Search

Background:Recent imaging studies demonstrate that the anterolateral ligament (ALL) is frequently injured at the time of anterior cruciate ligament (ACL) rupture. The intrinsic healing potential of these injuries after ACL reconstruction (ACLR) has not been defined.Purpose/Hypothesis:The primary objective was to evaluate the rate and duration of the healing process of injured ALLs after ACLR using serial 3-dimensional magnetic resonance imaging (3D-MRI). The secondary objective was to investigate whether any patient, injury, or surgical factors influenced the healing rate. The hypothesis was that serial imaging would demonstrate that the ALL has limited healing potential.Study Design:Case series; Level of evidence, 4.Methods:Patients enrolled in the study underwent 3D-MRI (slice thickness 0.5 mm) preoperatively and at 1, 6, 12, and 24 months after ACLR. Three observers determined the grade of ALL injury according to the Muramatsu classification. Inter- and intraobserver reliabilities were calculated. The rates of injury and time points for healing were determined. Full healing was defined as a change from a preoperative Muramatsu grade of B or C (indicating partial or complete injury) to grade A (normal). Multivariate analysis was used to investigate the association of aforementioned factors with the risk of incomplete healing.Results:A total of 44 patients were enrolled in the study. Of them, 71.2% had an ALL injury on preoperative imaging. Overall, full healing of ALL injuries occurred at a rate of 3.2%, 15.2%, and 30.3% at 1, 6, and 12 months, respectively. There were no changes in the Muramatsu grade in any patient beyond 12 months postoperatively. None of the complete lesions demonstrated full healing, but the proportion of patients with a grade C injury decreased from 13.6% preoperatively to 4.5% at 12 months due to an improvement to grade B in 4 of 6 patients (66%). Inter- and intraobserver reliabilities of the classification system were almost perfect at 0.81-0.94 and 0.95-1.00, respectively. None of the potential risk factors investigated were predictive of an increased risk of nonhealing.Conclusion:ALL injuries occurred in the majority of ACL-injured knees. They had limited intrinsic healing potential, with only 30.3% healing by 12 months after ACLR. The process of healing took >6 months in half of the patients in whom it occurred. No new cases of full healing occurred beyond 12 months postoperatively. No significant risk factors for failure of full healing to occur were identified, but it is likely that this aspect of the study was underpowered.

Introduction Several surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). Hypothesis The hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-peration than metallic cerclage but no differences in other clinical outcomes. Patients and methods A retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months post-operatively to evaluate clinical scores and complications. Results A total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at two months post-operatively due to painful prominence. There was no significant difference in reoperation rates between the STCC and MWCC groups (p = 1). There were no cases of non-union, malunion or loss of reduction throughout the series. At the final clinical follow-up of 18 months, there were no significant differences in KSS, KOOS or Bostman scores between the groups. Conclusion No significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. Level of evidence III.

The presence of preoperative tunnel widening and/or malposition can pose technical challenges for revision anterior cruciate ligament reconstruction. This Technical Note describes the use of outside-in drilling to avoid the need for 2-stage reconstruction in the presence of tunnel widening or semi-anatomic tunnels., Technique Video Video 1 This video presents a reproducible one-stage technique for the revision of anterior cruciate ligament reconstruction. It highlights the use of outside-in drilling to avoid the need for 2-stage reconstruction in the presence of tunnel widening or semi-anatomic tunnels.

Background: Return to sport (RTS) to the preinjury level is the main purpose after anterior cruciate ligament (ACL) reconstruction but the factors affecting the RTS are not completely known. Knee Santy Athletic Return to Sport (K-STARTS) is a composite test designed to assess readiness for RTS after ACL reconstruction. Purpose: To determine the key factors that influence K-STARTS scores in a large cohort of patients after ACL reconstruction. Study Design: Case-control study. Level of Evidence: Level 3. Methods: A retrospective analysis of prospectively collected data was undertaken. All patients who underwent ACL reconstruction surgery between March 2016 and May 2017 and also had a K-STARTS assessment at 6 months postoperatively were included. To identify factors influencing the K-STARTS score, an analysis of variance was performed. Age, sex, sports level, delay between injury and surgery, concomitant lesions, graft type, additional lateral tenodesis procedure, and participation in the RTS program were analyzed to identify factors influencing the K-STARTS score. Results: A total of 676 patients were included in the study. The K-STARTS score was significantly higher in male patients than in female patients (13.9 vs 12.4; P < 0.001), in younger patients (those aged Conclusion: Completion of a specific RTS program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological RTS test score at 6 months after ACL reconstruction. Clinical Relevance: This study shows that the completion of a specific RTS program affects positively the RTS test score at 6 months after ACL reconstruction.

Superior capsular reconstruction (SCR) is increasingly considered a "game-changer" for young patients with irreparable rotator cuff tears. Popular graft choices include fascia lata autograft (FLA) and human dermal allograft (HDA), with the latter strongly preferred in North America and Europe. Despite that, there seems to be a general perception that FLAs are associated with better healing rates due to better biology. However, critical analysis of the literature demonstrates abundant limitations that preclude strong conclusions about whether one graft type is optimal. Furthermore, recent studies have demonstrated that HDAs used for SCR have good healing potential and are also associated with generally good short-term clinical outcomes. A clinical pearl is that humeral sided repair failures are not uncommon, and double-row repair techniques should be thoughtfully considered. The main downside of FLAs is the associated donor site morbidity. Given the lack of proven advantage of FLAs, the impetus to move away from the current trend to use HDAs is low.

Most patellar dislocations are associated with disruption of the proximal medial patellar restraints (PMPRs). The PMPRs comprise the medial patellofemoral ligament (MPFL) and medial quadriceps tendon-femoral ligament (MQTFL). Although isolated MPFL reconstruction is the most frequently performed procedure for the surgical management of recurrent dislocation, recent studies have shown that the MQTFL has a synergistic role with the MPFL in resisting lateral patellar displacement close to full extension. It has therefore been suggested that surgical techniques that gain the benefits of both proximal and distal PMPR biomechanical behavior may be best. This article describes an established technique for combined MPFL and MQTFL reconstruction using semitendinosus autograft.

Background:Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift.Purpose:To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift.Results:The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53).Conclusion:This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.

We are united as an orthopaedic community in trying to improve the outcomes of anterior cruciate ligament (ACL) reconstruction. Graft rupture rates of 10% to 28% are reported in high-risk populations, reoperation for non-graft rupture-related indications are reported in 18% to 26%, and only 50% to 65% of recreational athletes return to their preinjury level of sports. Numerous groups across the world have published studies providing evidence demonstrating significant clinical efficacy of lateral extra-articular tenodesis in improving the outcomes of ACL surgery. Finally, the reductions in ACL graft rupture rates augmented with anterolateral ligament or a modified Lemaire reconstruction appear to be broadly comparable. In our hands, anterolateral ligament may result in fewer adverse events.

Needle arthroscopic procedures of the knee offer potential advantages over standard arthroscopic procedures. The small size of the instruments allows for surgery without the use of a scalpel or suture, potentially decreased recovery times, and potentially reduced complication rates compared with traditional arthroscopy. In some patients, the procedure can be performed without the use of either general anesthesia or sedation. The purpose of this article is to provide a standardized technique guide for needle arthroscopic partial medial meniscectomy under local anesthesia.

Purpose The aim of this study was to determine the inter- and intra-observer reliability of knee laxity assessment using a non-invasive navigation system in a population of healthy young athletes. It was hypothesized that knee laxity parameters recorded using non-invasive computer navigation would demonstrate good inter- and intra-observer reliability. Methods Healthy volunteers aged between 18 to 30 years were recruited to the study. Static and dynamic knee laxity parameters including anterior tibial translation and tibial rotation during the pivot shift test were recorded on awake patients using non-invasive computer navigation by two independent observers: at the first visit each athlete was evaluated by the consultant and resident surgeons independently; 6 weeks after the first visit all the participants were re-tested only by the resident surgeon. Inter- and intra-observer reliability was calculated and then interpreted according to Cicchetti’s criteria. Results One hundred healthy volunteers were recruited to the study, of these 38 were women (38%), and the average age was 25.5 ± 2.4 years. According to Cicchetti’s criteria the intra- and inter-observer reliability for static measurements were fair for anterior tibial translation (0.572 and 0.529, respectively) and excellent for total passive tibial rotation (0.859 and 0.883, respectively). For the dynamic measurements of translation and rotation during the pivot shift maneuver both measurements demonstrated good to excellent reliability with intra and inter observer reliability ranging from 0.684 to 0.936. Conclusion Non-invasive navigation for the assessment of knee laxity is associated with fair to excellent inter- and intra-observer reliability in a population of healthy volunteers.

Purpose To perform a systematic review of contemporary studies reporting clinical outcomes of primary anterior cruciate ligament (ACL) repair to determine whether these studies demonstrate any significant benefit of ACL repair and whether there is evidence of a deterioration of mid-term outcomes as seen in historical data. Methods A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A PubMed search using the keywords “repair” AND “Anterior Cruciate Ligament” was performed (limits: English language, publication date between January 1, 2014, and January 13, 2019). All identified studies reporting clinical outcomes of arthroscopic ACL repair were included. Critical appraisal was conducted using the Cochrane Risk of Bias Tool for Randomized Clinical Trials and the Methodological Index for Non-Randomized Studies. Basic parameters of each study including population characteristics, repair technique, physical examination findings, and clinical outcome scores were recorded and evaluated. Results Nineteen eligible studies were identified (including 5 comparative studies). None of the comparative studies showed any significant difference between repair and reconstruction groups with respect to International Knee Documentation Committee (IKDC), Lysholm, Tegner, side-to-side laxity difference, Lachman, pivot shift tests, or graft rupture rates. Four non-comparative studies reported outcomes at medium- to long-term follow up (range of mean follow up 43.3-79 months) with a mean Lysholm score between 85.3 and 100, mean IKDC subjective score between 87.3 and 100, and mean Tegner activity score between 5 and 7. Conclusions Comparative studies identified no significant differences between ACL repair and reconstruction with respect to Lysholm, IKDC, side-to-side laxity difference, pivot shift grade, or graft rupture rates. However, these studies had major limitations including small numbers and short durations of follow up. Case series demonstrated that excellent outcomes can be achieved at medium- to long-term follow up with the SAR technique. Level of Evidence IV; Systematic review of Level II to IV investigations.

Meniscal ramp lesions occur much more frequently than was previously considered, and particularly so in ACL-injured knees. The historically high rate of missed diagnoses is a result of unfamiliarity with this injury pattern within the orthopedic community, and also the difficulty in diagnosis. A systematic exploration of the posteromedial compartment of the knee is mandatory to reliably identify ramp lesions. Failure to recognize and repair these injuries is associated with persistent anterior and posteromedial instability. Understanding their nature, biomechanics, and epidemiology is essential in allowing orthopedic surgeons to suspect their presence and adequately treat these lesions.

The anterolateral ligament (ALL) has an important role as a knee stabiliser of coupled anterior translation and internal rotation. Significant and clinically important advantages of combined anterior cruciate ligament (ACL) and ALL reconstruction compared with isolated ACL reconstruction have been demonstrated. This chapter provides an overview of the relevant anatomy and biomechanics, surgical technique and clinical outcomes of ALL reconstruction.

Background Irreparable rotator cuff tears in active patients provide a significant challenge and a consensus on the gold standard treatment is currently lacking. Superior capsule reconstruction (SCR) has recently been advocated and functions by providing a passive biological constraint to superior humeral head migration. The aim of this study is to systematically review the literature to evaluate the role of SCR in terms of functional outcome scores and failure rates. Patients and methods A review of the online databases Medline and EMBASE was conducted in accordance with the PRISMA guidelines on the 28th January 2019. Clinical studies reporting SCR using any type of graft or surgical technique were included if reporting either functional outcome scores or rate of secondary surgery. The studies were appraised using the Methodological index for non-randomised studies tool. Results The search strategy identified nine studies eligible for inclusion; five reported on fascia lata autografts and four studies reported on dermal allografts. All nine studies reported significant improvement in functional scores after SCR. Rates of secondary surgery were only provided in the dermal allograft studies at short-term follow-up (mean 10.9 to 32.4 months) and ranged from 0 to 18.6%. Radiological assessment revealed graft failure in 5.5 to 55% of dermal allografts and 4.2 to 36.1% of fascia lata autografts. Conclusion This review demonstrates that SCR is a useful treatment modality for patients with irreparable rotator cuff tears. SCR was associated with significantly improved functional outcome scores in all studies. All studies reported a preserved or increased mean AHD. The radiological graft failure rate ranged from 4.2 to 55% and the short duration of follow-up in most studies means that this remains an important concern that requires longer-term evaluation. Level of evidence IV, systematic review.

Objectives: Anterior cruciate ligament (ACL) injuries are often associated with meniscal and chondral lesions. Meniscal lesions are present in up to 50% of ACL injured knees, and chondral lesions occur with an incidence of 20% to 40% in acute ACL-injured knees. The major importance of this lies in the fact that menisectomy and severe chondral damage are important predictors of poor outcomes including the subsequent development of knee osteoarthritis. Furthermore, patient reported outcomes following revision ACL reconstruction remain inferior to primary ACL reconstruction and this may, at least in part, be due to an increased incidence and severity of meniscal and chondral injuries. Although multiple studies have demonstrated that meniscal and chondral lesions are generally present at a higher rate at the time of revision ACL reconstruction when compared to primary ACL reconstruction, large studies following individual patients through primary and revision ACL reconstruction and tracking the change in the occurence of these injuries are scarce. The primary objective of this study was to determine the proportion of patients with meniscal and chondral injuries at the time of primary ACL reconstruction and determine how this rate changed by the time they underwent revision ACL reconstruction. The hypothesis was that the proportion of patients with meniscal and/or chondral lesions would be significantly greater at revision ACL reconstruction when compared to the primary procedures. Methods: Consecutive patients who underwent primary and then revision ACL reconstruction between March 1999 and February 2018 were identified using a single center registry. Patient characteristics, and intraoperative data from each procedure were collected and analyzed. This specifically included the occurrence and type of meniscal and chondral pathology. Descriptive statistics were used to evaluate the study sample using medians, descriptive data analysis was conducted depending on the nature of the criteria. Comparison between variables were assessed with student’s t test for quantitative variables and Mcnemar test for categorical variables. Statistical significance was set a t pResults: 213 consecutive patients underwent both primary ACL reconstruction and then revision surgery during the study period. The average time from primary ACLR to Revision was 46.8 ± 36.6 months (range 5-181).The mean age of patients at primary ACLR was 22.21±7.21 years. The mean age of patients at revision ACLR 26.1 ± 8.3 years. The mean IKDC for the entire population was 85.53 ± 11.59, The mean ACL-RSI score was 71.89 ± 23.95. The mean Lysholm score was 91.77±10.24. The proportion of patients with chondral lesions significantly increased from 7% at primary ACL to 15.5% at revision ACL (p < 0.05). Meniscal lesions also significantly increased from 44.6 % at primary ACLR to 70% at revision ACLR (p < 0.05). There was no significant difference in the rate of lateral meniscal lesions (11.7 vs 13.1, p > 0.05). However, the proportion of patients with a medial meniscus lesion (25.4 vs 36.2, p < 0.05) and bimeniscal lesions (7.5 vs 20.7, p < 0.05) increased significantly at revision ACL reconstruction. Conclusions: The proportion of patients with meniscal and//or chondral injuries at the time of revision ACL reconstruction is significantly higher than at the time of primary ACL reconstruction. Specifically, the rate of medial meniscus and bimeniscal injuries is significantly higher in patients undergoing revision ACL reconstruction

Ramp lesions are increasingly recognized as a hallmark of posteromedial knee instability. Although the precise mechanisms through which these lesions occur is not completely understood, the distal semimembranosus complex has been implicated in their pathogenesis due to its attachment to the posterior horn of the medial meniscus (PHMM). Arthroscopic dissection of the distal semimembranosus tendon, and the application of traction to it, results in posterior translation of the PHMM and stretching of the meniscocapsular region. This demonstrates a mechanism through which ramp lesions can occur. Furthermore, the subsequent open dissection highlights the complex anatomical relationships of the distal semimembranosus tendon complex, particularly its tensioning effect on the posterior oblique ligament. The clinical relevance of this is that when a ramp lesion occurs, it is likely to be part of a spectrum of posteromedial injury and it should be considered a hallmark of posteromedial instability rather than an isolated meniscocapsular injury.

Background: Professional athletes are reported to be at greater risk of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) than the nonprofessional population. However, this finding has been controversial, and confusion has arisen in the literature owing to the underpowering of previous studies. Purpose/Hypothesis: The purpose was to report the differences in the rate of SA after ACLR in a large series of patients and to perform pooled data analysis including previously published studies. The hypothesis was that professional athletes have a significantly higher risk of SA than nonprofessional athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed. Patients who underwent ACLR between January 2009 and July 2017 (with a minimum follow-up of 12 months) were considered for study eligibility. The rate of SA was determined, and multivariate analysis was used to evaluate potentially important risk factors, including participation in professional sport. Furthermore, a literature search was performed, and data were extracted from all identified relevant studies. A pooled data analysis was performed to determine differences in the risk of SA between professional and nonprofessional populations. Results: The current series comprised 4421 anterior cruciate ligament surgical procedures with 265 professional athletes. There were 15 cases of SA diagnosed over the study period (0.34%; 95% CI, 0.19%-0.56%). Ten cases occurred in professional athletes (3.8%; 95% CI, 1.82%-6.83%). The percentage of SA was 0.12% (95% CI, 0.04%-0.28%) in the nonprofessional population. Being a professional athlete was associated with a significantly increased risk of SA after ACLR (odds ratio, 21.038; 95% CI, 6.585-75.789; P < .0001). This finding was confirmed in the pooled data analysis comprising 11,416 patients including 1118 professional athletes (odds ratio, 5.03; 95% CI, 1.17-21.61). Conclusion: Professional athletes are at greater risk of SA after ACLR than nonprofessional athletes. The results of previous studies may have been conflicting owing to underpowering. The current study confirms the elevated risk by using a large clinical series and pooled data analysis to avoid the limitations of previous studies.

Background Management of displaced midshaft clavicle fractures is controversial. Nonoperative treatment can lead to shortening, a risk factor for nonunion and poor functional outcomes. These inferior results have resulted in authors recommending surgical fixation for fractures with significant shortening. The aim of this systematic review was to analyze the effect of fracture shortening on shoulder function and nonunion rates in nonoperatively managed displaced midshaft clavicle fractures. Methods A review of the online databases MEDLINE and Embase was conducted on February 16, 2018, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies with midshaft clavicle fractures treated nonoperatively reporting an evaluation of the degree of clavicle shortening and either shoulder function or nonunion were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results The search strategy identified 16 studies eligible for inclusion, comprising 4 randomized controlled trials and 12 nonrandomized retrospective comparative studies. Of the 12 case series, 11 failed to demonstrate any correlation between shortening and shoulder outcome scores. Of the 4 randomized controlled trials, 3 reported no significant association between fracture shortening and shoulder outcome scores. The studies also failed to demonstrate a significant association between nonunion and the presence of clavicle shortening. Conclusion There is no significant association between fracture shortening and nonunion rates or shoulder outcome scores in displaced midshaft clavicle fractures managed nonoperatively.

A renewed interest in arthroscopic knee ligament repair is emerging as a result of diagnostic and technical improvements. In pediatric patients with posterior cruciate ligament (PCL) injury, surgical reconstruction is rarely considered as an option because of the risk of iatrogenic physeal injury. In this Technical Note, we describe an arthroscopic surgical repair technique of PCL proximal avulsions in pediatric patients. The main reasons to consider arthroscopic PCL repair in this population include minimal surgical morbidity, preservation of the complex biomechanical properties of the native ligament, the small diameter of the bone tunnels, the physeal respecting nature of the procedure, the absence of graft harvesting, and the absence of fixation devices. The indications for this technique are limited to patients with an acute proximal PCL avulsion. Investigation performed from at Centre Orthopedique Santy, FIFA Medical Center of Excellence, Lyon, France.

Introduction Variations in the length of lateral extra-articular reconstruction (LER) have been widely investigated during knee flexion but there is no information about length changes during pivot shift. This study sought to assess the changes in LER tension during weightbearing knee flexion in a normal knee and in a computer-simulated pivot-shift scenario. Hypothesis Placing the femoral tunnel posterior and proximal to the lateral femoral epicondyle allows the LER to tighten early in the flexion range during weightbearing (squatting motion) and simulated pivot-shift. Material and methods A computer model was used to simulate weightbearing knee flexion and pivot shift scenarios. Changes in LER tension were calculated in both scenarios by estimating the distance between six femoral attachment sites (posterior and proximal to the lateral femoral epicondyle) and two tibial tunnel locations: Gerdy's tubercle (GT) and the anterolateral ligament (ALL) anatomic attachment site. Results Independent of the location of the femoral and tibial tunnels, the LER tightened by up to 22% of its resting length during the early portion of weightbearing knee flexion and then relaxed from 40° to 60° of knee flexion. The ALL tibial tunnel position allowed complete LER relaxation at 60° flexion whereas LER using the GT tibial tunnel position remained tighter. In the simulated pivot-shift test, and for all femoral tunnel locations, the LER tightened by 20% to 34% of its resting value for the GT tibial tunnel position and by 11% to 26% for the ALL tibial tunnel position. Discussion During weightbearing knee flexion, placing the femoral tunnel proximal and posterior to the femoral epicondyle was associated with LER tightening in the early degrees of flexion and LER relaxation between 40 and 60° flexion. LER tightening occurred during a simulated pivot-shift test supporting the concept that a posterior and proximal femoral LER tunnel position is most effective during weightbearing knee flexion and altered knee kinematics.

Background: Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction is associated with improved clinical outcomes as compared with isolated intra-articular reconstruction, but the indications are not precisely defined. It may be the case that patients with proven anterolateral injury on preoperative imaging are most likely to benefit, but the accuracy of magnetic resonance imaging (MRI) is not known. Purpose/Hypothesis: To evaluate the correlation between MRI and surgical exploration in acute ACL-injured knees. The hypothesis was that a positive correlation would be identified between imaging and surgical findings for ALL/capsule and iliotibial band (ITB) injuries and that MRI would be highly sensitive, specific, and accurate. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Between January and May 2016, patients presenting with acute ACL injuries were considered for study eligibility. Included patients underwent 1.5-T MRI, which was evaluated by 3 investigators who attributed a Ferretti grade of injury to the anterolateral structures. At the time of ACL reconstruction, a lateral exploration was undertaken, and macroscopic injuries were identified. An evaluation of correlation between MRI and surgical exploration findings was performed. Results: Twenty-six patients participated in the study, and 96% had an ALL/capsule injury. The sensitivity, specificity, and accuracy of MRI and the correlation ( K) with surgical exploration findings were as follows, respectively: any ALL/capsule abnormality—88%, 100%, 88.5%, and 0.47; differentiating partial or complete ALL/capsule tears—78.6%, 41.7%, 61.5%, and 0.23; ITB injuries—62.5%, 40%, 50%, and 0.27. The percentage agreement between MRI and surgical findings was 88% for ALL/capsule injury, 65% for ITB injury, and 53% for Ferretti grading. Conclusion: Surgical exploration demonstrates that injuries occur to the anterolateral structures in almost all acute ACL-injured knees. MRI is highly sensitive, specific, and accurate for detection of abnormalities of the ALL/capsule and shows a high percentage of agreement with surgical findings. MRI has low sensitivity, specificity, and accuracy for the diagnosis of ITB injury. The Ferretti grade could not be reliably established from MRI, and there was only fair agreement between MRI and surgical findings with respect to ITB abnormalities and determination of whether ALL/capsular tears were partial or complete.

Introduction ACL reconstruction is the gold standard of surgical treatment for ACL tears. Recently, there has been a renewed interest in ACL repair, and early results are promising. The purpose of this study was to compare outcomes following ACL repair versus ACL reconstruction at a minimum follow-up of two years. Materiel et methode A retrospective analysis of prospectively collected data was undertaken. Patients who underwent ACL repair were matched 1 :1 to those who underwent ACL reconstruction using a propensity score. All patients underwent a return to sports evaluation (isokinetic test, K-START and ACL-RSI) at 6 months post-operatively. At final face-to-face follow-up, physical examination findings (including side to side laxity difference & pivot shift) were recorded. At final overall follow-up return to sport, complications, re-operations and outcome measures, including Lysholm, Tegner, International Knee Documentation Committee (IKDC), ACL-RSI, Forgotten Joint Score-12 (FJS) were recorded. Resultats Eighty-two patients with ACL repair were matched with 82 patients who underwent isolated ACL reconstruction. 7 matched pairs were lost to follow-up, leaving 75 patients in each group. At 6 months postoperatively, the ACL repair group had a lower mean hamstring muscle deficit (1.7 % ± 12.8) (p Conclusions The outcomes of ACL repair were non-inferior to ACL reconstruction with respect to IKDC subjective scores and anteroposterior laxity. ACL repair was associated with better forgotten joint score and superior hamstring strength, without increase in graft rupture rates. ACL repair can be considered a useful option in carefully selected patients.

Background: Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning. Purpose/Hypothesis: The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT). Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was Results: Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP ( P = .134) and ML ( P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999). Conclusion: Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.

Introduction Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. Methods This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5–37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0–18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92–100% in 8 out of 10 studies at mean follow up range 6–78.7 months but two reported lower rates ranging from 58.3–84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10–16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. Conclusion Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. Level of Evidence IV; systematic review.

Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection. In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508. Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release). All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective. The National Institute for Health Research Health Technology Assessment programme. [Abstract copyright: Copyright © 2020 The Author(s). Publishedx by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.]

Background:The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established.Purpose:The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment.Study Design:Systematic (scoping) review.Methods:A scoping review of the literature was conducted in accordance with the framework of Arksey and O’Malley. A search strategy based on the terms “chondrolysis” AND “knee,” “chondrolysis” AND “meniscus,” and “chondral damage” AND “lateral meniscus” was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis.Results:Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee.Conclusion:Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.

Background: Cyclops syndrome is characterized by a symptomatic extension deficit attributed to impingement of a cyclops lesion within the intercondylar notch. The syndrome is an important cause of reoperation after anterior cruciate ligament reconstruction (ACLR). It has been suggested that remnant-preserving ACLR techniques may predispose to cyclops syndrome, but there is very limited evidence to support this. In general terms, risk factors for cyclops syndrome are not well-understood. Purpose: To determine the frequency of and risk factors for reoperation for cyclops syndrome in a large series of patients after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed, including all patients who underwent primary ACLR between January 2011 to December 2017. Patients undergoing major concomitant procedures were excluded. Demographic data, intraoperative findings (including the size of preserved remnants), and postoperative outcomes were recorded. Those patients who underwent reoperation for cyclops syndrome were identified, and potential risk factors were evaluated in multivariate analysis. Results: A total of 3633 patients were included in the study, among whom 65 (1.8%) underwent reoperation for cyclops syndrome. Multivariate analysis demonstrated that preservation of large remnants did not predispose to cyclops lesions (odds ratio [OR], 1.11; 95% CI, 0.63-1.93). The most important risk factor was extension deficit in the early postoperative period. If present at 3 weeks postoperatively, it was associated with a >2-fold increased risk of cyclops syndrome (OR, 2.302; 95% CI, 1.268-4.239; P < .01), which was increased to 8-fold if present 6 weeks after ACLR (OR, 7.959; 95% CI, 4.442-14.405; P < .0001). None of the other potential risk factors evaluated were found to be significantly associated with an increased frequency of cyclops syndrome. Conclusion: Failure to regain full extension in the early postoperative period was the only significant risk factor for cyclops syndrome after ACLR in a large cohort of patients. Other previously hypothesized risk factors, such as preservation of a large anterior cruciate ligament remnant, did not predispose to the development of this debilitating postoperative complication.

Missing (letter)

Transverse patellar fractures are a relatively common injury and typically require surgical fixation. An adequate restoration of patella integrity is essential for proper functioning of the extensor mechanism of the knee and for the prevention of patellofemoral osteoarthritis. Currently, the treatment of transverse fractures of the patellar bone involves several surgical techniques, most of which involve the use of metallic implants. Despite good clinical results following surgery, numerous complications exist, including primarily symptomatic hardware following surgical treatment. The purpose of this article is to describe the technique for treatment of a transverse patellar fracture using a high-resistance tape (FiberTape; Arthrex) and a tensioner (Arthrex) instead of traditional metallic implants.

Background: Distal humeral fractures represent about 1% to 2% of adult fractures. Open reduction and internal fixation (ORIF) has traditionally been the standard treatment; however, fracture comminution and osteoporotic bone may prevent adequate fixation, and total elbow arthroplasty (TEA) is an alternative. The aim of this meta-analysis was to determine which procedure provided superior clinical outcomes for elderly patients with distal humeral fractures. Methods: A systematic review of the literature was conducted in accordance with the PRISMA guidelines. Cases series and comparative studies reporting functional outcomes or complications after TEA and ORIF in patients over 60 yr of age with an acute distal humeral fracture were included. The studies were appraised using validated quality assessment scales. Results were pooled from different studies using meta-analysis techniques, and the functional outcomes, complications, and frequency of revision surgery were compared. Results: The search strategy identified 27 studies: one randomized controlled trial, four comparative studies, 14 ORIF cases series, and eight TEA case series. TEA was associated with statistically significant and clinically superior Mayo Elbow Performance score (MEPS) and Disability of the Arm, Shoulder and Hand (DASH) scores when compared to ORIF in elderly patients while having a statistically significant lower complication rate. Conclusions: Meta-analysis of comparative studies demonstrated that TEA is associated with statistically significant and clinically superior MEPS and DASH scores when compared to ORIF in elderly patients.

Knee extension deficit is frequently observed after anterior cruciate ligament reconstruction or rupture and other acute knee injuries. Loss of terminal extension often occurs because of hamstring contracture and quadriceps inactivation rather than mechanical intra-articular pathology. Failure to regain full extension in the first few weeks after anterior cruciate ligament reconstruction is a recognized risk factor for adverse long-term outcomes, and therefore, it is important to try to address it. In this Technical Note, a simple, rapid, and effective technique to help regain full knee extension and abolish quadriceps activation failure is described.

Objectives: Second ACL injuries (defined as a graft rupture or contralateral ACL rupture) are common after ACL reconstruction. It is postulated that this observation could reflect a premature attempt to return to sports (RTS) and that delaying RTS until certain quality indicators or rehabilitation milestones are met could reduce the risk. There is consequently considerable interest in the application of RTS criteria. Multiple authors have reported that patients who passed a battery of tests prior to RTS, had a lower risk of re-injury and an increased rate of return to sport. However, factors influencing RTS scores have not been well studied. Therefore, the aim of this study was to determine the key factors that influence RTS test scores. Methods: A retrospective analysis of consecutive patients who underwent primary ACL reconstruction between March 2016 and May 2017, who also had a documented RTS evaluation with K-STARTS, (a validated, composite psychological and functional RTS test battery (Fig 1)) at 6 months following surgery, was undertaken. All patients underwent the same standardized rehabilitation program (Table 1) but in addition to this they were offered the opportunity to participate in a separate individualized RTS program (Table 2). If patients chose to participate in the RTS program, this would occur in addition to the standard program and not instead of it. The first session would typically occur 3 months post-operatively and comprised of ten sessions that took place over a 12-week period. Demographic data and characteristics including the frequency of pre-injury sports participation, Tegner score, time from injury to surgery, graft type, the presence of meniscal lesions, whether a lateral tenodesis was performed, and whether patients participated in the specific RTS program in addition to physiotherapy were recorded. To identify factors influencing the K-STARTS score at six months postoperatively, an analysis of variances was performed. When a significant effect was found, post hoc comparisons were made using Tukey’s HSD tests with Bonferroni’s correction. Results: 676 patients were included in the study. Outcomes of the analysis of the influence of factors on the K-STARTS score is comprehensively presented in Table 3. The K-STARTS score was significantly higher in males than females (13.9 vs 12.4, pConclusions: Completion of a specific return to sports program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological return to sports test score at 6 months after ACL reconstruction.

Introduction Recurrent shoulder instability is frequently associated with glenohumeral bone loss. Recently there has been a surge of interest in arthroscopically performed bone block procedures. The aim of this systematic review was to determine the clinical and radiological outcomes of arthroscopic glenoid bone block stabilisation for recurrent anterior dislocation. Methods This systematic review was performed in accordance with PRISMA guidelines. The search strategy was applied to MEDLINE and Embase databases on 20th July 2020. Studies reporting either clinical or radiological outcomes following arthroscopic bone block stabilisation for recurrent anterior dislocation were included. Primary outcomes were function and instability scores. Secondary outcomes included recurrent instability, graft union and resorption rates, return to activity/sports, and complications. Pooled analysis was performed when an outcome was uniformly reported by more than one study. Critical appraisal of studies was conducted using the Methodological Index for Non-Randomized Studies (MINORS) tool. Results Application of the search strategy resulted in the inclusion of 15 eligible studies; 12 used iliac crest bone graft while 3 used distal tibial allograft. The overall population comprised 265 patients (mean age range, 25.5–37.5 years; 79% of participants were men). All post-operative outcome scores were significantly improved, and the overall rate of recurrent instability was low (weighted mean 6.6%, range 0–18.2%) at mean follow up of 30.4 months. The Rowe score was the most frequently reported outcome measure, improving on average by 53.9 points at final follow-up, exceeding the minimal clinically important difference (MCID) threshold. Graft union rates ranged between 92–100% in 8 out of 10 studies at mean follow up range 6–78.7 months but two reported lower rates ranging from 58.3–84% for autografts and 37.5% for allografts. Graft resorption rates averaged between 10–16% for autografts and 32% for allografts. Hardware-related complications occurred in 2% with the most frequent being screw breakage or symptomatic mechanical irritation. Conclusion Arthroscopic bone block stabilisation is associated with high rates of graft union, significant improvements in the WOSI, Rowe, Constant and SSV scores (exceeding MCID thresholds where known), and a low rate of complications, including re-dislocation in the short to mid-term. Graft union rates were high, but the long-term implications of graft resorption (which occurs more frequently with allograft) are unknown. Longer follow-up of these patients and future experimental studies are required to further examine the effects of graft type and fixation methods. Level of evidence IV; systematic review.

Objectives: The aim of this study was to report long term comparative clinical outcomes of isolated Anterior Cruciate Ligament (ACL) reconstruction versus combined ACL and Anterolateral Ligament (ALL) reconstruction in a matched pair analysis. Methods: A retrospective analysis of prospectively collected data was undertaken. Patients who underwent combined ACL and ALL reconstruction were matched 1:1 to patients who had undergone isolated ACL reconstruction using a propensity score. Matching was based upon age, BMI, side to side laxity difference, duration of time between injury and surgery, type of sports participation (e.g pivoting, contact), presence of concomitant meniscal injuries and their treatment. At the end of the study period all patients completed Lysholm, Tegner, IKDC and KOOS scores, and underwent telephone interview and medical notes review to determine whether they had experienced any complications or re-operations after the index procedure. Kaplan-Meier analysis was used to determine survivorship with respect to graft rupture rates in each group Results: 90 patients who underwent combined ACL and ALL reconstruction were matched to 90 patients who underwent isolated ACL reconstruction. The mean duration of follow up was 108.09±9.43 months (range 97-182). The combined ACLR and ALLR group had significant lower graft rupture rate (3.5%) than the isolated ACLR group (16%) (OR=5.306 ; CI =1.46-19.19 ; p=0.007) (Fig 1). There was no significant difference between groups with respect to non-graft rupture related reoperation rates (secondary meniscectomy, cyclops excision, arthroscopic lavage for infection or hemarthrosis). Contralateral ACL rupture rates were comparable between combined ACL and ALL reconstruction (16.27%) and isolated ACL reconstruction (19.5%) groups. The KOOS score was significantly higher in the combined group with respect to subdomains of pain (p=0.007) and quality of life (p=0.007). There was no significant difference in other KOOS domains, Tegner, Lysholm, or IKDC Conclusions: This study reports the first long-term results of combined ACL and ALL reconstruction. The results demonstrate a significantly lower graft failure rate when compared to isolated ACL reconstruction in a matched pair series with a minimum follow-up of 9 years.

Background:Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known.Purpose:To determine the rate of reoperation after combined ACL and ALL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort.Results:The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002).Conclusion:The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

The recent literature shows that imaging modalities, physical examination tests, and glenohumeral arthroscopy all have low sensitivities and specificities with respect to the diagnosis of the long head of biceps tendon pathology. Biceps tenoscopy is a strategy that aims to reduce the rate of missed diagnoses by improving visualization of the extra-articular part of the tendon. This is an area of predilection of pathology that is not adequately visualized with conventional arthroscopic techniques. This technical note presents the surgical technique for biceps tenoscopy.

Background The widespread historical abandonment of lateral extra-articular procedures in ACL-injured knees occurred due to concerns about high rates of adverse events. Recently there has been a resurgence in popularity of lateral extra-articular procedures and this warrants an urgent evaluation of their safety profile. Hypothesis/Purpose The aim of this study was to perform an interim analysis of the ongoing (blinded for journal review) randomized controlled trial in order to determine whether combined ACL and anterolateral ligament reconstruction (ACL + ALLR) is associated with an increased rate of adverse outcomes when compared to isolated ACL reconstruction (ACLR). The hypothesis was that there would be no significant difference between groups at a minimum follow-up of one year. Study Design Randomized Controlled Trial Methods Recruitment was commenced in November 2016. Patients scheduled for ACL reconstruction were randomized to either isolated ACL reconstruction (bone-patella tendon-bone autograft) or combined ACL + ALLR (hamstring tendon autograft). All patients with a minimum follow-up of one year, in March 2019 were included. Complications and re-operations, knee laxity parameters, range of motion, Tegner, Lysholm, IKDC and KOOS scores were evaluated. Results Deux cent vingt quatre patients (112 in each group) with a mean follow-up 12.3 ± 1.9 (range 12 to 19) months formed the study population. There was a significantly higher rate of re-operation for cyclops syndrome in the isolated ACL group (B-PT-B 8.9 %, ACL + ALLR 0 %, p = 0.0012). There was no significant difference in the frequency of graft rupture (B-PT-B 5.4 %, ACL + ALLR 0.9 %, p = 0.1191), range of motion deficits, pain, or re-operation for meniscectomy between groups. There were no cases of post-operative infection, venous thromboembolism, or arthrofibrosis. Subjective IKDC (81.2 vs. 86.8, p = 0.0048), Lysholm (88 vs. 92, p = 0.0131) and some components of KOOS were significantly better in the ACL + ALL group. Conclusion This study demonstrates no evidence of an increased risk of adverse events after combined ACL + ALL reconstruction when compared to isolated ACL reconstruction with a B-PT-B graft. The trend towards a reduced graft rupture rate and significantly better subjective IKDC, Lysholm and KOOS scores with the combined procedure is consistent with the previous literature and expected to be more pronounced at the end of the overall study period.

Background Pre-operative high-grade pivot shift is associated with higher rates of ACL graft failure; persistent instability and inferior patient reported outcomes. The pathophysiology of high-grade pivot shift is multifactorial and numerous factors have been implicated. Purpose The aim of this study was to determine risk factors for high-grade pivot shift, with a particular emphasis on addressing the limitations of previous studies, by including a comprehensive evaluation of both soft-tissue and osseous parameters. Study design Case series. Methods A prospective evaluation of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury) was undertaken. An open lateral exploration was undertaken at the time of the index procedure. Details regarding patient and injury characteristics were recorded. Osseous parameters (tibial slope and condylar ratios) were determined using established MRI protocols. A multivariate logistic regression with Penalized Maximum Likelihood was used to identify risk factors associated with grade 3 pivot shift. A stepwise descending strategy was applied from the initial full model to determine the most parsimonious one, removing step-by-step all the non-statistically significant parameters and keeping only the clinically relevant parameters and confounding factors (if any). Results The mean age of the population was 28.3 ± 9.8 years. 67.5% of patients were male. Thirty-five (17.5%) of patients had a high grade (grade 3) pivot shift and 165 (82.5%) had a low-grade pivot shift (grades 1 and 2). Both uni- and multivariate analyses demonstrated that injury to the Anterolateral structures of the knee was the only significant risk factor for high-grade pivot shift. When this was subcategorized further, it was identified that both complete and incomplete tears of the ALL, and Segond fractures were all significant risk factors for high-grade pivot shift. Conclusions A comprehensive evaluation of soft-tissue and osseous factors has identified that injury to the Anterolateral Structures of the knee is the most important risk factor for explosive pivot shift in acute ACL-injured knees.

In-office needle arthroscopy offers the potential advantage of reduced injury to intervention time, without the need for advanced imaging. It is particularly appropriate for those with contraindications to advanced imaging and also may reduce the risk of incorrect diagnoses in those situations in which imaging is associated with low sensitivity/specificity. The purpose of this article is to provide a standardized diagnostic approach to needle arthroscopy of the shoulder.

Despite technical advances in anterior cruciate ligament (ACL) reconstruction surgery, there remains a need to improve postoperative outcomes with respect to graft failure rates. Recently, it has been shown that combined ACL-anterolateral ligament (ALL) reconstruction (using a graft composed of a tripled semitendinosus and single-strand gracilis tendon) is associated with a significant reduction in graft rupture rates compared with isolated ACL reconstruction. It is recognized that the hamstring tendons are not always available (revision scenario) or are not always the primary ACL graft choice. Some surgeons prefer to use quadriceps tendon ACL grafts because of the suggestion that these grafts may be associated with equal or better functional scores. However, if surgeons wish to try to reduce the risk of graft failure by performing an ALL reconstruction, either a combined reconstruction or the use of an independent ALL graft, with a separate femoral socket, could be considered. The disadvantage of an independently performed extra-articular procedure is the risk of femoral socket collision with the femoral ACL tunnel. This Technical Note therefore describes the use of a combined ACL-ALL reconstruction using quadriceps tendon autograft (ACL graft), gracilis allograft (ALL graft), and a single femoral tunnel.

Multiligament knee injuries (MLKIs) are rare. Their importance lies in the fact that they can result in severe morbidity including arthrofibrosis, persistent pain, instability, and of course amputation. Management of these injuries can undoubtedly be challenging due to their infrequency, difficulties in accurate diagnosis, and the complex decision-making processes that are required to determine the optimal reconstructive procedures, graft choice, the timing of surgery, and strategies for rehabilitation.

Introduction Arthroscopic shoulder surgery is increasingly performed as a day case procedure. Nausea, vomiting and inadequate pain control are the most frequent reasons for reattendance or failed discharge. Gabapentin is advocated as an adjunct to mitigate these symptoms and its use in shoulder arthroscopy may provide improved post-operative symptom control. The aim of this study was to perform a meta-analysis of studies evaluating the role of gabapentin in the peri-operative management of shoulder arthroscopy. Hypothesis Gabapentin is associated with significant improvements in post-operative nausea, vomiting and pain control after shoulder arthroscopy. Material and methods A systematic review using Medline was conducted in accordance with the PRISMA guidelines. Randomised controlled trials studies reporting on patients >15 years old receiving either preoperative gabapentin or placebo before any shoulder arthroscopic surgery were considered for eligibility. Studies were appraised against the Consolidated Standards of Reporting Trials (CONSORT) checklist. A meta-analysis was performed using Review Manager 5.3. Results Four randomized controlled trials were identified for inclusion (n = 227). Meta-analysis demonstrated a beneficial effect of gabapentin in preventing nausea and vomiting in the postoperative period (Odds Ratio 0.30, p = 0.04). However, pooled data analysis did not show significant advantage in using gabapentin for postoperative pain control (p = 0.11), although one study demonstrated a significant reduction in opioid consumption after gabapentin. No significant difference was reported in post-operative dizziness or sedation between the groups. Discussion Gabapentin did not show any significant benefit in postoperative pain control but is associated with significant reductions in post-operative nausea and vomiting after shoulder arthroscopy. Level of evidence I, meta-analysis.

PURPOSE To evaluate clinical outcomes in professional athletes after combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction at a minimum follow-up of 2 years. METHODS A retrospective analysis of prospectively collected data from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group database was performed. All professional athletes who underwent primary combined ACL and ALL reconstruction between January 2011 and March 2016 were included. Patient assessment included physical examination, pre- and postoperative subjective and objective International Knee Documentation Committee (IKDC), Tegner activity scale, and Lysholm scores. RESULTS Seventy-two professional athletes underwent primary ACL and ALL reconstruction; 70 (97%) were available, with a mean follow-up of 3.9 years (range, 2-7). The preoperative side-to-side anteroposterior laxity difference was 7.1 ± 1.4 mm, and this decreased significantly after surgery to 0.4 ± 0.9 mm (P < .0001). Pivot-shift grade evolved from 16 grade I (22.8%) and 54 grade II or III (77.2%) preoperatively, to 66 absent pivot shift (94.3%) and 4 grade I (5.7; P < .001). By 1-year postoperatively, 60 athletes (85.7%) returned to professional sport, with a mean time interval of 7.9 months (range, 5-12). Preoperatively, the mean subjective IKDC was 56.1 ± 12.3, the Lysholm score was 48.4 ± 12.5, and the Tegner score was 9.3 ± 1. At final follow-up, the mean subjective IKDC was 90.5 ± 7.6 (P < .0001), the Lysholm score was 94.4 ± 7.5 (P < .0001), and the Tegner score was 8.8 ± 1.5 (P < .004). The objective IKDC evolved from 39 grade C (55.7%) and 31 grade D (44.3%) preoperatively to 65 grade A (92.9%) and 5 grade B (7.1%) (P < .0001). Eleven Patients (15,7%) underwent a subsequent ipsilateral reoperation including 4 (5.7%) revision ACL reconstructions. The risk of graft rupture was significantly higher in female patients (13.6% vs 2.1% in male patients; P = .048). CONCLUSIONS Combined ACL and ALL reconstruction is associated with excellent outcomes in professional athletes with respect to graft rupture rates, return to sport, knee stability, and reoperation rates after injury. LEVEL OF EVIDENCE Level IV, case series.

The purpose of this study was to evaluate the correlation between tibial acceleration parameters measured by the KiRA device and the clinical grade of pivot shift. The secondary objective was to report the risk factors for pre-operative high-grade pivot shift.Two-hundred and ninety-five ACL deficient patients were examined under anesthesia. The pivot shift tests were performed twice by an expert surgeon. Clinical grading was performed using the International Knee Documentation Committee (IKDC) scale and tibial acceleration data was recorded using a triaxial accelerometer system (KiRA). The difference in the tibial acceleration range between injured and contralateral limbs was used in the analysis. Correlation coefficients were calculated using linear regression. Multivariate logistic regression was used to identify risk factors for high grade pivot shift.The clinical grade of pivot shift and the side-to-side difference in delta tibial acceleration determined by KiRA were significantly correlated (r = 0.57; 95% CI 0.513-0.658, p 0.0001). The only risk factor identified to have a significant association with high grade pivot shift was an antero-posterior side to side laxity difference 6 mm (OR = 2.070; 95% CI (1.259-3.405), p = 0.0042).Side-to-side difference in tibial acceleration range, as measured by KiRA, is correlated with the IKDC pivot shift grade in anaesthetized patients. Side-to-side A-P laxity difference greater than 6 mm is reported as a newly defined risk factor for high grade pivot shift in the ACL injured knee.Level II.

Background: Lateral meniscus posterior root tears (LMPRTs) result in loss of hoop forces and significant increases in tibiofemoral contact pressures. Preoperative imaging lacks reliability; therefore, holding an appropriate index of suspicion, based on the epidemiology of and risk factors for LMPRT, may reduce the rate of missed diagnoses. Purpose: The primary objectives of this study were to evaluate the incidence of and risk factors for lateral meniscus root lesions in a large series of patients undergoing anterior cruciate ligament (ACL) reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: All patients who underwent primary or revision ACL reconstruction by a single surgeon between January 2011 and April 2018 were considered for study eligibility. From this overall population, all patients who underwent repair of an LMPRT were identified. The epidemiology of LMPRT was defined by the incidence within the study population, stratified by key demographic parameters. Potentially important risk factors for the presence of LMPRT were evaluated in multivariate logistic regression analysis. Results: A total of 3956 patients undergoing ACL reconstruction were included in the study. An LMPRT was identified and repaired in 262 patients (6.6%). Multivariate analyses demonstrated that significant risk factors for LMPRT included a contact sports injury mechanism (7.8% incidence with contact sport mechanism vs 4.5% with noncontact mechanism; odds ratio, 1.69; 95% CI, 1.266-2.285; P < .001) and the presence of a medial meniscal tear (7.9% incidence with medial meniscal tear vs 5.8% without; odds ratio, 1.532; 95% CI, 1.185-1.979; P < .001). Although the incidence of LMPRT in male patients (7.3%) was higher than in females (4.8%), this was not significant in multivariate analysis ( P = .270). Patient age, revision ACL reconstruction, and a preoperative side-to-side laxity difference ≥6 mm were not significant risk factors for LMPRT. Conclusion: The incidence of LMPRT was 6.6% in a large series of patients undergoing ACL reconstruction. Participation in contact sports and the presence of a concomitant medial meniscal tear were demonstrated to be important independent risk factors. Their presence should raise the index of suspicion for this injury pattern.

Background: The capsulo-osseous layer (COL), short lateral ligament, mid–third lateral capsular ligament, lateral capsular ligament, and anterolateral ligament (ALL) are terms that have been used interchangeably to describe what is probably the same structure. This has resulted in confusion regarding the anatomy and function of the anterolateral complex of the knee and its relation to the distal iliotibial band (ITB). Purpose: To characterize the macroscopic anatomy of the anterolateral complex of the knee, in particular the femoral condylar attachment of the distal ITB. We identified a specific and consistent anatomic structure that has not been accurately described previously; it connects the deep surface of the ITB to the condylar area and is distinct from the ALL, COL, and Kaplan fibers. Study Design: Descriptive laboratory study. Methods: Sixteen fresh-frozen human cadaveric knees were used to study the anterolateral complex of the knee. Standardized dissections were performed that included qualitative and quantitative assessments of the anatomy through both anterior (n = 5) and posterior (n = 11) approaches. Results: The femoral condylar attachment of the distal ITB was not reliably identified by anterior dissection but was in all posterior dissections. A distinct anatomic structure, hereafter termed the “condylar strap” (CS), was identified between the femur and the lateral gastrocnemius on one side and the deep surface of the ITB on the other, in all posteriorly dissected specimens. The structure had a mean thickness of 0.88 mm, and its femoral insertion was located between the distal Kaplan fibers and the epicondyle. The proximal femoral attachment of the structure had a mean width of 15.82 mm, and the width of the distal insertion of the structure on the ITB was 13.27 mm. The mean length of the structure was 26.33 mm on its distal border and 21.88 mm on its proximal border. The qualitative evaluation of behavior in internal rotation revealed that this anatomic structure became tensioned and created a tenodesis effect on the ITB. Conclusion: There is a consistent structure that attaches to the deep ITB and the femoral epicondylar area. The orientation of fibers suggests that it may have a role in anterolateral knee stability. Clinical Relevance: This new anatomic description may help surgeons to optimize technical aspects of lateral extra-articular procedures in cases of anterolateral knee laxity.