Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation.

AIMS: To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF). METHODS: A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications. RESULTS: In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop. CONCLUSION: Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion. LEVEL OF EVIDENCE: IV Systematic review including case series.

A constrained-condylar fixed-bearing total knee arthroplasty is stabilised by the medial soft tissues.

PURPOSE: Revision constrained-condylar total knee arthroplasty (CCK-TKA) is often used to provide additional mechanical constraint after failure of a primary TKA. However, it is unknown how much this translates to a reliance on soft-tissue support. The aim of this study was therefore to compare the laxity of a native knee to the CCK-TKA implanted state and quantify how medial soft-tissues stabilise the knee following CCK-TKA. METHODS: Ten intact cadaveric knees were tested in a robotic system at 0°, 30°, 60° and 90° flexion with ± 90  N anterior-posterior force, ± 8 Nm varus-valgus and ± 5 Nm internal-external torques. A fixed-bearing CCK-TKA was implanted and the laxity tests were repeated with the soft tissues intact and after sequential cutting. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were sequentially transected and the percentage contributions of each structure to restraining the applied loads were calculated. RESULTS: Implanting a CCK-TKA did not alter anterior-posterior laxity from that of the original native knee, but it significantly decreased internal-external and varus-valgus rotational laxity (p < 0.05). Post CCK-TKA, the sMCL restrained 34% of the tibial displacing load in anterior drawer, 16% in internal rotation, 17% in external rotation and 53% in valgus, across the flexion angles tested. The dMCL restrained 11% of the valgus rotation moment. CONCLUSIONS: With a fully-competent sMCL in-vitro, a fixed-bearing CCK-TKA knee provided more rotational constraint than the native knee. The robotic test data showed that both the soft-tissues and the semi-constrained implant restrained rotational knee laxity. Therefore, in clinical practice, a fixed-bearing CCK-TKA knee could be indicated for use in a knee with lax, less-competent medial soft tissues. LEVEL OF EVIDENCE: Controlled laboratory study.

Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability.

PURPOSE: Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability. METHODS: Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A-P and S-I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions. RESULTS: All three reconstructions restored the range of A-P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S-I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint. CONCLUSIONS: Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words).

Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study.

BACKGROUND: Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. METHODS: Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. RESULTS: In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). CONCLUSION: The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

Partial and Combined Partial Knee Arthroplasty: Greater Anterior-Posterior Stability Than Posterior Cruciate-Retaining Total Knee Arthroplasty.

BACKGROUND: Little is known regarding anterior-posterior stability after anterior cruciate ligament-preserving partial (PKA) and combined partial knee arthroplasty (CPKA) compared to standard posterior cruciate-retaining total knee arthroplasty (TKA). METHODS: The anterior-posterior tibial translation of twenty-four cadaveric knees was measured, with optical tracking, while under 90N drawer with the knee flexed 0-90°. Knees were tested before and after PKA, CPKA (medial and lateral bicompartmental and bi-unicondylar), and then posterior cruciate-retaining TKA. The anterior-posterior tibial translations of the arthroplasty states, at each flexion angle, were compared to the native knee and each other with repeated measures analyses of variance and post-hoc t-tests. RESULTS: Unicompartmental and bicompartmental arthroplasty states had similar laxities to the native knee and to each other, with ≤1-mm differences throughout the flexion range (P ≥ .199). Bi-unicondylar arthroplasty resulted in 6- to 8-mm increase of anterior tibial translation at high flexion angles compared to the native knee (P ≤ .023 at 80-90°). Meanwhile, TKA exhibited increased laxity across all flexion angles, with increased anterior tibial translation of up to 18 ± 6 mm (P < .001) and increased posterior translation of up to 4 ± 2 mm (P < .001). CONCLUSIONS: In a cadaveric study, anterior-posterior tibial translation did not differ from native laxity after PKA and CPKA. Posterior cruciate ligament-preserving TKA demonstrated increased laxity, particularly in anterior tibial translation.

The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically.

PURPOSE: To define the bony attachments of the medial ligaments relative to anatomical and radiographic bony landmarks, providing information for medial collateral ligament (MCL) surgery. METHOD: The femoral and tibial attachments of the superficial MCL (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL), plus the medial epicondyle (ME) were defined by radiopaque staples in 22 knees. These were measured radiographically and optically; the precision was calculated and data normalised to the sizes of the condyles. Femoral locations were referenced to the ME and to Blumensaat's line and the posterior cortex. RESULTS: The femoral sMCL attachment enveloped the ME, centred 1 mm proximal to it, at 37 ± 2 mm (normalised at 53 ± 2%) posterior to the most-anterior condyle border. The femoral dMCL attachment was 6 mm (8%) distal and 5 mm (7%) posterior to the ME. The femoral POL attachment was 4 mm (5%) proximal and 11 mm (15%) posterior to the ME. The tibial sMCL attachment spread from 42 to 71 mm (81-137% of A-P plateau width) below the tibial plateau. The dMCL fanned out anterodistally to a wide tibial attachment 8 mm below the plateau and between 17 and 39 mm (33-76%) A-P. The POL attached 5 mm below the plateau, posterior to the dMCL. The 95% CI intra-observer was ± 0.6 mm, inter-observer ± 1.3 mm for digitisation. The inter-observer ICC for radiographs was 0.922. CONCLUSION: The bone attachments of the medial knee ligaments are located in relation to knee dimensions and osseous landmarks. These data facilitate repairs and reconstructions that can restore physiological laxity and stability patterns across the arc of knee flexion.

Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery.

PURPOSE: To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. METHODS: Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. RESULTS: The anterior sMCL lengthened with flexion (p < 0.01) and further lengthened by external rotation (p < 0.001). The posterior sMCL slackened with flexion (p < 0.001), but was lengthened by internal rotation (p < 0.05). External rotation lengthened the anterior dMCL fibres by 10% throughout flexion (p < 0.001). sMCL release allowed the dMCL to become taut with valgus rotation (p < 0.001). The anterior and posterior POL fibres slackened with flexion (p < 0.001), but were elongated by internal rotation (p < 0.001). CONCLUSION: The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.

The medial ligaments and the ACL restrain anteromedial laxity of the knee.

PURPOSE: The purpose of this study was to determine the contribution of each of the ACL and medial ligament structures in resisting anteromedial rotatory instability (AMRI) loads applied in vitro. METHODS: Twelve knees were tested using a robotic system. It imposed loads simulating clinical laxity tests at 0° to 90° flexion: ±90 N anterior-posterior force, ±8 Nm varus-valgus moment, and ±5 Nm internal-external rotation, and the tibial displacements were measured in the intact knee. The ACL and individual medial structures-retinaculum, superficial and deep medial collateral ligament (sMCL and dMCL), and posteromedial capsule with oblique ligament (POL + PMC)-were sectioned sequentially. The tibial displacements were reapplied after each cut and the reduced loads required allowed the contribution of each structure to be calculated. RESULTS: For anterior translation, the ACL was the primary restraint, resisting 63-77% of the drawer force across 0° to 90°, the sMCL contributing 4-7%. For posterior translation, the POL + PMC contributed 10% of the restraint in extension; other structures were not significant. For valgus load, the sMCL was the primary restraint (40-54%) across 0° to 90°, the dMCL 12%, and POL + PMC 16% in extension. For external rotation, the dMCL resisted 23-13% across 0° to 90°, the sMCL 13-22%, and the ACL 6-9%. CONCLUSION: The dMCL is the largest medial restraint to tibial external rotation in extension. Therefore, following a combined ACL + MCL injury, AMRI may persist if there is inadequate healing of both the sMCL and dMCL, and MCL deficiency increases the risk of ACL graft failure.

Reconstruction of the anterior cruciate- and anterolateral ligament deficient knee with a modified iliotibial graft reduces instability more than with an intra-articular hamstring graft.

PURPOSE: To compare knee kinematics before and after anterior cruciate ligament ACL reconstruction (ACL-R) using hamstring graft (HG) and a double-stranded iliotibial tract graft attached to Gerdy's tubercle (providing an extra-articular anterolateral tenodesis) (named the modified iliotibial tract graft = MIT). METHOD: Eighteen cadaveric knees were tested in a 6 degree of freedom kinematics rig. An optical tracking system recorded kinematics of the knee from 0 to 80 degrees of flexion applying no load, internal/external rotation (IR/ER), valgus/varus rotation (VGR/VRR), simulated pivot shift (SPS), anterior translation (AT) and posterior translation loads. The knee was tested before and after resection of the ACL and the anterolateral ligament (ALL), respectively; then after HG-ACL-R and MIT-ACL-R. Grafts were fixed at 20° of flexion. Results were compared to the intact knee. RESULTS: ACL resection resulted in a significant increase in AT (p < 0.05) over the entire range of motion, peaking at 20° of flexion, mean difference 6.6 ± 2.25 mm (p = 0.0007). ACL-R with HG-ACL and MIT-ACL restored AT. Resection of the ALL increased IR in the fully extended knee, mean difference 2.4 ± 2.1° (p = 0.024). When compared to the intact knee and the knee after HG-ACL-R, MIT-ACL-R knee reduced IR/SPS significantly (p < 0.05) in deep flexion angles (60°-80°), peaking at 80° of flexion. The MIT-ACL-R caused significantly less VRR at 80° flexion (p = 0.02). CONCLUSION: MIT-ACL-R restored AT equally to the HG-ACL-R. The MIT-ACL-R reduced IR and SPS in deep flexion, resulting in overconstraint. MIT-ACL-R can be used as an alternative to standard reconstruction methods.

Flexor digitorum longus tendon transfer to the navicular: tendon-to-tendon repair is stronger compared with interference screw fixation.

PURPOSE: To assess whether early rehabilitation could be safe after flexor digitorum longus (FDL) tendon transfer, the current biomechanical study aimed to measure tendon displacement under cyclic loading and load to failure, comparing a traditional tendon-to-tendon (TT) repair with interference screw fixation (ISF). METHODS: 24 fresh-frozen cadaveric below knee specimens underwent FDL tendon transfer. In 12 specimens a TT repair was performed via a navicular bone tunnel. In a further 12 specimens ISF was performed. Using a materials testing machine, the FDL tendon was cycled 1000 times to 150 N and tendon displacement at the insertion site measured. A final load to failure test was then performed. Statistical analysis was performed using two-way ANOVA and an independent t test, with a significance level of p < 0.05. RESULT: No significant difference in tendon displacement occurred after cyclic loading, with mean tendon displacements of 1.9 ± 1.2 mm (mean ± SD) in the TT group and 1.8 ± 1.5 mm in the ISF group (n.s.). Two early failures occurred in the ISF group, none in the TT group. Mean load to failure was significantly greater following TT repair (459 ± 96 N), compared with ISF (327 ± 76 N), p = 0.002. CONCLUSION: Minimal tendon displacement of less than 2 mm occurred during cyclic testing in both groups. The two premature failures and significantly reduced load to failure observed in the ISF group, however, indicate that the traditional TT technique is more robust. Regarding clinical relevance, this study suggests that early active range of motion and protected weight bearing may be safe following FDL tendon transfer for stage 2 tibialis posterior tendon dysfunction.

ACL reconstruction combined with lateral monoloop tenodesis can restore intact knee laxity.

PURPOSE: An anterior cruciate ligament (ACL) injury is often combined with injury to the lateral extra-articular structures, which may cause a combined anterior and rotational laxity. It was hypothesised that addition of a 'monoloop' lateral extra-articular tenodesis (mLET) to an ACL reconstruction would restore anteroposterior, internal rotation and pivot-shift laxities better than isolated ACL reconstruction in combined injuries. METHOD: Twelve cadaveric knees were tested, using an optical tracking system to record the kinematics through 0°-100° of knee flexion with no load, anterior and posterior translational forces (90 N), internal and external rotational torques (5 Nm), and a combination of an anterior translational (90 N) plus internal rotational load (5 Nm). They were tested intact, after sectioning the ACL, sectioning anterolateral ligament (ALL), iliotibial band (ITB) graft harvest, releasing deep ITB fibres, hamstrings tendon ACL reconstruction, mLET combined with ACL reconstruction, and isolated mLET. Two-way repeated-measures ANOVA compared laxity data across knee states and flexion angles. When differences were found, paired t tests with Bonferroni correction were performed. RESULTS: In the ACL-deficient knee, cutting the ALL significantly increased anterior laxity only at 20°-30°, and only significantly increased internal rotation at 50°. Additional deep ITB release significantly increased anterior laxity at 40°-90° and caused a large increase of internal rotation at 20°-100°. Isolated ACL reconstruction restored anterior drawer, but significant differences remained in internal rotation at 30°-100°. After adding an mLET there were no remaining differences with anterior translation or internal rotation compared to the intact knee. With the combined injury, isolated mLET allowed abnormal anterior translation and rotation to persist. CONCLUSIONS: Cutting the deep fibres of the ITB caused large increases in tibial internal rotation laxity across the range of knee flexion, while cutting the ALL alone did not. With ACL deficiency combined with anterolateral deficiency, ACL reconstruction alone was insufficient to restore native knee rotational laxity. However, combining a 'monoloop' lateral extra-articular tenodesis with ACL reconstruction did restore native knee laxity.

Editorial Commentary: Taking a Wider View During Anterior Cruciate Ligament Reconstruction? The Case for Doing More Than Just Reconstructing the Anterior Cruciate Ligament Itself.

Anterior cruciate ligament reconstruction may leave a residual instability. If other pathology is identified, the surgeon should consider doing more than the isolated anterior cruciate ligament reconstruction to address peripheral lesions to the menisci, ligaments, and capsule in selected cases.

The Role of Fibers Within the Tibial Attachment of the Anterior Cruciate Ligament in Restraining Tibial Displacement.

PURPOSE: To evaluate the load-bearing functions of the fibers of the anterior cruciate ligament (ACL) tibial attachment in restraining tibial anterior translation, internal rotation, and combined anterior and internal rotation laxities in a simulated pivot-shift test. METHODS: Twelve knees were tested using a robot. Laxities tested were: anterior tibial translation (ATT), internal rotation (IR), and coupled translations and rotations during a simulated pivot-shift. The kinematics of the intact knee was replayed after sequentially transecting 9 segments of the ACL attachment and fibers entering the lateral gutter, measuring their contributions to restraining laxity. The center of effort (COE) of the ACL force transmitted to the tibia was calculated. A blinded anatomic analysis identified the densest fiber area in the attachment of the ACL and thus its centroid (center of area). This centroid was compared with the biomechanical COE. RESULTS: The anteromedial tibial fibers were the primary restraint of ATT (84% across 0° to 90° flexion) and IR (61%) during isolated and coupled displacements, except for the pivot-shift and ATT in extension. The lateral gutter resisted 28% of IR at 90° flexion. The anteromedial fibers showed significantly greater restraint of simulated pivot-shift rotations than the central and posterior fibers (P < .05). No significant differences (all <2 mm) were found between the anatomic centroid of the C-shaped attachment and the COE under most loadings. CONCLUSIONS: The peripheral anteromedial fibers were the most important area of the ACL tibial attachment in the restraint of tibial anterior translation and internal rotation during isolated and coupled displacements. These mechanical results matched the C-shaped anteromedial attachment of the dense collagen fibers of the ACL. CLINICAL RELEVANCE: The most important fibers in restraining tibial displacements attach to the C-shaped anteromedial area of the native ACL tibial attachment. This finding provides an objective rationale for ACL graft position to enable it to reproduce the physiological path of load transmission for tibial restraint.

Posterior capsular release is a biomechanically safe procedure to perform in total knee arthroplasty.

PURPOSE: Surgeons may attempt to strip the posterior capsule from its femoral attachment to overcome flexion contracture in total knee arthroplasty (TKA); however, it is unclear if this impacts anterior-posterior (AP) laxity of the implanted knee. The aim of the study was to investigate the effect of posterior capsular release on AP laxity in TKA, and compare this to the restraint from the posterior cruciate ligament (PCL). METHODS: Eight cadaveric knees were mounted in a six degree of freedom testing rig and tested at 0°, 30°, 60° and 90° flexion with ± 150 N AP force, with and without a 710 N axial compressive load. After the native knee was tested, a deep dished cruciate-retaining TKA was implanted and the tests were repeated. The PCL was then cut, followed by releasing the posterior capsule using a curved osteotome. RESULTS: With 0 N axial load applied, cutting the PCL as well as releasing the posterior capsule significantly increased posterior laxity compared to the native knee at all flexion angles, and CR TKA states at 30°, 60° and 90° (p < 0.05). However, no significant increase in laxity was found between cutting the PCL and subsequent PostCap release (n.s.). In anterior drawer, there was a significant increase of 1.4 mm between cutting the PCL and PostCap release at 0°, but not at any other flexion angles (p = 0.021). When a 710 N axial load was applied, there was no significant difference in anterior or posterior translation across the different knee states (n.s.). CONCLUSIONS: Posterior capsular release only caused a small change in AP laxity compared to cutting the PCL and, therefore, may not be considered detrimental to overall AP stability if performed during TKA surgery. LEVEL OF EVIDENCE: Controlled laboratory study.

The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting.

The structure and function of the anterolateral complex (ALC) of the knee has created much controversy since the 're-discovery' of the anterolateral ligament (ALL) and its proposed role in aiding control of anterolateral rotatory laxity in the anterior cruciate ligament (ACL) injured knee. A group of surgeons and researchers prominent in the field gathered to produce consensus as to the anatomy and biomechanical properties of the ALC. The evidence for and against utilisation of ALC reconstruction was also discussed, generating a number of consensus statements by following a modified Delphi process. Key points include that the ALC consists of the superficial and deep aspects of the iliotibial tract with its Kaplan fibre attachments on the distal femur, along with the ALL, a capsular structure within the anterolateral capsule. A number of structures attach to the area of the Segond fracture including the capsule-osseous layer of the iliotibial band, the ALL and the anterior arm of the short head of biceps, and hence it is not clear which is responsible for this lesion. The ALC functions to provide anterolateral rotatory stability as a secondary stabiliser to the ACL. Whilst biomechanical studies have shown that these structures play an important role in controlling stability at the time of ACL reconstruction, the optimal surgical procedure has not yet been defined clinically. Concern remains that these procedures may cause constraint of motion, yet no clinical studies have demonstrated an increased risk of osteoarthritis development. Furthermore, clinical evidence is currently lacking to support clear indications for lateral extra-articular procedures as an augmentation to ACL reconstruction. The resulting statements and scientific rationale aim to inform readers on the most current thinking and identify areas of needed basic science and clinical research to help improve patient outcomes following ACL injury and subsequent reconstruction.Level of evidence V.

It is safe and effective to use all inside meniscal repair devices for posteromedial meniscal 'ramp' lesions.

PURPOSE: Recently, it has been recognized that meniscocapsular ('ramp') lesions of the posterior one-third of the medial meniscus frequently occur during injuries causing ACL rupture, and that these lesions are easily missed at arthroscopy. Furthermore, it is clear that these lesions are biomechanically significant, adding to the deficits caused by ACL rupture, and that their repair can reverse this. The efficacy of an all inside repair technique has been questioned by some authors and by those who advocate a suture shuttle technique via an accessory posteromedial portal. The use of Ultra FastFix and FastFix 360 meniscal repair devices to repair posteromedial meniscocapsular separations was investigated in terms of safe deployment and the effectiveness. METHODS: Twenty cadaveric fresh frozen knees were used-ten in each of two groups. A ramp lesion was created using a Beaver knife. The lesion was then repaired with either 4 Ultra FastFix (Smith and Nephew) or 4 FastFix 360 (Smith and Nephew) meniscal repair devices. The knees were put through a standardized loading cycle consisting of 10 Lachman's tests and ten maximum loading manual anterior drawer tests at 90° of flexion. Each knee was then flexed and extended fully ten times. The specimens were sectioned just proximal to the menisci and each suture anchor identified and its position recorded and photographed. RESULTS: In the Ultra FastFix group, a single anchor was found to be in an intra-articular position-a failure rate of 2.5%. In the FastFix 360 group, 5 anchors failed-a 12.5% failure rate. In all cases, the anchors were attached to their suture and so not truly loose within the joint. CONCLUSIONS: This study confirms the safe and effective deployment of an all inside repair device for repair of medial meniscal 'ramp' lesions, and therefore its use is advocated in treating these difficult lesions. Ultra FastFix had the lower failure rate of 2.5%, which the authors believe is acceptable, and makes this device preferable to the FastFix360.

The infrapatellar fat pad is a dynamic and mobile structure, which deforms during knee motion, and has proximal extensions which wrap around the patella.

PURPOSE: The infrapatellar fat pad (IFP) is a common cause of knee pain and loss of knee flexion and extension. However, its anatomy and behavior are not consistently defined. METHODS: Thirty-six unpaired fresh frozen knees (median age 34 years, range 21-68) were dissected, and IFP attachments and volume measured. The rectus femoris was elevated, suprapatellar pouch opened and videos recorded looking inferiorly along the femoral shaft at the IFP as the knee was flexed. The patellar retinacula were incised and the patella reflected distally. The attachment of the ligamentum mucosum (LMuc) to the intercondylar notch was released from the anterior cruciate ligament (ACL), both menisci and to the tibia via meniscotibial ligaments. IFP strands projecting along both sides of the patella were elevated and the IFP dissected from the inferior patellar pole. Magnetic resonance imaging (MRI) of one knee at ten flexion angles was performed and the IFP, patella, tibia and femur segmented. RESULTS: In all specimens the IFP attached to the inferior patellar pole, femoral intercondylar notch (via the LMuc), proximal patellar tendon, intermeniscal ligament, both menisci and the anterior tibia via the meniscotibial ligaments. In 30 specimens the IFP attached to the anterior ACL fibers via the LMuc, and in 29 specimens it attached directly to the central anterior tibia. Proximal IFP extensions were identified alongside the patella in all specimens and visible on MRI [medially (100% of specimens), mean length 56.2 ± 8.9 mm, laterally (83%), mean length 23.9 ± 6.2 mm]. Mean IFP volume was 29.2 ± 6.1 ml. The LMuc, attached near the base of the middle IFP lobe, acting as a 'tether' drawing it superiorly during knee extension. The medial lobe consistently had a pedicle superomedially, positioned between the patella and medial trochlea. MRI scans demonstrated how the space between the anterior tibia and patellar tendon ('the anterior interval') narrowed during knee flexion, displacing the IFP superiorly and posteriorly as it conformed to the trochlear and intercondylar notch surfaces. CONCLUSION: Proximal IFP extensions are a novel description. The IFP is a dynamic structure, displacing significantly during knee motion, which is, therefore, vulnerable to interference from trauma or repetitive overload. Given that this trauma is often surgical, it may be appropriate that surgeons learn to minimize injury to the fat pad at surgery.

Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques.

PURPOSE: There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS: Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS: Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION: In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

ACL graft compression: a method to allow reduced tunnel sizes in ACL reconstruction.

PURPOSE: A common problem during ACL reconstruction is asymmetry of proximal-distal graft diameter leading to tunnel upsizing and graft-tunnel mismatch. Compression downsizing provides a graft of uniform size, allowing easy passage into a smaller tunnel. The purpose of this study was to quantify the graft compression technique and its effects on graft biomechanics and stability. It was hypothesised that compression downsizing would significantly reduce cross-sectional area (CSA); that no significant changes in graft biomechanics would occur; graft fixation stability would be improved. METHOD: Sixty-eight non-irradiated peroneus longus (PL) tendons were investigated. Twenty were halved and paired into ten four-strand grafts, 20 strands were compressed by 0.5-1 mm diameter and changes in CSA recorded using an alginate mould technique. The following properties were compared with 20 control strands: cyclic strain when loaded 70-220 N for 1000 cycles; stiffness; ultimate tensile load and stress; Young's modulus. 24 PL tendons were quadrupled into grafts, 12 were compressed and all 24 were submerged in Ringer's solution at 37 °C and the CSA recorded over 12 h. Twelve compressed and 12 control quadrupled grafts were mounted in porcine femurs, placed in Ringer's solution for 12 h at 37 °C and graft displacement at the bone tunnel aperture recorded under cyclic loading. RESULTS: Mean decreases in CSA of 31% under a stress of 471 kPa and 21% under a stress of 447 kPa were observed for doubled and quadrupled grafts, respectively. Compressed grafts re-expanded by 19% over 12 h compared to 2% for controls. No significant differences were observed between compressed and control grafts in the biomechanical properties and graft stability; mean cyclic displacements were 0.3 mm for both groups. CONCLUSIONS: No detrimental biomechanical effects of graft compression on allograft PL tendons were observed. Following compression, the grafts significantly increased in size during in vitro joint simulation. No significant difference was observed in graft stability between groups. Graft compression did not cause adverse mechanical effects in vitro. Smaller tunnels for compressed grafts reduce bone loss and ease anatomical placement.

Editorial Commentary: Anatomical Vandalism of the Hip? Hip Capsular Repair Seems a Sound Adjunct to Hip Arthroscopic Surgery.

The study "Contribution of the Pubofemoral Ligament to Hip Stability: A Biomechanical Study" by Martin, Khoury, Schröder, Johnson, Gómez-Hoyos, Campos, and Palmer found that cutting the hip capsular ligament allowed a large increase in femoral internal rotation, particularly in the flexed hip, causing subluxation to occur. In addition to providing new data on the role of the pubofemoral ligament, it raises the question of whether hip joint surgeons should repair the capsule-what are the likely consequences?-and whether any beneficial effects persist in long-term clinical follow-ups. For now, hip capsular repair seems a sound adjunct to hip arthroscopic surgery.