Functional outcome of an 'all-inside' technique in female anterior cruciate ligament reconstruction at long-term follow-up: A gender-sensitive analysis.

BACKGROUND: As the awareness towards gender-specific therapies continues to increase among all fields of medicine, so does the need for gender-sensitive evaluations of established surgical techniques. With a higher likelihood of anterior cruciate ligament injury in women, a critical assessment of the functional outcome of anterior cruciate ligament reconstruction regarding patient sex is indispensable. Almost all pre-existing literature on this subject is based on anterior cruciate ligament reconstructions carried out before 2008, when 'all-inside' techniques did not exist. This implicates the need to investigate this technique towards its differences in outcome between male and female patients. OBJECTIVES: The purpose of this study was to determine whether there is a difference concerning the functional outcome of an 'all-inside' technique for anterior cruciate ligament reconstruction in female patients when compared to a cohort of male patients matched for body mass index and age. DESIGN: Retrospective analysis. METHODS: All female patients who underwent anterior cruciate ligament reconstruction using an all-inside technique between 2011 and 2012 were examined for inclusion. Functional outcome parameters investigated included the Lysholm Knee Score, International Knee Documentation Committee score, Visual Analogue Scale score and the Tegner Activity Scale. All parameters were documented before surgery and at 3-, 6-, 12- and >24 months follow-up. At 24-month follow-up, anterior-posterior knee laxity was tested using the KT-2000 arthrometer device. For comparison, an equivalent group of male patients who underwent the same procedure was matched. RESULTS: 27 female patients were matched with 27 male patients. The average age was 29 years, and a mean follow-up of 90 months could be achieved with 27 of patients reaching a follow-up of > 10 years. The evaluated scores showed no significant difference between female and male patients. Women presented with poorer functional outcome at 3- as well as 6-month follow-ups compared to men, without reaching statistical significance. After 12 months, no further differences could be found. CONCLUSION: This study proved that an all-inside technique for anterior cruciate ligament reconstruction is able to produce the same functional outcome in female as in male patients at long-term follow-up. The results on short-term outcome indicate the need for further research towards gender-specific differences after anterior cruciate ligament reconstruction, their potential causes and potential of improvement. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Functional Outcome of All-Soft-Tissue Quadriceps Tendon Autograft in ACL Reconstruction in Young and Athletic Patients at a Minimum Follow-Up of 1 Year.

To investigate the functional outcome in young and athletic patients with ACL injuries, treated with an all-soft-tissue quadriceps tendon autograft at a minimum follow-up of 12 months. Methods: Patients who received a QT autograft ACL reconstruction between August 2018 and December 2020 were included in this study. Range of motion in the operated knee was described at 6 and 18 weeks after surgery and the functional outcome parameters (Lysholm score, IKDC score and Tegner activity scale) were calculated at 6 and ≥ 12 months after surgery. Results: Forty patients were included in this study, of which 29 identified as male and 11 as female. The average age was 31.3 years (range 16 to 57 years) and the mean follow-up time was 16.8 months (range 12 to 30 months). All functional outcome scores showed improvement over the course of the follow-up: Lysholm score 94.2 to 95.5 (n.s.), IKDC score 90.1 to 93.9 (n.s.), Tegner activity scale 3.7 to 5.0 (p > 0.001), all at six months and ≥12 months. No reruptures happened during the time of the follow-up. Conclusions: This study shows that the all-soft-tissue quadriceps tendon autograft technique can improve functional outcome in young and athletic patients with an ACL injury at short to intermediate follow-up.

Sufficient MRI graft structural integrity at 9 months after anterior cruciate ligament reconstruction with hamstring tendon autograft.

PURPOSE: To assess the MRI-measured structural integrity of hamstring autograft at 9 months after anterior cruciate ligament reconstruction (ACLR) surgery. METHODS: A prospective cohort study was conducted including 34 patients (mean age 36.8 ± 11.8 years; 73.5% males) who underwent ACLR with hamstring autograft. In addition, 36 patients (mean age 39.2 ± 10.5 years; 69.4% males) without any ACL injury were also reviewed and served as control group. The primary outcome used for examining graft maturity at 9 months after ACLR was the MRI-based signal-to-noise quotient (SNQ) of reconstructed ACL. SNQ values were stratified into 3 different categories: excellent: < 0.1; good: ≥ 0.1 and ≤ 0.19; fair: ≥ 0.2. The KT-1000 knee arthrometer was used to measure the side-to-side difference in the anterior tibial translation between the ACLR knee and the contralateral healthy knee in the ACLR group. RESULTS: Reconstructed ACLs were found with a mean SNQ of 0.078 ± 0.061, while almost all ACL-reconstructed patients (97%; 33 out of 34) were found with excellent or good SNQ values (< 0.019). The mean KT-1000 in the ACLR group was 0.071 mm ± 0.926 mm, while there were no patients in the ACLR cohort with a KT-1000 value > 3 mm. The mean 9-months MRI-based SNQ of ACLR group was significantly higher compared to the mean MRI-based SNQ of the control group (p < 0.001). Multiple regression analysis showed no correlation between SNQ and age, gender, time from injury to ACLR, graft size, or simultaneous treatment of additional intra-articular knee lesions. CONCLUSIONS: In this cohort of 34 ACL-reconstructed patients, 97% of hamstring tendon autografts demonstrated excellent/good MRI signal intensity and excellent functional results (KT-1000 < 3 mm) at 9 months after surgery. Based on this finding, it is suggested that return to sports after ACLR with hamstring autograft can be considered safe at 9 months post surgery. Furthermore, while structural integrity of the graft has been achieved at this time point, statistical differences found in SNQ values of ACL-reconstructed patients compared to ACLs of healthy individuals highlight the continuing process of graft maturation and remodelling. LEVEL OF EVIDENCE: Level III.

Patellar Size Variation at the Quadriceps Tendon-Bone Block Harvest Site: A Magnetic Resonance Imaging Study to Evaluate the Safe Zone for Harvesting a Sufficient Bone Block.

BACKGROUND: Quadriceps tendon (QT) autografts with and without a bone block are the least studied and least used options for anterior cruciate ligament reconstruction surgery. In particular, there is a lack of literature describing patellar anatomy. Until now, guidelines for patellar bone block harvesting have been based solely on personal experience. In this study, we intended to derive recommendations from physical regularities and objective criteria. PURPOSE: To determine the maximal, individual-related length and depth of the bone block that can be safely harvested and to provide guidelines to help surgeons make decisions on graft choice. STUDY DESIGN: Descriptive laboratory study. METHODS: The study group consisted of 50 male participants and 50 female participants (mean age, 29.4 ± 7.9 years) who underwent 3.0-T magnetic resonance imaging of their knee. Patellar height was determined at the center of the middle third of the QT insertion on the patella and the medial and lateral endpoints; the depth was measured at the midpoints of the respective heights. RESULTS: The mean width of the QT and the mean thickness were 49.0 ± 7.6 and 7.3 ± 1.0 mm, respectively. The mean patellar thickness in reference to the medial endpoint, the center, and the lateral endpoint was 18.3 ± 2.4, 17.9 ± 2.3, and 15.1 ± 2.3 mm, respectively, whereas the mean patellar height was 35.1 ± 4.1, 36.7 ± 4.2, and 35.1 ± 3.9 mm. In general, the tendon and patellar dimensions were significantly larger in male participants than in female participants (P = .016). CONCLUSION: Bone block harvesting, with its depth not exceeding 50% of the patellar thickness and its length accounting for <50% of the patellar height, poses the least risk for a patellar fracture when located medial to midline. If the bone block is excised from the medial half of the central area (the latter is defined by the middle third of the QT insertion), with the outer edge of the saw positioned at the medial border of the central area, a graft of 15 mm length, 10 mm width, and 8 mm depth can be safely harvested in all White male participants and almost all female participants taller than 165 cm, according to our findings. CLINICAL RELEVANCE: This is the first study presenting recommendations for patellar bone block harvesting at the quadriceps tendon insertionbased on physical regularities and objective criteria and not on personal experience.

Ramp lesions are frequently missed in ACL-deficient knees and should be repaired in case of instability.

PURPOSE: The aim of the current study was (1) to provide an overview of common definitions and classification systems of ramp lesions (RL) and (2) to systematically review the available literature with regard to the diagnosis and treatment of RLs in anterior cruciate ligament (ACL)-deficient knees. METHODS: Following the PRISMA guidelines, MEDLINE and Scopus were searched for articles (1) reporting on acute or chronic ACL injuries, (2) with concomitant medial meniscus injury, (3) located at the posterior meniscocapsular attachment site (and red-red zone). Ex vivo studies, reviews and technical notes were excluded. RESULTS: Twenty-seven studies were included based on the criteria mentioned above. RLs are common in ACL-deficient knees with a prevalence ranging from 9 to 24%. RLs should especially be suspected in younger patients, patients with an increased meniscal slope and in patients with prolonged time from injury to surgery. The sensitivity of MRI for the detection of RLs ranges from 48 to 86% at a specificity of 79-99%. For arthroscopy, RLs are easily missed through standard anterior portals (sensitivity 0-38%). RL repair leads to a significant improvement of subjective knee scores, regardless of the specific fixation technique. For stable RLs, the literature suggests equivalent postoperative stability for trephination and abrasion compared to surgical RL repair. CONCLUSION: Ramp lesions are frequently missed in ACL-deficient knees on standard arthroscopy with anterior portals only. If a RL is suspected, exploration via an additional posteromedial portal is indicated. In case of instability, RL repair should be performed. LEVEL OF EVIDENCE: IV.

Graft Inclination Angles in Anterior Cruciate Ligament Reconstruction Vary Depending on Femoral Tunnel Reaming Method: Comparison Among Transtibial, Anteromedial Portal, and Outside-In Retrograde Drilling Techniques.

PURPOSE: To compare graft coronal and sagittal inclination angles in anterior cruciate ligament (ACL) reconstruction performed by different femoral tunnel drilling techniques with respect to intact native ACL. METHODS: In total, 72 patients were prospectively enrolled in the study. The inclusion criteria were complete ACL rupture and patient age between 18 and 55 years. Reconstructions were performed using 4 different femoral tunnel drilling technique: transtibial (TT), anteromedial portal with rigid (AMP-RR) or flexible (AMP-FR) reamer, and outside-in retrograde drilling (OI) techniques. Eighteen patients with intact native ACL were included as controls. Sagittal and coronal graft inclination angles were measured by magnetic resonance imaging 6 months after the procedure by 1 radiologist blinded in regards to the used technique. RESULTS: OI and AMP-FR techniques allowed for the maintenance of native-like ACL inclination in both the sagittal and coronal planes, whereas TT and AMP-RR increased the sagittal angle by a mean of 9.5° (P < .001) and 6.7° (P = .003), respectively, compared with native ACLs. AMP-RR and TT also showed increased sagittal graft inclination compared with AMP-FR (+6.1°, P = .009 and +9.0°, P < .001, respectively) and OI-drilling techniques (+5.5°, P = .024 and +8.4°, P < .001, respectively). No differences were observed among study groups in terms of coronal graft inclination. CONCLUSIONS: The study hypothesis was partially confirmed, since OI and AMP-FR techniques, but not AMP-RR, using an independent portal for femoral drilling produce a more anatomic graft inclination on the sagittal plane with respect to TT. LEVEL OF EVIDENCE: II, prospective comparative study.

Hamstring tendon autografts do not show complete graft maturity 6 months postoperatively after anterior cruciate ligament reconstruction.

PURPOSE: In this prospective, double-center cohort study, we aim to assess how the anterior cruciate ligament (ACL) signal intensity on magnetic resonance imaging (MRI) potentially varies between a group of patients with anatomic ACL reconstruction using autogenous hamstring grafts 6 months postoperatively and a healthy ACL control group, and how MRI-based graft signal intensity is related to knee laxity. METHODS: Sixty-two consecutive patients who underwent ACL reconstruction using quadrupled hamstring tendon autograft were prospectively invited to participate in this study, and they were evaluated with MRI after 6 months of follow-up. 50 patients with an MRI of their healthy ACL (Clinica Luganese, Lugano, Switzerland) and 12 patients of their contralateral healthy knee (Department of Orthopaedic and Trauma Surgery, Medical University of Vienna, Austria) served as the control group. To evaluate graft maturity, the signal-to-noise quotient (SNQ) was measured in three regions of interest (ROIs) of the proximal, mid-substance and distal ACL graft and the healthy ACL. KT-1000 findings were obtained 6 months postoperatively in the ACL reconstruction group. Statistical analysis was independently performed to outline the differences in the two groups regarding ACL intensity and the correlation between SNQ and KT-1000 values. RESULTS: There was a significant difference in the mean SNQ between the reconstructed ACL grafts and the healthy ACLs in the proximal and mid-substance regions (p = 0.001 and p = 0.004). The distal region of the reconstructed ACL showed a mean SNQ similar to the native ACL (n.s). Patients with a KT-1000 between 0 and 1 mm showed a mean SNQ of 0.1; however, a poor correlation was found between the mean SNQ and KT-1000 findings, probably due to the small sample size of patients with higher laxity. CONCLUSION: After 6 months of follow-up, hamstring tendon autografts for anatomic ACL reconstruction do not show equal MRI signal intensity compared to a healthy ACL and should therefore be considered immature or at least not completely healed even if clinical laxity measurement provides good results. However, in the case of a competitive athlete, who is clinically stable and wants to return to sports at 6 months, performing an MRI to confirm the stage of graft healing might be an option. LEVEL OF EVIDENCE: Prospective, comparative study II.

Risk factors predicting prognosis and outcome of elderly patients with isolated traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI), particularly in the elderly patient population, is known to be the single largest cause of death and disability worldwide. The purpose of this retrospective study was to evaluate clinical factors predicting poor outcome with special emphasis on the impact of respiratory failure (RF) on mortality in elderly patients with isolated severe TBI. METHODS: All elderly patients (age ≥ 65 years) with isolated severe head injury, admitted to this level I trauma center, during a period of 18 years (from January 1992 to December 2010) were identified from the trauma registry. The medical records were reviewed for demographics, mechanism of injury (MOI), GCS score at admission, RF, pupillary light reflex (LR), CT findings (subdural hematoma, subarachnoid hematoma, edema, midline-shift), and whether there was conservative treatment or surgical intervention and the Glasgow Outcome Score (GOS) at hospital discharge. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome. RESULTS: The following variables influenced the mortality: respiratory failure, pupillary response, and the injury severity score (ISS). A significant increased risk of death was also found for patients with a midline shift of over 15 mm. CONCLUSIONS: The present study predicts a strong correlation between respiratory failure, pathological pupillary response, a higher ISS, and substantial midline shift with poor outcomes in elderly patients sustaining an isolated severe TBI. TRIAL REGISTRATION: Clinical trials: ID: NCT02386865 . Registered 12 March 2015-retrospectively registered.

Progression of function and pain relief as indicators for returning to sports after arthroscopic isolated type II SLAP repair-a prospective study.

BACKGROUND: One of the currently used surgical techniques in isolated type II SLAP lesions is arthroscopic SLAP repair. Postoperatively, patients tend to suffer from a prolonged period of pain and are restricted in their sports activities for at least 6 months. The aim of this study was to prospectively evaluate the clinical outcome as well as the postoperative course of pain after arthroscopic type II SLAP repair. METHODS: Outcome measures were assessed using the Individual Relative Constant Score (CSindiv), the American Shoulder and Elbow Surgeons (ASES) Score, the Visual Analogue Scale (VAS), and the Short Form 36 (SF-36). Data were collected preoperatively, as well as at 3, 6, 12 and >24 months postoperatively. RESULTS: Eleven patients with an average age of 31.8 years (range: 22.8-49.8 years) underwent arthroscopic repair of isolated type II SLAP lesions. Mean follow-up time was 41.9 months (range: 36.1-48.4 months). 6 months after surgery, there was a statistically significant improvement of function according to the CSindiv (p = 0.004), the ASES Score (p = 0.006), and the SF-36 subscale "physical functioning" (p = 0.014) and a statistically significant decrease of pain according to the VAS (p = 0.007) and the SF-36 subscale "bodily pain" (p = 0.022) compared to preoperative levels. CONCLUSIONS: Arthroscopic repair of isolated type II SLAP lesions with suture anchors leads to a satisfactory functional outcome and return to pre-injury sports levels, with delayed, but significant pain relief observed 6 months after surgery. Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength. TRIAL REGISTRATION: Researchregistry1761 (UIN).

Displaced Neer Type IIB distal-third clavicle fractures-Long-term clinical outcome after plate fixation and additional screw augmentation for coracoclavicular instability.

BACKGROUND: Unstable Neer Type IIB fractures require meticulous surgical treatment. Thus, the aim of this study was to present long-term outcomes after plate fixation and minimally invasive coracoclavicular (CC) stabilization using screw fixation. METHODS: A consecutive series of patients with unstable Neer Type IIB displaced clavicle fractures, treated by open reduction and internal fixation (ORIF) with a plate and additional screw fixation for coracoclavicular ligament instability, was reviewed in order to determine long-term clinical and radiological outcome. RESULTS: Seven patients, six males and one female, with a mean age of 37 ± 8 years (median: 36 years; range, 28-51 years), were evaluated. At latest follow-up, after a mean of 67 months (range, 11-117 months), patients presented with the following mean scores: DASH: 0.57, ASES: 98.81, UCLA: 34.29, VAS: 0.43, Simple Shoulder Test: 11.57. However, two complications were observed: one case of implant loosening and one non-union. There were no differences observed between the CC distances comparing postoperative X-rays to those in final follow-up. In 25% of our patients early postoperative complications occurred. In all patients reoperation was necessary to remove the implanted screw. CONCLUSION: The results of the present study indicate that the treatment of Neer Type IIB lateral clavicle fractures with ORIF using a plate and additional CC screw fixation, leads to satisfying clinical and radiological outcomes in the long-term. However, considering an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw does not seem to justify this technique anymore.

Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty.

INTRODUCTION: Revision arthroplasty is currently the recommended treatment for periprosthetic femoral fractures after primary total hip arthroplasty (THA) and stem loosening (Vancouver B2). However, open reduction and internal fixation (ORIF) utilizing locking compression plate (LCP) might be an effective treatment with a reduced surgical time and less complex procedure in a typically elderly patient collective with multiple comorbidities. The purpose of this study was to compare the functional and radiographic outcomes in two cohorts with Vancouver B2 periprosthetic femoral fractures after primary THA, treated either by ORIF with LCP fixation, or by revision arthroplasty utilizing a non-cemented long femoral stem. MATERIALS AND METHODS: 36 patients with Vancouver B2 periprosthetic femoral fractures following THA, who had been treated between 2000 and 2014, were reviewed. Eight fractures were treated with LCP fixation, fourteen fractures with the first-generation revision prosthesis (Helios), and fourteen fractures with the second-generation revision prosthesis (Hyperion). The patients were assessed clinically with the Parker mobility score and radiographically. RESULTS: A total of ten males and 26 females formed the basis of this report with an average age of 81 years (range, 64 to 96 years). All fractures treated with LCP fixation alone healed uneventfully and there were no signs of secondary stem migration, malalignement or plate breakage. The average surgical time was shorter in the ORIF cohort; however, the results were not statistically significant. The postoperative Parker mobility score at latest follow-up showed no difference between the groups. CONCLUSIONS: According to the results of the current study, we conclude that the use of LCP fixation can be a sufficient option for the treatment of Vancouver B2 periprosthetic femoral fractures correspondingly with femoral stem loosening.

Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years' Follow-up.

PURPOSE: To evaluate the clinical and functional outcomes for anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique with a minimum follow-up of 24 months. METHODS: Patients undergoing anatomic ACL reconstruction via the all-inside technique between January 2011 and October 2012 were reviewed for inclusion in this study. Functional outcome measures, including the Lysholm score, International Knee Documentation Committee score, visual analog scale score, and Tegner Activity Scale, were used to evaluate outcomes before surgery and at 3, 6, 12, and > 24 months. At final follow-up, anteroposterior knee stability was assessed with KT-2000 (MEDmetric, San Diego, CA) measurements. RESULTS: Of the 92 patients who underwent primary all-inside ACL reconstruction, 79 patients returned to final follow-up with a minimum of 2 years. There were 53 men and 26 women with a mean age of 29 years (range, 18 to 54 years) and a mean follow-up of 29 months (range, 24 to 45 months). The International Knee Documentation Committee score (44.6 v 89.7, P < .0001), Lysholm score (53.4 v 93.1, P < .001), visual analog scale score (5 v 0.1, P < .001), and Tegner activity score (2 v 6, P < .001) showed a significant improvement between baseline and final clinical follow-up. The mean side-to-side KT-2000 difference at final follow-up was 1.7 mm (range; 0 to 6 mm). Overall 10 patients (12.7%) sustained an ACL graft rerupture after a mean of 17.6 months (range, 6.9 to 28.6 months). CONCLUSIONS: The current data support our first hypothesis that primary anatomic ACL reconstruction using the all-inside technique leads to improved functional outcomes between baseline and clinical follow-up at 24 months. Further, there was no difference in knee stability between the ACL reconstructed- and the contralateral normal knee at 24 months, which confirms our second hypothesis.

Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS™ system at a minimum follow-up of 10 years.

BACKGROUND: Since the 1980's several artificial ligaments were used for reconstruction of the anterior cruciate ligament (ACL) serving different complications. The aim of this study was to assess the clinical and functional outcomes of primary ACL reconstruction using the Ligament Augmentation Reconstruction System (LARS™) with a minimum follow-up of 10-years. The LARS™ presents a synthetic material consisting of non-absorbing polyethylene terephthalate fibres used for ligament reconstruction. METHODS: Outcomes of 18 patients who underwent arthroscopic ACL reconstruction using the LARS™ system between 2000 and 2004 with a minimum follow-up of 10 years were observed. The International Knee Documentation Committee score (IKDC), Visual Analog Scale (VAS), Lysholm score, and Tegner Activity Scale were assessed. Clinical assessment was performed by Lachman testing, assessment of side-to-side difference on KT-2000 testing and plain radiography evaluation of osteoarthritis. RESULTS: There were seven males and 11 females, mean age 29 years (range, 18 to 44 years) and a mean follow-up of 151.5 months. Five patients (27.8%) sustained a re-rupture of the LARS™ system and underwent revision surgery after a mean time of 23 months and four patients (22.2%) presented with a re-rupture. The average IKDC score was 76.60 ± 18.18, the average Lysholm score was 88.00 ± 10.07 and the average Tegner activity score was five at final follow-up. CONCLUSION: Our results indicate that the LARS™ system should currently not be suggested as a potential graft for primary reconstruction of the ACL. In special cases, however, the LARS™ system can serve as an alternative graft.

Plate failure following plate osteosynthesis in periprosthetic femoral fractures.

BACKGROUND: Increasing numbers of total knee and hip arthroplasties result in a growing number of periprosthetic femoral fractures (PPFF). PPFF with a stable stem component are treated commonly with plate osteosynthesis. Therefore plate failure is seen as a major complication. The aim of this retrospective study was to investigate the patients' outcome after plate failure. METHODS: The database of a Level 1 trauma center was searched for all patients treated for a PPFF with plate osteosynthesis. Patients with plate failure were investigated specifically. Standard demographic data, details on initial arthroplasty, trauma, and treatment were recorded for all patients. All fractures were classified and their outcome reviewed. RESULTS: Seven (8.8%) out of 80 patients treated with plate osteosynthesis following PPFF met our inclusion criterion being plate failure. All these patients were female, with an average age at primary surgery of 74 ± 13 years and a mean follow-up of 885 days (range, 264-2549). Four patients suffered a PPFF after total hip arthroplasty (THA) (2 Vancouver Type B1 and 2 Type C) and three after total knee arthroplasty (TKA) (Lewis-Rorabeck Type II). Following plate failure, four patients healed uneventfully and three patients experienced complications such as pseudarthrosis, screw loosening, and further plate failure. CONCLUSION: In patients with poor bone quality, bone graft, bone cement, and bone biologics have to be considered in revision surgery. Furthermore, long-stem revision and tumor prosthesis are an additional solution.

Does flexible tunnel drilling affect the femoral tunnel angle measurement after anterior cruciate ligament reconstruction?

PURPOSE: To quantify the mean difference in femoral tunnel angle (FTA) as measured on knee radiographs between rigid and flexible tunnel drilling after anatomic anterior cruciate ligament (ACL) reconstruction. METHODS: Fifty consecutive patients that underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a flexible reamer were included in this study. The control group was comprised of 50 patients all of who underwent primary anatomic ACL reconstruction with a single femoral tunnel drilled with a rigid reamer. All femoral tunnels were drilled through a medial portal to ensure anatomic tunnel placement. The FTA was determined from post-operative anterior-to-posterior (AP) radiographs by two independent observers. A 5° difference between the two mean FTA was considered clinically significant. RESULTS: The average FTA, when drilled with a rigid reamer, was 42.0° ± 7.2°. Drilling with a flexible reamer resulted in a mean FTA of 44.7° ± 7.0°. The mean difference of 2.7° was not statistically significant. The intraclass correlation coefficient for inter-tester reliability was 0.895. CONCLUSIONS: The FTA can be reliably determined from post-operative AP radiographs and provides a useful and reproducible metric for characterizing femoral tunnel position after both rigid and flexible femoral tunnel drilling. This has implications for post-operative evaluation and preoperative treatment planning for ACL revision surgery. LEVEL OF EVIDENCE: IV.

Primary cementless hip arthroplasty as a potential risk factor for non-union after long-stem revision arthroplasty in periprosthetic femoral fractures.

PURPOSE: In case of stem loosening in periprosthetic femoral fractures (PPFF), revision arthroplasty should be performed. The first hypothesis of this study was that advanced patient age and female gender shows higher non-union rates. The second hypothesis was that primary cementless arthroplasty is associated with a higher non-union rate compared to cemented primary hip arthroplasty. METHODS: All PPFF occurring between January 2000 and June 2010 treated by revision arthroplasty were included. Multiple regression analysis was performed to identify independent variables leading to fracture non-union. RESULTS: Eighty one patients (78 % female) met the inclusion criteria. In 20/81 patients (24.7 %) no adequate fracture healing could be determined on radiographs 12 months after revision surgery. Although age and female gender showed a positive correlation with bony non-union after PPFF as expected, the p-values were not statistically significant. Multiple regression analysis revealed primary cementless prosthesis (p = 0.001) to be the only independent variable associated with non-union. CONCLUSION: Non-cemented primary prosthesis might be a negative predicting factor for the development of non-union after long-stem revision arthroplasty in PPFF. We therefore recommend the thorough debridement of pannus tissue thus inducing bone healing before the implantation of revision prostheses.

Altered tibiofemoral kinematics in the affected knee and compensatory changes in the contralateral knee after anterior cruciate ligament reconstruction.

BACKGROUND: Previous studies of knee kinematics after anterior cruciate ligament (ACL) reconstruction have generally employed low-effort tasks and typically not assessed changes in kinematics over time. HYPOTHESES: (1) During single-legged hop landing, ACL-reconstructed limbs will have altered kinematics compared with contralateral (ACL-intact) limbs 5 months after surgery. (2) Kinematic differences between limbs will decrease over time because of changes in both ACL-reconstructed and ACL-intact limbs. STUDY DESIGN: Controlled laboratory study. METHODS: In vivo kinematics of ACL-reconstructed and contralateral ACL-intact knees were evaluated for 14 subjects during single-legged forward-hop landings at 5 and 12 months after surgery on the basis of dynamic stereo x-ray imaging. Differences between limbs and changes over time were assessed via repeated-measures analysis of variance. RESULTS: Five months after surgery, ACL-reconstructed knees landed significantly less flexed compared with contralateral ACL-intact knees (20.9° vs 28.4°, respectively; P < .05). The ACL-reconstructed knees were significantly more externally rotated (12.2° vs 6.5°; P < .05) and medially translated (3.8 vs 2.3 mm; P < .009) compared with ACL-intact knees. Anterior-posterior translation was similar between limbs. From 5 to 12 months, knee flexion at landing increased in ACL-reconstructed knees (mean change, +3.4°; P < .05) and decreased in contralateral knees (mean change, -3.3°; P < .05). External tibial rotation also significantly decreased in ACL-reconstructed knees (-2.2°; P < .05) and increased in contralateral knees (+1.1°; P = .117) over time. Medial tibial translation decreased slightly over time only in ACL-reconstructed knees (-0.3 mm). CONCLUSION: Five months after ACL reconstruction, landing kinematics differed between ACL-reconstructed and contralateral ACL-intact knees during a dynamic high-loading activity. These differences decreased over time, owing to changes in both the ACL-reconstructed and contralateral ACL-intact limbs. CLINICAL RELEVANCE: This study identified kinematic changes over time in both the ACL-injured and contralateral ACL-intact knees after ACL reconstruction. These kinematic adaptations could have important implications for postoperative care, including evaluating the optimal timing of return to sports and the development of bilateral neuromuscular rehabilitation programs that may improve patient outcomes and reduce reinjuries in both the short and long terms.

Strategies for revision surgery after primary double-bundle anterior cruciate ligament (ACL) reconstruction.

PURPOSE: The purpose of this article was to discuss pre- and intra-operative considerations as well as surgical strategies for different femoral and tibial tunnel scenarios in revision surgery following primary double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Based on the current literature of ACL revision surgery and surgical experience, an algorithm for revision surgery after primary double-bundle ACL reconstruction was created. RESULTS: A guideline and flowchart were created using a case-based approached for revision surgery after primary double-bundle ACL reconstruction. CONCLUSION: Revision surgery after primary double-bundle ACL reconstruction can be a challenging procedure that requires flexibility and a repertoire of surgical techniques. The combination of pre-operative planning with 3D-CT reconstruction, in addition to careful intra-operative assessment, and the use of this flowchart can simplify the ACL revision procedure. LEVEL OF EVIDENCE: V.

Quantitative evaluation of the pivot shift by image analysis using the iPad.

PURPOSE: To enable comparison of test results, a widely available measurement system for the pivot shift test is needed. Simple image analysis of lateral knee joint translation is one such system that can be installed on a prevalent computer tablet (e.g. iPad). The purpose of this study was to test a novel iPad application to detect the pivot shift. It was hypothesized that the abnormal lateral translation in ACL deficient knees would be detected by the iPad application. METHODS: Thirty-four consecutive ACL deficient patients were tested. Three skin markers were attached on the following bony landmarks: (1) Gerdy's tubercle, (2) fibular head and (3) lateral epicondyle. A standardized pivot shift test was performed under anaesthesia, while the lateral side of the knee joint was monitored. The recorded movie was processed by the iPad application to measure the lateral translation of the knee joint. Lateral translation was compared between knees with different pivot shift grades. RESULTS: Valid data sets were obtained in 20 (59 %) ACL deficient knees. The remaining 14 data sets were invalid because of failure to detect translation or detection of excessive translation. ACL deficient knees had larger lateral translation than the contra-lateral knees (p < 0.01). In the 20 valid data sets, which were graded as either grade 1 (n = 10) or grade 2 (n = 10), lateral translation was significantly larger in the grade 2 pivot shift (3.6 ± 1.2 mm) than the grade 1 pivot shift (2.7 ± 0.6 mm, p < 0.05). CONCLUSION: Although some technical corrections, such as testing manoeuvre and recording procedure, are needed to improve the image data sampling using the iPad application, the potential of the iPad application to classify the pivot shift was demonstrated.