Combined ACLR and lateral extra-articular tenodesis with a continuous iliotibial band autograft is a viable option in a population of athletes who participate in pivoting sports.

PURPOSE: The aim of this study was to evaluate the clinical results, return to sport and complications after anterior cruciate ligament reconstruction (ACLR) associated with lateral extra-articular tenodesis using continuous plasty with an iliotibial band. METHODS: This was a prospective multicentre study involving 186 patients who had surgery for anterior cruciate ligament (ACL) rupture. Patients with multiligament ruptures and revision surgery were excluded from the study. All patients included were involved in pivoting sports and wished to resume their activity after surgery. Patients were assessed at a minimum 2-year follow-up using functional and psychological questionnaires (subjective International Knee Documentation Committee [IKDC], Tegner, Lysholm and ACL-RSI scores), ligament assessment including instrumented laxity measurement (Rolimeter), Lachman test and pivot shift and isokinetic testing. Return to sport was assessed using a questionnaire, and complications and repeat surgeries were recorded. RESULTS: At a mean follow-up of 43.1 months, the subjective IKDC, Lysholm, ACL-RSI and objective IKDC scores were significantly improved (59.8 vs. 94.5 p < 0.0001, 75 vs. 99 p < 0.0001, 60 vs. 93 p < 0.0001, IKDC A 0% vs. 72%, B 12% vs. 27%, C 60% vs. 1% D 28% vs. 0% p < 0.0001). The Tegner activity level was 9 (3-10) before the accident and 9 (3-10) at the last review. Seventy-six percent of the patients had returned to sports at the same level. The differential laxity was 6.6 mm (±1.7) preoperatively and 1.1 mm (±1.4) postoperatively. Additionally, 97% were equal in pivot shift at the last follow-up. At the 6-month isokinetic assessment, the muscle strength recovery for the quadriceps and hamstring was over 85% compared with the healthy side for 79% and 70% of the patients, respectively. Ten patients had graft rupture (5.6%). Four (2.4%) patients had a contralateral ACL rupture, and seven (4%) underwent a reoperation with meniscectomy. CONCLUSION: Anterior ligament reconstruction with lateral extra-articular tenodesis using a continuous strip of iliotibial band enables 76% of patients in a population with a high demand for sports to resume their activities at the same level. The clinical results and complication rates, particularly reruptures (5.6%), were similar to those of other techniques involving lateral extra-articular tenodesis. LEVEL OF EVIDENCE: Level II.

The posterior cruciate ligament-posterior femoral cortex angle: a reliable and accurate MRI method to quantify the buckling phenomenon of the PCL in ACL-deficient knees.

PURPOSE: The aim was to validate a new MRI method to measure the buckling phenomenon of the PCL, representative of anterior tibial translation, by comparing its reliability and accuracy to identify anterior cruciate ligament (ACL)-deficient knees with existing methods. METHODS: Patients were selected retrospectively and separated into a group of primary ACL injuries and ACL-intact knees. Exclusion criteria were: skeletal immaturity, PCL or a concomitant collateral ligament injury, signs of osteoarthritis (> 1 Kellgren and Lawrence score), tibial plateau fracture, previous ACL reconstruction or displaced meniscal bucket handle tear. The assessment of the curvature of the anterolateral bundle of the PCL was performed on T2 sagittal MRI slices according to 3 methods: (1) the PCL angle (PCLA), (2) the PCL inclination angle (PCLIA) and (3) a new method: the PCL-posterior cortex angle (PCL-PCA), representing the angle between the vertical part of the PCL-ALB and the posterior diaphyseal cortex of the femur. For each method, the inter- and intra-observer reliability was measured. The ability to discriminate both ACL-deficient and ACL-intact knees was evaluated using ROC curves. RESULTS: Twenty-four patients were included in each group. Intra-observer reliability was excellent for all 3 methods (ICCs > 0.90). Inter-observer reliability was excellent for the PCL-PCA (ICC > 0.90) and good for the PCLA and the PCLIA (ICCs between 0.75 and 0.90). The PCL-PCA had the highest precision (lowest standard error of measurement: 2.7°). It yielded an excellent discrimination between the ACL and CTL groups (AUC 0.80 [0.67-0.93]) with the highest sensitivity (71% [52.8-89.2]) and specificity (88% [75-100]) for a positive threshold when the angle was ≤ 22.7°. The PCLA and PCLIA methods led to acceptable discrimination and lower sensitivities and specificities (PCLA: AUC 0.71, sensitivity 63%, specificity 79%, threshold ≤ 117.9°; PCLIA: AUC 0.62, sensitivity 50%, specificity 83%, threshold ≤ 21.4°). CONCLUSION: In comparison with previously described methods, the PCL-PCA was the most reliable and accurate method to measure the PCL buckling phenomenon on MRI in anterior cruciate ligament (ACL)-deficient knees. It offers an easy and objective method for the follow-up of ACL-injured patients and can therefore be recommended for routine use. LEVEL OF EVIDENCE: IV.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction.

PURPOSE: To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage. METHODS: A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles. RESULTS: A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01). CONCLUSIONS: The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients. LEVEL OF EVIDENCE: Level III.

Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees.

PURPOSE: Double-level knee osteotomy (DLO) is a challenging procedure that requires precision in preoperative planning and intraoperative execution to achieve the desired correction. It is indicated in cases of severe varus or valgus deformities where a single-level osteotomy would yield significantly tilted joint line obliquity (JLO). This study aimed to evaluate the effectiveness of DLO in achieving accurate correction without compromising JLO, using patient-specific cutting guides (PSCGs), in cases of bifocal valgus maligned knees. METHODS: A single-centre, retrospective analysis of prospectively collected data for a total of 26 patients, who underwent DLO by PSCGs for valgus malaligned knees, between 2015 and 2020. Post-operative alignment was evaluated and the delta for different lower limb0.05, not statistically significant (ns)). All KOOS subs alignment parameters was calculated; the hip-knee-ankle angle (ΔHKA), medial proximal tibial angle (ΔMPTA), and lateral distal femoral angle (ΔLDFA). At the two-year follow-up, changes in the KOOS sub-scores, UCLA scores, lower limb discrepancy (LLD), and mean time to return to work and sport were recorded. All intraoperative and postoperative complications were recorded. The Mann-Whitney U test with a 95% confidence interval (95% CI) was used to evaluate the differences between two variables; one-way ANOVA between more than two variables and the paired Student's t-test was used to estimate the evolution of functional outcomes. RESULTS: The postoperative mean ΔHKA was 0.9 ± 0.9°, the mean ΔMPTA was 0.7 ± 0.7°, and the mean ΔLDFA was 0.7 ± 0.8° (all values with p > 0.05, not statistically significant (ns)). All KOOS subscore's mean values were improved to an extent two-fold superior to the reported minimal clinically important difference (MCID) (all with p < 0.0001). There was a significant increase in the UCLA score at the final follow-up (5.4 ± 1.5 preoperatively versus 7.7 ± 1.4, p < 0.01). The mean time to return to sport and work was 4.7 ± 1.1 and 4.3 ± 2.1 months, respectively. There was an improvement in Lower-limb discrepancy preoperative (LLD = 1.3 ± 2 cm) to postoperative measures (LLD = 0.3 ± 0.4 cm), ns. Complications were 2 femoral hinge fractures, 2 deep vein thromboses, 1 delayed tibial healing, and 1 hardware removal for hamstring irritation syndrome. CONCLUSION: DLO is effective and safe in achieving accurate correction in bifocal valgus malaligned knees with maintained lower limb length and low complication rate with no compromise of JLO. LEVEL OF EVIDENCE: III.

The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury.

PURPOSE: The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. METHODS: Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6 months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. RESULTS: Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). CONCLUSION: The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. LEVEL OF EVIDENCE: III.

The ALR-RSI score is a valid and reproducible scale to assess psychological readiness before returning to sport after modified Broström-Gould procedure.

PURPOSE: Psychological readiness scores have been developed to optimize the return to play in many sports-related injuries. The purpose of this study was to statistically validate the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale after modified Broström-Gould (MBG) procedure. METHODS: A similar version of the ACL-RSI scale with 12 items was adapted to quantify the psychological readiness to RTS after MBG and to describe construct validity, discriminant validity, feasibility, reliability and internal consistency of the scale, according to the COSMIN methodology. The term "knee" was replaced by "ankle". The AOFAS and Karlsson scores were used as references patient-related outcome measurements (PROMs). RESULTS: A total of 71 patients were included. The ALR-RSI score after MBG procedure was highly (r > 0.5) correlated to the AOFAS and Karlsson scores, with a Pearson coefficient r = 0.69 [0.54-0.80] and 0.72 [0.53-0.82], respectively. The mean ALR-RSI score was significantly greater in the subgroup of 55 patients who resumed sports activity compared to those that no longer practiced sport: 61.9 (43.8-79.6) vs 43.4 (25.0-55.6), (p = 0.01). The test-retest showed an "excellent" reproducibility with a ρ intraclass correlation coefficient of 0.93 [0.86-0.96]. The Cronbach's alpha statistic was 0.95, attesting an "excellent" internal consistency between the 12 ALR-RSI items. CONCLUSION: The ALR-RSI score is a valid and reproducible tool for the assessment of psychological readiness to RTS after an MBG procedure for the management of CLAI, in a young and active population. The ALR-RSI score may help to identify and counsel athletes on their ability to return to sport. LEVEL OF EVIDENCE: III.

Evaluation of the "Minimal Clinically Important Difference" (MCID) of the KOOS, KSS and SF-12 scores after open-wedge high tibial osteotomy.

PURPOSE: Defining a Minimal Clinically Important Difference (MCID) value for Patient-Reported Outcome Measures (PROMs) is crucial for determining the effectiveness of a procedure and calculating the sample size for trial planning. The purpose of this study was to determine the MCID of several PROMs (Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and the SF-12) in patients who underwent medial opening-wedge High-Tibial Osteotomy (owHTO) with Patient-Specific Cutting Guides (PSCGs), using anchor-based methods. METHODS: Patients undergoing isolated medial owHTO with PSCGs between January 2013 and January 2017 were enrolled in this single-center, prospective, observational study. Three outcome scores were collected pre-operatively and at the 2 years follow-up evaluation: KOOS, KSS and SF-12. The MCIDs were calculated using anchor-based method: at 2 years postoperatively: "Compared with before surgery, how would you rate operated joint now?" The responses were recorded using a five-point scale. Patients who answered "about the same" or "somewhat worse" were classified into the no change group, while those who answered "somewhat better" were classified into the minimal change group. A receiver operating characteristic (ROC) curve was used to define the cutoff point that best discriminated between the minimal change and no change groups for each PROMs RESULTS: 196 patients were included, 75 (somewhat better) and 24 patients (about the same and somewhat worse) were, respectively, assigned to the "no change" and "minimal change" groups. There was no significant difference between the two groups in terms of baseline characteristics and postoperative complications. At 24 months follow-up all the PROMs (KOOS, KSS and SF-12) were significantly better for the "minimal change" group compared to the "no change" group. MCID was 15.4 for KOOS pain, 15.1 for KOOS symptoms, 17 for KOOS ADL, 11.2 for KOOS sports/recreation, 16.5 for KOOS QQL, 3 for KSS symptoms, 5.6 for KSS activity, 7.2 for SF-12 physical component and 6.3 for PCS mental component. CONCLUSION: This study determined the MCIDs of common used PROMs in patients undergoing owHTO. LEVEL OF EVIDENCE: Prospective Cohort Study, Level II.

Litigation in arthroscopic surgery: a 20-year analysis of legal actions in France.

PURPOSE: The main objective of this study was to identify the epidemiological characteristics of litigation following arthroscopic procedures, performed in private practice and public hospitals in France. The secondary objective was to establish a risk profile for medical malpractice lawsuits after arthroscopic surgery. METHODS: All court decisions related to arthroscopic surgery between 1994 and 2020 were collected and reviewed cases from the two main French legal databases (Legifrance and Doctrine). Data were retrospectively collected and included: gender, joint and defendant's specialty involved, reason behind the lawsuit, initial indication and the type of arthroscopic procedure performed. The final verdicts as well as the indemnity awarded to the plaintiff (if any) were recorded. RESULTS: One-hundred eighty cases met the inclusion criteria of the study and were analyzed: 58 cases were before administrative courts and 122 were before civil courts. An orthopaedic surgeon was involved alone or in solidum in 45.6% of cases (82/180), followed by anesthesiologists in 5.6% (10/180). The private surgery center or public hospital were implicated in 63.9% (115/180) of cases. The 2 most common joints involved in litigation following arthroscopic surgery were the knee (82.2%, n = 148) and the shoulder (11.1%, n = 20). The main reasons behind the lawsuit were related to postoperative infection in 78/180 cases and to a musculoskeletal complication in 45/180 cases (25%). A failure to inform was also reported in 34/180 cases (18.9%). Of the 180 cases, 122 cases (67.8%) resulted in a verdict for the plaintiff. The average indemnity award for the plaintiff was 77.984 euros [2.282-1.117.667]. A verdict for the plaintiff was significantly associated with postoperative infection or a wrong-side surgery, while technical error and musculoskeletal complications were more significantly likely to result in a verdict in favor of the defendant (p = 0.003). CONCLUSION: This study evaluated and mapped lawsuits following after arthroscopic surgery in France over a period of more than 20 years. The main joint involved in lawsuits was knee. The main causes of lawsuits following arthroscopic surgery were related to postoperative infection, musculoskeletal complications and failure to inform. LEVEL OF EVIDENCE: Level IV.

Return to Competitive Level of Play and Performance in Regular Golfers After Total Hip Arthroplasty: Analysis of 599 Patients at Minimum 2-Year Follow-Up.

BACKGROUND: Total hip arthroplasty (THA) is performed in an increasingly younger and athletic population. Regular and competitive golfers are concerned with the likelihood of recovering their preoperative level of play. The purpose of this study was to assess the impact of primary THA on golfers' game, with a minimum follow-up of two years. METHODS: Questionnaires were sent to the French Golf Federation's golfing members. Those who were older than 40 years and had undergone a unilateral primary THA provided information on the timing of return to play, pain during golfing, transportation mode, drive length, handicap and weekly playtime, before hip replacement, and postoperatively. In addition, data relating to the surgical procedure were collected. RESULTS: Surveys were completed by 883 competitive golfers of which 599 were eligible for inclusion. The mean time to return to a complete 18-hole course was 4.73 months (SD 4.15, range: 0.7-36). Participants surveyed at a minimum 2 years after THA played at a higher level than before surgery with a handicap improvement of 1.8 (P < .01) and increased their mean weekly playtime from 8.8 to 9.3 hours (P = .24, NS). Eighty-eight percent reported an increased or no change in drive distance. Hip pain while playing golf decreased after surgery (6.8 to 2.5 on the visual analog scale, P < .001). CONCLUSION: This study highlighted that hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play.

Presoaking of Semitendinosus Graft With Vancomycin Does Not Alter Its Biomechanical Properties: A Biomechanical In Vitro-Controlled Study Using Graft From Living Donors.

PURPOSE: To compare the biomechanical properties of human semitendinosus graft presoaked with or without vancomycin under a load to failure tensile test. METHODS: Thirty semitendinosus grafts harvested during anterior cruciate ligament reconstruction were included. These were dissected equally into 2 halves and subsequently randomly allocated to a vancomycin group and to a control group. A digital caliper was used to precisely measure each samples thickness, length, and width. For the vancomycin group, samples were presoaked in a solution of 5 mg/mL vancomycin for a duration of 10 minutes and the control group samples were presoaked in a physiological serum equally for 10 minutes. Mechanical testing was performed on a universal testing machine (Instron 5566-A) after a preconditioning of 10 cycles of 1 mm extension and a progression of 10 mm/min to failure for each sample. The stress-strain curve was obtained to determine the elastic modulus (Young's modulus), the ultimate tensile stress, the ultimate tensile elongation (UTE) before failure and the elasticity limit. RESULTS: For the control group, the average Young's modulus value was 4.8 ± 0.8, the average UTS was 25.2 ± 5.2 MPa, the average percentage of UTE was 78 ± 17%, and the average elasticity limit value was 17.3 ± 5.3 MPa. For the vancomycin group, the average Young's modulus value was 4.7 ± 0.9, the average ultimate tensile stress was 24.1 ± 6.1 MPa, the average percentage of UTE was 82 ± 14%, and the average elasticity limit value was 18.5 ± 5.9 MPa. No significant difference was observed between the 2 groups for all investigated parameters. CONCLUSIONS: Presoaking of human semitendinosus graft with vancomycin does not alter its biomechanical properties. CLINICAL RELEVANCE: This study demonstrates that vancomycin presoaking used to prevent post-anterior cruciate ligament reconstruction septic arthritis does not affect immediate biomechanical properties of semitendinosus tendons.

Clinical Outcomes of Arthroscopic Primary Anterior Cruciate Ligament Repair: A Systematic Review from the Scientific Anterior Cruciate Ligament Network International Study Group.

PURPOSE: To perform a systematic review of contemporary studies reporting clinical outcomes of primary anterior cruciate ligament (ACL) repair to determine whether these studies demonstrate any significant benefit of ACL repair and whether there is evidence of a deterioration of mid-term outcomes as seen in historical data. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A PubMed search using the keywords "repair" AND "Anterior Cruciate Ligament" was performed (limits: English language, publication date between January 1, 2014, and January 13, 2019). All identified studies reporting clinical outcomes of arthroscopic ACL repair were included. Critical appraisal was conducted using the Cochrane Risk of Bias Tool for Randomized Clinical Trials and the Methodological Index for Non-Randomized Studies. Basic parameters of each study including population characteristics, repair technique, physical examination findings, and clinical outcome scores were recorded and evaluated. RESULTS: Nineteen eligible studies were identified (including 5 comparative studies). None of the comparative studies showed any significant difference between repair and reconstruction groups with respect to International Knee Documentation Committee (IKDC), Lysholm, Tegner, side-to-side laxity difference, Lachman, pivot shift tests, or graft rupture rates. Four non-comparative studies reported outcomes at medium- to long-term follow up (range of mean follow up 43.3-79 months) with a mean Lysholm score between 85.3 and 100, mean IKDC subjective score between 87.3 and 100, and mean Tegner activity score between 5 and 7. CONCLUSIONS: Comparative studies identified no significant differences between ACL repair and reconstruction with respect to Lysholm, IKDC, side-to-side laxity difference, pivot shift grade, or graft rupture rates. However, these studies had major limitations including small numbers and short durations of follow up. Case series demonstrated that excellent outcomes can be achieved at medium- to long-term follow up with the SAR technique. LEVEL OF EVIDENCE: IV; Systematic review of Level II to IV investigations.

A Playtime and Handicap Analysis of 143 Regular Golfers After Total Knee Arthroplasty at Minimum 2-Year Follow-Up.

BACKGROUND: Regular and competitive golfers are concerned by the ability to recover their previous activity golfing after total knee arthroplasty (TKA). The purpose of this study was to conduct targeted analysis of the effect of unilateral total knee replacement on the playtime and golf level in a population of experienced golfers, with a minimum follow-up of two years. METHODS: Questionnaires were distributed to the French Golf Federation's golfing members. Those who were older than 50 years and had undergone a unilateral primary TKA provided information on the timing of return to play, mode of movement on the course, pain during golfing, physical activity via University of California Los Angeles scale, level of golf and weekly playing time, before and after surgery. In addition, surgeons' recommendations and level of arthroplasty satisfaction were collected. RESULTS: Questionnaires were completed by 290 competitive golfers, of which 143 were eligible for inclusion. The average time to return to the 18-hole course was 3.7 months. Participants surveyed at a minimum 2 years after TKA played at a higher level than before surgery with a handicap improvement of 0.85 and increased their average weekly playtime from 8.9 to 10.2 hours. Knee pain while playing golf decreased after surgery (6.13 to 1.27 on the visual analog scale) and the University of California Los Angeles score improved (7.02 to 7.85). CONCLUSION: This study demonstrated the ability of regular golfers to return to golf within six months after unilateral total knee replacement, with increasing level of golf and weekly playtime and better golfing comfort.

Long-term results of custom-made femoral stems.

BACKGROUND: The progress of 3D imaging and manufacturing of implants has made it possible to achieve a custom-made concept in THA. The custom-made cementless femoral stem provides optimal implant stability combined with restoration of the native hip mechanics. OBJECTIVE: The purpose of this study was to evaluate the long-term survivorship of custom-made hip femoral stems in two populations of patients undergoing THA: patients under 50 years old (young patients group) and patients with high-grade developmental dysplasia of the hip (DDH group). METHODS: A series of 232 primary custom-made cementless THA stems were retrospectively evaluated in patients less than 50 years old at the time of surgery and at follow-up after an average of 20 years. A second series of 26 custom-made cementless stem THAs for late DDH (21 patients) including only Crowe grade III and grade IV were also retrospectively evaluated with an average follow-up of 16 years. The clinical and radiological evaluations were performed preoperatively and at yearly intervals. RESULTS: For the young patient group, the follow-up ranged from 14 to 27 years. The HHS and the Merle D'Aubigne-Postel score significantly improved from preoperatively to a mean of 94.1 (range 48-100) and 15.9 (range 9-18), respectively. Taking stem revision for aseptic loosening as an endpoint, survivorship was 96.8% at 20 years (95% confidence interval, CI 95.1-98.5). For the DDH group, the follow-up ranged from 10 to 22 years. The mean HHS increased significantly from preoperative 49 ± 22 points to the most recent follow-up examination with 86 13 points and survivorship was 96.1% (95% CI, 92.7-99.9). CONCLUSION: Custom-made femoral stems provide good functional outcome and long-term survivorship in two specific populations of patients undergoing THAs: patients under 50 years old with high expectations and patients with high-grade DDH.

Presentation of an intraosseous suspensory fixation technique for pediatric and adult ACL reconstruction.

The aim is to present a technique for pediatric and adult ACL reconstruction using an intraosseous suspensory fixation. This technique uses a 4-strands hamstring graft fixed in the femoral tunnel, with a loop locked in a polyetheretherketone (PEEK) cage. The ACLip® device offers an inside-out drilling system and a closer fixation to the joint than an extracortical button fixation. The technique can be easily used both in adults and in skeletally immature patients. The first practical experience shows promising results regarding the safety and the effectiveness of the technique. Level of evidence: IV.

Increased Intra-Articular Internal Tibial Rotation Is Associated With Unstable Medial Meniscus Ramp Lesions in ACL-Injured Athletes: An MRI Matched-Pair Comparative Study.

Purpose: To analyze internal tibial rotation through magnetic resonance imaging (MRI) of patients with anterior cruciate ligament (ACL) injuries with and without an unstable medial meniscal ramp lesion (MMRL). Methods: Retrospective analysis of prospectively data was performed to include all consecutive patients who underwent primary ACL reconstruction (ACLR) between January 2022 and June 2022. Two groups, ACLR + unstable MMRL and ACLR without MMRL, were constituted. Propensity score matching analysis was used to limit selection bias. The angle between surgical epicondylar axes (SEAs) and the tangent line of the posterior tibial condyles (PTCs) was measured to analyze the rotational alignment between distal femur and proximal tibia. MMRLs were defined unstable if they were ≥1 cm, if the lesions extend beyond the lower pole of the femoral condyle, and/or if there was displacement into the medial compartment by anterior probing. Results: Twenty-eight propensity-matched pairs were included. The ACLR + unstable MMRL presented a significantly greater internal rotation of the tibia compared to ACLR without MMRL (P < .001). An internal tibial rotation was associated with unstable ramp lesions in ACL-injured patients (odds ratio [OR], 0.36; 95% CI, 0.25-0.41; P < .0001). If SEA-PTC was 0°, the sensitivity and specificity of the SEA-PTC angle to detect unstable MMRL were respectively 100% (95% CI, 85%-100%) and 18% (95% CI, 8%-36%). Otherwise, if SEA-PTC angle was -10°, the sensitivity and specificity of the SEA-PTC angle to detect unstable MMRL were respectively 43% (95% CI, 27%-61%) and 96% (95% CI, 81%-100%). Bone edema of the posterior medial tibial plateau was significantly associated with unstable ramp lesions (OR, 1.58; 95% CI, 1.21-2.06; P = .029). Conclusions: Unstable MMRL concomitant to an ACL rupture was associated with an increased tibial internal rotation. Level of Evidence: Level III, retrospective comparative trial.

Secondary Meniscectomy Rates and Risk Factors for Failed Repair of Ramp Lesions Performed at the Time of Primary ACL Reconstruction: An Analysis of 1037 Patients From the SANTI Study Group.

BACKGROUND: Studies evaluating secondary meniscectomy rates and risk factors for failure of ramp repair are sparse and limited by small numbers and heterogeneity. PURPOSES/HYPOTHESIS: The purposes were to determine the secondary meniscectomy rate for failure of ramp repair performed using a posteromedial portal suture hook at the time of anterior cruciate ligament reconstruction (ACLR) and to identify risk factors for secondary meniscectomy. It was hypothesized that patients who underwent ACLR combined with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of secondary meniscectomy compared with those undergoing isolated ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing primary ACLR and ramp repair between 2013 and 2020 were included in the study. Final follow-up for each patient was defined by his or her last appointment recorded in a prospective database (with a study end date of March 2023). The database and medical records were used to determine whether patients had undergone secondary meniscectomy for failure of ramp repair. Survivorship of ramp repair (using secondary meniscectomy as an endpoint) was determined using the Kaplan-Meier method. Multivariate analysis was used to investigate possible risk factors. RESULTS: A total of 1037 patients were included in the study. The secondary meniscectomy rate after ramp repair was 7.7% at a mean final follow-up of 72.4 months. Patients without combined ACLR + LEAP were >2-fold more likely to undergo a secondary medial meniscectomy compared with those with combined ACLR + LEAP (hazard ratio, 2.455; 95% CI, 1.457-4.135; P = .0007). Age, sex, preoperative Tegner score, and time between injury and surgery were not significant risk factors for failure. CONCLUSION: The rate of secondary meniscectomy after ramp repair performed through a posteromedial portal at the time of primary ACLR was low. Patients who underwent isolated ACLR (rather than ACLR + LEAP) were >2-fold more likely to undergo a secondary medial meniscectomy for failure of ramp repair. Additional risk factors for failure of ramp repair were not identified.

Incidence of and Risk Factors for Arthrogenic Muscle Inhibition in Acute Anterior Cruciate Ligament Injuries: A Cross-Sectional Study and Analysis of Associated Factors From the SANTI Study Group.

BACKGROUND: Arthrogenic muscle inhibition (AMI) is a process in which neural inhibition after injury or surgery to the knee results in quadriceps activation failure and knee extension deficit. PURPOSE: To determine the incidence and spectrum of the severity of AMI after acute anterior cruciate ligament (ACL) injury using the Sonnery-Cottet classification, to determine the interobserver reliability of the classification system, and to investigate potential important factors associated with AMI after ACL injury. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients who had an acute ACL injury between October 2021 and February 2022 were considered for study inclusion. Eligible patients underwent a standardized physical examination at their first outpatient appointment. This included an assessment of quadriceps inhibition, identification of any extension deficits, and grading of AMI and its reversibility according to the Sonnery-Cottet classification. RESULTS: A total of 300 consecutive patients with acute ACL ruptures were prospectively enrolled in the study. Of them, 170 patients (56.7%) had AMI. Patients evaluated with AMI showed a significantly inferior Lysholm score, International Knee Documentation Committee score, Simple Knee Value, and Knee injury and Osteoarthritis Outcome Score than patients without AMI (P < .0001). Multivariate analysis revealed that the presence of effusion, concomitant injuries, and high pain scores were associated with a significantly greater risk of AMI. Additional associations with the presence of AMI included a short duration between injury and evaluation, the use of crutches, and using a pillow as a support at night. In contrast, a previous ACL injury was associated with significantly lower odds of developing AMI (OR, 0.025; 95% CI, 0-0.2; P = .014). Among the 170 patients with AMI, 135 patients (79%) showed a resolution of their inhibition at the end of the consultation after application of simple exercises; the remaining 35 patients required specific rehabilitation. Interobserver reliability of the classification system was almost perfect (95% CI, 0.86-0.99). CONCLUSION: AMI occurs in over half of patients with acute ACL injuries. When it occurs, it is easily reversible in the majority of patients with simple exercises targeted at abolishing AMI. The presence of "red flags" should increase the index of suspicion for the presence of AMI, and these include the presence of an effusion, high pain scores, a short time between injury and evaluation, multiligament injuries, the use of crutches, and using a pillow as a support at night. Patients with a history of ipsilateral or contralateral ACL injury are at a significantly lower risk of AMI than those with a first-time ACL injury.

Ramp Lesions of the Medial Meniscus.

PURPOSE OF REVIEW: To provide an overview of the recent scientific literature about ramp lesions of the medial meniscus and to summarise the current evidence on their prevalence, classification, biomechanics, surgical techniques and clinical outcomes. RECENT FINDINGS: Ramp lesions may be present in more than 1 patient undergoing ACL reconstruction out of 5 and almost half of the medial meniscal tears observed in this population. Due to the risk of persistent anterior and rotational laxity after ACL reconstruction, their repair has been advocated. There is no general agreement to date on whether and when ramp lesions should be treated surgically. Comparative studies have failed to show that the repair of stable lesions was superior in comparison to nonoperative approaches. A lower failure rate and secondary meniscectomy has been reported with a suture hook repair through the posteromedial portal in comparison with an all-inside technique. Furthermore, reconstructions of the anterolateral complex in association with ACL reconstruction may have a protective effect on ramp repair. Ramp lesions of the medial meniscus in ACL-injured knees cannot be neglected anymore. Given their novelty, their clinical impact has not been fully assessed yet, but the evidence is growing that they need to be systematically identified and eventually repaired, for which they require advanced surgical knowledge. There is, to date, no consensus on whether and when ramp lesions should be treated surgically. Their subtypes, size and stability may influence the decision-making process.