Malrotated lateral knee radiographs do not allow for a proper assessment of medial or lateral posterior tibial slope.

PURPOSE: The aim of this study was to investigate whether malrotation of lateral knee radiographs influences posterior tibial slope (PTS) measurements. METHODS: Lateral knee radiographs of all patients who underwent knee surgery at a single institution between June 2022 and January 2023 and received multiple lateral knee radiographs were included. Radiographs were categorised as malrotated lateral knee radiographs or lateral knee radiographs based on the radiographic distance between the medial and lateral posterior femoral condyles. Medial PTS (MPTS) and lateral PTS (LPTS) were evaluated on malrotated lateral knee radiographs and lateral knee radiographs and compared using the paired t test. Intra- and interrater reliability between four raters were assessed for MPTS and LPTS measurements. RESULTS: A total of 92 lateral knee radiographs (46 pairs of malrotated lateral knee radiographs and lateral knee radiographs; 50.0% right side) from 46 patients (33.2 ± 12.4 years, 69.6% male) were included. Mean posterior femoral condyle distance in malrotated lateral knee radiographs was 8.1 ± 4.4 mm. Overall, MPTS and LPTS were significantly higher on malrotated lateral knee radiographs versus lateral knee radiographs (medial: 10.5 ± 3.2° vs. 9.7 ± 3.5°, p < 0.05; lateral: 10.6 ± 3.4° vs. 9.7 ± 3.3°, p < 0.05). Mean absolute difference between MPTS and LPTS on malrotated lateral knee radiographs versus lateral knee radiographs were |1.9| ± |1.5|° and |2.0| ± |1.8|°, respectively. Intrarater reliability was 'moderate' and interrater reliability was 'good' for both MPTS and LPTS. CONCLUSION: Malrotation of lateral knee radiographs led to a significant distortion of both the MPTS and LPTS. In clinical practice, attention should be placed on the (mal)rotation of lateral knee radiographs, especially in patients for whom a slope-correcting osteotomy is being discussed. LEVEL OF EVIDENCE: Level IV.

Partial ruptures of the distal triceps tendons show only slightly lower ultimate load to failure: a biomechanical study.

OBJECTIVE: Partial ruptures of the distal triceps tendon are usually treated surgically from a size of > 50% tendon involvement. The aim of this study was to compare the ultimate load to failure of intact triceps tendons with partially ruptured tendons and describe the rupture mechanism. METHODS: Eighteen human fresh-frozen cadaveric elbow specimens were randomly assigned to two groups with either an intact distal triceps tendon or with a simulated partial rupture of 50% of the tendon. A continuous traction on the distal triceps tendon was applied to provoke a complete tendon rupture. The maximum required ultimate load to failure of the tendon in N was measured. In addition, video recordings of the ruptures of the intact tendons were performed and analysed by two independent investigators. RESULTS: A median ultimate load to failure of 1,390 N (range Q0.25-Q0.75, 954 - 2,360) was measured in intact distal triceps tendons. The median ultimate load to failure of the partially ruptured tendons was 1,330 N (range Q0.25-Q0.75, 1,130 - 1.470 N). The differences were not significant. All recorded ruptures began in the superficial tendon portion, and seven out of nine tendons in the lateral tendon portion. DISCUSSION: Partial ruptures of the distal triceps tendon demonstrate a not statistically significant lower ultimate load to failure than intact tendons and typically occur in the superficial, lateral portion of the tendon. This finding can be helpful when deciding between surgical and conservative therapy for partial ruptures of the distal triceps tendon.

Osteoarticular Open Flake Fracture Refixation: The "Parachute" Technique.

Osteochondral fractures of the patella, also known as "flake fractures," frequently occur after patellar dislocation. In such fractures, a piece of patellar cartilage with subchondral bone breaks off due to patellar dislocation or subsequent reposition. Various surgical techniques have evolved for surgical therapy with the goal of realigning the patellar cartilage. This article presents a cost-effective surgical technique for achieving stable refixation of large osteochondral fragments in patellar flake fractures. The proposed technique entails creating transosseous tunnels in a confluent fashion at the margins, exactly between the fragment and the natural cartilage. Sutures are passed through the established tunnels for flake refixation. This refixation method ensures evenly distributed pressure without penetration of the fragment itself, resulting in the formation of a characteristic parachute configuration composed of confluent bone tunnels and absorbable sutures. The suitability of flake refixation is assessed through an algorithm, allowing for appropriate patient selection. The described technique offers several advantages, including its simplicity and cost-effectiveness, a flexible configuration of the sutures, and the ability to provide stable refixation for large osteochondral fragments.

Bone bruise distribution predicts anterior cruciate ligament tear location in non-contact injuries.

Purpose: It is unclear whether different injury mechanisms lead to divergent anterior cruciate ligament (ACL) tear locations. This study aims to analyse the relationship between bone bruise (BB) distribution or depth and ACL tear location. Methods: A retrospective analysis of 446 consecutive patients with acute non-contact ACL injury was performed. Only patients with complete ACL tears verified during subsequent arthroscopy were included. Magnetic resonance imaging (MRI) was used to classify BB location, BB depth, ACL tear location and concomitant injuries (medial/lateral meniscus and medial/lateral collateral ligament). Demographic characteristics included age, gender, body mass index (BMI), type of sport and time between injury and MRI. Multiple linear regression analysis was used to identify independent predictors of ACL tear location. Results: One hundred and fifty-eight skeletally mature patients met the inclusion criteria. The presence of BB in the lateral tibial plateau was associated with a more distal ACL tear location (ß = -0.27, p < 0.001). Less BB depth in the lateral femoral condyle showed a tendency towards more proximal ACL tears (ß = -0.14; p = 0.054). Older age predicted a more proximal ACL tear location (ß = 0.31, p < 0.001). No significant relationship was found between ACL tear location and gender, BMI, type of sport, concomitant injuries and time between injury and MRI. Conclusion: ACL tear location after an acute non-contact injury is associated with distinct patterns of BB distribution, particularly involving the lateral compartment, indicating that different injury mechanisms may lead to different ACL tear locations. Level of Evidence: Level III.

Glenolabral Articular Disruption (GLAD) Is Not Associated with Worse Outcomes or Higher Instability Recurrence after Arthroscopic Bankart Repair-A Matched-Pair Analysis.

Background: This study aimed to compare clinical outcomes and recurrence of instability after arthroscopic Bankart repair (ABR) in patients with anterior shoulder instability, with and without a GLAD lesion, while distinguishing between primary and recurrent instability. Methods: Consecutive patients who underwent isolated ABR between January 2012 and December 2021 were included. Patients with a concomitant GLAD lesion were matched in with patients without a GLAD lesion according to the following criteria: age, sex, BMI, follow-up time, and primary versus recurrent instability. At minimum two-year follow-up, the clinical outcome (Rowe score, redislocation rate) and the functional outcome, including the American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Shoulder Instability Index (WOSI), Oxford Shoulder Instability Score (OSIS), satisfaction (1-10 scale, 0 = unsatisfied, 10 = very satisfied), and Visual Analogue Scale (VAS), were compared between groups. Results: In total, 28 patients (14 GLAD vs. 14 Bankart; age: 32.5 ± 13.0 years; sex: 92.9% male; BMI: 24.6 ± 2.2) were included 6.9 ± 2.8 (2-11) years after isolated ABR (follow-up rate 63.6%). Clinical and functional outcome did not differ significantly between patients with versus without GLAD lesions (ASES score: 100 [96.5-100] vs. 97.5 [93.3-100], p = 0.27); WOSI (%): 9.0 [3.7-24.5] vs. 3.8 [0.8-8.9], p = 0.22; Rowe score: 90.0 [75.0-100] vs. 95.0 [78.8-100], p = 0.57; OSIS: 46 [44.7-48] vs. 46 [43.0-48], p = 0.54; satisfaction: 8.9 ± 1.4 vs. 8.0 ± 1.4, p = 0.78; VAS 0 [0-1.3] vs. 0 [0-1.0]. In both groups, two patients (14.3%) reported a redislocation during the observation period. Conclusions: At short- to mid-term follow-up, ABR showed favorable outcomes, low dislocation rates, and high patient satisfaction, regardless of the presence of a GLAD lesion or primary versus recurrent instability. However, follow-up time was heterogeneous, and the follow-up rate was marginal.

The Posterior Tibial Slope Is Not Associated With Graft Failure and Functional Outcomes After Anatomic Primary Isolated Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Biomechanical studies have shown that an increased medial posterior tibial slope (MPTS) may affect anteroposterior knee laxity and tibial shear forces, ultimately increasing the risk for graft failure after anterior cruciate ligament (ACL) reconstruction. Previous clinical studies have, however, reported inconclusive results. PURPOSE: The purpose of this study was to evaluate the relationship between the MPTS and graft failure as well as functional outcomes after anatomic primary isolated ACL reconstruction using a hamstring tendon autograft. It was hypothesized that an increased MPTS would be associated with a higher ACL graft failure rate. Furthermore, a higher MPTS would negatively correlate with functional outcomes in patients without ACL graft failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients who underwent isolated primary ACL reconstruction with an anteromedial portal drilling technique between January 2011 and December 2019 were retrospectively reviewed. The MPTS was measured on preoperative lateral knee radiographs. At a minimum of 24 months postoperatively, the ACL graft failure rate and patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form, Lysholm score, Tegner Activity Scale, visual analog scale for pain and subjective instability) were evaluated. Differences in the MPTS between patients with and without ACL graft failure as well as the frequency of graft failure between those with an MPTS <12° and those with an MPTS ≥12° were assessed for statistical significance. Binary logistic regression analysis was performed to stratify the risk of graft failure with the following variables: MPTS, age at surgery, and sex. Correlation analysis was performed to evaluate the relationship between the MPTS and PROM in patients without ACL graft failure. RESULTS: In total, 326 patients were included (median follow-up, 71.0 months [IQR, 49.0-104.0 months]). There was no significant difference in the MPTS between patients with and without graft failure (10.6°± 3.2° vs 11.2°± 2.8°, respectively; P = .264). Additionally, there was no significant difference in the frequency of graft failure between patients with an MPTS <12° and those with an MPTS ≥12° (15.6% vs 16.5%, respectively; P = .835). Binary logistic regression showed that younger age at the time of surgery (odds ratio, 1.069 [95% CI, 1.031-1.109]) was associated with graft failure; sex and MPTS were not associated with graft failure. In patients without ACL graft failure, there was no significant correlation between the MPTS and PROM. CONCLUSION: In patients who underwent anatomic primary isolated ACL reconstruction, an increased MPTS was not associated with a higher rate of graft failure or inferior functional outcomes. Younger age was a significant nonmodifiable risk factor for ACL graft failure.

The 50 most cited studies on posterior tibial slope in joint preserving knee surgery.

PURPOSE: To determine the 50 most cited studies on posterior tibial slope (PTS) in joint preserving knee surgery and assess their level of evidence, objective study quality scores as well as to examine whether the study quality correlated with the citation count and citation density in the top 50 list. METHODS: A literature search on Web of Science was performed to determine the 50 most cited studies on the topic of PTS in joint preserving knee surgery between 1990 and 2022. The studies were evaluated for their bibliographic parameters, level of evidence rating (LOE), citation counts, the Modified Coleman Methodological Score (MCMS), the Methodological Index for Non-Randomized Studies (MINORS), and the Radiologic Methodology and Quality Scale (MQCSRE). RESULTS: Of the top 50 list, 16 studies were published in the American Journal of Sports Medicine. A total of 23 studies were produced in the United States (46%). Of 10 different study types, case control studies (n = 16, 32%) and cadaveric studies (n = 10, 20%) were most common. 15 studies (30%) were purely radiological studies. 6 studies were level II (12%), 23 level III (46%), 15 level IV (30%), and 6 level V studies (12%), respectively. The number of citations ranged from 42 to 447 (mean 105.6 ± 79.2 citations) and showed a mean citation density of 10.3 ± 5.2, composed of the decades 1994 - 2000 (8.3 ± 4.1), 2001 - 2010 (11.1 ± 5.9), 2011 - 2019 (10.1 ± 5.1). Mean quality scores were 55.9 ± 13.0 for MCMS (n = 18), 14.5 ± 3.2 for MINORS (n = 18) and 18.1 ± 3.7 for MQCSRE (n = 20), respectively. High citation counts did not correlate with higher study quality scores (p > 0.05). Radiological studies were not significantly cited more often than non-radiological studies (mean 116.9 ± 88.3 vs. 100.8 ± 75.8 citations; p > 0.05). CONCLUSION: In joint preserving knee surgery, the 50 most cited studies on PTS did not represent a ranking of the highest methodological quality scores. Citation counts and citation density over the past three decades did not significantly differ, even though the number of articles in the presented list multiplied over the same period. This list can serve as a reference tool for orthopedic surgeons aiming to review PTS literature.