Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021

BACKGROUND

Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR.

PURPOSE/HYPOTHESIS

The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44.

RESULTS

The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07).

CONCLUSION

Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

Isolated, Proximal Tibiofibular Injuries in Athletic Patients: A Critical Analysis Review

While infrequently reported, isolated injuries to the proximal tibiofibular (TF) joint primarily occur in young, athletic patients participating in sporting activities requiring explosive, high impact movements, increasing the risk for potential twisting injuries, especially across a hyperflexed knee. The proximal TF joint is stabilized by bony, muscular and ligamentous structures, including both the anterior and posterior proximal tibiofibular complexes, with the anterior complex providing more robust stability. Proximal TF injuries frequently involve anterior and lateral displacement of the proximal fibula relative to its native articulation with the tibia. Proper diagnosis is dependent on careful and meticulous history and physical examination, as missed injuries are common, leading to the potential for continued pain, weakness and disability, especially in athletic patients. While spontaneous joint reduction has been reported, injuries may require formal closed reduction, with irreducible and chronic injuries requiring open reduction and stabilization, with recent investigations reporting satisfactory outcomes following anatomic reconstruction of the proximal TF ligament.

Functional anterior cruciate ligament braces may have a role in select patient groups although there is presently limited evidence supporting or refuting their routine use: A scoping review of clinical practice guidelines and an updated bracing classification

PURPOSE

The purpose of this study was to perform a scoping review of clinical practice guidelines (CPGs) concerning the use of functional anterior cruciate ligament (ACL) braces and to clarify the nomenclature for bracing relevant to ACL injury treatment in order to support prescribing clinicians.

METHODS

A PubMed search for CPGs for the use of braces following ACL injury or reconstruction was performed. CPGs on the treatment of ACL injuries with sufficient attention to postoperative braces were included in this scoping review. The references used for supporting the specific CPG recommendations were reviewed. Specific indications for brace use including brace type, period of use following surgery and activities requiring brace use were collected.

RESULTS

Six CPGs were identified and included this this review. Three randomised trials provided the evidence for recommendations on functional brace use following ACL reconstruction in the six CPGs. Functional ACL braces were the primary focus of the three randomised trials, although extension braces (postoperative knee immobilisers) were also discussed. A novel dynamic ACL brace category has been described, although included CPGs did not provide guidance on this brace type.

CONCLUSIONS

Guidance on the use of functional ACL braces following ACL reconstruction is provided in six CPGs supported by three randomised trials. However, the brace protocols and patient compliance in the randomised trials render these CPGs inadequate for providing guidance on the use of functional ACL braces in the general and high-risk patient populations when returning to sport after ACL reconstruction. Functional ACL braces are commonly utilised during the course of ACL injury treatment although there is presently limited evidence supporting or refuting the routine use of these braces. Future studies are, therefore, necessary in order to provide guidance on the use of functional and dynamic ACL braces in high-risk patient populations.

LEVEL OF EVIDENCE

Level II.

Meniscal extrusion consensus statement: A collaborative survey within the Meniscus International Network (MenIN) Study Group

PURPOSE

The purpose of the present study was to perform a survey administered to members of the Meniscus International Network (MenIN) Study Group, seeking to delineate the most contentious aspects of meniscal extrusion classification and provide a foundation for new, more comprehensive definitions and treatments for these pathologies.

METHODS

MenIN Study Group is a group of international experts treating and performing research on meniscus pathology and treatment. All MenIN Study Group members were asked to complete a survey aimed at establishing criteria for the optimal classification system for meniscal extrusion. Data obtained from the completed questionnaires were transferred into a spreadsheet and then analysed. All responses are presented as counts, percentages or means.

RESULTS

Forty-seven (85.5%) MenIN Study Group members completed the survey and were included in this analysis. Key aspects recommended for inclusion in a comprehensive classification system for meniscal extrusion included laterality (93.6%), anatomical location (76.6%), patient age (76.6%), body mass index (BMI) (68.1%) and aetiology (68.1%). For classifying meniscal extrusion, 53.2% considered the distance in millimetres from the tibial plateau's outer margin as the most reliable measurement technique on imaging. Preferences for imaging modalities varied, with 44.7% favouring weight-bearing magnetic resonance imaging (MRI) and 36.2% opting for weight-bearing ultrasound due to its greater availability. Respondents advocated for a classification system addressing stability or progression of meniscal extrusion (66%), reducibility (53.2%), potential progression of knee osteoarthritis (OA) (83%), influencing treatment approaches (83%), a gradation system (83%), consideration of dynamic factors (66%), association with clinical outcomes and prognosis (76.6%) and investigation around centralization procedures (57.4%).

CONCLUSIONS

In conclusion, the findings of this survey shed light on the global perspectives regarding meniscal extrusion classification. It was generally felt that a new classification of extrusion measured on MRI scans at the mid-tibial plateau should be developed, which considers factors such as laterality, anatomical location, age, BMI and aetiology. Additionally, the results support the integration of dynamic factors and clinical outcomes in MRI-based classifications to inform treatment approaches.

LEVEL OF EVIDENCE

Level IV.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Anatomic Anterolateral Ligament Reconstruction with Iliotibial Band Graft and Concomitant Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction (ACLR) attempts to restore native ACL function. Persistent anterolateral instability is a common symptom after ACLR that can lead to worse patient outcomes. Additional surgeries, like anterolateral ligament reconstruction (ALLR), can augment the ACL graft and help increase anterolateral rotational stability. Certain indications for ACLR with ALLR include high-grade pivot shift, increased posterior tibial slope (>12°), revision ACLR, and concomitant ligamentous or meniscal injuries. We describe an anatomic ALLR technique using an 8 cm long × 1 cm wide strip of the inferior aspect of the iliotibial band fixed at the native attachment sites of the ALL.

Biomechanical Performance of Transtibial Pull-Out Posterior Horn Medial Meniscus Root Repair Is Improved With Knotless Adjustable Suture Anchor-Based Fixation

Background

While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading.

Hypothesis

Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques.

Study Design

Controlled laboratory study.

Methods

A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure.

Results

The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest (P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load (P < .001) and relief displacement (P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement (P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement (P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load (P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment (P < .0001).

Conclusion

Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root.

Clinical Relevance

Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.

Hypermobile lateral meniscus: A systematic review of current treatment options

PURPOSE

The reliable data on the incidence of hypermobile lateral meniscus (HLM) and its clinical manifestations, diagnostic methods and therapeutic approaches are limited. This systematic study aimed to review available treatment options for HLM and the outcomes of each approach.

METHODS

A systematic search was performed in four electronic databases (PubMed, EMBASE, Scopus, Web of Science) to identify studies in which arthroscopically confirmed cases of HLM were treated surgically or nonsurgically, and the required data comprising study characteristics, patient data, treatment approaches and outcome measures were extracted from eligible studies.

RESULTS

Twenty studies with a total of 212 patients (138 males and 74 females) and 219 knees were included. The most frequently reported symptoms were locking sensations, knee pain, giving way and snapping. Treatments used by the studies were: radiofrequency energy in two studies; arthroscopic partial meniscectomy in one study; open surgery in two studies; and arthroscopic meniscal repair in 17 studies. Eleven studies used an all-inside repair method and an inside-out meniscal repair was reported in eight studies. Three studies reported the usage of posterior arthroscopy for therapeutic or diagnostic approaches. Evaluation of symptom resolution was the main outcome measurement for which almost all of the studies stated relief of symptoms after intervention.

CONCLUSION

Despite the lack of definite consensus about the most appropriate intervention for HLM, therapeutic preference was directed towards arthroscopic all-inside and inside-out repair techniques. Although the surgeon's decision remains the key factor in choosing the most suitable treatment option for each individual, posterior arthroscopic meniscal repair may be considered as a better option for HLM treatment according to the findings of this review.

LEVEL OF EVIDENCE

Level IV.

The Functional Integrity of the Anterior Cruciate Ligament Can Be Objectively Assessed With the Use of Stress Radiographs: A Systematic Review

Background

Stress radiography is a viable imaging modality that can also be used to assess the integrity of the anterior cruciate ligament (ACL) after primary or secondary injury. Because conventional radiography is relatively easy, affordable, and available worldwide, the diagnostic efficacy of ACL standing, lateral decubitus, and supine stress radiography should be evaluated.

Purpose

To examine the existing literature regarding the application of stress radiography in evaluating the integrity of the ACL.

Study Design

Systematic review; Level of evidence, 3.

Methods

Using the PubMed and MEDLINE databases for relevant articles published between 1980 and the present, a systematic review was conducted to identify evidence related to the radiographic diagnosis or assessment of ACL tears. The literature search was conducted in September 2022.

Results

Of 495 studies, 16 (1823 patients) were included. Four studies examined standing stress radiography, and 12 investigated lateral decubitus or supine stress radiography. Significant heterogeneity in imaging technique and recorded anterior tibial translation was identified. Anterior tibial translation for ACL-injured knees ranged from 1.2 to 10.6 mm for standing stress radiographs and 2.7 to 11.2 mm for supine stress radiographs, with high sensitivities and specificities for both.

Conclusion

Stress radiography was a dependable diagnostic method for identifying ACL rupture. Further research is necessary to determine the ideal anatomic landmarks, optimal patient positioning, and appropriate applied stresses to establish a standardized protocol for both assessing ACL tears and evaluating the postoperative integrity of ACL reconstruction using stress radiography.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Meniscal Radial Tears: A Classification System Based on Tear Morphology

Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.

Gluteal Complex is important in External Snapping Hip: intraoperative identification of syndrome origin and endoscopic stepwise release-a case series

PURPOSE

External snapping hip syndrome (ESHS) was historically attributed to isolated iliotibial band (ITB) contracture. However, the gluteus maximus complex (GMC) may also be involved. This study aimed to intraoperatively identify the ESHS origin and assess the outcomes of endoscopic treatment based on the identified aetiological type.

METHODS

From 2008-2014, 30 consecutive patients (34 hips) with symptomatic ESHS cases refractory to conservative treatment underwent endoscopic stepwise "fan-like" release, gradually addressing all known reasons of ESHS: from the isolated ITB, through the fascial part of the GMC until a partial release of gluteus maximus femoral attachment occurred. Snapping was assessed intra-operatively after each surgical step and prospectively recorded. Functional outcomes were assessed via the MAHORN Hip Outcome Tool (MHOT-14).

RESULTS

Twenty seven patients (31 hips) were available to follow-up at 24-56 months. In all cases, complete snapping resolution was achieved intra-operatively: in seven cases (22.6%) after isolated ITB release, in 22 cases (70.9%), after release of ITB + fascial part of the GMC, and in two cases (6.5%) after ITB + fascial GMC release + partial release of GM femoral insertion. At follow-up, there were no snapping recurrences and MHOT-14 score significantly increased from a pre-operative average of 46 to 93(p<0.001).

CONCLUSION

Intraoperative identification and gradual addressing of all known causes of ESHS allows for maximum preservation of surrounding tissue during surgery while precisely targeting the directly involved structures. Endoscopic stepwise "fan-like" release of the ITB and GMC is an effective, tailor-made treatment option for ESHS regardless of the snapping origin in the patients with possibility to manually reproduce the snapping.

The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies

PURPOSE

To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees.

METHODS

An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale.

RESULTS

Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift.

CONCLUSIONS

The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees.

CLINICAL RELEVANCE

This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.

A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation

Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

The effect of nonsteroidal anti-inflammatory drug use on soft tissue and bone healing in the knee: a systematic review

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to mitigate pain and inflammation associated with musculoskeletal conditions; however, there is conflicting data on the adverse effects of these drugs on tissue and bone healing. The objective of this study was to investigate the effect of NSAIDs on the healing of knee, soft tissue, and bone.

Methods

A systematic literature search was conducted across PubMed/MEDLINE, Excerpta Medical Database (Embase)/Ovid, and the Cochrane Central Register of Controlled Trials databases. Clinical, animal, and in vitro studies on the effect of NSAIDs on knee healing were included. Risk of bias assessment was performed using the Cochrane bias assessment tool and Methodological Index for Non-Randomized Studies scoring system for included clinical studies, and the Systematic Review Center for Laboratory Animal Experimentation assessment tool for all included animal studies. General study population characteristics, interventions used, NSAIDs utilized, outcome measures, and study results were analyzed using descriptive statistics.

Results

Fifteen articles met the inclusion criteria. Of the 15 studies, there were three clinical, ten animal, and two in vitro studies. In clinical studies, nonselective cyclooxygenase (COX) inhibitors and selective COX-2 inhibitors did not cause a significant increase in failure of anterior cruciate ligament (ACL) reconstructions or meniscal repairs with NSAID administration pre-, peri-, or post-operatively in comparison to placebo or no NSAID administration. Among animal studies assessing COX-2 inhibitor effects on soft tissue, healing was impaired (2/4), delayed but unaffected (1/4), or unaffected (1/4). In animal studies assessing COX-1 inhibitors, ligament healing was either increased (1/4), unaffected (2/4), or impaired (1/4). Meanwhile, administration of non-selective COX inhibitors in animals did not affect soft tissue (3/3) and cartilage (1/1) healing. Two in vitro studies identified a negative outcome on patellar tendon and ACL cell proliferation or viability after non-selective COX inhibition and variable results after selective COX-2 inhibition.

Conclusions

Animal studies on postoperative NSAID use after knee surgery suggest that administration of selective and nonselective COX-2 inhibitors may impair healing of soft tissue, bone and tendon-to-bone; however, further clinical studies are needed to better characterize dose and duration dependent risks of NSAIDs.

Inflammatory synovial biomarkers and state of the tibiofemoral joint in the post-surgical settings: a narrative review

Background and Objective

Knee surgery attempts to restore the native biomechanics of the knee, improve stability, and decrease the progression of osteoarthritis (OA). However, despite improvements in surgical techniques, tissue degradation and OA are common after knee surgery, occurring in higher rates in surgical knees compared to non-surgical knees. The aim of this study is to analyze previous literature to determine which synovial fluid biomarkers contribute to knee tissue degradation and decrease patient outcomes in the post-surgical setting of the knee.

Methods

A narrative review of relevant literature was performed in July 2023. Studies reporting on synovial biomarkers associated with the post-surgical knee were included.

Key Content and Findings

The literature reported that proinflammatory synovial biomarkers cause cartilage degradation and turnover which eventually leads to OA. The associated biomarkers are typically present prior to physical symptoms so understanding which one's correlate to OA is important for potential therapeutic treatments in the future. Studying the preoperative, early postoperative, and late postoperative synovial biomarkers will allow physicians to develop an improved understanding of how these biomarkers progress and correlate to knee tissue degradation and OA. This understanding could lead to further developments into potential treatment options. Research into inhibiting or reversing these inflammatory biomarkers to slow the progression of knee tissue degradation has already begun and has reported some promising results but is currently limited in scope.

Conclusions

Synovial fluid biomarkers in the post-surgical knee setting may contribute to decreased patient outcomes and the progression of knee tissue degradation. There is no current consensus on which of these biomarkers are the most detrimental or associated with decreased patient outcomes. With an improved understanding of the individual biomarkers, potential personalized therapeutic treatment could be used by physicians in the future to improve patient outcomes after surgery.

Effect of anti-inflammatory treatments on patient outcomes and concentrations of inflammatory modulators in the post-surgical and post-traumatic tibiofemoral joint setting: a narrative review

Background and Objective

There are several anti-inflammatory therapeutic options that can be used in the context of post-surgical and post-traumatic knee settings. Each of these options carries with it certain benefits, as well as potential issues depending on the duration and administration of each therapy. An understanding of how these anti-inflammatory drugs modulate various biomarkers of inflammation is also necessary in understanding how they can affect patient and objective outcomes following acute knee injury or surgery. This review covers the many traditional therapeutic options that have been used in treating knee injuries, as well as some natural therapeutics that have shown anti-inflammatory properties.

Methods

A current review of the literature was conducted and synthesized into this narrative review.

Key Content and Findings

Many traditional anti-inflammatory therapeutics have been shown to be beneficial in both post-traumatic and post-surgical tibiofemoral joint settings at reducing inflammation and improving patient outcomes. However, many of these treatments have risks associated with them, which becomes problematic with prolonged, repeated administration. Natural anti-inflammatory compounds may also have some benefit as adjunctive treatment options in these settings.

Conclusions

There are multiple different therapeutic options that can be used in acute knee settings, but the specific mechanism of injury or surgical context should be weighed when determining the best clinical approach.

Do the Differences in the Epiligament of the Proximal and Distal Parts of the Anterior Cruciate Ligament Explain Their Different Healing Capacities? Quantitative and Immunohistochemical Analysis of CD34 and α-SMA Expression in Relation to the Epiligament Theory

The aim of this study was to assess the epiligament theory by determining the normal epiligament morphology of the proximal and distal parts of the anterior cruciate ligament in humans and analyzing the differences between them and the midportion of the ligament in terms of cell numbers and expression of CD34 and α-SMA. Samples were obtained from the anterior cruciate ligaments of 12 fresh knee joints. Monoclonal antibodies against CD34 and α-SMA were used for immunohistochemistry. Photomicrographs were analyzed using ImageJ software, version 1.53f. The cell density was higher in the epiligament than in the ligament connective tissue. Cell counts were higher in the proximal and distal thirds than in the midsubstance of the epiligament. CD34 was expressed similarly in the proximal and distal thirds, although it seemed slightly more pronounced in the distal third. α-SMA expression was more robust in the proximal than the distal part. The results revealed that CD34 and α-SMA are expressed in the human epiligament. The differences between the numbers of cells in the proximal and distal parts of the epiligament and the expression of CD34 and α-SMA enhance epiligament theory. Future investigations into improving the quality of ligament healing should not overlook the epiligament theory.

Inconsistent Return to Sport Despite Improved Outcomes After Re-revision Anterior Cruciate Ligament Reconstruction: An Updated Systematic Review

PURPOSE

The primary objective was to systematically review the literature evaluating patient-reported outcomes and return to sport after re-revision anterior cruciate ligament reconstruction (ACLR) procedures. The secondary objectives were 2-fold: to identify the risk factors that lead to revision ACLR failure and to assess the secondary knee structure injuries after the initial revision ACLR.

METHODS

A systematic review of the literature was performed using the MEDLINE/PubMed and Cochrane databases. The inclusion criteria were outcomes of re-revision ACLR, minimum of 2 years' follow-up, human studies, and English language. Basic science articles, epidemiologic studies, editorials, surgical technique articles, surveys, cadaveric studies, and animal studies were excluded.

RESULTS

Fifteen studies met the inclusion criteria and were considered for review. There were 6 Level III and 9 Level IV studies that included 399 patients undergoing re-revision ACLR. The rate of concomitant meniscal lesions at the time of re-revision ranged from 35% to 90%. The prevalence of concomitant cartilaginous lesions at the time of re-revision ranged from 13.6% to 90%. Compared with preoperative scores, patient-reported outcomes overall improved after re-revision ACLR, with mean preoperative Lysholm scores ranging from 38.4 to 73.15 that improved to postoperative scores ranging from 68 to 87.8. However, return to sport at preinjury levels was inconsistent, with rates ranging from 12.5% to 80%.

CONCLUSIONS

Re-revision ACLR was found to restore knee stability and improve functional outcomes. Despite this improvement, there was a low rate of return to sport at the preinjury level. Functional outcomes were also inferior when compared with primary ACLR. In addition, concomitant knee pathologies were found to rise in prevalence compared with revision and primary ACLR cases.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Complete Arthroscopic Posterior Knee Capsulotomy in Patients With Knee Extension Deficit: Preliminary Results of a Clinical Trial

Background

Guided physiotherapy and surgical arthrolysis are effective in most patients with knee extension deficit. However, in refractory cases, posterior knee capsulotomy may be needed.

Purpose

To assess extension restoration, pain reduction, and functional improvement after arthroscopic complete posterior knee capsulotomy in patients with extension deficit refractory to guided physiotherapy and surgical arthrolysis.

Study Design

Case series; Level of evidence, 4.

Methods

Included were patients with symptomatic asymmetric extension deficit >3° refractory to at least 6 months of guided physiotherapy and initial arthrolysis (15 patients with 12-month follow-up and 8 patients with 24-month follow-up). The mean duration of extension deficit was 24.6 months. An arthroscopic complete posterior knee capsulotomy was performed with transection of the posteromedial, posterolateral and central capsule, and the posterior septum. The primary outcome measure was knee extension, with hyperextension denoted as negative knee extension values. Secondary outcome measures included visual analog scale (VAS) for pain during maximum effort and exercise, International Knee Documentation Committee (IKDC) score, and Knee injury and Osteoarthritis Outcome Score (KOOS).

Results

The mean patient age was 40.0 years (range, 26-70 years); 6 out of 15 patients had developed knee contracture after isolated anterior cruciate ligament reconstruction. The mean knee extension deficit decreased from 16.9° (range, 7° to 45°) preoperatively to -0.2° (range, -5° to 5°) at 12-month follow-up (P = .003) and to -0.3° (range, -5° to 5°) at 24-month follow-up (P = .035). The mean VAS pain score decreased from 3.5 (range, 1-6) preoperatively to 1.1 (range, 0-2) at 12-month follow-up (P = .004) and to 1.5 (range, 0-4) at 24-month follow-up (P = .005). The mean IKDC increased from 37.9 (range, 21-62) preoperatively to 63.9 (range, 46-87) at 12-month follow-up (P < .001) and to 60.9 (range, 39-80) at 24-month follow-up (P = .003). The mean KOOS increased from 45.0 (range, 30-62) preoperatively to 75.3 (range, 49-94) at 12-month follow-up (P < .001) and to 72.3 (range, 49-92) at 24-month follow-up (P = .003). There were no significant differences between 12- and 24-month follow-up in extension deficit or functional outcomes. One patient had a midcalf subcutaneous hematoma 5 weeks postoperatively, requiring evacuation.

Conclusion

Arthroscopic complete posterior knee capsulotomy was able to restore knee extension, reduce pain, and improve function, with 12-month follow-up results sustained at 24-month follow-up.

Registration

NCT05385393 (ClinicalTrials.gov identifier).

A modified Delphi consensus statement on patellar instability: part II

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.

Patellar Base Support Technique During Manipulation Under Anesthesia for Knee Arthrofibrosis Limits the Risk of Iatrogenic Complications

Knee extension contracture is a common postinjury and postsurgical complication, which decreases knee joint flexion. Many techniques have been described in the literature to restore knee flexion, with the most common one being an arthroscopic lysis of adhesions. However, in severe cases, additional intra- and extra-articular procedures are needed to restore full knee flexion. Manipulation under anesthesia (MUA) is one of them. Unfortunately, it may lead to devastating complications, such as iatrogenic rupture of the patellar tendon or fractures of the patella or tibial tuberosity. Therefore, the purpose of this report is to present a safer modification of MUA for knee extension contracture in cases in which excessive force is demanded to achieve flexion. The key aim of the "patellar base support" technique (PBS technique) is to stretch the contracted quadriceps muscle with controlled and decreased tension on the patella, patellar tendon, and tibial tuberosity.

Reference standards for stress radiography measurements in knee ligament injury and instability: a systematic review

PURPOSE

Stress radiographs are an easily accessible, cost-effective tool in the evaluation of acute and chronic ligament knee injuries. Stress radiographs provide an objective, quantifiable, and functional assessment of the injured ligament and can be a useful adjunct when planning surgical management and to objectively assess postoperative outcomes. This study aimed to review the literature reporting on stress radiographic techniques in evaluating knee ligament injury and instability and propose thresholds for interpreting stress radiography techniques.

METHODS

The following three databases, OVID MEDLINE, the EMBASE library, and the Cochrane Controlled Trials Register, were systematically searched on January 23, 2023, for studies published from January 1970 to January 2023. The search extended to the reference lists of all relevant studies and orthopedic journals. Included studies were those that described a stress technique for the diagnosis of knee ligament injury; studies that reported a description or comparison of the accuracy and/or reliability of one or several stress radiography techniques, or studies that reported a comparison with alternative diagnostic modalities.

RESULTS

Sixteen stress radiography techniques were reported for assessing the ACL with stress applied in the anterior plane, 10 techniques for assessing the PCL with stress applied in the posterior plane, 3 techniques for valgus stress, and 4 techniques for varus stress. The Telos device was the most commonly used stress device in the ACL and PCL studies. There was no consensus on the accuracy and reliability of stress radiography techniques for the diagnosis of any knee ligament injury. Stress radiography techniques were compared with alternative diagnostic techniques including instrumented arthrometry, MRI, and physical examination in 18 studies, with variability in the advantages and disadvantages of stress radiography techniques and alternatives. Analysis of results pooled from different studies demonstrated average delta gapping in knees with a completely injured ligament compared to the normal contralateral knee as per the following: for the ACL 4.9 ± 1.4 mm; PCL 8.1 ± 2.5 mm; MCL 2.3 ± 0.05 mm; and the FCL 3.4 ± 0.2 mm.

CONCLUSION

Despite heterogeneity in the available literature with regard to stress examination techniques and device utilization, the data support that stress radiography techniques were accurate and reliable when compared to numerous alternatives in the diagnosis of acute and chronic knee ligament injuries. The present study also provides average increased ipsilateral compartment gapping/translation for specific knee ligament injuries based on the best available data. These values provide a reference standard for the interpretation of stress radiography techniques, help to guide surgical decision-making, and provide benchmark values for future investigations.

LEVEL OF EVIDENCE

III.

Non-anatomical reconstruction of chronic posterolateral corner knee injuries show failure rates from 0% to 36% versus 4.3% to 24.2% for anatomic reconstruction techniques: An updated systematic review reflecting the 2019 expert consensus statement

OBJECTIVE

To review and update the literature regarding outcomes following surgical management of chronic, grade III posterolateral corner (PLC) injuries, with an emphasis on estimating failure rates based upon objective parameters in light of the 2019 expert consensus, while secondarily comparing the failure rates of anatomic versus non-anatomic reconstruction techniques.

METHODS

A literature search was performed using the PubMed, Embase, MEDLINE, and Cochrane Library databases. Inclusion criteria consisted of level I-IV human clinical studies reporting subjective and objective outcomes in patients following surgical management for chronic (>6 weeks from injury) grade III PLC injuries, with a minimum two-year follow-up. The criterion for objective surgical failure was based on post-operative varus stress radiographs and defined as a side-to-side difference of 3 ​mm or more of lateral gapping.

RESULTS

A total of six studies, consisting of 10 separate cohorts encompassing a total of 230 patients, were identified. PLC reconstruction was performed in all cohorts, with 80 ​% (n ​= ​8/10) of these cohorts utilising an anatomic reconstruction technique. A failure rate ranging from 4.3 ​% to 36 ​% was found. Subgroup analysis revealed a failure rate of 4.3 ​%-24.2 ​% for anatomic reconstruction techniques, whereas a 0 ​%-36 ​% failure rate was found for non-anatomic reconstruction. Arthrofibrosis was the most common complication (range, 0 ​%-12.1 ​%) following surgery. 0 ​%-8 ​% of patients required revision PLC surgery.

CONCLUSION

PLC reconstruction yields a wide variability in failure rates according to the side-to-side difference of 3 ​mm or more of lateral gapping on post-operative varus stress radiographs, with low revision rates following anatomic and non-anatomic reconstruction techniques.

LEVEL OF EVIDENCE

IV; Systematic Review of Level III and IV studies.

The accessory heads of the quadriceps femoris muscle may affect the layering of the quadriceps tendon and potential graft harvest lengths

PURPOSE

The aim of the study was to assess the quadriceps femoris system for the presence of additional layers.

METHODS

One hundred and twenty-eight lower limbs fixed in 10% formalin were examined.

RESULTS

Five types of quadriceps tendon layering were found based on the accessory heads of the quadriceps muscle. Type I (55%)-represented by four heads and four layers, and it was something new because standard orthopaedic textbooks described quadriceps tendon as a structure composed of only three layers. Type II (27.4%)-the first four layers were the same as in Type 1, but the accessory tendon of the fifth head of the quadriceps femoris muscle had the deepest attachments. Type III (10.9%)-this type included 6 heads of quadriceps femoris. It consisted of five layers. Type IV (3.1%)-this type included 7 quadriceps femoris heads. This type consisted of only four layers. Type V (3.1%)-this type included 8 heads of the quadriceps femoris heads. This type consist of 5 layers.

CONCLUSION

The findings of this study provide a detailed anatomy of the quadriceps tendon including the accessory tendons of the accessory heads of the quadriceps tendon. The accessory heads of the quadriceps femoris muscle contribute to the layering of the quadriceps tendon. The second conclusion of this study is the development of safe distances depending on the types. Not all types are perfect for harvesting-Type IV seems to be the safest type, in turn Type V the most dangerous.

Editorial Commentary: Meniscal Extrusion

With the improved recognition of meniscal root tears over the past decade, it has become clear that root repairs are necessary in most patients indicated for a repair to prevent the further progression of osteoarthritis. Root repairs are cost beneficial to and prevent the early need for a total knee arthroplasty. As further postoperative follow-up occurs for root repairs, we have found that most patients have significantly improved patient-reported outcomes, while it is still clear that further clinical outcome study as well as further refinement of surgical technique is necessary. The next thing that we have to investigate is how to prevent recurrent meniscal extrusion after a root repair. Nonanatomic repair significantly alters tibiofemoral biomechanics and results in notably increased meniscal extrusion. In contrast, biomechanical studies show anatomic repair of the meniscus attachment within 1 cm of the meniscus attachment site restores joint loading close to normal.

A modified Delphi consensus statement on patellar instability: part I

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.

Arthroscopic Trans-septal Portal of the Knee With Direct Visualization and No Need for Posterolateral Portal Creation

Arthroscopic visualization and access of the posterior knee are limited when using standard anterior and posterior portals. The creation of a trans-septal portal allows for complete access to the posterior compartment as arthroscopic instruments are able to be passed back and forth between the posteromedial and posterolateral compartments. Due to the close proximity of the popliteal artery and its branches, precise portal placement and safe orientation of arthroscopic instruments are critical to avoid iatrogenic injury. The conventional technique of trans-septal portal creation, involving a posterolateral portal, can be difficult in some cases. To overcome these obstacles, a posteromedial technique of trans-septal portal creation is presented. By using the medial parapatellar portal as the viewing portal, our technique allows for direct visualization of the posterior septum on each step of creation of the trans-septal portal, eliminating the need for "blind" maneuvers. What is more, no posterolateral portal is needed, decreasing the risk of potential complications. Using the posterior cruciate ligament fibers as a main landmark for trans-septal portal placement, preservation of the posterior part of the septum is achieved. This ensures optimal safe-margin distance away from the popliteal neurovascular bundle and making the technique safe and reproducible.

Knee extension contracture with fixed anterior tibia subluxation treated with PCL release and quadricepsplasty: a case report

58-year-old male presented with knee extension contracture (25°) with iatrogenic fixed anterior tibial subluxation. Consecutive arthroscopic arthrolysis, manipulation under anesthesia, and quadriceps-Z-plasty during one surgery failed to restore flexion. Therefore, shortened posterior cruciate ligament was released, which eliminated subluxation and allowed 115° flexion. Despite physiotherapy, flexion progressively decreased to 70° postoperatively. Revision quadricepsplasty by transverse incisions restored 120° of flexion maintained at 31-months follow-up. International Knee Documentation Committee increased 4/87- > 50/87, Knee injury and Osteoarthritis Outcome 7/100- > 68/100 at follow-up. Posterior cruciate ligament release and repeated quadricepsplasty could be a viable salvage option in severe extension contracture with fixed anterior tibial subluxation.

Continuous Vertical Inside-Out Versus Traditional Vertical Inside-Out Meniscal Repair: A Biomechanical Comparison

Background

Biomechanical assessment of meniscal repairs is essential for evaluating different meniscal suturing methods and techniques. The continuous meniscal suture technique is a newer method of meniscal repair that may have biomechanical differences compared with traditional techniques.

Purpose

To evaluate the displacement, stiffness after cyclical loading, and load to failure for a continuous vertical inside-out meniscal suture versus a traditional vertical inside-out meniscal suture in a porcine medial meniscus.

Study Design

Controlled laboratory study.

Methods

A total of 28 porcine knees were acquired and divided into 2 test groups of 14 medial meniscus each. A 2.0-cm longitudinal red-white zone cut was made in the body of the medial meniscus for each knee. The continuous suture (CS) group received 4 vertical stitches performed with a continuous vertical meniscal suture technique, and the inside-out suture (IO) group received a traditional vertical suture with 4 stitches. Two traction tapes were passed between the sutures and positioned in the biomechanical testing fixture device. Each specimen underwent load-to-failure testing at 5 mm/s, and displacement, system stiffness, and maximum load to failure were compared between the groups.

Results

The displacement after the cyclic test was 0.53 ± 0.12 and 0.48 ± 0.07 mm for the CS and IO groups, respectively. There was no significant difference between the groups (P = .2792). The stiffness at the ultimate load testing was 36.3 ± 1.9 and 35.3 ± 2.4 N/mm for groups CS and IO, respectively, with no significant difference between the groups (P = .2557). In the load-to-failure test, the ultimate load was 218.2 ± 63.9 and 238.3 ± 71.3 N in the CS and IO groups, respectively, with no significant group differences (P = .3062).

Conclusion

A continuous vertical meniscal suture created a configuration for treating longitudinal meniscal lesions that was beneficial and biomechanically similar to a traditional vertical suture technique.

Clinical Relevance

The study findings indicate that use of the continuous vertical inside-out meniscal suture technique is a possible therapeutic option.

Incomplete meniscal healing in early second-look arthroscopy does not indicate failure of repair: a case series

PURPOSE

To assess if incomplete meniscal healing during second-look arthroscopy at six to eight weeks after all-inside suture hook meniscus repair results in longer-term failure of repair in patients with restored knee stability.

METHODS

From 2008 to 2013, 41 patients with post-traumatic, longitudinal, vertical, complete meniscal tears with concomitant ACL injury were treated via a two-stage surgical procedure and prospectively evaluated. In the first stage, all-inside meniscus repair was performed using suture hook passers and non-absorbable sutures. In total, there were 26 medial and 16 lateral meniscus tears. A second-stage ACL reconstruction, performed six to eight weeks later, served as an early second-look arthroscopic evaluation of meniscal healing. Clinical follow-up was performed at a minimum of 24 months.

RESULTS

Second-look arthroscopy revealed 31 cases (75.6%) of complete and ten cases (24.4%) of incomplete meniscal healing. Two patients were lost prior to follow-up, and three were excluded due to recurrent instability. Therefore, 36 patients were assessed at the final follow-up. All patients with complete meniscal healing during second-look arthroscopy achieved clinical success at follow-up. Six out of nine (66.7%) of patients with incomplete meniscal healing during second-look arthroscopy achieved clinical success at follow-up (p = 0.012). One saphenous neuropathy occurred (2.4%).

CONCLUSION

Incomplete meniscal healing during early second-look arthroscopy after all-inside meniscal repair using suture hook passers and non-absorbable sutures did not necessarily result in longer-term failure in patients with restored knee stability. The described method of meniscal repair was associated with a low rate of symptomatic re-tears and complications.

Meniscal Extrusion Measurements After Posterior Medial Meniscus Root Tears: A Systematic Review and Meta-analysis

BACKGROUND

Meniscal extrusion has become increasingly utilized when evaluating meniscus root abnormalities. However, no consensus definition or approach exists on how to measure extrusion.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the extent of heterogeneity in meniscal extrusion measurement techniques and reported extrusion values in knees with posterior medial meniscus root tears (PMMRTs). We hypothesized that meniscal extrusion measurement techniques would vary considerably throughout reported studies, with resultant wide-ranging published extrusion values.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The inclusion criteria consisted of all clinical and cadaveric studies reporting on meniscal extrusion after PMMRTs, excluding studies lacking data in full extension, those presenting only semiquantitative analyses, articles reporting only differences in meniscal extrusion, and review articles.

RESULTS

A total of 45 studies were included. Imaging modality types included magnetic resonance imaging (89%), 3-dimensional reconstruction with computed tomography (7%), linear displacement transducers (2%), and a combination of magnetic resonance imaging and ultrasound (2%). The 3 most commonly used landmarks to acquire coronal images for meniscal extrusion measurements were the medial collateral ligament (38%), the midpoint of the anterior-posterior length of the medial meniscus (23%), and the middle of the medial femoral condyle (19%). The pooled mean extrusion values according to the measurement location were 3.5 ± 0.7 mm, 3.9 ± 0.8 mm, and 4.5 ± 2.1 mm, respectively, with no significant differences noted between the modality types (P = .23). The pooled mean meniscal extrusion from all included studies was 3.2 ± 2.0 mm.

CONCLUSION

Substantial variation exists in measurement techniques for meniscal extrusion, particularly as it relates to the coronal cross-sectional reference location. Further studies should aim to provide clear descriptions of the measurement method and have uniform measurement methodology to allow comparisons and pooling between studies.

Impaction Fractures of the Lateral Femoral Condyle Related to Anterior Cruciate Ligament Injury: A Scoping Review Concerning Diagnosis, Prevalence, Clinical Importance, and Management

Background

During pivot-shift anterior cruciate ligament (ACL) injury, bone bruises or impaction fractures of the lateral femoral condyle (LFC-IF) may occur due to impaction between the posterior part of the lateral tibial plateau and anterocentral part of the LFC. The purpose of the study was to systematically review the literature concerning the diagnosis, prevalence, clinical importance, and management of LFC-IF occurring during ACL injuries.

Methods

Included were studies concerning impaction fractures of the anterocentral part of the LFC occurring during ACL injuries. Studies concerning only bone bruises or cartilage lesions, without subchondral bone impaction, were not included. A search was performed in Medline and Scopus databases, with final search in May 2022. A secondary search was conducted within the bibliographies of included articles and using "Cited In" option. Two authors independently extracted data in three domains: study design, LFC-IF characteristics, and LFC-IF importance and management.

Results

A total of 35 studies were included for review with several studies reporting on multiple domains. Summarily, 31 studies were on the diagnosis and prevalence, 19 studies reported on the clinical importance, and 4 studies reported on the management of LFC-IF.

Conclusions

A LFC-IF occurs due to the pivot-shift mechanism of ACL injury. Its radiological feature is defined as an impaction of terminal sulcus deeper than 1 mm and is present in up to 52% of patients with a torn ACL. An LFC-IF causes injury to the cartilage, probably leads to its progressive degeneration, and is significantly associated with an increased risk of a lateral meniscus injury. A large LFC-IF might be associated with greater rotational knee instability. Although several techniques of LFC-IF treatment were proposed, none of them has been evaluated on a large cohort of patients to date.

Increased Risk of Fracture, Dislocation, and Hospitalization Are Associated With Collision in Contact Sports

Purpose

To quantitatively determine whether there is an added risk of orthopaedic injury attributable to the collision forces that athletes participating in collision-contact (CC) sports regularly encounter.

Methods

The National Electronic Injury Surveillance System was used to collect data on patients presenting to an emergency department with a contact sports-related injury between 2014 and 2020. Select contact sports were classified as either belonging to a CC or noncollision-contact (NCC) sports group based on involvement of frequent and intentional player-to-player collisions.

Results

From 2014 to 2020, 25,784 patients with team-based sports related injuries presented to an emergency department, of whom 7,591 sustained an injury during a CC sport and 18,193 during a NCC sport. The CC group was associated with significantly increased odds of sustaining at least 1 fracture (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.35-1.52) (P < .001), dislocation (OR 1.2, 95 % CI 1.06-1.33) (P < .001), and being admitted into the hospital (OR 1.6, 95% CI 1.34-1.86) (P < .001), compared with the NCC group.

Conclusions

We found that frequent and intentional high-energy collisions associated with CC sports significantly increase the risk of sustaining fractures and dislocations. Furthermore, we found that that the injuries sustained by players engaging in CC sports required hospitalization at a significantly greater rate than those sustained in contact sports that do not involve frequent and intentional player-to-player collisions.

Level of Evidence

Level III, prognostic (retrospective cohort study).

ACL Mucoid Degeneration-Anterior and Posterior Arthroscopic Decompression for Combined Knee Flexion-Extension Deficit

Mucoid degeneration of the ACL (MDACL, ACL ganglion cysts) is a disease involving ACL thickening due to accumulation of mucoid substance and fiber degeneration with possible formation of "ganglions". Clinically, it leads to anteroposterior impingement and painful limitation of knee range of motion due to impingement of the anterior portion of the thickened ACL with the intercondylar notch during knee extension and the thickened posterior part of the ligament with posterior structures of the knee in flexion. Different treatment methods have been described, including total or partial resection of the ACL degenerative fibers. However, these techniques do not allow for ACL preservation and are associated with a risk of postoperative instability. Also, most procedures treat anterior impingement only. Therefore, the aim of this technical note is to present an arthroscopic technique allowing for minimally invasive anteroposterior ACL decompression. The technique is focused on evacuation of the interfibrous mucoid substance, ganglions, and bony decompression, as well as maintenance of ligament integrity. Its greatest advantage is that it is safe and ACL-preserving yet allows for comprehensive treatment of all intra- and extra-ligamentous possible reasons of MDACL origin and promoting good healing conditions.

Combined Rip-Stop and Transtibial Pull-out Technique for Lateral Meniscus Radial Repairs

Radial tears of the meniscus disrupt circumferential fibers that allow for the dispersion of axial tibiofemoral forces. Both nonoperative treatment and meniscectomy carry increased risk of early-onset degeneration of the joint because of decreased contact surface area and increased point-loading of the chondral surfaces. Radial type tears are also notable for the relatively high failure rate associated with repair. The purpose of this technical note is to demonstrate our surgical technique for a radial lateral meniscus repair construct that allows for good apposition and anatomic reduction of the meniscus with less risk of residual postoperative extrusion through use of a combination inside-out rip-stop and transtibial pull-out suturing repair.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The "New Terrible Triad"

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the "new terrible triad" of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures

Background

There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment.

Purpose

To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs.

Results

A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes (P < .05 for all). Arthroscopic surgery was associated with lower postoperative posterior tibial translation compared with open surgery (range, 0.6-3.2 vs 1.7-3.1 mm), greater preoperative to postoperative improvement in Lysholm score (54.6 vs 48.8; P < .0001), higher postoperative Tegner score (6.64 ± 1.03 vs 6.14 ± 2.29; P = .0448), and a higher rate of return to sport (100% vs 89.5%; P = .009). Nonoperative management was associated with a significantly lower fracture union rate (87% vs 99.1%; P < .0001) and greater postoperative side-to-side posterior translation (4.9 ± 4.3 mm) when compared with operative management.

Conclusion

Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (>4 mm) with a lower rate of fracture union compared to surgical treatment.

Injury Patterns in Posterolateral Corner Knee Injury

Background

Posterolateral corner (PLC) knee injuries associated with different injury mechanisms are not well known.

Purpose/Hypothesis

This study sought to assess the patterns of associated injuries in the setting of PLC injury. The hypothesis was that there are recognizable injury patterns in PLC injuries that may correlate with injury mechanism.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Patients who sustained a multiligament knee injury were retrospectively reviewed. Patients who sustained an acute grade 3 PLC injury and underwent surgery were enrolled in this study. A description of the PLC injury (location of the injury of the fibular collateral ligament [FCL], popliteus tendon, and/or popliteofibular ligament) and reported concomitant injuries (biceps femoris tendon or meniscal tears, cartilage pathology and/or peroneal nerve palsy, or bone bruises) were collected and classified based on intraoperative and magnetic resonance imaging (MRI) findings.

Results

Of 135 patients reviewed, 83 did not have PLC involvement and 13 were excluded due to insufficient MRI scans available. Thus, 39 patients were included in this study. For both the anterior cruciate ligament (ACL)-PLC and ACL-posterior cruciate ligament-PLC injury patterns, the most frequent injury pattern entailed a bone bruise of the anteromedial (AM) femur and tibia, an FCL tear from the fibular head, the popliteus tendon avulsed off the femur, a biceps femoris tendon torn off the fibular head, and a common peroneal nerve palsy. Conversely, when no bone bruise occurred on the AM femur and tibia, the FCL was injured on the femoral side and the popliteus tendon, biceps femoris, and peroneal nerve were not injured.

Conclusion

AM bone bruise was associated with a peroneal nerve injury in almost half of the patients, and peroneal nerve injury was not seen if there was no AM bone bruise.

Anatomy of the anterior cruciate ligament and the common autograft specimens for anterior cruciate ligament reconstruction

A thorough understanding of the anatomical properties of the native anterior cruciate ligament (ACL), as well as the native specimens that are most commonly considered as viable autograft choices for anterior cruciate ligament reconstruction (ACLR), is warranted for continuing to pursue the best-possible graft choice for patients undergoing ACLR. While a wide variety of graft choices remain available to the operating surgeon, choosing the correct graft choice remains a consideration and discussion with patients on the pros and cons of each option. This article combines a review of the current literature on the quantitative and qualitative anatomy of the native ACL and common autograft specimens with the expert consensus of the senior author on the surgically-pertinent anatomy of these structures. The purpose of this article is to review the anatomy pertaining to the native ACL, along with the distal anatomy of the hamstring tendons, patellar tendon and quadriceps tendon (QT). Multiple tendinous and ligamentous structures exist around the knee that serve as viable candidates for use as autologous grafts for ACLR, and the anatomy of these distal extents of these structures are discussed thoroughly, including bony attachments, quantitative and relational anatomy, cross sectional area, and histological features of these structures.

Treatment of a Failed Posterior Cruciate Ligament Avulsion Fracture Fixation in a Skeletally Immature Patient: A Case Report

CASE

A 12-year-old skeletally immature girl presented with 1 year of persistent instability after an open reduction and internal fixation (ORIF) for a posterior cruciate ligament (PCL) avulsion fracture. With a period of nonoperative management, her PCL stress radiographic measurements significantly decreased and her posterior tibial slope increased because the primary ORIF effectively led to growth arrest with an early fusion of the posterior tibial physis. At age 13 years when she was skeletally mature, revision PCL and fibular collateral ligament (FCL) reconstructions were performed. Promising clinical outcomes were observed at age 17 years.

CONCLUSION

Pediatric patients with a failed PCL ORIF can successfully be managed with a period of nonoperative bracing and a revision PCL reconstruction once skeletally mature.

Diagnosis by Manual Maneuver of Medial Meniscus Ramp Lesions

The intra-articular injury most often associated with a chronic anterior cruciate ligament tear involves the posterior horn of the medial meniscus. A specific type of medial meniscal injury, called a ramp lesion, has received greater attention for identification and treatment because of its considerable incidence and diagnostic difficulty. Based on their location, these lesions may be arthroscopically "hidden" during traditional anterior visualization. The purpose of the present Technical Note is to describe the Recife maneuver. This maneuver diagnoses injuries to the posterior horn of the medial meniscus using additional arthroscopic management through a standard portal. The Recife maneuver is performed with the patient in the supine position. A 30° arthroscope is inserted through the anterolateral portal, and the posteromedial compartment is accessed according to the transnotch view (modified Gillquist view). In the proposed maneuver, with the knee in 30° of flexion, a valgus stress with internal rotation is performed, followed by palpation of the popliteal region and digital pressure on the joint interline. This maneuver allows a greater visualization of the posterior compartment, allowing the diagnostic evaluation of the integrity between the meniscus and the capsule, in a safer way, being able to identify ramp tears without the need to create a posteromedial portal. We recommend that the addition of the diagnostic visualization step of the posteromedial compartment as described by the Recife maneuver be performed to assess the meniscal status in routine anterior cruciate ligament reconstruction.

Combined All-Inside Anterior Cruciate Ligament Reconstruction With Semitendinosus Plus Anterolateral Ligament Reconstruction With Intact Gracilis Tibial Insertion and Transtibial Passage

The indications for combining anterior cruciate ligament reconstruction with anterolateral ligament reconstruction have increased considerably in recent years since several anatomical, clinical, and biomechanical studies have proven the importance of the anterolateral periphery in knee rotational stability. Much is still being discussed on how to combine these techniques in terms of which grafts and fixation options to use, as well as avoiding tunnel convergence. This study aims to describe anterior cruciate ligament reconstruction with a triple-bundle semitendinosus tendon graft all-inside technique combined with an anterolateral ligament reconstruction maintaining the gracilis tendon insertion on the tibia, using independent anatomical tunnels. With this, we were able to reconstruct both using only hamstring autografts, reducing morbidity in other possible donor areas, in addition to allowing stable fixation of both grafts without tunnel convergence.

Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques

Various uses of posterior knee arthroscopy have been shown, including all-inside repair of posterior meniscal lesions, posterior cruciate ligament (PCL) reconstruction or PCL avulsion fixation, extensile posterior knee synovectomy for pigmented villonodular synovitis or synovial chondromatosis, posterior capsular release in the setting of knee flexion contractures, and loose bodies removal. Posterior arthroscopy provides direct access to the posterior meniscal borders for adequate abrasion and fibrous tissue removal. This direct view of the knee posterior structures enables the surgeon to create a stronger biomechanical repair using vertical mattress sutures. During PCL reconstruction, posterior arthroscopy gives the surgeon proper double access to the tibial insertion site, which can result in less acute curve angles and the creation of a more anatomic tibial tunnel. Moreover, it gives the best opportunity to preserve the PCL remnant. Arthroscopic PCL avulsion fixation is more time-consuming with a larger cost burden compared to open approaches, but in the case of other concomitant intra-articular injuries, it may lead to a better chance of a return to pre-injury activities. The high learning curve and overcaution of neuromuscular injury have discouraged surgeons from practicing posterior knee arthroscopy using posterior portals. Evidence for using posterior portals by experienced surgeons suggests fewer complications. The evidence suggests toward learning posterior knee arthroscopy, and this technique must be part of the education about arthroscopy. In today's professional sports world, where the quick and complete return of athletes to their professional activities is irreplaceable, the use of posterior knee arthroscopy is necessary.

Long-term clinical results of using a posteromedial all-inside and anteromedial inside-out approach to repair unstable or irreducible bucket-handle medial meniscal tears

BACKGROUND

In irreducible bucket-handle medial meniscal tears (BHMMTs), the displaced central fragment is rotated 180° or more, meaning reduction is impossible without derotation of the tear. In chronic cases, the rotated meniscus is deformed and degenerated; thus, the issue of reproducibility and repairability arises. This study presents the clinical outcomes of chronic irreducible and unstable locked BHMMTs. Radiological outcomes were also evaluated using magnetic resonance imaging (MRI).

METHODS

This is a retrospective study of 37 patients with 11 cases of irreducible BHMMT and 26 cases of reducible but unstable chronic BHMMT who underwent operations between 2011 and 2016. Posterior arthroscopy was performed after temporary meniscus fixation using a provisional needle fixation technique. After the posterior repair with vertical mattress sutures was completed using an all-inside technique, the classic outside-in technique was performed for the anterior third of the meniscus. The Lysholm, International Knee Documentation Committee (IKDC), and Tegner activity scores were obtained from all patients before surgery and at the latest follow-up. Radiological evaluations were performed using MRI before surgery and at 6 months postoperatively.

RESULTS

Between 2011 and 2016, a total of 37 consecutive patients with irreducible and chronic BHMMTs underwent surgery. The average postoperative follow-up was 7.2 ± 1.4 years (mean ± SD). Postoperative Lysholm (89.57 ± 2.7) and IKDC (87.22 ± 3.2) scores improved significantly at the last follow-up when compared with the pre-operative scores (38.44 ± 4.5 and 23.52 ± 7.8, respectively). According to the Tegner activity scale, patients' postoperative activity levels remained unchanged compared to preoperative levels at the last follow-up.

CONCLUSION

Posterior knee arthroscopy with the all-inside posterior suture and inside-out anteromedial suture technique presented in this study yielded excellent clinical outcomes when used to repair chronic irreducible or unstable BHMMTs.

LEVEL OF EVIDENCE

Level IV.

Biomechanical considerations for graft choice in anterior cruciate ligament reconstruction

Injury to the anterior cruciate ligament (ACL) of the knee is common and often requires surgical reconstruction. There are numerous graft options available to the operating surgeon, to each of which a growing body of dedicated literature exists. Each of these potential choices of ACL graft specimen has a distinctive set of biomechanical properties, clinical outcome profiles, and other special considerations (e.g., autograft versus allograft, harvest site factors, and operating time). The purpose of this review is to discuss the biomechanical characteristics of the native ACL alongside those of several of the most commonly used ACL graft specimens based on a current review of the biomechanical literature. In doing so, this review will also briefly discuss the biomechanical implications for allograft versus autograft usage and single-bundle versus double-bundle repair techniques. This review lists and discusses the stress, strain, stiffness, Young's modulus, and ultimate load to failure of the native ACL, several common autografts [patellar bone-tendon-bone (BTB), hamstring tendon (HT), and quadriceps tendon (QT)], and several common allografts. Given the important biomechanical role of the ACL in stabilizing the knee to translational and rotational forces, it is crucial that the operating surgeon make a decision on graft choice that is informed in the biomechanical implications of ACL graft selection.

Morphological variations of the calcaneal tendon: clinical significance

The calcaneal tendon, the largest and strongest in the human body, is created by the common junction of tendons of the gastrocnemius and soleus muscles. It is not a homogenous structure, being represented by layers in various arrangements. Morphological variability can be seen in the connection between the aponeurosis of the gastrocnemius muscle and the soleus muscle. Some types of plantaris tendon can be associated with a higher possibility of Achilles tendinopathy. Moreover, the presence of accessory structures, such as an accessory soleus muscle or additional gastrocnemius muscle heads may result in symptomatic pathologies. The main aim of this review is to summarize the current state of knowledge regarding the calcaneal tendon. Another aim is to present morphological variations of the calcaneal tendon and their clinical significance. Such information may be useful for clinicians, especially orthopedists, and surgeons. This review also provides an overview of embryological development and morphological variation among fetuses. Materials and methods: review was conducted according to PRISMA guidelines. An electronic search was conducted in five databases. Top quality tools were used to assess the quality of evidence in the studies reviewed. Research papers that made up the database of this review were analyzed, selected and assessed by two independently working researchers.

Open Popliteus Tendon Reconstruction Using a Hamstring Tendon Autograft

The popliteus tendon plays a critical role in restraining the tibia against external rotation. It is often injured in the setting of posterolateral corner injuries. However, it is rarely injured in isolation from other structures of the posterolateral corner. This Technical Note describes an open anatomic reconstruction of the popliteus tendon. Although several techniques exist, this technique has been biomechanically validated and shown to have good outcomes. An early rehabilitation protocol focused on protected range of motion, edema control, quadriceps strengthening, and pain control is essential for maximizing patient outcomes.

Consensus statements: when and how?

The Bone & Joint Journal has published several consensus statements in recent years, many of which have positively influenced clinical practice and policy.^1-13 However, even the most valued consensus statements have limitations, and all ultimately represent Level V evidence. Consensus studies add greatest value where higher-order evidence to aid decision making is ambiguous or lacking. In all settings, care must be taken to critically appraise standards of methodology, with particular attention to potential biases that may influence the conclusions which are drawn.