Tibial sided Anterolateral Ligament Injuries are Associated with Poor Healing and Residual Pivot Shift Testing Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: ; to investigate if tibial sided anterolateral ligament (ALL) injuries are associated with poor healing and residual pivot shift. METHODS: ; Patients who underwent anterior cruciate ligament reconstructions within postinjury 6 weeks from January 2008 to March 2021 were included. They had concomitant ALL injury confirmed by preoperative magnetic resonance imaging (MRI) and were followed minimum 20 months. Preoperative ALL injury was graded by the Muramatsu classification and postoperative ALL healing were graded by a modification of the Lee classification (good, partial, and non-visualized). The patients were allocated to an improved group (IG) and an unimproved group (UG) based on a comparison of pre- and postoperative MRI. ALL tear site, postoperative knee stability, Lysholm score, and Tegner activity scale (PROs) were compared between the two groups. RESULTS: ; 128 patients were enrolled. 94.5 % patients achieved the minimal clinically important difference (MCID) for PROs, respectively. The ALL was torn at the femoral side in 46.9% patients, at mid-substance in 31.2.%, and at tibial side in 21.9%, Preoperatively, 86 (67.2%) patients had a partial tear and 42 (32.8%) patients had a complete tear. Based on the postoperative MRI appearances, 38 (29.7%) and 90 (70.3%) patients were allocated to the IG and UG, respectively. The tibial side tears were significantly frequent in UG (p= .032). Pivot shift showed a significantly higher incidence in UG than IG (p=.004). Lachman test and PROs did not differ between the two groups. CONCLUSIONS: ; Tibial-sided ALL tears occurred in 18.7% of the UG compared to 3.2% of the IG, and 45.6% of the UG had a postoperative grade 1 or 2 pivot shift, compared to 15.8% of the IG. Percentages of patients with the MCID for PROs did not differ between the two groups. However, the clinical relevance is limited by a high transfer bias.

Increase in Deltoid Compartment Pressures Immediately After Arthroscopic Rotator Cuff Repair Does Not Significantly Affect Postoperative Opioid Consumption.

Purpose: To investigate the association between changes in individual (anterior, lateral, and posterior) and overall deltoid compartment pressures and postoperative opioid consumption up to 14 days after primary double-row arthroscopic rotator cuff repair (ARCR). Methods: In 113 consecutive patients undergoing primary double-row ARCR, anterior, lateral, and posterior deltoid compartment pressures were measured prior to incision and immediately after closure with a manometer. Postoperatively, all patients were provided with an identical rehabilitation protocol, quantity and dose of opioid tablets, and pain journal in which to record daily opioid consumption and visual analog scale pain scores for 14 days after surgery. The pain journals were collected at the first postoperative visit, and opioid consumption was calculated based on morphine equivalents. Statistical analysis was performed to determine the association between deltoid compartment pressures and opioid consumption postoperatively. Results: Sixty-nine percent of patients who met the inclusion criteria (74 of 107) returned the pain journals. The mean age at the time of surgery was 57.4 ± 8.8 years (range, 30-75 years), with female patients being significantly older (P = .03). The mean length of surgery was 71.7 ± 16.3 minutes. No significant association between increase in individual (anterior, lateral, or posterior) or mean overall compartment pressures and morphine equivalents of opioid consumption was appreciated on any postoperative day. Conclusions: No significant correlation between increase in individual or overall deltoid compartment pressures after ARCR and postoperative opioid consumption in the immediate postoperative period was found in this study. Level of Evidence: Level II, prospective cohort study.

Bone Morphological Characteristics as Risk Factors for Anterior Cruciate Ligament Injury: Comparison Between Contact and Noncontact Injury.

Background: Altered bone morphologies are considered risk factors for noncontact anterior cruciate ligament (ACL) injuries. Purpose/Hypothesis: This study aimed to investigate bone morphological characteristics as risk factors for ACL tears in contact injuries and compare these factors with those for noncontact ACL injuries. We hypothesized that altered bone morphologies would also be risk factors for contact ACL injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Enrolled were patients who underwent primary ACL reconstructions between January 2000 and December 2021 within 6 weeks after injury. Patients in the ACL group were classified according to injury mechanism (contact vs noncontact). During the same period, a control group of patients matched by age, height, and body mass index to the ACL group was selected. The lateral femoral condylar ratio (LFCR), notch width index (NWI), and lateral posterior tibial slope (PTS) were measured. Measured parameters were compared between the control, contact, and noncontact groups using analysis of variance. Results: There were 86 patients in the control group, 102 patients in the contact ACL group, and 105 patients in the noncontact ACL group. The demographic characteristics of the 3 groups did not differ significantly. The contact group had significantly higher LFCRs and lower NWIs compared with the control group (P < .001 and P = .001, respectively). The noncontact group had significantly higher LFCRs and PTSs and lower NWIs compared with the control group (P = .031; P < .001; and P < .001, respectively). The noncontact group had significantly higher PTSs and lower NWIs compared with the contact group (P = .003 and P =.014, respectively). In the contact group, the LFCR, PTS, and NWI were significant risk factors for ACL tears (odds ratio [OR], 1.25 [P < .001]; OR, 1.16 [P = .008]; and OR, 1.27 [P = .001], respectively), and in the noncontact group, the PTS and NWI were significant risk factors for ACL tears (OR, 1.20 [P < .001]; OR, 1.59 [P < .001], respectively). Conclusion: Altered bone morphological characteristics of the knee were found to be risk factors for ACL tears in contact injuries as well as noncontact injuries. Altered morphology has a more significant effect in noncontact ACL injuries.

Clinical and Magnetic Resonance Imaging Outcomes After Human Cord Blood-Derived Mesenchymal Stem Cell Implantation for Chondral Defects of the Knee.

Background: There is a paucity of literature reporting clinical and magnetic resonance imaging (MRI) outcomes after allogeneic umbilical cord blood-derived mesenchymal stem cell (UCB-MSC) implantation for chondral defects of the knee. Purpose: To report clinical and MRI outcomes after UCB-MSC implantation for chondral lesions of the knee. Study Design: Case series; Level of evidence, 4. Methods: Inclusion criteria were patients aged between 40 and 70 years with focal chondral lesions of grade 3 or 4 on the medial femoral condyle, defect sizes >4 cm2, and intact ligaments. Exclusion criteria were patients who required realignment osteotomy or who had a meniscal deficiency, ligamentous instability, or a concomitant full-thickness chondral defect in the lateral or patellofemoral compartment. A mixture of human UCB-MSCs and sodium hyaluronate was implanted into the chondral defect through mini-arthrotomy. MRI at 1-year follow-up was performed to evaluate repaired cartilage hypertrophy. Repaired cartilage thickness was measured, and hypertrophy was classified as grade 1 (<125%), grade 2 (<150%), or grade 3 (<200%). Patient-reported outcomes (PROs; International Knee Documentation Committee, visual analog scale for pain, and Western Ontario and McMaster Universities Osteoarthritis Index) were evaluated preoperatively and at 1, 2, and 3 years postoperatively. Repaired cartilage hypertrophy was evaluated for a correlation with PRO scores. Results: Enrolled were 85 patients with a mean age of 56.8 ± 6.1 years and a mean chondral defect size of 6.7 ± 2.0 cm2. At follow-up, a significant improvement in all PRO scores was seen compared with preoperatively (P < .001 for all). MRI at 1-year follow-up demonstrated that 28 patients had grade 1 repaired cartilage hypertrophy, 41 patients had grade 2, and 16 patients had grade 3. MRI performed in 11 patients at 2 years after surgery indicated no difference in repaired cartilage hypertrophy between the 1- and 2-year time points. The grade of repaired cartilage hypertrophy did not correlate with PRO scores. Conclusion: Clinical outcomes improved significantly at short-term follow-up after UCB-MSC implantation. Although all patients showed repaired cartilage hypertrophy, it did not correlate with clinical outcomes.

Combined Anterolateral Ligament and Anterior Cruciate Ligament Injury Is Associated With Increased Lateral Femoral Condyle Ratio.

PURPOSE: to investigate the association between the lateral femoral condylar ratio (LFCR), the posterior tibial slope (PTS), and injury of the anterolateral ligament (ALL). METHODS: Inclusion criteria were patients with acute anterior cruciate ligament (ACL) tear after noncontact injury during sports from October 1997 to May 2021. The LFCR and PTS were measured, and injury of the ALL was evaluated. Patients were divided into 2 groups: isolated ACL tear (isolated group) and combined ACL with ALL tear (combined group). The LFCR and PTS were compared between the isolated and combined groups. For each risk factor, the receiver operating characteristic curve, the area under the curve (AUC), and its 95% confidence interval (CI) were calculated to determine the cutoff for detecting increased risk of ALL injury. RESULTS: There were 83 patients in the isolated group and 176 patients in the combined group. Demographics of the 2 groups did not differ significantly. The LFCR was significantly larger in the combined group than in the isolated group (P = .000). The PTS did not differ between the two groups (P = .405). The LFCR (odds ratio [OR] = 1.58; P = .000) was a significant factor. Age, body mass index, and PTS were not associated with an ALL injury. The AUC (0.79; 95% CI, 0.74-0.85) for the LFCR had a sensitivity of 73% and specificity of 76% to predict an ALL rupture. The calculated cutoff of 64.5 was associated with an increased risk for ALL rupture (OR = 8.65; 95% CI, 4.73-15.81) when compared with the isolated group. CONCLUSIONS: An increased LFCR was associated with the ALL injury. However, increased PTS was not associated with ALL injury. These findings need to be considered for clinicians in treating ACL tear patients at risk for an ALL injury. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making.

BACKGROUND: There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty. METHODS: Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores. RESULTS: A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were -1.54 ± 2.0, -2.59 ± 2.2, and -2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] -1.03, 95% CI -2.0, -0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4, -0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score. CONCLUSION: Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

Correlation Between Anatomic Landmarks and Bony Trough Position in Lateral Meniscal Allograft Transplant.

Background: Determining the rotational axis of the bony trough during lateral meniscal allograft transplant (MAT) is difficult. The use of anatomic landmarks may help a surgeon determine the rotational alignment of the graft during the procedure. Purpose: To investigate the association between the knee's anatomic landmarks and the position of the bony trough to prevent extrusion after lateral MAT. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Enrolled were 44 patients who underwent lateral MAT between July 2000 and February 2011. The patients' mean age at the time of surgery was 30.8 years. Extrusion was measured on magnetic resonance imaging (MRI) scans at a mean of 3.6 months postoperatively, and patients were divided into an extrusion group (n = 15) and a no-extrusion group (n = 29). Three coronal MRI scans from each patient were selected, each from the region at the level of the tibial tuberosity (TT), the anterior bony trough, and the posterior bony trough. We measured the distance between the center of the anterior bony trough and the center of the TT (the TT distance) and the distance between the center of the posterior bony trough and the medial border of the lateral femoral condyle (LFC) (the LFC distance). Results: The mean center of the anterior bony trough was in a more medial position relative to the center of the TT in the no-extrusion group (-2.9 ± 4.8 mm) compared with the extrusion group (1.3 ± 4.9 mm; P = .010). The mean center of the posterior bony trough was in a more medial position relative to the medial border of the LFC in the no-extrusion group (-1.7 ± 3.9 mm) compared with the extrusion group (1.0 ± 3.2 mm; P = .027). Both TT distance and LFC distance were significantly correlated with extrusion (P = .005 and .025, respectively). The cutoff value was -0.24 mm for the anterior bony trough and -0.58 mm for the posterior bony trough (negative values indicate that the trough was medial to the respective landmarks). Conclusion: To prevent extrusion of the allograft, the center of the anterior bony trough needs to be aligned with the center of the TT, and the center of the posterior bony trough needs to be aligned with the medial border of the LFC.

Accuracy of the Arthroscopic Location of the Center of the Anterior Horn During Lateral Meniscal Allograft Transplantation.

Background: Anatomic placement of the meniscal allograft is imperative to achieve satisfactory outcomes after meniscal allograft transplantation (MAT). Few studies have reported on the accuracy of the provisional location of the center of the anterior horn of the lateral meniscus (AHLM). Hypothesis: The authors hypothesized that the provisional center would not coincide with the anatomic center of the AHLM. Study Design: Descriptive laboratory study. Methods: Tibial plateaus were retrieved from 93 consecutive patients who underwent total knee arthroplasty. A complete radial cut was made 2 cm lateral to the insertion of the AHLM on the retrieved tibial plateau. While moving the stump of the anterior horn with forceps, the center of the insertion was determined, and a Kirschner wire (provisional wire) was drilled into the location. The insertion area of the AHLM was dissected carefully, and the periphery of the insertion area of the anterior horn was marked. Another Kirschner wire (anatomic wire) was drilled into the center of the dissected anterior horn. The resected tibial plateau was positioned so that the longitudinal line of the tibial plateau was aligned on a plastic ruler. The distance between the provisional and anatomic wires was measured by a digital caliper along the longitudinal and vertical axes. Results: The mean distance between the provisional and anatomic wires was 2.5 ± 1.2 mm. The provisional wire in 14 patients (15%) was placed at the anatomic center. In 36 patients (39%), the provisional wire was drilled anterolateral to the anatomic center, and in 18 patients (19%), the wire was drilled anteromedial to the anatomic center. In 21 patients (23%), the provisional wire was located within 2 mm of the anatomic center, and in 62 patients (67%), the wire was located within 3 mm of the anatomic center. Conclusion: The provisional wire was located a mean of 2.5 mm from the anatomic center, and only 23% of patients had wires that were located within 2 mm of the anatomic center. In 39% of patients, the provisional wire was drilled anterolateral to the anatomic center. This finding needs to be considered during lateral MAT. Clinical Relevance: Without dissection of the AHLM, the determination of the anatomic center of the anterior horn is not accurate during lateral MAT.

An Increased Lateral Femoral Condyle Ratio in Addition to Increased Posterior Tibial Slope and Narrower Notch Index Is a Risk Factor for Female Anterior Cruciate Ligament Injury.

PURPOSE: To investigate the relationship between the lateral femoral condyle ratio (LFCR) among osseous morphologic characteristics of the knee and anterior cruciate ligament (ACL) injury in female patients. METHODS: Inclusion criteria were female patients (ACL group, n = 59) undergoing primary ACL reconstruction from 2012 to 2018. Control female patients (control group, n = 58) were matched by age, height, and body mass index to ACL group. They had no meniscal or ligament tear, and no trochlear dysplasia on magnetic resonance imaging. The LFCR, notch width index (NWI), and posterior tibial slope (PTS) were measured and compared between the ACL and control groups. For each risk factor, the receiver operating characteristic curve and the area under the curve and its 95% confidence interval (CI) was calculated to determine the cutoff for detecting increased risk of ACL injury. RESULTS: The LFCR was significantly larger in the knees in the ACL group than in the control group (P = .001). The NWI was significantly smaller and the PTS was significantly larger in the knees in the ACL group than in the control group (P = .000, P = .000, respectively). The NWI (odds ratio [OR] 1.41; P = .000) was the most significant factor, followed by the PTS (OR 1.29; P = .003) and the LFCR (OR 1.26; P = .001). The area under the curve (0.67, 95% CI 0.58-0.77) for the LFCR had a sensitivity of 66% and specificity of 66% to predict an ACL injury. The cutoff of 63.9 was associated with an increased risk for ACL injury (OR 3.71; 95% CI 1.73-7.95). CONCLUSIONS: An increased LFCR was associated with female ACL injury. The LFCR, NWI, and PTS are predictive risk factors for an ACL injury. These findings need to be considered for clinician in identifying female patients at risk for an ACL injury. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Lateral Capsular Stabilization in Lateral Meniscal Allograft Transplantation.

BACKGROUND: Stabilization of the lateral capsule to the tibial plateau may decrease midbody extrusion after lateral meniscal allograft transplantation (MAT). However, there is a paucity of literature reporting on postoperative magnetic resonance imaging (MRI) findings after lateral capsular stabilization (LCS) at the time of lateral MAT. PURPOSE/HYPOTHESIS: The purpose was to describe MRI findings after LCS and compare postoperative extrusion between isolated lateral MAT and lateral MAT with LCS. It was hypothesized that allograft extrusion would be reduced after MAT with LCS but that the stabilized capsule would increase the risk of tears to the capsule or allograft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were patients who underwent lateral MAT with 6-month follow-up MRI. Concomitant LCS was performed for patients with redundant lateral capsule displaced from the lateral tibial plateau as evident on coronal MRI or arthroscopic examination (MAT+LCS group); otherwise, patients underwent MAT only (isolated MAT group). The Lysholm score, Tegner score, and lateral joint space on radiographs were compared between the 2 groups at 2 years postoperatively, and the stabilized lateral capsule and allograft were evaluated using 6-month follow-up MRI. Extrusion, rotation, and position of the allograft bridge were compared between the 2 groups. Regression analysis was performed to identify factors predictive of degree of extrusion. RESULTS: There were 10 patients in the MAT+LCS group and 13 patients in the isolated MAT group. No significant differences were found between groups in preoperative patient characteristics or postoperative Lysholm score, Tegner score, lateral joint space, or MRI parameters. Postoperative extrusion was not related to obliquity angle, position of the bony bridge, or presence of LCS. In the MAT+LCS group, 1 patient showed a tear of the lateral capsule and a radial tear of the allograft, and 3 patients had a meniscocapsular separation at the midbody of the allograft. In the isolated MAT group, 1 patient had a peripheral tear at the midbody, but there was no tear of the allograft in the other patients. CONCLUSION: LCS did not decrease extrusion of lateral meniscal transplantation, but it can lead to increased risk for graft or capsule tear.

Comparison Between Early and Late Retensioning of an Adjustable-Loop Cortical Suspension Device During Hamstring ACL Reconstruction.

BACKGROUND: Biomechanical studies have demonstrated significant loosening of the adjustable-loop device as compared with the fixed-loop device used in anterior cruciate ligament reconstruction. Retensioning of the adjustable loop has been recommended; however, the timing of the retensioning is unknown. HYPOTHESIS: Early (ER) and late retensioning (LR) will show similar gapping between the femoral tunnel and graft on follow-up magnetic resonance imaging (MRI) and similar clinical outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included 101 patients who underwent hamstring anterior cruciate ligament reconstruction using the adjustable-loop device for femoral fixation between June 2016 and January 2018. All patients a had follow-up MRI on postoperative day 1. Patients with revision surgery and those with reinjury after reconstruction were excluded. In the ER group, retensioning and knot tying of the initially tightened adjustable loop were performed after the flip of the button and before the graft was fixed at the tibia. In the LR group, retensioning and knot tying were performed after initial tightening of the adjustable loop and graft fixation at the tibial side. The tunnel-graft gap measured on multiplanar reformatted images of MRI scans was compared between the groups, as were clinical outcomes. RESULTS: The mean age of the patients at the time of surgery was 30.3 years (range, 14-61 years). ER and knot tying were performed in 56 patients and LR and knot tying in 45. Preoperative characteristics of the 2 groups showed no significant differences. The mean ± SD tunnel-graft gap was 1.5 ± 2.0 mm in the ER group and 5.4 ± 4.0 mm in the LR group (P < .001). There were no significant differences in clinical outcomes between the groups. CONCLUSION: ER and knot tying demonstrated less tunnel-graft gap than that of LR. However, there were no differences in clinical outcomes according to the timing of retensioning.

Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Controlled Study.

BACKGROUND: Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR. METHODS: Adult patients undergoing arthroscopic RCR were prospectively enrolled and randomized to one of two groups. The control received our institution's standard-of-care pain protocol, including oxycodone-acetaminophen 5 to 325 mg on discharge. The ketorolac group received the standard-of-care protocol, intravenous ketorolac at the completion of the procedure, and oral ketorolac on discharge. Pain and functional outcome scores and narcotic utilization were recorded three times per day for the first 5 days after surgery. Repeat magnetic resonance imaging was done at least 6 months postoperatively. RESULTS: In our study, 39 patients were included for final analysis; the mean age of the cohort was 55.7 ± 10.6 years, and 66.7% of patients were male. No differences were observed in preoperative demographics, comorbidities, cuff tear morphology, and functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 10.6 fewer narcotic pills, a consumption reduction of 54.6% (19.42 versus 8.82, P < 0.001). No difference was observed in functional outcome scores at up to 6 weeks postoperatively between the two groups. No difference was observed in adverse events between the two groups with no reported cases of gastritis or gastrointestinal bleeding. Twenty-two of 39 patients underwent repeat magnetic resonance imaging at a mean of 7.9 months postoperatively, of which 5 (22%) demonstrated a retear of their rotator cuff. No significant difference was observed between the ketorolac and control groups in the rate of retear (P = 1.00). DISCUSSION: Adjunctive ketorolac substantially reduces narcotic utilization after arthroscopic RCR.

Obesity Is Preferentially Associated With Patellofemoral Compartment Wear: A Magnetic Resonance Imaging Assessment.

BACKGROUND: A well-known association exists between obesity and knee osteoarthritis (OA) for both incidence and progression of the disease. However, the cartilage wear patterns in OA associated with obesity are less well studied. METHODS: The OA initiative, a prospective sample of 4,796 patients, was used for this study. After the application of inclusion and exclusion criteria, patients were stratified into increasing body mass index (BMI) cohorts (BMI < 25, 25 ≤ BMI < 30, 30 ≤ BMI < 40, and 40 ≤ BMI). Knee MRIs were assessed using the semiquantitative MRI Osteoarthritis Knee Score scores. Patellofemoral (PF), medial, and lateral compartment cartilage scores were compared among BMI cohorts, controlling for confounders using linear regression models. RESULTS: In total, 2,006 patients were present in our cohort, 773 men (38.5%) and 1,233 women (61.5%); the mean age was 61.7 ± 8.9 years. Increasing BMI was independently associated with increasing grades of PF wear for both right and left knees in the lateral patella facet (right knee ß: 0.208, 95% confidence interval [CI]: 0.128 to 0.288, P < 0.001, left knee ß: 0.147, 95% CI: 0.056 to 0.237, P = 0.002), medial femoral trochlea (right knee ß: 0.135, 95% CI: 0.065 to 0.204, P < 0.001, left knee ß: 0.142, 95% CI: 0.063 to 0.221, P < 0.001), and lateral femoral trochlea (right knee ß: 0.163, 95% CI: 0.093 to 0.232, P < 0.001, left knee ß: 0.147, 95% CI: 0.067 to 0.226, P < 0.001). For the right knee, increasing BMI was associated with medial compartment wear in the posterior femoral area (ß: 0.070, 95% CI: 0.015 to 0.126, P = 0.013) and lateral compartment wear in the central tibial area (ß: 0.070, 95% CI: 0.002 to 0.138, P = 0.045). For the left knee, increasing BMI was associated with medial compartment wear in the central femoral area (ß: 0.093, 95% CI: 0.016 to 0.171, P = 0.018). DISCUSSION: Obesity is preferentially associated with increasing cartilage wear in the PF compartment in comparison to the tibiofemoral compartment. Physical therapy and exercise programs that promote weight loss should be modified to decrease forces on the PF joint.

Hamstring Anterior Cruciate Ligament Reconstruction Using an Adjustable-Loop Cortical Suspension Device: Immediate Postoperative Magnetic Resonance Imaging.

The purpose of this study is to determine whether the hamstring grafts are fully inserted into the femoral tunnel with the adjustable loop using immediate postoperative magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) reconstructions. A total of 62 consecutive patients underwent hamstring ACL reconstruction using an adjustable-loop cortical suspension device for the femoral fixation and the Intrafix sheath and screw for the tibial fixation. Multiplanar reformatted images of 3-T MRI scans were obtained at the 1st postoperative day before weight bearing is initiated in all patients to evaluate the gap (the tunnel-graft gap) between the top of the hamstring graft and top of the femoral tunnel. Postoperative MRI scans showed that the tunnel-graft gap was 1.5 ± 2.7 mm (range, 0-12 mm). In 43 (69.4%) patients, there was no gap between the top of the femoral tunnel and hamstring graft. In 19 (30.6%) patients, there was a gap between the tunnel and graft, and nine patients demonstrated a tunnel-graft gap greater than 5 mm. Immediate postoperative MRI scans demonstrated that an adjustable-loop cortical suspension device may not pull the hamstring graft completely into the femoral tunnel.

Comparison of Postoperative Tunnel Widening After Hamstring Anterior Cruciate Ligament Reconstructions Between Anatomic and Nonanatomic Femoral Tunnels.

PURPOSE: To evaluate the effect of the location of the femoral tunnel on 3-dimensional (3D) computed tomography (CT) upon the postoperative tunnel widening after anterior cruciate ligament (ACL) reconstructions. METHODS: Inclusion criteria were patients who underwent hamstring ACL reconstructions using an adjustable-loop cortical suspension device, underwent 3D CT at the day after surgery, and were followed for a minimum of 2 years after surgery. Exclusion criteria were patients with combined ligament injury and reinjury after reconstruction. Using 3D CT, the center of the femoral tunnel aperture was located on a standardized grid system. The center of the ACL footprint was defined from the literature. The femoral tunnel location was classified as anatomic if it located within 2 standard deviations of the center position. If it was outside the 2 standard deviations, the tunnel was classified as nonanatomic. The patients were divided into either anatomic or nonanatomic groups. Femoral tunnel angles on both sagittal and coronal planes were measured. Both femoral and tibial tunnels measured on anteroposterior and lateral radiographs at immediate postoperative day and at 2 years after surgery. Postoperative knee stability and patient-reported outcomes were evaluated. RESULTS: There were 37 patients in anatomical group and 52 patients in nonanatomical group among enrolled 87 patients. There were no differences in demographics between the 2 groups. There were no differences in the femoral tunnel angles and postoperative tunnel widening between the 2 groups. A higher position correlated to the femoral tunnel widening at 2 years postoperatively. Postoperative knee stability and patient-reported outcomes showed no statistically significant differences between the 2 groups. CONCLUSIONS: There was no significant difference in postoperative tunnel widening or clinical outcomes between anatomic and nonanatomic femoral tunnel location after hamstring ACL reconstructions. A higher position correlated to the femoral tunnel widening at 2 years postoperatively. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Radiologic and Clinical Outcomes After Hamstring Anterior Cruciate Ligament Reconstruction Using an Adjustable-Loop Cortical Suspension Device With Retensioning and Knot Tying.

PURPOSE: To report magnetic resonance imaging (MRI) findings and clinical outcomes after anterior cruciate ligament reconstruction using an adjustable-loop device (ALD) with retensioning and knot tying. METHODS: The inclusion criteria were patients who underwent hamstring anterior cruciate ligament reconstruction using an ALD with retensioning and knot tying between May and December 2015 and were followed up for a minimum of 2 years. The exclusion criteria were patients with combined ligament injury, revision surgery, or reinjury after reconstruction. After initial tightening of the adjustable loop, retensioning and knot tying were performed and the graft was fixed at the tibia. Multiplanar reformatted images of 3-T MRI scans were obtained on the immediate postoperative day and at 6 months after surgery to measure the gap between the top of the graft and the top of the femoral tunnel (i.e., tunnel-graft gap). Differences in the tunnel-graft gap between the immediate postoperative day and 6 months after surgery (i.e., gap difference) were calculated and correlated with knee stability and functional outcomes. RESULTS: Thirty-six patients were enrolled in this study. The mean tunnel-graft gap was 2.1 ± 2.8 mm on the immediate postoperative day and 4.6 ± 3.5 mm at 6 months after surgery (P < .001). The mean gap difference was 2.5 ± 2.0 mm. The mean KT-1000 measurement was 1.5 ± 2.2 mm, and mean Lysholm score and Tegner activity scale score were 93.6 ± 5.5 and 5.6 ± 1.5, respectively. The gap difference correlated negatively with the follow-up Lysholm score (P = .004); however, knee stability and the Tegner activity scale score were not correlated. CONCLUSIONS: Although the ALD was secured by retensioning and knot tying, MRI showed that the graft was not fully inserted in some patients and the tunnel-graft gap increased at 6 months' follow-up. The increase in the tunnel-graft gap did not correlate with knee stability or the Tegner activity scale score but correlated negatively with the Lysholm score. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Lateral Meniscal Allograft Transplant via a Medial Approach Leads to Less Extrusion.

BACKGROUND: Accurate positioning of the bony bridge is crucial to prevent extrusion of meniscal allografts after transplant. However, oblique or lateralized placement of the bony bridge of the lateral meniscal allograft may occur due to technical error or a limited visual field. The patellar tendon may be an obstacle to approaching the anterior horn of the lateral meniscus, resulting in a laterally placed allograft. Therefore, lateral meniscal transplant through a medial arthrotomy would be an alternative approach. However, no report exists regarding allograft extrusion when comparing medial and lateral arthrotomy techniques in lateral meniscal transplants. HYPOTHESIS: Extrusion of the midbody of the allograft is less severe and the rotation of the bony bridge is less oblique in lateral meniscal allograft transplants through the medial parapatellar approach than those through the lateral approach. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A bony bridge was used to perform 55 lateral meniscal transplants through either a medial or a lateral arthrotomy. Thirty-two allografts were transplanted through a medial arthrotomy and 23 were transplanted through a lateral arthrotomy, not randomly. Because correct positioning of the bony trough through the medial arthrotomy was easier than that through the lateral arthrotomy, the method of the arthrotomy was changed for the latter. The procedure for both groups was identical except for the arthrotomy technique, and rehabilitation was identical for both groups. Follow-up magnetic resonance imaging was conducted for all patients to measure the postoperative extrusion and obliquity of the bony bridge of the allograft. On the coronal view, extrusion was measured as the distance between the outer edge of the articular cartilage of the lateral tibial plateau and the outer edge of the meniscal allograft. On the axial view, a line (line B) was drawn along the longitudinal axis of the bony bridge. The posterior tibial condylar tangential line was drawn between the medial and lateral posterior tibial condylar cortices. A line (line T) was drawn perpendicular to the posterior tibial condylar tangential line. The angle (trough angle) between lines B and T was measured. Postoperative extrusion and the trough angle were compared between the medial and lateral arthrotomy groups. RESULTS: The median extrusion of the midbody of the allograft was 2.2 mm (interquartile range [IQR], 2.4 mm; range, 0-4.6 mm) in the medial arthrotomy group and 3.1 mm (IQR, 1.5 mm; range, 0-5.3 mm) in the lateral arthrotomy group ( P = .001). Seven (21.9%) patients demonstrated extrusion in the medial arthrotomy group, and 15 (65.2%) patients had extrusion in the lateral group ( P = .002). The median trough angle was 0.9° (IQR, 9.3°; range, -8.8-15.8°) in the medial arthrotomy group and 11.6° (IQR, 2.8°; range, 3-19.8°) in the lateral arthrotomy group ( P < .001). CONCLUSION: Based on this experience, lateral meniscal allograft transplant through a medial arthrotomy is preferred to decrease postoperative extrusion of the allograft.

Clinical and Radiological Outcomes After Hamstring Anterior Cruciate Ligament Reconstructions: Comparison Between Fixed-Loop and Adjustable-Loop Cortical Suspension Devices.

BACKGROUND: Few studies have compared clinical and radiological outcomes after hamstring anterior cruciate ligament (ACL) reconstruction with fixed-loop and adjustable-loop cortical suspension devices. Purpose/Hypothesis: The purpose of this retrospective study was to compare clinical outcomes and tunnel widening after hamstring ACL reconstructions with fixed- and adjustable-loop cortical suspension devices. The hypothesis was that compared with femoral graft fixation with the fixed-loop device, fixation with the adjustable-loop device would show similar clinical outcomes and would result in less tunnel widening after hamstring ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 117 consecutive patients underwent hamstring ACL reconstruction at a single institution. The fixed-loop cortical suspension device was used in 67 patients, and the adjustable-loop cortical suspension device was used in 50 patients. All patients were observed for a minimum of 2 years. Postoperative knee laxity was evaluated with the Lachman test, pivot-shift test, and KT-1000 arthrometer. Functional evaluations were performed by use of the Lysholm score and the Tegner activity scale. On anteroposterior (AP) and lateral radiographs, the measured diameters of the femoral tunnel at 1 year after surgery were compared with the diameter of the reamer used at surgery. The measured diameters of the tibial tunnel at 1 year after surgery were compared with those taken immediately after surgery. RESULTS: The mean KT-1000 arthrometer laxity measurement was 1.5 ± 1.8 mm in the fixed-loop group and 1.2 ± 2.3 mm in the adjustable-loop group ( P = .530). Results of postoperative knee laxity evaluations and functional outcomes from both groups showed no statistically significant differences. However, the fixed-loop group showed significantly better stability in the pivot-shift test than did the adjustable-loop group ( P = .018). On AP radiographs, the mean diameter of the femoral and tibial tunnels increased by 42.2% ± 15.9% and 37.0% ± 17.8%, respectively, in the fixed-loop group and by 43.0% ± 15.4% and 36.8% ± 18.2% in the adjustable-loop group. On lateral radiographs, the mean diameter of the femoral and tibial tunnels increased by 38.1% ± 14.8% and 39.9% ± 13.8%, respectively, in the fixed-loop group and by 35.8% ± 12.2% and 38.1% ± 21.0% in the adjustable-loop group. No significant differences were found between the 2 groups in postoperative femoral and tibial tunnel widening on AP radiographs ( P = .801 and .951, respectively) or lateral radiographs ( P = .422 and .621, respectively). CONCLUSION: Compared with femoral fixation by use of the fixed-loop device, femoral fixation by use of the adjustable-loop device showed similar clinical outcomes but did not reduce tunnel widening after hamstring ACL reconstructions.

Comparison of the insertion of the posterior horn of the lateral meniscus: discoid versus non-discoid.

PURPOSE: The purpose of this study was to compare the insertion sites of the posterior horn between discoid and non-discoid lateral meniscus using magnetic resonance imaging (MRI). METHODS: Two hundred and twenty-seven patients who had MRI scans before surgery and underwent arthroscopy were enroled in this study. A coronal view showing the narrowest width of the midbody of the lateral meniscus was chosen to measure the widths of the entire tibial plateau and the midbody of the lateral meniscus. Considering the ratio of the meniscal width to the tibial plateau width, the patients were divided into non-discoid, incomplete discoid, and complete discoid groups. On a coronal view accurately showing the insertion of the posterior horn of the lateral meniscus, a distance between the peak of the lateral tibial eminence and the centre of the insertion of the posterior horn, and a width of the lateral tibial plateau between the lateral edge of the tibial plateau and the peak of the lateral tibial eminence were measured. RESULTS: The insertion centre of the posterior horn was located more medially in the incomplete and complete discoid groups than in the non-discoid group (p = 0.003, 0.010, respectively). When individual differences in the knee size were corrected, the insertion centre of the posterior horn in the incomplete discoid and complete discoid groups was located more medially than in the non-discoid group (p = 0.009, 0.003, respectively). CONCLUSION: The insertion centre of the posterior horn of the lateral meniscus is located more medially to the apex of the lateral tibial eminence in the discoid group than in the non-discoid group. This finding needs to be considered for an accurate position of the posterior horn of lateral meniscus during the lateral meniscal allograft transplantation. LEVEL OF EVIDENCE: IV.