High incidence of complication following tibial tubercle surgery.

OBJECTIVES: Tibial tubercle osteotomy (TTO) is a common procedure that is frequently used in the treatment of recurrent patellar instability and/or patellar chondrosis. Current estimates of TTO complications in the literature vary widely, with complication rates reaching 59 percent. This variability is due, in part, to inconsistent definitions of complication between studies. The purpose of this study was to identify our complication rate following TTO procedures, with sub-analysis of whether the complication rate was affected by: 1. An intra-articular component defined as an additional procedure that altered post-operative rehabilitation and 2. A distalization of the tubercle translation. METHODS: All patients between May 2009 and May 2015 who underwent a TTO were retrospectively identified. Complications were defined as major (fracture of the tibia, deep infection, non-union, delayed union, arthrofibrosis, deep vein thrombosis (DVT) and loss of screw fixation) versus minor (superficial wound infection, disturbance of cutaneous sensation and delay in wound healing). Subgroup analysis of distalization versus no distalization and intra-versus extra-articular concomitant procedures were also analysed. RESULTS: One hundred and sixty-three TTOs in 150 patients were included in the final cohort with a mean follow-up of 21.3 months. The overall complication rate was 35 major complications (21.5%) and 13 minor complications (8.0%), with a total complication rate of 29.5 percent. TTO distalization did not increase the rate of complications. DVT was only seen in the intra-articular procedure cohort (n = 3/1.8%). Arthrofibrosis was the most common complication, occurring in 17 knees. CONCLUSION: The overall complication rate of TTOs was 29.5%, with arthrofibrosis (10.4%) as the largest complication. DVT increased with concomitant intra-articular procedure. Distalization of the tubercle compared to no distalization had no significant effect on complications. LEVEL OF EVIDENCE: Retrospective Cohort study, level III.

No Difference Between Anchorless and Traditional Suture Anchors in Arthroscopic Bankart Repair: A Clinical Comparison.

Background Shoulder instability and recurrent dislocations are common problems encountered by orthopedic surgeons and are frequently associated with a Bankart lesion. These are classically treated with either open or arthroscopic repair utilizing traditional suture anchors, though anchorless fixation techniques have recently been developed as an alternate fixation method that reduces native bone loss and has comparable pull-out strength. Methods A retrospective review was performed at a single institution for patients who underwent Bankart repair from January 2008 through February 2014. American Shoulder and Elbow Surgeons (ASES) questionnaires were mailed to 35 patients with anchorless fixation and 35 age-, gender-, and surgeon-matched patients with traditional suture anchors. Statistical analysis was performed comparing re-dislocation, additional surgery, and ASES scores with statistical significance set at p < 0.05. Results Eleven patients in the anchorless implant group and 15 patients in the anchor group completed the questionnaire. The mean follow-up was 4.1 years in the anchorless group and 5.6 years in the anchor group (p=0.04). The number of implants was 4.82 in the anchorless group and 3.87 in the anchor group (p = 0.04). No difference was found in re-dislocation rates (p = 0.80) or additional surgery on the affected shoulder (p = 0.75). ASES scores were found to have no statistical difference (89.89 for the anchorless group versus 85.37 for the anchor group; p = 0.78). Conclusion In patients undergoing arthroscopic Bankart lesion repair with traditional anchors compared to anchorless fixation, there appears to be no difference in shoulder re-dislocation rates, recurrent ipsilateral shoulder surgery, or ASES scores.

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

Meniscal root tears are soft-tissue and/or osseous injuries characterized by an avulsion of, or tear within 1 cm of, the native meniscal insertion1. These injuries account for 10% to 21% of all meniscal tears, affecting nearly 100,000 patients annually2. Medial meniscal posterior-root tears (MMPRTs) expose the tibiofemoral joint to supraphysiologic contact pressure, decreased contact area, and altered knee kinematics similar to a total meniscectomy3. This injury predisposes the patient to exceedingly high rates of osteoarthritis and total knee arthroplasty secondary to an inability to resist hoop stress4. The arthroscopic transosseous repair of an MMPRT is described in the present article. Description: (1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. Alternatives: If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. Rationale: The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. Expected Outcomes: At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Important Tips: Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

Prospective Outcomes of Cryopreserved Osteochondral Allograft for Patellofemoral Cartilage Defects at Minimum 2-Year Follow-up.

OBJECTIVE: To analyze the clinical outcomes, knee function, and activity level of patients after treatment of full-thickness cartilage defects involving the patellofemoral compartment of the knee with cryopreserved osteochondral allograft. DESIGN: Nineteen patients with cartilage defects involving the patellofemoral compartment were treated. The average age was 31 years (range 15-45 years), including 12 females and 7 males. Patients were prospectively followed using validated clinical outcome measures including Veterans RAND 12-item Health Survey (VR-12), International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner activity scale. Graft incorporation was evaluated by magnetic resonance imaging (MRI) or second-look arthroscopy. RESULTS: The cartilage defects included the patella (n = 16) and the femoral trochlea (n = 3). Mean VR-12 scores increased from 31.6 to 46.3 (P < 0.01), mean IKDC increased from 40.0 to 69.7 (P < 0.01), mean KOOS increased from 53.9 to 80.2 (P < 0.01), and mean Tegner scores increased from 3.0 to 4.9 (P < 0.01), at average follow-up of 41.9 months (range 24-62 months). Of the 3 patients who underwent second-look arthroscopy, all demonstrated a well-incorporated graft. Mean MOCART score for the 6 patients with follow-up MRI was 62.5 (range 25-85). The reoperation rate was 21.1% and 2 patients (12.5%) experienced progressive patellofemoral osteoarthritis requiring conversion to patellofemoral arthroplasty. CONCLUSION: Patients with unipolar cartilage defects involving the patellofemoral compartment of the knee can have positive outcomes at minimum 2-year follow-up after surgical treatment with a cryopreserved osteochondral allograft when concomitant pathology is also addressed, but the reoperation rate is high and bipolar cartilage lesions may increase the failure rate.

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

Reliability of EOS compared to conventional radiographs for evaluation of lower extremity deformity in adult patients.

OBJECTIVE: The purpose of this study was to compare reliability of lower extremity imaging measurements using EOS and conventional X-ray (CR) of adult patients with mechanical axis malalignment. MATERIALS AND METHODS: Ten patients (20 lower limbs) of mean age of 31.6 years (range 21-39) with post-traumatic deformities who presented for evaluation of osteotomies and/or ligament and cartilage reconstructions were prospectively enrolled. Two independent observers performed full-length anterior-posterior (AP) measurements 2 weeks apart on both CXR and two-dimensional (2D) EOS images. Measurements included weight-bearing axis (WBA), varus/valgus angle (V/V), femoral length (FL), tibial length (TL), femoral mechanical axis (FMA), tibial mechanical axis (TMA), and total limb length (TLL). Reliability was determined with random effects modeling of intraclass correlation coefficients (ICC) set to consistency. Three statistical operations were performed to compare interrater validity in CXR and EOS: students' two-sample t test, paired two-sample t test, and Pearson's correlative r-statistical agreement. RESULTS: There was a statistically significant difference for V/V, FL, and TLL (all p < 0.01) between CXR and EOS. A relatively large proportion of the population consistently had larger V/V measures for EOS compared to CXR. In contrast, the FL and TLL measures were consistently larger for CXR compared to EOS. The differences between CXR and EOS measurements were statistically significant, though the small differences in values were not clinically meaningful. Agreement of all measures remained high (r = 0.84-0.99). CONCLUSION: Using 2D EOS for lower extremity measurements is reproducible, reliable, and comparable to the gold standard, standing long leg radiographs.

Epidemiology of Hand and Wrist Injuries in NCAA Men's Football: 2009-2010 to 2013-2014.

BACKGROUND: Participation in National Collegiate Athletic Association (NCAA) football is at an all-time high. This population of athletes experiences a substantial injury burden, with many injuries affecting the upper extremities. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the epidemiology of hand and wrist injuries in college football players from the academic years 2009-2010 to 2013-2014. We hypothesized that variables such as event type (practice vs game), mechanism of injury, and player position would have an effect on the injury incidence. STUDY DESIGN: Descriptive epidemiological study. METHODS: An epidemiological study utilizing the NCAA Injury Surveillance Program was performed to investigate rates and patterns of hand and wrist injuries in participating varsity football teams from 2009-2010 to 2013-2014. RESULTS: A total of 725 hand and wrist injuries were captured in 899,225 athlete-exposures. The observed practice injury rate was 0.51 injuries per 1000 athlete-exposures, compared with a game injury rate of 3.60 (P < .01). Player-on-player contact was the most common injury mechanism reported, with blocking being the most common activity at the time of injury. Offensive linemen were most likely to experience an injury. Of all injuries sustained, 71.4% resulted in no time loss from competition, whereas 9.8% of injuries resulted in longer than 7 days of time loss. A fracture resulted in the greatest time loss from competition (mean ± SD, 8.3 ± 24.0 days; median, 0 days [range, 0-148 days] for injuries sustained in a practice setting) (mean ± SD, 7.7 ± 15.8 days; median, 0 days [range, 0-87 days] for injuries sustained in a game setting). CONCLUSION: Hand and wrist injuries were found to be significantly more common in games when compared with practices. This study provides valuable prognostic data regarding expected time loss on a per-injury pattern basis. Further investigation on specific injury subtypes and expected time loss as a result of these injures would provide trainers, players, and coaches with useful information on an expected postinjury recovery and rehabilitation timeline.

Oral Contraceptive Pills Are Not a Risk Factor for Deep Vein Thrombosis or Pulmonary Embolism After Arthroscopic Shoulder Surgery.

BACKGROUND: Worldwide, more than 100 million women between the ages of 15 and 49 years take oral contraceptive pills (OCPs). OCP use increases the risk of venous thromboembolism (VTE) through its primary drug, ethinylestradiol, which slows liver metabolism, promotes tissue retention, and ultimately favors fibrinolysis inhibition and thrombosis. PURPOSE: To evaluate the effects of OCP use on VTE after arthroscopic shoulder surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A large national payer database (PearlDiver) was queried for patients undergoing arthroscopic shoulder surgery. The incidence of VTE was evaluated in female patients taking OCPs and those not taking OCPs. A matched group was subsequently created to evaluate the incidence of VTE in similar patients with and without OCP use. RESULTS: A total of 57,727 patients underwent arthroscopic shoulder surgery from 2007 to 2016, and 26,365 patients (45.7%) were female. At the time of surgery, 924 female patients (3.5%) were taking OCPs. The incidence of vascular thrombosis was 0.57% (n = 328) after arthroscopic shoulder surgery, and there was no significant difference in the rate of vascular thrombosis in male or female patients (0.57% vs 0.57%, respectively; P > .99). The incidence of VTE in female patients taking and not taking OCPs was 0.22% and 0.57%, respectively (P = .2). In a matched-group analysis, no significant difference existed in VTE incidence between patients with versus without OCP use (0.22% vs 0.56%, respectively; P = .2). On multivariate analysis, hypertension (odds ratio [OR], 2.00; P < .001) and obesity (OR, 1.43; P = .002) were risk factors for VTE. CONCLUSION: OCP use at the time of arthroscopic shoulder surgery is not associated with an increased risk of VTE. Obesity and hypertension are associated with a greater risk for thrombolic events, although the risk remains very low. Our findings suggest that patients taking OCPs should be managed according to the surgeon's standard prophylaxis protocol for arthroscopic shoulder surgery.

Open Reduction, Bone Grafting, and Internal Fixation of Osteochondritis Dissecans Lesion of the Knee.

Osteochondritis dissecans (OCD) of the femoral condyle is an idiopathic focal bone abnormality affecting the subchondral bone and can result in unstable osteochondral lesions. The treatment of unstable OCD lesions with open reduction and internal fixation with metallic compression screws is well documented in the literature. Fixation is performed to prevent dislodgement of unstable OCD lesions or fix displaced fragments that have been surgically reduced. The procedure is performed by approaching the knee through a midline incision and medial parapatellar arthrotomy. The lesion is identified, and a scalpel is used to incise the cartilage circumferentially, leaving 1 side intact, to create a "trap door" flap. The OCD fragment is lifted from the bed, and the bed is prepared by debriding the fibrocartilage scar and bone-grafting the bed. The osteochondral fragment is reduced back to the bed, and guidewires are placed to secure the reduction and plan screw trajectories. Guide pins are overdrilled and Herbert compression screws are placed to secure the OCD fragment. The wound is irrigated and closed. Complications are rare, but later screw removal is typically recommended. Reported outcomes are satisfactory, with an 80% rate of radiographic healing and good-to-excellent patient-reported outcomes.

Osteochondral Allograft Cartilage Transplantation for a Full-Thickness Femoral Condyle Chondral Lesion.

Cartilage lesions of the knee pose a difficult challenge for orthopaedic surgeons. Osteochondral allograft transplantation is an option in the setting of large chondral or osseous defects, or after failure of other treatment options1-3. The use of allograft offers the benefit of utilizing both viable hyaline cartilage and bone4. Fresh allografts are usually transplanted into the femoral condyle, although they can also be used in the patella, tibial plateau, or femoral trochlea1. Research has shown that patients who undergo this procedure for the treatment of focal and diffuse chondral defects have favorable outcomes and satisfaction scores1. The procedure is performed as follows. (1) Preoperative evaluation: patients are evaluated for a cartilage procedure after obtaining history, examination, and imaging (radiographs and magnetic resonance imaging). (2) Approach: a longitudinal parapatellar tendon arthrotomy is performed. (3) Debridement: the lesion is identified, and unstable cartilage is debrided back to stable cartilage. (4) Measure defect: the recipient site depth is measured in 4 positions, as on the face of a clock (12, 3, 6, and 9 o'clock). (5) Template allograft: a sizer is used to template the allograft hemicondyle. (6) Secure and harvest allograft: the allograft is secured in the Osteochondral Allograft Transplantation Surgery (OATS) Workstation (Arthrex) and harvested from cadaver bone. (7) Measure depth: the recipient depth measurements are marked on the allograft. (8) Cut graft: the graft is held with allograft-holding forceps while graft is cut with a saw. (9) Check measurements: allograft measurements are checked to ensure that they match recipient measurements. (10) Round edges: the osseous ends are rounded to assist with insertion of graft. (11) Irrigate: the allograft is irrigated after final cuts. (12) Graft insertion: the graft is inserted after lining up the 12-o'clock position recipient and donor reference marks and is held in place with a press fit. (13) Closure: standard closure in layers is performed.

Femoral Cortical Button Malposition Rates in Anterior Cruciate Ligament Reconstruction: A Retrospective Review.

The purpose of this study was to determine the rate of malposition of the femoral cortical button during anterior cruciate ligament reconstruction and to present a classification system of femoral cortical button positioning that is both accurate and reproducible. A total of 361 patients undergoing primary anterior cruciate ligament reconstruction during a 5-year period were identified, and postoperative button position was graded as follows: reduced and congruent (entirety of button <2 mm from cortex); reduced and incongruent (part of button <2 mm from cortex, part of button >2 mm from cortex); displaced (entirety of button >2 mm from cortex); intraosseous (all or part of button remains within bone); or ungradable. Radiographs were evaluated by 2 orthopedic surgeons at 2 time points to define interrater and intrarater reliability. A total of 312 buttons (86.43%) were reduced and congruent, 18 (4.99%) were reduced and incongruent, 10 (2.77%) were displaced, 13 (3.60%) were intraosseous, and 8 (2.21%) were ungradable based on the available postoperative imaging. There was outstanding interrater reliability, with an overall kappa value of 0.84. Intrarater reliability for raters 1 and 2 was 0.77 and 0.83, respectively, representing excellent intrarater reliability for both observers. Cortical button placement during femoral fixation in anterior cruciate ligament reconstruction is variable. This study presents a classification system for grading femoral cortical button placement that is accurate and reproducible. An organized grading scheme may be useful for future studies of the effect of cortical button malposition on stability and durability of fixation. [Orthopedics. 2019; 42(1):e56-e60.].

High tibial osteotomy with modern PEEK implants is safe and leads to lower hardware removal rates when compared to conventional metal fixation: a multi-center comparison study.

PURPOSE: Various implant materials have been used in medial, opening-wedge high tibial osteotomy (HTO) including traditional metal and modern polyetheretherketone (PEEK) implants. The purpose of this study was to compare metal and PEEK implants and determine safety, varus deformity correction, as well as short- to mid-term hardware removal and arthroplasty rates. METHODS: HTO performed with metal and PEEK implants were reviewed between 2000 and 2015 at two institutions with a minimum of 2 years follow-up. Postoperative complications, radiographic measures, and osteotomy union were compared between groups using Kruskal-Wallis and Fisher's exact testing. Survival free of hardware removal and arthroplasty was compared between groups using Kaplan-Meier testing. Risk factors for HTO conversion to arthroplasty were examined using Cox proportional hazards regression. RESULTS: Ninety-five HTOs were performed in 90 patients (59 M, 31 F) using 50 metal and 45 PEEK implants. Mean follow-up was 4.2 years (range 2.0-16.5). Two metal and two PEEK HTO patients experienced nonunions, resulting in revision HTO at a mean of 1.0 years postoperatively (range 0.4-1.4 years). Both implant groups demonstrated similar, significant improvements in coronal deformity, with mean angulation improving from 6.0° and 5.4° varus preoperatively to 1.1° and 1.0° valgus postoperatively for the metal (p < 0.01) and PEEK groups (p < 0.01), respectively. 2- and 5-year hardware removal-free survival was 94% and 94% for PEEK, which was significantly superior to 80% and 73% observed for metal (p = 0.02). 2- and 5-year arthroplasty-free survival was similar for the metal (98% and 94%) and PEEK groups (100% and 78%) (n.s.). HTO performed for focal cartilage defects was observed to demonstrate decreased arthroplasty risk (HR 0.36, p = 0.03) when compared to HTO performed for osteoarthritis. CONCLUSIONS: Both metal and PEEK implants were found to be effective in obtaining and maintaining coronal varus deformity correction, with 88% overall arthroplasty-free survival at 5 years. Metal fixation demonstrated a higher rate of hardware removal while HTO performed for medial compartment osteoarthritis predicted conversation to arthroplasty. LEVEL OF EVIDENCE: III.

Isolated Medial Patellofemoral Ligament Reconstruction with Semitendinosus Tendon Allograft.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is recommended to surgically stabilize the patella against excessive lateral patellar translation. It is currently the cornerstone of treatment for recurrent lateral patellar instability. The MPFL is often disrupted during acute patellar dislocations but may also be attenuated in the setting of recurrent lateral instability. Numerous techniques have been developed with the primary goal of restoring the static function of the MPFL in resisting lateral translation of the patella during early flexion of the knee. There are now numerous options for the surgical technique, fixation devices, and graft choice, with equal clinical results as long as key surgical principles are maintained1. This article provides a step-by-step description of our preferred technique as well as offering technical pearls and a review of patient outcomes. DESCRIPTION: The MPFL is reconstructed anatomically using a hamstring allograft or autograft with an ideal width of 4 to 5 mm. The graft is secured to the femur with an interference screw at its anatomic insertion point, which can be defined by radiographic or anatomic landmarks, is passed through the soft tissues between the capsule and the medial retinaculum/vastus medialis oblique muscles, and is secured to the superomedial patellar border. ALTERNATIVES: Nonoperative treatment of lateral patellar dislocations is associated with recurrent dislocation rates of 35% to 50%; surgical treatment for recurrent dislocations has afforded improved patient outcomes2,3. In general, there are 3 surgical options to restore the function of the MPFL. Historically, acute repair was thought to offer the MFPL a chance to "heal" and resume its function; however, the literature has failed to support this as a reliable option in the setting of lateral patellar instability4. Similarly, delayed tightening or imbrication of the MPFL in the setting of chronic laxity has not demonstrated worthwhile clinical results5. MPFL reconstruction with a graft, as described here, has provided the most consistent outcomes. RATIONALE: Isolated reconstruction of the MPFL is indicated for patients with a history consistent with recurrent lateral patellar instability and a physical examination demonstrating excessive lateral patellar translation. Patients with high-grade trochlear dysplasia and patella alta may be better treated with concomitant osseous procedures such as trochleoplasty or tibial tubercle osteotomy.

Bacterial Contamination of a Marking Pen in Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A sterile surgical marking pen is commonly used during anterior cruciate ligament reconstruction (ACLR) to outline the proposed skin incision and then to mark the graft during preparation. Once in contact with the skin, the pen is a potential source of bacterial transmission and subsequent infections after ACLR. PURPOSE/HYPOTHESIS: The purpose of this study was to assess whether the skin marking pen is a fomite for contamination during arthroscopic ACLR. We hypothesized that there would be a difference in the rate of culture-positive pens between control pens and the study pens used to delineate the proposed skin incision. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty surgical marking pens were collected prospectively from patients undergoing ACLR over a 12-month period. All patients underwent standard preoperative sterile preparation and draping procedures. Proposed incisions were marked with a new sterile pen, and the pen tip was immediately sent for a 5-day inoculation in broth and agar. Negative controls (unopened new pen) and positive controls (used to mark the skin incisions preoperatively) were also cultured. Additionally, blank culture dishes were observed during the growth process. All pens were removed from the surgical field before incision, and new marking pens were used when needed during the procedure. RESULTS: Three of the 20 study pens (15%) demonstrated positive growth. All 3 pens grew species of Staphylococcus. None of the negative controls demonstrated growth, 6 of the 12 positive controls showed growth, and none of the blank dishes exhibited growth. CONCLUSION: This study found a 15% rate of surgical marking pen contamination by Staphylococcus during ACLR. It is recommended that the skin marking pen not be used for any further steps of the surgical case and be discarded once used. CLINICAL RELEVANCE: Infections after ACLR are rare but may result in significant morbidity, and all measures to reduce them should be pursued. Surgeons performing ACLR should dispose of the surgical marking pen after skin marking and before intraoperative use such as graft markup.

Open Implantation of Autologous Chondrocytes Cultured on Porcine Collagen Membrane for the Treatment of a Full-Thickness Patellar Cartilage Lesion.

Large cartilage defects in the knee are debilitating for patients and challenging for surgeons to treat. Autologous chondrocyte implantation (ACI) has gained popularity over the past 20 years and has become the treatment of choice for large cartilage defects for some surgeons. Termed matrix-applied ACI (MACI), use of autologous chondrocytes cultured on porcine collagen membrane has recently been approved by the U.S. Food and Drug Administration for the treatment of symptomatic full-thickness cartilage defects in the knee. This new technique for cartilage repair is the third generation of chondrocyte implantation technology and the first to involve the use of a scaffolding to grow chondrocytes1. MACI is a simpler technique than previous generations and has more reliable chondrocyte seeding. Research has shown that patients do well postoperatively, with improvements in patient-reported outcome out to 5 years postoperatively3. These improvements are statistically greater for patients who underwent MACI when compared to those who underwent microfracture2. (1) Preoperative evaluation: patients are indicated for a cartilage procedure after magnetic resonance imaging (MRI) and clinical examination. (2) Stage 1: a diagnostic arthroscopy is performed, and chondrocytes are harvested and cultured. (3) Approach: a short vertical incision is made, followed by a medial parapatellar arthrotomy. (4) Debridement: the lesion is identified and debrided back to stable cartilage. (5): Hemostasis: hemostasis is obtained with an epinephrine-soaked sponge. (6) Template creation: foil is used to create a template of the lesion. (7) Cells cutting: with use of the foil, the membrane of cells is cut to the appropriate size and shape. (8) Implantation: the cut membrane is placed on the lesion and secured with fibrin glue. (9) Testing: the knee is taken through a range of motion and the stability of the membrane is confirmed. (10) Closure: standard closure in layers is performed.

MRI and Arthroscopy Correlation in the Patellofemoral Joint.

The patellofemoral joint is an articulation between the patella and the femoral trochlea, which serves to increase the lever arm of the extensor mechanism. The stability of the patella within the trochlear groove is supported statically by the bony confines of the groove itself, as well as the medial patellofemoral ligament, and dynamically by the vastus musculature. Pathologic changes seen on magnetic resonance imaging (MRI) are frequently well correlated with findings found by arthroscopy at the time of surgery. Degenerative changes to the articular cartilage, osteochondral lesions and loose bodies, tears in the retinaculum, and the medial patellofemoral ligament can be seen in MRI and are well correlated with arthroscopy. In addition, other findings that may predispose an individual to injury or degenerative changes over time, such as patella alta and trochlear dysplasia, can also be assessed by MRI and observed arthroscopically.

Patellofemoral Articulating Osteochondral (Kissing) Lesion Treated with Autologous Chondrocyte Implantation: A Case Report.

INTRODUCTION: Autologous chondrocyte implantation (ACI) is an effective treatment for chondral defects of the knee; however, its use in kissing lesions is less well documented. CASE REPORT: A 23-year-old female with a kissing lesion of the patellofemoral compartment on magnetic resonance imaging underwent two-stage ACI to her medial patella (20 mm × 22 mm) and medial trochlea (27 mm × 18 mm). At 1-year follow-up, the patient had returned to all activities with near-complete resolution of symptoms and substantial improvement in clinical outcome scores. CONCLUSION: Patients with kissing lesions of the knee can be treated successfully with ACI performed to multiple sites.

Medial patellofemoral ligament reconstruction: patient selection and perspectives.

Patellofemoral instability is a painful and often recurring disorder with many negative long-term consequences. After a period of failed nonoperative management, surgical intervention has been used to reduce the incidence of patellar subluxation and dislocations. Medial patellofemoral ligament (MPFL) reconstruction successfully addresses patellofemoral instability by restoring the deficient primary medial patellar soft tissue restraint. When planning MPFL reconstruction for instability, it is imperative to consider the patient's unique anatomy including the tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, and patella alta. Additionally, it is important to individualize surgical treatment in the skeletally immature, hypermobile, and athletic populations.

Revisiting Fulkerson's Original Technique for Tibial Tubercle Transfer: Easing Technical Demand and Improving Versatility.

Tibial tubercle osteotomy is a well-described treatment option for a variety of patellofemoral disorders. Many techniques have evolved since its inception, including combinations of anteriorization, medialization, and distalization of the tibial tubercle. Although differing in their indications and end goal destination of the tubercle, these techniques share the challenging technical demands of achieving successful correction based off preoperative planning and prevention of intraoperative complications. We present our technique using osteotomy guide pins in a medial to lateral direction, originally described by Fulkerson in 1982. The advantages of our technique include better visualization for angle of osteotomy confirmation; versatility that provides options for any combination of anteriorization, medialization, or distalization; and the opportunity to maintain a distal cortical hinge if so desired.