Combined Lateral Extra-Articular Tenodesis or Combined Anterolateral Ligament Reconstruction and Anterior Cruciate Ligament Reconstruction Improves Outcomes Compared to Isolated Reconstruction for Anterior Cruciate Ligament Tear: A Network Meta-analysis of Randomized Controlled Trials.

PURPOSE: To conduct a network meta-analysis (NMA) comparing the results of randomized controlled trials (RCTs) among patients who underwent either isolated anterior cruciate ligament (ACL) reconstruction or combined lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR). METHODS: RCTs that compared isolated ACL reconstruction and combined LET or ALLR were included with minimum 12 months follow-up. Studies that used the double-bundle technique were excluded. Outcome assessment included the number of positive pivot shifts, amount of anterior tibial translation, and International Knee Documentation Committee (IKDC) subjective, Tegner, and Lysholm scores. Bayesian NMA and the surface under the cumulative ranking area (SUCRA) were evaluated. RESULTS: A total of 1,077 patients from 11 RCTs were enrolled in this study. In NMA, the odds ratios (ORs) of positive pivot shift were significantly lower in ACL + ALLR (OR: 0.17; 95% CI: 0.027-0.67) than isolated ACL reconstruction, but no difference between ACL + ALLR and ACL + LET. There were no significant differences in anterior tibial translation among the techniques, but the IKDC subjective and Lysholm scores of ACL + ALLR and ACL + LET were significantly higher than isolated ACL reconstruction. ACL + ALLR were the most preferred in terms of residual pivot shift, anterior tibial translation, and IKDC subjective scores (SUCRA = 88.2%, 86.4%, and 93.1%, respectively). Additional lateral procedures resulted in significantly lower risk of graft failure (OR: 0.27; 95% CI: 0.1-0.71) than isolated ACL reconstruction. CONCLUSIONS: ACL + ALLR were found to have significantly better outcomes in terms of knee rotational stability and graft failure rate than isolated ACL reconstructions, but the clinical outcomes were uncertain after a minimum 12 months follow-up. Considering the greatest probability of obtaining better knee rotational stability in this NMA, ACL + ALLR was found to be the most preferred technique for patients with ACL injury. LEVEL OF EVIDENCE: Level II, network meta-analysis and systematic review of Level I and II studies.

Incidence and type of meniscal tears in multilligament injured knees.

PURPOSE: Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery. METHODS: Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury. RESULTS: A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries p = 0.025; lateral-sided injuries p = 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (p < 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (p < 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (p < 0.001). CONCLUSIONS: Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision. METHODS: The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document. RESULTS: The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below. CONCLUSION: ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance. LEVEL OF EVIDENCE: II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy.

PURPOSE: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision. METHODS: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document. RESULTS: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article. CONCLUSION: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults. LEVEL OF EVIDENCE: Level II.

Unplanned return to the operating room after arthroscopic procedures: a need to consider 12 months after the initial surgery.

INTRODUCTION: The purpose of this study was to report the proportion and cause of unplanned revision surgery rates within 1 year following arthroscopic procedures. Our hypothesis was that there is a significant rate of unplanned returns (URs) occurring between 3 and 12 months after the initial procedure and that causes of revision are different when considering the delay after the index surgery. MATERIALS AND METHODS: Among 4142 consecutive patients who underwent an arthroscopic procedure in a single department of orthopedics and traumatology, patients undergoing revision surgery for any reasons directly related to the primary procedure were included. Cause for revision, surgical site, delay from index procedure, and number of revisions were screened. RESULTS: Seventy-eight patients underwent 97 revision surgeries (2.3%) for reasons directly related to the primary procedure. Most revision surgeries were performed after month 3 following index surgery (59 patients, 60.8%). Mean time to revision surgery was 5.3 ± 4.3 months (range 0-365 days). Usual early-onset (< 3 months) reasons for unplanned revision were surgical site infection (17 patients, 0.41%), wound-healing defect (12 patients, 0.29%), and hemorrhagic complication (7 patients, 0.17%). Reasons for delayed unplanned revision (> 3 months) were index procedure failure (21 patients, 0.51%), stiffness (18 patients, 0.43%), and removal of hardware (16 patients, 0.41%). CONCLUSIONS: Reasons for return to the operating room (OR) are different depending on the timepoint from index procedure. Patients should receive relevant information accordingly when scheduling any arthroscopic procedure, including up to 1-year potential complications. LEVEL OF EVIDENCE: Prognostic study, Case series, Level IV.

Incidence and risk factors of prolonged grief in relatives of patients with terminal cancer in French palliative care units: The Fami-Life multicenter cohort study.

OBJECTIVES: Psychological consequences of grief among relatives are insufficiently known. We reported incidence of prolonged grief among relatives of deceased patients with cancer. METHODS: Prospective cohort study of 611 relatives of 531 patients with cancer hospitalized for more than 72 hours and who died in 26 palliative care units was conducted. The primary outcome was prolonged grief in relatives 6 months after patient death, measured with the Inventory Complicated Grief (ICG > 25, range 0-76, a higher score indicates more severe symptoms) score. Secondary outcomes in relatives 6 months after patient death were anxiety and depression symptoms based on Hospital Anxiety and Depression Scale (HADS) score (range 0 [best]-42 [worst]), higher scores indicate more severe symptoms, minimally important difference 2.5. Post-traumatic stress disorder symptoms were defined by an Impact Event Scale-Revised score >22 (range 0-88, a higher score indicates more severe symptoms). RESULTS: Among 611 included relatives, 608 (99.5%) completed the trial. At 6 months, significant ICG scores were reported by 32.7% relatives (199/608, 95% CI, 29.0-36.4). The median (interquartile range ICG score) was 20.0 (11.5-29.0). The incidence of HADS symptoms was 87.5% (95% CI, 84.8-90.2%) at Days 3-5 and 68.7% (95% CI, 65.0-72.4) 6 months after patient's death, with a median (interquartile range) difference of -4 (-10 to 0) between these 2 time points. Improvement in HADS anxiety and depression scores were reported by 62.5% (362/579) relatives. SIGNIFICANCE OF RESULTS: These findings support the importance of screening relatives having risk factors of developing prolonged grief in the palliative unit and 6 months after patient's death.

No Differences In Clinical Outcomes Between Rectangular and Round Tunnel Techniques For Anterior Crucial Ligament Reconstruction.

PURPOSE: To compare the clinical outcomes between conventional round tunnel and rectangular tunnel in anatomic anterior cruciate ligament (ACL) reconstruction. METHODS: This was a retrospective comparative cohort study between March 2015 and September 2018. The primary ACL reconstructions using anteromedial portal technique with minimum of 2 years follow-up were enrolled for this study. The exclusion criteria were patients with revision ACL reconstruction, high tibial osteotomy, multiligament injuries, and associated fractures around the knee. Outcome measures included the subjective International Knee Documentation Committee score, Tegner activity score, knee laxity testing, and measurement of the centers of the femoral and tibial tunnels on postoperative computed tomography (CT) images. RESULTS: Forty-seven patients with ACL reconstruction with rectangular tunnel (group 1) and 108 patients with ACL reconstructions with conventional rounded tunnel (group 2) were included consecutively. There were no significant differences between groups in terms of clinical scores or knee laxity, as well as femoral and tibial tunnel positions on CT. One patient in group 2 had ACL failure because of trauma and was treated with revision surgery. Two patients had incomplete tibial fracture, but they healed spontaneously and showed no residual laxity at final follow-up. The intraobserver and interobserver reliability for the radiological measurements ranged from 0.78 to 0.86. CONCLUSIONS: There were no differences in radiological and clinical results between rectangular tunnel group and conventional round tunnel group for arthroscopic ACL reconstruction. ACL reconstruction with a rectangular tunnel could be considered as a reliable technique, but care should be taken during tunnel establishment because of risk of fractures and malposition of rectangular tunnel.

The severity of patellar and trochlear dysplasia are correlated.

PURPOSE: Patellar instability is a frequent clinical situation in adolescents and young adults. One of the most important risk factors of this condition is trochlea dysplasia. Few studies have analyzed the role of patellar dysplasia. The objective of this paper was to assess the correlation between trochlear and patellar dysplasia. The hypothesis is that patellar dysplasia increased in parallel with femoral trochlear dysplasia. METHODS: The study included patients operated on at least one knee for patellar instability between 2008 and 2020. For these patients, symptomatic knees (operated or not) were included if they had lateral and patellofemoral skyline radiographs. Two blinded observers categorized each trochlear and patellar dysplasia according to the Dejour and Wiberg classifications. Patellar height was also measured by applying the Caton-Deschamps index. RESULTS: A total of 100 patients were selected, involving 149 symptomatic knees. A significant correlation between trochlear and patellar dysplasia types was found (0.82; p < 0.0001). Dejour types B and C of trochlear dysplasia were significantly more often associated with patellar dysplasia than Dejour type A (p = 0.033 and p = 0.019, respectively). Moreover, severe Wiberg 3 patellar dysplasia was significantly associated with type D Dejour trochlear dysplasia than with the sum of all other Dejour types taken together (p < 0.0001). CONCLUSION: This study confirms a linear correlation between the severity of patellar and trochlear dysplasia. Further studies are needed to evaluate the place of patellar dysplasia in the therapeutic strategy. LEVEL OF EVIDENCE: Level IV.

Management of acute knee dislocation with vascular injury: the use of the external fixator. A systematic review.

INTRODUCTION: Vascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator. MATERIAL AND METHODS: The present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports. RESULTS: Descriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups. CONCLUSIONS: External fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries. LEVEL OF EVIDENCE: IV.

Litigation after primary total hip and knee arthroplasties in France: review of legal actions over the past 30 years.

INTRODUCTION: Since the law of March 4, 2002, several modifications have impacted medical practices and their medico-legal implications. In case of an infectious complication not related to a fault of the practitioners (surgeons, anesthetists), the patient has the right to compensation assumed by the care structures. Moreover, the lack of preoperative information is no longer just a failing of the ethical standards but a breach of medical and legal obligations. Then, aims of this study were: (1) to describe the reasons for a lawsuit in France following total primary hip (THA) and total knee (TKA) arthroplasties and (2) to compare litigation characteristics of private and public practices. MATERIALS AND METHODS: Civil (private practice) and administrative (public practice) court decisions in France between 1990 and 2020 were collected using the two main legal data sources (Legifrance, Doctrine). RESULTS: Eighty-three TKA and 173 THA cases were identified. Reasons for complaint in primary THA were mainly infection (29%), prosthetic failures (18%), nerves injuries (17%), and leg length discrepancies (11%). The main grounds for complaint in favor of the plaintiff were diagnostic or indication mistakes (100%), infections (80%), especially if a lack of information was recognized (88%). Reasons for complaint following primary TKA were mainly infections (65%) and persistent pain or stiffness (12%). Whatever the reason, the verdict was in favor of the plaintiff in about 2/3 of the cases. THAs were more at risk of appeal in administrative procedures than in civil (p = 0.008). There were more cases of implant failure in civil proceedings (p = 0.008). Indemnities after primary THA was higher in public activity litigation (p = 0.04). There were no differences in verdicts, grounds for complaints, and compensation between public and private practices for primary TKA. CONCLUSION: The main complaint about all the arthroplasties in France was a septic complication. The lack of information could be an added pejorative element for the final verdict.

Evaluation of the "Minimal Clinically Important Difference" (MCID) of the KOOS, KSS and SF-12 scores after open-wedge high tibial osteotomy.

PURPOSE: Defining a Minimal Clinically Important Difference (MCID) value for Patient-Reported Outcome Measures (PROMs) is crucial for determining the effectiveness of a procedure and calculating the sample size for trial planning. The purpose of this study was to determine the MCID of several PROMs (Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and the SF-12) in patients who underwent medial opening-wedge High-Tibial Osteotomy (owHTO) with Patient-Specific Cutting Guides (PSCGs), using anchor-based methods. METHODS: Patients undergoing isolated medial owHTO with PSCGs between January 2013 and January 2017 were enrolled in this single-center, prospective, observational study. Three outcome scores were collected pre-operatively and at the 2 years follow-up evaluation: KOOS, KSS and SF-12. The MCIDs were calculated using anchor-based method: at 2 years postoperatively: "Compared with before surgery, how would you rate operated joint now?" The responses were recorded using a five-point scale. Patients who answered "about the same" or "somewhat worse" were classified into the no change group, while those who answered "somewhat better" were classified into the minimal change group. A receiver operating characteristic (ROC) curve was used to define the cutoff point that best discriminated between the minimal change and no change groups for each PROMs RESULTS: 196 patients were included, 75 (somewhat better) and 24 patients (about the same and somewhat worse) were, respectively, assigned to the "no change" and "minimal change" groups. There was no significant difference between the two groups in terms of baseline characteristics and postoperative complications. At 24 months follow-up all the PROMs (KOOS, KSS and SF-12) were significantly better for the "minimal change" group compared to the "no change" group. MCID was 15.4 for KOOS pain, 15.1 for KOOS symptoms, 17 for KOOS ADL, 11.2 for KOOS sports/recreation, 16.5 for KOOS QQL, 3 for KSS symptoms, 5.6 for KSS activity, 7.2 for SF-12 physical component and 6.3 for PCS mental component. CONCLUSION: This study determined the MCIDs of common used PROMs in patients undergoing owHTO. LEVEL OF EVIDENCE: Prospective Cohort Study, Level II.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France.

PURPOSE: The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery. METHODS: All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded. RESULTS: One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003). CONCLUSION: This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform. LEVEL OF EVIDENCE: Level IV.

The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. METHODS: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. RESULTS: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. CONCLUSION: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. LEVEL OF EVIDENCE: Level V.

Méthodologies de la recherche en soins palliatifs : les défis de l'interdisciplinarité.

AIM: This article aims to set some theoretical and practical milestones to better understand the challenges of interdisciplinary research in palliative care. METHOD: A theoretical perspective of the main challenges of interdisciplinary research is provided through a review of existing literature, supported by practical experiences learnt from the implementation of two research projects on the improvement of the organization of healthcare services in palliative care in France. RESULTS: Palliative care is historically and philosophically grounded in interdisciplinary culture. Implementation of interdisciplinary research in palliative care is particularly challenging as it implies engaging in a “paradigm dialogue” with different disciplines involved. Beyond the relational skills inherent in and required for actual interdisciplinary practice, interdisciplinary research calls for metacognitive skills such as the ability to search, identify, understand, connect and integrate theoretical and methodological perspectives of different disciplines. CONCLUSION: Addressing the challenges of interdisciplinary research in palliative care requires an educational program that integrates an interdisciplinary approach at the early stage of the medical and healthcare curriculum. Paradigm dialogue should also be encouraged in national research and innovation programs.

The use of an asymmetrical tibial tray in TKA optimises tibial rotation when fitted to the posterior tibial plateau border.

PURPOSE: The aim of this study was to evaluate the suitability of positioning an asymmetrical tibial tray relative to the posterior tibial edge and to analyse the relationship between the posterior fit and tibial rotation after computer-assisted total knee arthroplasty (TKA). It was hypothesised that an asymmetrical tray would adjust to the posterior border of the tibial plateau with proper tibial rotation. METHODS: Ninety-three consecutive knees underwent total knee arthroplasty using a Persona fixed-bearing system (63 varus deformities and 30 valgus deformities) and a 3-month follow-up CT scan. An independent examiner measured different variables: the femoral angle between the clinical epicondylar axis and the posterior condylar line of the femoral component, the tibial angle between the posterior borders of the tibial tray and the tibial plateau, and the tibial rotation with respect to the femoral component. These measurements were also compared between varus and valgus subgroups. RESULTS: For the varus and valgus subgroups, the mean postoperative femoral angle was 2.1º ± 1.2º and 2.5º ± 1.0º, respectively (n.s.). The mean posterior fitting angle of the tibial tray was 0.1º ± 2.4º and 1.4º ± 3.2º for the varus and valgus subgroups, respectively, with a significant difference between groups (p = 0.03). The tibial rotations with respect to the femoral component for the varus and valgus groups were 0.9º ± 3.3º and 2.2º ± 3.1º of external rotation, respectively (n.s.). CONCLUSIONS: This study demonstrated that fitting an asymmetrical tibial tray to the posterior border of the tibial plateau could optimise tibial rotation. The posterior border was considered to be a reliable and easily identifiable landmark for proper tibial rotation and coverage during a primary TKA. LEVEL OF EVIDENCE: IV.

Large variability exists in the management of posterolateral corner injuries in the global surgical community.

PURPOSE: The management of posterolateral corner (PLC) injuries has significantly evolved over the past 2 decades. The purpose of this study was to determine the current worldview of key concepts on the diagnosis, treatment strategy, and rehabilitation for patients presenting with PLC injuries. METHODS: A 12-question multiple-choice online survey was designed to address key questions in the diagnosis, treatment, and rehabilitation of PLC injuries. The survey was distributed to the most important international sports medicine societies worldwide. Clinical agreement was defined as > 80% of agreement in responses and general agreement was defined as > 60% of agreement in responses. RESULTS: 975 surgeons completed the survey with 49% from Europe, 21% from North America, 12% from Latin America, 12% from Asia, and smaller percentages from Africa and Oceania. Less than 14% of respondents manage more than ten PCL injuries yearly. Clinical agreement of > 80% was only evident in the use of MRI in the diagnosis of PLC injury. Responses for surgical treatment were split between isometric fibular-based reconstruction techniques and anatomically based fibular and tibial-based reconstructions. A general agreement of > 60% was present for the use of a post-operative brace in the early rehabilitation. CONCLUSION: In the global surgical community, there remains a significant variability in the diagnosis, treatment, and postoperative management of PLC injuries. The number of PLC injuries treated yearly by most surgeons remains low. As global clinical consensus for PLC remains elusive, societies will need to play an important role in the dissemination of evidence-based practices for PLC injuries. LEVEL OF EVIDENCE: IV.

Predictive factors for failure of anterior cruciate ligament reconstruction via the trans-tibial technique.

INTRODUCTION: Factors for graft failure after trans-tibial (TT) ACL reconstruction, including anterolateral ligament (ALL) injury and degree of synovialization, remain unclear. This study is to evaluate the risk factors for graft failures after TT ACL reconstruction including ALL injury and synovialization. MATERIALS AND METHODS: A total 391 patients who underwent primary TT ACL reconstruction were included. Failure was defined as greater than grade 2 laxity on the Lachman or pivot shift tests or 5 mm of anterior translation on stress radiograph. After applying inclusion/exclusion criteria, 31 patients with failure were categorized as group 1 and 89 patients without failure were categorized as group 2. Chi-square test and Cox proportional hazard analyses were performed. RESULTS: Preoperatively, 64 patients had ALL injuries (53.3%), 58 had medial meniscal (MM) tears (48.3%), and 62 had lateral meniscal (LM) tears (51.6%). Ninety-three patients (77.5%) had acute injuries and 27 had chronic injuries as per 6-weeks duration. Significant risk factors for failure were LM tear (hazard ratio [HR], 4.018; 95% confidence interval [CI] 1.677-9.629; p = 0.002), chronicity (HR, 6.812; 95% CI 2.758-16.824; p = 0.000), presence of ALL injury (HR, 3.655; 95% CI 1.442-9.265; p = 0.006), and poor synovialization (HR, 3.134; 95% CI 1.298-7.566; p = 0.011) in Cox proportional hazard analysis. If combined MM and LM tears were found, an increased risk of failure was also identified (combined tears: HR, 3.951; 95% CI 1.754-8.901; p = 0.001/preoperative high-grade laxity: HR, 4.546; 95% CI 1.875-11.02; p = 0.001). CONCLUSION: Chronic ACL injuries, meniscus tear, preoperative ALL injuries, preoperative high-grade laxity and poor synovialization are significant risk factors. Therefore, these factors should be carefully assessed and properly treated in TT ACL reconstruction. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Meniscal repair associated with a partial meniscectomy for treating complex horizontal cleavage tears in young patients may lead to excellent long-term outcomes.

INTRODUCTION: While open repair of horizontal meniscal tears in young active patients has shown good results at mid- and long-term follow-up, complex horizontal tears (cleavage associated with meniscal flaps) are often treated by arthroscopic subtotal meniscectomy. The aim of this study was to evaluate long-term outcomes after arthroscopic removal of meniscal flaps associated with an open meniscal repair for treating complex lesions in young active patients. The hypothesis was that this salvage procedure would be efficient in such rare cases. METHODS: Fourteen patients underwent an arthroscopic partial meniscectomy associated with an open meniscal repair to treat a painful complex horizontal meniscal cleavage between 2005 and 2010. There were two females and 12 males with a median age of 28.4 years (range 15-48 years). Patients were assessed by KOOS and IKDC scores, return to sport and the need for a secondary meniscectomy. RESULTS: Thirty patients were evaluated at a median follow-up of 8.5 years (range 7-12 years). One patient required revision of a partial meniscectomy and one other a meniscal replacement (15% failure rate). All other patients showed improvement with regard to their symptoms and returned to sports, ten (91%) of them at the same level. The mean IKDC subjective score was 86.1 (± 10.9). The mean KOOS scores were: pain 91.4 (± 7.5), symptoms 91.4 (± 10.2), daily activity 97.1 (± 4), sports 84.4 (± 20.7) and quality of life 84 (± 14.2). For six patients, scores at median follow-up of 2.6 years were available and compared to newly obtained data. IKDC score at 8.6 years follow-up was not significantly different. KOOS scores for daily activity and sports were maintained. CONCLUSIONS: Even in the presence of a complex lesion, horizontal cleavage can be repaired in young patients with good subjective and objective outcomes and a low rate of long-term failure as with other meniscal lesions in young active patients. LEVEL OF EVIDENCE: IV.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique. METHODS: A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document. RESULTS: Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%. CONCLUSIONS: This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols. LEVEL OF EVIDENCE: Consensus of expert opinion, Level V.

Sectioning of the Anterior Intermeniscal Ligament Changes Knee Loading Mechanics.

PURPOSE: The purpose of this cadaver research project was to describe the biomechanical consequences of anterior intermeniscal ligament (AIML) resection on menisci function under load conditions in full extension and 60° of flexion. METHODS: Ten unpaired fresh frozen cadaveric knees were dissected leaving the knee joint intact with its capsular and ligamentous attachments. The femur and tibia were sectioned 15 cm from the joint line and mounted onto the loading platform. A linear motion x-y table allows the tibial part of the joint to freely translate in the anterior-posterior direction. K-scan sensors were used to define contact area, contact pressure, and position of pressure center of application (PCOA). Two series of analysis were planned: before and after AIML resection, mechanical testing was performed with specimens in full extension (1,400 N load) and in 60° of flexion (700 N load) to approximate heel strike and foot impulsion during the gait. RESULTS: Sectioning of the AIML produced mechanical variations below the 2 menisci when specimens were at full extension and loaded to 1,400 N: increasing the mean contact pressure (delta 0.4 ± 0.2 MPa, +15% variation P = .008) and maximum contact pressure (delta 1.50 ± 0.8 MPa, 15% variation P < .0001) and decreasing of tibiofemoral contact area (delta 71 ± 51 mm2, -15% variation P < .0001) and PCOA (delta 2.1 ± 0.8 mm). At 60° flexion, significant differences regarding lateral meniscus mechanical parameters were observed before and after AIML resection: mean contact pressure increasing (delta 0.06 ± 0.1 MPa, +21% variation P = .001), maximal contact-pressure increasing (delta 0.17 ± 0.9 MPa, +28% variation P = .001), mean contact area decreasing (delta 1.84 ± 8 mm2, 4% variation P = .3), and PCOA displacement to the joint center (mean displacement 0.6 ± 0.5 mm). CONCLUSIONS: The section of the intermeniscal ligament leads to substantial changes in knee biomechanics, increasing femorotibial contact pressures, decreasing contact areas, and finally moving force center of application, which becomes more central inside the joint. CLINICAL RELEVANCE: AIML resection performed ex vivo in this study, might potentially be deleterious in vivo. Clinical studies focusing on preserving or even repairing the AIML are needed to evaluate those ex vivo elements.