How does anterior glenoid bone loss affect shoulder stability? A cadaveric analysis of glenoid concavity and bony shoulder stability ratio.

BACKGROUND: Concavity compression is an important glenohumeral stabilizing factor, and recent studies have suggested that peripheral glenoid bone loss creates the most relevant change in stability. This study analyzed changes in the bony shoulder stability ratio (BSSR) with sequential anterior glenoid bone loss (0%-40% width) and with reconstructive bone graft procedures. The aim was to quantify the critical bone defect size that would significantly alter the BSSR and determine restoration of the BSSR with the Latarjet procedure. METHODS: Anterior glenoid defects were created with sequential osteotomies (10%-40%), and defects were reconstructed using 2 Latarjet modifications (classic Latarjet procedure and congruent-arc Latarjet [CAL] procedure). We obtained 108 computed tomography scans of (1) intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). The glenoid concavity depth and concavity radius were measured, and the BSSR was determined using a validated mathematical formula. Statistical analysis was performed to determine significant differences between the intact state and each of the deficient and reconstructed glenoids. RESULTS: The glenoid concavity radius increased by approximately 30% (14 mm) and the glenoid concavity depth decreased by 50% (1.5 mm) from the 0% to 40% defect. The maximal sequential change in depth (1.2 mm, 44%; P < .001) and radius (6 mm, 12%; P < .001) occurred at the 10% glenoid defect. The overall BSSR decreased by approximately 40% (0.15) from the intact glenoid to the 40% defect. This change in the BSSR was most profound (0.11, 30%; P < .001) at the 10% glenoid defect and was only marginal thereafter between the 20% and 40% defects (0.24, 0.22, and 0.21). The Latarjet procedure adequately restored glenoid concavity; however, the CAL procedure significantly overcorrected all 3 parameters at 10% defect. CONCLUSION: The glenoid concavity depth and BSSR undergo progressive deformation with sequential bone loss, and 90% of this change occurs with a 10% glenoid defect. Articular concavity and the BSSR are adequately restored with the Latarjet procedure, and the CAL procedure significantly overcorrects concavity in mild (0%-10%) defects.

Tegner level is predictive for successful return to sport 2 years after anterior cruciate ligament reconstruction.

PURPOSE: For a successful return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR), patients are recommended to attend a comprehensive rehabilitation program, followed by an RTS assessment, that is a combination of tests. The purpose of this study was to predict a successful return to sport using the results of the RTS assessment and self-reported questionnaires at minimum 2 years after ACLR. METHODS: A total of 123 consecutive ACLR patients undertook an intensive rehabilitation program followed by a comprehensive RTS assessment that included an established combination of balance and strength tests, the ACL-return to sport after Injury scale (ACL-RSI) questionnaire and a KT1000 laximetry test. Preinjury and expected Tegner and Lysholm were collected at baseline, at RTS and prospectively collected at minimum 2-year follow-up. The patients were asked if they returned to their previous sport and at which level. All variables were included in a regression analysis predicting a successful return to previous sport, return to the same level of sport as well as the Tegner level at 2 years. RESULTS: Sixty-two patients (50%) returned to their previous sport by the 2-year follow-up, without a difference in preinjury Tegner between these two groups (n.s.). Expected preoperative Tegner was the only significant predictor of a successful return to previous sport (p = 0.042; OR 1.300, 95% CI 1.010-1.672). Out of the 62 patients returning to their previous sport, 38 (61%) reported to be on the same or higher level. The only predictive variable for returning to the same level was the higher preinjury Tegner level (p = 0.048; OR 1.522). Multivariate regression analysis of Tegner level at 2 years found younger age to be the only predictive value. From the RTS assessment tests, the ACL-RSI questionnaire and the posterolateral balance test were predictive variables for Tegner at 2-year follow-up, albeit in the univariate regression analysis. CONCLUSIONS: Preoperative Tegner and expected Tegner level collected prior to an ACL reconstruction can aid in the objective prediction of patients' return to sport after 2 years. High-level athletes are more likely to return to their previous sport and to the previous level. Younger patients achieve a higher Tegner level at 2 years. LEVEL OF EVIDENCE: Level III study.

Clinical Outcomes of Arthroscopic Primary Anterior Cruciate Ligament Repair: A Systematic Review from the Scientific Anterior Cruciate Ligament Network International Study Group.

PURPOSE: To perform a systematic review of contemporary studies reporting clinical outcomes of primary anterior cruciate ligament (ACL) repair to determine whether these studies demonstrate any significant benefit of ACL repair and whether there is evidence of a deterioration of mid-term outcomes as seen in historical data. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A PubMed search using the keywords "repair" AND "Anterior Cruciate Ligament" was performed (limits: English language, publication date between January 1, 2014, and January 13, 2019). All identified studies reporting clinical outcomes of arthroscopic ACL repair were included. Critical appraisal was conducted using the Cochrane Risk of Bias Tool for Randomized Clinical Trials and the Methodological Index for Non-Randomized Studies. Basic parameters of each study including population characteristics, repair technique, physical examination findings, and clinical outcome scores were recorded and evaluated. RESULTS: Nineteen eligible studies were identified (including 5 comparative studies). None of the comparative studies showed any significant difference between repair and reconstruction groups with respect to International Knee Documentation Committee (IKDC), Lysholm, Tegner, side-to-side laxity difference, Lachman, pivot shift tests, or graft rupture rates. Four non-comparative studies reported outcomes at medium- to long-term follow up (range of mean follow up 43.3-79 months) with a mean Lysholm score between 85.3 and 100, mean IKDC subjective score between 87.3 and 100, and mean Tegner activity score between 5 and 7. CONCLUSIONS: Comparative studies identified no significant differences between ACL repair and reconstruction with respect to Lysholm, IKDC, side-to-side laxity difference, pivot shift grade, or graft rupture rates. However, these studies had major limitations including small numbers and short durations of follow up. Case series demonstrated that excellent outcomes can be achieved at medium- to long-term follow up with the SAR technique. LEVEL OF EVIDENCE: IV; Systematic review of Level II to IV investigations.

Anterior knee translation measurements after ACL reconstruction are influenced by the type of laximeter used.

PURPOSE: Laximeters were designed to diagnose an anterior cruciate ligament (ACL) deficient knee, but their use has now focused on providing an objective assessment of the anterior translation (AT) of an intact and ACL-reconstructed knee. In this study we report the introduction and direct comparison of an automated and computerized AT measurement device, GNRB, with the device previously established by the institute and as the current literature standard, the KT1000. METHODS: A prospective data collection was commenced upon introduction of the GNRB. The measurements of AT in each patient were performed by the same investigator with each device using 134 N applied to both knees, giving a side-to-side difference. The investigators were a sport scientist, a biomechanical engineer and a physiotherapist. Increased AT was defined as a difference > 3 mm. RESULTS: Three investigators performed the measurements in 122 patients, 9.8 (± 1.8) months after ACL reconstruction. Mean AT of the healthy knee was 5.7 mm with KT1000 and 4.4 mm with GNRB (p = 0.002). Mean AT of the ACL reconstructed knee was 7.0 mm with the KT1000 and 5.3 mm with the GNRB (p = 0.037). The KT1000 had a higher variance of results than the GNRB (p < 0.001). There were 25 patients with increased AT measured by KT1000 compared with 12 patients using the GNRB (p < 0.016), with only 5 on both devices. CONCLUSIONS: GNRB has better consistency of results when compared to the KT1000. Both devices lack comparability for detecting increased AT, with the KT1000 recording a side-to-side difference of more than 3 mm in twice as many patients as the GNRB. LEVEL OF EVIDENCE: II.

Healthy knee KT1000 measurements of anterior tibial translation have significant variation.

PURPOSE: The most commonly used arthrometer for measuring and reporting anterior tibial translation after anterior cruciate ligament reconstruction is the KT1000. Reports on its consistency and reproducibility vary in the literature, but it remains the "gold standard". The purpose of this study was to assess agreement of KT1000 measurements in a daily clinical setting. METHODS: A retrospective analysis of anterior knee translation in the healthy knee of 770 patients over a 17-year time period was performed. In this cohort, a total of 24 investigators performed 1890 measurement sets at 89 Newtons (N), 134N and at maximum manual force (MMax) level. To assess the inter- and intra-observer agreement, the intraclass-correlation coefficient (ICC) was calculated. The "investigator effect" was a difference between two examiners in the same patient and the "device effect'' a difference within one examiner in the same patient. Minimally important difference (MID) was calculated as 0.5 of the standard deviation. RESULTS: Thirteen investigators were female, performing 1099 measurements and 11 were male, performing 791 measurements. ICC ranged between 0.558 and 0.644. At the MMax level, male investigators had a higher mm reading than female investigators (p < 0.001). Increased experience did not correlate with a higher ICC. MID ranged between 0.85 and 1.65 mm. CONCLUSION: This study investigated the KT1000 arthrometer in a clinical setting with a large number of investigators. This device delivers moderate agreement of results. Both the device and investigator effect are present. The MMax level has shown the lowest agreement and a dependency on the investigator gender. LEVEL OF EVIDENCE: Level III diagnostic study.

Bone defect-induced alteration in glenoid articular surface geometry and restoration with coracoid transfer procedures: a cadaveric study.

BACKGROUND: This study analyzed the alteration in glenoid articular geometry with increasing anterior bone loss, as well as its subsequent correction with 2 modifications of the Latarjet procedure. METHODS: Anterior defects were simulated by creating glenoid osteotomies (10%, 20%, 30%, and 40%), and defects were reconstructed using 2 Latarjet modifications (classic and congruent arc). A total of 108 computed tomography scans were performed (1) on intact scapulae (n = 12), (2) after each bone defect (n = 48), and (3) after each reconstruction (n = 48). Glenoid parameters (width, area, arc length, and version) were analyzed on computed tomography scans. Statistical analysis was used to determine significant differences between intact, deficient, and reconstructed glenoids. RESULTS: All parameters were reduced with every 10% defect increment (mean change in width, 2.5 mm; area, 64 mm2; version, 2.2°; and arc length, 2.2 mm). Width correction with the classic Latarjet procedure was not statistically significant in 30% and 40% defects. Area correction in 30% defects was not significant with the classic Latarjet procedure and was significantly undercorrected in 40% defects. Version correction was not significant after the classic Latarjet procedure in 20%, 30%, and 40% defects. Arc-length correction was not significant in 20% and 30% defects with the classic Latarjet procedure and was significantly undercorrected in 40% defects. The congruent-arc Latarjet procedure overcorrected glenoid parameters in all defects; however, area and arc length were not significantly different from intact glenoids in 40% defects (P < .05). CONCLUSION: Glenoid articular geometry is progressively altered with a sequential increase in anterior bone defects from 0% to 40%. The classic Latarjet procedure provided significant correction in bone defects of 10% and 20%. The congruent-arc Latarjet procedure restored and overcorrected most parameters even in 40% glenoid defects.

Analysis of technical feasibility and neurovascular safety of endoscopic distal biceps repair: a cadaveric study.

BACKGROUND: This cadaveric study was designed to analyze the safety of endoscopic repair of distal biceps tendon (DBT) tears using 2 reattachment techniques. We evaluated the proximity of neurovascular structures to endoscopy portals; iatrogenic injury to neurovascular, musculotendinous, and osseous structures; and changes in compartment pressures. We hypothesized that an all-endoscopic repair of the ruptured DBT would be technically safe and the risk of iatrogenic injury would be low. METHODS: A 2-portal endoscopic tendon repair was performed in 28 fresh-frozen cadaveric elbows with button devices (with or without interference screws) (n = 17) and suture anchors (n = 11). Dissection was performed, and neurovascular, musculotendinous, and osseous structures were assessed for iatrogenic injury. The repair construct (tendon-tuberosity contact area and implant placement site) was evaluated, and compartment pressures were measured. Statistical analysis was performed to determine significant differences in iatrogenic injury, compartment pressure changes, and tendon-bone contact area between different devices. RESULTS: The lateral cutaneous nerve, cephalic vein, and radial artery were in close proximity to the portals. The button group showed a significantly higher number of iatrogenic injuries than the anchor group (P = .036). All-suture anchor repair showed a significantly higher contact area (mean, 85 mm2) than repairs with all other devices (P < .001). Compartment pressures increased by 2-4 mm in each of the 3 compartments tested (P < .001). CONCLUSION: Endoscopic DBT repair was technically feasible with both fixation techniques. Button devices were associated with a significantly higher number of iatrogenic injuries. Endoscopic repair with dual suture anchors was safe in cadavers; however, further clinical results are necessary to establish the clinical safety of this technique.

Cadaveric Study of Insertional Anatomy of Distal Biceps Tendon and its Relationship to the Dynamic Proximal Radioulnar Space.

PURPOSE: To quantify and assess the relationship between the insertional dimensions of the distal biceps tendon (DBT) and radioulnar space (RUS) in 3 rotational positions. We hypothesized that in all positions RUS would be adequate for the DBT and would remain adequate even after an incremental increase (1 to 3 mm) in tendon thickness. METHODS: Eleven fresh-frozen cadaveric elbows were dissected; DBT dimensions and bicipital tuberosity measurements were performed and insertional footprints were quantified using a distal biceps footprint index. The RUS was measured at 3 levels of the bicipital tuberosity and in 3 positions of forearm rotation. We performed statistical analysis to analyze differences in RUS (positional and inter-level). In addition, significant differences between DBT thickness (native and incremental) and RUS were analyzed to identify potential sites of radioulnar impingement. RESULTS: The DBT had a mean length of 92 mm; thickness ranged from 2.9 to 6.1 mm. Three variations in DBT insertional footprint were observed and quantified. The RUS linear distance reduced significantly from a supinated to a pronated position at each of 3 bicipital tuberosity levels; the reduction was statistically significant at the lower tuberosity level (45%). Pronation RUS distance was adequate for native DBT thickness and was significantly less when DBT thickness increased by 2 and 3 mm. CONCLUSIONS: Radioulnar space reduces significantly from the supinated to the pronated position and is most evident in the lower aspect of the tuberosity. In addition, the RUS in pronation is inadequate for incremental increases in DBT thickness. CLINICAL RELEVANCE: Postoperative DBT impingement in the RUS may be prevented by avoiding techniques that increase the thickness of the tendon and by using a reattachment site at the proximal aspect of the tuberosity.

Effect of Peri-Operative Blood Transfusion on Short and Long-Term Mortality Rates in Elderly Patients With Neck of Femur Fractures: A Retrospective Study.

Introduction  The current reported mortality rate for elderly neck of femur fractures (eNOFF) is relatively high in the UK. eNOFF patients commonly suffer from associated cardiovascular co-morbidities and tend to have fragile physiological states and poor physiological reserves. Although some studies have shown a potential link between blood transfusion and mortality in eNOFF patients, there is no general consensus on this matter. Therefore, our study aims to explore the possible association between blood transfusion and length of hospital stay (LOHS) as well as short- and long-term mortality rates in eNOFF patients by reviewing the practice of blood transfusion. Methods  This retrospective study was conducted at Wrexham Maelor Hospital, which is part of the Betsi Cadwaladr University Health Board (BCUHB), Wales. The study included patients who were 65 years of age or older and presented with neck of femur fractures. Only patients who required surgical intervention were included, and those managed non-operatively were excluded from the study. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, New York, United States). Furthermore, unpaired t-tests and log-rank (Mantel-Cox) tests were performed to compare the groups that received blood transfusions.  Results  During the study period, a total of 501 eNOFF patients were included in the primary cohort of the study, with a mean age of 81 years (ranging from 65 to 102). The majority of the patients were female (n=340). Of the 501 patients, 79 (15.8%) received a blood transfusion during their treatment. Around 52.9% of the eNOFF patients were categorized as American Society of Anesthesiologists (ASA) III, but there was no statistically significant difference in the requirement of blood transfusion between patients in ASA III, II, and IV categories, as compared to ASA I. Additionally, the mean time to surgery was higher in patients who received a blood transfusion (35.8 hours), and this difference was statistically significant (p=0.035). Moreover, the average LOHS after surgery for eNOFF was longer in patients who needed peri-operative blood transfusion (22 days), and this difference in the means was statistically significant (p=0.022). At the one-year post-surgery mark, mortality was higher in the transfused group (33%), and long-term five-year mortality rates were also higher in this group (63.2%).  Conclusion  Peri-operative blood transfusion may confer certain benefits in the management of eNOFF ptients. However, it should not be regarded as a panacea for improving long-term outcomes. The decision to administer blood transfusion must be made on a case-by-case basis, with careful assessment of individual clinical indications, and the potential risks and benefits taken into consideration. To achieve optimal clinical outcomes, close monitoring and follow-up of eNOFF patients, both in the short-term and long-term, are essential.

Long Term Outcomes of Computer-Navigated Lateral Opening Wedge Distal Femoral Osteotomy for Lateral Compartment Knee Arthrosis.

Objective The primary aim of the present study was to evaluate the long-term outcomes including survivorship of computer navigated distal femoral lateral opening wedge osteotomy (DFLOWO). The secondary aim was to identify the potential factors that may influence its survivorship. Methods A retrospective analysis of prospectively collected data for patients with lateral compartment arthritis who underwent navigated DFLOWO from December 2006 to November 2012 was performed. The International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores were analyzed for outcome measures. Conversion to arthroplasty during the follow-up was the end point. Results A total of 19 DFLOWOs were performed in 17 patients with a mean age of 46.6 ± 6.5 years formed the study cohort. The coronal alignment was corrected from a mean of 7.1° (2-11°) valgus to a mean of 2.1° (0.5°-3°) varus. The IKDC scores improved from mean of 39 preoperatively to 53 at the mean long-term follow-up of 9.1 years. The mean KOOS scores at the long-term follow-up were pain 71, symptoms 56, activities of daily living 82, sports and recreation 59, quality of life 43. Survivorship of the DFLOWO was 78.9% at a follow-up of 9.1 years. Presence of ≥ grade 2 according to the International Cartilage Repair Society (ICRS) cartilage degeneration in the medial compartment of the knee and >7° preoperative valgus deformity were strongly correlated with conversion to total knee arthroplasty (TKA) at the long-term follow-up ( r = 0.66). Conclusions Computer navigated DFLOWO has satisfactory clinical outcomes and 79% survivorship in long-term follow-up. Presence of more than ICRS ≥ grade 2 degenerative changes in the medial compartment of knee with > 7° preoperative valgus deformity negatively affects the survivorship of DFLOWO in the long-term follow-up.

Anterior Cruciate Ligament Femoral Socket Preparation Using a Cannulated, Calibrated Drill With Adjustable Stop and Slotted Cannula.

Anteromedial portal-guided femoral tunnel preparation during anterior cruciate ligament reconstruction can be difficult owing to poor visualization. This may cause iatrogenic damage to the medial femoral condyle cartilage and the posterior cruciate ligament fibers or overdrilling through the lateral femoral cortex, creating difficulties in the use of femoral suspensory devices during anterior cruciate ligament reconstruction. We describe an accurate and safe technique for femoral graft socket preparation using a cannulated, calibrated drill with an adjustable stop and slotted cannula. This easy and reproducible technique uses simple additional instruments and effectively addresses concerns related to femoral graft socket preparation, without requiring additional surgical time.

Lateral Hind-Foot Endoscopic Anterolateral/Posterolateral (LEAP) Subtalar Arthrodesis: An Effective Minimally Invasive Technique to Achieve Subtalar Fusion and Deformity Correction.

Arthrodesis surgery aims to provide relief for chronic joint pain and correct limb alignment by achieving a stable union between articulating bones. The key factors to achieving sound arthrodesis is adequate debridement of arthritic cartilage and creating well-apposed bleeding subchondral bone surfaces without compromising the surrounding soft tissue envelope. Arthroscopic subtalar arthrodesis is technically demanding but provides better visualization of the articular surfaces and is safer for the surrounding soft tissues compared to the open approach. Early published reports of the arthroscopic subtalar arthrodesis from the lateral sinus tarsi approach and posterior approach have shown promising results with high rates of union and less wound healing complications. However, there are concerns about access to all facets of subtalar joint, nerve injury, and deformity correction. In this technique, the article authors describe the lateral endoscopic anterolateral/posterolateral (LEAP) approach for subtalar arthrodesis to improve visualization and access to all facets of the subtalar joint to ensure adequate preparation of apposing surfaces, sound union, and facilitate deformity correction of hind-foot. Strategic portal placement also avoids injury to sural nerve. This is a safe and effective minimally invasive technique for subtalar arthrodesis.

The Patient Experience of Inpatient Care During the COVID-19 Pandemic: Exploring Patient Perceptions, Communication, and Quality of Care at a University Teaching Hospital in the United Kingdom.

The coronavirus disease 2019 (COVID-19) pandemic has necessitated many rapid changes in the provision and delivery of health care in hospital. This study aimed to explore the patient experience of inpatient care during COVID-19 pandemic. An electronic questionnaire was designed and distributed to inpatients treated at a large University Health Board over a 6-week period. It focused on hospital inpatients' experience of being cared for by health care professionals wearing personal protective equipment (PPE), explored communication, and patients' perceptions of the quality of care. A total of 704 patients completed the survey. Results demonstrated that patients believe PPE is important to protect the health of both patients and staff and does not negatively impact on their care. In spite of routine use of PPE, patients were still able to identify and communicate with staff. Although visiting restrictions were enforced to limit disease transmission, patients maintained contact with their relatives by using various electronic forms of communication. Overall, patients rated the quality of care they received at 9/10. This single-center study demonstrates a positive patient experience of care at an unprecedented time.

A comprehensive scoping review of tibial cysts after anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to perform a scoping review of published literature reporting on surgical management of tibial cysts which developed after ACLR. METHODS: A scoping review was conducted following the Arksey and O'Malley framework for scoping studies and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. A search strategy using the terms ["Tibial Cyst" AND "ACL"], ["Pretibial Cyst" AND "ACL"] was applied to the PUBMED database. RESULTS: Thirty-seven studies published between 1990 and 2019 were a part of this scoping review. Non-absorbable implants for tibial graft fixation were used in 10 studies (comprising a total 21 patients), while bio-absorbable implants were used in 27 studies (comprising a total 115 patients). Incidence of tibial cyst was reported in 3 studies (434 primary ACLRs) from whom 3.9% (n = 17) developed tibial cyst. Tibial cyst development in relation to use of bio-absorbable screws for tibial ACL graft fixation was reported in 16 studies (42.1%). Use of bio-absorbable screws with another factor was found to be related to tibial cyst development in another 1 study (2.6%). Most common symptoms were presence of mass or swelling, pain, tenderness, drainage, instability and effusion. CONCLUSION: This scoping review demonstrated that tibial cysts is more frequently related to bioabsorbable screws, however it can also occur due to other causes. Current literature on tibial cyst after ACLR is of low-quality evidence. Future research is required to better understand aetiology, risk factors for cyst formation and the best possible mode of management. LEVEL OF EVIDENCE: IV.

Risk Factors for Rapid Chondrolysis After Partial Lateral Meniscectomy: A Scoping Review of the Literature.

BACKGROUND: The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established. PURPOSE: The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment. STUDY DESIGN: Systematic (scoping) review. METHODS: A scoping review of the literature was conducted in accordance with the framework of Arksey and O'Malley. A search strategy based on the terms "chondrolysis" AND "knee," "chondrolysis" AND "meniscus," and "chondral damage" AND "lateral meniscus" was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis. RESULTS: Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee. CONCLUSION: Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.

ACL rupture in the immediate build-up to the Olympic Games: return to elite alpine ski competition 5 months after injury and ACL repair.

Anterior cruciate ligament (ACL) rupture in the immediate build-up to a major international competition can preclude an athletes' participation due to the prolonged period of rehabilitation that is typically required after ACL reconstruction. ACL repair is an alternative strategy that has been postulated to confer the advantage of rapid rehabilitation and earlier return to sport. A 33-year-old professional alpine skier sustained a right knee ACL rupture in September 2017. The athlete indicated that she wanted to participate in the 2018 Olympics. Arthroscopic ACL repair and reconstruction of the anterolateral ligament was undertaken. At 3 months, Lachman's test revealed a hard end point, a negative pivot shift and no side-to-side laxity difference. MRI at 6 and 12 weeks demonstrated a continuous ACL with no intraligament signal change. At 20 weeks postoperatively, she successfully participated in the slalom at the 2018 Olympic Games.

Risk Factors for Lateral Meniscus Posterior Root Tears in the Anterior Cruciate Ligament-Injured Knee: An Epidemiological Analysis of 3956 Patients From the SANTI Study Group.

BACKGROUND: Lateral meniscus posterior root tears (LMPRTs) result in loss of hoop forces and significant increases in tibiofemoral contact pressures. Preoperative imaging lacks reliability; therefore, holding an appropriate index of suspicion, based on the epidemiology of and risk factors for LMPRT, may reduce the rate of missed diagnoses. PURPOSE: The primary objectives of this study were to evaluate the incidence of and risk factors for lateral meniscus root lesions in a large series of patients undergoing anterior cruciate ligament (ACL) reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients who underwent primary or revision ACL reconstruction by a single surgeon between January 2011 and April 2018 were considered for study eligibility. From this overall population, all patients who underwent repair of an LMPRT were identified. The epidemiology of LMPRT was defined by the incidence within the study population, stratified by key demographic parameters. Potentially important risk factors for the presence of LMPRT were evaluated in multivariate logistic regression analysis. RESULTS: A total of 3956 patients undergoing ACL reconstruction were included in the study. An LMPRT was identified and repaired in 262 patients (6.6%). Multivariate analyses demonstrated that significant risk factors for LMPRT included a contact sports injury mechanism (7.8% incidence with contact sport mechanism vs 4.5% with noncontact mechanism; odds ratio, 1.69; 95% CI, 1.266-2.285; P < .001) and the presence of a medial meniscal tear (7.9% incidence with medial meniscal tear vs 5.8% without; odds ratio, 1.532; 95% CI, 1.185-1.979; P < .001). Although the incidence of LMPRT in male patients (7.3%) was higher than in females (4.8%), this was not significant in multivariate analysis ( P = .270). Patient age, revision ACL reconstruction, and a preoperative side-to-side laxity difference ≥6 mm were not significant risk factors for LMPRT. CONCLUSION: The incidence of LMPRT was 6.6% in a large series of patients undergoing ACL reconstruction. Participation in contact sports and the presence of a concomitant medial meniscal tear were demonstrated to be important independent risk factors. Their presence should raise the index of suspicion for this injury pattern.

Figure-of-4 Cruciate Remnant Objective Assessment Test Reducibility of Anterior Cruciate Ligament Stump for Feasibility of Arthroscopic Primary Anterior Cruciate Ligament Repair.

Suture of the anterior cruciate ligament (ACL) has reemerged as a treatment option for proximal ACL tears. Preoperative imaging can provide insight into the feasibility of performing arthroscopic primary ACL repair, but the final decision is taken only after confirming with arthroscopy that the ACL remnant is reducible. We describe a test called the Figure-of-4 Cruciate Remnant Objective Assessment test that objectively interprets the reducibility of the ACL remnant for arthroscopic primary ACL repair.

Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament-Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs.

BACKGROUND: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of anterior cruciate ligament reconstruction (ACLR) has been shown to improve knee biomechanics. PURPOSE: The primary objectives of this study were to evaluate the incidence of and risk factors for ramp lesions among a large series of patients undergoing ACLR. Secondary objectives were to determine the reoperation rate for failure of ramp repair, defined by subsequent reoperations for partial medial meniscectomy. STUDY DESIGN: Case-control study; Level of evidence, 3. Case series; Level of evidence, 4. METHODS: All patients underwent transnotch posteromedial compartment evaluation of the knee during ACLR. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of 2 years was undertaken to determine the secondary partial meniscectomy rate for failed ramp repair. RESULTS: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions among 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male sex, patients aged <30 years, revision ACLR, chronic injuries, preoperative side-to-side laxity >6 mm, and concomitant lateral meniscal tears. The secondary meniscectomy rate was 10.8% at a mean follow-up of 45.6 months (range, 24.2-66.2 months). Patients who underwent ACLR + anterolateral ligament reconstruction had a >2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95% CI, 0.226-0.864; P = .021). CONCLUSION: There is a high incidence of ramp lesions among patients undergoing ACLR. The identification of important risk factors for ramp lesions should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.

Expect the Unexpected: Mycobacterial Infection in Post Total Knee Arthroplasty Patients.

Orthopaedic Surgeons rarely encounter mycobacterial infections in Post Total Knee Arthroplasty (TKA) patients. We present series of two cases to create awareness among clinicians to expect the unexpected. Tuberculosis typical/ atypical is a hidden culprit in catch clinical situations when chronic infection is Suspected, but the lab investigations are negative in persistently symptomatic patients. In such situations clinicians should suspect atypical or complex mycobacterial infections and evaluate the patients accordingly. Clinical suspicion, evaluation, isolation and treatment of atypical or complex mycobacterial infections with sensitive chemotherapy, leads to complete resolution of infection and full functional rehabilitation.