1
|
Vakili S, Lanting B, Getgood A, Willing R. Comparison of the Kinematics and Laxity of Total Knee Arthroplasty Bearing Designs Stabilized With Specimen-Specific Virtual Ligaments on a Joint Motion Simulator. J Biomech Eng 2024; 146:081005. [PMID: 38529555 DOI: 10.1115/1.4064621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Indexed: 03/27/2024]
Abstract
A variety of total knee arthroplasty (TKA) designs offer increased congruency bearing options, primarily to compensate for a loss of posterior cruciate ligament (PCL) function. However, their efficacy in providing sufficient stability under different circumstances requires further investigation. The preclinical testing of prosthesis components on joint motion simulators is useful for quantifying how design changes affect joint stability. However, this type of testing may not be clinically relevant because surrounding ligaments are either ignored or greatly simplified. This study aimed to assess the kinematics and stability of TKA joints during various motions using condylar-stabilized (CS) bearings without a PCL versus cruciate-retaining (CR) bearings with an intact PCL. TKA prosthetic components were tested on a joint motion simulator while being stabilized with five different sets of specimen-specific virtual ligament envelopes. In comparison to CR knees, CS knees without a PCL exhibited a greater amount of posterior tibial displacement laxity, with a mean increase of 2.7±2.1 mm (p = 0.03). Additionally, significant differences were observed in the anterior-posterior kinematics of the knee joint during activities of daily living (ADL) between the two designs. These results were consistent with previous cadaveric investigations, which indicated that CS knees without a PCL are less resistant to posterior tibial displacement than CR knees with one. This study employing virtual ligaments confirms previous findings that the raised anterior lip of some CS bearings may not completely compensate for the absence of the PCL; however, as both studies used reduced joint contact forces, the contributions of this design feature may be attenuated.
Collapse
Affiliation(s)
- Samira Vakili
- School of Biomedical Engineering, Western University, 1151 Richmond Street N, London, ON N6A 5B9, Canada; Western's Bone and Joint Institute, Western University, London, ON N6A 5B9, Canada
| | - Brent Lanting
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada; Western's Bone and Joint Institute, Western University, London, ON N6A 5A5, Canada
| | - Alan Getgood
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada; Fowler-Kennedy Sport Medicine Clinic, Department of Surgery, Western University, 3M Centre, London, ON N5A 3K7, Canada; Western's Bone and Joint Institute, Western University, London, ON N6A 5A5, Canada
| | - Ryan Willing
- School of Biomedical Engineering, Western University, 1151 Richmond Street N, London, ON N6A 5B9, Canada; Department of Mechanical & Materials Engineering, Western University, 1151 Richmond Street N, London, ON N6A 5B9, Canada; Western's Bone and Joint Institute, Western University, London, ON, Canada
| |
Collapse
|
2
|
Whittaker JL, Kalsoum R, Bilzon J, Conaghan PG, Crossley K, Dodge GR, Getgood A, Li X, Losina E, Mason DJ, Pietrosimone B, Risberg MA, Roemer F, Felson D, Culvenor AG, Meuffels D, Gerwin N, Simon LS, Lohmander LS, Englund M, Watt FE. Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop. Osteoarthr Cartil Open 2024; 6:100449. [PMID: 38440780 PMCID: PMC10910316 DOI: 10.1016/j.ocarto.2024.100449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 03/06/2024] Open
Abstract
Objective The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies. Design An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward. Results Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population. Conclusions Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.
Collapse
Affiliation(s)
- Jackie L. Whittaker
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
- Arthritis Research Canada, Vancouver, Canada
| | - Raneem Kalsoum
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - James Bilzon
- Department for Health, University of Bath, Bath, UK
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, UK
| | - Philip G. Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Kay Crossley
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - George R. Dodge
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Mechano Therapeutics LLC, Philadelphia, PA, USA
| | - Alan Getgood
- Division of Orthopedic Surgery, Bone and Joint Institute, Fowler Kennedy Sport Medicine Clinic, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Xiaojuan Li
- Program of Advanced Musculoskeletal Imaging (PAMI), Cleveland Clinic, OH, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, OH, USA
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, USA
| | - Deborah J. Mason
- Biomechanics and Bioengineering Research Centre Versus Arthritis, School of Biosciences, Cardiff University, Cardiff, UK
| | - Brian Pietrosimone
- Department of Exercise and Sport Science, University of North Carolina, USA
| | - May Arna Risberg
- Norwegian School Sport Sciences, Oslo, Norway
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Frank Roemer
- Department of Radiology, Universitätsklinikum Erlangen & Friedrich- Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - David Felson
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Adam G. Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - Duncan Meuffels
- Orthopedic and Sport Medicine Department, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - L. Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Martin Englund
- Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Fiona E. Watt
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, University of Oxford, UK
| |
Collapse
|
3
|
Beel W, Firth AD, Tulloch S, Abdelrehman T, Olotu O, Bryant D, Getgood A. Extrusion After Meniscal Allograft Transplantation Is Lower or Equal With Bony Compared With Soft-Tissue Root Fixation: A Systematic Review. Arthroscopy 2024:S0749-8063(24)00232-9. [PMID: 38521206 DOI: 10.1016/j.arthro.2024.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/19/2024] [Accepted: 02/29/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE To provide an update on the incidence and extent of graft extrusion after meniscal allograft transplantation (MAT) and to systematically review the literature to identify whether the type of root fixation or additional surgical techniques may reduce the risk of graft extrusion development. METHODS A systematic search, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, was conducted using the MEDLINE database, EMBASE database, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL) database. Patients undergoing medial meniscal allograft transplantation (MMAT) or lateral meniscal allograft transplantation (LMAT) were included. The primary outcome measure was meniscal extrusion measured on postoperative magnetic resonance imaging scans taken more than 6 weeks after MAT. The following extrusion outcomes were investigated: absolute extrusion (AE), relative percentage of extrusion (RPE), and proportion of major extrusion (PME). Additional surgical techniques that reduced the risk of graft extrusion development in the included comparative studies were identified. RESULTS For MMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.2 mm versus 3.36 mm and RPE of 44.43% versus 33.18%. The pooled mean PME for MMAT with soft-tissue fixation was 51.62%. For LMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.72 mm versus 2.78 mm, RPE of 31.89% versus 29.47%, and PME of 64.37% versus 35.80%. Additional capsulodesis was identified as a technique to reduce LMAT extrusion. CONCLUSIONS This study highlights that graft extrusion is a common finding after MMAT and LMAT, independent of the root fixation technique. However, MAT extrusion with bony fixation was, depending on the outcome measurement, lower than or equal to that with soft-tissue fixation. LEVEL OF EVIDENCE Level IV, systematic review of Level I, III, and IV studies.
Collapse
Affiliation(s)
- Wouter Beel
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Andrew D Firth
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Canada; Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Scott Tulloch
- Department of Orthopedic Surgery, Western Health, Footscray Hospital, Melbourne, Australia
| | | | - Olumide Olotu
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Dianne Bryant
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada.
| |
Collapse
|
4
|
Barton KI, Boldt KR, Sogbein OA, Steiner NJ, Moatshe G, Arendt E, Getgood A. Femoral Internal Torsion Greater than Twenty-Five Degrees and/or External Tibial Torsion Greater than Thirty Degrees as Measured by Computed Tomography are Threshold Values for Axial Alignment Correction in Patellofemoral Instability. J ISAKOS 2024:S2059-7754(24)00030-0. [PMID: 38365167 DOI: 10.1016/j.jisako.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES Patellofemoral instability (PFI) has multiple predisposing anatomic factors including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea dysplasia, excessive lateral patellar tilt, and excessive lateral Q vector. Yet, few studies have analyzed surgical thresholds for performing axial alignment corrective osteotomies in the treatment of PFI and patella maltracking. The objective of this systematic literature review was to determine if there is a threshold for axial plane alignment that triggers surgical correction for treatment of patellar instability in the published literature. METHODS Using a predetermined search strategy, a systematic literature search of 10 major databases and grey literature resources was completed. Only studies reporting on patellar instability with outcomes were included. Radiologic indications, additional procedures, outcomes, and complications were reported. Titles and abstracts were screened, and full text manuscripts were then selected and extracted. Variables related to radiographic and clinical parameters, patient demographics, surgery performed, surgical correction, complications, and reoperations were recorded pre-operative and post-operative. RESULTS A total of 1132 abstracts and titles were screened by two reviewers yielding 15 eligible studies. The reported threshold identified in our study for axial plane alignment that triggers surgical correction in most of the published literature when discussing PFI was either tibial torsion greater than 30 degrees and/or femoral anteversion greater than 25 degrees. Following rotational osteotomy of one or both long bones, one study (7%) reported improvements in tubercle-sulcus angle, two studies (13%) reported improvements in femoral-tibial angle, four studies (27%) reported decreases in tibial torsion. For patient reported outcomes, seven studies (47%) reported improvement in Kujala score, five studies (33%) reported postoperative improvement in Lysholm, and four studies (27%) reported improved International Knee Documentation Committee (IKDC) score. Nine studies (60%) reported pre-operative femoral anteversion; however, only two studies compared pre- and post-operative values (one study reported a decrease in anteversion where another study reported an increase in anteversion). CONCLUSION When treating PFI, the reported threshold for axial plane alignment that triggers surgical correction in most of the published literature was tibial torsion greater than 30 degrees and/or femoral anteversion greater than 25 degrees as measured by CT. However, there is no consensus on axial alignment measurement technique. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Kristen I Barton
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, Canada; Faculty of Health Sciences, Western University, London, ON, Canada.
| | - Kevin R Boldt
- School of Kinesiology, Trent University, Peterborough, ON, Canada
| | - Olawale A Sogbein
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, Canada
| | | | | | | | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, Canada; Orthopaedic Surgery, Schulich School of Dentistry and Medicine, Western University, London, ON, Canada; Faculty of Health Sciences, Western University, London, ON, Canada
| |
Collapse
|
5
|
Vivacqua TA, Winkler PW, Lucidi GA, Firth AD, Musahl V, Getgood A. Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts. Arthroscopy 2024:S0749-8063(24)00090-2. [PMID: 38331366 DOI: 10.1016/j.arthro.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic trial.
Collapse
Affiliation(s)
- Thiago Alberto Vivacqua
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Philipp W Winkler
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria; Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Gian Andrea Lucidi
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Andrew D Firth
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Volker Musahl
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Alan Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.
| |
Collapse
|
6
|
Martin RK, Marmura H, Wastvedt S, Pareek A, Persson A, Moatshe G, Bryant D, Wolfson J, Engebretsen L, Getgood A. External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial. Knee Surg Sports Traumatol Arthrosc 2024; 32:206-213. [PMID: 38226736 DOI: 10.1002/ksa.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE Level 3, cohort study.
Collapse
Affiliation(s)
- R Kyle Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Orthopaedic Surgery, CentraCare, Saint Cloud, Minnesota, USA
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
| | - Hana Marmura
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
| | - Solvejg Wastvedt
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Andreas Persson
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Dianne Bryant
- School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
| | - Julian Wolfson
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lars Engebretsen
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo, Norway
- Orthopaedic Clinic, Oslo University Hospital Ullevål, Oslo, Norway
| | - Alan Getgood
- Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
7
|
Palmer J, Getgood A, Lobenhoffer P, Nakamura R, Monk P. Medial opening wedge high tibial osteotomy for the treatment of medial unicompartmental knee osteoarthritis: A state-of-the-art review. J ISAKOS 2024; 9:39-52. [PMID: 37839705 DOI: 10.1016/j.jisako.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
Medial unicompartmental knee osteoarthritis is a common condition that is frequently associated with significant pain and dysfunction. Medial opening wedge high tibial osteotomy (MOWHTO) offers a unique opportunity to preserve the knee joint and potentially alter the course of the degenerative process. Recent advances in this field of surgery have enabled surgeons to perform a MOWHTO in a safe, reliable and reproducible manner. This state-of-the-art review highlights the most important advances in the field of MOWHTO. Key concepts related to patient selection, pre-operative planning, surgical accuracy and patient outcome are considered. The importance of an individualized approach is emphasized and its influence on the future direction of the procedure is discussed.
Collapse
Affiliation(s)
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada, N6A 3K7
| | | | - Ryuichi Nakamura
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, 919-0476, Japan
| | - Paul Monk
- Unisports Orthopaedics, Auckland, 1072, New Zealand; Department of Trauma and Orthopaedics, Auckland City Hospital, Auckland, 1023, New Zealand.
| |
Collapse
|
8
|
Degen RM, Donnelly E, Toobaie A, Ng KCG, Getgood A, Willing R. Early Postoperative Activities of Daily Living Do Not Adversely Affect Joint Torques or Translation Regardless of Capsular Condition: A Cadaveric Study. Arthroscopy 2024; 40:362-370. [PMID: 37391102 DOI: 10.1016/j.arthro.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/04/2023] [Accepted: 05/31/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE To evaluate the impact of capsular management on joint constraint and femoral head translations during simulated activities of daily living (ADL). METHODS Using 6 (n = 6) cadaveric hip specimens, the effect of capsulotomies and repair was then evaluated during simulated ADL. Joint forces and rotational kinematics associated with gait and sitting, adopted from telemeterized implant studies, were applied to the hip using a 6-degrees of freedom (DOF) joint motion simulator. Testing occurred after creation of portals, interportal capsulotomy (IPC), IPC repair, T-capsulotomy (T-Cap), partial T-Cap repair, and full T-Cap repair. The anterior-posterior (AP), medial-lateral (ML), and axial compression DOFs were operated in force control, whereas flexion-extension, adduction-abduction, and internal-external rotation were manipulated in displacement control. Resulting femoral head translations and joint reaction torques were recorded and evaluated. Subsequently, the mean-centered range of femoral head displacements and peak signed joint restraint torques were calculated and compared. RESULTS During simulated gait and sitting, the mean range of AP femoral head displacements with respect to intact exceeded 1% of the femoral head diameter after creating portals, T-Caps, and partial T-Cap repair (Wilcoxon signed rank P < .05); the mean ranges of ML displacements did not. Deviations in femoral head kinematics varied by capsule stage but were never very large. No consistent trends with respect to alterations in peak joint restrain torques were observed. CONCLUSIONS In this cadaveric biomechanical study, capsulotomy and repair minimally affected resultant femoral head translation and joint torques during simulated ADLs. CLINICAL RELEVANCE The tested ADLs appear safe to perform after surgery, regardless of capsular status, because adverse kinematics were not observed. However, further study is required to determine the importance of capsular repair beyond time-zero biomechanics and the resultant effect on patient-reported outcomes.
Collapse
Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario; Bone and Joint Institute, Western University, London, Ontario; Department of Surgery, Western University, London, Ontario.
| | - Emma Donnelly
- Department of Mechanical and Materials Engineering, Western University, London, Ontario
| | - Asra Toobaie
- Department of Surgery, Western University, London, Ontario
| | - K C Geoffrey Ng
- Department of Surgery, Western University, London, Ontario; Department of Medical Biophysics, Western University, London, Ontario; Department of Medical Imaging, Western University, London, Ontario; Robarts Research Institute, London, Ontario
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario; Bone and Joint Institute, Western University, London, Ontario; Department of Surgery, Western University, London, Ontario
| | - Ryan Willing
- Department of Mechanical and Materials Engineering, Western University, London, Ontario; Department of Medical Imaging, Western University, London, Ontario; Robarts Research Institute, London, Ontario
| |
Collapse
|
9
|
Hurley ET, Sherman SL, Chahla J, Gursoy S, Alaia MJ, Tanaka MJ, Pace JL, Jazrawi LM, Hughes AJ, Arendt EA, Ayeni OR, Bassett AJ, Bonner KF, Camp CL, Campbell KA, Carter CW, Ciccotti MG, Cosgarea AJ, Dejour D, Edgar CM, Erickson BJ, Espregueira-Mendes J, Farr J, Farrow LD, Frank RM, Freedman KB, Fulkerson JP, Getgood A, Gomoll AH, Grant JA, Gwathmey FW, Haddad FS, Hiemstra LA, Hinckel BB, Savage-Elliott I, Koh JL, Krych AJ, LaPrade RF, Li ZI, Logan CA, Gonzalez-Lomas G, Mannino BJ, Lind M, Matache BA, Matzkin E, Mandelbaum B, McCarthy TF, Mulcahey M, Musahl V, Neyret P, Nuelle CW, Oussedik S, Verdonk P, Rodeo SA, Rowan FE, Salzler MJ, Schottel PC, Shannon FJ, Sheean AJ, Strickland SM, Waterman BR, Wittstein JR, Zacchilli M, Zaffagnini S. A modified Delphi consensus statement on patellar instability: part II. Bone Joint J 2023; 105-B:1265-1270. [PMID: 38035602 DOI: 10.1302/0301-620x.105b12.bjj-2023-0110.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jorge Chahla
- Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Safa Gursoy
- Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J L Pace
- Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | | | - Christopher L Camp
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David Dejour
- Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Cory M Edgar
- Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | | | - João Espregueira-Mendes
- Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal
| | - Jack Farr
- OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA
| | - Lutul D Farrow
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Andreas H Gomoll
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - John A Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - F W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jason L Koh
- NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Catherine A Logan
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Brian J Mannino
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Martin Lind
- Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Bogdan A Matache
- Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bert Mandelbaum
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | | | - Mary Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Sam Oussedik
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium
| | - Scott A Rodeo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Fiachra E Rowan
- Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland
| | - Matthew J Salzler
- Department of Orthopedics, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Patrick C Schottel
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Fintan J Shannon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | | | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
10
|
Heard M, Marmura H, Bryant D, Litchfield R, McCormack R, MacDonald P, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Getgood A. Corrigendum to 'No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction - Results from the stability randomized trial' [Journal of ISAKOS 8 (2023) 246-254]. J ISAKOS 2023; 8:513. [PMID: 37845163 DOI: 10.1016/j.jisako.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- M Heard
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; Banff Sport Medicine, T1W 0L5, Canada
| | - H Marmura
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - D Bryant
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - R Litchfield
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada
| | - R McCormack
- Department of Orthopaedics, University of British Columbia, V5Z 1M9, Canada; New West Orthopaedic & Sports Medicine Centre, V3L 5P5, Canada
| | - P MacDonald
- Department of Surgery, University of Manitoba, R3A 1R9, Canada; Pan Am Clinic, R3M 3E4, Canada
| | - T Spalding
- University Hospital Coventry and Warwickshire NHS Trust, CV2 2DX, UK
| | - P Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, 9000, Belgium; Antwerp Orthopedic Center, 2018, Belgium
| | - D Peterson
- Department of Surgery, McMaster University, L8S 4K1, Canada
| | - D Bardana
- Department of Surgery, Queen's University, K7L 2V7, Canada
| | - A Rezansoff
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; University of Calgary Sport Medicine Centre, T2N 1N4, Canada
| | - A Getgood
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada.
| |
Collapse
|
11
|
Hurley ET, Hughes AJ, Savage-Elliott I, Dejour D, Campbell KA, Mulcahey MK, Wittstein JR, Jazrawi LM, Alaia MJ, Arendt EA, Ayeni OR, Bassett AJ, Bonner KF, Camp CL, Carter CW, Chahla J, Ciccotti MG, Cosgarea AJ, Edgar CM, Erickson BJ, Espregueira-Mendes J, Farr J, Farrow LD, Frank RM, Freedman KB, Fulkerson JP, Getgood A, Gomoll AH, Grant JA, Gursoy S, Gwathmey FW, Haddad FS, Hiemstra LA, Hinckel BB, Koh JL, Krych AJ, LaPrade RF, Li ZI, Logan CA, Gonzalez-Lomas G, Mannino BJ, Lind M, Matache BA, Matzkin E, McCarthy TF, Mandelbaum B, Musahl V, Neyret P, Nuelle CW, Oussedik S, Pace JL, Verdonk P, Rodeo SA, Rowan FE, Salzler MJ, Schottel PC, Shannon FJ, Sheean AJ, Sherman SL, Strickland SM, Tanaka MJ, Waterman BR, Zacchilli M, Zaffagnini S. A modified Delphi consensus statement on patellar instability: part I. Bone Joint J 2023; 105-B:1259-1264. [PMID: 38037678 DOI: 10.1302/0301-620x.105b12.bjj-2023-0109.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.
Collapse
Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - David Dejour
- Orthopaedic Department, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Loyola University, Chicago, Illinois, USA
| | - Jocelyn R Wittstein
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | | | - Christopher L Camp
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Cory M Edgar
- Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | | | - João Espregueira-Mendes
- Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal
| | - Jack Farr
- OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA
| | - Lutul D Farrow
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Andreas H Gomoll
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - John A Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - F W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Jason L Koh
- NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Catherine A Logan
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Brian J Mannino
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Martin Lind
- Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Bogdan A Matache
- Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Bert Mandelbaum
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Sam Oussedik
- University College London Hospitals NHS Foundation Trust, London, UK
| | - J L Pace
- Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium
| | - Scott A Rodeo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Fiachra E Rowan
- Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland
| | - Matthew J Salzler
- Department of Orthopedics, Tufts University School of Medicine, Boston, USA
| | - Patrick C Schottel
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, Burlington, Vermont, USA
| | - Fintan J Shannon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | | | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
12
|
McNeill K, Marmura H, Werstine M, Alcock G, Birmingham T, Willits K, Getgood A, LeBel ME, Litchfield R, Bryant D, Giffin JR. The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2023; 32:884-893. [PMID: 37699588 DOI: 10.1123/jsr.2022-0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 09/14/2023]
Abstract
CONTEXT The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. METHODS One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. RESULTS There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval, 1.3 to 10.4; P = .01). CONCLUSION A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.
Collapse
Affiliation(s)
- Kestrel McNeill
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
| | - Hana Marmura
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Bone and Joint Institute, Western University, London, ON,Canada
| | - Melanie Werstine
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
| | - Greg Alcock
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
| | - Trevor Birmingham
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Bone and Joint Institute, Western University, London, ON,Canada
- Wolf Orthopedic Biomechanics Lab, Western University, London, ON,Canada
| | - Kevin Willits
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Marie-Eve LeBel
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Dianne Bryant
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - J Robert Giffin
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Wolf Orthopedic Biomechanics Lab, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| |
Collapse
|
13
|
Vakili S, Lanting B, Getgood A, Willing R. Development of Multibundle Virtual Ligaments to Simulate Knee Mechanics After Total Knee Arthroplasty. J Biomech Eng 2023; 145:1163160. [PMID: 37216311 DOI: 10.1115/1.4062421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Indexed: 05/24/2023]
Abstract
Preclinical evaluation of total knee arthroplasty (TKA) components is essential to understanding their mechanical behavior and developing strategies for improving joint stability. While preclinical testing of TKA components has been useful in quantifying their effectiveness, such testing can be criticized for lacking clinical relevance, as the important contributions of surrounding soft tissues are either neglected or greatly simplified. The purpose of our study was to develop and determine if subject-specific virtual ligaments reproduce a similar behavior as native ligaments surrounding TKA joints. Six TKA knees were mounted to a motion simulator. Each was subjected to tests of anterior-posterior (AP), internal-external (IE), and varus-valgus (VV) laxity. The forces transmitted through major ligaments were measured using a sequential resection technique. By tuning the measured ligament forces and elongations to a generic nonlinear elastic ligament model, virtual ligaments were designed and used to simulate the soft tissue envelope around isolated TKA components. The average root-mean-square error (RMSE) between the laxity results of TKA joints with native versus virtual ligaments was 3.5 ± 1.8 mm during AP translation, 7.5 ± 4.2 deg during IE rotations, and 2.0 ± 1.2 deg during VV rotations. Interclass correlation coefficients (ICCs) indicated a good level of reliability for AP and IE laxity (0.85 and 0.84). To conclude, the advancement of virtual ligament envelopes as a more realistic representation of soft tissue constraint around TKA joints is a valuable approach for obtaining clinically relevant kinematics when testing TKA components on joint motion simulators.
Collapse
Affiliation(s)
- Samira Vakili
- School of Biomedical Engineering, Western University, 1151 Richmond Street North, London, ON N6A 3K7, Canada; Western's Bone and Joint Institute, University Hospital, London, ON N6G 2V4, Canada
| | - Brent Lanting
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada; Western's Bone and Joint Institute, University Hospital, London, ON N6G 2V4, Canada
| | - Alan Getgood
- Department of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, London, ON N6A 5A5, Canada; Department of Surgery, Fowler-Kennedy Sport Medicine Clinic 3M Centre, Western University, London, ON N6A 3K7, Canada; Western's Bone and Joint Institute, University Hospital, London, ON N6G 2V4, Canada
| | - Ryan Willing
- School of Biomedical Engineering, Western University, London, ON N6A 3K7, Canada; Department of Mechanical and Materials Engineering, Western University, 1151 Richmond Street North, London, ON N6A 5B9, Canada; Western's Bone and Joint Institute, University Hospital, London, ON N6G 2V4, Canada
| |
Collapse
|
14
|
Heard M, Marmura H, Bryant D, Litchfield R, McCormack R, MacDonald P, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Getgood A. No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction - Results from the stability randomized trial. J ISAKOS 2023; 8:246-254. [PMID: 36646169 DOI: 10.1016/j.jisako.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Results from the Stability Study suggest that adding a lateral extra-articular tenodesis (LET) to a hamstring tendon autograft reduces the rate of anterior cruciate ligament reconstruction (ACLR) failure in high-risk patients. The purpose of this study is to report adverse events over the 2-year follow-up period and compare groups (ACLR alone vs. ACLR + LET). METHODS Stability is a randomized clinical trial comparing hamstring tendon ACLR with and without LET. Patients aged 14-25 years with an ACL deficient knee were included. Patients were followed and adverse events documented (type, actions taken, resolution) with visits at 3, 6, 12, and 24 months postoperatively. Adverse events were categorized as none, minor medical, minor surgical, contralateral ACL rupture, or graft rupture. Patient reported outcome measures (PROMs) collected at each visit included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score (IKDC), and ACL Quality of Life Questionnaire (ACL-QOL). RESULTS In total, 618 patients were randomized (mean age 18.9 years, 302 (49%) male). Forty-five patients (7%) suffered graft rupture; 34 (11%) in the ACLR group compared to 11 (4%) in the ACLR + LET group (RRR = 0.67, 95% CI 0.36 to 0.83, p < 0.001). There were no differences in effusion or infection rates between groups. The ACLR + LET group experienced an increased number of hardware removals (10 vs. 4). Overall, the rate of minor medical events (11%), minor surgical events (7%), and ipsilateral or contralateral ACL tears (10%) were low considering the high-risk patient profile. Increasing severity of adverse events was associated with lower PROMs at 24 months post-operative. Patients in the ACLR + LET group reported greater degree of pain at 3 months only. There were no clinically significant differences in range of motion between groups. CONCLUSIONS The addition of LET to hamstring tendon autograft ACLR in young patients at high risk of re-injury resulted in a statistically significant reduction in graft rupture. While the addition of LET may increase rates of hardware irritation, there was no significant increase in overall rates of minor medical adverse events, minor surgical events, or overall re-operation rates. The concerns regarding complications associated with a LET did not materialize in this study. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- M Heard
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; Banff Sport Medicine, T1W 0L5, Canada
| | - H Marmura
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - D Bryant
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - R Litchfield
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada
| | - R McCormack
- Department of Orthopaedics, University of British Columbia, V5Z 1M9, Canada; New West Orthopaedic & Sports Medicine Centre, V3L 5P5, Canada
| | - P MacDonald
- Department of Surgery, University of Manitoba, R3A 1R9, Canada; Pan Am Clinic, R3M 3E4, Canada
| | - T Spalding
- University Hospital Coventry and Warwickshire NHS Trust, CV2 2DX, UK
| | - P Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, 9000, Belgium; Antwerp Orthopedic Center, 2018, Belgium
| | - D Peterson
- Department of Surgery, McMaster University, L8S 4K1, Canada
| | - D Bardana
- Department of Surgery, Queen's University, K7L 2V7, Canada
| | - A Rezansoff
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; University of Calgary Sport Medicine Centre, T2N 1N4, Canada
| | - A Getgood
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada.
| |
Collapse
|
15
|
Chandrabalan A, Firth A, Litchfield RB, Appleton CT, Getgood A, Ramachandran R. Human osteoarthritis knee joint synovial fluids cleave and activate Proteinase-Activated Receptor (PAR) mediated signaling. Sci Rep 2023; 13:1124. [PMID: 36670151 PMCID: PMC9859807 DOI: 10.1038/s41598-023-28068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023] Open
Abstract
Osteoarthritis (OA) is the most prevalent joint disorder with increasing worldwide incidence. Mechanistic insights into OA pathophysiology are evolving and there are currently no disease-modifying OA drugs. An increase in protease activity is linked to progressive degradation of the cartilage in OA. Proteases also trigger inflammation through a family of G protein-coupled receptors (GPCRs) called the Proteinase-Activated Receptors (PARs). PAR signaling can trigger pro-inflammatory responses and targeting PARs is proposed as a therapeutic approach in OA. Several enzymes can cleave the PAR N-terminus, but the endogenous protease activators of PARs in OA remain unclear. Here we characterized PAR activating enzymes in knee joint synovial fluids from OA patients and healthy donors using genetically encoded PAR biosensor expressing cells. Calcium signaling assays were performed to examine receptor activation. The class and type of enzymes cleaving the PARs was further characterized using protease inhibitors and fluorogenic substrates. We find that PAR1, PAR2 and PAR4 activating enzymes are present in knee joint synovial fluids from healthy controls and OA patients. Compared to healthy controls, PAR1 activating enzymes are elevated in OA synovial fluids while PAR4 activating enzyme levels are decreased. Using enzyme class and type selective inhibitors and fluorogenic substrates we find that multiple PAR activating enzymes are present in OA joint fluids and identify serine proteinases (thrombin and trypsin-like) and matrix metalloproteinases as the major classes of PAR activating enzymes in the OA synovial fluids. Synovial fluid driven increase in calcium signaling was significantly reduced in cells treated with PAR1 and PAR2 antagonists, but not in PAR4 antagonist treated cells. OA associated elevation of PAR1 cleavage suggests that targeting this receptor may be beneficial in the treatment of OA.
Collapse
Affiliation(s)
- Arundhasa Chandrabalan
- Department of Physiology and Pharmacology, Bone and Joint Institute, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Andrew Firth
- Division of Orthopedic Surgery, Bone and Joint Institute, Fowler Kennedy Sport Medicine Clinic, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Robert B Litchfield
- Division of Orthopedic Surgery, Bone and Joint Institute, Fowler Kennedy Sport Medicine Clinic, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - C Thomas Appleton
- Department of Physiology and Pharmacology, Bone and Joint Institute, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.,Department of Medicine, Bone and Joint Institute, Schulich School of Medicine and Dentistry, The Dr. Sandy Kirkley Centre for Musculoskeletal Research, London, ON, Canada
| | - Alan Getgood
- Division of Orthopedic Surgery, Bone and Joint Institute, Fowler Kennedy Sport Medicine Clinic, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Rithwik Ramachandran
- Department of Physiology and Pharmacology, Bone and Joint Institute, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.
| |
Collapse
|
16
|
Lodhia P, Nazari G, Bryant D, Getgood A, McCormack R, Getgood AM, Bryant DM, Litchfield R, Willits K, Birmingham T, Hewison C, Firth AD, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, McCormack RG, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Payne K, Heard M, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, MacDonald PB, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Rezansoff A, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Peterson D, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Bardana D, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Verdonk PC, Declerq G, Vuylsteke K, Van Haver M. Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis. Am J Sports Med 2022; 50:3502-3509. [PMID: 36260487 PMCID: PMC9630854 DOI: 10.1177/03635465221128581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. PURPOSE To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. RESULTS Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups. CONCLUSION At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.
Collapse
Affiliation(s)
- Parth Lodhia
- Parth Lodhia, MD, University of British Columbia, 403-233
Nelson’s Crescent, New Westminster, V3L 0E4, Canada (
)
| | - Goris Nazari
- Canadian Institutes of Health Research, Ottawa,
Ontario, Canada
| | - Dianne Bryant
- The University of Western Ontario, London,
Ontario, Canada
| | - Alan Getgood
- Western Ontario University, London, Ontario,
Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western
University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | | | | | - Kyrsten Payne
- Fraser Orthopaedic Institute, New Westminster,
Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary,
Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent,
Belgium,Investigation performed at University of
British Columbia, Vancouver, BC, Canada
| |
Collapse
|
17
|
Donnelly E, Vakili S, Getgood A, Willing R, Degen RM. Cadaveric Biomechanical Evaluation of Capsular Constraint and Microinstability After Hip Capsulotomy and Repair. Orthop J Sports Med 2022; 10:23259671221128348. [PMID: 36313006 PMCID: PMC9608050 DOI: 10.1177/23259671221128348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022] Open
Abstract
Background: It remains unclear if capsular management contributes to iatrogenic instability (microinstability) after hip arthroscopy. Purpose: To evaluate changes in torque, stiffness, and femoral head displacement after capsulotomy and repair in a cadaveric model. Study Design: Controlled laboratory study. Methods: A biomechanical analysis was performed using 10 cadaveric hip specimens. Each specimen was tested under the following conditions: (1) intact, (2) portals, (3) interportal capsulotomy (IPC), (4) IPC repair, (5) T-capsulotomy (T-cap), (6) partial T-cap repair, and (7) T-cap repair. Each capsular state was tested in neutral (0°) and then 30°, 60°, and 90° of flexion, with forces applied to achieve the displacement-controlled baseline limit of external rotation (ER), internal rotation (IR), abduction, and adduction. The resultant end-range torques and displacement were recorded. Results: For ER, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; capsular repairs failed to restore torque and stiffness at 0°; and IPC repair failed to restore stiffness at 30° (P < .05 for all). For IR, capsulotomies significantly reduced torque and stiffness at 0°, 30°, and 60° and reduced stiffness at 90°; and capsular repairs failed to restore torque or stiffness at 0°, 30°, and 60° and failed to restore stiffness at 90° (P < .05 for all). For abduction, IPC significantly decreased torque at 60° and 90° and decreased stiffness at all positions; T-cap reduced torque and stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). For adduction, IPC significantly reduced torque at 0° and reduced stiffness at 0° and 30°; T-cap reduced torque at 0° and 90° and reduced stiffness at all positions; IPC repair failed to restore stiffness at 0° and 90°; and T-cap repair failed at 0°, 60°, and 90° (P < .05 for all). There were no statistically significant femoral head translations observed in any testing configurations. Conclusion: Complete capsular repair did not always restore intact kinematics, most notably at 0° and 30°. Despite this, there were no significant joint translations to corroborate concerns of microinstability. Clinical Relevance: Caution should be employed when applying rotational torques in lower levels of flexion (0° and 30°).
Collapse
Affiliation(s)
- Emma Donnelly
- Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | | | - Alan Getgood
- Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Willing
- Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Ryan M. Degen
- Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada.,Ryan M. Degen, MD, Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada ()
| |
Collapse
|
18
|
Arakgi ME, Burkhart TA, Hoshino T, Degen R, Getgood A. Biomechanical Comparison of Three Suspensory Techniques for all Soft Tissue Central Quadriceps Tendon Graft Fixation. Arthrosc Sports Med Rehabil 2022; 4:e843-e851. [PMID: 35747631 PMCID: PMC9210367 DOI: 10.1016/j.asmr.2021.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 12/01/2021] [Indexed: 10/27/2022] Open
|
19
|
Di Loreto R, Getgood A, Degen R, Burkhart TA. Bone Volumes and Trajectory Angles for Acetabular Anchor Placement Can Be Optimized. Arthrosc Sports Med Rehabil 2022; 4:e447-e452. [PMID: 35494283 PMCID: PMC9042773 DOI: 10.1016/j.asmr.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study was to determine the optimal anchor placement and trajectory when repairing acetabular labral tears during hip arthroscopy with the primary focus on the 12 to 3 o’clock positions on the acetabular rim. Methods Three-dimensional computational models of the pelvis were generated from 13 cadaveric specimens using 3D slicer medical imaging software. A set of cones, consistent with the dimensions of a commonly used sutured anchor, were virtually embedded into the models at the 12, 1, 2, and 3 o’clock positions around the acetabulum. Mirror images of the cone were extended toward the superficial aspect of the hip. The volume of bone occupied by the virtual anchor, the trajectory angle, and the volume of overlap between adjacent anchor locations were calculated. Results Bone volume was significantly greater at the 1 o’clock position (4196.2 [1190.2] mm3) compared with all other positions (P < .001). The 3 o’clock position had the smallest volume (629.2 [180.0] mm3) and was also significantly less than the 12 (P < .001) and 2 o’clock (P = .014) positions). The trajectory angle of 32.04 [5.05]°) at the 1 o’clock position was significantly greater compared with all other positions (P < .001). The least amount of adjacent position overlap occurred between the 2 and 3 o’clock positions (.12 [.42] mm3), and this was statistically smaller than the overlap between cones at the 12 and 1 o’clock positions (214.28 [251.88] mm3; P = .029) and the 1 and 2 o’clock positions (139.51 [177.14] mm3; P = .044). Conclusions Trajectory angles and the thickness of bone around the acetabulum were the greatest at the 12 to 1 o’clock positions, with the 1 o’clock position identified as that with the largest trajectory angle for safe anchor insertion. Clinical Relevance The use of a single, workhorse portal, for anchor insertion may not be recommended and careful selection of a portal allowing a direct approach should be used for anterior anchor insertion.
Collapse
|
20
|
Marsh JD, Degen R, Birmingham TB, Giffin JR, Getgood A, Litchfield R, Willits K, McClure JA, Welk B. The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study. Can J Surg 2022; 65:E114-E120. [PMID: 35181579 PMCID: PMC8863184 DOI: 10.1503/cjs.002221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.
Collapse
Affiliation(s)
- Jacquelyn D Marsh
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Ryan Degen
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Trevor B Birmingham
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - J Robert Giffin
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Alan Getgood
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Robert Litchfield
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Kevin Willits
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - J Andrew McClure
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Blayne Welk
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| |
Collapse
|
21
|
Docter S, Lukacs MJ, Fathalla Z, Khan MCM, Jennings M, Liu SH, Dong S, Getgood A, Bryant DM. Inconsistencies in the Methodological Framework Throughout Published Studies in High-Impact Orthopaedic Journals: A Systematic Review. J Bone Joint Surg Am 2022; 104:181-188. [PMID: 34648473 DOI: 10.2106/jbjs.21.00116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Both the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines recommend that clinical trials follow a study framework that aligns with their objective to test the relative efficacy or safety (equality) or effectiveness (superiority, noninferiority, or equivalence) between interventions. We conducted a systematic review to assess the proportion of studies that demonstrated inconsistency between the framing of their research question, sample size calculation, and conclusion and those that should have framed their research question differently based on the compared interventions. METHODS We included studies from 5 high-impact-factor orthopaedic journals published in 2017 and 2019 that compared at least 2 interventions using patient-reported outcome measures. RESULTS We included 228 studies. The sample size calculation was reported in 60.5% (n = 138) of studies. Of these, 52.2% (n = 72) were inconsistent between the framing of their research question, sample size calculation, and conclusion. The majority (n = 137) of sample size calculations were for equality, but 43.8% of these studies concluded superiority, noninferiority, or equivalence. Studies that framed their research question as equality (n = 186) should have been framed as superiority (n = 129), equivalence (n = 52), or noninferiority (n = 3). Only 2 studies correctly framed their research question as equality. CONCLUSIONS Studies published in high-impact journals were inconsistent between the framing of their research question, sample size calculation, and conclusion. Authors may be misinterpreting research findings and making clinical recommendations solely based on p values. Researchers are encouraged to state and justify their methodological framework and choice of margin(s) in a publicly published protocol as they have implications for sample size and the applicability of conclusions. CLINICAL RELEVANCE The results of clinical research must be interpreted using confidence intervals, with careful consideration as to how the confidence intervals relate to clinically meaningful differences in outcomes between treatments. The more typical practice of relying on p values leaves the clinician at high risk of erroneous interpretation, recommendation, and/or action.
Collapse
Affiliation(s)
- Shgufta Docter
- Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Michael J Lukacs
- Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Zina Fathalla
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michaela C M Khan
- Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Morgan Jennings
- Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Shu-Hsuan Liu
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Susan Dong
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Alan Getgood
- Bone and Joint Institute, Western University, London, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Fowler Kennedy Sport Medicine, Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Faculty of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Division of Orthopaedics, Department of Surgery, Fowler Kennedy Sport Medicine, Western University, London, Ontario, Canada
| |
Collapse
|
22
|
Getgood A. Editorial Commentary: Indications for Lateral Extra-Articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction. Arthroscopy 2022; 38:125-127. [PMID: 34972553 DOI: 10.1016/j.arthro.2021.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 02/02/2023]
Abstract
Lateral extra-articular tenodesis and other anterolateral procedures improve patient outcomes when combined with anterior cruciate ligament reconstruction. Failure rates are >50% lower in young patients at high risk of reinjury. We defined patients at high risk as those aged 14 to 25 years with 2 or more factors of the following criteria: 1) returning to contact pivoting sport, 2) high-grade anterolateral rotatory laxity, as measured by pivot shift test (grade 2 or higher), and 3) generalized ligamentous laxity (Beighton score greater than 4) or knee hyperextension recurvatum of greater than 10°. Other indications may include Segond fracture, chronic anterior cruciate ligament lesion, radiographic lateral femoral notch sign, and lateral coronal plane laxity. A clearer understanding of indications determined by a comprehensive clinical assessment and risk stratification is needed. As indications continue to be "stretched," we need to better understand the role of lateral extra-articular tenodesis and when to employ it in our practice.
Collapse
|
23
|
Malone A, Price J, Price N, Peck V, Getgood A, Petrella R, Helliwell J. Safety and pharmacokinetics of EP-104IAR (sustained-release fluticasone propionate) in knee osteoarthritis: A randomized, double-blind, placebo-controlled phase 1 trial. Osteoarthritis and Cartilage Open 2021; 3:100213. [DOI: 10.1016/j.ocarto.2021.100213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022] Open
|
24
|
Abstract
Valgus malalignment is an important risk factor in recurrent patella instability. This article explores the role of corrective osteotomy and discusses the various described methods both on the femoral and tibial sides of the joint. A detailed operative technique of medial closing wedge distal femoral osteotomy is included.
Collapse
Affiliation(s)
- Scott Taylor
- Department of Surgery, Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Alan Getgood
- Department of Surgery, Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada.
| |
Collapse
|
25
|
Blokker AM, Wood R, Milner JC, Holdsworth DW, Burkhart TA, Getgood A. Novel quantification of the regional strain distribution in the anterior cruciate ligament in response to simulated loading using micro-CT imaging. J Exp Orthop 2021; 8:95. [PMID: 34677691 PMCID: PMC8536806 DOI: 10.1186/s40634-021-00416-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/12/2021] [Indexed: 11/12/2022] Open
Abstract
Purpose A large percentage of anterior cruciate ligament (ACL) surgical reconstructions experience sub-optimal outcomes within 2 years. A potential factor contributing to poor outcomes is an incomplete understanding of micro-level, regional ACL biomechanics. This research aimed to demonstrate a minimally invasive method that uses micro-CT imaging to quantify regional ACL strains under clinically relevant joint loading. Methods A pattern of 0.8 mm diameter zirconium dioxide beads were arthroscopically inserted into four regions of the ACL of four cadaveric knee specimens (mean [SD] age = 59 [9] years). A custom micro-CT compatible joint motion simulator then applied clinically relevant joint loading conditions, while an image was acquired at each condition. From the resulting images, strains within each region were calculated using the centroid coordinates of each tissue-embedded bead. Strain repeatability was assessed using the mean intra-specimen standard deviation across repeated load applications. A one-way repeated measures ANOVA (α = 0.05) was used to determine regional strain variations. Results The mean intra-specimen standard deviation across repeated load application was ±0.003 strain for all specimens. No statistically significant differences were found between tissue regions, although medium and large effect sizes (0.095–0.450) suggest that these differences may be clinically relevant. Conclusions The method presented here demonstrates a minimally invasive measurement of regional ACL strain under clinically relevant joint loads using micro-CT imaging. The strain measurements demonstrated excellent reliability across the five repeated load applications and suggest a non-homogenous distribution of strain through the ACL.
Collapse
Affiliation(s)
| | - Ryan Wood
- Fowler Kennedy Sports Medicine Institute, Western University, London, ON, Canada
| | - Jaques C Milner
- Robarts Research Institute, Western University, London, ON, Canada
| | - David W Holdsworth
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Timothy A Burkhart
- Kinesiology and Physical Education, University of Toronto, 55 Harbord St, Toronto, ON, M5S 2W6, Canada.
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, London, ON, Canada.,Department of Surgery, Western University, London, ON, Canada
| |
Collapse
|
26
|
Sidhu R, Moatshe G, Firth A, Litchfield R, Getgood A. Low rates of serious complications but high rates of hardware removal after high tibial osteotomy with Tomofix locking plate. Knee Surg Sports Traumatol Arthrosc 2021; 29:3361-3367. [PMID: 32789527 DOI: 10.1007/s00167-020-06199-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to analyse adverse events encountered in medial opening wedge high tibial osteotomy (MOWHTO) utilizing contemporary surgical techniques with the Tomofix locking plate (DePuy Synthes, Raynham, MA, USA) and categorize them by their severity and need for further medical/surgical management. It was hypothesized that there would be low rates of serious complications after medial opening wedge high tibial osteotomy utilizing an internal locking plate fixator. METHODS This study included 169 consecutive patients (200 knees) who underwent MOWHTO with a Tomofix locking plate at a single center, completing a minimum 2-year follow-up. Types of intra- and post-operative adverse events were retrospectively identified by an independent observer and categorized by their severity and further need of management. Additional surgery due to elective hardware removal was not included in the adverse event classification. RESULTS There were in total 58 (29%) adverse events, the majority (13.5%) of which required no additional treatment (class 1). Class 1 events included lateral cortex hinge fractures that were observed in 8.5% (17 knees) and delayed wound healing 2% (4/200). Adverse events requiring additional or extended nonoperative management (class 2) were 9%. These included post-operative stiffness in 1% (2/200), low grade infection in 1.5% (3/200), delayed union in 5.4% (11/200), deep vein thrombosis 0.5% (1/200). One hundred and four knees (52%) underwent elective hardware removal. Serious adverse events requiring unplanned additional or revision surgery and/or long-term medical care (class 3) were the least reported (6.5%). Aseptic non-union was reported in 2.5%, deep infection requiring revision in 2% and limited hardware failure 1%. CONCLUSION A low rate of serious complications (6.5%) requiring unplanned additional surgery (class 3) was found. The overall rate of complications following MOWHTO with Tomofix locking plate was 29% and the majority (13.5%) required no additional treatment (class 1). Lateral hinge fractures were the most common complication (8.5%) and these were associated with corrections over 12 mm. However, 52% knees required a further operation for elective hardware removal. LEVEL OF EVIDENCE Level IV, prospective study without control group.
Collapse
Affiliation(s)
- Rajeshwar Sidhu
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Gilbert Moatshe
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada.,OSTRC, Norwegian School of Sports Sciences, Oslo, Norway
| | - Andrew Firth
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Robert Litchfield
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada.
| |
Collapse
|
27
|
Nazari G, Barton KI, Bryant D, Getgood A, Brown CH. Five- and six-strand hamstring grafts consistently produce appropriate graft diameters for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:2940-2947. [PMID: 33037449 DOI: 10.1007/s00167-020-06313-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Hamstring tendon graft diameter less than 8 mm has been correlated with an increased risk of anterior cruciate ligament reconstruction (ACLR) graft failure. The purpose of this study was to measure and compare the diameter of 3-, 4-, 5-, and 6-strand gracilis and semitendinosus (ST) hamstring tendon (HT) ACLR grafts, and to determine if there is a correlation between anthropometric data, HT length, and diameter of the HT ACLR graft. METHODS Male patients (n = 78) undergoing primary or revision ACLR with a HT autograft between July 2018 and March 2020 were recruited. Pre-operative anthropometric data was collected. Gracilis and ST tendons were harvested and the length and diameter measured. The following HT graft configurations were prepared in each patient: triple ST; double gracilis + double ST; double gracilis + triple ST; triple gracilis + triple ST. Paired t-tests and Pearson's correlation coefficients were used to assess demographics, anthropometrics, graft diameter, and tendon length. A non-parametric test was used to compare femoral and tibial ACL graft diameters of the 3-, 4-, 5-, and 6-strand HT graft configurations. RESULTS For the femoral end, 10%, 19%, 69% and 86% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5- and 6-strand HT graft configurations respectively. For the tibial end, 27%, 10%, 83%, and 92% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5-, and 6-strand HT graft configurations respectively. The largest increases in HT graft diameters were noted between the femoral end of 6- vs. 3-strand grafts (mean difference 1.7 ± 0.5 mm; p < 0.001) and between the tibial end of 6- vs. 4-strand grafts (mean difference 2.0 ± 0.5 mm; p < 0.001). Height and leg length were moderately positively correlated with ST tendon length (r = 0.54-0.51) and gracilis tendon length (r = 0.52-0.45), and thigh and shank lengths were moderately positively correlated with ST tendon length (r = 0.43 and 0.40, respectively). CONCLUSION Traditional 4-strand HT ACL autografts in male patients undergoing ACLR in the United Arab Emirates result in graft diameters less than 8 mm in the majority of patients. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
| | - Kristen I Barton
- Western University, London, Canada
- Orthopaedic Surgery, London Health Sciences Centre, London, Canada
| | - Dianne Bryant
- Western University, London, Canada
- Fowler Kennedy Sports Medicine Clinic, London, Canada
| | - Alan Getgood
- Western University, London, Canada
- Orthopaedic Surgery, London Health Sciences Centre, London, Canada
- Fowler Kennedy Sports Medicine Clinic, London, Canada
- International Knee and Joint Centre, Abu Dhabi, United Arab Emirates
| | - Charles H Brown
- International Knee and Joint Centre, Abu Dhabi, United Arab Emirates.
| |
Collapse
|
28
|
Batty L, Getgood A. Combined Biplanar Medial Closing-Wedge Distal Femoral Osteotomy and Quadriceps Tendon Medial Patellofemoral Ligament Reconstruction. Arthrosc Tech 2021; 10:e1685-e1694. [PMID: 34354913 PMCID: PMC8322471 DOI: 10.1016/j.eats.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/09/2021] [Indexed: 02/03/2023] Open
Abstract
Lateral patellofemoral instability is multifactorial in etiology, with bony and soft-tissue factors contributing. Coronal plane alignment, in particular genu valgum, is important to consider when evaluating lateral patellofemoral instability. When genu valgum is present and thought to be a significant contributing factor, we typically address this with an extra-articular, biplanar, medial closing-wedge distal femoral osteotomy (DFO). This can be combined with a medial patellofemoral ligament reconstruction using a partial-thickness quadriceps tendon graft via the same incision. A medial closing-wedge DFO with locking plate fixation affords a highly stable construct suitable for early weight-bearing. The locking plate is less prominent as compared with a lateral opening-wedge DFO, and it does not irritate the iliotibial band or cause tightening of the illiopatellar expansion. The biplanar nature of the osteotomy prevents extension of the osteotomy into the proximal trochlear, helps to control rotation in both axial and sagittal plane after wedge removal, and increases the bony surface area for healing. The quadriceps tendon medial patellofemoral ligament reconstruction allows a graft that can be tailored in terms of length and diameter, does not require an anchor on the patellar, and can be performed through the same incision as for the DFO.
Collapse
Affiliation(s)
- Lachlan Batty
- St. Vincent’s Hospital, Epworth HealthCare, Western Health Melbourne, Victoria, Australia
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada,Address correspondence to Dr. Alan Getgood, M.Phil., M.D., F.R.C.S.(Tr.&Orth.), Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, N6A 3K7 Canada.
| |
Collapse
|
29
|
de Sa D, Crum RJ, Rabuck S, Ayeni O, Bedi A, Baraga M, Getgood A, Kaar S, Kropf E, Mauro C, Peterson D, Vyas D, Musahl V, Lesniak BP. The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification. J Knee Surg 2021; 34:509-519. [PMID: 31569256 PMCID: PMC8995042 DOI: 10.1055/s-0039-1697902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REV: ision using I: maging to guide S: taging and E: valuation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel "usability" (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post-failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80-0.98) suggesting "substantial" agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3.
Collapse
Affiliation(s)
- Darren de Sa
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raphael J Crum
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stephen Rabuck
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Olufemi Ayeni
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Baraga
- Department of Orthopaedic Surgery, University of Miami, Miami, Florida
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Scott Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, Missouri
| | - Eric Kropf
- Temple Orthopaedics at the Navy Yard, Vincera Institute, Philadelphia, Pennsylvania
| | - Craig Mauro
- Burke and Bradley Orthopaedics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Devin Peterson
- Department of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dharmesh Vyas
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
30
|
Görtz S, Tabbaa SM, Jones DG, Polousky JD, Crawford DC, Bugbee WD, Cole BJ, Farr J, Fleischli JE, Getgood A, Gomoll AH, Gross AE, Krych AJ, Lattermann C, Mandelbaum BR, Mandt PR, Mirzayan R, Mologne TS, Provencher MT, Rodeo SA, Safir O, Strauss ED, Wahl CJ, Williams RJ, Yanke AB. Metrics of OsteoChondral Allografts (MOCA) Group Consensus Statements on the Use of Viable Osteochondral Allograft. Orthop J Sports Med 2021; 9:2325967120983604. [PMID: 34250153 PMCID: PMC8237219 DOI: 10.1177/2325967120983604] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/31/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Osteochondral allograft (OCA) transplantation has evolved into a first-line
treatment for large chondral and osteochondral defects, aided by
advancements in storage protocols and a growing body of clinical evidence
supporting successful clinical outcomes and long-term survivorship. Despite
the body of literature supporting OCAs, there still remains controversy and
debate in the surgical application of OCA, especially where high-level
evidence is lacking. Purpose: To develop consensus among an expert group with extensive clinical and
scientific experience in OCA, addressing controversies in the treatment of
chondral and osteochondral defects with OCA transplantation. Study Design: Consensus statement. Methods: A focus group of clinical experts on OCA cartilage restoration participated
in a 3-round modified Delphi process to generate a list of statements and
establish consensus. Questions and statements were initially developed on
specific topics that lack scientific evidence and lead to debate and
controversy in the clinical community. In-person discussion occurred where
statements were not agreed on after 2 rounds of voting. After final voting,
the percentage of agreement and level of consensus were characterized. A
systematic literature review was performed, and the level of evidence and
grade were established for each statement. Results: Seventeen statements spanning surgical technique, graft matching,
indications, and rehabilitation reached consensus after the final round of
voting. Of the 17 statements that reached consensus, 11 received unanimous
(100%) agreement, and 6 received strong (80%-99%) agreement. Conclusion: The outcomes of this study led to the establishment of consensus statements
that provide guidance on surgical and perioperative management of OCAs. The
findings also provided insights on topics requiring more research or
high-quality studies to further establish consensus and provide stronger
evidence.
Collapse
Affiliation(s)
- Simon Görtz
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Suzanne M Tabbaa
- University of California-San Francisco, San Francisco, California, USA
| | - Deryk G Jones
- Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA
| | - John D Polousky
- Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA
| | | | | | - William D Bugbee
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Brian J Cole
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Jack Farr
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - James E Fleischli
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Alan Getgood
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Andreas H Gomoll
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Allan E Gross
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Aaron J Krych
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Christian Lattermann
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Bert R Mandelbaum
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Peter R Mandt
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Raffy Mirzayan
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Timothy S Mologne
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Matthew T Provencher
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Scott A Rodeo
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Oleg Safir
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Eric D Strauss
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Christopher J Wahl
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Riley J Williams
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| | - Adam B Yanke
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of California-San Francisco, San Francisco, California, USA.,Ochsner Sports Medicine Institute, Jefferson, Louisiana, USA.,Children's Health Andrews Institute for Orthopedics and Sports Medicine, Plano, Texas, USA.,Oregon Health and Science University, Portland, Oregon, USA.,Investigation performed at Metrics of Osteochondral Allografts (MOCA), JRF Ortho, Centennial, Colorado, USA
| |
Collapse
|
31
|
Crum RJ, Kay J, Lesniak BP, Getgood A, Musahl V, de SA D. Bone Versus All Soft Tissue Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2021; 37:1040-1052. [PMID: 33098947 PMCID: PMC9004211 DOI: 10.1016/j.arthro.2020.10.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 10/03/2020] [Accepted: 10/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine existing literature on objective and patient-reported outcomes and complications after anterior cruciate ligament reconstruction (ACLR) with bone-quadriceps-tendon (B-QT) or soft tissue-quadriceps tendon (S-QT) to further clarify the role of graft type in primary ACLR. METHODS In accordance with PRISMA guidelines, PubMed, Embase, and Medline were searched in October 2019 for English-language, human studies of all evidence levels on patients undergoing primary ACLR with B-QT or S-QT autograft. RESULTS 24 of 1,381 studies satisfied criteria, with 20 using B-QT (1,534 patients, mean age 29.6 years [range 14 to 59], mean follow-up 41.2 months [range 12 to 120]) and 5 using S-QT (181 patients, mean age 32.4 years [range 15 to 58), mean follow-up 25.5 months [range 12 to 46]). International Knee Documentation Committee (IKDC) scores were 67.3 to 89.5 with B-QT and 80.4 to 81.6 with S-QT. Lysholm scores were 85.7 to 97.4 with B-QT and 81.6 to 89.2 with S-QT. More B-QT patients demonstrated rotatory laxity on pivot shift compared with S-QT (0% to 39% versus 0%, respectively). The most common complication was graft rupture, and no differences were observed between graft choices (B-QT 0% to 9% versus S-QT 0% to 3.8%). CONCLUSIONS The main findings from this review report that more B-QT patients demonstrated postoperative rotatory instability than S-QT patients, and that there are no differences in graft rupture between the 2 graft choices. Although statistical conclusions may not be drawn because of heterogeneity in reporting, it appears that the B-QT group featured much wider major and minor complication profiles. LEVEL OF EVIDENCE IV, systematic review of level I-IV studies.
Collapse
Affiliation(s)
- Raphael J. Crum
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, U.S.A
| | - Jeffrey Kay
- Department of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Bryson P. Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, U.S.A
| | - Darren de SA
- Department of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
32
|
Lebedeva K, Bryant D, Docter S, Litchfield RB, Getgood A, Degen RM. The Impact of Resident Involvement on Surgical Outcomes following Anterior Cruciate Ligament Reconstruction. J Knee Surg 2021; 34:287-292. [PMID: 31461757 DOI: 10.1055/s-0039-1695705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hands-on participation in the operating room (OR) is an integral component of surgical resident training. However, the implications of resident involvement in many orthopaedic procedures are not well defined. This study aims to assess the effect of resident involvement on short-term outcomes following anterior cruciate ligament reconstruction (ACLR). The National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent ACLR from 2005 to 2012. Demographic variables, resident participation, 30-day complications, and intraoperative time parameters were assessed for all cases. Resident and nonresident cases were matched using propensity scores. Outcomes were analyzed using univariate and multivariate regression analyses, as well as stratified by resident level of training. Univariate analysis of 1,222 resident and 1,188 nonresident cases demonstrated no difference in acute postoperative complication rates between groups. There was no significant difference in the incidence of overall complications based on resident level of training (p = 0.109). Operative time was significantly longer for cases in which a resident was involved (109.5 vs. 101.7 minutes; p < 0.001). Multivariate analysis identified no significant predictors of major postoperative complications, while patient history of chronic obstructive pulmonary disease was the only independent risk factor associated with minor complications. Resident involvement in ACLR was not associated with 30-day complications despite a slight increase in operative time. These findings provide reassurance that resident involvement in ACLR procedures is safe, although future investigations should focus on long-term postoperative outcomes.
Collapse
Affiliation(s)
- Kate Lebedeva
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Dianne Bryant
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Shgufta Docter
- Department of Orthopedic Surgery, School of Physical Therapy, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| |
Collapse
|
33
|
Docter S, Fathalla Z, Lukacs MJ, Khan MCM, Jennings M, Liu SH, Dong S, Getgood A, Bryant DM. Interpreting Patient-Reported Outcome Measures in Orthopaedic Surgery: A Systematic Review. J Bone Joint Surg Am 2021; 103:185-190. [PMID: 32941309 DOI: 10.2106/jbjs.20.00474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Consolidated Standards of Reporting Trials (CONSORT) Statement recommends that studies report results beyond p values and include treatment effect(s) and measures of precision (e.g., confidence intervals [CIs]) to facilitate the interpretation of results. The objective of this systematic review was to assess the reporting and interpretation of patient-reported outcome measure (PROM) results in clinical studies from high-impact orthopaedic journals, to determine the proportion of studies that (1) only reported a p value; (2) reported a treatment effect, CI, or minimal clinically important difference (MCID); and (3) offered an interpretation of the results beyond interpreting a p value. METHODS We included studies from 5 high-impact-factor orthopaedic journals published in 2017 and 2019 that compared at least 2 intervention groups using PROMs. RESULTS A total of 228 studies were analyzed, including 126 randomized controlled trials, 35 prospective cohort studies, 61 retrospective cohort studies, 1 mixed cohort study, and 5 case-control studies. Seventy-six percent of studies (174) reported p values exclusively to express and interpret between-group differences, and only 22.4% (51) reported a treatment effect (mean difference, mean change, or odds ratio) with 95% CI. Of the 54 studies reporting a treatment effect, 31 interpreted the results using an important threshold (MCID, margin, or Cohen d), but only 3 interpreted the CIs. We found an absolute improvement of 35.5% (95% CI, 20.8% to 48.4%) in the reporting of the MCID between 2017 and 2019. CONCLUSIONS The majority of interventional studies reporting PROMs do not report CIs around between-group differences in outcome and do not define a clinically meaningful difference. A p value cannot effectively communicate the readiness for implementation in a clinical setting and may be misleading. Thus, reporting requirements should be expanded to require authors to define and provide a rationale for between-group clinically important difference thresholds, and study findings should be communicated by comparing CIs with these thresholds.
Collapse
Affiliation(s)
- Shgufta Docter
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada
| | - Zina Fathalla
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Lukacs
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada
| | - Michaela C M Khan
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada
| | - Morgan Jennings
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada
| | - Shu-Hsuan Liu
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Susan Dong
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Alan Getgood
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Faculty of Health Sciences (S.D., M.J.L., M.C.M.K., M.J., and D.M.B.), Fowler Kennedy Sports Medicine Clinic, Division of Orthopaedics, Department of Surgery (A.G. and D.M.B.), and Bone and Joint Institute (S.D., M.J.L, M.C.M.K., M.J., A.G., and D.M.B.), Western University, London, Ontario, Canada.,Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
34
|
Abdelrahman T, Moatshe G, Arendt E, Feller J, Getgood A. Combined Medial Patellofemoral Ligament and Medial Patellotibial Ligament Reconstruction for Recurrent Lateral Patellar Dislocation in Flexion. Arthrosc Tech 2021; 10:e385-e395. [PMID: 33680770 PMCID: PMC7917088 DOI: 10.1016/j.eats.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023] Open
Abstract
Recurrent lateral patellar dislocation can be a challenging entity to manage. It results from an imbalance between the restraints to lateralization of the patella and the forces applied to the patella within the biomechanical environment of the knee. The medial patellofemoral ligament has been recognized as the most important static soft-tissue restraint. However, the medial patellotibial ligament and medial patellomeniscal ligament are important for patellar stability at higher degrees of knee flexion. Lateral patellar dislocation in flexion poses a particularly challenging clinical entity with a combination of unique characteristics that need to be addressed to achieve optimal patellar tracking and stability. In this technical note, we describe a combined medial patellofemoral ligament and medial patellotibial ligament reconstruction technique to address lateral patellar dislocation in flexion.
Collapse
Affiliation(s)
- Taher Abdelrahman
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Gilbert Moatshe
- Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo University Hospital, Orthopaedic Clinic, Oslo, Norway
| | | | | | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Robarts Research Institute, Western University, London, Canada,Address correspondence to Alan Getgood, M.Phil., M.D., F.R.C.S.(Tr&Orth), Fowler Kennedy Sport Medicine Clinic, Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Robarts Research Institute, Western University, London, Ontario, Canada N6A 3K7.
| |
Collapse
|
35
|
Degen RM, Pasic N, Baha P, Getgood A, Burkhart TA. Biomechanical evaluation of a hybrid suture and anchor-based hip capsular repair. Clin Biomech (Bristol, Avon) 2021; 81:105246. [PMID: 33338896 DOI: 10.1016/j.clinbiomech.2020.105246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/18/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip capsulotomies, performed routinely during hip arthroscopy, can contribute to adverse joint kinematics. Direct repair is not always feasible. Therefore, the aim of this study was to evaluate the biomechanics of a conventional all-suture repair versus a hybrid suture and anchor-based capsular repair. METHODS Nine paired (n = 18) hips were tested on a joint-motion simulator, utilizing optical trackers to capture kinematic data. Pairs were randomly allocated to capsular repair type and tested as (1) intact, (2) after T-capsulotomy, and (3) repair each at 0°, 45°, and 90° flexion. Internal and external rotation torques and abduction/adduction torques of 3 N·m were applied and rotational range of motion and joint translations recorded. FINDINGS At 0°, following repair there were no significant differences in joint rotation or translations between repairs (p > 0.134). At 45°, both repair types restored motion to near intact values, with no significant differences between groups. Similarly, there were no significant differences in joint translations between repairs. At 90°, both types of capsular repair failed to restore rotational range of motion, with persistent increases in motion (47.0 ± 16.7°) compared to the intact condition (44.1 ± 15.8°, p = 0.006); however, there were no significant differences between repair groups. There were no significant differences in joint translations between repairs. INTERPRETATION Use of a hybrid repair produced comparable joint rotation and translation under all testing conditions as an all-suture repair. As such, this technique represents a viable option for capsular repair where proximal capsular tissue is deficient.
Collapse
Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada.
| | - Nick Pasic
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Pardis Baha
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| | - Timothy A Burkhart
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, Ontario N6A 3K7, Canada
| |
Collapse
|
36
|
Getgood A. Editorial Commentary: Return to Sport Following Extra-Articular Augmentation of Anterior Cruciate Ligament Reconstruction-Let the LET (Lateral Extra-Articular Tenodesis) Games Commence! Arthroscopy 2021; 37:388-390. [PMID: 33384095 DOI: 10.1016/j.arthro.2020.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 02/02/2023]
Abstract
The debate around extra-articular augmentation (EA) of anterior cruciate ligament (ACL) reconstruction continues to provide a rich source of research articles that we ultimately hope will improve patient outcomes. When combined with ACL reconstruction, anterolateral ligament reconstruction or lateral extra-articular tenodesis procedures reduce graft failure and persistent rotatory laxity. An important metric of ACL reconstruction outcome is return to play (RTP). RTP rates are also excellent when EA procedures are used in both primary and revision ACL reconstruction. However, when it comes to RTP, EA augmentation has yet to show significant improvement over isolated ACL reconstruction.
Collapse
|
37
|
Chahla J, Kunze KN, LaPrade RF, Getgood A, Cohen M, Gelber P, Barenius B, Pujol N, Leyes M, Akoto R, Fritsch B, Margheritini F, Rips L, Kautzner J, Duthon V, Togninalli D, Giacamo Z, Graveleau N, Zaffagnini S, Engbretsen L, Lind M, Maestu R, Von Bormann R, Brown C, Villascusa S, Monllau JC, Ferrer G, Menetrey J, Hantes M, Parker D, Lording T, Samuelsson K, Weiler A, Uchida S, Frosch KH, Robinson J. The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation. Knee Surg Sports Traumatol Arthrosc 2021; 29:2976-2986. [PMID: 33104867 PMCID: PMC7586411 DOI: 10.1007/s00167-020-06336-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/13/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. METHODS A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. RESULTS Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. CONCLUSION A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. LEVEL OF EVIDENCE Level V.
Collapse
Affiliation(s)
- Jorge Chahla
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison Street Suite 300, Chicago, IL, 60612, USA.
| | - Kyle N. Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | | | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, London, ON Canada
| | - Moises Cohen
- Universidade Federal de São Paulo, São Paulo, SP Brazil
| | - Pablo Gelber
- Department of Orthopaedic Surgery, Hospital de La Sta Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain ,ICATME-Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Björn Barenius
- Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Pujol
- Centre Hospitalier de Versailles, Le Chesnay, France ,Oslo University Hospital, Oslo, Norway
| | | | - Ralph Akoto
- Asklepios Klinik St. Georg, Chirurgisch Traumatologisches Zentrum, Hamburg, Germany
| | - Brett Fritsch
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | | | - Leho Rips
- Sports Traumatology Center, Sports Medicine and Rehabilitation Clinic, Tartu University Hospital, Tartu, Estonia
| | | | | | | | - Zanon Giacamo
- University of Pavia, IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | | | | | - Rodrigo Maestu
- Centro de Tratamiento de Enfermedades Articulares, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | - David Parker
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | | | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden ,Nanometer Structure Consortium, Lund University, Lund, Sweden
| | | | - Soshi Uchida
- Wakamatsu Hospital, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Karl Heinz Frosch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany ,Asklepios Clinic St. Georg, Hamburg, Germany
| | - James Robinson
- International Knee and Joint Centre, Abu Dhabi, UAE ,Avon Orthopaedic Centre, Bristol, UK
| |
Collapse
|
38
|
Moslemian A, Sidhu R, Roessler P, Wood R, Degen R, Getgood A, Willing R. Influence of the posterior cruciate ligament on kinematics of the knee during experimentally simulated clinical tests and activities of daily living. J Biomech 2020; 115:110133. [PMID: 33257006 DOI: 10.1016/j.jbiomech.2020.110133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 10/15/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022]
Abstract
Clinical outcomes following posterior cruciate ligament (PCL) reconstruction are often suboptimal. A better understanding of the biomechanical contributions of the PCL to knee stability under physiologic, clinically-relevant loading conditions could improve reconstruction techniques and outcomes. We employed a servohydraulic joint motion simulator to investigate the kinematics of intact and PCL-deficient knees during simulated clinical tests and activities of daily living(ADL), including gait, stair ascent and descent. PCL transection caused the tibia to be displaced posterior, relative to the intact joint, throughout flexion. PCL transection also increased the amount of posterior tibial displacement measured during posterior laxity testing by up to 9.6 ± 1.7 mm at 75° (p = 0.001). During internal-external rotational laxity testing, PCL transection increased the allowable internal and external rotation of the tibia, by up to 2.9 ± 0.5°at90° (p = 0.001) and 1.0 ± 0.2° at45°(p = 0.001), respectively. PCL transection did not have a significant effect on abduction-adduction kinematics or laxity, regardless of flexion angle. PCL transection resulted in a relative posterior displacement of the tibia during the stance phase of gait when the knee was extended (2.2 ± 2.2 mm, p = 0.045), and when the knee was flexed during stair ascent (2.4 ± 2.2 mm, p = 0.035) and descent (1.6 ± 1.4 mm, p = 0.037). Our results support previous studies of the role of the PCL on neutral joint kinematics and laxity, and provide new data quantifying the effect of PCL transection on AP kinematics during simulated ADL.
Collapse
Affiliation(s)
- Alireza Moslemian
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Roger Sidhu
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Philip Roessler
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Wood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Degen
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Willing
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.
| |
Collapse
|
39
|
Pasic N, Burkhart TA, Baha P, Ayeni OR, Getgood A, Degen RM. A Biomechanical Comparison of 2 Hip Capsular Reconstruction Techniques: Iliotibial Band Autograft Versus Achilles Tendon Allograft. Am J Sports Med 2020; 48:3288-3295. [PMID: 33044838 DOI: 10.1177/0363546520962071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several techniques for hip capsular reconstruction have been described to address gross instability or microinstability due to capsular deficiency. However, objective biomechanical data to support their use are lacking. PURPOSE To compare the kinematic effect of 2 capsular reconstruction techniques (iliotibial band [ITB] graft and Achilles tendon graft). Kinematic effect encompassed rotational range of motion (ROM) as well as joint translation in the coronal, sagittal, and axial planes. STUDY DESIGN Controlled laboratory study. METHODS 8 paired, fresh-frozen hemi-pelvises (16 hips) were tested on a custom-designed joint motion simulator in the intact state and after capsulectomy. Pairs were randomly allocated to either ITB or Achilles reconstruction and retested. Testing was performed at 0°, 45°, and 90° of flexion. Internal-external rotation (IR-ER) torques and abduction-adduction torques of 3 N·m were applied to the femur via a load cell at each position, and rotational ROM and joint translation in the coronal, sagittal, and axial planes were recorded. RESULTS At 45° and 90°, there was a significant effect of the condition of the hip on the total IR-ER (P = .004, effect size [ES] = 0.305; and P < .001, ES = 0.497; respectively). At 45°, mean ± SD total rotation was significantly greater for the capsulectomy (59.7°± 15.9°) state compared with intact (53.3°± 13.2°; P = .007). At 90°, reconstruction significantly decreased total rotation to 49.0°± 18.9° compared with a mean total rotation of 52.8°± 18.7° after capsulectomy (P = .02). No difference was seen in the total abduction-adduction of the hip between conditions. Comparisons of the 2 different reconstruction techniques showed no significant differences in total IR-ER or abduction-adduction ROM or joint translation in the coronal, sagittal, or axial planes. For translation, at both 0° and 45° there was a statistically significant effect of the condition on the medial-lateral translation (P = .033; ES = 0.204). Reconstruction, independent of technique, was successful in significantly decreasing (P = .030; P = .014) the mean medial-lateral translation at 0° and 45° of hip flexion from 5.2 ± 3.8 mm and 5.6 ± 4.0 mm to 2.8 ± 1.9 mm and 3.9 ± 3.2 mm, respectively. CONCLUSION The integrity of the native hip capsule played a significant role in rotational stability, where capsulectomy significantly increased rotational ROM. Both ITB and Achilles reconstruction techniques restored normal rotational ROM of the hip at 90° of flexion as well as coronal plane stability at 0° and 45° of hip flexion. No differences were seen between ITB and Achilles reconstruction techniques. CLINICAL RELEVANCE Both capsular reconstruction techniques provide comparable joint kinematics, restoring rotation and translation to normal values with the exception of rotational ROM at 45°, which remained significantly greater than the intact state. The most significant results were the rotational stability at 90° of hip flexion and coronal plane stability at 0° and 45° of hip flexion, which were significantly improved compared with the capsulectomy state.
Collapse
Affiliation(s)
- Nicholas Pasic
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Timothy A Burkhart
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada.,Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.,School of Kinesiology, Western University, London, Ontario, Canada
| | - Pardis Baha
- School of Kinesiology, Western University, London, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| |
Collapse
|
40
|
Cotter EJ, Gowd AK, Bohl DD, Getgood A, Cole BJ, Frank RM. Medical Comorbidities and Functional Dependent Living Are Independent Risk Factors for Short-Term Complications Following Osteotomy Procedures about the Knee. Cartilage 2020; 11:423-430. [PMID: 30188188 PMCID: PMC7488949 DOI: 10.1177/1947603518798889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To characterize rates and risk factors for adverse events following distal femoral osteotomy (DFO), high tibial osteotomy (HTO), and tibial tubercle osteotomy (TTO) procedures. DESIGN Patients undergoing DFO, HTO, or TTO procedures during 2005 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Rates of adverse events were characterized for each procedure. Demographic, comorbidity, and procedural factors were tested for association with occurrence of any adverse events. RESULTS A total of 1,083 patients were identified. Of these, 305 (28%) underwent DFO, 273 (25%) underwent HTO, and 505 (47%) underwent TTO. Mean ages for patients undergoing each procedure were the following: DFO, 51 ± 23 years; HTO, 40 ± 13 years; and TTO, 31 ± 11 years. The most common comorbidities for DFO were hypertension (34%) and smoking (17%); for HTO, hypertension (22%) and smoking (21%); and for TTO, smoking (20%) and hypertension (11%). Independent risk factors for occurrence of any adverse event were age ⩾45 years for DFO (odds ratio [OR] = 3.1, P < 0.001) and HTO (OR = 2.3, P = 0.029), and body mass index >30 for HTO (OR = 2.5, 95% confidence interval = 1.1-5.7, P = 0.031). When all osteotomy procedures were analyzed collectively, additional variables including diabetes mellitus (OR = 2.2, P = 0.017), chronic obstructive pulmonary disease (OR = 5.5, P = 0.003), and dependent functional status (OR = 3.0, P = 0.004) were associated with adverse events. CONCLUSIONS The total rate of adverse events was not independently associated with the type of osteotomy procedure. In addition, patients with age >45, diabetes mellitus, chronic obstructive pulmonary disease, and dependent functional status have greater odds for adverse events and should be counseled and monitored accordingly.
Collapse
Affiliation(s)
- Eric J. Cotter
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anirudh K. Gowd
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Daniel D. Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alan Getgood
- Division of Orthopaedic Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Brian J. Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Rachel M. Frank
- Department of Orthopaedic Surgery, University of Colorado, Boulder, CO, USA,Rachel M. Frank, Department of Orthopaedic Surgery, University of Colorado School of Medicine, 2150 Stadium Drive, Boulder, CO 80309, USA.
| |
Collapse
|
41
|
Burkhart TA, Baha P, Blokker A, Petrov I, Holdsworth DW, Drangova M, Getgood A, Degen RM. Hip capsular strain varies between ligaments dependent on both hip position- and applied rotational force. Knee Surg Sports Traumatol Arthrosc 2020; 28:3393-3399. [PMID: 32363474 DOI: 10.1007/s00167-020-06035-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To noninvasively characterize the ligament strain in the hip capsule using a novel CT-based imaging technique. METHODS The superior iliofemoral ligament (SIFL), inferior iliofemoral ligament (IIFL), ischiofemoral ligament (IFL) and pubofemoral ligament (PFL) were identified and beaded in seven cadavers. Specimens were mounted on a joint motion simulator within an O-arm CT scanner in - 15°, 0°, 30°, 60°, and 90° of flexion. 3 Nm of internal rotation (IR) and external rotation (ER) were applied and CT scans obtained. Strains were calculated by comparing bead separation in loaded and unloaded conditions. Repeated-measures ANOVA was used to evaluate differences in strain within ligaments between hip positions. RESULTS For the SIFL, strain significantly decreased in IR at 30° (p = 0.045) and 60° (p = 0.043) versus 0°. For ER, there were no significant position-specific changes in strain (n.s.). For the IIFL, strain decreased in IR and increased in ER with no significant position-specific differences. For the IFL, strain increased with IR and decreased with ER with no significant position-specific differences. Finally, in the PFL there was a significant flexion angle-by-load interaction (p < 0.001; ES = 0.566), with peak strains noted at 60˚, however pair-wise comparisons failed to identify significant differences between positions (n.s.). Strain decreased in ER, with no significant position-specific differences. CONCLUSION The SIFL and IIFL limit hip external rotation with greater effect in higher flexion angles, while the IFL and PFL limit hip internal rotation. Following hip arthroscopy, consideration should be given to restricting external rotation as traditional capsulotomies cause injury to the SIFL and IIFL.
Collapse
Affiliation(s)
- Timothy A Burkhart
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada.,Bone and Joint Institute, Western University, London, ON, Canada
| | - Pardis Baha
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Alexandra Blokker
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | - Ivailo Petrov
- Bone and Joint Institute, Western University, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, Western University, London, ON, Canada
| | - David W Holdsworth
- Bone and Joint Institute, Western University, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Maria Drangova
- Bone and Joint Institute, Western University, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Alan Getgood
- Bone and Joint Institute, Western University, London, ON, Canada.,Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Ryan M Degen
- Bone and Joint Institute, Western University, London, ON, Canada. .,Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
| |
Collapse
|
42
|
Roessler PP, Burkhart TA, Getgood A, Degen RM. Suture Tape Reduces Quadriceps Tendon Repair Gap Formation Compared With High-Strength Suture: A Cadaveric Biomechanical Analysis. Arthroscopy 2020; 36:2260-2267. [PMID: 32353619 DOI: 10.1016/j.arthro.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical differences between quadriceps tendon (QT) repair with high-strength suture (HSS) versus suture tape (ST) with varying number of suture passes. METHODS In total, 28 fresh-frozen QTs were randomized into 2 groups: (1) HSS; or (2) ST; specimens were then further randomized into subgroups of either 4 or 6 suture passes. Specimens were secured within a materials testing system and a 150-N preload was applied for 10 seconds followed by a cyclic loading protocol between 50 N and 250 N for 1000 cycles. Video was used to follow tracking markers used to calculate the magnitude of tendon displacement. Two-way univariate analysis of variance was used to determine the effect of suture type and passes on the displacement after preloading and mixed repeated-measures analysis of variance was used to determine the effect of suture type and passes on displacement following cyclic loading. RESULTS There were large increases in displacement following the preload across all conditions (7.82 ± 3.64 mm), with no statistically significant differences between groups. There was a significant difference in the mean (± standard deviation) displacement between the ST (5.24 ± 2.82 mm) and HSS (7.93 ± 2.91 mm) starting at 200 cycles, which became more pronounced with successive testing out to 1000 cycles (P = .021). There were no significant difference with respect to the number of suture or tape passes. CONCLUSIONS Following preloading at 150 N, significant displacement occurred in both QT repair groups. ST demonstrated significantly less displacement than HSS under cyclic loading and had greater ultimate failure loads. CLINICAL RELEVANCE When performing QT repair, emphasis should be placed on appropriate pretensioning of sutures to at least 150 N before knot-tying. In addition, where available, ST should be used over HSS to reduce further cyclic elongation and improve ultimate failure loads.
Collapse
Affiliation(s)
- Philip P Roessler
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada
| | - Timothy A Burkhart
- Lawson Health Research Institute, Mechanical and Materials Engineering, Western University, London Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada.
| |
Collapse
|
43
|
Svantesson E, Hamrin Senorski E, Webster KE, Karlsson J, Diermeier T, Rothrauff BB, Meredith SJ, Rauer T, Irrgang JJ, Spindler KP, Ma CB, Musahl V, The Panther Symposium Acl Injury Clinical Outcomes Consensus Group, Fu FH, Ayeni OR, Della Villa F, Della Villa S, Dye S, Ferretti M, Getgood A, Järvelä T, Kaeding CC, Kuroda R, Lesniak B, Marx RG, Maletis GB, Pinczewski L, Ranawat A, Reider B, Seil R, van Eck C, Wolf BR, Yung P, Zaffagnini S, Hao Zheng M. Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group. Orthop J Sports Med 2020; 8:2325967120934751. [PMID: 32754624 PMCID: PMC7378729 DOI: 10.1177/2325967120934751] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/12/2020] [Indexed: 01/16/2023] Open
Abstract
A stringent outcome assessment is a key aspect of establishing evidence-based
clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To
establish a standardized assessment of clinical outcome after ACL treatment, a
consensus meeting including a multidisciplinary group of ACL experts was held at
the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in
June 2019. The aim was to establish a consensus on what data should be reported
when conducting an ACL outcome study, what specific outcome measurements should
be used, and at what follow-up time those outcomes should be assessed. The group
reached consensus on 9 statements by using a modified Delphi method. In general,
outcomes after ACL treatment can be divided into 4 robust categories: early
adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent
ligament disruption, and clinical measures of knee function and structure. A
comprehensive assessment after ACL treatment should aim to provide a complete
overview of the treatment result, optimally including the various aspects of
outcome categories. For most research questions, a minimum follow-up of 2 years
with an optimal follow-up rate of 80% is necessary to achieve a comprehensive
assessment. This should include clinical examination, any sustained reinjuries,
validated knee-specific PROs, and health-related quality of life questionnaires.
In the midterm to long-term follow-up, the presence of osteoarthritis should be
evaluated. This consensus paper provides practical guidelines for how the
aforementioned entities of outcomes should be reported and suggests the
preferred tools for a reliable and valid assessment of outcome after ACL
treatment.
Collapse
Affiliation(s)
- Eleonor Svantesson
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Eric Hamrin Senorski
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Kate E Webster
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Jón Karlsson
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Theresa Diermeier
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Sean J Meredith
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - James J Irrgang
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Kurt P Spindler
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - C Benjamin Ma
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | | | - Freddie H Fu
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Olufemi R Ayeni
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Francesco Della Villa
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Stefano Della Villa
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Scott Dye
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Mario Ferretti
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Alan Getgood
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Timo Järvelä
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Christopher C Kaeding
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Ryosuke Kuroda
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Bryson Lesniak
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Robert G Marx
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Gregory B Maletis
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Leo Pinczewski
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Anil Ranawat
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Bruce Reider
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Romain Seil
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Carola van Eck
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Brian R Wolf
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Patrick Yung
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Stefano Zaffagnini
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Ming Hao Zheng
- Investigation performed at UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
44
|
Diermeier T, Rothrauff BB, Engebretsen L, Lynch AD, Ayeni OR, Paterno MV, Xerogeanes JW, Fu FH, Karlsson J, Musahl V, Brown CH, Chmielewski TL, Clatworthy M, Villa SD, Ernlund L, Fink C, Getgood A, Hewett TE, Ishibashi Y, Johnson DL, Macalena JA, Marx RG, Menetrey J, Meredith SJ, Onishi K, Rauer T, Rothrauff BB, Schmitt LC, Seil R, Senorski EH, Siebold R, Snyder-Mackler L, Spalding T, Svantesson E, Wilk KE. Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group. Orthop J Sports Med 2020; 8:2325967120931097. [PMID: 32637434 PMCID: PMC7315684 DOI: 10.1177/2325967120931097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/03/2020] [Indexed: 12/14/2022] Open
Abstract
Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.
Collapse
Affiliation(s)
- Theresa Diermeier
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lars Engebretsen
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew D Lynch
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Olufemi R Ayeni
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark V Paterno
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John W Xerogeanes
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jon Karlsson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Charles H Brown
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Terese L Chmielewski
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark Clatworthy
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stefano Della Villa
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lucio Ernlund
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christian Fink
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alan Getgood
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy E Hewett
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yasuyuki Ishibashi
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Darren L Johnson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey A Macalena
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert G Marx
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jacques Menetrey
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sean J Meredith
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kentaro Onishi
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Laura C Schmitt
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Romain Seil
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric H Senorski
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rainer Siebold
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lynn Snyder-Mackler
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tim Spalding
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eleonore Svantesson
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kevin E Wilk
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
45
|
Dhollander A, Sellan M, Firth AD, Getgood A. Valgus stress radiography following superficial medial collateral ligament reconstruction using a modified LaPrade technique with adjustable loop femoral fixation. Acta Orthop Belg 2020; 86:280-286. [PMID: 33418619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose of this study was to assess postoperative laxity of MCL reconstructions utilizing a modified LaPrade superficial MCL reconstruction. We retrospectively reviewed post-operative valgus stress radiographs in 23 multiligament injured patients who underwent concurrent sMCL and cruciate ligament reconstruction by a single surgeon. Post- operatively, 23 patients underwent valgus stress radiographs that were assessed at a mean of 8.7 months (range: 4-13 months), and mean SSD was 0.64mm ± 0.42mm. Eight patients underwent both pre- and post-operative valgus stress radiographs. Post-operative (0.09mm ± 0.63mm) SSD was found to be significantly reduced compared to pre-operative (2.07mm ± 0.44mm) SSD (mean diff. = 1.98mm, 95% CI = 0.72-3.24, P=0.007). Inter-observer reliability value for medial compartment gap measurement was 0.91 with a 95% confidence interval of 0.34- 0.97. In conclusion, presented technique results in excellent static stability of the knee as measured by valgus stress radiography at a minimum of 6 months postoperative. Level of Evidence: IV.
Collapse
|
46
|
Getgood A, Hewison C, Bryant D, Litchfield R, Heard M, Buchko G, Hiemstra LA, Willits KR, Firth A, MacDonald P. No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Arthroscopy 2020; 36:1690-1701. [PMID: 32147485 DOI: 10.1016/j.arthro.2020.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the functional outcomes of patients included in the Stability Study randomized controlled trial comparing anterior cruciate ligament reconstruction (ACLR) alone with ACLR with lateral extra-articular tenodesis (LET) at 6, 12, and 24 months postoperatively. METHODS Six hundred eighteen patients undergoing ACLR, all under the age of 25 years either returning to contact pivoting sport or displaying signs of high-grade rotatory laxity or generalized ligamentous laxity, were randomly assigned to receive ACLR alone or ACLR plus LET. A total of 356 of these patients were randomized at centers participating in the functional assessments. Our primary outcome was Limb Symmetry Index, calculated using a series of 4-hop tests at 6, 12, and 24 months postoperatively. Secondary outcome measures included pain, patient-reported function, and isokinetic strength testing. RESULTS We found no statistically significant difference in the proportion of patients either unwilling or unfit to complete the hop testing in the ACLR alone or ACLR with LET group at 6 months (40 vs 40 respectively; P = 1.00), 12 months (25 vs 27; P = .76), and 24 months (21 vs 23; P = .87). Of those who completed hop testing, there were no statistically significant differences between groups in Limb Symmetry Index at 6, 12, or 24 months. Self-reported function (Lower Extremity Functional Score) significantly favored the ACLR alone group at 3 (P = .01) and 6 months (P = .02) postoperative but was similar by 12 months postoperative. Pain scores (P4) also showed a statistically significant difference in favor of the ACL alone group, but this also resolved by 6 months. Quadriceps peak torque (P = .03) and average power (P = .01) were also significantly different in favor of the ACLR alone group at 6 months postoperative; however, these were similar between groups by 12 months postoperative (P = .11 and P = .32, respectively). CONCLUSIONS The addition of a LET to ACLR results in slightly increased pain, a mild reduction in quadriceps strength, and reduced subjective functional recovery up to 6 months postoperatively. However, these differences do not have any impact on objective function as measured by hop test limb symmetry index. LEVEL OF EVIDENCE I, Randomized Controlled Trial.
Collapse
Affiliation(s)
- Alan Getgood
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | | | - Dianne Bryant
- Lawson Health Research Institute, London, Ontario, Canada; Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Mark Heard
- Banff Sport Medicine, Banff, Alberta, Canada
| | - Greg Buchko
- Banff Sport Medicine, Banff, Alberta, Canada
| | | | - Kevin R Willits
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Andrew Firth
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Peter MacDonald
- Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
| | | |
Collapse
|
47
|
Abstract
Multiligament knee injuries (MLKI) are complex and challenging to treat. The posteromedial corner (PMC) structures are commonly torn in MLKI. A thorough and systematic evaluation is imperative to avoid a missed diagnosis and for planning treatment. With several structures injured, the treatment method (operative vs. nonoperative, repair vs. reconstruction), availability of allografts, timing of surgery, and rehabilitation are some of the factors that have to be considered in the decision-making. Persistent valgus instability because of untreated or not healed medial collateral ligament (MCL) tears will increase graft forces on the cruciate ligament grafts, thus increasing the risk of reconstruction graft failure. In recent years, there has been a growing body of literature on the anatomy and biomechanics of the medial structures that has aided in the development of biomechanically and clinically validated anatomic PMC reconstructions. Despite good healing potential of the MCL, in MLKI, surgical treatment is recommended for grade III PMC injuries to aid early rehabilitation and reduce the risk of surgical failure. Several studies have reported satisfactory outcomes after surgical treatment of MLKI involving the medial side. Early functional rehabilitation is imperative to reduce the risk of arthrofibrosis.
Collapse
Affiliation(s)
- Gilbert Moatshe
- Orthopaedic Clinic, Oslo University Hospital and University of Oslo, Oslo, Norway.,Oslo Sports Trauma Research Center, The Norwegian School of Sports Sciences, Oslo, Norway.,Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Alexander R Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | | | - Lars Engebretsen
- Orthopaedic Clinic, Oslo University Hospital and University of Oslo, Oslo, Norway.,Oslo Sports Trauma Research Center, The Norwegian School of Sports Sciences, Oslo, Norway
| |
Collapse
|
48
|
Chahla J, Hinckel BB, Yanke AB, Farr J, Bugbee WD, Carey JL, Cole BJ, Crawford DC, Fleischli JE, Getgood A, Gomoll AH, Gortz S, Gross AE, Jones DG, Krych AJ, Lattermann C, Mandelbaum BR, Mandt PR, Minas T, Mirzayan R, Mologne TS, Polousky JD, Provencher MT, Rodeo SA, Safir O, Sherman SL, Strauss ED, Strickland SM, Wahl CJ, Williams RJ. An Expert Consensus Statement on the Management of Large Chondral and Osteochondral Defects in the Patellofemoral Joint. Orthop J Sports Med 2020; 8:2325967120907343. [PMID: 32258181 PMCID: PMC7099674 DOI: 10.1177/2325967120907343] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/03/2019] [Indexed: 12/18/2022] Open
Abstract
Background Cartilage lesions of the patellofemoral joint constitute a frequent abnormality. Patellofemoral conditions are challenging to treat because of complex biomechanics and morphology. Purpose To develop a consensus statement on the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint using a modified Delphi technique. Study Design Consensus statement. Methods A working group of 4 persons generated a list of statements related to the functional anatomy, indications, donor graft considerations, surgical treatment, and rehabilitation for the management of large chondral and osteochondral defects in the patellofemoral joint to form the basis of an initial survey for rating by a group of experts. The Metrics of Osteochondral Allografts (MOCA) expert group (composed of 28 high-volume cartilage experts) was surveyed on 3 occasions to establish a consensus on the statements. In addition to assessing agreement for each included statement, experts were invited to propose additional statements for inclusion or to suggest modifications of existing statements with each round. Predefined criteria were used to refine statement lists after each survey round. Statements reaching a consensus in round 3 were included within the final consensus document. Results A total of 28 experts (100% response rate) completed 3 rounds of surveys. After 3 rounds, 36 statements achieved a consensus, with over 75% agreement and less than 20% disagreement. A consensus was reached in 100.00% of the statements relating to functional anatomy of the patellofemoral joint, 88.24% relating to surgical indications, 100.00% relating to surgical technical aspects, and 100.00% relating to rehabilitation, with an overall consensus of 95.5%. Conclusion This study established a strong expert consensus document relating to the functional anatomy, surgical indications, donor graft considerations for osteochondral allografts, surgical technical aspects, and rehabilitation concepts for the management of large chondral and osteochondral defects in the patellofemoral joint. Further research is required to clinically validate the established consensus statements and better understand the precise indications for surgery as well as which techniques and graft processing/preparation methods should be used based on patient- and lesion-specific factors.
Collapse
Affiliation(s)
- Jorge Chahla
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Betina B Hinckel
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Jack Farr
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | | | - William D Bugbee
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - James L Carey
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Dennis C Crawford
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - James E Fleischli
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Alan Getgood
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Andreas H Gomoll
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Simon Gortz
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Allan E Gross
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Deryk G Jones
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Aaron J Krych
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Christian Lattermann
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Bert R Mandelbaum
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Peter R Mandt
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Tom Minas
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Raffy Mirzayan
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy S Mologne
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - John D Polousky
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Matthew T Provencher
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Scott A Rodeo
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Oleg Safir
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Seth Lawrence Sherman
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Eric D Strauss
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Sabrina M Strickland
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Christopher J Wahl
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| | - Riley J Williams
- Investigation performed at Midwest Orthopaedics at Rush and the Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
49
|
Spang RC, Getgood A, Strickland SM, Amendola AN, Gomoll AH. Optimizing Anterior Cruciate Ligament (ACL) Outcomes: What Else Needs Fixing Besides the ACL? Instr Course Lect 2020; 69:653-660. [PMID: 32017758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This review focuses on the management of anterior cruciate ligament (ACL) reconstruction patients when other concomitant pathology may need to be addressed at the time of surgery. Given the role of the posterior horn of the medial meniscus in preventing osteoarthritis progression and contributing to knee stability, medial meniscus repair should always be considered when performing ACL reconstruction. Meniscal transplant may also be appropriate in select patients with normal knee alignment and absent of cartilage abnormalities in the compartment. Varus alignment with a varus thrust or increased posterior tibial slope will increase stress on the ACL graft and may predispose to early failure. Alignment should be assessed with appropriate radiographs and corrective osteotomy in isolation or in conjunction with ACL reconstruction should be considered for certain patients. Low-grade medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries can be treated nonsurgically prior to ACL reconstruction. These are frequently missed with either physical examination or radiographic imaging. High-grade LCL injuries are often treated with repair versus reconstruction in conjunction with ACL reconstruction depending on the timing of the injury. When chronic MCL injuries show opening in extension, MCL reconstruction may be needed in addition to the ACL reconstruction to improve outcome. The role of extra-articular reconstruction or anterolateral ligament (ALL) reconstruction remains controversial but may have a role in protecting rotatory stability in primary ACL reconstruction for high-risk patients, and in the revision setting. Cartilage lesions noted in the setting of ACL injury should be considered. Small, asymptomatic lesions in locations unrelated to the ACL injury may not necessitate additional intervention. Large symptomatic lesions may require additional cartilage restoration procedures at the time of ACL reconstruction or in a staged fashion. In this ICL, we will address the diagnosis, management, and surgical indications of other concomitant pathology associated with ACL ruptures.
Collapse
|
50
|
Jesani S, Getgood A. Modified Lemaire Lateral Extra-Articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction. JBJS Essent Surg Tech 2019; 9:ST-D-19-00017. [PMID: 32051777 DOI: 10.2106/jbjs.st.19.00017] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background A modified Lemaire lateral extra-articular tenodesis (LET) is a procedure that is designed to address anterolateral complex (ALC) deficiency. The procedure is performed as an augmentation to anterior cruciate ligament reconstruction (ACLR) to reduce anterolateral rotatory laxity. Studies have demonstrated improved rotational control and reduced failure rates of ACLR when LET is added. This is particularly helpful in young patients with high-grade rotatory laxity returning to contact pivoting sport, and in the revision ACLR scenario. Description A 6-cm skin incision is placed just posterior to the lateral epicondyle. The subcutaneous tissue is dissected down to the iliotibial band (ITB). A 1-cm-wide by 8-cm-long strip of the posterior half of the ITB is fashioned, leaving the distal attachment at Gerdy's tubercle intact. The free end is whipstitched with number-1 Vicryl suture, tunneled deep to the fibular collateral ligament (FCL), and attached to the metaphyseal flare of the lateral femoral condyle at the insertion of the distal Kaplan fibers of the ITB. Fixation is performed with a staple, with the graft tensioned to no more than 20 N (by simply holding it taut and not "tensioned"), with the knee held at 60° of flexion and neutral rotation of the tibia. Alternatives A number of procedures to address ALC deficiency have been described. The most common methods currently are variations of the ITB LET (Lemaire [ITB graft detached proximally, passed under the FCL, and attached to the femur] or Ellison [ITB graft detached distally, passed deep to the FCL, and reattached at Gerdy's tubercle]) or anterolateral ligament reconstructions. No clinical studies have been performed that demonstrate that one technique is superior to another. Rationale Current ACLR procedures focus on intra-articular graft placement to replace the ACL. Unfortunately, high rates of graft failure and persistent rotatory laxity (pivot shift) have been observed, particularly in young, high-demand individuals returning to contact pivoting sport. ALC deficiency has been shown to be a major cause of high-grade anterolateral rotatory laxity. The LET procedure is therefore designed to augment ACLR and reduce anterolateral rotation. The aim of adding LET to ACLR is to reduce the strain on the ACLR graft, reduce the prevalence of the pivot shift, and thereby potentially reduce the rate of ACLR graft failure.
Collapse
Affiliation(s)
- Satyen Jesani
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alan Getgood
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| |
Collapse
|