Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group.

BACKGROUND: Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. PURPOSES: To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. RESULTS: The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). CONCLUSION: Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.

Femoral Positioning of the Anterolateral Ligament Graft With and Without Ultrasound Location of the Lateral Epicondyle.

BACKGROUND: In anterior cruciate ligament (ACL) reconstruction with anterolateral ligament (ALL) reconstruction, precise positioning of the ALL graft on the femur and tibia is key to achieve rotational control. The lateral femoral epicondyle is often used as a reference point for positioning of the ALL graft and can be located by palpation or with ultrasound guidance. PURPOSE: To compare the ALL graft positioning on the femoral side between an ultrasound-guided technique and a palpation technique for the location of the lateral epicondyle. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 120 patients receiving a primary combined ACL and ALL reconstruction between June and December 2019 were included. The location of the lateral epicondyle was determined by palpation in the palpation group (n = 60) and with preoperative ultrasound guidance in the ultrasound group (n = 60). Groups were comparable in age, sex, body mass index (BMI), and operated side. The planned positioning of the femoral ALL graft was proximal and posterior to the lateral epicondyle. The effective positioning of the femoral ALL graft was evaluated on postoperative lateral radiographs. The primary outcome was location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle. Results were analyzed in 2 subgroups according to BMI. RESULTS: All 60 anterolateral grafts (100%) in the ultrasound group were positioned in a 10-mm quadrant posterior and proximal to the lateral epicondyle, as opposed to 52 (87%) in the palpation group (P = .006). Errors in graft positioning with palpation occurred in overweight patients (BMI >25) as well as nonoverweight patients (P = .3). CONCLUSION: Femoral positioning of the ALL graft posterior and proximal to the lateral epicondyle is more reproducible with ultrasound guidance when compared with palpation alone, regardless of BMI.

Lower donor-site morbidity using QT autografts for ACL reconstruction.

PURPOSE: Comparing scar cosmesis and regional hypoesthesia at the incision site between quadriceps tendon (QT), bone-patellar tendon-bone (BPTB), and hamstring tendon (HT) for anterior cruciate ligament (ACL) reconstruction. METHODS: Ninety patients undergoing ACL reconstruction with QT, HT or BPTB were evaluated at 1-year post-op. Scar cosmesis was assessed using the patient and observer scar assessment scale (POSAS) and length of the incision. Sensory outcome was analyzed by calculating the area of hypoesthesia around the scar. The classical ACL reconstruction functional follow-up was measured using the Lysholm score and KOOS. RESULTS: Concerning QT versus BPTB group, QT patients have a significantly lower mean POSAS (24.8 ± 6.3 vs. 39.6 ± 5.8; p < 0.0001), shorter mean incision (2.8 ± 0.4 cm vs. 6.4 ± 1.3 cm; p < 0.0001), lower extent of hypoesthesia (8.7 ± 5.1 cm2 vs. 88.2 ± 57 cm2; p < 0.0001), and better Lysholm score (90.1 ± 10.1 vs. 82.6 ± 13.5; n.s.). No significant difference was seen in KOOS (90.7 ± 7.2 vs. 88.4 ± 7.0; n.s.). Concerning QT versus HT group, no significant difference was found regarding mean POSAS score (24.8 ± 6.3 vs. 31.8 ± 6.2; n.s.), mean length of the incision (2.8 ± 0.4 cm vs. 2.5 ± 0.6 cm; n.s.), KOOS (90.7 ± 7.2 vs. 89.8 ± 8.2; n.s.) and mean Lysholm score (90.1 ± 10.1 vs. 87.8 ± 0.6; n.s.). The mean measured area of hypoesthesia was significantly higher in the HT group (70.3 ± 77.1 cm2 vs. 8.7 ± 5.1 cm2; p < 0.0001). CONCLUSION: Quadriceps tendon harvesting technique has the safest incision by causing less sensory loss compared to BPTB and HT. It also has the advantage of a short incision with more cosmetic scar compared to BPTB, with no difference compared to HT. However, no significant difference in terms of functional outcome was shown between the three autografts. These findings provide surgeons evidence about their clinical practice and help with graft choice decisions. LEVEL OF EVIDENCE: III.

Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts.

BACKGROUND: Comprehensive studies evaluating quadriceps tendon (QT) autograft for anterior cruciate ligament (ACL) reconstruction are lacking. The optimal choice of graft between bone-patellar tendon-bone (BPTB), hamstring tendon (HT), and QT is still debatable. HYPOTHESIS: The current literature supports the use of QT as a strong autograft with good outcomes when used in ACL reconstruction. STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A systematic search of the literature was performed in PubMed, MEDLINE, Cochrane, and Ovid databases to identify published articles on clinical studies relevant to ACL reconstruction with QT autograft and studies comparing QT autograft versus BPTB and HT autografts. The results of the eligible studies were analyzed in terms of instrumented laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, donor-site pain, and graft failure. RESULTS: Twenty-seven clinical studies including 2856 patients with ACL reconstruction met the inclusion criteria. Comparison of 581 QT versus 514 BPTB autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .45), Lachman test (P = .76), pivot-shift test grade 0 (P = .23), pivot-shift test grade 0 or 1 (P = .85), mean Lysholm score (P = .1), mean subjective IKDC score (P = .36), or graft failure (P = .50). However, outcomes in favor of QT were found in terms of less donor-site pain (risk ratio for QT vs BPTB groups, 0.25; 95% CI, 0.18-0.36; P < .00001). Comparison of 181 QT versus 176 HT autografts showed no significant differences in terms of instrumented mean side-to-side difference (P = .75), Lachman test (P = .41), pivot-shift test grade 0 (P = .53), Lysholm score less than 84 (P = .53), mean subjective IKDC score (P = .13), donor-site pain (P = .40), or graft failure (P = .46). However, outcomes in favor of QT were found in terms of mean Lysholm score (mean difference between QT and HT groups, 3.81; 95% CI, 0.45-7.17; P = .03). CONCLUSION: QT autograft had comparable clinical and functional outcomes and graft survival rate compared with BPTB and HT autografts. However, QT autograft showed significantly less harvest site pain compared with BPTB autograft and better functional outcome scores compared with HT autograft.

EMG in piriformis syndrome diagnosis: Reliability of peroneal H-reflex according to results obtained after surgery, Botox injection and medical treatment.

Diagnosing piriformis syndrome (PS) throughout the past decades was not that easy, however peroneal H-reflex was proved as reliable test for PS with the change in wave amplitude and delay in conduction as parameters for diagnosis. We interpreted these parameters according to treatment's results carried out for patients presenting clinical PS, aiming to define a threshold value for peroneal H-reflex delay to accurately diagnose. A retrospective mono-centric review of 27 patients, 9 females and 18 males, aged 22-65 years, benefited from peroneal H-reflex test and treated for clinical PS. These patients were classified into 3 groups according to treatment modality they received: 11 patients underwent surgical treatment, 7 patients underwent Botox injections (4 of them benefited from surgery later on) and 9 patients received pharmacological treatment. From 11 operated patients with 4 < delay < 9 ms, 10 had complete improvement and 1 remained in pain. For 7 patients having injection of Botox 100-300 IU, with 5 < delay < 7 ms had a transient recovery, 4 of them have benefited later from surgery, the 3 others reproved pain. Between 9 patients who have declined invasive treatment, 7 patients with 4 < delay < 10 ms didn't demonstrate any improvement after medical treatment and are suspected of PS, 2 others with delay < 4 ms recovered from a non-confirmed PS. A threshold value to diagnose PS was reached through peroneal H-reflex delay ranges, classified as: high with a delay > 5 ms, moderate: 4 < delay < 5 ms and poor: <4 ms.

Evaluation of reproducibility of robotic knee testing device (GNRB) on 60 healthy knees.

INTRODUCTION: There is a main concern about the usefulness and the accuracy of the different laximeters. The GnrB device is becoming more popular, but according to the literature it's not clear whether it is fully reliable. OBJECTIVE: GNRB laxity measurements are not reproducible for measurement of anterior translation of the tibia. MATERIAL AND METHODS: We analyzed the reproducibility of GNRB measurements in healthy subjects by the Test-Retest method in 2 sessions. RESULTS: 30 pairs of healthy knees were assessed. Test-Retest agreement was poor for both absolute values and for differentials at 134 and 200 N with an intra-class correlation ranging from 0.210 to 0.486. There was a significant differance in anterior tibial translation, in side-to-side difference, according to the patellar pressure. CONCLUSION: The reproducibility is found to be poor under optimum conditions of comparability. The patellar pressure influences strongly thelaxity value.