Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft.

BACKGROUND: Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. METHODS: This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. RESULTS: A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. CONCLUSION: In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Extensor mechanism reconstruction with allograft following total knee arthroplasty: a systematic review and meta-analysis of achilles tendon versus extensor mechanism allografts for isolated chronic patellar tendon ruptures.

BACKGROUND: Extensor mechanism rupture is a severe complication with an incidence of 0.1-2.5% after total knee arthroplasty (TKA). Achilles tendon allograft (ATA) and extensor mechanism allograft (EMA) in TKA surgery have yielded mixed clinical results. Our systematic review aims to identify the proportion of failure in extensor mechanism reconstruction after TKA using allograft and evaluate clinical and functional outcomes and the most common complications. Furthermore, we performed a meta-analysis among studies dealing with isolated patellar tendon ruptures to assess the failure rate, surgical complications, and clinical findings (extensor lag and knee range of motion) of extensor mechanism reconstruction using either ATA or EMA grafts. METHODS: A systematic review of the literature was performed following the PRISMA guidelines, including the studies dealing with the use of EMA and ATA for extensor mechanism rupture following TKA. Coleman Methodology Score and the MINORS score were used to assess the quality of the studies. A meta-analysis was performed to evaluate the failure rate, complications, and clinical findings (extensor lag and knee range of motion) of the ATA and EMA treatments in isolated patellar tendon ruptures. RESULTS: A total of 238 patients (245 knees), with a mean age ranging from 54 to 74 years, who underwent extensor mechanism reconstruction with an allograft were identified in the 18 included studies. We analysed 166 patellar tendon ruptures, 29 quadriceps tendon ruptures, and 29 patellar fractures in the analysis. A chronic injury was described in the majority of included cases. ATA and whole EMA were used in 89 patients (92 knees) and 149 patients (153 knees), respectively. The overall failure percentage was 23%, while EMA and ATA were 23 and 24%. The most common complication was extensor lag (≥ 20°). The overall incidence of postoperative infection was 7%. Eleven of 14 included papers reported more than 100° of the mean postoperative knee flexion. The percentage of patients requiring walking aids is 55 and 34.5% in ATA and EMA, respectively. The failure outcome after extensor mechanism reconstruction in isolated patellar tendon ruptures was 27%, with no statistical difference between EMA and ATA in terms of failure rate and clinical outcomes. CONCLUSIONS: Extensor mechanism reconstruction with allograft represents a valid treatment option in patients with acute or chronic rupture following total knee arthroplasty. Persistent extensor lag represents the most common complication. EMA is associated with a lower frequency of patients requiring walking aids at last follow-up, although it has similar clinical and functional outcomes to ATA. In patellar tendon ruptures, ATA has a comparable success rate with EMA. LEVEL OF EVIDENCE: Level IV, therapeutic study. TRIAL REGISTRATION: PROSPERO 2019 CRD42019141574.

Repair of Chronic Patellar Tendon Rupture with Extensor Mechanism Allograft Augmentation.

The purpose of this study was to evaluate the effectiveness of our novel chronic patellar tendon repair with allograft augmentation in an active-duty military population. From 2014 to 2018, five patients with chronic patellar tendon ruptures were treated with a primary repair of the patellar tendon augmented with Achilles tendon allograft. All patients were followed for 12 months, and their range of motion, Lysholm scores, and straight leg raise ability were assessed. Additionally, their return to active military duty was followed. All patients were managed with tendon reapproximation and Achilles allograft augmentation. Lysholm scores improved in all patients from an average of 35 to 87 postoperatively. No patients demonstrated postoperative extensor lag, and patients regained an average flexion of 130 degrees. All patients returned to active military duty. We presented a safe and effective technique to manage chronic patellar tendon ruptures that produced good outcomes. (Journal of Surgical Orthopaedic Advances 32(3):242-245, 2023).

Distal biceps tendon repairs and reconstructions-an analysis of demographics, prodromal symptoms and complications.

INTRODUCTION: The purpose of this study was to evaluate the demographics, complications and prodromal symptoms (any pain or unpleasant sensation in the area distal biceps tendon preceding the injury) of distal biceps tendon tears (DBTTs) of patients treated with primary repair or Achilles allograft reconstruction. MATERIALS AND METHODS: 228 consecutive DBTTs in 226 patients from a single centre were evaluated. The demographic data, prodromal symptoms and postoperative adverse events were documented. RESULTS: There were 225 males and 1 female patient. The age distribution showed a bimodal pattern in the whole cohort, but once the 48 (20%) elite athletes were excluded, the age was normally distributed, peaking in the 5th decade. Direct repairs were performed in 184 cases and reconstruction with Achilles tendon allograft in 45 cases. An adverse event was observed in 34 (19%) patients who underwent direct repair and in 3 (7%) cases with graft reconstruction, corresponding to RR of 0.32 (95% CI 0.1-0.96, p = 0.04). Adjusting with the potential confounders (age, occupation and smoking), the OR was 0.35; 95% CI 0.09-1.3, p = 0.11). Adverse events included 28 (12.3% of all adverse events) lateral antebrachial cutaneous nerve (LABCN) neurapraxias, 5 (2.1%) other neurapraxias, 6 (2.6%) heterotopic ossifications and 1 (0.4%) re-rupture. Twenty-three (10%) patients reported prodromal symptoms before the tear. CONCLUSIONS: DBTT is a condition that affects men predominantly. The observed bimodal incidence distribution was related to elite athletes, but in the normal population the peak occurs at the age typical to tendinopathies. LABCN neurapraxia was the most common adverse event, and graft use does not seem to predispose to adverse events.

Extracellular Vesicle-Educated Macrophages Promote Early Achilles Tendon Healing.

Tendon healing follows a complex series of coordinated events, which ultimately produces a mechanically inferior tissue more scar-like than native tendon. More regenerative healing occurs when anti-inflammatory M2 macrophages play a more dominant role. Mesenchymal stromal/stem cells (MSCs) are able to polarize macrophages to an M2 immunophenotype via paracrine mechanisms. We previously reported that coculture of CD14+ macrophages (MQs) with MSCs resulted in a unique M2-like macrophage. More recently, we generated M2-like macrophages using only extracellular vesicles (EVs) isolated from MSCs creating "EV-educated macrophages" (also called exosome-educated macrophages [EEMs]), thereby foregoing direct use of MSCs. For the current study, we hypothesized that cell therapy with EEMs would improve in vivo tendon healing by modulating tissue inflammation and endogenous macrophage immunophenotypes. We evaluated effects of EEMs using a mouse Achilles tendon rupture model and compared results to normal tendon healing (without any biologic intervention), MSCs, MQs, or EVs. We found that exogenous administration of EEMs directly into the wound promoted a healing response that was significantly more functional and more regenerative. Injured tendons treated with exogenous EEMs exhibited (a) improved mechanical properties, (b) reduced inflammation, and (c) earlier angiogenesis. Treatment with MSC-derived EVs alone were less effective functionally but stimulated a biological response as evidenced by an increased number of endothelial cells and decreased M1/M2 ratio. Because of their regenerative and immunomodulatory effects, EEM treament could provide a novel strategy to promote wound healing in this and various other musculoskeletal injuries or pathologies where inflammation and inadequate healing is problematic. Stem Cells 2019;37:652-662.

The effect of autologous Achilles bursal tissue implants in tendon-to-bone healing of rotator cuff tears in rats.

BACKGROUND: The aim of this study was to investigate the influence of autologous bursal tissue derived from the Achilles bursa on tendon-to-bone healing after rotator cuff tear repair in a rat model. METHODS: A total of 136 Sprague-Dawley rats were randomly assigned to either an untreated or a bursal tissue application group or biomechanical testing and histologic testing after rotator cuff repair. After separating the supraspinatus tendon close to the greater tuberosity, the tendon was reattached either unaltered or with a bursal tissue interposition sewn onto the interface. Immunohistologic analysis was performed 1 and 7 weeks after supraspinatus tendon reinsertion. Biomechanical testing of the tendon occurred 6 and 7 weeks after reinsertion. RESULTS: Immunohistologic results demonstrated a significantly higher percentage of Type II collagen (P = .04) after 1 and 7 weeks in the tendon-to-bone interface using autologous bursal tissue in comparison to control specimens. The bursa group showed a significantly higher collagen I to III quotient (P = .03) at 1 week after surgery in comparison to the 7-week postsurgery bursa groups and controls. Biomechanical assessment showed that overall tendon stiffness (P = .002) and the tendon viscoelasticity in the bursa group (P = .003) was significantly improved after 6 and 7 weeks. There was no significant difference (P = .55) in force to failure between the bursa group and the control group after 6 and 7 weeks. CONCLUSION: Autologous bursal tissue derived from the Achilles bursa and implanted to the tendon-to-bone interface after rotator cuff repair facilitates a faster healing response to re-establish the biologic and biomechanical integrity of the rotator cuff in rats.

Excision Arthroplasty With Interpositional Achilles Tendon Autograft: A Novel Approach to Talonavicular Joint Osteoarthritis Associated With Ankle Arthrodesis.

Talonavicular joint arthritis is a great concern after ankle fusion. Although arthrodesis is the gold standard treatment for this complication, it could initiate a vicious cycle of further adjacent joint arthritis. An alternative that may delay or eliminate the need for arthrodesis is excision arthroplasty; however, there are only a few reports on its application on a talonavicular joint. We report 3 cases of excision arthroplasty with interpositional Achilles tendon autograft for the treatment of end-stage talonavicular osteoarthritis in low-demand elderly patients. In 1 patient, excision arthroplasty was performed after tibiotalocalcaneal arthrodesis, and in 2 patients, it was performed after tibiotalar arthrodesis, in which the subtalar joints were also damaged and fused simultaneously on performance of the interpositional arthroplasty of the talonavicular joint. In all cases, pain relief and functional activities of daily living improvement were achieved with this procedure. At a minimum follow-up of 1 year, no patient reported adjacent joint symptoms or flatfoot progression. These cases show that interpositional arthroplasty with Achilles tendon autograft is an effective treatment for end-stage talonavicular arthritis in patients with fused ankle and subtalar joints. This procedure was helpful in relieving pain and improving activities of daily living function in low-demand elderly patients with the preservation of movement of the talonavicular joint. Autograft was considered to be superior to other grafts with respect to availability, graft rejection, or allergy development. Fused subtalar joint resolved the concerning issues, such as flatfoot progression and muscular weakness of ankle plantar flexion, associated with this procedure.

Bridging Repair of Large Rotator Cuff Tears Using a Multilayer Decellularized Tendon Slices Graft in a Rabbit Model.

PURPOSE: The purpose of this study was to evaluate the efficacy of an extracellular matrix scaffold with multilayer decellularized tendon slices (MDTSs) for reconstructing large rotator cuff tears in a rabbit model. METHODS: Large defects in the infraspinatus tendons were created bilaterally in 36 rabbits. The graft group underwent bridging repair of the defects with the MDTSs grafts from Achilles tendons of adult beagle dogs, and the control group underwent repair with the autologous excised tendon. Specimens underwent histologic observation, biomechanical testing, and microcomputed tomography analysis at 2, 4, and 8 weeks after surgery. RESULTS: Histologic analysis confirmed that the MDTSs graft promoted cell ingrowth and tissue integration, and fibrocartilage and Sharpey fibers formed at the enthesis at 8 weeks. Accordingly, the MDTSs graft generated a histologic appearance similar to that of the autogenous tendon graft. Mechanical testing revealed a significant increase of the regenerated tendons in ultimate load and stiffness from 4 to 8 weeks postoperatively, which was similar to autologous tendon repair. Microcomputed tomography analysis demonstrated that the MDTSs graft promoted bone formation at the tendon-bone insertion, thus improving the mechanical properties of the repair tendon. CONCLUSIONS: The MDTSs graft used to bridge large rotator cuff defects in a rabbit model promoted host cell ingrowth, enhanced the remodeling of regenerated tendon, and promoted fibrocartilage formation, thus improving the biomechanical properties of the repaired tendon. This study thereby provides fundamental information for rotator cuff regeneration with the MDTSs graft. CLINICAL RELEVANCE: Rotator cuff regeneration using MDTSs grafts is a promising procedure for large rotator cuff tears.

Short- to mid-term outcomes of anatomic MCL reconstruction with Achilles tendon allograft after multiligament knee injury.

PURPOSE: Multiple techniques have been described in the literature for reconstruction of the medial collateral ligament. The purpose of this study is to describe functional outcome, range of motion, and knee stability following anatomic MCL reconstruction utilizing an Achilles tendon bone allograft after multiligament knee injury. METHODS: A comprehensive search of a single-hospital multiligament knee injury (MLKI) procedural database was conducted to identify all patients that underwent reconstruction of the MCL utilizing an Achilles tendon bone allograft and with 2-year clinical follow-up. Medical charts were retrospectively reviewed to determine each patient's knee dislocation (KD) grade, final range of motion, stability on clinical examination, and the incidence of complications and reoperations. KOOS, IKDC, and Marx scores were also collected. RESULTS: Thirty-two knees in 32 patients (21 males and 11 females) with a mean age of 30 years (range 15-51) were followed for an average of 40 months (range 28-87 months) following MCL reconstruction with Achilles tendon bone allograft. For patients with multiligament knee injuries, there were 14 KD-I (11 ACL/MCL; 3 MCL/PCL; 1 MCL/ACL/LCL; 1 MCL/PCL/LCL), 12 KD 3-M, and 3 KD-IV. One patient underwent isolated revision MCL reconstruction. At final follow-up, clinically significant valgus laxity was observed in only 1 patient (3%). All patients were able to achieve full extension of the knee and the average flexion was 121.1 ± 19.6. The average IKDC score was 67.6 ± 19.9 (range 27.7-98.9), the average KOOS score 77.1 ± 16.8 (range 31-100). The average Marx score was 4.9 (range 0-16, SD 5.2). Thirty-one of 32 (96%) patients reported being satisfied with results of the surgery. Knee dislocation grades were significantly correlated with post-operative outcome measures. CONCLUSION: In a series utilizing a modified Marx Achilles tendon, MCL reconstruction in the setting of MLKI demonstrated satisfactory clinical and functional outcomes, as well as patient satisfaction at short- to mid-term follow-up. Furthermore, knee dislocation grades were demonstrated to correlate with post-operative IKDC, KOOS, and Marx scores. LEVEL OF EVIDENCE: Type IV.

The use of Achilles tendon allograft for latissimus dorsi tendon reconstruction: a minimally invasive technique.

Treatment of subacute, retracted latissimus dorsi and teres major tendon ruptures in young overhead athletes is challenging. This case report describes management of a subacute retracted latissimus dorsi and teres major rupture with Achilles tendon allograft reconstruction using a two-incision minimally invasive technique. Level of evidence V.

Surgical options for chronic patellar tendon rupture in total knee arthroplasty.

PURPOSE: The purpose of this study was to compare mid-term results of three different reconstructive techniques for chronic patellar tendon disruption after total knee arthroplasty (TKA). Several surgical techniques have been proposed, but to date it is still unclear which is the best solution. The hypothesis was that allografts provide better functional results than autografts in restoring a correct joint function. METHODS: Twenty-one reconstructions were performed in twenty-one patients (three groups of seven patients) with chronic patellar tendon lesion following TKA. Group I underwent reconstruction with an Achilles tendon allograft with a calcaneal block, Group II with an autograft of the quadriceps tendon reinforced by the semitendinosus tendon and Group III with a full extensor mechanism allograft consisting of the tibial tubercle, patellar tendon, patella, and quadriceps tendon. Preoperatively and at each follow-up, the value of the extensor lag and the Knee Score (KS) were recorded. RESULTS: The mean extensor lag decreased from 50° ± 19.4° to 3° ± 1.6°. The KSS improved from 44.7 ± 20.5 to 78.9 ± 13.6 points. The comparison between the groups showed statistically significant differences in the mean postoperative KS between Groups I (average score of 87.7 ± 14.3 points) and II (average score of 70 ± 4.1 points), but not between Groups I and III (average score of 78.9 ± 14.6 points) or between Groups II and III. Differences in the postoperative extensor lag were not significant between the three groups. CONCLUSIONS: The present study may serve surgeons in choosing the best reconstructive strategy for a chronic patellar tendon lesion in TKA. According to the reported results, an Achilles tendon allograft should be considered the gold standard repair. The autograft technique is suitable when the host tissue is competent, particularly when dealing with younger patients or post-infection. A full extensor mechanism allograft may represent a reliable solution when the defect involves the patellar bone or the quadriceps tendon. LEVEL OF EVIDENCE: IV.

Effect of radiocapitellar Achilles disc arthroplasty on coronoid and capitellar contact pressures after radial head excision.

BACKGROUND: Long-term radiographic arthritis has been commonly reported after radial head excision. Concern over radial head arthroplasty may arise in certain situations including capitellar arthritis, radiocapitellar malalignment, and in young and active patients. We hypothesized that radial head excision increases coronoid contact pressures, which may at least be partially reduced by radiocapitellar Achilles tendon disc arthroplasty. METHODS: Coronoid and capitellar contact pressure was measured on 6 human cadaveric elbows on a custom-designed gravity-valgus simulator under passive flexion from 0° to 90°. Sequential testing, starting with the intact specimen, resection of the radial head, and finally, radiocapitellar Achilles tendon disc arthroplasty were performed on each specimen. RESULTS: Mean contact pressure of the coronoid significantly increased after radial head excision (P < .0001) and significantly improved after Achilles disc arthroplasty (P < .0001). The pressure difference was most pronounced on the lateral coronoid. From 15° to 85° of elbow flexion, mean contact pressures on the lateral coronoid were 291 kPa and 476 kPa before and after radial head excision, respectively (P < .0001). Achilles disc arthroplasty significantly lowered coronoid contact pressures to 385 kPa (P = .002); however, they remained significantly higher than those in the intact radial head group (P = .0009). CONCLUSIONS: Radial head resection increases contact pressure in the coronoid, especially the lateral coronoid. This study showed that radiocapitellar Achilles disc arthroplasty significantly improves contact pressures on the coronoid after radial head resection. Achilles disc arthroplasty could be considered in patients who are not candidates for radial head arthroplasty.

Long-term results of extensor mechanism reconstruction using Achilles tendon allograft after total knee arthroplasty.

PURPOSE: Disruption of the extensor mechanism after total knee arthroplasty (TKA) is an infrequent but devastating complication. Presently, limited data exists regarding the optimal treatment and long-term outcomes. METHODS: Patients who underwent reconstruction of their knee extensor mechanism using Achilles tendon allograft following TKA between January 2003 and January 2012 were identified. Sixteen patients with 17 reconstructions (10 patellar tendons, 7 quadriceps tendons) were studied. All patients underwent evaluation at an average of 45.7 months. Ten of the patients were followed to an average of 65.4 months. RESULTS: After reconstruction, the average extensor lag was 6.6° and average knee flexion was 105.1°. Of the patients with a minimum follow-up of two years and an average follow-up of 65.4 months, the average extensor lag and knee flexion was 8.4° and 107.9°, respectively, with quadriceps strength maintained at an average of 4/5. The quadriceps tendon reconstructions had an average extensor lag and flexion of 2.9° and 103°, respectively. The patellar tendon reconstructions, excluding one re-rupture, had an average extensor lag and flexion of 9.6° and 105.1°, respectively. Four patients died during the follow-up period. All but one of the patients were below the mean for age-matched controls on the SF-36. CONCLUSION: Achilles tendon allograft reconstruction is a reliable and durable treatment for patients who sustain not only patellar tendon ruptures, but also quadriceps tendon ruptures following TKA. Despite the success of this technique, the injury and procedure have a profound impact on overall function.

Achilles tendon allograft-augmented latissimus dorsi tendon transfer for the treatment of massive irreparable posterosuperior rotator cuff tears.

INTRODUCTION: The purpose of this study was to investigate clinical outcomes following Achilles tendon allograft-augmented latissimus dorsi tendon transfer (LDTT) for the treatment of irreparable posterosuperior rotator cuff tears with a minimum of 2 years post-operative follow-up. We hypothesized that patients would show significant improvement in outcomes scores with a low failure rate. MATERIALS AND METHODS: Patients who were treated with Achilles tendon allograft-augmented LDTT for irreparable posterosuperior rotator cuff tears with a minimum follow-up of 2 years were included. Patient-reported outcomes scores, including ASES, QuickDASH, SANE, SF-12 PCS, and satisfaction, were collected pre- and post-operatively. Pre- and post-operative scores were compared with a Wilcoxon test. Revision to reverse total shoulder arthroplasty (RTSA) was considered as failure. RESULTS: Between March 2006 and November 2014, a total of 16 patients with a mean age of 49 years (range 34-57 years) were included. Minimum 2-year outcomes data were available for 14 of the 16 patients (87.5%) with a mean follow-up of 5.5 years (range 2.1-10.5 years). Two patients (12.5%) advanced to RTSA at a mean of 1.1 years following LDTT. Postoperative median subjective outcomes scores improved, but did not reach statistical significance (SF-12 PCS: 35.4-46.4, P = 0.182; ASES: 47.5-69.9, P = 0.209; QuickDASH: 57.9-31.8, P = 0.176; SANE: 40.0-39.5, P = 0.273). Median post-operative patient satisfaction was 5 on a 10-point scale (range 1-10). CONCLUSION: Patients with irreparable rotator cuff tears treated with Achilles tendon allograft-augmented latissimus dorsi tendon transfer did not experience significant post-operative improvement in patient-reported outcomes. Thus, the use of an additional allograft-augmentation remains questionable. LEVEL OF EVIDENCE: Retrospective case series, level IV.

Evaluating the Femoral-Side Critical Corner in Posterior Cruciate Ligament Reconstruction: The Effect of Outside-In Versus Inside-Out Creation of Femoral Tunnels on Graft Contact Pressure in a Synthetic Knee Model.

PURPOSE: To characterize and compare the graft contact characteristics of outside-in (OI) and inside-out (IO) femoral tunnels during single-bundle reconstruction of the anterolateral bundle of the posterior cruciate ligament in a synthetic knee model. METHODS: Femoral tunnels were separately made in 16 synthetic femora (8 OI and 8 IO). Achilles tendon allografts were fixed using suspensory fixation with a pressure sensor between the allograft and femoral tunnel. Grafts were cyclically loaded; force, contact area, contact pressure, and peak pressure at the aperture were measured. This process was repeated using the same allograft to assess the other tunnel angle in a separate specimen. RESULTS: IO specimens showed higher mean contact pressure at all loading cycles, with significance shown at 50 N (P = .02). Peak pressure was also greater in IO specimens at all loading cycles and reached statistical significance at 100 N (P = .04). IO specimens had a lower contact area at 150 N (P = .04). No statistically significant differences in force were observed between the 2 groups. CONCLUSIONS: OI creation of the femoral tunnel for anterolateral bundle reconstruction of the posterior cruciate ligament resulted in decreased mean and peak contact pressures at the femoral aperture compared with IO tunnel creation at the specific trajectories and loading parameters tested in this synthetic femoral model. These biomechanical data suggest that OI creation of the femoral tunnel may help reduce in vivo graft contact pressure at the femoral aperture. CLINICAL RELEVANCE: These data suggest that a tunnel drilled from OI may result in less graft pressure at the femoral aperture, which may prevent graft elongation and optimize graft survival.

Remnant-preserving and re-tensioning technique to cover the graft in anterior cruciate ligament reconstruction.

PURPOSE: This study set out to assess the clinical and radiographic outcomes and the extent of synovial coverage on second-look arthroscopy of anterior cruciate ligament (ACL) reconstruction using a remnant-preserving and re-tensioning technique to easily cover the graft with a remnant. METHODS: Forty-three subjects with ACL rupture underwent remnant-preserving and re-tensioning ACL reconstruction using a free tendon Achilles allograft between 2011 and 2013. The clinical outcomes were assessed by Lysholm knee score, Lachman stress test, pivot shift test, International Knee Documentation Committee (IKDC) classification, and Tegner Activity Scale score. Side-to-side difference (SSD) was assessed on stress radiographs. The extent of synovialization was evaluated on second-look arthroscopy. RESULTS: The mean Lysholm score was 54 ± 11 before surgery and 94 ± 5 at the last follow-up (p < 0.001). On Lachman stress test, 42 subjects had grade 0 or 1 on the Lachman stress test, and 42 had grade 0 or 1 on the pivot shift test. Forty-one subjects had IKDC classification A or B; two were classified as C or D. The median Tegner Activity Scale score was 6.5 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.048). Mean SSD on stress radiographs was 9.9 ± 2.6 mm preoperatively and 1.0 ± 1.7 mm at the last follow-up (p < 0.001). In the assessment of the extent of synovial coverage of the graft, 39 subjects were in group 1 (>75 %) for synovial coverage of the graft, three were in group 2 (50-75 %), and one was in group 4 (≤25 %). CONCLUSIONS: The remnant-preserving and re-tensioning technique resulted in satisfying short-term results clinically and radiologically and good synovial coverage on second-look arthroscopy. LEVEL OF EVIDENCE: Case series, Level IV.

Multiple looping technique for tibial fixation in posterior cruciate ligament reconstruction using free tendon Achilles allograft.

PURPOSE: This study was conducted to evaluate case series outcomes of a new tibial fixation technique using a free tendon graft during posterior cruciate ligament (PCL) reconstruction which is less affected by tibial metaphysis bone density. METHODS: Thirty-two subjects underwent single-bundle PCL reconstruction using a free tendon Achilles allograft. The graft was looped to be double stranded. The free ends of the graft were fixed to the femoral side using suture washer, and the looped end was fixed to the tibial side using the multiple looping technique. Range of motion of the knee and side-to-side difference were assessed at the last follow-up. The Lysholm Knee score was evaluated preoperatively and at the last follow-up. The Tegner Activity Scale score was evaluated before injury and at the last follow-up. RESULTS: Twenty-eight subjects were followed up for at least 18 months. Mean follow-up was 27.7 ± 4.8 months. All subjects showed normal range of motion at the last follow-up. The mean side-to-side difference was 10.4 ± 2.8 mm preoperatively and 2.3 ± 1.8 mm at the last follow-up (p < 0.001). The mean Lysholm Knee score was 58 ± 9 preoperatively and 91 ± 5 at the last follow-up (p < 0.001). The median Tegner Activity Scale score was 7 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.001). CONCLUSIONS: The multiple looping technique for tibial fixation resulted in satisfactory outcomes from single-bundle PCL reconstruction without any significant complications. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel.

PURPOSE: Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries, and lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot reconstruction. The purpose of this study was to evaluate the outcomes of combined PCL/MCL reconstruction using a single femoral tunnel with a minimum 2-year follow-up. METHOD: A retrospective study of thirteen patients with combined PCL/MCL injuries was conducted. The patients underwent PCL and MCL reconstruction using an Achilles tendon allograft with a single tunnel in the medial femoral condyle, thereby avoiding tunnel conversion. RESULTS: All patients achieved a range of motion of at least 100°. The mean loss of extension and flexion values compared to the contralateral side was 1° ± 2° and 9° ± 10°, respectively. Our results included 26 reconstructions with three (11.5 %) failures, two in the PCL (15.3 %) and one in the MCL (7.6 %), in three different patients. In the final evaluation, the mean IKDC subjective score was 71.63 ± 16.23, the mean Lysholm score was 80.08 ± 13.87, and the median Tegner score was 6 (range = 2-7). CONCLUSION: The PCL/MCL reconstruction technique using a single femoral tunnel and an Achilles tendon allograft is safe, avoids the convergence of tunnels in the medial femoral condyle, has excellent results, and is reproducible. LEVEL OF EVIDENCE: IV.

Anterior hip capsuloligamentous reconstruction with Achilles allograft following gross hip instability post-arthroscopy.

The increasing use of hip arthroscopy has led to further development in our understanding of hip anatomy and potential post-operative complications. Iatrogenic gross hip instability following hip arthroscopy is a concerning complication described in recent orthopaedic literature. Post-arthroscopy hip instability is thought to be multifactorial, related to a variety of patient, surgical and post-operative factors. Given its infrequency, there is scarcity of literature describing appropriate surgical management and operative technique for addressing this instability. This study reports a case of gross hip instability following hip arthroscopy, describing a novel technique of management through anterior hip capsuloligamentous reconstruction with Achilles tendon allograft. Level of evidence V, Case Study.

Reconstruction of Disrupted Extensor Mechanism After Total Knee Arthroplasty.

BACKGROUND: Disruption of the extensor mechanism after total knee arthroplasty (TKA) is a debilitating complication that results in extension lag, limited range of motion, difficulty in walking, frequent falls, and chronic pain. This study presents the clinical and radiographic results of reconstruction after extensor mechanism disruption in TKA patients. METHODS: Consecutive patients with allograft reconstruction of extensor mechanism after TKA were identified retrospectively from an academic tertiary center for revision TKA. RESULTS: Sixteen patients with a mean age of 61 ± 14 years at extensor mechanism reconstruction with a minimum of 2-year follow-up were included. The mean follow-up was 3.3 ± 2.2 years. Knee Society score (KSS), before and at final follow-up extension lag, range of motion, and radiographic change in patellar height were reviewed. There were statistically significant improvements between preoperative and final follow-up KSS (P < .001; KSS for pain, preoperative 40 ± 14 points to final follow-up 67 ± 15 points [P < .001]; KSS for function, preoperative 26 ± 21 points to final follow-up 48 ± 25 points [P < .001]). The extension lag was also reduced from 35° ± 16° preoperatively to 14° ± 18° (P < .001) at final follow-up. There was an average proximal patellar migration of 8 ± 10 mm. Five (31%) cases had an extensor lag of >30° or revision surgery for repeat extensor mechanism reconstruction, infection, or arthrodesis. CONCLUSION: Our 10-year experience using allografts during extensor mechanism reconstruction demonstrates reasonable outcomes, but failures are to be anticipated in approximately one-third of patients.