion.

Tibial Slope Correction as an Infratuberosity Closing-Wedge Extension Osteotomy in ACL-Deficient Knees.

ACL insufficiency can be caused by different reasons. Elevated posterior tibial slope is a deformity which is discussed to have relevant influence on the outcome of ACL surgery. A increased posterior tibial slope of 12° or more leads to significant more ACL insufficiency. The surgical therapy of this pathology is a high tibial extension osteotomy. Publications ashowing a clinical follow up and results of this surgery are rare. In this video the technique of a closed wedge high tibial extension osteotomy is shown. Osteosynthesis is performed with two screws and an anklestable plate osteosynthesis. An arthroscopy with bone graft filling of the femoral ACL tunnel is performed first, followed by filling of the tibial tunnel in an open approach.

Lateral extra-articular tenodesis in patients with revision anterior cruciate ligament (ACL) reconstruction and high-grade anterior knee instability

BackgroundAdditional lateral extra-articular procedures can reduce the risk of failure of primary anterior cruciate ligament reconstruction (ACLR). There is limited evidence on the effect of lateral extra-articular procedures in revision ACL surgery. The purpose of this study was to evaluate the clinical outcome of patients with lateral extra-articular tenodesis (LET) in combination with revision ACLR for combined ACL graft failure and high-grade anterior knee instability. MethodsBetween 2016 and 2018, 75 patients with graft failure after primary ACLR and high-grade anterior knee instability who received revision ACLR were included in the retrospective study. High-grade anterior knee instability was defined as high-grade pivot-shift or side-to-side difference of more than six millimeters in Rolimeter®-testing. An additional modified Lemaire tenodesis was performed in 59 patients during revision ACLR. Seventy-three patients were clinically examined with a minimum of two years after revision surgery. ResultsFailure of the revision ACLR occurred in 8.2% (n = 6) of the cases. LET lead to significant decreased failure rates (five percent vs. 21%, p = .045) and decreased incidence of a positive pivot-shift in patients with revision ACLR and high-grade anterior knee instability in comparison to patients without LET. Also, postoperative functional scores were significantly increased in the group of additional LET. ConclusionsAdditional LET in patients with revision ACLR and high-grade anterior instability significantly reduces the risk of failure of revision ACLR, the incidence of pivot-shift and increases postoperative functional outcome.

Excellent medium-term survival of an all-inside tensionable knotted suture device justifies repair of most meniscal tears encountered during reconstructive knee ligament surgery.

All-inside meniscal repair devices have evolved to allow surgeons to undertake complex repairs in a timely and efficient manner. This is advantageous in active patients, where meniscus preservation is critical in preserving joint function and stability. The aim of the study was to evaluate the failure rate of all-inside meniscal repair performed in patients undergoing reconstructive ligament surgery using a particular meniscal repair device. Patients were identified using a single-site prospectively maintained patient registry. Primary outcome was failure, defined as return to surgery with documented failure of repair. Complication rates and functional scores were also recorded. Patients in whom meniscal repair failure was identified were further assessed, to identify any common features. Over an 8-year period, 323 patients underwent meniscal repair at the time of ligament reconstruction, compared to 244 meniscectomies. Of these, 286 patients underwent repair using an all-inside suture device. One-hundred and twenty-seven repairs were to the medial meniscus only, 124 were lateral, and in 35 patients both menisci were repaired. Follow-up was to a median of 51.5months. There were 31 (9.7%) failures reported at a median of 22months post-operatively (IQR 13.5-41.5). Medial repair failures were seen more frequently than lateral (13.6% versus 5.6% OR 2.62 95% CI 1.17-5.88 p = 0.022). Failure of ACL reconstruction was associated with meniscal repair failure (OR 5.83 95% CI 1.55-21.95 p = 0.0039). Multi-ligament reconstruction was undertaken in 70/286 patients receiving meniscal repair and was not associated with failure (OR 1.3 95% CI 0.57-2.98 p = 0.51). Mode number of all-inside sutures used was 3 in both medial and lateral repairs (Range 1-9 lateral; 1-7 medial). All-inside repair is a safe and versatile technique which can be used in the majority of meniscal tears encountered during ligament reconstruction with excellent mid-term success. Failure is seen more commonly in medial sided repairs and with failure of ACL reconstruction. IV.

Distal Tibial Tuberosity Focal Dome Osteotomy Combined With Intra-Articular Condylar Osteotomy (Focal Dome Condylar Osteotomy) for Medial Osteoarthritis of the Knee Joint

High tibial osteotomy for medial-compartment knee osteoarthritis (OA) is an established biological knee reconstruction surgical procedure. In open- and closed-wedge high tibial osteotomy, the angulation correction axes are away from the center of rotation and angulation. This results in translation deformity, which alters the orientation of the adjacent joint and the length of the limb. In the present study, we combined the distal tibial tuberosity focal dome osteotomy centered on the center of rotation and angulation with the longitudinal condylar osteotomy (focal dome condylar osteotomy) for knee OA. The advantages of this procedure are as follows: physiological orientation of adjacent joint is achieved; limb length is maintained; joint stabilization in the coronal plane is achieved; patella infra is prevented; sufficient bone contact between the medial and posterior cortex is achieved; early weight-bearing walking is possible; and fibular osteotomy is not required. This study describes the details of the surgical procedure, including our compass cutter for accurate dome osteotomy and the postoperative rehabilitation program for patients with knee OA and moderate-to-severe varus deformity.

Soft tissue coverage options around the knee

Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.

Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes.

To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study wasto improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A (n = 54) underwent ACLR, while those in group B (n = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18-40) and 24 (18-33) years in groups A and B, respectively, and the median follow-up was 60 (55-65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively (p < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2-6.1) mm in patients in group A and 1.2 ± 0.7 (1.2-3.2) mm in patients in group B (p < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores (p < 0.001). Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. 1.

The Clinical Outcome of Simultaneous Lateral Closed- Wedge Distal Femoral Osteotomy and Anterior Cruciate Ligament Reconstruction in the ACL-deficient Knees with Symptomatic Femoral Varus Deformity.

Nowadays combined high tibial osteotomy and ACL reconstruction is accepted as a safe and effective surgery for patients with symptomatic varus osteoarthritis and anterior knee instability; however, the source of varus deformity is sometimes the femoral bone. No studies have reported concomitant ACL reconstruction and distal femoral osteotomy in ACL-deficient knees with femoral varus deformity and medial osteoarthritis till now. This prospective study presents the technique and clinical outcome of a consecutive series of simultaneous lateral closed-wedge distal femoral osteotomy and ACL reconstruction. Nineteen patients with confirmed ACL rupture and femoral varus deformity (mechanical lateral distal femoral angle ≥ 93°) associated with medial osteoarthritis (± lateral thrust) were included the study. The patients underwent simultaneous lateral closed-wedge distal femoral osteotomy and ACL reconstruction. At the end of one year follow up, the final range of motion and stability of the knees and the last alignment of extremities were recorded. Surgical outcomes were assessed on 2000 IKDS subjective scores and KOOS subscales. The mean preoperative varus knee was 10.6° (±2.2°) mostly from the femoral side. The mean union time was 3.2 (±0.4) months. Regarding the radiological evaluation, the alignment of extremity and mLDFA were corrected significantly compared to the pre-operative findings. At the end of one year follow up, all patients were free of knee instability. Subjective assessment based on questionnaires showed a significant improvement in all aspects of knee function after surgery, however there was no considerable change in the knees range of motion. Simultaneous lateral closed- wedge distal femoral osteotomy and ACL reconstruction is a valuable procedure in femoral varus knees with medial osteoarthritis and anterior knee instability. After one year follow up all aspects of knee function were improved without serious complications.

Trends in ACL Repair in Children

Trends in ACL Repair in Children

Anticoagulant Usage Following Anterior Cruciate Ligament Reconstruction is Associated with Increased Rate of Manipulation Under Anesthesia

Objectives:Although uncommon, arthrofibrosis following anterior cruciate ligament reconstruction (ACLR) is considered to be a significant and disabling complication for a young, athletic population. In this study, we aimed to determine: (1) the prevalence of manipulation under anesthesia (MUA) for treatment of arthrofibrosis following ACLR (2) whether anticoagulant use following ACLR is associated with an increased risk of MUA. We anticipate that postoperative use of anticoagulants will be associated with an increased risk of subsequent MUA.Methods:A retrospective cohort study was conducted using data collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007-2017. Subjects were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Patients were initially identified by ACL sprain or tear diagnosis utilizing ICD codes. Patients who underwent a concomitant MCL, PCL or LCL repair or reconstruction were excluded from this analysis. Patients who underwent MUA within one year of ACLR were then identified. Patient demographic characteristics including age, sex, and Charlson Comorbidity Index (CCI) were recorded. In addition, previously identified risk factors for knee stiffness were collected, including history of diabetes mellitus and obesity. Lastly, the time between ACL tear and surgery and ACL reconstruction to MUA were collected and categorized into 2 groups: (1) <4 weeks and (2) >4 weeks. Anticoagulants included in this analysis were warfarin, aspirin, low-molecular-weight heparin, direct factor Xa inhibitors and fondaparinux. Patient demographics, comorbidities, timing to surgery, concomitant meniscal repair, and postoperative complications were analyzed with a logistic multivariate analysis to determine adjusted associations of risk factors of arthrofibrosis. A p-value of < 0.05 was used as the cutoff for statistical significance.Results:There were 7,798 patients who met the inclusion criteria for this analysis. 115 (1.5%) patients received a subsequent MUA within one-year, while 7,683 (98.5%) patients did not. Among patients who underwent ACLR, 234 (3.0%) patients were on anticoagulants postoperatively. Patients who were on anticoagulants following ACLR were more likely to require an MUA (OR: 4.626; 95% CI: 2.462-8.093; p<0.001; Table 1). Other risk factors for MUA are listed in Table 1.Conclusion:The key finding of this study was that the use of anticoagulants is associated with increased rates of MUA following ACLR. One potential mechanism for the effect of anticoagulants may be the increased risk of postoperative hematoma. Recurrent hematoma has been suggested as a risk factor for arthrofibrosis requiring MUA following ACLR due to increased vascular micro-permeability that anticoagulants can produce. The presence of blood products in the joint may stimulate the accumulation of inflammatory mediators and subsequent fibrosis, as it is well-established that unresolved inflammation can initiate and propagate scar tissue formation.In conclusion, arthrofibrosis after ACLR is associated with postoperative use of thromboprophylaxis. Healthcare providers should be cognizant of this risk when considering anticoagulant usage in this patient population.

Moderately Increased Post-Operative Anterior Knee Laxity does not Predict Decreases in Patient-Reported Outcome Scores or Subsequent Knee Surgery between 2 and 6 Years after ACL reconstruction

Objectives:A primary goal of anterior cruciate ligament reconstruction is to reduce pathologically increased anterior and rotational laxity of the knee. The impact of residual anterior laxity on patient-reported outcomes and the risk of subsequent ipsilateral knee surgery has not been clearly elucidated. The goal of this study is to determine the influence of residual anterior knee laxity on changes in patient-reported outcomes from 2 to 6 years following ACL reconstruction and risk of subsequent ipsilateral knee surgery during that period.Methods:From a prospective multi-center cohort of patients, 429 patients under age 35 years injured in sports with no history of concomitant ligament surgery, revision ACL surgery, or surgery of the contralateral knee were identified at a minimum 2 years following primary ACL reconstruction. These patients underwent a KT-1000 assessment of anterior knee laxity examination relative to the contralateral normal knee by an independent examiner and completed patient-reported outcome assessments with KOOS and IKDC scores. Patients were followed until the 6-year mark following ACL reconstruction and any ipsilateral knee surgeries performed during this period were noted. Patients completed the same patient-reported outcome assessments at 6 years post-operative. Subsequent surgery risk was calculated and compared between those patients with side-to-side KT-1000 differences between -1 and 2 mm and those with a side-to-side KT-1000 differences between 2 and 6mm. Multiple linear regression models were built to determine the relationship between KT-1000 and 2 to 6 year change in patient-reported outcome score while controlling for age, sex, BMI, smoking status, meniscus and cartilage status, and graft type.Results:Thee hundred seventy-seven patients (87.9%) were available for follow-up at the six year mark post-operative. There were 36 patients with a side to side KT-1000 difference less than -1 mm (tighter than contralateral) that were excluded from the analysis. Side-to-side KT-1000 difference was between -1 and 2 mm (IKDC A) in 153 patients, between 2 and 6 mm (IKDC B) in 162 patients, and greater than 6 mm in 26 patients. Subsequent knee surgery was performed significantly more patients in the IKDC A group (23 of 153 patients, 15%) than in the IKDC B group (13 of 162 patients, 8%) (p = 0.05). Increased side-to-side KT-1000 differences at 2-year post-operative were correlated with decreases in subjective IKDC score (β = -0.67, p = 0.038) and KOOS-sport subscale (β = -0.90, p = 0.029) but not with other KOOS subscales. A 5mm increase in anterior laxity at 2 years would predict a 3.4 point decrease in IKDC subjective score and a 4.5 point decrease in the KOOS sport subscale at 6 years post-operative.Conclusion:Three presence of 2 to 6 mm of residual side-to-side KT-1000 difference is not associated with an increased risk of subsequent ipsilateral knee surgery or clinically relevant decrease in patient-reported outcome score up to 6 years following ACL reconstruction.

Meniscal and Articular Cartilage Predictors of Outcome following Revision ACL Reconstruction: A 6-Year Follow-up Study

Objectives:Previous work has shown that having a lateral meniscectomy prior to revision ACL surgery, as well as grade 3-4 chondral damage to the trochlea at the time of revision ACL surgery results in poorer outcomes at 2 years. Alternatively, meniscal or articular cartilage (AC) pathology documented at the time of a revision surgery were not found to be significant risk factors for 2-year activity levels. The purpose of this study was to follow this cohort for a longer time period, to determine if either meniscal and/or articular cartilage pathology noted at the time of revision ACL surgery significantly affects a patient’s activity level, sports function, and OA symptoms at 6-year follow-up.Methods:Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 6 years and asked to complete the identical set of outcome instruments.Regression analysis was used to control for age, gender, BMI, smoking status, activity level, baseline outcome scores, revision number, time since their last ACL reconstruction, graft choice, and previous and current meniscal and articular cartilage pathology, in order to assess the meniscal and AC pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction.Results:1234 patients met the inclusion criteria and were successfully enrolled, with 716 (58%) males and a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Surgeons noted previous pathology in the medial meniscus (39%), lateral meniscus (20%), and articular surfaces (12%) at the time of revision surgery. Surgeons reported current pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (MFC; 43%), lateral femoral condyle (LFC; 29%), medial tibial plateau (MTP; 11%), lateral tibial plateau (LTP; 17%), patella (30%), and trochlea (21%). At 6 years, follow-up was obtained on 77% (949/1234). Previous and current meniscal pathology (both medial and lateral), as well as current AC pathology (in the MFC, LTP, trochlea, and patella) were found to be significant drivers of poorer outcomes at 6 years. The most consistent cartilage-related factors driving outcome in revision patients were either a previous or current repair or excision of the medial meniscus and patellofemoral AC pathology. Six-year Marx activity levels were negatively impacted by having either a repair or an excision of the medial meniscus (odds ratio range =0.58-66; 95% CI=0.38-0.91; p=0.01) or having grade 3-4 patellar chondrosis (OR=0.57; 95% CI= 0.35-0.95; p=0.03). Conversely, 6-year activity levels significantly improved by having either a lateral meniscus repair or excision (OR=1.49-2.22; 95% CI=1.07-4.04; p=0.005). Previous medial or lateral meniscal pathology negatively affected all KOOS subscales except for sports/recreation (p<0.05). Articular pathology significantly impaired KOOS symptoms, sports/recreation and the quality of life subscales (p<0.05). The KOOS sports/recreation subscale was significantly affected by articular cartilage pathology (LTP, patella, trochlea; p<0.03). Lower baseline outcome scores, lower baseline activity level, and being a smoker all significantly increased the odds of reporting poorer clinical outcomes at 6 years.Conclusion:Meniscal and articular cartilage pathology was found to have a larger impact at 6 years following revision ACL surgery, as compared to 2-year follow-up. In contrast to 2-year follow-up, incidence of medial meniscal and AC pathology at the time of a patient’s revision surgery were found to significantly diminish a patient’s activity level at 6 years, whereas the incidence of lateral meniscal repair or excision was found to improve a patient’s activity level. Having a previous medial meniscal repair or excision or exhibiting grade 2-4 chondral damage noted at the time of ACL revision reconstruction results in poorer IKDC and KOOS scores and worse WOMAC pain and ADL scores at 6 years following revision surgery.

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.