Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Arthroscopic Transphyseal ACL Reconstruction With Lateral Extraarticular Tenodesis With Unusual Arthroscopic Meniscal Findings in a Case of an Adolescent Girl Previously Diagnosed With Amniotic Band Syndrome.

Amniotic band syndrome (ABS) constriction rings in the lower limb are common. Despite this, there is insufficient literature on anatomical abnormalities in the knee joints of children with ABS. There is an increasing incidence of paediatric anterior cruciate ligament (ACL) injuries recently. ACL reconstruction in this population has an extra dilemma of sparing the physis to prevent growth disturbances. Treating both these conditions simultaneously is a challenge that is rarely encountered. In our literature review, we found no case such as this. As such a case is being described for the first time, we also found certain meniscal anatomical variations on diagnostic arthroscopy. A 12-year-old adolescent Indian girl presented with an ACL tear in her left leg after a school sports injury. She had a known case of ABS constriction bands in both her lower limbs. Her distal femoral and proximal femoral physis was fused on radiographs, so we went ahead with a transphyseal ACL soft-tissue graft reconstruction. On the diagnostic round, we found an anatomical variation of the menisci, which was previously not described since arthroscopy of the knee in an adolescent kid with ABS has not been published in the literature as of yet. These kinds of clinical presentations can become common in the future as more and more kids with ABS take part in recreational sports. In such a scenario, having knowledge about common anatomical variations in the knee of such syndromic patients is essential. While performing ACL reconstructions in this population, we have to be aware of the risk of growth deformities along with vascular and neurological complications, which are added risks with constriction bands around the lower limb.

A Single-Stage Medial Opening Wedge High Tibial Osteotomy for Varus Alignment Correction With Revision Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction.

Anterior cruciate ligament (ACL) injuries are a common clinical entity among people involved in contact sports activities. With the number of primary ACL reconstructions increasing, there has been a proportional increase in the revision of failed ACL reconstruction surgeries. As our understanding of knee kinematics improves over time, there has been evidence that alignment of the lower limb weight-bearing axis also plays an important part in ACL functioning. Medial opening wedge high tibial osteotomy (MOWHTO) is one such procedure that has been used extensively worldwide to correct the varus lower limb alignment. This procedure is usually reserved for young active patients with varus lower limb weight-bearing alignment. The technical dilemma for the surgeon arises when there is a need to revise a failed ACL reconstruction while at the same time correcting the axis malalignment. The general dictum says that alignment correction is done first followed by ligament reconstruction in a dual-stage procedure. However, single-stage surgery is possible in certain indications. In this case report, we present the case of a 31-year-old male involved in recreational sports who sustained a repeat ACL tear five years post the index surgery. He also had a significant varus alignment of the lower limb weight-bearing axis which was considered to be one of the causes of index surgery failure. In this report, we would like to highlight the problems we encountered in a single-stage procedure and certain surgical facets of a single-stage alignment surgery with arthroscopic revision ACL reconstruction.

Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee.

BACKGROUND: Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee. METHODS: This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS). RESULTS: A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery. CONCLUSION: GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.

Mucoid degeneration of the anterior cruciate ligament.

PURPOSE: Mucoid degeneration of the anterior cruciate ligament (ACL) is not a well-known entity. Only 1 case of mucoid degeneration of the ACL has been reported in the English-language literature. This article describes 5 cases of mucoid degeneration of the ACL with clinical features, magnetic resonance imaging (MRI) findings, and a method of arthroscopic management of these cases. TYPE OF STUDY: Case series. METHODS: Over a period of 21 months from 1999 to 2001, 5 patients were diagnosed to be suffering from mucoid degeneration of the ACL using MRI, histopathologic, and arthroscopic criteria. All patients presented with progressive knee pain and restriction of flexion without history of a significant trauma or instability preceding the symptoms. MRI showed an increased signal in the substance of the ACL both in the T1- and T2-weighted images, with a mass-like configuration that was reported as a partial or complete tear of the ACL by most radiologists. At arthroscopy, the ACL was homogenous, bulbous, hypertrophied, and taut, occupying the entire intercondylar notch. The ligamentum mucosum was absent in all patients. A debulking of the ACL was performed by a judicious excision of the degenerate mucoid tissue, taking care to leave behind as much of the intact ACL as possible. Releasing it and performing a notchplasty treated impingement of the ACL to the roof and lateral wall. The ACL was not fully excised in any of the patients. RESULTS: All patients were pain free and had recovered full flexion except one who experienced painful flexion beyond 120 degrees. None of the patients showed symptoms of instability. Postoperative MRI performed after at least 12 months in 2 patients showed some intact ACL fibers in a now-thinned ACL mass. CONCLUSIONS: Mucoid degeneration of the ACL is a clinical condition afflicting active middle-aged people without a single significant traumatic episode with a specific MRI picture. They respond well to a judicious arthroscopic release of the ACL with notchplasty. LEVEL OF EVIDENCE: Level IV.