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Lateral extra-articular augmentation (LEA) of anterior cruciate ligament reconstructions significantly reduces graft failure rates. Currently, proximally fixed LEA procedures are popular techniques. However, there are concerns about these techniques regarding anterior cruciate ligament tunnel collision, kinematic overconstraint, and increasing lateral-compartment contact forces. These issues are potentially avoided by the modified Ellison procedure, which is a distally fixed LEA technique. This article describes the surgical details of this easily reproducible technique.

Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabilizer to control anterolateral rotational laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ALCR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.

Given the common occurrence of residual laxity and re-injury post anterior cruciate ligament reconstruction (ACLR), additional anterolateral procedures are increasingly used in combination with an ACLR. Despite the perception that there is a risk of over-constraining the lateral tibiofemoral (LTF) compartment, potentially leading to osteoarthritis, assessment on their effect on intra-articular compartment pressures is still lacking. Our objective was therefore, through a pilot biomechanical study, to compare LTF contact pressures after the most commonly used anterolateral procedures.A controlled laboratory pilot study was performed using 4 fresh-frozen cadaveric whole lower limbs. Through 0° to 90° of flexion, LTF contact pressures were measured with a Tekscan sensor, located under the lateral meniscus. Knee kinematics were obtained in 3 conditions of rotation (NR: neutral, ER: external and IR: internal rotation) to record the position of the knees for each loading condition. A Motion Analysis system with a coordinate system based on CT scans 3D bone modelling was used. After an ACLR, defined as the reference baseline, 5 anterolateral procedures were compared: anterolateral ligament reconstruction (ALLR), modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh procedures. The last 3 procedures were randomised. For each procedure, the graft was fixed in NR at 30° of flexion and with a tension of 20 N.Compared with isolated ACLR, addition of either ALLR or modified Ellison procedure did not increased the overall LTF contact pressure (all p0.05) through the full range of flexion for the IR condition. Conversely, deep Lemaire, superficial Lemaire and modified MacIntosh procedure (all p0.05) did increase the overall LTF contact pressure compared with ACLR in IR. No significant difference was observed in ER and NR conditions.This pilot study, comparing the main anterolateral procedures, revealed that addition of either ALLR or modified Ellison procedure did not change the overall contact pressure in the LTF compartment through 0° to 90° of knee flexion. In contrast, the deep and superficial Lemaire, and modified MacIntosh procedures significantly increased overall LTF contact pressures when the knee was internally rotated.

Objective The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. Methods A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. Results Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). Conclusion In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. Level of evidence The level-of-evidence statement does not apply for this laboratory experiments study.

Background: The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis: The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design: Cohort study; Level of evidence, 3. Methods: From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results: Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [ P = .021]; mean passive, 2.76° vs 5.00°, respectively [ P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion: At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Barfod, KW, Feller, JA, Clark, R, Hartwig, T, Devitt, BM, and Webster, KE. Strength testing after anterior cruciate ligament reconstruction: A prospective cohort study investigating overlap of tests. J Strength Cond Res 33(11): 3145-3150, 2019-The purpose of the present study was to determine whether overlap (redundancy) exists between individual tests in a comprehensive strength testing protocol used after anterior cruciate ligament reconstruction (ACLR). If overlap is present, one or more components of the protocol could potentially be omitted to make the testing protocol more efficient, but without compromising the usefulness of the testing. Sixty-nine patients (46 male and 23 female patients; mean age 28 years) were strength tested at 6 and 12 months after ACLR as part of a prospective cohort study. The following knee flexor and extensor strength tests were performed: isokinetic concentric strength at 60 and 180°·s, isokinetic eccentric strength at 60°·s, and isometric knee flexor strength at 60° flexion. Peak and average torque values were extracted, and the ratio between the operated and non-operated limb was calculated as a limb symmetry index. Overlap of strength tests was investigated by fitting a linear regression model to the data with an R threshold of 0.56 used as an indication of overlap. Overlap between peak and mean torque was present for extensor and flexor concentric and eccentric measurements at 12 months and for concentric measurements at 6 months. Peak torque measurements were therefore used for subsequent analysis. Concentric extensor peak torque at 60 and 180°·s showed overlap at 6 months (R = 0.73) but not at 12 months (R = 0.37). No other overlap was identified. In conclusion, there is little room for omission of individual strength testing protocol components because of the lack of overlap between tests. Isometric, eccentric, and concentric tests may all provide unique information and all, therefore, should be considered for inclusion.

Background: The coronavirus 2019 (COVID-19) pandemic has had a profound impact on health care in Australia. To contain the spread of the virus, strict physical distancing and social isolation policies were implemented from late March 2020. This presented a situation in which patients recovering from anterior cruciate ligament (ACL) reconstruction had limited access to face-to-face supervised rehabilitation and rehabilitation facilities. Purpose: To explore the impact of social distancing and isolation policies on postoperative rehabilitation in patients after ACL reconstruction. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients who had ACL reconstruction from October 2019 until the end of March 2020 (6 months before the implementation of COVID-19 restrictions) completed an online self-report questionnaire containing 5 sections: utilization of health care professionals for rehabilitation, frequency of rehabilitation, patient concerns and attitude, perceived impact on recovery, and changes to employment status. We compared the responses of patients who had surgery in 2019 with those who had surgery in 2020. Statistical analysis was performed using frequency statistics and central tendency measures. Results: A total of 185 patients (97 men, 88 women) completed the survey, for a 73% response rate. Patients had a mean age of 28 years (range, 13-57 years) and had undergone surgery a mean 4.5 months prior (range, 1.5-8 months). Most patients (80%) maintained face-to-face rehabilitation, predominantly with a physical therapist, regardless of whether their surgery took place in 2019 or 2020; rehabilitation with active, supervised exercises was most common. Almost all patients were performing strengthening exercises (164/185), and most were performing range-of-motion (139/185) and aerobic (123/185) activities at their homes. Patients were minimally concerned about access to supervised rehabilitation and knee reinjury, but they were concerned about access to equipment. Because of COVID-19, 30% were working from home; 17% were on reduced hours and 8% on increased hours; 15% were on leave or unemployed; and 30% reported no change in employment status. Conclusion: Patients who had undergone ACL reconstruction just before or during the first few months of the COVID-19 pandemic were able to maintain in-person contact with their health professionals during rehabilitation, and they had a positive outlook and managed well despite the restrictions.

Background: Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment. Purpose: To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Included were 25 consecutive patients with at least 2 of the following risk factors: age Results: At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL–Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months. Conclusion: The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.

Background: Most lateral extra-articular tenodesis (LET) procedures rely on passing a strip of the iliotibial band (ITB) under the fibular (lateral) collateral ligament and fixing it proximally to the femur. The Ellison procedure is a distally fixed lateral extra-articular augmentation procedure with no proximal fixation of the ITB. It has the potential advantages of maintaining a dynamic element of control of knee rotation and avoiding the possibility of overconstraint. Hypothesis: The modified Ellison procedure would restore native knee kinematics after sectioning of the anterolateral capsule, and closure of the ITB defect would decrease rotational laxity of the knee. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric knees were tested in a 6 degrees of freedom robotic system through 0° to 90° of knee flexion to assess anteroposterior, internal rotation (IR), and external rotation laxities. A simulated pivot shift (SPS) was performed at 0°, 15°, 30°, and 45° of flexion. Kinematic testing was performed in the intact knee and anterolateral capsule–injured knee and after the modified Ellison procedure, with and without closure of the ITB defect. A novel pulley system was used to load the ITB at 30 N for all testing states. Statistical analysis used repeated measures analyses of variance and paired t tests with Bonferroni adjustments. Results: Sectioning of the anterolateral capsule increased anterior drawer and IR during isolated displacement and with the SPS (mean increase, 2° of IR; P < .05). The modified Ellison procedure reduced both isolated and coupled IR as compared with the sectioned state ( P < .05). During isolated testing, IR was reduced close to that of the intact state with the modified Ellison procedure, except at 30° of knee flexion, when it was slightly overconstrained. During the SPS, IR with the closed modified Ellison was less than that in the intact state at 15° and 30° of flexion. No significant differences in knee kinematics were seen between the ITB defect open and closed. Conclusion: A distally fixed lateral augmentation procedure can closely restore knee laxities to native values in an anterolateral capsule–sectioned knee. Although the modified Ellison did result in overconstraint to isolated IR and coupled IR during SPS, this occurred only in the early range of knee flexion. Closure of the ITB defect had no effect on knee kinematics. Clinical Relevance: A distally fixed lateral extra-articular augmentation procedure provides an alternative to a proximally fixed LET and can reduce anterolateral laxity in the anterolateral capsule–injured knee and restore kinematics close to the intact state.

The proliferation of disconnected information systems accumulating increasing volumes of heterogeneous data is a formidable challenge in the healthcare domain. It is necessary to address this challenge as the entire domain gradually transitions into e-healthcare and patient-centered healthcare delivery models. The lack of data integration at systems level prohibits clinicians from building a comprehensive understanding of the patient condition and further deprives patients of developing a holistic awareness of their medical conditions. In this paper, we propose an open data integration platform for patient, clinical, medical and historical data siloed across multiple health information systems. As an open platform, it can accommodate and integrate further heterogeneous data sources such as data streams generated by wearable IoT devices. As an integration platform, it facilitates the centralization of data assets. This centralization empowers every stakeholder in a patient-centered care setting to actively participate in decision-making. A range of analytics and reporting solutions, such as data warehouse, interactive dashboards, and predictive analytics tools, can be deployed upon this open data integration platform. The proposed platform is currently being adapted and implemented to address patient-centered healthcare and clinical decision support requirements in a sports injury clinic at a not-for-profit private hospital in Melbourne, Australia. Use Case based demonstration of the platform’s suitability for holistic information management, decision support, and predictive analytics justify its role in the advancement of e-healthcare.

Background: Younger patients who sustain anterior cruciate ligament (ACL) ruptures are at high risk for reinjury after ACL reconstruction. Restoring muscle strength before return to sports (RTS) is regarded as an important factor in reducing the reinjury risk, and quadriceps and hamstring strength assessment is commonly included in RTS testing. However, it is not clear whether reduced strength is a risk factor for subsequent graft rupture in this patient population. Purpose: To investigate the association between quadriceps and hamstring strength at 12 months after primary ACL reconstruction and ACL graft rupture in young patients. Study Design: Case-control study; Level of evidence, 3. Methods: The cohort consisted of 210 patients (100 men and 110 women) who were younger than 20 years at the time of primary ACL reconstruction with a hamstring tendon autograft and who had no previous contralateral ACL injury. Isokinetic strength testing (60 and 180 deg/s) of knee flexors and extensors was performed at 12 months postoperatively, and the limb symmetry index (LSI) for each strength outcome was calculated. RTS rates and the incidence of further ACL graft ruptures were recorded. Results: Measures of central tendency (mean and median) of LSI values ranged from 88 to 98. The percentage of patients with LSI ≥90 was 57% to 69% for quadriceps strength and 45% to 47% for hamstring strength. Overall, 19 patients (9%) sustained an ACL graft rupture. No significant differences were found between the patients who sustained an ACL graft rupture and those who did not in terms of quadriceps and hamstring strength at 12 months. No significant associations were found between achieving LSI ≥90 for quadriceps peak torque and subsequent ACL graft rupture. Conclusion: In young patients who underwent an ACL reconstruction, no association was noted between quadriceps and hamstring strength at 12 months postoperatively and subsequent graft ruptures. The role of strength testing as part of the RTS criteria after ACL reconstruction, and specifically the use of limb symmetry thresholds, warrants further investigation and clarification.

Background: Preservation of the tibial stump during anterior cruciate ligament reconstruction (ACLR) is controversial. While proposed benefits include enhanced graft revascularization, improved proprioception, and decreased graft rupture rates, a potential complication is the development of a symptomatic cyclops lesion. It is therefore important to determine whether any benefits outweigh potential complications. Purpose: To determine whether greater preservation of the tibial stump remnant would be associated with a decreased graft rupture rate without a concomitant increase in the rate of surgery for symptomatic cyclops lesions at 2 years after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 658 patients in whom the amount of tibial stump preserved was classified as no stump (n = 228), 50% (n = 88) was followed up for 2 years, with graft ruptures and surgical treatment for cyclops lesions recorded. Contingency and Kaplan-Meier survival analyses were used to determine trends among the 3 remnant preservation groups in terms of graft rupture rates and surgery for cyclops lesions. Subgroup analysis was also conducted to examine sex-based differences. Results: There was no significant association between graft rupture rates and remnant preservation. There was a significant trend for fewer operations for symptomatic cyclops lesions with greater remnant preservation when the entire cohort was analyzed ( P = .04) and also when only female patients were analyzed ( P = .04). Conclusion: Although preservation of the tibial stump remnant was not associated with a reduced graft rupture rate, it was also not associated with increased rates of surgery for symptomatic cyclops lesions.

Background: Various technologies have been developed to quantify the pivot shift, as it is regarded as a key indicator of anterolateral rotatory laxity of the knee. Purpose: To determine the usefulness of a commercially available triaxial accelerometer (Kinematic Rapid Assessment [KiRA]) in numerically quantifying the pivot shift in patients under anesthesia with an anterior cruciate ligament (ACL)–deficient knee. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Both knees of 50 patients (26 male [mean age, 30.4 years], 24 female [mean age, 26.6 years]) under anesthesia were assessed immediately before unilateral ACL reconstruction by an orthopaedic fellow and 1 of 3 experienced knee surgeons. The pivot-shift grade and 2 KiRA outputs (range of acceleration and slope of acceleration change) were compared. Results: The surgeon and fellow recorded the same pivot-shift grade for 45 of 50 patients (90%). Data from the 5 patients with no agreement and 1 patient with extreme outlying data were excluded from subsequent analysis. Using the KiRA range and slope data, the surgeon identified the injured knee in 74% and 76% of patients, respectively, while the fellow’s rate of injured knee identification was 74% and 80%, respectively. A correlation could be found only between pivot-shift grade and surgeon-derived range data ( ρ = 0.40; P < .01) but not slope data or any fellow-derived outputs. Using the surgeon-derived range data, there was a significant difference between a grade 3 pivot (>5 m/s2) and a grade 1 or 2 pivot (2) ( P = .01). Conclusion: Although a correlation between KiRA output data and pivot-shift grade was found when the device was used by an experienced surgeon, there was no correlation when used by a well-trained but less experienced orthopaedic fellow. Furthermore, the KiRA output data identified the ACL-deficient knee correctly in only 74% of patients. Although a threshold acceleration range value could be identified, above which the value was associated with a grade 3 pivot shift, this was dependent on the examiner, and distinction between other grades could not be made.

Background Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration. Methods From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1–14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD). Results ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile. Conclusions In conclusion, MIAS leads to good clinical results with—in majority—minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD. Trial registration The study was retrospectively registered in the German Clinical Trials Register (Nr.00015656).

The ligamentum teres (LT) has traditionally been described as a redundant structure with no contribution to hip biomechanics or function. There has been renewed interest in the LT as a source of hip pathology due to the high prevalence of LT pathology observed at the time of hip arthroscopy. The LT acts a secondary stabilizer to supplement the work of the capsular ligaments and works in a sling-like manner to prevent subluxation of the hip at the extremes of motion. The presence of free nerve endings within the LT indicates a definite role in pain generation, with the LT undergoing various mechanical and histological adaptations to hip pathology.

Background:After anterior cruciate ligament (ACL) reconstruction (ACLR), changes in the appearance of the ACL graft can be monitored using magnetic resonance imaging (MRI).Purpose:The purpose of this study was to evaluate and compare the MRI signal intensity (SI) of hamstring and quadriceps tendon grafts during the first postoperative year after ACLR. As a secondary aim, the relationship of SI to clinical and anatomic measurements was analyzed.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 78 patients who underwent ACLR with an autologous graft were reviewed; 55 received hamstring grafts and 23 received quadriceps tendon grafts. At 3 and 9 months postoperatively, 3-T MRI was performed using a dedicated knee coil, and the median SI of the intra-articular ACL graft was measured on sagittal-plane images. Postoperative lateral radiographs were analyzed to determine medial and lateral posterior tibial slope (PTS). Side-to-side difference in anterior knee laxity between injured and uninjured limbs was measured at 6 and 12 months postoperatively.Results:The median SI of quadriceps grafts was significantly greater than hamstring grafts at 3 months after ACLR ( P = .02). Between 3 and 9 months, the median SI of quadriceps grafts decreased ( P < .001), while that of hamstring grafts did not significantly change ( P = .55). The lateral PTS was significantly correlated with median SI measurements at 3 and 9 months such that greater lateral PTS values were associated with greater median SI. The side-to-side difference in anterior knee laxity decreased for the quadriceps group ( P = .04) between 6 and 12 months but did not change for the hamstring group ( P = .88).Conclusion:The median SI of quadriceps grafts significantly decreased on MRI between 3 and 9 months after ACLR, while the median SI of hamstring grafts did not significantly change. The change in MRI appearance of the quadriceps grafts was paralleled by a reduction in anterior knee laxity between 6 and 12 months after surgery. In the absence of standardized imaging techniques and imaging analysis methods, the role of MRI in determining graft maturation, and the implications for progression through rehabilitation to return to sport, remain uncertain.

In recent times, there has been an increased awareness of high-grade proximal hamstring injuries, many of which are now being managed surgically. Yet, surgical treatment of these injuries is challenging and carries potential risks of serious neurologic complications. Indeed, it is likely that postoperative neurologic complications are under-recognized. As such, knowledge of the intimate anatomic relation of the pudendal nerve and other neural structures around the proximal hamstring is essential and should provide a road map for safer and more successful surgery.

Arthroscopic resection of the anterior inferior iliac spine (AIIS) for subspine impingement has become a relatively common procedure. The AIIS is the origin of the direct head of rectus femoris (dhRF). Previous studies have reported that removal of the contributing portion of the AIIS causing impingement is unlikely to weaken the attachment of the dhRF. The purpose of this article is to report a case of avulsion of the dhRF, following revision hip arthroscopy for the treatment of subspine impingement. A 23-year-old professional footballer underwent revision left hip arthroscopy for the treatment of subspine impingement. 5-mm of bone was resected inferior to the AIIS. Two-weeks post-operatively, he presented with sudden onset, severe left anterior thigh pain following a fall and hyperextension of his left hip. The patient felt a pop over the anterior aspect of his hip. He noticed immediate swelling, severe pain and stiffness. Examination revealed diffuse swelling, 4/5-power on straight-leg-raise, focal tenderness over the AIIS but no palpable gap. MRI confirmed the clinical suspicion of a dhRF avulsion. Given the minimal loss of power and the lack of significant retraction, the patient was treated conservatively. He was instructed to avoid excessive hip extension. He returned to full participation at 3-months. This article highlights a case of avulsion of the dhRF due to a hyperextension injury of the hip following arthroscopic resection of subspinal impingement, a previously unreported complication. Resection of soft and bone from the AIIS may weaken the insertion of the dhRF. Care should be taken during post-operative rehabilitation to avoid trauma and excessive forces on the dhRF tendon, which may lead to rupture. Rehabilitation should be focused on range of motion of the hip.

Background: Deficits in neuromuscular control are common after anterior cruciate ligament (ACL) reconstruction and may be associated with further knee injury. The knee valgus angle during a single-leg squat (SLS) is one measure of neuromuscular performance. Purpose: To determine whether the knee valgus angle during SLS changes between 6 and 12 months after ACL reconstruction and to assess how the operative knee valgus angle compares with that of the contralateral side. Study Design: Case series; Level of evidence, 4. Methods: A cohort of 100 patients with uninjured contralateral knees were assessed at 6 and 12 months after primary hamstring autograft ACL reconstruction. Participants performed the SLS on each leg, and the knee valgus angle was measured via frame-by-frame video analysis at 30° of flexion and at each patient’s maximum knee flexion angle. Results: For the operative limb at 30° of flexion, a small but statistically significant reduction was noted in the valgus angle between 6 and 12 months (5.46° vs 4.44°; P = .002; effect size = 0.24). At 6 months, a slightly higher valgus angle was seen in the operative limb compared with the nonoperative limb (5.46° vs 4.29°; P = .008; effect size = 0.27). At maximum flexion, no difference was seen between limbs in the valgus angle at either 6 or 12 months, and no change was seen in the operative limb between 6 and 12 months. At 6 months and 30° of knee flexion, 13 patients had a valgus angle greater than 10°. This group also had a higher mean valgus angle in the contralateral limb compared with the contralateral limb in the other 87 patients (8.5° vs 3.65°; P < .001). Conclusion: During a controlled SLS, the knee valgus angle remained essentially constant, and minimal limb asymmetries were present over the 6- to 12-month postoperative period, a time when athletes typically increase their activity levels. Whether changes or asymmetries will be seen with more dynamically challenging tasks remains to be determined. When present, high valgus angles were commonly bilateral.

Background: None of the anterolateral procedures used in combination with ACL reconstruction (ACLR) to control rotational laxity have demonstrated superiority. The objective was to compare the capacity of the main anterolateral procedures associated with ACLR to restore intact knee kinematics in case of combined ACL and anterolateral structure injury. Methods: The complete kinematics of 10 cadaveric knees, previously modelled by TDM, were recorded using a 3D Motion Analysis® system. Intact knee kinematics, including internal rotation (IR) of the tibial and anterior-posterior (AP) laxity at 30 and 90° flexion were initially assessed, followed by a sequential section of the ACL and anterolateral complex (ALC) (anterolateral ligament (ALL), ALL capsule and Kaplan fibers). After the ACLR, 5 anterolateral procedures were performed consecutively on the same knee: ALLR; Ellison; Deep Lemaire; Superficial Lemaire; and MacIntosh. The last three procedures were randomized. For each procedure, the graft was fixed in neutral rotation at 30° flexion with a tension of 20 N. Results: ACLR alone did not restore overall knee kinematics when there was an ACL+ALC injury, and resulted in residual rotational laxity of the tibia (p > 0.001). Only the ALLR (p=0.262) and modified Ellison (p=0.081) procedures restored normal global IR kinematics. Superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinematic profiles (respectively: p=0.013, p=0.018 and p=0.030). In terms of ACLR, the addition of an anterolateral procedure did not provide additional control over AP translation at 30 and 90° (p > 0.05), exception for the surficial Lemaire procedure at 90° (p = 0.032). Discussion: ACLR alone was not sufficient to restore normal kinematics in ACL and ALC-deficient knees. ALLR and Ellison procedures restored physiological kinematics, unlike the MacIntosh procedure which caused additional control of IR and thereby induced over-constraint. Conclusion: The addition of ALLR or the modified Ellison procedure, which restore intrinsic kinematics, might be useful during primary ACL reconstruction to avoid repeated injury without a risk of over-constraint. The superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinetics but provided additional rotation control that could be useful in revision surgery.

Background: Increased posterior tibial slope has been identified as a possible risk factor for injury to the anterior cruciate ligament (ACL) and has also been shown to be associated with ACL reconstruction graft failure. It is currently unknown whether increased posterior tibial slope is an additional risk factor for further injury in the context of revision ACL reconstruction. Purpose: To determine the relationship between posterior tibial slope and further ACL injury in patients who have already undergone revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 330 eligible patients who had undergone revision ACL reconstruction between January 2007 and December 2015 were identified from a clinical database. The slope of the medial and lateral tibial plateaus was measured on perioperative lateral radiographs by 2 fellowship-trained orthopaedic surgeons using a digital software application. The number of subsequent ACL injuries (graft rupture or a contralateral injury to the native ACL) was determined at a minimum follow-up of 2 years (range, 2-8 years). Tibial slope measurements were compared between patients who sustained further ACL injury to either knee and those who did not. Results: There were 50 patients who sustained a third ACL injury: 24 of these injuries were to the knee that underwent revision ACL reconstruction, and 26 were to the contralateral knee. Medial and lateral slope values were significantly greater for the third-injury group compared with the no–third injury group (medial, 7.5° vs 6.3° [ P = .01]; lateral, 13.6° vs 11.9° [ P = .001]). Conclusion: Increased posterior tibial slope, as measured from lateral knee radiographs, was associated with increased risk of graft rupture and contralateral ACL injury after revision ACL reconstruction. This is consistent with the concept that increased posterior slope, particularly of the lateral tibial plateau, is an important risk factor for recurrent ACL injury.

Microinstability of the hip is a relatively recent concept but one that is gaining increased acceptance. As our understanding of the factors that contribute to microinstability has increased, so too has our ability to identify "at-risk" patients, in whom a capsular repair should be considered after hip arthroscopy to achieve optimal results and avoid iatrogenic instability (dislocation or microinstability). However, each of our patients is different, and as such, we must be able to tailor our capsulotomies and repairs accordingly based on the bony morphology, capsular volume, and properties of the tissue.

The ligamentum teres has traditionally been described as a vestigial remnant or redundant structure with little contribution to hip biomechanics or function. However, interest in the ligamentum teres has been renewed as evidence has emerged that it not only plays a role as a pain generator in the hip but also acts as a secondary stabilizer to supplement the work of the capsular ligaments. Furthermore, an association has been proposed between tearing of the ligamentum teres and the development of degenerative hip disease. However, the question remains, is it a cause-and-effect relationship?

Implant-associated infection is a major source of morbidity in orthopaedic surgery. There has been extensive research into the development of materials that prevent biofilm formation, and hence, reduce the risk of infection. Silver nanoparticle technology is receiving much interest in the field of orthopaedics for its antimicrobial properties, and the results of studies to date are encouraging. Antimicrobial effects have been seen when silver nanoparticles are used in trauma implants, tumour prostheses, bone cement, and also when combined with hydroxyapatite coatings. Although there are promising results with in vitro and in vivo studies, the number of clinical studies remains small. Future studies will be required to explore further the possible side effects associated with silver nanoparticles, to ensure their use in an effective and biocompatible manner. Here we present a review of the current literature relating to the production of nanosilver for medical use, and its orthopaedic applications. Cite this article: Bone Joint J 2015; 97-B:582–9.

Background:The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.Purpose:To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR.Study Design:Systematic review; Level of evidence, 3.Methods:Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures.Results:Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P = .008; I2= 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; P = .10; I2= 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes.Conclusion:In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes.

Objective: The purpose of this article is to report on a distinctive pattern of linear femoral head chondral lesions that were observed in 7 patients who underwent hip arthroscopy for the treatment of mixed-type femoroacetabular impingement (FAI). Design: Between 2010 and 2012, 702 patients were treated with hip arthroscopy at our institution for symptomatic FAI. Among those patients, 7 were found to have a unique vertical chondral fissure located on the posterior femoral head. A retrospective review of the preoperative history, physical examination, and radiographic findings in addition to the intraoperative findings and surgical procedures performed was carried out for each patient. Results: All patients were diagnosed with mixed-type FAI by dynamic examination intraoperatively. The femoral head cartilage lesions were noted to be both linear and deep and resembled the appearance of a crevasse. Three of the 7 patients in whom these lesions were identified reported an acute event preceding their pain. Of the other 4 patients, 3 were involved in sports that involved vigorous rotational hip movements: golf, tennis, and wrestling. Notably, none of these lesions were identifiable on preoperative 3-T MRI scans. Conclusions: This series reports on a previously undefined femoral head cartilage lesion. It is hypothesized that increased pathologic translational movements and perching of the femoral head on the posterior rim of the acetabulum create this pattern of chondral damage. Recognition of this pattern of damage on the femoral head is important in the setting of mixed-type FAI.

No information exists on the level of internet use among parents of pediatric patients with scoliosis. The internet may represent a medium through which to provide information to augment the outpatient consultation. The aim of this research was to establish the prevalence of internet use amongst a cohort of parents attending a pediatric scoliosis outpatient clinic.A previously used questionnaire (Baker et al., Eur Spine J, 19:1776-1779, 2010) was distributed to parents attending a dedicated scoliosis outpatient clinic with their children. Demographic data and details about use of the internet were collected.Fifty-eight percent of respondents had used the internet to search for information on scoliosis, and 94 % were interested in a local internet provided information provision. A positive history of corrective surgery and possession of health insurance were independent positive predictors of internet use.As surgeons we need to be aware of our patients' use of the internet, and there is the opportunity to use this medium to provide additional education.

Background and purpose Metal ion toxicity both locally and systemically following MoM hip replacements remains a concern. Cobalt ions have been shown to induce secretion of proinflammatory chemokines locally; however, little is known about their effect systemically. We investigated the in vitro effect of cobalt ions on a variety of cell lines by measuring production of the proinflammatory chemokines IL-8 and MCP-1. Method Renal, gastrointestinal, and respiratory epithelium and also neutrophils and monocytes were exposed to cobalt ions at 4, 12, 24, and 48 hours. Results We found that cobalt ions enhanced the secretion of IL-8 and MCP-1 in renal epithelial cells, gastric and colon epithelium, monocytes and neutrophils, and small airway epithelial cells but not in alveolar cells. Secretion of IL-8 and MCP-1 was markedly elevated in renal epithelium, where a 16-fold and 7-fold increase occurred compared to controls. There was a 6-fold and 4-fold increase in IL-8 and MCP-1 secretion in colon epithelium and a 4-fold and 3-fold increase in gastric epithelium. Small airway epithelial cells showed a maximum increase in secretion of 8-fold (IL-8) and of 4-fold (MCP-1). The increase in chemokine secretion observed in alveolar cells was moderate and did not reach statistical significance. Monocytes and neutrophils showed a 2.5-fold and 2-fold increase in IL-8 secretion and a 6-fold and 4-fold increase in MCP-1 secretion at 48 and 24 hours, respectively. Interpretation These data demonstrate the potent bioactivity of cobalt ions in a variety of cell types and the potential to induce a proinflammatory response.

Background: Although isolated posterior cruciate ligament reconstruction (PCLR) has become a more frequently performed procedure, reports of functional outcomes and return-to-sport (RTS) rates to support its use are still limited. Purpose: To systematically review the literature to determine the rates of RTS and the functional outcomes of patients after isolated PCLR. Study Design: Systematic review: Level of evidence, 4. Methods: Two reviewers independently searched 5 databases for patient-based clinical studies with a minimum 2-year follow-up that analyzed functional outcome and RTS following isolated PCLR. Studies with multiligament knee reconstruction were excluded. Risk of bias was performed with a modified Downs and Black checklist. The primary outcomes were Tegner and Lysholm scores, rates of RTS, and International Knee Documentation Committee (IKDC) subjective scores. Secondary outcomes were IKDC objective scores, instrumented knee laxity assessment, and Telos radiographic analysis. Where feasible, these data were pooled via a random effects meta-analysis model. Results: Of the 240 titles identified, 14 studies were included. The median time from injury to surgery was 10.6 months (range, 6 weeks–21 years). The pooled mean postoperative Tegner and Lysholm scores were 5.7 (95% CI, 5.4-6.0) and 87.8 (95% CI, 85.6-90.0), respectively, following isolated PCLR; the pooled effect size between pre- and postoperative values was 2.8 (95% CI, 1.6-4.0) and 3.7 (95% CI, 2.6-4.9), respectively. An RTS rate of 44% (95% CI, 23%-66%) was identified. IKDC subjective scores improved to a pooled mean of 73.5 (95% CI, 62.8-84.1), with an effect size of 3.0 (95% CI, 0.4-5.6). The proportion of patients with postoperative IKDC objective scores of grade A/B was 82%. The pooled postoperative KT-1000/KT-2000 side-to-side difference was 3.4 mm (95% CI, 2.5-4.3 mm), with an effect size of 2.8 (95% CI, 1.1-4.5). The pooled postoperative Telos side-to-side difference measurement was 3.5 mm (95% CI, 2.8-4.3 mm), with an effect size of 3.9 (95% CI, 3.3-4.5). Conclusion: The results of this review demonstrate that while isolated PCLR results in a significant improvement in functional outcome scores and improved knee laxity, there is a low rate of return to preinjury level of sport. The prolonged period from injury to surgery might reduce functional improvement and RTS following reconstruction. Therefore, comparison of the outcomes of isolated PCLR and nonoperative treatment is impracticable owing to the potential for selection bias.

Background: The internet is a valuable tool, but concerns exist regarding the quality and accuracy of medical information available online. Purpose: To evaluate the source and quality of information on the internet relating to anterolateral ligament reconstruction (ALLR) compared with anterior cruciate ligament reconstruction (ACLR). Study Design: Cross-sectional study. Methods: A questionnaire was administered to 50 ACLR patients in Australia to determine their use of the internet to research their operation and their familiarity with the anterolateral ligament (ALL) of the knee. The most common search terms were determined, and the first 70 websites returned by the 5 most popular search engines were used to assess the quality of information about ACLR and ALLR. Each site was categorized by type and was assessed for quality and validity using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and a novel specific content score for each procedure. The presence of the Health on the Net Code (HONcode) seal was also recorded. Results: The majority (84%) of ACLR patients used the internet to research their operation. The quality of information available for ALLR was significantly inferior to that for ACLR according to the DISCERN score (37.3 ± 3.4 vs 54.4 ± 4.6; P < .0001) and specific content score (5.3 ± 1.3 vs 11.0 ± 1.5; P < .0001). ACLR websites were predominantly physician produced, while the majority of ALLR websites were academic. In contrast to ACLR websites, the majority of ALLR websites did not provide information on the indication for treatment or potential complications. ALLR websites scored better on the JAMA benchmark criteria due to the predominance of academic websites. A greater proportion of ACLR websites (14.6%) versus ALLR websites (2.5%) provided an HONcode seal. Correlation was demonstrated between the DISCERN score and specific content scores for both ACLR and ALLR but not with JAMA benchmark criteria. The specific content score had high reliability for both ACLR and ALLR. Conclusion: The majority of patients undergoing ACLR in Australia used the internet to research the procedure. The quality of information on the internet relating to ALLR was significantly inferior to information about ACLR. Most ALLR websites failed to include crucial information about the indication or options for treatment, prognosis, and potential complications. Surgeons should be aware of the information to which their patients are exposed through the internet and should be proactive in directing patients to appropriate websites.

To present a case of medial epicondylitis in an adolescent baseball pitcher that appeared to improve when addressing the upper extremity kinetic chain with a variety of conservative management strategies.An 18-year-old right hand dominant high school baseball pitcher had recurring sharp pain in his right elbow. Previous trials of medication and physical therapy were only partially successful in resolving the problem. The patient's pain was rated as an 8 on a numerical pain scale during throwing activities. A variety of tender points were noted in the right upper extremity. The patient had discontinued playing competitive baseball due to the pain.The patient was treated 14 times over 15 weeks. Treatment included cervical, thoracic and upper extremity manipulation, soft tissue mobilization and progressive sport-specific training for the upper extremity. After the first treatment he was able to throw the ball and was able to continue throwing during the treatment program. The patient returned to league play after the treatment program.A course of conservative care addressing multiple elements of the upper extremity kinetic chain seemed beneficial for this athlete.

Background:The pathomechanics of hip microinstability are not clearly defined but are thought to involve anatomical abnormalities, repetitive forces across the hip, and ligamentous laxity.Purpose/Hypothesis:The purpose of this study was to explore the relationship between generalized joint hypermobility (GJH) and hip capsular thickness. The hypothesis was that GJH would be predictive of a thin hip capsule.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A prospective study was performed on 100 consecutive patients undergoing primary hip arthroscopy for the treatment of hip pain. A Beighton test score (BTS) was obtained prior to each procedure. The maximum score was 9, and a score of ≥4 was defined as hypermobile. Capsular thickness at the level of the anterior portal, corresponding to the location of the iliofemoral ligament, was measured arthroscopically using a calibrated probe. The presence of ligamentum teres (LT) pathology was also recorded.Results:Fifty-five women and 45 men were included in the study. The mean age was 32 years (range, 18-45 years). The median hip capsule thickness was statistically greater in men than women (12.5 and 7.5 mm, respectively). The median BTS for men was 1 compared with 4 for women ( P < .001). A statistically significant association was found between BTS and capsular thickness; a BTS of Conclusion:Measurement of the GJH is highly predictive of hip capsular thickness. A BTS of

Focal femoral inlay resurfacing has been developed for the treatment of full-thickness chondral defects of the knee. This technique involves implanting a defect-sized metallic or ceramic cap that is anchored to the subchondral bone through a screw or pin. The use of these experimental caps has been advocated in middle-aged patients who have failed non-operative methods or biological repair techniques and are deemed unsuitable for conventional arthroplasty because of their age. This paper outlines the implant design, surgical technique and biomechanical principles underlying their use. Outcomes following implantation in both animal and human studies are also reviewed.Cite this article: Bone Joint J 2013;95-B:301–4.

Background: Quantitative magnetic resonance imaging (MRI) techniques, such as T2 and T2 star (T2*) mapping, have been used to evaluate ligamentous tissue in vitro and to identify significant changes in structural integrity of a healing ligament. These studies lay the foundation for a clinical study that uses quantitative mapping to evaluate ligaments in vivo, particularly the posterior cruciate ligament (PCL). To establish quantitative mapping as a clinical tool for identifying and evaluating chronic or acute PCL injuries, T2 and T2* values first must be determined for an asymptomatic population. Purpose: To quantify T2 and T2* mapping properties, including texture variables (entropy, variance, contrast, homogeneity), of the PCL in an asymptomatic population. It was hypothesized that biomarker values would be consistent throughout the ligament, as measured across 3 clinically relevant subregions (proximal, middle, and distal thirds) in the asymptomatic cohort. Study Design: Cross-sectional study; Level of evidence, 4. Methods: Unilateral knee MRI scans were acquired for 25 asymptomatic subjects with a 3.0-T MRI system using T2 and T2* mapping sequences in the sagittal plane. The PCL was manually segmented and divided into thirds (proximal, middle, and distal). Summary statistics for T2 and T2* values were calculated. Intra- and interrater reliability was assessed across 3 raters to 2 time points. Results: The asymptomatic PCL cohort had mean T2 values of 36.7, 29.2, and 29.6 ms in the distal, middle, and proximal regions, respectively. The distal PCL exhibited significantly higher mean, variance, and contrast and lower homogeneity of T2 values than the middle and proximal subregions ( P < .05). T2* results exhibited substantial positive skew and were therefore presented as median and quartile (Q) values. Median T2* values were 7.3 ms (Q1-Q3, 6.8-8.9 ms), 7.3 ms (Q1-Q3, 7.0-8.5 ms), and 7.3 ms (Q1-Q3, 6.4-8.2 ms) in the distal, middle, and proximal subregions, respectively. Conclusion: This is the first study to identify T2 and T2* mapping values, and their texture variables, for the asymptomatic PCL. The distal third of the PCL had significantly greater T2 values than the proximal or middle thirds. Clinical Relevance: T2 and T2* values of the asymptomatic PCL can provide a baseline for comparison with acute and chronic PCL injuries in future studies.

Background: The resurgence in recent attention given to the Anterolateral Ligament has fuelled debate regarding its potential role in knee kinematics, injury, and the need for repair or reconstruction. Surgeons have long recognised that a laterally based extra-articular reconstruction (LEAR) offers a powerful tool to control rotation of the knee. The principle subsequently emerged that combining extra- and intra-articular reconstructions was less likely to fail than either technique performed in isolation. Although successful in reducing anterolateral instability, LEAR fell out of favour when reports emerged about its unpredictability and unsatisfactory results in some cases. Aim: The purpose of this study was to systematically review the current literature on the clinical outcomes following primary anterior cruciate ligament reconstruction (ACLR) with a LEAR. A secondary aim was to compare the clinical outcomes of combined ACLR and LEAR with ACLR alone. Methodology: Systematic Review. Relevant articles were identified by two independent reviewers following a search of seven electronic databases. The inclusion criteria was all published peer-reviewed studies including randomized controlled trials, nonrandomized comparative studies, cohort studies, and case series (> 10 patients) with outcome data following primary ACLR with a LEAR with more than two years follow-up. The exclusion criteria included extra-articular procedures performed in isolation, synthetic ACLR or LEAR, cases with greater than two surgically treated knee ligaments or combined alignment knee surgery, ACL repair, reports on guidelines, technical notes, reviews or systematic reviews. Methodological quality assessment was performed using the MINORS criteria. Data was obtained using a data-extraction form developed specifically for this review. The outcomes of interest included postoperative clinical examination, objective, subjective, functional and radiographic evaluation. A meta-analysis was performed using a random effects model on available data. Results: The literature search yielded 363 articles. After titles and abstracts were reviewed, 125 articles were selected for full-text review, of which 32 studies met the inclusion criteria (11 comparative studies 21 non-comparative studies). Of the 11 comparative studies, 5 recommended a combined LEAR and ACLR, 5 were in favour of the ACLR alone, and 1 was equivocal. Meta-analysis demonstrated a statistically significant difference for the pivot-shift test in favour of a combined LEAR and ACLR. All but 2 of the non-comparative groups reported a satisfactory outcome with combined ACLR and LEAR at a minimum of two years. Three long-term studies (>10 years) found there was no increased rate of lateral compartment osteoarthrosis with LEAR. Conclusions: A meta-analysis of data acquired from studies comparing ACLR to a combined ACLR with a LEAR, revealed a significantly reduced the post-operative pivot shift with LEAR. Review of the recommendations of 11 comparatives studies reached an equivocal verdict as to effectiveness of a LEAR in conjunction with ACLR. A number of studies advocated that a LEAR was not necessary when treating an acutely rupture ACLR in the primary setting, however, in the chronic setting it may have greater utility. Based on the available radiographic data, long term follow-up of ACLR with LEAR, there was no evidence of an increased incidence of lateral compartment osteoarthrosis.

We report a 15-year-old girl who underwent a mid-carpal fusion for undiagnosed impaction-fractures of the capitate, lunate, and triquetrum after a fall on her outstretched left hand in a dorsiflexed and radially deviated position. The joint was dis-impacted, and the height of the lunate was restored using a cortical bone graft. The damaged proximal capitate articular surface was decorticated to facilitate fusion, as was the lunotriquetral articulation. Kirschner wires were inserted along the coronal plane. At the one-year follow-up, the patient had achieved a satisfactory range of motion and fusion of the capitate-lunate-triquetral articulations.

A case of injury to the third web space of the right hand of a rugby player, as a result of buddy strapping with electrical insulating tape of the little and ring finger, is presented. A deep laceration of the web space and distal palmar fascia resulted, necessitating wound exploration and repair. This case highlights the danger of using electrical insulating tape as a means to buddy strap fingers.

Nationally 62% of individuals in Ireland have internet access. Previous published work has suggested that internet use is higher among those with low back pain. We aimed to determine the levels of internet access and use amongst an elective spinal outpatient population and determine what characteristics influence these. We distributed a self-designed questionnaire to patients attending elective spinal outpatient clinics. Data including demographics, history of surgery, number of visits, level of satisfaction with previous consultations, access to the internet, possession of health insurance, and details regarding use of the internet to research one’s spinal complaint were collected. 213 patients completed the questionnaire. 159 (75%) had access to the internet. Of this group 48 (23%) used the internet to research their spinal condition. Increasing age, higher education level, and possession of health insurance were all significantly associated with access to the internet (p < 0.05). A higher education level predicted greater internet use while possession of insurance weakly predicted non-use (p < 0.05). In our practice, internet access is consistent with national statistics and use is comparable to previous reports. Approximately, one quarter of outpatients will use the internet to research their spinal condition. Should we use this medium to disseminate information we need to be aware some groups may not have access.

Objectives: As the demand increases for demonstration of competence in surgical skill, the need for validated assessment tools also increases. The purpose of this study was to validate the use of a sawbones model for the assessment of performance of anterior cruciate reconstruction (ACLR) by residents. We hypothesized that the combination of a checklist and a previously validated global rating scale be a valid and reliable means of assessing ACLR when performed by residents in a dry model. Methods: All residents, sports medicine staff and fellows were invited to perform an ACLR on an ACL Sawbones model. Demographics regarding previous exposure to knee arthroscopy and ACLR were collected. All participants were asked to perform a hamstring ACLR using an anteromedial portal with Endobutton fixation on the femur - a detailed surgical manuscript and technique video was sent to all residents prior to the study. Residents were evaluated by faculty using a task-specific checklist created using a modified Delphi procedure, and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale. Each procedure was recorded, with videotaping of the hand movements and arthroscopic video recordings of the intra-articular procedure. These videos were scored by a fellow blinded to the year of training of each resident. Results: A total of 29 residents, six staff and five faculty performed an ACLR on the sawbones model (40 total). The overall reliability (Cronbach's Alpha) of the test using the total ASSET score was very high (>0.9). The reliability for the femoral checklist was 0.75, for the tibial checklist was 0.78, and 0.68 for the graft passage and fixation. One-way analysis of variance for the total ASSET score and the total checklist score demonstrated a difference between residents based upon year of training (p&lt0.001). Post hoc analysis demonstrated a significant difference in global ratings and checklist scores between junior residents (PGY1-3) and senior residents (PGY4&5), seniors and fellows, and fellows and staff (p0.8). Conclusion: The use of a sawbones models to assess resident performance of ACLR using the ASSET global rating scale is valid and reliable. These models may be used to ensure a minimal level of competence prior to resident performance of ACLR in the operating room.

Objectives: While the acquisition of competent technical skill is a defining characteristic of surgery, it is not measured systematically in residency. As all post-graduate medical training slowly shifts to a competency-based model, effective assessments of surgical and other technical skills after modules will become necessary. However, the best method for of assessing competence in technical skill in this setting is unknown, and is limited by both cost and access to resources. We hypothesized that a multi-station Objective Structured Assessment of Technical skill (OSATS), using sawbones models, would be a valid and reliable method of assessing resident competence in surgical skills after a sports medicine rotation. Methods: At the start of their three-month sports medicine rotation, each resident was provided a list of 10 surgical skills in which they were expected to demonstrate competence (Table 1). At the end of the rotation, each resident undertook an OSATS comprised of six randomly chosen stations - low-fidelity sawbones models were used in all stations. Residents were evaluated by faculty / staff surgeons using a previously validated global rating scale (the Arthroscopic Surgical Skill Evaluation Tool (ASSET)), as well as task-specific checklists created using a modified Delphi procedure, and a final five-point global rating scale (GRS) using the Drefus model of skill acquisition (1=novice, 2=advanced beginner, 3=competent, 4=proficient, 5=expert). All arthroscopic procedures were recorded, and all hand movements were videotaped - the videos were reviewed by a single, blinded observer, and correlation sought between the faculty ratings and the observer ratings. Results: Over 18 months, 27 residents (19 junior, 8 senior) sat the OSATS after their rotation, as well as seven sports medicine staff and seven fellows, for a total of 41 participants. The overall reliability of the OSATS as measured by Cronbach's Alpha was very high (0.9). A significant difference by year in training was seen for the overall GRS, the total ASSET score, and the total checklist score, as well as for each individual technical skill (p&lt0.001) - this difference was also seen for all stations. Post hoc analysis demonstrated a significant difference in the total ASSET score between junior (PGY1-3) and senior (PGY4&5) residents, senior residents and fellows, as well as between fellows and faculty (p0.8). Conclusion: The results of this study demonstrate that an OSATS using dry models is a valid and reliable means of assessing technical skill in orthopaedic residents after a sports medical rotation. Interestingly, junior residents were not able to perform technical skills as well as senior residents despite an identical rotation, suggesting that overall surgical experience and exposure is as important as intensive teaching.

Background: Hip endoscopy facilitates the treatment of extra-articular disorders of the proximal femur. Unfortunately, current knowledge of proximal femur anatomy is limited to qualitative descriptions and lacks surgically relevant landmarks. Purpose: To provide a quantitative and qualitative analysis of proximal femur anatomy in reference to surgically relevant bony landmarks. Study Design: Descriptive laboratory study. Methods: Fourteen cadaveric hemipelvises were dissected. A coordinate measuring device measured dimensions and interrelationships of the gluteal muscles, hip external rotators, pectineus, iliopsoas, and joint capsule in reference to osseous landmarks. Results: The vastus tubercle, superomedial border of the greater trochanter, and femoral head-neck junction were distinct and reliable osseous landmarks. The anteroinferior tip of the vastus tubercle was 17.1 mm (95% CI: 14.5, 19.8 mm) anteroinferior to the center of the gluteus medius lateral insertional footprint and was 22.9 mm (95% CI: 20.1, 25.7 mm) inferolateral to the center of the gluteus minimus insertional footprint. The insertions of the piriformis, conjoint tendon of the hip (superior gemellus, obturator internus, and inferior gemellus), and obturator externus were identified relative to the superomedial border of the greater trochanter. The relationship of the aforementioned footprints were 49% (95% CI: 43%, 54%), 42% (95% CI: 33%, 50%), and 64% (95% CI: 59%, 69%) from the anterior (0%) to posterior (100%) margins of the superomedial border of the greater trochanter, respectively. The hip joint capsule attached distally on the proximal femur 18.2 mm (95% CI: 14.2, 22.2 mm) from the head-neck junction medially on average. Conclusion: The vastus tubercle, superomedial border of the greater trochanter, and the femoral head-neck junction were reliable osseous landmarks for the identification of the tendinous and hip capsular insertions on the proximal femur. Knowledge of the interrelationships between these structures is essential for endoscopic navigation and anatomic surgical repair and reconstruction. Clinical Relevance: The qualitative and quantitative clinically relevant anatomic data presented here will aid in the diagnosis of proximal femur pathology and will provide a template for anatomic repair or reconstruction.

Background The Wnt/β-catenin pathway is a major signaling cascade in bone biology, playing a key role in bone development and remodeling. The objectives of this study were firstly, to determine the effects of dexamethasone exposure on Wnt/β-catenin signaling at an intracellular and transcriptional level, and secondly, to assess the phenotypic effects of silencing the Wnt antagonist, Dickkopf-1 (Dkk1) in the setting of dexamethasone exposure. Methods Primary human osteoblasts were exposed in vitro to 10-8 M dexamethasone over a 72 h time course. The phenotypic marker of osteoblast differentiation was analyzed was alkaline phosphatase activity. Intracellular β-catenin trafficking was assessed using immunoflourescence staining and TCF/LEF mediated transcription was analyzed using a Wnt luciferase reporter assay. Dkk1 expression was silenced using small interfering RNA (siRNA). Results Primary human osteoblasts exposed to dexamethasone displayed a significant reductions in alkaline phosphatase activity over a 72 h time course. Immunoflourescence analaysis of β-catenin localization demonstrated a significant reduction in intracytosolic and intranuclear β-catenin in response to dexamethasone exposure. These changes were associated with a reduction of TCF/LEF mediated transcription. Silencing Dkk1 expression in primary human osteoblasts exposed to dexamethasone resulted in an increase in alkaline phosphatase activity when compared to scrambled control. Conclusions Wnt/β-catenin signaling plays a key role in regulating glucocorticoid-induced osteoporosis in vitro. Silencing Dkk1 expression rescues dexamethasone-induced suppression of primary human osteoblast differentiation. Targeting of the Wnt/β-catenin signaling pathway offers an exciting opportunity to develop novel anabolic bone agents to treat osteoporosis and disorders of bone mass.

s / Osteoarthritis and Cartilage 21 (2013) S63–S312 S204 385 COMPARISON OF RADIOGRAPHIC HIP JOINT SPACE IN WEIGHT BEARING AND SUPINE X-RAYS IN PATIENTS WITH HIP PATHOLOGY M.J. Philippon, K.K. Briggs, P. Goljan, B.M. Devitt, L.P. Peixoto. Steadman Philippon Res. Inst., Vail, CO, USA Purpose: Hip arthroscopy is often used to treat many pathologies about the hip. Diagnosis is based on history, physical examination and radiographic findings. Studies have shown that decreased joint space (2mm or less) in the hip is a negative prognostic factor for a favorable outcome following arthroscopic treatment. The purpose of this study is to investigate the potential influence of a patient's weight bearing status (supine vs. standing) on radiographic joint space findings of the hip. Methods:Weight bearing and supine pelvic radiographs of 44 hip joints were evaluated. All radiographs were evaluated twice by three reviewers in order to determine intra and inter-observer reliability. The average patient age was 36 (range 18 to 69), with 11 males and 11 females. The average BMI was 23. Joint space was measured at the lateral edge, middle sourcil, and above the fovea of the hip. The first readings of a single reviewer were used in order to most closely mirror the practices of a clinical setting. The measurements of the reviewer with the highest intra-observer reliability were utilized. Results: Intra-rater reliability for joint space measurements at the lateral sourcil, middle sourcil, and fovea the weightbearing films were 0.483, 0.679, 0.683 and for the supine films were 0.718, 0.750, 0.697 respectively. Inter-rater reliability at the lateral sourcil, middle sourcil and fovea for the weightbearing films were 0.531, 0.627, and 0.410 respectively and for the supine films were 0.475, 0.462, and 0.528 respectively. There was a significant difference between joint space as measured on weight bearing and supine radiographs at all three measurement locations (lateral edge measurement P