Patient injury claims for posterior cruciate ligament injury: a nationwide registry study in Finland.

BACKGROUND AND PURPOSE: Posterior cruciate ligament (PCL) injuries usually occur in combination with other ligamentous knee injuries. The outcome varies and may be poor due to suboptimal treatment. We investigated claims following PCL injury treatment on a nationwide scale. PATIENTS AND METHODS: All patient PCL injury claims filed in Finland from 1997 to 2015 were collected from the Patient Insurance Centre (PIC) register. We reviewed and analyzed all records to determine the causes of claims. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO). RESULTS: We found out from HILMO background data that, during the 19-year study period, 1,891 PCL and 1,380 multiligament reconstructions were performed in 99 different hospitals. The number of PCL injuries treated conservatively is unknown. During this same period, 49 claims arrived at the PIC, and 39/49 of these patients were operated on. 12/49 claims were compensated. Of these 12 claims, 6 were compensated for technical errors and 4 were compensated for diagnostic delays. CONCLUSION: The number of patient injury claims was few, and compensated claims were even fewer. Technical errors and diagnostic delays were the most common reasons for reimbursement.

Biomechanical assessment of disease outcome in surgical interventions for medial meniscal posterior root tears: a finite element analysis.

BACKGROUND: The adverse consequences of medial meniscus posterior root tears have become increasingly familiar to surgeons, and treatment strategies have become increasingly abundant. In this paper, the finite element gait analysis method was used to explore the differences in the biomechanical characteristics of the knee joint under different conditions. METHODS: Based on CT computed tomography and MR images, (I) an intact knee (IK) model with bone, cartilage, meniscus and main ligaments was established. Based on this model, the posterior root of the medial meniscus was resected, and (ii) the partial tear (PT) model, (iii) the entire radial tear (ERT) model, and (iv) the entire oblique tear (EOT) model were established according to the scope and degree of resection. Then, the (v) meniscus repair (MR) model and (vi) partial meniscectomy (PM) model were developed according to the operation method. The differences in stress, displacement and contact area among different models were evaluated under ISO gait loading conditions. RESULTS: Under gait loading, there was no significant difference in the maximum stress of the medial and lateral tibiofemoral joints among the six models. Compared with the medial tibiofemoral joint stress of the IK model, the stress of the PM model increased by 8.3%, while that of the MR model decreased by 18.9%; at the same time, the contact stress of the medial tibiofemoral joint of the ERT and EOT models increased by 17.9 and 25.3%, respectively. The displacement of the medial meniscus in the ERT and EOT models was significantly larger than that in the IK model (P < 0.05), and the tibial and femoral contact areas of these two models were lower than those of the IK model (P < 0.05). CONCLUSIONS: The integrity of the posterior root of the medial meniscus plays an important role in maintaining normal tibial-femoral joint contact mechanics. Partial meniscectomy is not beneficial for improving the tibial-thigh contact situation. Meniscal repair has a positive effect on restoring the normal biomechanical properties of the medial meniscus.

Personalized volumetric assessment of lower body muscles in patients with knee injuries: A descriptive case series.

BACKGROUND: Patients with knee joint pathology present with variable muscular responses across the muscles of the lower limb and pelvis. Conventional approaches to characterizing muscle function are limited to gross strength assessments that may overlook subtle changes both in the thigh, hip and shank musculature. PURPOSE: To describe individualized patterns of lower extremity muscle volumes in patients with knee pathologies. METHODS: This was a retrospective case series performed in a University medical center. Nine patients diagnosed with meniscus tear recommended to undergo meniscectomy volunteered. Participants underwent 3.0 Tesla magnetic resonance imaging (MRI) of the lower extremities. Thirty-five MRI-derived muscle volumes were compared between limbs and expressed as percentage asymmetry. For additional context, z-scores were also calculated for mass- and height-normalized muscles and pre-determined muscle groupings relative to a normative database. RESULTS: There were no consistent patterns observed when considering between-limb asymmetries among all patients. The ankle musculature (dorsiflexors, plantar flexors, and invertors) was the only muscle group to be consistently smaller than normal for all patients, with the psoas major and flexor hallucis longus being the only individual muscles. The severity or chronicity of injury and presence of surgical intervention did not appear to have a clear effect on muscle volumes. CONCLUSION: Patients with a history of meniscal pathology demonstrate inconsistent patterns of lower extremity muscle volumes about the hip, knee, and ankle between limbs and in comparison to uninjured individuals. These data support the need for individualized assessment and intervention in this population.

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. METHODS: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. FINDINGS: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. INTERPRETATION: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. FUNDING: The UK National Institute for Health Research Health Technology Assessment Programme.

Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques.

Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.

Risk Factors for Infection and Revision Surgery following Patellar Tendon and Quadriceps Tendon Repairs: An Analysis of 3,442 Patients.

Disruption of the extensor mechanism is debilitating with surgical repair being the accepted treatment. The incidence of infection and reoperation after extensor mechanism repair are not well reported in the literature. Thus, the objective of the current study was to (1) determine the incidence of surgical site infection and reoperation within 1 year of primary extensor mechanism repair and (2) identify independent risk factors for infection and reoperation following patellar and quadriceps tendon repair. A retrospective review of the 100% Medicare Standard Analytic files from 2005 to 2014 was performed to identify patients undergoing isolated patellar tendon repair and quadriceps tendon repair. Diagnosis of infection within 1 year of operative intervention and revision repair were assessed. Extensor mechanism injuries in the setting of total knee arthroplasty and polytrauma were excluded. Multivariate logistic regression analysis was performed to evaluate risk factors for postoperative infection and reoperation within 1 year. Infection occurred in 6.3% of patients undergoing patellar tendon repair and 2.6% of patients undergoing quadriceps tendon repair. Diabetes mellitus (odds ratio [OR] = 1.89, p = 0.005) was found to be an independent risk factor for infection following patellar tendon repair. Reoperation within 1 year occurred in 1.3 and 3.9% following patellar tendon and quadriceps tendon repair, respectively. Age less than 65 years (OR = 2.77, p = 0.024) and obesity (OR = 3.66, p = 0.046) were significant risk factors for reoperation after patellar tendon repair. Hypertension (OR = 2.13, p = 0.034), hypothyroidism (OR = 2.01, p = 0.010), and depression (OR = 2.41, p = 0.005) were significant risk factors for reoperation after quadriceps tendon repair. Diabetes mellitus was identified as a risk factor for infection after patellar tendon repair. Age less than 65 years, peripheral vascular disease, and congestive heart failure were risk factors for infection after quadriceps tendon repair. The current findings can be utilized to counsel patients regarding preoperative risk factors for postoperative complications prior to surgical intervention for extensor mechanism injuries.

Return to Work After Autologous Chondrocyte Implantation of the Knee in Patients with Workers Compensation Insurance.

OBJECTIVE: This retrospective analysis aimed to evaluate patient and defect characteristics on return to work after autologous chondrocyte implantation (ACI) for all patients with workers compensation insurance in our clinic. METHODS: Retrospective analysis of medical records of patients with workers compensation treated with ACI in our clinic over 10 years (August 2004 to November 2014). Data were collected on demographics, lesion size and location, number of defects, duration of symptoms, and outcomes. RESULTS: A total of 28 patients with 30 ACI procedures were included in this analysis. Patients had a mean age of 40.0 years, were mostly male, and tended to be overweight (mean body mass index = 31.5 kg/m2). Most patients were employed in occupations with high physical demand (85.7%) compared with lower physical demand jobs (14.3%). The mean number of lesions per knee = 1.73. Overall, the mean total surface area of the defect was large (12.6 cm2), with large mean individual lesion size of 7.39 cm2. All 28 patients returned to work in some capacity, with a total of 22 (79%) returning to full work, and 6 (21%) returning to modified work. There were no significant differences in the comparison of patients who returned to full versus modified work, in mean age, body mass index, high versus low physical demand occupation, or lesion characteristics (size, chronicity, or location). CONCLUSIONS: Our results demonstrate that in a challenging workers compensation cohort, in patients with multiple large defects, treatment with ACI allows a high percentage of patients to return to their normal vigorous work activities within 9 months to 1 year following cartilage restoration. This study is a level IV retrospective case series.

First Clinical Application of Polyurethane Meniscal Scaffolds with Mesenchymal Stem Cells and Assessment of Cartilage Quality with T2 Mapping at 12 Months.

BACKGROUND: Complex meniscal lesions often require meniscectomy with favorable results in the short term but a high risk of early osteoarthritis subsequently. Partial meniscectomy treated with meniscal substitutes may delay articular cartilage degeneration. PURPOSE: To evaluate the status of articular cartilage by T2 mapping after meniscal substitution with polyurethane scaffolds enriched with mesenchymal stem cells (MSC) and comparison with acellular scaffolds at 12 months. METHODS: Seventeen patients (18-50 years) with past meniscectomies were enrolled in 2 groups: (1) acellular polyurethane scaffold (APS) or (2) polyurethane scaffold enriched with MSC (MPS). Patients in the MPS group received filgrastim to stimulate MSC production, and CD90+ cells were obtained and cultured in the polyurethane scaffold. The scaffolds were implanted arthroscopically into partial meniscus defects. Concomitant injuries (articular cartilage lesions or cartilage lesions) were treated during the same procedure. Changes in the quality of articular cartilage were evaluated with T2 mapping in femur and tibia at 12 months. RESULTS: In tibial T2 mapping, values for the MPS group increased slightly at 9 months but returned to initial values at 12 months (P > 0.05). In the APS group, a clear decrease from 3 months to 12 months was observed (P > 0.05). This difference tended to be significantly lower in the APS group compared with the MPS group at the final time point (P = 0.18). In the femur, a slight increase in the MPS group (47.8 ± 3.4) compared with the APS group (45.3 ± 4.9) was observed (P > 0.05). CONCLUSION: Meniscal substitution with polyurethane scaffold maintains normal T2 mapping values in adjacent cartilage at 12 months. The addition of MSC did not show any advantage in the protection of articular cartilage over acellular scaffolds (P > 0.05).

How to translate and locally adapt a PROM. Assessment of cross-cultural differential item functioning.

Translating patient-reported outcome measures (PROMs) can alter the meaning of items and undermine the PROM's psychometric properties (quantified as cross-cultural differential item functioning [DIF]). The aim of this paper was to present the theoretical background for PROM translation, adaptation, and cross-cultural validation, and assess how PROMs used in sports medicine research have been translated and adapted. We also assessed DIF for the Knee Injury and Osteoarthritis Outcome Score (KOOS) across Danish, Norwegian, and Swedish versions. We conducted a search in PubMed and Scopus to identify the method of translation, adaptation, and validation of PROMs relevant to musculoskeletal research. Additionally, 150 preoperative KOOS questionnaires were obtained from the Scandinavian knee ligament reconstruction registries, and cross-cultural DIF was evaluated using confirmatory factor analysis and Rasch analysis. There were 392 studies identified, describing the translation of 61 PROMs. Ninety-four percent were performed with forward-backward technique. Forty-nine percent used cognitive interviews to ensure appropriate wording, understandability, and adaptation to the target culture. Only two percent were validated according to modern test theory. No study assessed cross-cultural DIF. One KOOS subscale showed no cross-cultural DIF, two had DIF with respect to some (but not all) items, and thus conversion tables could be constructed, and two KOOS subscales could not be pooled. Most PROM translations are of undocumented quality, despite the common conclusion that they are valid and reliable. Scores from three of five KOOS subscales can be pooled across the Danish, Norwegian, and Swedish versions, but two of these must be adjusted for DIF.

Cartilage Injury in the Knee: Assessment and Treatment Options.

Cartilage injuries in the knee are common and can occur in isolation or in combination with limb malalignment, meniscus, ligament, and bone deficiencies. Each of these problems must be addressed to achieve a successful outcome for any cartilage restoration procedure. If nonsurgical management fails, surgical treatment is largely based on the size and location of the cartilage defect. Preservation of the patient's native cartilage is preferred if an osteochondral fragment can be salvaged. Chondroplasty and osteochondral autograft transfer are typically used to treat small (<2 cm) cartilage defects. Microfracture has not been shown to be superior to chondroplasty alone and has potential adverse effects, including cyst and intralesional osteophyte formation. Osteochondral allograft transfer and matrix-induced autologous chondrocyte implantation are often used for larger cartilage defects. Particulated juvenile allograft cartilage is another treatment option for cartilage lesions that has good to excellent short-term results but long-term outcomes are lacking.

Successful reconstruction of the posterior cruciate ligament: assessment of posterior cruciate ligament footprints using an objective coordinate system.

INTRODUCTION: Anatomic cruciate ligament reconstruction is known to be correlated with better clinical results. The aim of the study was to provide a simple method to enable anatomic results in the setting of PCL reconstruction. We, therefore, assessed the tibial and femoral insertion site of the posterior cruciate ligament (PCL) by the use of an objective coordinate system in an anatomical study. We also sought to show reproducibility of these measurements using intra- and inter-observer coefficients. MATERIALS AND METHODS: We studied 64 knees, previously preserved according to Thiel's technique. After proper preparation of the articular surfaces of both the tibiae and femora, photographs were taken according to a standardized protocol. PCL footprints were measured by the use of a coordinate system twice by two examiners. We evaluated these measurements by use of the Cohen's kappa inter- and intra-observer coefficient for two observers. RESULTS: Tibial and femoral measurements of PCL footprints were generated with highly comparable inter- (k = 0.970) and intra-observer (k = 0.992) coefficients and may, therefore, be considered as highly reproducible. CONCLUSION: Our findings confirmed the reproducibility of defining PCL footprints using a coordinate system and may contribute to planning intraoperative graft-placement to ensure optimal conditions in the upcoming techniques for PCL reconstruction.

Compensation claims after knee cartilage surgery is rare. A registry-based study from Scandinavia from 2010 to 2015.

BACKGROUND: Focal cartilage defects (FCDs) in the knee joint has a high prevalence. A broad range of treatment options exists for symptomatic patients. Knowledge of patient compensation claims following surgical treatment of FCDs is missing. The purpose of this study is to evaluate compensation claims filed to the Scandinavian registries for patient compensation following treatment of FCDs in the knee joint from 2010 to 2015 and identify possible areas of improvement. METHODS: A cross-sectional study design was used to obtain all complaints following surgical treatment of FCDs from the Scandinavian registries from 2010 to 2015. Data such as age, gender, type of treatment, type of complaint, reason of verdict and amount of compensation were collected and systematically analyzed. RESULTS: 103 patients filed a compensation claim. 43 had received debridement (41.7%), 54 microfracture (MF) (52.4%), 3 mosaicplasty (2.9%) and 3 autologous chondrocyte implantation (ACI) (2.9%). Of the 103 claims, 36 were granted (35%). 21 following debridement (58.3%), 13 after MF (36.1%), 1 following mosaicplasty (2.8%) and 1 after ACI (2.8%). The most common reason for complaint was infection (22.1%), of which 89% were granted. The average compensation was €24.457 (range €209 - €458.943). CONCLUSION: Compensation claims following surgical treatment of knee cartilage injuries in Scandinavia are rare. Establishing nationwide cartilage registries can add further knowledge on this troublesome disease.

Change of Direction Assessment Following Anterior Cruciate Ligament Reconstruction: A Review of Current Practice and Considerations to Enhance Practical Application.

Change of direction (CoD) has been indicated as a key mechanism in the occurrence of anterior cruciate ligament (ACL) injury during invasion sports. Despite these associations, assessments of knee function in athletic populations at the time of return to sport following ACL reconstruction (ACLr) have often focused on strength and single-leg hop tests, with a paucity of evidence to describe the CoD characteristics. Therefore, the aim of this narrative review was to describe the movement strategies exhibited following ACLr during CoD tasks and to critically analyze the range of tests that have been used. Specifically, we examined their ability to identify between-limb deficits and individuals who display a heightened risk of secondary injury and/or reductions in their level of pre-injury performance. MEDLINE, PubMed and SPORT Discuss databases were used and 13 articles were identified that met the inclusion criteria. Examination of the available literature indicates that current field-based practices are not representative of relevant sport demands and are unable to effectively assess knee function following ACLr. Laboratory-based studies have identified residual deficits and altered movement strategies at the time of return to sport, and this in part may be related to risk of re-injury. However, these assessments exhibit inherent limitations and are not practically viable for monitoring progress during rehabilitation. Consequently, alternative solutions that are more-aligned with the multitude of factors occurring during CoD maneuvers in chaotic sports environments are warranted to allow practitioners to 'bridge the gap' between the laboratory and the sports field/court. This approach may facilitate a more informed decision-making process with the end goal being, a heightened 'return to performance' and a lower risk of re-injury.

Multiligament knee injuries treated by one-stage reconstruction using allograft: Postoperative laxity assessment using stress radiography and clinical outcomes.

BACKGROUND: Surgical treatment of multiligament knee injuries (MLKIs) leads to better outcomes but there are controversies about optimal surgical strategies. Debates remain about timing of surgery: acute, staged or delayed and about graft choice: autograft, allograft or a combination of both. Therefore, we performed a retrospective study aiming to evaluate postoperative laxity using stress radiographs and clinical outcomes after one-stage reconstructions of injured ligaments using non-irradiated, fresh-frozen allografts. HYPOTHESIS: MLKIs treated by one-stage reconstructions using non-irradiated, fresh-frozen allograft may lead to satisfactorily postoperative laxity and clinical outcomes. METHODS: Between November 2013 and July 2015, 23 patients with MLKIs underwent one-stage reconstruction using allograft. Knee injuries were defined according Schenk classification of Knee Dislocation (KD). Patients were evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, and the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form at a minimum follow-up of 24 months. Postoperative anterior, posterior, varus, and valgus laxities were assessed using stress radiographs and expressed as side-to-side differences (SSD) in millimeters. RESULTS: Three of 23 patients were lost to follow-up. There were 6 KD-I, 12 KD-III, and 2 KD-IV lesions, 12 lateral-side and 10 medial-side lesions, and 13 acute and 7 chronic cases. Three patients had associated neurovascular injuries. Mean follow-up was at 29.4±6.1 months. Mean valgus SSD was 0.2mm±1.4mm (range, -2.1-2.2mm), mean varus SSD was 1.4mm±2.5mm (range, -1.7-6.0mm), mean posterior SSD was 7.2mm±3.9mm (range, 1.2-16.0mm), mean anterior SSD was 3.6mm±5.1mm (range, -4.8-16.8mm). Overall IKDC ratings were: 4 grade A, 3B, 7C, and 6D. Three patients complained of postoperative instability, with an IKDC rating of D. The mean subjective IKDC score was 67.2±19.6, the mean Lysholm Knee Scoring Scale was 77.3±16.5, and the mean KOOS results were 78.5±16.6 for pain, 67.7±17.4 for symptoms, 86.5±14.2 for daily activities, 56±25.4 for sports, and 47.2±28.6 for quality of life. Nineteen of 20 patients returned to sport-6 to the same level. One patient underwent an arthroscopic arthrolysis due to postoperative arthrofibrosis. CONCLUSIONS: Using non-irradiated allografts for one-stage reconstructions of all the injured ligaments in MLKIs is effective and safe. Anteroposterior stability was difficult to restore, but patients returned to their daily activities and sometimes to their sports activity at the same preinjury level. LEVEL OF EVIDENCE: Level IV, case series.

Meniscal Root Injuries.

Meniscal root tears are an increasingly recognized injury leading to notable functional limitations, potential rapid cartilage deterioration of the affected compartment, and subsequent risk of total knee arthroplasty if left untreated. Repair of these tears is advised when articular cartilage remains intact because both medial and lateral meniscus root repairs have demonstrated favorable results. Recent literature demonstrates decreased rates of osteoarthritis and arthroplasty after medial meniscus root repair compared with partial meniscectomy and nonsurgical management. The transtibial pull-out repair technique is most commonly used and provides a biomechanically strong suture construct with standard and familiar knee arthroscopy portals. Furthermore, repair has recently been shown to be economically effective by decreasing overall societal healthcare costs when compared with more conservative management strategies. This review outlines the evaluation, treatment, and documented outcomes of meniscal root repair, which is imperative to the preservation of knee function and maintaining quality of life.

A Cost-Effectiveness Analysis of Isolated Meniscal Repair Versus Partial Meniscectomy for Red-Red Zone, Vertical Meniscal Tears in the Young Adult.

PURPOSE: To evaluate the cost-effectiveness of treating isolated red-red zone, vertical meniscal tears with either isolated meniscal repair (IMR) or partial meniscectomy (PM) in the young adult using conservative modeling. METHODS: A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after IMR or PM for an isolated meniscal tear. Event probabilities, costs, and utilities were used for the index procedures, and the development of osteoarthritis (OA) and subsequent need for knee arthroplasty were calculated or selected from the published literature. Differences in cost, difference in quality-adjusted life years (QALYs), and the incremental cost effect ratio were calculated to determine which index procedure is most cost effective. RESULTS: Total direct costs from PM were modeled at $38,648, and the total direct costs of IMR were $23,948, resulting in a projected cost savings of $14,700 with IMR. There was a modeled gain in QALYs of 17 for PM and 21 for IMR, resulting in an increase in 4 QALYs for the IMR treatment group. This results in an incremental cost effect ratio of $3,935 per QALY, favoring IMR as the dominant procedure. CONCLUSIONS: Meniscal repair for isolated red-red zone, vertical meniscal tears was predicted to have lower direct costs and improve QALYs compared with partial meniscectomy over 40-year modeling, indicating isolated meniscal repair to be the cost-effective procedure in the treatment of an isolated meniscal tear in the young adult population. LEVEL OF EVIDENCE: Level 3: economic and decision analysis.

Routine postoperative radiographs after tibia plateau fixation have minimal impact on patient care.

INTRODUCTION: Common practice in orthopedic surgery is to obtain postoperative radiographs to evaluate for healing or complications. Images obtained in the post-anesthesia care unit (PACU) have not been shown to positively impact patient care. This study plans to evaluate the clinical utility and cost-effectiveness of PACU postoperative radiographs following tibial plateau open reduction and internal fixation (ORIF). METHODS: Data from 211 patients who underwent a tibial plateau ORIF over a 5-year period at a single institution were retrospectively reviewed to determine if a patient received a postoperative radiograph in the PACU. Radiograph and clinical notes were reviewed to determine if postoperative radiograph resulted in management changes. Radiograph charges were calculated using CPT codes. RESULTS: A total of 142 of 211 patients (67.3%) who underwent tibial plateau ORIF received a postoperative radiograph while in the PACU. The majority of the radiographs had normal findings (88.7%). Of the 142 patients with postoperative imaging, subsequent management changes occurred for only one patient (0.7%). In this case, an incidental foot fracture was found which resulted in further CT imaging to assess the fracture. Other abnormal radiograph readings (11.3%) were generally due to incidental, chronic findings that did not require management changes. The average postoperative radiograph cost was $433.55 per patient, totaling $91,480 for 142 patients over a 5-year period. CONCLUSIONS: Routine postoperative radiographs following tibial plateau ORIF resulted in minimal management change patients in this series. The substantial cost of postoperative radiographs yielding little clinical utility suggests the use of routine PACU imaging following tibial plateau ORIF should be discontinued. Imaging would only be indicated in situations where intraoperative complications are suspected, thus reducing unnecessary imaging and patient cost.

Quantitative and Qualitative Assessment of Posterolateral Meniscal Anatomy: Defining the Popliteal Hiatus, Popliteomeniscal Fascicles, and the Lateral Meniscotibial Ligament.

BACKGROUND: Surgical treatment of lateral meniscal tears can be challenging due to the greater mobility of the lateral meniscus, thin capsule, and management of the popliteal hiatus. There has been a lack of quantitative assessments of the structural attachments to the posterior horn of the lateral meniscus (PHLM) to guide repairs. PURPOSE: To qualitatively and quantitatively describe the anatomy of the PHLM, popliteomeniscal fascicles, and the posterolateral capsule. STUDY DESIGN: Descriptive laboratory study. METHODS: Fourteen male, nonpaired, fresh-frozen cadaveric knees were used. The attachments of the posterolateral capsule, popliteomeniscal fascicles, and meniscofemoral ligaments to the lateral meniscus and the attachment of the meniscotibial ligament to the tibia were identified. A 3-dimensional coordinate measuring system was used to measure the relationships of these attachments to surgically relevant landmarks and their structural relationship with the lateral meniscus. RESULTS: The posterolateral capsule attachment had a confluent attachment at the superior margin of the PHLM, quantitatively attaching to the proximal 11% of the total height of the PHLM. On average, the length of the posterolateral capsule attachment to the superior surface of the PHLM was 16.7 ± 2.7 mm. The average length of the meniscotibial attachment to the posteroinferior aspect of the meniscus was 12.8 ± 3.9 mm. There was a lack of ligamentous attachments to the lateral meniscus between the lateral aspect of the meniscotibial ligament and the anterior aspect of the anterosuperior popliteomeniscal fascicle, where only popliteomeniscal fascicle and capsular attachments to the posterior meniscus were present. CONCLUSION: This anatomic study provides quantitative guidelines for the complex attachments to the PHLM. Knowledge of the quantitative descriptions of these attachments may aid in an improved intraoperative diagnosis of PHLM tears that extend to the popliteal hiatus, and further studies related to the surgical repair of the intricate attachments to the PHLM are recommended. CLINICAL RELEVANCE: The findings of this study provide the anatomic foundation for an improved understanding of the role of the meniscocapsular, meniscotibial, and popliteomeniscal fascicle attachments of the posterolateral meniscus. Understanding the differences between the lengths of the superior and inferior aspects of the popliteal hiatus will help to further refine characterization of tears extending into the popliteal hiatus and to avoid potential overconstraint of the more mobile lateral meniscus during a repair by anatomically reproducing its native structural attachments.

Increased rates of knee arthroplasty and cost of patients with meniscal tears treated with arthroscopic partial meniscectomy versus non-operative management.

PURPOSE: The purpose of this study was to determine the cost of arthroscopic partial meniscectomy (APM), one of the most common surgeries performed by orthopaedic surgeons, and the associated rate of progression to knee arthroplasty (KA) compared to patients treated non-operatively after diagnosis of meniscal tear. METHODS: Utilizing data mining software (PearlDiver, Colorado Springs, CO), a national insurance database of approximately 23.5 million orthopaedic patients was queried for patients diagnosed with a meniscal tear. Patients were classified by treatment: non-operative and arthroscopic partial meniscectomy and were followed after initial diagnosis for cost and progression to knee arthroplasty. RESULTS: There were 176,407 subjects in the non-op group and 114,194 subjects in the arthroscopic partial meniscectomy group. Arthroscopic partial meniscectomy generated more cost than non-operative ($3842.57 versus $411.05, P < 0.001). Arthroscopic partial meniscectomy demonstrated greater propensity to need future knee arthroplasty (11.4% at 676 days) than those treated non-operatively (9.5% at 402 days) (P < 0.001). Female patients demonstrated a higher rate of progression to knee arthroplasty in the arthroscopic partial meniscectomy and non-operative groups (P < 0.001). CONCLUSION: Compared to non-operative treatment for meniscal tears, arthroscopic partial meniscectomy is more expensive and does not appear to decrease the rate of progression to knee arthroplasty. Patients undergoing arthroscopic partial meniscectomy yielded on average a delay of only 9 months (274 days) before undergoing knee arthroplasty. Female patients experienced a significantly higher rate of progression to knee arthroplasty. The authors recognize the limitations of this type of study including its retrospective nature, reliance upon accurate coding and billing information, and the inability to determine whether symptoms including mechanical locking played a role in the decision to perform an APM. LEVEL OF EVIDENCE: IV.

Multiple Ligament Injured Knee: Initial Assessment and Treatment.

The multiple ligament injured knee (knee dislocation) is oftentimes part of a multisystem injury complex that can include injuries not only to knee ligaments but also to blood vessels, skin, nerves, bones (fractures), head, and other organ system trauma. These additional injuries can affect surgical timing for knee ligament reconstruction and also affect the results of treatment. This article presents the author's approach and experience to the initial assessment and treatment of the multiple ligament injured (dislocated) knee.