Location of medial collateral ligament tears: introduction to a magnetic resonance imaging-based classification.

PURPOSE: Despite established tear grade classifications, there is currently no radiological classification for sMCL tear locations. This study aims to establish a magnetic resonance imaging (MRI) tear location classification system for sMCL tears, to enhance understanding and guide treatment decisions by categorizing tear types. METHODS: A retrospective search in a single institution's MRI database identified patients with acute, Grade III sMCL tears (< 30 days between injury and MRI) from January to December 2022. Non-acute and partial tears were excluded, and three observers assessed tear types based on the proposed sMCL MRI tear location system: type I (proximal 25%), Ib (proximal femoral bony avulsion), II (midsubstance, 25-75%), III (distal 25%), IIIb (distal tibial bony avulsion), IIIs (Stener-like lesion). The interclass correlation coefficient (ICC) was used to assess interrater and intrarater reliability for continuous data; Fleiss and Cohen's kappa assessed interrater and intrarater reliability for categorical data. RESULTS: MRI scans of thirty patients with diagnosed sMCL injuries (53% female, mean age 37 ± 13 years, range 16-68 years) were included based on inclusion/exclusion criteria. Interrater reliability was excellent (ICC: 0.968, 95% CI, 0.933-0.985), and intrarater reliability was excellent (ICC: 0.938, 95% CI: 0.874-0.970 & 0.900, 95% CI, 0.789-0.952). Type I injuries were most common (60%), followed by type III (33.3%), type II (3.3%), type Ib (3.3%), type IIIb (0.0%), and type IIIs (0.0%). CONCLUSION: The presented MRI-based sMCL tear location classification provides a reproducible system for grading high-grade sMCL injuries. We propose that this framework will significantly unify tear location understanding and support more informed treatment decisions.

Autologous matrix-induced chondrogenesis provides better outcomes in comparison to autologous minced cartilage implantation in the repair of knee chondral defects.

PURPOSE: In symptomatic mid-sized focal chondral defects, autologous matrix-induced chondrogenesis (AMIC) and minced cartilage implantation (MCI) offer two versatile treatment options. This study aimed to conduct a matched-patient analysis of patient-reported outcome measures to compare these two surgical treatment methods for focal chondral defects. METHODS: At the first centre, patients underwent a single-stage procedure in which autologous cartilage was hand-minced, implanted into the defect and fixed with fibrin glue. At the second centre, patients underwent AMIC, which was fixed in place with fibrin glue. All patients were seen 2-4 years postoperatively. Postoperative outcomes were assessed using the visual analogue scale for pain (VAS), the Lysholm score and the five domains of the knee osteoarthritis outcome score (KOOS). Patients from each surgical centre were matched by age, sex, defect size and defect localisation. RESULTS: In total, 48 patients from two surgical centres (24 from each site) were matched for sex, age (MCI 30.3 ± 14.9 years vs. AMIC 30.8 ± 13.7 years) and defect size (MCI 2.49 ± 1.5 cm2 vs. AMIC 2.65 ± 1.1 cm2). Significantly better scores in the AMIC cohort were noted for VAS (p = 0.004), Lysholm (p = 0.043) and the KOOS subscales for pain (p = 0.016) and quality of life (p = 0.036). There was a significantly greater proportion of positive responders for Lysholm in the AMIC group (92%) compared with the MCI group (64%). CONCLUSIONS: The AMIC procedure delivers superior patient outcomes compared with hand-minced autologous cartilage implantation. These are mid-term outcomes, with follow-up between 2 and 4 years. LEVEL OF EVIDENCE: Level III.

Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis.

PURPOSE: To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR). METHODS: A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools. RESULTS: A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction. CONCLUSIONS: ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears. LEVEL OF EVIDENCE: Level III.

Cortical bone thickness on preoperative CT scans as predictor of bone quality in distal femur fractures: a retrospective study in Caucasians.

AIM: Distal femur fractures (DFF) are rare, but associated with high complication rates and mortality, particularly in patients with osteoporosis. To improve preoperative assessment, we analyzed if cortical bone thickness on CT and AP radiographs is associated with clinical parameters of bone quality. METHODS: Retrospective single-center study of adult patients presenting at a level-one trauma center, with a DFF between 2011 and 2020. Clinical parameters for bone quality, such as age, sex, body mass index (BMI), energy impact level of trauma, and known history of osteoporosis, were assessed. Mean cortical bone thickness (CBTavg) on AP radiograph was determined using a previously published method. Cortical thickness on CT scan was measured at 8 and 14 cm proximal to the articular surface of the lateral condyle. RESULTS: 71 patients (46 females) between 20 and 100 years were included in the study. Cortical thickness determined by CT correlated significantly with CBTavg measurements on AP radiograph (Spearman r = 0.62 to 0.80; p < 0.001). Cortical thickness was inversely correlated with age (Spearman r = - 0.341 to - 0.466; p < 0.001) and significantly associated with trauma impact level and history of osteoporosis (p = < 0.001). The CT-based values showed a stronger correlation with the clinical parameters than those determined by AP X-ray. CONCLUSION: Our results showed that cortical thickness of the distal femur correlates with clinical parameters of bone quality and is therefore an excellent tool for assessing what surgical care should be provided. Interestingly, our findings indicate that cortical thickness on CT is more strongly correlated with clinical data than AP radiograph measurements.

Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement.

INTRODUCTION: The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures. METHODS: Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients. RESULTS: Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening. CONCLUSION: Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.

Long-term outcomes of total hip arthroplasty in patients with developmental dysplasia of the hip: a minimum 21-year follow-up.

PURPOSE: Early osteoarthritis (OA) due to developmental dysplasia of the hip (DDH) is a known indication for total hip arthroplasty (THA). Though screening tools and joint-preserving procedures have been established successfully, there still is a relevant number of patients suffering DDH. Due to the lack of long-term outcome studies, we like to close this gap and present the results of a highly specialized center. METHODS: The study included 126 patients, who were treated in our institution with primary THA for DDH between January 1997 and December 2000. At the time of final follow-up, at a mean of 23 years postoperatively, 110 patients (121 hips) were clinically evaluated using the Harris-Hip Score. In addition, complication and surgical revision rates were assessed. We collected surgery-related data like implant choice and special surgical features such as autologous acetabular reconstruction or femoral osteotomies. Additionally, the severity of preoperative DDH was measured radiographically according to Crowe classification. RESULTS: There were 91 female (83%) and 19 male (17%) patients with an average age of 51 ± 9.5 years (range 21-65) included. Mean follow-up was 23 ± 1.3 years (21-25), with a minimum of 21 years being necessary for inclusion. Using revision for any indication as primary endpoint, the Kaplan-Meier survivorship was 98.3% at 10 years and 81.8% at final follow-up. The overall revision rate was 18% (22 cases), which were split up as follows: 20 (17%) implant failures (loosened or broken components), one (1%) periprosthetic infection and one (1%) periprosthetic fracture. Regarding complications, we observed nine (7%) dislocations and one case (1%) with severe heterotopic ossification that required surgical excision. The mean Harris-Hip score at latest follow-up was 78 ± 14 points (32-95). CONCLUSIONS: Though implants and surgical techniques have improved over time, our results suggest THA in patients suffering DDH to be seriously challenging with relatively high overall complications in long-term observation and fair clinical outcome after 21 years postoperatively. There is evidence that prior osteotomy might be associated with a higher revision rate.

Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries.

BACKGROUND: The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS: Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION: In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.

Comparison of different intraoperative reduction monitoring methods in a cadaveric intraarticular calcaneal fracture model: 3D scan vs arthroscopy vs nanoscopy.

AIMS: Visualization of the subtalar joint surface in surgical management of calcaneal factures remains a big challenge and anatomic reduction of the articular surface is essential for a good clinical outcome. We hypothesize that video-assistance can provide superior fracture reduction compared to fluoroscopy and that nanoscopy (NSC) achieves more extensive visualization compared to fracturoscopy (FSC). METHODS: Ten human cadaveric feet with artificially pre-fractured intraarticular calcaneal fractures with involvement of the posterior facet were treated via a minimal invasive subtalar approach. After initial control of reduction by 2D fluoroscopy, the reduction was further analyzed intraoperatively by FSC and NSC. 3D Scan served as gold standard control of reduction. Need of revision of reduction after the different visualization techniques was recorded and the extent of visualization of the subtalar joint surface in the medio-lateral dimension was compared for FSC and NSC. To quantify access and visualization of the medial and posterior facet, a depth gauge was used to measure from laterally at the clinically widest portion of the calcaneus targeted to the sustentaculum tali. The distance in millimetres was referred to the complete medio-lateral distance seen on paracoronal CT at the widest portion of the calcaneus. RESULTS: Fracture analysis in preoperative CT-scans according to Sanders classification revealed four type IC, two IIA, three IIC and one IIIAC fractures. Mean visualization of the medial and posterior facet was significantly improved with NSC (30.4 ± 3.78 mm) compared to FSC (23.6 ± 6.17 mm) (p = 0.008). An imperfect reduction requiring revision was more often required with NSC compared to FSC. Insufficient reduction using video-assistance was found in two cases. CONCLUSION: In order to optimize subtalar joint reduction and congruency, video-assisted techniques, especially NSC, provide superior visualization and thus can improve reduction in the surgical treatment of intraarticular calcaneal fractures.