Comparison of Graft Type and Fixation Method in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis Based on Randomized Control Studies.

BACKGROUND: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee. ACL reconstruction (ACLR) proves the standard for treating this injury. However, graft choice and method of fixation remain a heavily debated topic. This study investigates the following: bone-patellar tendon-bone (BPTB) vs. hamstring tendon (HT) autograft, single-bundle vs. double-bundle hamstring graft, and metal vs. bioabsorbable screws in ACLR. METHODS: A systematic review was performed on PubMed and Google Scholar according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were collected on patient demographics, complications, and functionality scores including International Knee Documentation Committee (IKDC) and Lysholm scores. A systematic review and meta-analysis were conducted with Review Manager. Outcome measurements were determined using forest plots with significant differences considered p < 0.05. RESULTS: Twenty-five studies were included, accounting for 2,170 patients. No statistically significant difference was appreciated when comparing BPTB to hamstring autografts. Patients who received a double bundle HT autograft exhibited significantly superior outcomes in terms of revision (p = 0.05), failure (p = 0.002), normal pivot shift tests (p = 0.04), and normal IKDC (p = 0.008). When comparing screw types, bioabsorbable screws had a greater Lysholm score (p = 0.01) and lower failure rates for copolymer screws (p = 0.03). CONCLUSION: Overall, the data collected suggested that BPTB and HT autografts display similar postoperative results. However, if an HT autograft is used, the data suggest a double-bundle graft improves both functionality and decreases the possible complications. Finally, bioabsorbable screws prove superior to metal screws when looking at both functionality and failure rates. Further research into the superior graft type is still needed. LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Medial and Lateral Patellar Instability Leading to Medial Patellofemoral Ligament and Lateral Retinaculum Reconstruction: A Case Report.

CASE: Combined medial and lateral patellar instability is exceptionally rare with only 3 reported cases to date. Here, we present the case of a 37-year-old White woman with multiple recurrent medial and lateral patellar instability. After failure of conservative care with bracing and therapy, she underwent surgical stabilization with medial and lateral allograft reconstruction. CONCLUSION: This case provides an example of the condition and successful surgical follow-up.

Opioid Prescribing Practices of Orthopaedic Surgeons: Results of a National Survey.

INTRODUCTION: Opioids are widely used after orthopaedic procedures. Nonmedical opioid use is a growing public health issue. METHODS: An anonymous online survey was distributed by e-mail to the orthopaedic societies of all 50 states and several large private practices to assess practicing orthopaedic surgeons' opioid prescribing practices. RESULTS: A total of 555 orthopaedic surgeons practicing in 37 states responded. The most commonly prescribed opioid for both teenagers and adults was hydrocodone/acetaminophen. Of note, 42.3% reported that a patient they have prescribed opioids for developed an opioid dependency, whereas 35.3% do not believe that opioid use is a problem in their practice. Of note, 30.3% reported prescribing refills, and factors significantly associated with increased prescribing of refills included a greater number of years in practice (P < 0.001) and practicing in a suburban rather than an urban or rural environment (P = 0.03). CONCLUSION: Orthopaedic surgeons rarely prescribe any refills, tend to prescribe less opioids to teenagers than adults, and prescribe fairly uniformly for patients who are treated nonsurgically or undergo minor or arthroscopic surgery. They exhibit considerable variation in prescribing for fractures and major procedures.

Quadriceps Strength Predicts Self-reported Function Post-ACL Reconstruction.

INTRODUCTION/PURPOSE: Quadriceps strength is a useful clinical predictor of self-reported function after anterior cruciate ligament reconstruction (ACLR). However, it remains unknown if quadriceps strength normalized to body mass (QBM) or quadriceps strength limb symmetry index (QLSI) is the best predictor of self-reported function in individuals with ACLR. We sought to determine whether QBM and QLSI are able to predict individuals with ACLR who self-report high function (≥90% on the international knee documentation committee (IKDC) index). METHODS: Ninety-six individuals with a history of a primary unilateral ACLR were recruited for a multisite cross-sectional descriptive laboratory experiment. Bilateral isometric quadriceps strength was collected at 90° of knee flexion to calculate QBM and QLSI (ratio of the ACLR limb to the contralateral limb). Area under the curve (AUC) values were calculated using receiver operating characteristic curve analyses to determine the capacity of QBM and QLSI to predict individuals with high self-reported function on the IKDC index. RESULTS: QBM displayed high accuracy (AUC = 0.76; 95% confidence interval, 0.66-0.86) for identifying participants with an IKDC index ≥90%. A QBM cutoff score of 3.10 N·m·kg was found to maximize sensitivity (0.61) and specificity (0.84), and displayed 8.15 (3.09-21.55) times higher odds of reporting high function. QLSI displayed a moderate accuracy (AUC = 0.62, 0.50-0.73) for identifying participants with an IKDC index ≥90%. A QLSI cutoff score of 96.5% maximized sensitivity (0.55) and specificity (0.70), and represented 2.78 (1.16-6.64) times higher odds reporting high function. CONCLUSION: QBM is a stronger predictor of high self-reported function compared with QLSI in individuals with ACLR. Rehabilitation guidelines may benefit from incorporating the use of QBM measurements for the purpose of predicting participants that may maintain high self-reported function.

Longitudinal Evaluation of Stair Walking Biomechanics in Patients with ACL Injury.

PURPOSE: After anterior cruciate ligament (ACL) injury and reconstruction, abnormal biomechanics during daily tasks may have prominent and detrimental long-term consequences on knee joint health. The purpose of this study was to longitudinally evaluate hip and knee joint biomechanics during stair ascent and descent in patients with acute ACL injury and at return to activity after ACL reconstruction. METHODS: Twenty individuals with unilateral ACL injury (age, 20.9 ± 4.4 yr; height, 172.4 ± 7.5 cm; mass, 76.2 ± 12.2 kg) that were scheduled to undergo surgical reconstruction were compared with 20 healthy matched controls (age, 21.7 ± 3.7 yr; height, 173.7 ± 9.9 cm; mass, 76.1 ± 19.7 kg). Lower extremity biomechanics were recorded using three-dimensional motion analysis during stair ascent and descent at two testing sessions (before surgery and at approximately 6 months after surgery or when they were allowed to return to unrestricted physical activity). Time between sessions for healthy participants was matched on the basis of the ACL group. Peak sagittal and frontal plane knee and hip joint angles and moments, joint angles at initial contact, and joint excursions across stance phase were evaluated. RESULTS: The ACL-injured limb of patients experienced smaller knee extension moments than the uninjured limb and healthy controls during stair ascent and descent (P < 0.05) before and 6 months after ACL reconstruction. During stair ascent, ACL patients experienced more extended knee joint positions and less sagittal plane knee joint excursions, coupled with greater frontal plane hip joint excursions (P < 0.05). CONCLUSIONS: Patients with ACL injury experience reductions in knee flexion angle and knee extension moments during stair walking. These alterations were observed both before and after reconstruction, suggesting that early gait retraining interventions may be beneficial in these patients.

Neural Excitability Alterations After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Neuromuscular dysfunction is common after anterior cruciate ligament reconstruction (ACL-R). However, little is known about quadriceps spinal-reflex and descending corticomotor excitability after ACL-R. Understanding the effects of ACL-R on spinal-reflex and corticomotor excitability will help elucidate the origins of neuromuscular dysfunction. OBJECTIVE: To determine whether spinal-reflex excitability and corticomotor excitability differed between the injured and uninjured limbs of patients with unilateral ACL-R and between these limbs and the matched limbs of healthy participants. DESIGN: Case-control study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 28 patients with unilateral ACL-R (9 men, 19 women; age = 21.28 ± 3.79 years, height = 170.95 ± 10.04 cm, mass = 73.18 ± 18.02 kg, time after surgery = 48.10 ± 36.17 months) and 29 participants serving as healthy controls (9 men, 20 women; age = 21.55 ± 2.70 years, height = 170.59 ± 8.93 cm, mass = 71.89 ± 12.70 kg) volunteered. MAIN OUTCOME MEASURE(S): Active motor thresholds (AMTs) were collected from the vastus medialis (VM) using transcranial magnetic stimulation. We evaluated VM spinal reflexes using the Hoffmann reflex normalized to maximal muscle responses (H : M ratio). Voluntary quadriceps activation was measured with the superimposed-burst technique and calculated using the central activation ratio (CAR). We also evaluated whether ACL-R patients with high or low voluntary activation had different outcomes. RESULTS: The AMT was higher in the injured than in the uninjured limb in the ACL-R group (t27 = 3.32, P = .003) and in the matched limb of the control group (t55 = 2.05, P = .04). The H : M ratio was bilaterally higher in the ACL-R than the control group (F1,55 = 5.17, P = .03). The quadriceps CAR was bilaterally lower in the ACL-R compared with the control group (F1,55 = 10.5, P = .002). The ACL-R group with low voluntary activation (CAR < 0.95) had higher AMT than the control group (P = .02), whereas the ACL-R group with high voluntary activation (CAR ≥ 0.95) demonstrated higher H : M ratios than the control group (P = .05). CONCLUSIONS: The higher VM AMT in the injured limbs of ACL-R patients suggested that corticomotor deficits were present after surgery. Higher bilateral H : M ratios in ACL-R patients may be a strategy to reflexively increase excitability to maintain voluntary activation.

Contributions of neural excitability and voluntary activation to quadriceps muscle strength following anterior cruciate ligament reconstruction.

BACKGROUND: Persistent quadriceps weakness is common following anterior cruciate ligament reconstruction (ACLr). Alterations in spinal-reflexive excitability, corticospinal excitability and voluntary activation have been hypothesized as underlying mechanisms contributing to quadriceps weakness. The aim of this study was to evaluate the predictive capabilities of spinal-reflexive excitability, corticospinal excitability and voluntary activation on quadriceps strength in healthy and ACLr participants. METHODS: Quadriceps strength was measured using maximal voluntary isometric contractions (MVIC). Voluntary activation was quantified via the central activation ratio (CAR). Corticospinal and spinal-reflexive excitability were measured using active motor thresholds (AMT) and Hoffmann reflexes normalized to maximal muscle responses (H:M), respectively. ACLr individuals were also split into high and low strength subsets based on MVIC. RESULTS: CAR was the only significant predictor in the healthy group. In the ACLr group, CAR and H:M significantly predicted 47% of the variance in MVIC. ACLr individuals in the high strength subset demonstrated significantly higher CAR and H:M than those in the low strength subset. CONCLUSION: Increased quadriceps voluntary activation, spinal-reflexive excitability and corticospinal excitability relates to increased quadriceps strength in participants following ACLr. CLINICAL RELEVANCE: Rehabilitation strategies used to target neural alterations may be beneficial for the restoration of muscle strength following ACLr.

Negligence, genuine error, and litigation.

Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system.

Medical malpractice reform: the role of alternative dispute resolution.

BACKGROUND: Alternative dispute resolution (ADR) refers to techniques used to resolve conflicts without going to the courtroom. As healthcare and malpractice costs continue to rise, there is growing interest in tactics such as early apology, mediation, and arbitration in the medical arena. QUESTIONS/PURPOSES: (1) Why is ADR needed? (2) Is ADR useful in health care? (3) What are the current legal and political developments favoring ADR? (4) What obstacles remain? METHODS: We performed MEDLINE, PubMed, and Google Scholar searches with key words "medical malpractice", "ADR", and "alternative dispute resolution" to obtain public policy studies, law review articles, case analyses, ADR surveys, and healthcare review articles. RESULTS: Early apology and disclosure programs report 50% to 67% success in avoiding litigation as well as substantial reductions in the amount paid per claim. Mediation boasts 75% to 90% success in avoiding litigation, cost savings of $50,000 per claim, and 90% satisfaction rates among both plaintiffs and defendants. Arbitration is viewed as less satisfying and less efficient than mediation but still more time- and cost-effective than litigation. The current legal environment is favorable to ADR with recent court decisions upholding pretreatment arbitration clauses. The main obstacle to ADR is the mandatory reporting requirement of the National Practitioner Data Bank (NPDB). CONCLUSIONS: ADR has the potential to help reform the current tort system, reducing cost and increasing both parties' satisfaction. Easing the reporting requirements for the NPDB would lead to more widespread acceptance of ADR among physicians.

Biomechanical verification that PCL reconstruction is unnecessary in the muscle-stabilized knee.

Treatment of isolated posterior cruciate ligament (PCL) injuries is controversial. This is due in part to the discrepancy between clinical and biomechanical studies in the literature. Clinically, isolated PCL injuries are treated nonoperatively, and patients do well as long as they have adequate quadriceps function. Biomechanically, however, PCL injuries have been shown in cadavers to lead to altered kinematics and increased contact pressures. These studies, however, did not simulate weight-bearing muscle forces, which can compensate for the PCL deficiency. We sought to study the biomechanical effects of PCL deficiency and reconstruction in a cadaveric knee, but with reproduction of the muscle-stabilizing effects of the quadriceps and hamstring muscles. We used a novel 6 degrees of freedom testing system to simulate a muscle-stabilized cadaveric knee and recorded both kinematics and contact pressure data. Four conditions were tested: normal, PCL-deficient, and PCL single- and double-bundle reconstructed states. We found that with muscle stabilization, there were no significant changes in kinematics or contact pressures in the knee between any of these conditions. This corroborates clinical findings and verifies that PCL reconstruction is unnecessary in the muscle-stabilized knee.

Transitioning to anatomic anterior cruciate ligament graft placement.

Anterior cruciate ligament (ACL) reconstruction techniques continue to improve. Recent biomechanical studies have found improved rotational stability as femoral tunnel placement becomes more horizontal and closer to the true ACL footprint. Clinical studies also correlate improved outcomes with these more anatomic reconstructions. This article reviews the transition from traditional to anatomic ACL reconstructions, as well as 3 techniques for achieving this: the modified transtibial technique, use of an accessory medial portal, and the retrograde drilling technique.

Meniscal debridement: current concepts.

The meniscus is a commonly injured structure in the knee. When intact, it serves multiple biomechanical functions that protect the underlying articular cartilage. When injured, it can cause pain and mechanical symptoms that restrict activity. Although meniscal tears can be effectively treated with arthroscopic debridement, there is concern that any amount of meniscectomy, no matter how small, is a risk factor for the development of long-term osteoarthritis. This article reviews current concepts in arthroscopic meniscal debridement, including clinical outcome studies, to understand which factors affect outcome after this commonly performed procedure.

Meniscus transplantation: current concepts.

Treatment options are limited for young, meniscal-deficient patients with pain. This patient population is not age appropriate for total joint replacement, yet the loss of the meniscus leaves them at significant risk for the development of osteoarthritis. One increasingly popular option is the use of allograft meniscal transplantation. However, many questions, both clinical and biomechanical, still surround allograft meniscus transplantation. Clinical questions include risks of disease transmission, patient factors affecting ultimate outcome, optimal graft preservation methods, and surgical technique choice. Biomechanical questions include whether allograft meniscus transplantation can reproduce the functions of the meniscus, the effects of proper sizing and fixation methods on contact mechanics, and the effects of freezing on allograft strength. This article reviews these questions and more current concepts regarding allograft meniscus transplantation.

Bone cement improves suture anchor fixation.

Suture anchor fixation failure can occur if the anchor pulls out of bone. We hypothesized that suture anchor fixation can be augmented with polymethylmethacrylate cement, and that polymethylmethacrylate can be used to improve fixation in a stripped anchor hole. Six matched cadaveric proximal humeri were used. On one side, suture anchors were placed and loaded to failure using a ramped cyclic loading protocol. The stripped anchor holes then were injected with approximately 1 cc polymethylmethacrylate, and anchors were replaced and tested again. In the contralateral humerus, polymethylmethacrylate was injected into anchor holes before anchor placement and testing. In unstripped anchors, polymethylmethacrylate increased the number of cycles to failure by 34% and failure load by 71% compared with anchors not augmented with polymethylmethacrylate. Polymethylmethacrylate haugmentation of stripped anchors increased the cycles to failure by 31% and failure load by 111% compared with unstripped uncemented anchors. No difference was found in cycles to failure or failure load between cemented stripped anchors and cemented unstripped anchors. Polymethylmethacrylate can be used to augment fixation, reducing the risk of anchor pull-out failure, regardless whether the suture anchor hole is stripped or unstripped.

Effect of gravity on localization of chondrocytes implanted in cartilage defects.

The transplantation of autologous chondrocytes under a periosteal flap has been used to treat focal cartilage defects. Results have been promising but occasionally involve complications ranging from graft hypertrophy to detachment. The objective of this study was to determine if gravitational forces affect the uniformity of cell distribution within the defect. Using an ex vivo bovine model, the orientation relative to gravity of a repaired full-thickness articular cartilage defect was found to affect the initial distribution of transplanted chondrocytes, prelabeled with 3H-thymidine. After 4 hours, the injected cells (3H-radioactivity) were primarily at the base of the defect (79%) in samples oriented in the up position, primarily at the dependent semicylindrical half of the defect (83%) in samples oriented to the side, and primarily at the periosteal top of the defect (78%) in samples oriented upside-down. Subsequently, the cell distribution remained unchanged after reorientation into other positions. These results indicate that injected chondrocytes localize under the influence of gravity within the initial few hours after injection. Therefore, the defect orientation during this time can be an important factor in the uniformity of cell distribution in the autologous chondrocyte implantation procedure and may be an important determinant of the ultimate clinical outcome.