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The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.

Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients’ morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) ( P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) ( P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) ( P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 ( P

Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system.A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system.Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%).Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.

Objectives: High tibial osteotomy (HTO) is a well-established procedure for addressing varus deformity of the knee or offloading the medial compartment in cases of medial compartment osteoarthritis. Altering the weightbearing axis of the tibia through HTO may result in unintended changes to the posterior tibial slope (PTS) and thus the sagittal stability of the knee. In 2003, Lobenhoffer described a biplanar “L” shaped HTO with an ascending cut in the coronal plane, leaving the tibial tubercle on the distal side of the osteotomy. Since then, multiple techniques have been described, including an “Inverse L”, leaving the tibial tubercle on the proximal end of the osteotomy. We present a modified “flex” version to the plate fixation used in the “L” and “Inverse L” technique with the goal of minimizing changes in the PTS during HTO. To quantify the effect of osteotomy technique on PTS, “L” (n=5), “Inverse L” (n=5), “L with flex” (n=6), and “Inverse L with flex” (n=6) techniques were performed on cadaveric specimens following medial opening wedge HTO (Figure1). Pre- and post-osteotomy fluoroscopic images were taken and PTS measured to determine whether one technique was more effective at minimizing PTS change after medial HTO. Methods: The tibia from 22 fresh frozen cadaveric male specimen (11 pairs, mean age 46 + 14) were removed of all soft-tissue. Native anteroposterior and lateral radiographs were taken. Three independent observers measured the PTS angle using the circle method. Two 2.4mm Kirschner wires were placed through the medial cortex of the tibia at the metaphyseal-diaphyseal junction aimed towards the tip of the fibular head as a guide for the sagittal cut performed in the posterior four-fifths of the tibia. The oblique osteotomy stopped 10-15mm medial to the lateral tibial cortex and the joint line to avoid fracture. The osteotomy site was then medially opened 10mm. One specimen from each pair was randomized to receive the “L” shaped ascending HTO with the contralateral limb receiving the “Inverse L” shaped descending HTO. Vertical cuts on the coronal plane extending 3-4cm (proximally for the “L” and distally for “Inverse L”) were completed. 6 specimens from each group were subsequently fixed proximally with an anteriorly angled plate (15 degrees) which was forced posteriorly and fixed to the shaft (Figure 2). This plate “flex” technique was applied to purposefully correct PTS. All osteotomies were fixed using a standard locking AO Tomofix plate with 3 proximal screws and 4 distal screws. Pre- and post-HTO proximal tibia plateau orientations were collected using eight OptiTrack motion capture cameras as an adjunct to tibial slope measures completed through radiographic analysis. Three rigid body marker triads were used: distally along the anterior midline of tibia, medial superior articular surface, and the fixture frame. Post-HTO, the independent observers again measured PTS with the circle method. Change in tibial slope data was averaged among radiograph reviewers and compared to motion capture data. A one-way ANOVA statistical analysis was completed. Results: PTS as measured by reviewers before and after HTO using the “circle method” and the motion capture analysis of the change in orientation of the tibial plateau are reported in Table 1. For all specimens, the posterior tibial slope decreased by 1.77 degrees (+/- 3.2). There was no statistically significant difference in change of tibial slope amongst all techniques, measured by lateral radiographs or motion capture analysis. Conclusions: There was no statistical difference in the change in posterior tibial slope across treatment types. Reviewer calculations of tibial slope using the circle technique was not different from measures observed through high resolution motion capture. No difference in the change in PTS may allow surgeons to select the technique that they feel most comfortable using on their patient with less concern of causing changes in the PTS and sagittal instability during an HTO. Additionally, this may allow for versatility in the event that patient anatomical characteristics interfere or impede the use of a specific technique. Future studies incorporating pre- and post-CT data to quantify hinge fracture and further characterize slope are underway. [Figure: see text][Figure: see text][Table: see text]