Quadriceps tendon size does not affect postoperative strength recovery following quadriceps tendon anterior cruciate ligament reconstruction.

OBJECTIVE: The influence of quadriceps tendon (QT) size on postoperative quadriceps strength following QT anterior cruciate ligament reconstruction (ACLR) is unclear. Therefore, this study aimed to determine the relationship between QT morphology and postoperative quadriceps strength recovery following primary ACLR using a QT autograft. METHODS: Patients who underwent primary ACLR using QT autograft from 2014 to 2022 followed by a postoperative isometric strength measurement between 5 and 8 months were retrospectively reviewed. Using preoperative magnetic resonance imaging findings, the anterior-posterior (A-P) thickness, medial-lateral (M-L) width, and cross-sectional area (CSA) of the QT were measured. Postoperative residual CSA of QT was estimated based on the graft-harvest diameter. The quadriceps index (QI) was also calculated, which was determined by dividing the maximum isometric quadriceps torque on the involved side by the maximum quadriceps torque on the uninvolved side. Associations between the QI and QT morphology were assessed. Furthermore, multivariable logistic regression analysis with the addition of sex as a covariate was performed with the addition of each individual measure of QT morphology to determine the association with a QI â€‹≥80%. RESULTS: A total of 84 patients (mean age: 21.9 â€‹± â€‹7.3 years; 46 female) were included. Residual CSA showed a statistically significant positive correlation with the QI (r â€‹= â€‹0.221, p â€‹= â€‹0.043). There were no statistically significant correlations between QI and CSA, A-P thickness, or M-L width. Multivariable logistic analysis adjusting for sex demonstrated that each individual measure of QT morphology was not statistically significantly associated with a QI â€‹≥80%. CONCLUSION: A statistically significant correlation between measures of preoperative QT size and postoperative quadriceps strength were not detected in patients undergoing primary QT autograft ACLR. A smaller residual QT CSA based on QT harvest diameter was weakly associated with decreased quadriceps strength 5-8 months postoperatively, but this association was not independent of sex. Future studies examining the impact of QT morphology on quadriceps strength at longer follow-up intervals are needed. LEVEL OF EVIDENCE: IV.

Nonanatomic femoral tunnel placement increases the risk of subsequent meniscal surgery after ACLR: Part II-Patients without recurrent ACL injury.

PURPOSE: The purpose of this study was to identify risk factors for subsequent meniscal surgery following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients without recurrent ACL injury. METHODS: Patients aged ≥14 years who underwent primary ACLR with minimum 1-year follow-up and without recurrent ACL injury were retrospectively reviewed. Patient demographics and surgical data at the time of ACLR were collected. Postoperative radiographs were used to measure femoral and tibial tunnel position, and posterior tibial slope. Univariate and multivariate analyses were performed to identify risk factors for subsequent meniscal surgery. RESULTS: Of 629 ACLRs that fulfilled the inclusion criteria, subsequent meniscal surgery was performed in 65 [10.3%] patients. Multivariate analysis revealed that medial meniscal repair at the time of ACLR, younger age, anterior femoral tunnel position and distal femoral tunnel position were significantly associated with subsequent meniscal surgery (p < 0.001, p = 0.016, p = 0.015, p = 0.035, respectively). The frequency of femoral tunnel placement >10% outside of the literature-established anatomic position was significantly higher in those who underwent subsequent meniscal surgery compared to those who did not (38.3% vs. 20.3%, p = 0.006). Posterior tibial slope and ACL graft type were not significantly associated with subsequent meniscal surgery. CONCLUSION: Medial meniscal repair at the time of ACLR, younger age and nonanatomic femoral tunnel placement were risk factors for subsequent meniscal surgery in patients without recurrent ACL injury. Femoral tunnel placement <10% outside of the native anatomic position is important to reduce the risk of subsequent meniscal surgery. LEVEL OF EVIDENCE: Level IV.

Comparison of visibility in needle arthroscopy of the ankle according to surgical experience: A cadaveric study.

BACKGROUND: Literature regarding the feasibility of inexperienced surgeons using needle arthroscopy is limited. The present study aimed to clarify the feasibility of performing ankle needle arthroscopy for inexperienced surgeons. METHODS: Diagnostic needle arthroscopy was performed for 10 cadaveric ankles by two surgeons with different levels of experience in ankle arthroscopy (inexperienced and expert surgeons). The visibility of arthroscopy was assessed based on a 15-point checklist and compared between surgeons. In addition, iatrogenic articular cartilage injury created by the inexperienced surgeon was investigated. RESULTS: The number of visible points was significantly larger for the expert surgeon than for the inexperienced surgeon (14.1 ± 1.0 vs. 13.7 ± 1.0, P = 0.035). The location of cartilage injury was greatest on the medial talar dome when viewing from the anteromedial portal at a rate of 30%. CONCLUSION: Ankle needle arthroscopy may be an option for surgeons in the future, however, differences in surgeon experience may impact effective visualization.

Risk of Cephalic Vein Injury During the Creation of an Anterior Portal in Shoulder Arthroscopy.

Background: There is a risk of cephalic vein injury during shoulder arthroscopy. However, limited data regarding its anatomic course are available. Purpose: To analyze the positional relationship and factors affecting the distance between the coracoid tip and cephalic veins. Study design: Case series; Level of evidence, 4. Methods: A total of 80 contrast-enhanced computed tomography images from 80 patients (mean age, 49.6 ± 20.3 years; 61 men) were retrospectively analyzed. The distance between the center of the coracoid tip and the vertical line through the cephalic vein was measured in the axial (D1) and sagittal (D2) planes. The distance between 1 cm lateral to the center of the coracoid tip and the vertical line through the cephalic vein was measured in the sagittal plane (D3). Each distance was compared according to patient sex and laterality. Associations between each distance and the patient's age, height, weight, and body mass index were investigated. Results: The mean D1 was 18.4 ± 7.3 mm in 59 patients. The mean D2 was 23.4 ± 11.6 mm, and it was within 10 mm in 10 patients (12.5%). The mean D3 was 33.7 ± 12.2 mm. There was no significant difference in D1, D2, and D3 according to patient sex or laterality. A positive correlation was observed only between D3 and patient height (r = 0.320; P = .034). Conclusion: The cephalic vein was found to travel a mean of 23.4 mm distal and 33.7 mm distal to 1 cm lateral to the coracoid tip. Therefore, Care should be taken to avoid cephalic vein injury when creating an anterior inferior portal or 5-o'clock portal around these areas.

Near complete quadriceps tendon healing 2 years following harvest in anterior cruciate ligament reconstruction.

PURPOSE: Despite the recent increase in the use of quadriceps tendon (QT) autograft in anterior cruciate ligament reconstruction (ACLR); however, there remains a paucity of literature evaluating the postoperative morphology of the QT. The present study aimed to determine the postoperative morphologic change of the QT at a minimum of 2 years following harvesting during ACLR. METHODS: Patients who underwent ACLR with QT autograft and underwent magnetic resonance imaging (MRI) at a minimum of 2 years following harvesting were retrospectively included in the study. The anterior-to-posterior (A-P) thickness, medial-to-lateral (M-L) width, cross-sectional area (CSA), and signal/noise quotient (SNQ) of the QT were assessed at 5 mm, 15 mm, and 30 mm proximal to the superior pole of the patella on MRI. The CSA was adjusted by the angle between the QT and the plane of the axial cut based on a cosine function (adjusted CSA). The A-P thickness, M-L width, adjusted CSA, and SNQ were compared pre- and postoperatively. In addition, defects or scar tissue formation in the harvest site were investigated on postoperative MRI. RESULTS: Thirty patients were recruited for the study. The mean duration between postoperative MRI and surgery was 2.8 ± 1.1 years. The mean A-P thickness was 10.3% and 11.9% larger postoperatively at 5 mm and 15 mm, respectively. The mean M-L width was 7.3% and 6.5% smaller postoperatively at 5 mm and 15 mm, respectively. There were no significant differences in the adjusted CSA between pre- and post-operative states (275.7 ± 71.6 mm2 vs. 286.7 ± 91.8 mm2, n.s.). There was no significant difference in the postoperative change in the SNQ of the QT at all assessment locations. Defect or scar tissue formation at the harvest site was observed in 4 cases (13.3%), and 5 cases (16.6%), respectively. CONCLUSION: At a minimum of 2 years following QT harvest during ACLR, the QT became slightly thicker and narrower (approximately 11% and 7%, respectively). While the current study demonstrates that QT re-harvesting can be considered due to nearly normalized tendon morphology, future histological and biomechanical studies are required to determine the re-harvesting potential of the QT. LEVEL OF EVIDENCE: IV.

Harvest location has a minimal impact on differences in cross-sectional area of quadriceps tendon in anterior cruciate ligament reconstruction.

PURPOSE: Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon (QT) has been gaining popularity. However, it is unknown how differences in harvest location of the QT affect its thickness and cross-sectional area (CSA). The present study aimed to clarify the differences in thickness and CSA of the QT based on location of tendon harvesting. METHODS: Patients scheduled for, or who underwent, ACL reconstruction were prospectively included in the study. The short-axis images on ultrasound were used to assess the CSA of the QT at 30 and 60 mm proximal to the superior pole of the patella. QT autografts with CSAs greater than or equal to 10 mm of width were included and measured at three different locations, namely the center, medial one-third, and lateral one-third at the widest diameter of the QT. Patients with less than 10-mm width of the QT at 60 mm proximal to the superior pole of the patella were excluded. The thickness and CSA were compared based on the location of tendon harvest. RESULTS: Thirty-seven patients were recruited for the study. The mean thickness and CSA were larger in the center of the QT compared to the lateral one-third at 30 mm proximal to the superior pole of the patella (thickness, 6.7 ± 1.3 mm vs. 5.9 ± 1.3 mm; P = 0.009; CSA, 65.6 ± 11.4 mm2 vs. 58.8 ± 11.9 mm2; P = 0.036). There were no significant differences in thickness and CSA of the QT among the three assessment locations at 60 mm proximal to the superior pole of the patella (n.s.). CONCLUSION: The thickness and CSA of QT was greater in the center compared to the lateral one-third at 30 mm proximal to the QT insertion point. However, the difference in value was clinically non-significant, and therefore, harvest location of the QT autograft may not meaningfully impact intraoperative graft diameter. As a result, surgeons may choose the harvest location without concern for resultant graft diameter as long as the enough length of QT is secured. LEVEL OF EVIDENCE: III.

Comparison of Visibility and Risk of Neurovascular Tissue Injury Between Portals in Needle Arthroscopy of the Anterior Ankle Joint: A Cadaveric Study.

Background: For needle arthroscopy with 0° viewing, the visible range of intra-articular structures and the difference between portals remain unknown, as do the risks for neurovascular tissue at each portal. Purpose: To clarify the visibility and safety of needle arthroscopy. Study Design: Descriptive laboratory study. Methods: Ten cadaveric ankle specimens were used. A needle arthroscope with a 1.9-mm diameter was inserted from 4 portals (anteromedial [AM], anterolateral [AL], medial midline [MM], and anterocentral [AC]). Visibility was assessed using a 15-point ankle arthroscopy checklist. In addition, the ankles were dissected to measure the distance between each portal and neurovascular tissues. The visibility of the ankle joint was compared between portals. Results: The success rate of visibility in the deltoid ligament and the tip of the medial malleolus was 100% from the AM, MM, and AC portals and 10% from the AL portal, with significant differences between the portals (P < .01). The visibility success rates in the origin of the anterior talofibular ligament and the tip of the lateral malleolus were 20% for the AM portal, 90% for the MM and AC portals, and 100% for the AL portal, with significant differences between the portals (P < .01). All other points of the ankle joint were visualized from all the portals with a 100% success rate. The AC portal was in contact with the anterior neurovascular bundle in 4 of the 10 specimens. Conclusion: When needle arthroscopy was performed from the AM or AL portal, the site opposite to the portal in the ankle joint was difficult to visualize. Conversely, most points of the ankle joint could be visualized from the MM and AC portals. Care should be taken when creating an AC portal because of its proximity to the anterior neurovascular bundle. Clinical Relevance: The present study provides information regarding which portal should be selected to perform needle arthroscopy in the ankle joint, which will be beneficial for management of ankle injuries.

Ultrasonographic Assessment of Glenohumeral Joint Stability Immediately After Arthroscopic Bankart-Bristow Procedure.

Background: The changes in glenohumeral joint stability after surgery in a clinical setting are yet unknown. Purpose/Hypothesis: This study aimed to compare the anterior humeral head translation between pre- and postsurgical conditions using ultrasonography. It was hypothesized that ultrasonographic assessment would reveal decreased anterior translation. Study Design: Case series; Level of evidence, 4. Methods: A total of 27 patients (24 male, 3 female; mean age, 24.1 ± 9.7 years) with anterior shoulder instability were studied prospectively. All the patients underwent the arthroscopic Bankart-Bristow procedure under general anesthesia, and ultrasonographic evaluation was performed before and immediately after surgery. The forearm was fixed with an arm positioner in the beach-chair position, and the ultrasonographic transducer was located at the posterior part of the shoulder to visualize the humeral head and glenoid rim at the level of interval between the infraspinatus tendon and teres minor tendon. The upper arm was drawn anteriorly with a 40-N force at 0°, 45°, and 90° of shoulder abduction with neutral rotation. The distance from the posterior edge of the glenoid to that of the humeral head was measured using ultrasonography with and without anterior force. Anterior translation was defined by subtracting the distance with anterior force from the distance without anterior force. Results: The humeral head position was translated posteriorly immediately after surgery in all patients. Anterior translation decreased significantly after surgery at 45° (7.7 ± 4.3 vs 5.8 ± 2.0 mm; P = .031) and 90° (8.9 ± 3.4 vs 6.1 ± 2.2 mm; P < .001) of abduction, whereas there was no difference between pre- and postsurgical translation at 0° of abduction (4.9 ± 2.3 vs 4.0 ± 2.1 mm, P = .089). Conclusion: Ultrasonographic assessment immediately after a Bankart-Bristow procedure showed the humeral head was translated posteriorly relative to the glenoid at 0°, 45°, and 90° of abduction. The surgery also decreased anterior translation in response to an anteriorly directed force at 45° and 90° of abduction.

Ultrasound Assessment of Anterior Humeral Head Translation in Patients With Anterior Shoulder Instability: Correlation With Demographic, Radiographic, and Clinical Data.

Background: Ultrasonography can be used to quantitatively assess anterior humeral head translation (AHHT) at different degrees of shoulder abduction. Risk factors for recurrent shoulder instability have been identified. Hypothesis: It was hypothesized that the number of dislocations or glenoid or humeral bone loss would be associated with more AHHT as measured using ultrasound. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 39 patients who underwent surgery for anterior shoulder instability were prospectively studied. Ultrasound assessment of AHHT was performed immediately after general anesthesia was induced. The upper arm was placed at 0°, 45°, and 90° of abduction, and a 40-N anterior force was applied to the proximal third of the arm. The distance from the posterior edge of the glenoid to that of the humeral head was measured at each abduction angle using ultrasound with and without a 40-N anterior force, and the AHHT was calculated. The differences in translation at each shoulder angle were compared. Additionally, the authors investigated the association between AHHT and demographic, radiographic, and clinical data. Results: Compared with the AHHT at 0° of abduction (5.29 mm), translation was significantly larger at 45° of abduction (8.90 mm; P < .01) and 90° of abduction (9.46 mm; P < .01). The mean translation was significantly larger in female patients than in male patients at all degrees of abduction (P ≤ .036 for all). There was no correlation between AHHT at any abduction angle and number of dislocations, clinical data, or radiographic data (including bone loss). Conclusion: Ultrasound assessment of AHHT showed larger amounts of laxity at 45° and 90° than at 0° of abduction. Anterior glenohumeral laxity was greater in female than male patients. Glenoid or humeral bone loss did not correlate with AHHT, thereby clarifying that bone loss has no direct effect on measurements of capsular laxity in neutral rotation.

Bilateral suprascapular notches are asymmetrically shaped in a third of the Asian population.

PURPOSE: The side-to-side differences within an individual's suprascapular notch (SSN) and the clinical characteristics of an ossified superior transverse scapular ligament are unclear. Therefore, the morphological asymmetry of the SSN was investigated, and the factors associated with the ossification of the superior transverse scapular ligament were analyzed. METHODS: Two hundred and seventy-six computed tomography images were retrospectively analyzed, which included those of both scapulae of Asian patients (mean age, 62.1 ± 19.1 years; males, 197) with high-energy injuries or respiratory diseases. Variations in the SSN were classified into six types based on Rengachary's classification using reconstructed three-dimensional computed tomography. The group with a type VI SSN (completely ossified superior transverse scapular ligament) in at least one scapula was compared with the other group for age, sex, and chronic comorbidities. RESULTS: Among 276 patients, 95 (34.4%) had asymmetric SSNs and 15 (5.4%) had type VI SSNs. There were no significant differences in age, sex, or comorbidities between both the groups. However, on comparing age groups, the prevalence of type VI SSN was higher in patients aged > 70 years than in those aged < 70 years. Fifteen patients had type VI SSNs, which were unilateral in 10 patients. CONCLUSION: Asymmetric SSNs were observed in a third of the Asian patients. There were variations in SSNs between individuals and also within an individual. In the cases with suprascapular nerve paralysis, the difference in SSN morphology compared to a healthy side should be considered. LEVEL OF EVIDENCE: III.