High rates of donor site healing using quadriceps tendon for anterior cruciate ligament reconstruction: A case series.

Purpose: To investigate the healing of the quadriceps tendon donor site after partial thickness graft harvesting through ultrasound imaging at a short-term follow-up of 6-month following anterior cruciate ligament reconstruction (ACLR) and to investigate the clinical outcomes. Methods: Between March 2019 and August 2020, 61 knees were retrospectively included in this study. Intraoperatively, the length, width and thickness of the harvested QT graft were measured. At a 6-month follow-up, patients were assessed by one of five radiologists, following the same protocol to calculate the defect volume, and patients performed a self-evaluation of pain on the Visual Analogue Scale, International Knee Documentation Committee (IKDC) and the Knee injury and Osteoarthritis Outcome Scores (KOOS). Results: Intraoperatively, the QT grafts had a volume of 4635.4 ± 912.5 mm3. Postoperatively, ultrasound was performed at 6.5 ± 0.7 months, and the defect volume was 323.3 ± 389.2 mm3, representing a healing rate of 93% ± 9% of the donor site. At a minimum 6-month follow-up, IKDC was 61.6 ± 16 and KOOS was 70.2 ± 16.6. Age was significantly associated with the healing rate (ß: -0.005; p = 0.032). Conclusion: At 6 months follow-up, the defect size of the QT donor site had healed by 93 ± 9% leaving a mean defect volume of 323.3 mm3 according to ultrasound measurements. This suggests that the QT has a high capacity for healing after graft harvesting, with 10 patients reaching full defect closure 6 months after surgery. The clinical relevance of these findings is that the quadriceps tendon donor site has high rates of healing, but surgeons should be aware of lower healing rates in older patients. Level of Evidence: Level IV, retrospective case series.

A review of Marcel Lemaire's original work on lateral extra-articular tenodesis.

This classic discusses Marcel Lemaire's original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament's role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire's procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire's fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the "modified Lemaire technique" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

Does an early post traumatic knee brace reduce the incidence of knee rotational instability?

PURPOSE: Several anterolateral stabilization procedures have been developed recently to address rotational instability of the knee. Currently, these procedures tend to be systematically used by some practitioners. However, antero-lateral structures of the knee (including the anterolateral ligament, ALL) have a self-healing potential which can reduce the need to perform an antero-lateral procedure. In this study, it was hypothesized that early post-traumatic immobilization of the knee with a knee brace would allow partial healing of antero-lateral structures and also allow control of the pivot shift, thus avoiding antero-lateral extra-articular stabilization. The objective of this study was to compare the severity of pivot shift between two groups of patients who all experienced anterior cruciate ligament (ACL) tear and respectively underwent post-traumatic immobilization of the knee versus no immobilization. METHODS: This was a comparative, multicentric (three centers' study) retrospective, consecutive study including 168 patients who underwent ACL reconstruction between May and September 2022. The application or not of post-traumatic immobilization and its duration, the severity of pivot shift observed in the operating room under general anesthesia, the presence of anterolateral lesions as revealed by MRI and the patients' pre-injury sport activity were recorded. RESULTS: A grade 3 pivot shift was found in 44 patients (27%). It was more frequently observed in the group without a brace compared to the group with a knee brace (18 patients out of 36: 50% versus 26 patients out of 132: 19.7%; p = 0.0012). Wearing a brace, whether hinged (OR = 0.221, [0.070-0.652]; p = 0.006) or not (OR = 0.232, [0.076-0.667]; p = 0.0064), was protective from the risk of developing a significant pivot shift. CONCLUSION: This study demonstrated that the presence of pivot-shift was lower in the patients that had an early post-injury knee brace before their ACL reconstruction. Based on this result, systematic brace placement could be advocated for in patients after knee trauma. LEVEL OF EVIDENCE: III, prognostic retrospective case-control study.

Evaluation of the impact of large language learning models on articles submitted to Orthopaedics & Traumatology: Surgery & Research (OTSR): A significant increase in the use of artificial intelligence in 2023.

INTRODUCTION: There has been an unprecedented rise is the use of artificial intelligence (AI) amongst medical fields. Recently, a dialogue agent called ChatGPT (Generative Pre-trained Transformer) has grown in popularity through its use of large language models (LLM) to clearly and precisely generate text on demand. However, the impact of AI on the creation of scientific articles is remains unknown. A retrospective study was carried out with the aim of answering the following questions: identify the presence of text generated by LLM before and after the increased usage of ChatGPT in articles submitted in OTSR; determine if the type of article, the year of submission, and the country of origin, influenced the proportion of text generated, at least in part by AI. MATERIAL AND METHODS: A total of 390 English articles were submitted to OTSR in January, February and March 2022 (n=204) and over the same months of 2023 (n=186) were analyzed. All articles were analyzed using the ZeroGPT tool, which provides an assumed rate of AI use expressed as a percentage. A comparison of the average rate of AI use was carried out between the articles submitted in 2022 and 2023. This comparison was repeated keeping only the articles with the highest percentage of suspected AI use (greater than 10 and 20%). A secondary analysis was carried out to identify risk factors for AI use. RESULTS: The average percentage of suspected LLM use in the entire cohort was 11%±6, with 160 articles (41.0%) having a suspected AI rate greater than 10% and 61 (15.6%) with an assumed AI rate greater than 20%. A comparison between articles submitted in 2022 and 2023 revealed a significant increase in the use of these tools after the launch of ChatGPT 3.5 (9.4% in 2022 and 12.6% in 2023 [p=0.004]). The number of articles with suspected AI rates of greater than 10 and 20% were significantly higher in 2023: >10%: 71 articles (34.8%) versus 89 articles (47.8%) (p=0.008) and >20%: 21 articles (10.3%) versus 40 articles (21.5%) (p=0.002). A risk factor analysis for LLLM use, demonstrated that authors of Asian geographic origin, and the submission year 2023 were associated with a higher rate of suspected AI use. An AI rate >20% was associated to Asian geographical origin with an odds ratio of 1.79 (95% CI: 1.03-3.11) (p=0.029), while the year of submission being 2023 had an odds ratio of 1.7 (95% CI: 1.1-2.5) (p=0.02). CONCLUSION: This study highlights a significant increase in the use of LLM in the writing of articles submitted to the OTSR journal after the launch of ChatGPT 3.5. The increasing use of these models raises questions about originality and plagiarism in scientific research. AI offers creative opportunities but also raises ethical and methodological challenges. LEVEL OF EVIDENCE: III; case control study.

ACL Reconstruction With Quadrupled ST Graft and Mini-Invasive Anterolateral Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction with hamstring graft is the most common procedure around the world. More recently, the use of the semitendinosus (ST), in a quadrupled arrangement, has been described with great results. Having a thicker tendon instead of double gracilis, ST offers a graft with a diameter superior to 8 mm, thus more closely resembling the native ACL and decreasing the risk of graft failure. It has also been published that preservation of the ACL stump was paramount to obtain better graft vascularization and proprioception. In addition, reconstructing the anterolateral ligament is associated with better results. The aim of this technical note is to present an ACL reconstruction technique using a quadrupled ST graft with a double suspensory fixation associated with ACL stump preservation and a mini-invasive anterolateral ligament reconstruction.

Tibial component rotation alters soft tissue balance in a cruciate retaining total knee arthroplasty.

Our aim was to understand whether using different landmarks for tibial component rotation influenced articular contact pressures in a balanced total knee arthroplasty (TKA). Twelve patients underwent TKA (Triathlon CR, Stryker Inc., Mahwah, NJ) and contact pressures were assessed using a wireless sensor. Robotic arm assisted TKA using a functional alignment technique was performed, with balanced gaps between medial and lateral compartments. Compartment pressures were measured with the trial tibial component rotated to Akagi's line and to Insall's axis respectively. Rotating the tibial component to Akagi's line resulted in a significantly greater proportion of knees being balanced and lower contact pressures than when the tibial component was rotated to Insall's axis at 10°, 45° and 90° of flexion (p < 0.05). Medial compartment pressures were significantly increased in 10° of flexion, as were lateral compartment pressures in all positions when the tibial component was aligned to Insall's axis (p < 0.05). The mean difference in rotation observed with the two landmarks was 6.9° (range 4.1-9.1°). Rotational alignment of the tibial component using Akagi's line reduced contact pressures, improved balance and reduced the need for soft tissue release when compared with Insall's axis in robotic arm assisted TKA.

The crevice sign: a new indicator of meniscal instability in ACL reconstructions.

PURPOSE: Meniscus preservation is key in knee surgery. The newly documented crevice sign indicates instability of the medial meniscus in ACL-deficient knees. Once the sign is visualised, it is imperative that the stability of the medial meniscus is assessed and potentially treated. It was hypothesized that there would be a strong correlation between the presence of an unstable medial meniscal tear in patients with the crevice sign in ACL-deficient knees. METHODS: This was a multicenter prospective study carried out to evaluate the incidence of medial meniscal tears in patients with ACL-deficient knees and their correlation with a crevice sign. All patients (128) who had undergone ACL reconstruction between May 2020 and November 2020 were assessed arthroscopically for meniscal stability and divided in to two groups: stable (n = 84) and unstable (n = 44). Thereafter, the presence of the crevice sign was determined in each case. RESULTS: The populations were comparable in terms of sex and age (Table 1). Fisher's exact test showed a significant association between the presence of the crevice sign and the instability of the medial meniscus (p < 0.001). Descriptive statistics suggest that the presence of crevice sign was associated more frequently to MM instability (38.6% vs 1.2%; p < 0.001). The specificity of this test was 98.8% and its sensitivity was 38.6%. The positive predictive value (PPV) was 94.4% and the negative predictive value (NPV) was 75.5%. Table 1 Descriptions and comparisons of internal meniscus instability of patients by presence of crevice sign Internal meniscus instability (N = 44) Internal meniscus stability (N = 84) Total (N = 128) Gender  N 44 84 128   Male 33 (75.0) 58 (69.0) 91 (71.1)   Female 11 (25.0) 26 (31.0) 37 (28.9) Fisher's exact test (n.s.) Age (years)  N 44 84 128   Mean (ET) 28.6 (9.4) 30.1 (10.2) 29.6 (9.9)   Median (IIQ) 26.5 (22.0;34.5) 27.0 (22.5;37.0) 27.0 (22.0;36.0)   [Min-Max] [14-54] [14-52] [14-54] Wilcoxon test bilateral (n.s.) Crevice sign  N 44 84 128   Absent 27 (61.4) 83 (98.8) 110 (85.9)   Present 17 (38.6) 1 (1.2) 18 (14.1) Fisher's exact test p < 0.001 CONCLUSION: The hypothesis was confirmed since medial meniscal instability was strongly correlated with the existence of the crevice sign and showed high specificity and PPV. LEVEL OF EVIDENCE: III.

Variable rotation of the femur does not affect outcome with patient specific alignment navigated balanced TKA.

PURPOSE: Excessive internal and external rotation of the femoral component has been associated with poor outcome with a measured-resection neutral mechanical alignment TKA. This technique assumes that every tibia is in 3° of varus so the femoral component is placed in 3° of external rotation relative to the posterior condylar axis to enable a balanced flexion gap. This is not the case as there is wide variability in the bony anatomy and soft tissue envelope of the knee so flexion imbalance may occur. A patient-specific alignment navigated balanced TKA technique was performed whereby the tibia is cut anatomically up to 3° of varus, then a ligament tensor is used to determine the optimal femoral component position for a balanced TKA. This results in variable femoral rotation. The hypothesis is that matching the femoral component rotation to the patient's anatomic tibial cut and soft tissue envelope will not affect clinical outcome METHODS: In a single surgeon series 287 consecutive varus aligned TKA's were performed using this technique with an Attune cruciate retaining fixed bearing TKA with an anatomic patella resurfacing. The angle between the posterior femoral cuts and the posterior condylar axis was collected using Brainlab software. Functional scores were collected prospectively preoperatively and at two years. The variable femoral component rotation was correlated with and compared with the functional outcome scores. RESULTS: The femoral rotation varied from 7° of internal rotation to 8°of external rotation relative to the posterior condylar axis. The mean rotation was 1.1° of external rotation. There was no significant difference in the Oxford score, WOMAC score, Forgotten Knee Score, KOOS Joint Replacement score or Patient Satisfaction in respect to the variable femoral rotation relative to the posterior condylar axis. CONCLUSION: When a more anatomic-balanced TKA technique is used variable femoral rotation will not affect clinical outcome at two years LEVEL OF EVIDENCE: II Prospective Cohort Study.

Combining load sensor and robotic technologies for ligament balance in total knee arthroplasty.

Good ligament balance in total knee arthroplasty (TKA) is thought to improve clinical results, but is highly surgeon-dependent when performed without technological assistance. We therefore describe a TKA technique using the Mako robotic arm (Stryker, Kalamazoo, Michigan, USA) as sole means of balancing ligament tension by bone recuts associated to control by the VERASENSE load sensor (Orthosensor, Inc, Dania Beach, Florida, USA). In this preliminary series of 29 patients, 27 (93%) showed a well-balanced knee in extension at end of procedure, and 23 (79%) showed a well-balanced knee in flexion and extension, without any periarticular soft-tissue release. The load sensor analyzes ligament balance after the initial bone cuts, and guides possible further femoral or tibial recuts. This technique enables quantifiable alignment and control of ligament tension. Collecting objective intraoperative data should improve knowledge in placing TKA prostheses.

Preservation of the Tibial Stump During Anterior Cruciate Ligament Reconstruction Surgery Did Not Increase the Rate of Surgery for Symptomatic Cyclops Lesions.

BACKGROUND: Preservation of the tibial stump during anterior cruciate ligament reconstruction (ACLR) is controversial. While proposed benefits include enhanced graft revascularization, improved proprioception, and decreased graft rupture rates, a potential complication is the development of a symptomatic cyclops lesion. It is therefore important to determine whether any benefits outweigh potential complications. PURPOSE: To determine whether greater preservation of the tibial stump remnant would be associated with a decreased graft rupture rate without a concomitant increase in the rate of surgery for symptomatic cyclops lesions at 2 years after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of 658 patients in whom the amount of tibial stump preserved was classified as no stump (n = 228), <50% (n = 342), or >50% (n = 88) was followed up for 2 years, with graft ruptures and surgical treatment for cyclops lesions recorded. Contingency and Kaplan-Meier survival analyses were used to determine trends among the 3 remnant preservation groups in terms of graft rupture rates and surgery for cyclops lesions. Subgroup analysis was also conducted to examine sex-based differences. RESULTS: There was no significant association between graft rupture rates and remnant preservation. There was a significant trend for fewer operations for symptomatic cyclops lesions with greater remnant preservation when the entire cohort was analyzed (P = .04) and also when only female patients were analyzed (P = .04). CONCLUSION: Although preservation of the tibial stump remnant was not associated with a reduced graft rupture rate, it was also not associated with increased rates of surgery for symptomatic cyclops lesions.

Postoperative thromboprophylaxis does not reduce the incidence of thromboembolic events after ACL reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstructive surgery is one of the most common ligament-related surgeries performed in France. The French Society of Anesthesia & Intensive Care Medicine (SFAR) recommends the systematic use of low-molecular weight heparin postoperatively to prevent venous thromboembolisms (VTE). However, these recommendations differ from one country to another; several national societies do not recommend them. To specify the benefits of such a treatment, we did a retrospective case-control study to evaluate the incidence of symptomatic VTE after ACL reconstruction. Hypothesis We hypothesized that the rate of symptomatic VTE would be the same, whether a course of postoperative anticoagulants is prescribed or not. METHODS: This was a retrospective, multicenter, multi-surgeon study. Of the four participating surgeons, two never prescribed thromboprophylaxis after surgery while the other two always prescribed a 10-day course of low-molecular weight heparin. All patients who underwent primary ACL reconstruction using an autologous graft between the 1st of January 2019 and the 15th of February 2020 were included. The 535 patients who had undergone ACL reconstruction were divided into two groups: (Group 1) 279 patients in the group without anticoagulants; 96% received a four-strand semi-tendinosus graft (ST4) and 4% received a quadriceps tendon (QT) graft; the mean age of these patients was 30 years (14-58); 41% of them were women and 22% of them were smokers; the mean body mass index was 24.4 (18-37); the mean tourniquet time was 37minutes. (Group 2) 256 patients in the group with anticoagulants; 81% received a semi-tendinosus/gracilis graft, 15% received a ST4 and 4% a QT; the mean age of these patients was 29 years (14-60); 38% of them were women and 21% of them were smokers; the mean body mass index was 25.0 (18-38); the mean tourniquet time was 34minutes. The two groups were comparable in all respects except for the type of graft used. All patients were contacted at a minimum interval of 3 months after their surgery, by telephone. Doppler ultrasonography was done solely when a VTE was suspected. RESULTS: In the group without anticoagulants, 249 of 279 patients were contacted, while in the group with anticoagulants, 221 of 256 were contacted. The two groups were comparable in terms of age, gender ratio, tourniquet time, body mass index and proportion of smokers. Two cases of deep vein thrombosis (all in the calf region) were found in each group with no associated pulmonary embolism. There was no difference between groups in the VTE rate. DISCUSSION: Our hypothesis was confirmed since the incidence of symptomatic VTE was the same whether postoperative anticoagulants were prescribed or not. The incidence of symptomatic VTE after ACL reconstruction was identical whether thromboprophylaxis was used or not. This casts doubt on the need for postoperative thromboprophylaxis, especially in younger patients who do not have risk factors, and brings into question whether the recommendations in France should be changed. LEVEL OF EVIDENCE: III (retrospective case-control study).

Association Between Radiological Evidence of Kaplan Fiber Injury, Intraoperative Findings, and Pivot-Shift Grade in the Setting of Acute Anterior Cruciate Ligament Injury.

BACKGROUND: Biomechanical studies have suggested that the Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotation of the knee. There is a paucity of clinical information on whether injury to the KF in the setting of anterior cruciate ligament (ACL) rupture contributes to increased rotatory laxity of the knee. PURPOSE/HYPOTHESIS: The purpose was to evaluate the association among radiological evidence of KF injury, intraoperative arthroscopic findings, and grade of pivot shift at the time of ACL reconstruction (ACLR). It was hypothesized that KF injury would be associated with increased injury to the lateral compartment of the knee and a higher grade of pivot shift. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective magnetic resonance imaging (MRI) analysis was conducted on 267 patients with ACL-injured knees who underwent primary ACLR. Patients who had MRI and surgery within 60 days of injury were included (mean age, 23.6 years); there were 158 (59.2%) male patients. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. Associations were made among MRI findings, intraoperative findings, and grade of pivot shift with the patient examined under anesthesia at the time of ACLR. A comparison was made between patients with and without radiological evidence of KF injury. RESULTS: The prevalence of KF injury was 17.6% (47/267 patients). Arthroscopic evidence of lateral meniscal injury was associated with KF injury (KF intact, 31%; KF injured, 55%; P = .010). The majority of patients in the intact and injured KF groups had a grade 2 pivot shift (75% and 70%, respectively). A minority had grade 3 pivot shift: 5% in the intact group versus 6.4% in the injured group. There was no association between radiological evidence of KF injury and pivot-shift grade (P = .600). CONCLUSION: In acute ACL injury, KF injuries were not very common (17.6%), and the rate of grade 3 pivot shift was low (5.2%). When present, KF injuries were not associated with a higher-grade pivot shift. However, there was an association between KF injury and lateral meniscal tears identified at the time of ACLR. The role of KFS in controlling anterolateral rotatory laxity in the acute ACL injury in the clinical setting may be less evident when compared with the biomechanical setting.