Virtual range of motion is a safe and acceptable alternative to intra-operative manual range of motion testing in direct anterior robotic total hip arthroplasty.

Introduction: In robotic total hip arthroplasty (THA), virtual range of motion (VROM) modeling allows the surgeon to account for spinopelvic motion and create an impingement-free range of motion that is patient-specific. The primary purpose of this study was to evaluate the risk of dislocation in patients undergoing direct anterior THA using VROM rather than manual ROM trialing. Methods: Prospectively collected data was reviewed retrospectively of all consecutive anterior THAs performed by a single fellowship-trained surgeon. No patients were excluded from the study. VROM identified bone and implant impingement, which was recorded in degrees of hip external rotation(ER) at 0° of hip extension (standing), and in degrees of hip internal rotation(IR) at 90° of hip flexion (sitting). No patients had manual ROM trialing performed. Dislocation events were recorded during the first 3 months of follow-up. 362 patients, with a mean age of 67 and mean BMI of 28.8, were included. Results: This cohort, including 154 patients (42.5%) with abnormal spinopelvic motion, demonstrated zero dislocations using VROM. The average ER impingement occurred at 60.9° ER (range 20-90°), and 50.8° IR (range 25-90°). Patients with ER impingement <55° had significantly less acetabular anteversion (16.4° ±3.3°, p < 0.001). Compared to the entire cohort, anteversion of the acetabulum was also decreased in the stuck-sitting subgroup (17.4° ±3.3°, p < 0.001) and increased in the stuck standing subgroup (20.5° ±3.6°, p < 0.001). ER impingement was a stronger predictor of acetabular anteversion than spinopelvic motion category (r = 0.458). Patients with ER impingement <45° (6.4%) or IR impingement <35° (6.6%) were "early impingers". Conclusion: In this cohort of anterior THA patients with a high proportion of abnormal spinopelvic motion, a technique utilizing only VROM produced no dislocations. An impingement-free zone of 45° ER standing and 35° IR sitting is recommended.

Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

Heterotopic Ossification Following Direct Anterior Total Hip Arthroplasty With and Without Postoperative Analgesic Nonsteroidal Anti-inflammatories.

BACKGROUND: Heterotopic ossification (HO) can result in poorer clinical outcomes following total hip arthroplasty (THA). Multiple modes of intervention have been evaluated for HO prevention, including the use of nonsteroidal anti-inflammatories. Additionally, multimodal pain management strategies including celecoxib have become more prominent. Therefore, this study aims to evaluate the influence of celecoxib as part of postoperative analgesia on the risk of developing HO following the direct anterior approach (DA) for THA. METHODS: A retrospective query identified primary DA THAs performed by a single surgeon between 2013 and 2020. Patients were grouped according to those who received 3 weeks celecoxib upon discharge, and those who did not. Radiographs were used to categorize patients according to the Brooker classification system for HO. Preoperative and 2-week, 6-week, 3-month, and 1-year postoperative X-rays were evaluated. RESULTS: A total of 688 DA THAs were included, demonstrating a 9.6% (n = 66) incidence of HO with Brooker classification: 1: 5.7% (n = 39); 2: 2.6% (n = 18); 3: 1.2% (n = 8); and 4: 0.1% (n = 1). Patients who did not receive celecoxib had a 14.3% (52/364) rate of HO following THA (odds ratio 4.53, P < .001) vs only 4.3% (14/324) in the celecoxib group (odds ratio 0.22, P < .001). Overall, 9 patients (1.3%) went on to develop significant HO (Booker 3 or greater): 8 (2.2%) in the control group and 1 (0.3%) in the celecoxib group (P < .001). CONCLUSION: Our findings suggest a significant reduction in the formation of HO following DA THA when using postoperative analgesic celecoxib as part of a multimodal pain protocol. Future prospective randomized studies are needed to identify ideal dosage, duration, and formulation to reduce the risk of HO while optimizing multimodal pain management.

Erratum to: Clinical Results and Failure Mechanisms of a Nonmodular Constrained Knee Without Stem Extensions.

[This corrects the article DOI: 10.1007/s11420-012-9277-9.].

Lower limb alignment control: is it more challenging in lateral compared to medial unicondylar knee arthroplasty?

INTRODUCTION: Limb alignment after unicondylar knee arthroplasty (UKA) has a significant impact on outcomes. The literature lacks lateral UKA alignment studies, making our understanding of this issue based on medial UKA. METHODS: We evaluated limb alignment in 241 patients who underwent medial (229 knees) or lateral (37 knees) UKA. Alignment was measured pre and postoperatively in radiographs and intra-operatively using a navigation system. We compared the percentage of over-correction and the difference between post-operative alignment and navigation measurement. RESULTS: Percentage of overcorrection was significantly higher in the lateral UKAs (11%) compared to the medial UKAs (4%). In medial UKAs, the mean difference between the intraoperative alignment and the post-operative was 1.33°. This was significantly lower than the mean 1.86° difference in the lateral UKAs. CONCLUSIONS: Our data demonstrated an increased risk of "overcorrection," and greater difficulty in predicting postoperative alignment using computer navigation, when performing lateral UKAs compared to medial UKAs.

Cruciate-retaining TKA is an option in patients with prior patellectomy.

BACKGROUND: The recommendation for using posterior-stabilized (PS) implants in patellectomy patients undergoing total knee arthroplasty (TKA) is based on older case series with heterogeneous patient populations. The use of cruciate-retaining implants in these patients has not been evaluated with more contemporary implant designs. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the survivorship and functional outcomes (Knee Society score, presence of an extensor lag, and range of motion) of cruciate-retaining (CR) TKA in patients with prior patellectomy. METHODS: Between 1986 and 2012, we performed 27 CR TKAs in 25 patients after patellectomy. Of those, 23 CR TKAs in 21 patients were available for followup at a minimum of 2 years (mean, 11.2 years; range, 2.3-25.1 years). In this retrospective study, we queried a prospectively maintained database to assess functional outcomes and survivorship. RESULTS: Aseptic loosening-free survival was 100% at 5 and 10 years, and survival with revision for any reason as the outcome was 96% at 5 years (95% confidence interval [CI], 87.7%-100%) and 84% at 10 years (95% CI, 69.5%-100%). One patient was revised for aseptic loosening at 10.2 years postoperatively. Mean Knee Society scores improved from 36±13 preoperatively to 92±9.6 at followup. Extensor lag was present in seven patients preoperatively and only three at followup. Average knee flexion at followup was 112°±12.5°. CONCLUSIONS: In this study we found good long-term survivorship and functional outcomes with a CR implant design in patients following patellectomy. Earlier studies have favored PS over CR implants for patients with patellectomies. We believe this series suggests that CR TKA is indeed an option in patients with patellectomy. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection.

Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

BACKGROUND: Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic. QUESTIONS/PURPOSES: We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. METHODS: Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. RESULTS: The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups. CONCLUSIONS: A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Accelerometer-based, portable navigation vs imageless, large-console computer-assisted navigation in total knee arthroplasty: a comparison of radiographic results.

Computer-assisted surgery (CAS) systems improve alignment accuracy in total knee arthroplasty (TKA) but have not been widely implemented. Eighty knees underwent TKA using an accelerometer-based, portable navigation device (KneeAlign 2; OrthAlign Inc, Aliso Viejo, California), and the radiographic results were compared with 80 knees performed using a large-console, imageless CAS system (AchieveCAS; Smith and Nephew, Memphis, Tennessee). In the KneeAlign 2 cohort, 92.5% of patients had an alignment within 3° of a neutral mechanical axis (vs 86.3% with AchieveCAS, P < .01), 96.2% had a tibial component alignment within 2° of perpendicular to tibial mechanical axis (vs 97.5% with AchieveCAS, P = .8), and 94.9% had a femoral component alignment within 2° of perpendicular to the femoral mechanical axis (vs 92.5% with AchieveCAS, P < .01). The mean tourniquet time in the KneeAlign 2 cohort was 48.1 ± 10.2 minutes vs 54.1 ± 10.5 minutes in the AchieveCAS cohort (P < .01). Accelerometer-based, portable navigation is as accurate as large-console, imageless CAS systems in TKA.

Plasma 25-hydroxyvitamin d levels in operative patella fractures.

BACKGROUND: Patella fractures have not traditionally been considered "fragility" fractures. QUESTIONS/PURPOSE: The purpose of this study was to examine the demographic patterns (age and gender distribution) and plasma 25-hydroxyvitamin D levels of a cohort of patients with operative patella fractures. PATIENTS AND METHODS: Medical records were reviewed on all consecutive patients presenting to our institution with operative patella fractures from 2003 to 2009. Seventy-eight operative patella fractures (25 male, 53 female) were identified with a mean age of 58 years (range, 22-89 years). RESULTS: The majority of patients with patella fractures in this series were females over the age of 50 years who sustained low-energy falls from a standing height or less. Twenty-four patients (80%) had vitamin D insufficiency or deficiency at the time of injury. For 68 patients (87%), the patella fracture represented their first fracture. Patients with known osteoporosis risk factors did not have higher rates of vitamin D insufficiency/deficiency. CONCLUSIONS: The age and gender distribution, as well as the prevalence of vitamin D insufficiency/deficiency, of operative patella fractures, suggest that these patients likely have abnormal vitamin D levels and should undergo a metabolic bone work-up.

Treatment of Lisfranc fracture-dislocations with primary partial arthrodesis.

BACKGROUND: The optimal method of treatment for Lisfranc fracture-dislocations remains controversial, and the role of primary partial arthrodesis for combined osseous-ligamentous Lisfranc injuries is unclear. This study reviewed the outcomes of Lisfranc injuries treated by primary partial arthrodesis. METHODS: Patients who underwent primary partial arthrodesis for a primarily ligamentous or combined osseous and ligamentous Lisfranc fracture-dislocation were reviewed retrospectively and assessed at followup according to radiographic, clinical and standardized patient-based outcomes. Twenty-five patients (12 ligamentous, 13 combined), median age of 46 (range, 20 to 73) years, were followed for an average of 42 (range, 24 to 96) months. RESULTS: The average American Orthopedic Foot and Ankle Society (AOFAS) score was 81 points (scale 0 to 100), with patients in general losing points for mild pain, limitations of recreational activities, and fashionable footwear requirements. There was no statistical difference between ligamentous and combined injuries with regard to the physical or mental component scores on the SF-36. At latest followup, patients reported an average return to 85% of their preinjury activity level (range, 50% to 100%). Twenty-one patients (84%) expressed satisfaction with their outcome and at latest followup, the mean visual analog pain scale (VAS) score was 1.8 out of 10 (range, 0 to 8). Three patients showed radiographic signs of post-traumatic arthritis of adjacent joints. CONCLUSION: Treatment of both primarily ligamentous and combined osseous and ligamentous lisfranc injuries with primary partial arthrodesis produced good clinical and patient-based outcomes.

Surgical decision making for arthroscopic partial meniscectomy in patients aged over 40 years.

PURPOSE: To identify clinical variables that affect a surgeon's decision to recommend arthroscopic partial meniscectomy (APM). METHODS: Members of 2 orthopaedic specialty societies were invited to participate in an online survey by e-mail. The survey consisted of surgeon demographics and case scenarios to evaluate clinical decision making for APM. Posterior probabilities were calculated to determine the effect of clinical factors on the likelihood of recommending APM. RESULTS: Of the respondents with valid e-mail addresses, 733 (19.3%) returned a completed survey, but only 533 (14.1%) met the eligibility criteria (treated or referred an APM candidate within the past year). Respondents were aged 46.7 ± 9.4 and had performed a mean of 115 APMs in the previous year. Posterior probabilities for a combination of 6 clinical indicators identified 3 factors that most influenced a surgeon's decision to recommend APM: radiographic findings, McMurray test, and failure of nonoperative management. CONCLUSIONS: Significant variation exists among practicing orthopaedic surgeons with regard to decision making for APM. The 3 clinical factors that most influenced a surgeon's decision to recommend APM were normal radiographic findings, failed nonoperative treatment, and the presence of positive physical examination findings (i.e., positive McMurray test, joint line tenderness, and effusion). LEVEL OF EVIDENCE: Level III, decision analysis.

Popliteal venotomy during posterior cruciate ligament reconstruction in the setting of a popliteal artery bypass graft.

Injury to the vascular structures in the popliteal fossa during arthroscopic cruciate ligament reconstruction can be limb threatening or even life threatening. We present the first report, to our knowledge, of an isolated injury to a popliteal vein during arthroscopic posterior cruciate ligament reconstruction. Unfortunately, the venotomy led to cardiopulmonary arrest and flash pulmonary edema in this patient. Preoperative planning is paramount to assess risk of injury to vascular structures, which may be increased in patients who have had prior procedures on the affected knee. Furthermore, vascular surgery consultation preoperatively after a magnetic resonance angiogram or venogram and avoiding the use of epinephrine in the arthroscopy fluid should be considered when performing these higher-risk procedures.

Revision ACL reconstruction in skeletally mature athletes younger than 18 years.

BACKGROUND: Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction. QUESTIONS/PURPOSES: We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels. PATIENTS AND METHODS: We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months). RESULTS: At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure. CONCLUSIONS: Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical results and failure mechanisms of a nonmodular constrained knee without stem extensions.

INTRODUCTION: In the setting of persistent knee instability despite appropriate ligament balancing for primary total knee arthroplasty, most surgeons advocate the use of an implant with increased articular constraint. These implants are commonly supplemented with stem extensions to improve stress transfer and decrease the risk of aseptic loosening. However, disadvantages exist with the use of stem extensions, including increased cost, intramedullary invasion, and diaphyseal pain. The objectives of this study were to (1) compare the clinical results as assessed by the Knee Society, Hospital for Special Surgery, and SF-12 scores, (2) determine the incidence of failure as defined by the need for a revision procedure, and (3) to analyze the causes or modes of failure of a nonmodular constrained condylar knee without the use of stem extensions versus a conventional, posterior-stabilized design. MATERIALS AND METHODS: From 2002 to 2007, 190 TKAs were implanted using a primary, nonmodular constrained (NMC) prosthesis without stem extensions. During the same time period, clinical data were available for 140 TKAs implanted using a standard, posterior-stabilized (PS) design. Preoperative demographic data was reviewed, in addition to the rate and reason for revision in each cohort. Clinical data included HSS, Knee Society, and SF-12 scores at the latest follow-up, and the results of the NMC and PS cohorts were statistically compared using a Student's two-tailed t test. RESULTS: The mean age of patients in the NMC cohort was 72.3 ± 10.2 years, and the mean length of follow-up was 7.3 ± 2.1 years. The mean age of the PS cohort was 67.1 ± 8.7 years, with a mean follow-up of 6.1 ± 2.2 years. No statistically significant differences in the HSS, Knee Society, or SF-12 scores were appreciated between the two cohorts. The revision rate in the NMC cohort was 4.2 % compared to 4.3 % for the PS cohort. The most common cause of failure in the NMC cohort was femoral component loosening, all of which occurred when Palacos cement was used for fixation. NMC components (55.6 %) implanted with Palacos cement failed due to femoral component loosening. In contrast, all PS components requiring revision were revised for persistent instability. DISCUSSION: At mid-term follow-up, NMC prostheses without stem extensions have excellent clinical results and are a viable option for patients with ligamentous instability. The use of Palacos cement in this scenario was associated with a high rate of femoral component loosening, possibly due to the decreased intrusion depth of Palacos when compared to Simplex cement.

An analysis of the hip and knee reconstruction section of the orthopaedic in-training examination.

This article analyzes the hip and knee reconstruction section of the Orthopaedic In-Training Examination (OITE). All of the hip and knee reconstruction questions from 2005 to 2009 were analyzed, and the following data were recorded: number of questions per year in the hip and knee section, total number of questions on the OITE per year, national average score by year in training, references cited, taxonomy classification of each question, topics that were tested, imaging modalities used for a given question, and treatment modalities tested. Eight percent to 9% of the questions on the OITE each year were hip and knee reconstruction-related questions. Performance improved with each year in training, but not by a statistically significant amount. The most commonly tested topics over the past 5 years were anatomy and physiology, ligament and/or gap balancing during total knee arthroplasty (TKA), surgical approaches, properties of polyethylene, periprosthetic fractures about an arthroplasty, and questions dealing with the mechanical properties of implants. In 4 out of 5 years, the majority of questions were classified as Taxonomy 1 (knowledge and recall). The bulk of the questions each year did not require the examinee to interpret a radiograph or make a treatment decision. The most common references cited were from Journal of Bone and Joint Surgery (American), followed by the Journal of Arthroplasty. This detailed analysis of the hip and knee reconstruction section of the OITE should improve resident performance, and may serve as a study tool for the OITE.

Radiographic analysis of a hand-held surgical navigation system for tibial resection in total knee arthroplasty.

Tibial intramedullary or extramedullary alignment guides have not been shown to be highly accurate in performing the tibial resection in total knee arthroplasty (TKA). Since May 2010, a total of 42 knees underwent a TKA using a hand-held, accelerometer-based surgical navigation system for performing the tibial resection (KneeAlign; OrthAlign Inc, Aliso Viejo, Calif). Postoperative standing anteroposterior hip-to-ankle and lateral knee-to-ankle radiographs demonstrated that 97.6% of the tibial components were placed within 90° ± 2° to the mechanical axis in the coronal plane, and 96.2% of the components were placed within 3° ± 2° to the mechanical axis in the sagittal plane. The KneeAlign greatly improves the accuracy of tibial component alignment in TKA.

Anomalous external jugular vein: clinical concerns in treating clavicle fractures.

Operative treatment of clavicle fractures has seen growing acceptance, as evidence emerges to support its use over nonoperative management. Of particular popularity, more recently, is the percutaneous intramedullary techniques for fixation of these injuries. The complex neurovascular anatomy in close proximity to the clavicle requires precision with these procedures. Anatomic variations in this region pose an even greater, and often unforeseen, danger to the operating surgeon and patient. Here, we present a case report of an anomalous external jugular vein coursing anterior to the clavicle that was encountered during an open surgical approach to a clavicle fracture. The purpose of this case presentation is to serve as a caution to surgeons treating clavicle fractures by both open and percutaneous means. Inadvertent injury to anomalous neurovascular structures can be devastating to the patient and can be avoided by the careful surgical approaches recommended.

Outcomes of posterior cruciate ligament treatment: a review of the evidence.

OBJECTIVES: The purpose of this systematic review is to assess the current recommendations in an evidence-based manner with regard to posterior cruciate ligament (PCL) reconstruction. METHODS: We conducted a systematic review of multiple databases, evaluating studies on the outcomes of PCL treatment in isolation and in the multiligamentous injured knee. RESULTS: Twenty-one studies of isolated PCL reconstructions and 10 studies of combined PCL reconstruction were identified for inclusion. Eight studies reported graft failure as an outcome, with an overall rate of 11.6%. Three studies reported outcomes of single bundle PCL reconstruction using hamstring autograft; there were 12 graft failures in 96 reconstructions (12.5%). There were 2 graft failures in a total of 17 combined PCL/anterior cruciate ligament/posterolateral corner reconstructions (11.8%). In the combined PCL studies, return to preinjury activity level ranged from 19 to 68%. In the isolated PCL studies, 50 to 82% of patients were able to return to preinjury activity level. There were no significant differences in functional outcomes (Lysholm and IKDC). From 37% to 70% of patients in the combined PCL studies had a normal posterior drawer test at final follow-up. One study showed a significant difference in the mean posterior drawer test side-to-side difference between the 7-strand and 4-strand hamstring autograft groups (1.7 vs. 3.7 mm, P<0.05). CONCLUSIONS: Currently, firm recommendations on what treatment or technique to choose cannot be given based upon the available literature. There is a need for higher-quality clinical studies to guide treatment decisions. Generally good results are reported after PCL reconstruction, but the long-term studies available suggest that normal stability in the majority of patients is not restored.

Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes.

Tear of the anterior cruciate ligament (ACL) is the most common ligamentous injury of the knee. Reconstructing this ligament is often required to restore functional stability of the knee. Many graft options are available for ACL reconstruction, including different autograft and allograft tissues. Autografts include bone-patellar tendon-bone composites (PT), combined semitendinosus and gracilis hamstring tendons (HT), and quadriceps tendon. Allograft options include the same types of tendons harvested from donors, in addition to Achilles and tibialis tendons. Tissue-engineered anterior cruciate grafts are not yet available for clinical use, but may become a feasible alternative in the future. The purpose of this systematic review is to assess whether one of the popular grafts (PT and HT) is preferable for reconstructing the ACL. For this objective, the authors selected only true level I studies that compared these graft choices in functional clinical outcomes, failure rates, and other objective parameters following reconstruction of the ACL. In addition, this review discusses mechanical considerations related to different allograft tissues.