Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ

BACKGROUND

There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate.

RESULTS

A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007).

CONCLUSION

The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.

Endoscopic treatment of gluteus medius tendon tear

Tears in the gluteus medius and minimus tendons are a common cause of greater trochanter pain syndrome (GTPS). Given the non-specific clinical signs and imaging findings, they are often misdiagnosed, with delayed treatment. The lesions can show several aspects: trochanteric bursitis, simple tendinopathy, partial or full-thickness tear, tendon retraction, or fatty degeneration. Non-surgical treatment associates physical rehabilitation and activity modification, oral analgesics, anti-inflammatories and peri-trochanteric injections (corticosteroids, PRP). In the event of symptoms recalcitrant to medical treatment, surgery may be indicated. A 5-stage classification according to intraoperative observations and elements provided by MRI is used to guide technique: isolated bursectomy with microperforation, single or double row tendon repair, or palliative surgery such as muscle transfer (gluteus maximus with or without fascia lata). The development of conservative hip surgery now makes it possible to perform all of these surgical techniques endoscopically, with significant improvement in functional scores and pain in the short and medium term and a lower rate of complications than with an open technique. However, tendon retraction and fatty degeneration have been reported to be factors of poor prognosis for functional results and tendon healing and palliative tendon transfer gives mixed results for recovery of tendon strength. It is therefore preferable not to wait for the onset of Trendelenburg gait to propose endoscopic repair of the gluteus medius tendon in case of pain with a tear visible on MRI and failure of more than 6 months' medical treatment. Based on expert opinion, this article provides an update on the diagnosis of gluteus medius lesions, treatment, and in particular the place of endoscopy, indications and current results. LEVEL OF EVIDENCE: V.

Return to Sport After Revision ACL Reconstruction: A Comparative Cohort Study of Outcomes After Single- Versus Multiple-Revision Surgeries

BACKGROUND

The return-to-sport rate at 2 years after multiple-revision anterior cruciate ligament (ACL) reconstructions has not been evaluated.

HYPOTHESIS

It was hypothesized that patients who undergo multiple-revision ACL reconstructions would have a lower return-to-sport rate at 2 years after surgery than those who undergo a single-revision reconstruction. Furthermore, it was hypothesized that the multiple-revision group would have lower functional scores.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A single-center cohort study in patients who underwent revision ACL reconstruction was begun in 2012. This study included 2 groups: Patients who underwent a single revision, and those who underwent multiple revisions. The main evaluation criterion was the return to sport at the 2-year follow-up. The secondary criteria were the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and ACL-Return to Sport after Injury (ACL-RSI) functional knee scores at the 1- and 2-year follow-ups.

RESULTS

A total of 322 patients (single-revision group: n = 302; multiple-revision group: n = 20) were included. A significant difference in the percentage of patients who stopped all sports activity was found between the 2 groups at 2 years (single-revision group: 19.4%; multiple-revision group: 50%). The return-to-sport rate at the same or lower level of performance was higher in the single-revision group as well (17% vs 14.3% for return at the same level; 45.6% vs 14.3% for return at a lower level; P = .03). At the 2-year follow-up, the functional scores of the single-revision group were significantly higher those than in the multiple-revision group: IKDC (77.7 ± 13.82 vs 64.79 ± 15.22; P < .001), KOOS (72.66 ± 17.63 vs 52.5 ± 15.64; P < .001), Lysholm (84.05 ± 11.88 vs 72.5 ± 13.49; P < .001), and ACL-RSI (52.34 ± 21.83 vs 46.43 ± 14.8; P = .0036).

CONCLUSION

Only a small percentage of patients returned to the same level of sport after single- revision and multiple-revision ACL reconstruction, yet significantly more in the former. More patients who underwent multiple revisions gave up their sport. Functional scores were higher for single-revision than multiple-revision surgeries.

Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center

INTRODUCTION

For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals.

OBJECTIVES

The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors.

METHODS

We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test.

RESULTS

A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI.

CONCLUSION

En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures.

LEVEL OF EVIDENCE

III, case-control study.