Majority of competitive soccer players return to soccer following hip arthroscopy for femoroacetabular impingement: female and older aged players are less likely to return to soccer.

PURPOSE: To determine return to soccer rates and soccer performance in a large cohort of competitive soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with not returning to soccer. METHODS: An institutional hip preservation registry was retrospectively reviewed for patients identified as competitive soccer players who underwent primary hip arthroscopy for FAI performed between 2010 and 2017. Patient demographics and injury characteristics as well as clinical and radiographic findings were recorded. All patients were contacted for return to soccer information using a soccer-specific return to play questionnaire. Multivariable logistic regression analysis was used to identify potential risk factors for not returning to soccer. RESULTS: Eighty-seven competitive soccer players (119 hips) were included. 32 players (37%) underwent simultaneous or staged bilateral hip arthroscopy. The mean age at surgery was 21.6 ± 7.0 years. Overall, 65 players (74.7%) returned to soccer, of which 43 players (49% of all included players) returned to pre-injury level of play or better. Most common reasons for not returning to soccer were pain or discomfort (50%) followed by fear of re-injury (31.8%). The mean time to return to soccer was 33.1 ± 26.3 weeks. Among 22 players who did not return to soccer, 14 (63.6%) reported satisfaction from surgery. Multivariable logistic regression analysis revealed female players (odds ratio [OR] = 0.27; confidence interval [CI] = 0.083 to 0.872; p = 0.029) and older aged players (OR = 0.895; 95% CI = 0.832 to 0.963; p = 0.003) were less likely to return to soccer. Bilateral surgery was not found to be a risk factor. CONCLUSION: Hip arthroscopic treatment for FAI in symptomatic competitive soccer players allowed three-quarters of them to return to soccer. Despite not returning to soccer, two-thirds of players who did not return to soccer were satisfied with their outcome. Female and older aged players were less likely to return to soccer. These data can better guide clinicians and soccer players with realistic expectations related to the arthroscopic management of symptomatic FAI. LEVEL OF EVIDENCE: III.

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review.

PURPOSE: Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data. METHODS: Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS. RESULTS: One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery. CONCLUSION: This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature. LEVEL OF EVIDENCE: IV.

Editorial Commentary: The Pivot Shift and Lachman Examinations: Teammates With Distinct Roles.

The pivot shift and Lachman examinations are "teammates" with complementary but distinct roles in the successful diagnosis and treatment of anterior cruciate ligament rupture and injury to the surrounding soft-tissue envelope of the knee. The Lachman test measures anterior tibial translation in response to an applied anterior tibial load. This test assesses the integrity of the native or reconstructed anterior cruciate ligament and the secondary medial restraints including the medial meniscus and medial collateral ligament. In contrast, the pivot shift exam creates coupled tibiofemoral motions in response to a complex combination of multiplanar loads. This test assesses the stabilizing role of the native or reconstructed anterior cruciate ligament and the secondary lateral restraints including the lateral meniscus and anterolateral complex. The pivot shift grade depends not only on the soft the tissue stabilizers of the knee but also on the shape of the proximal tibia and the distal femur including lateral tibial slope and femoral condylar offset. Both examinations have unique strengths and weaknesses, but when combined as diagnostic tools, they achieve far more collectively than what each can achieve alone.

Time interval affects physical activity scores: a comparison of the Marx Activity Rating Scale and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

PURPOSE: The Marx Activity Rating Scale (Marx Scale) is a commonly used activity-related patient-reported outcome which evaluates the highest activity level within the last year, whereas the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) assesses highest activity level within the last month. This study aims to determine whether the different timeframes used for the common items of Marx Scale and HSS Pedi-FABS affect scores, and if so, to determine whether age or injury status affect this difference. METHODS: The Marx Scale and four analogous items on the HSS Pedi-FABS were administered in random order to patients being evaluated for knee injuries and in addition to healthy controls to enroll an uninjured comparison group. Responses to each question were scored from 0 to 4 for a maximum overall score of 16. Paired and independent-sample t tests were used to determine mean differences between groups. RESULTS: The final cohort included 88 participants of which 47% were children (ages 10-17) and 51% had a knee injury. All participants except for healthy adults scored significantly lower on the HSS Pedi-FABS than the Marx Scale (p < 0.05). On the HSS Pedi-FABS activity scale, healthy participants scored significantly higher than injured participants (p < 0.01), but there were no significant differences based on age. Conversely, on the Marx Scale, children scored higher than adults (p ≤ 0.001), but there were no significant differences based on injury. CONCLUSION: Physical activity level differs when evaluated with the Marx Scale or the analogue part of HSS Pedi-FABS with timeframe being the only difference between the two. The lower scores on the HSS Pedi-FABS are likely due to seasonal changes in activity which do not affect the Marx Scale. HSS Pedi-FABS analyzes a shorter window and it is more likely to capture changes in physical activity due to a recent injury than the Marx Scale which is better suited for assessing general physical activity level unaffected by seasonality or recent injury. Understating the differences between these physical activity scales can better guide clinicians when using them and interpreting scores. LEVEL OF EVIDENCE: II.

Non-treatment of stable ramp lesions does not degrade clinical outcomes in the setting of primary ACL reconstruction.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of various methods of treatment of stable and unstable ramp lesions compared to patients with no meniscal pathology at the time of primary ACL reconstruction. METHODS: All patients with a preoperative MRI performed at our facility who were enrolled in an institutional ACL registry and 1-year clinical follow-up were identified. A musculoskeletal radiologist reviewed preoperative MRI scans for evidence of a ramp lesion. Ramp lesions were classified as stable if a peripheral tear of the posterior horn of the medial meniscus was identified by MRI, but did not displace into the medial compartment with anteriorly directed probing at the time of surgery. Ramp lesions were classified as unstable if a tear was identified by preoperative MRI at the meniscocapsular junction and the meniscus was displaceable into the medial compartment with probing. Reoperation rates for ACL graft failure or recurrent medial meniscus pathology were collected. Patient-reported outcome scores (IKDC, SF12 PCS, SF12 MCS, and Marx Activity scale) were recorded at baseline and final follow-up. RESULTS: A total of 162 patients were included in the analysis with median 2-year (range 1-5 years) clinical follow-up. Patients with a repaired unstable ramp lesion had a significantly higher likelihood of reoperation for recurrent medial meniscus pathology than patients without meniscal pathology at the time of index surgery. Patients with an untreated stable ramp lesion had a similar rate of reoperation when compared to patients without meniscal pathology. At final follow-up, there was no difference between groups in IKDC score, SF12 PCS/MCS, or Marx activity score or change in any score. CONCLUSIONS: Patients with untreated stable ramp lesions have similar clinical outcomes at median 2-year (range 1-5 years) follow-up when compared to patients without a ramp lesion. Treatment of stable ramp lesions at the time of ACL reconstruction does not have clinical benefit. LEVEL OF EVIDENCE: III.

Editorial Commentary: Revision Multiligament Knee Reconstruction Can Restore Stability in a High Percentage of the Cases When Well Executed.

A thorough and comprehensive evaluation of failed multiligament knee reconstructions is a key component for optimal outcomes of revision cases. Addressing all associated injuries during surgery, either staged or not, will potentially guarantee better subjective and objective scores. Older age and high-energy mechanism of injury are associated with worse functional outcomes.

The correlation of supraspinatus outlet view with computed tomography for visualization of the anterior acromial undersurface.

INTRODUCTION: Understanding the real shape of the undersurface of the acromion prior to acromioplasty is indispensable. Today, Supraspinatus outlet view (SSOV) is a standard view used to determine the shape of the anterior acromion. Three types of acromial undersurface were described by Bigliani and Morrison. The purpose of this study was to find out whether the real acromial type can be visualized on X-ray SSOV and compare the shape of the anterior undersurface of the acromion visualized on SSOV, with the shape revealed on 2D CT reconstructions. METHODS: The SSOV X-rays and CT scans of 30 consecutive patients suffering from rotator cuff dysfunction were retrospectively analyzed. The shape of the acromion visualized on plain X-rays was classified according to Bigliani and Morrison classification system. Two-dimensional CT reconstructions were performed, reproducing the lateral, middle, and medial sections of the acromion. The acromial type that was visualized on each of those reconstructions was separately classified according to the Bigliani and Morrison system. A complete profile of the acromial undersurface was constructed from the integration of acromial types seen on each CT section. The acromial morphology seen on X-rays and CTs was compared. RESULTS: A total of 30 patients comprised the study cohort; mean age was 57 (STD = 8.5) years. Three Type I, 22 Type II, and 5 Type III acromions were visualized on the SSOV X-rays. CT reconstructions revealed seven different morphological acromial profiles (I,I,I; I,II,II; I,II,III, etc.), which we divided into 3 groups: (1) Uniform (30%), (2) Internally curved (20%), and (3) Internally hooked (50%). The acromial type visualized on X-ray correlated with the acromial type on at least one CT section in all of the cases. In the case of uniform acromial profile, there is a full correlation between the acromial type visualized on X-rays and the type visualized on CT. In non-uniform profiles, there was an incomplete correlation between the types of the acromion visualized on SSOV and CT. SSOV X-rays correlated with or underestimated, but never overestimated, the acromial morphological type. DISCUSSION: The curved or hooked portion of the acromial undersurface is not always visualized on the SSOV. On X-rays, the middle and lateral sections are seen more accurate than the medial section. CONCLUSION: Surgeons should be aware that SSOV X-rays may underestimate the true type of the acromial undersurface.

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures.

AIM OF THE STUDY: Bleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options. METHOD: We conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation. RESULTS: Three patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention. DISCUSSION: Vascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory. CONCLUSIONS: A vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.

[TREATMENT OF ACHILLES TENDON RUPTURES].

INTRODUCTION: Achilles tendon ruptures cause considerable morbidity and functionality reduction. There is lack of consensus regarding the best option for treatment following acute Achilles tendon rupture. Recent studies have failed to show substantial difference in outcome following conservative or operative treatment using an early active rehabilitation program. Meta-analyses have shown that conservative management has increased the risk of re-rupture, whereas operative intervention carries risks of complications related to the wound and iatrogenic nerve injury. This article reviews the updated literature-based guidelines for the treatment of Achilles tendon tears.

[CLINICAL AND ARTHROSCOPIC FINDINGS IN MENISCAL INJURY AND KNEE INSTABILITY: A PROSPECTIVE STUDY].

INTRODUCTION: Medical history and physical examination are expected to provide the basic knowledge allowing diagnosis of a disease and thus enabling to plan the course of treatment. OBJECTIVE: This study aimed to examine this hypothesis by comparing pre-operative diagnosis of meniscal and anterior cruciate ligament (ACL) injuries to final surgical findings. MATERIAL AND METHODS: We prospectively compared the pre-surgical diagnosis to the arthroscopic findings in 753 arthroscopic procedures. RESULTS: Clinical diagnosis of a medial meniscal (MM) tear was proven by arthroscopy in 65% of cases. Clinical diagnosis of a lateral meniscal (LM) tear was proven by arthroscopy in 54% of cases. Clinical complaints of instability correlated with partial or complete ACL rupture in 85% of cases. The accuracy of the clinical examination concerning ACL integrity ranged from 86% to 90%. Lachman and Pivot tests were slightly superior to the Drawer test. DISCUSSION: Arthroscopic surgery is the most common surgical procedure in orthopedics. The diagnosis, which is based on history and physical examination in most cases, allows proper management of the case and an appropriate treatment plan. In most scenarios, these operations are conducted based on the diagnosis and treatment performed before surgery. In this study we showed that even in experienced and skilled hands, a clinical diagnosis of meniscal tear was approved by arthroscopy in only 54% to 65% of cases. A clinical diagnosis of ACL injury was approved by arthroscopy, in 99% of cases. CONCLUSION: When planning conservative treatment or surgical intervention for a knee injury, it should be kept in mind that the clinical diagnosis of ACL rupture is highly reliable, while the clinical diagnosis of meniscal injury is only moderately reliable. Thus, especially when planning surgical intervention, the utilization of further imaging would be desirable when isolated meniscal injury is suspected.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling.

OBJECTIVE: To compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. METHODS: Ninety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value â€‹< â€‹0.05 indicated statistical significance. RESULTS: Forty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5-10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 â€‹± â€‹1.9 mm vs. 2.8 â€‹± â€‹2.3 mm (p â€‹< â€‹0.01), pivot shift grade 2-3 in 4% vs. 34% (p â€‹< â€‹0.01), return to preinjury Tegner level in 51% vs. 36% (p â€‹= 0.1) and to preinjury Marx score in 29% vs. 11% (p â€‹= 0.02), and IKDC-subjective 88 â€‹± â€‹10 vs. 82 â€‹± â€‹13 vs (p â€‹< â€‹0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r â€‹= â€‹-0.314, p â€‹< â€‹0.01; r â€‹= â€‹-0.263, p â€‹< â€‹0.01; r â€‹= â€‹-0.218, p â€‹= â€‹0.03, respectively). CONCLUSION: Young men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. LEVEL OF EVIDENCE: III (Retrospective cross-sectional comparative study).

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement.

BACKGROUND: The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood. PURPOSE: (1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue. STUDY DESIGN: Controlled laboratory study. METHODS: IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05). RESULTS: The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003). CONCLUSION: LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue. CLINICAL RELEVANCE: Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

Current Concepts on Tissue Adhesive Use for Meniscal Repair-We Are Not There Yet: A Systematic Review of the Literature.

BACKGROUND: Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020. RESULTS: Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%). CONCLUSION: The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair.

Factors Associated With an Intra-articular Infection After Anterior Cruciate Ligament Reconstruction: A Large Single-Institution Cohort Study.

BACKGROUND: An intra-articular infection after anterior cruciate ligament (ACL) reconstruction (ACLR) is a rare complication but one with potentially devastating consequences. The rare nature of this complication raises difficulties in detecting risk factors associated with it and with worse outcomes after one has occurred. PURPOSE: To (1) evaluate the association between an infection after ACLR and potential risk factors in a large single-center cohort of patients who had undergone ACLR and (2) assess the factors associated with ACL graft retention versus removal. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All ACLR procedures performed at our institution between January 2010 and December 2018 were reviewed; a total of 11,451 procedures were identified. A retrospective medical record review was performed to determine the incidence of infections, patient and procedure characteristics associated with an infection, infection characteristics, incidence of ACL graft retention, and factors associated with the retention versus removal of an ACL graft. Multivariable logistic regression analysis was used to identify potential risk factors for an infection after ACLR. RESULTS: Of the 11,451 ACLR procedures, 48 infections were identified (0.42%). Multivariable logistic regression analysis revealed revision ACLR (odds ratio [OR], 3.13 [95% CI, 1.55-6.32]; P = .001) and younger age (OR, 1.06 [95% CI, 1.02-1.10]; P = .001) as risk factors for an infection. Compared with bone-patellar tendon-bone autografts, both hamstring tendon autografts (OR, 4.39 [95% CI, 2.15-8.96]; P < .001) and allografts (OR, 5.27 [95% CI, 1.81-15.35]; P = .002) were independently associated with an increased risk of infections. Overall, 15 ACL grafts were removed (31.3%). No statistically significant differences besides the number of irrigation and debridement procedures were found for retained versus removed grafts, although some trends were identified (P = .054). CONCLUSION: In a large single-center cohort of patients who had undergone ACLR and those with an infection after ACLR, patients with revision cases and younger patients were found to have a higher incidence of infection. The use of bone-patellar tendon-bone autografts was found to be associated with the lowest risk of infection after ACLR compared with both hamstring tendon autografts and allografts. Larger cohorts with a larger number of infection cases are needed to determine the factors associated with graft retention versus removal.

Differences in the Demographics and Preferred Management of Knee Cartilage Injuries in Soccer Players Across FIFA Centers of Excellence.

OBJECTIVE: We sought to report on the demographics and epidemiology of knee cartilage injuries and preferred management in soccer players, across FIFA Medical Centers of Excellence (FMCE). DESIGN: A descriptive questionnaire focusing on characteristics of knee cartilage injuries and their management in soccer players during the 10-year period prior to the distribution of the questionnaire was sent to all FMCE around the world in September 2019 via an online platform. Voluntary responses from centers were processed and analyzed. Descriptive characteristics were reported using median and interquartile ranges (IQR) for continuous variables and frequencies and percentages (%) for discrete variables. RESULTS: A total of 15 centers from 5 continents responded to the questionnaire and reported on a total of 4526 soccer players. Among centers, the median age was 27 years (IQR: 23-38), the median rate of male players was 75% (IQR: 68-90), and the median rate of professional players was 10% (IQR: 5-23). The most common reported etiology for cartilage injury was traumatic (median 40%, IQR: 13-73). The most common nonoperative treatment utilized was physical therapy (median 90%, IQR: 51%-100%) and the most common operative treatment utilized was bone marrow stimulation/micro-fracture (median 40%, IQR: 19-54%). The utilization of other cartilage restoration procedures varied across centers. CONCLUSIONS: Our findings highlight different tendencies in the management of these injuries across FMCE and emphasize the need for collaborative efforts focusing on establishing consensus guidelines for the optimal management of these challenging injuries in soccer players.

Preoperative Grades of Osteoarthritis and Meniscus Volume Correlate with Clinical Outcomes of Osteochondral Graft Treatment for Cartilage Defects in the Knee.

OBJECTIVE: To identify preoperative imaging-based indicators of knee degeneration that correlate with graft failure risk and postoperative clinical outcome scores after osteochondral graft treatment for chondral defects of the knee. DESIGN: Prospectively collected data from 113 patients (mean age, 34 years; 65% male) treated with mosaicplasty or osteochondral allograft transplantation (OCA) was reviewed. Four different aspects of knee degeneration were examined based on preoperative radiographs or magnetic resonance imaging: (1) Osteoarthritis using the Kellgren-Lawrence (KL) grading system, (2) meniscus volume, (3) meniscus quality, and (4) synovitis. Primary outcomes included graft failure, defined by removal/revision of the graft or conversion to arthroplasty, and patient responses to clinical outcome scores. RESULTS: Forty-one knees (36%) underwent mosaicplasty, and 72 knees (64%) underwent OCA. Mean duration of follow-up was 4.5 years (range, 2-14 years). A preoperative KL grade of ≥3 was correlated with increased failure rates (P = 0.01), lower postoperative International Knee Documentation Committee form (IKDC), Activities of Daily Living of the Knee Outcome Survey (KOS-ADL), and Overall Condition scores (P < 0.01), and decreased improvement in Overall Condition scores (P = 0.01). Within an individual tibiofemoral compartment, a preoperative meniscus volume grade of ≥3 (indicating <50% meniscus volume remaining) was correlated with increased condylar graft failure rates (P < 0.01). Preoperative meniscus quality and synovitis grades were not associated with graft failure rates or clinically meaningful differences in postoperative outcome scores. CONCLUSIONS: Greater preoperative osteoarthritis and meniscus volume loss were correlated with increased graft failure rates after osteochondral graft treatment for chondral defects of the knee.

Lateral Extra-articular Tenodesis Alters Lateral Compartment Contact Mechanics under Simulated Pivoting Maneuvers: An In Vitro Study.

BACKGROUND: There is concern that utilization of lateral extra-articular tenodesis (LET) in conjunction with anterior cruciate ligament (ACL) reconstruction (ACLR) may disturb lateral compartment contact mechanics and contribute to joint degeneration. HYPOTHESIS: ACLR augmented with LET will alter lateral compartment contact mechanics in response to simulated pivoting maneuvers. STUDY DESIGN: Controlled laboratory study. METHODS: Loads simulating a pivot shift were applied to 7 cadaveric knees (4 male; mean age, 39 ± 12 years; range, 28-54 years) using a robotic manipulator. Each knee was tested with the ACL intact, sectioned, reconstructed (via patellar tendon autograft), and, finally, after augmenting ACLR with LET (using a modified Lemaire technique) in the presence of a sectioned anterolateral ligament and Kaplan fibers. Lateral compartment contact mechanics were measured using a contact stress transducer. Outcome measures were anteroposterior location of the center of contact stress (CCS), contact force from anterior to posterior, and peak and mean contact stress. RESULTS: On average, augmenting ACLR with LET shifted the lateral compartment CCS anteriorly compared with the intact knee and compared with ACLR in isolation by a maximum of 5.4 ± 2.3 mm (P < .001) and 6.0 ± 2.6 mm (P < .001), respectively. ACLR augmented with LET also increased contact force anteriorly on the lateral tibial plateau compared with the intact knee and compared with isolated ACLR by a maximum of 12 ± 6 N (P = .001) and 17 ± 10 N (P = .002), respectively. Compared with ACLR in isolation, ACLR augmented with LET increased peak and mean lateral compartment contact stress by 0.7 ± 0.5 MPa (P = .005) and by 0.17 ± 0.12 (P = .006), respectively, at 15° of flexion. CONCLUSION: Under simulated pivoting loads, adding LET to ACLR anteriorized the CCS on the lateral tibial plateau, thereby increasing contact force anteriorly. Compared with ACLR in isolation, ACLR augmented with LET increased peak and mean lateral compartment contact stress at 15° of flexion. CLINICAL RELEVANCE: The clinical and biological effect of increased anterior loading of the lateral compartment after LET merits further investigation. The ability of LET to anteriorize contact stress on the lateral compartment may be useful in knees with passive anterior subluxation of the lateral tibia.

Graft Selection in Anterior Cruciate Ligament Reconstruction.

Surgical reconstruction of the anterior cruciate ligament (ACL) is often indicated to restore functional stability and prevent early degeneration of the knee joint, as there is little biological healing capacity of the native ACL. Although a reconstructed ACL does not fully restore the original structure or biomechanics properties of the native ACL, the graft used for reconstruction must not only have structural and mechanical properties that closely resemble those of the native ligament, it must also have minimal antigenicity and enough biological potential to incorporate into host bone. There are several considerations in graft selection: autograft versus allograft, and soft tissue grafts versus grafts with bone plugs. Commonly used grafts include bone-patella tendon-bone, hamstring, and quadriceps; among allografts, options further include tibias anterior and posterior, Achilles, an peroneal tendons. Optimal graft selection is not only dependent on graft properties, but perhaps more importantly on patient characteristics and expectations. The purpose of this review is to summarize the relevant biological, biomechancial, and clinical data regarding various graft types and to provide a basic framework for graft selection in ACL reconstruction.

Complications in Posterior Cruciate Ligament Injuries and Related Surgery.

Posterior cruciate ligament (PCL) injury, especially in isolation, is a less frequent injury than injury to the anterior cruciate ligament and other ligaments of knee. In addition, the complex injury patterns involving the PCL, the technically demanding nature of surgical treatments, the anatomic proximity to vital neurovascular structures and the controversy surrounding optimal management of PCL injuries, make these injuries and their treatment potentially prone to more complications. This chapter will review the common complications of PCL injuries and related surgery.