Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique.

PURPOSE: In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS. METHODS: We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities. RESULTS: Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique. CONCLUSION: Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Editorial Commentary: Resident Education: At What Cost?

Arthroscopic trainees may struggle to learn basic skills, resulting in slower and more expensive surgical procedures. However, the reward of resident involvement includes the satisfaction and benefit to society associated with medical mentorship, and the learning-clinical and otherwise-that is associated with teaching.

Editorial Commentary: Knee Dislocations: What's Working and Who's Not.

Knee dislocations are severe injuries that are being seen with increasing frequency. Surgical treatment of knee dislocations improves outcomes, but many patients are unable to return to physical occupations or sporting activities. Patient factors and associated trauma can significantly affect the patient's final functional activity level. Future studies are needed to better assess our treatment methods of these challenging injuries.

International Perspective on Revision Anterior Cruciate Ligament Reconstruction: What Have We Been Missing?

Primary anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. A graft failure rate of 5% to 10% after primary ACL reconstruction has resulted in an increased need for revision ACL reconstruction. ACL reconstruction failure etiologies include trauma, technical errors, and biologic factors. Based on the current literature, the outcomes of revision ACL reconstruction are clearly inferior compared with those of primary reconstruction. A thorough patient evaluation, including surgical history, a physical examination, and imaging studies, is crucial in the assessment of a failed ACL reconstruction. Tunnel malposition, which is a technical error, is the most common reason for ACL reconstruction failure. Tunnel positioning and widening are important factors to consider in the decision to perform either one-stage or two-stage revision ACL reconstruction. Other concomitant factors such as malalignment, pathologic posterior tibial slope, and meniscal or ligamentous deficiency (in particular, deficiency of the anterolateral ligament) must be considered and addressed to achieve an optimal outcome. Patients who have a positive pivot shift test and rotational instability may require extra-articular anterolateral ligament reconstruction. In addition, patients who have severe pathologic tibial slope and anterior tibial translation may require a tibial deflexion osteotomy.

Management of patellar problems in skeletally mature patients with nail-patella syndrome.

PURPOSE: Nail-patella syndrome (NPS) or hereditary onychoosteodysplasia is a rare autosomal dominant disease, characterized by a tetrad of findings, which include fingernail abnormalities, hypoplasia of the patellae, radial head dislocation and prominent iliac horns. Most of the literature on the treatment of patellar problems in NPS concerns paediatric patients, and there is no standard treatment algorithm for adult patients. METHODS: We reviewed the charts of skeletally mature patients with NPS who presented to our clinic. We reviewed the presenting complaints, the physical examination findings and the radiographic imaging. RESULTS: We identified seven skeletally mature patients with NPS who presented with patellofemoral complaints. Their symptoms were instability, pain, or a combination of the two. Examination and imaging revealed a wide range of severity but included patellar instability and patellar arthritis. In our series, milder forms of the disease were treated with non-operative measures, but the majority of our patients required surgery including medial patellofemoral ligament reconstruction, tibial tuberosity transposition, patellofemoral and total knee arthroplasty. At midterm follow-up, most patients had good results. CONCLUSION: Nail-patella syndrome has a wide range of presentations and severity in skeletally mature patients. Knee surgeons should be familiar with the spectrum of clinical presentation and the range of treatment options available in order to provide optimum treatment for patients with this disorder. LEVEL OF EVIDENCE: IV.

Early weight bearing versus delayed weight bearing in medial opening wedge high tibial osteotomy: a randomized controlled trial.

PURPOSE: The need for a period of non-weight bearing after medial opening wedge high tibial osteotomy remains controversial. It is hypothesized that immediate weight bearing after medial opening wedge high tibial osteotomy would have no difference in functional scores at one year compared to delayed weight bearing. METHODS: Fifty patients, median age 54 years (range 40-65), with medial compartment osteoarthritis, underwent a medial opening wedge high tibial osteotomy utilizing a locking plate without bone grafting. Patients were randomized into an Immediate or a Delayed (2 months) weight bearing group. All patients were assessed at one-year follow-up and the two groups compared. The primary outcome measure was the IKS score. Secondary outcome measures included the IKDC score, the VAS pain score and rate of complications. RESULTS: The functional scores significantly improved in both groups. The IKS score increased from 142 ± 31 to 171 ± 26 in the Immediate group (p < 0.001) and from 148 ± 22 to 178 ± 23 in the Delayed group (p < 0.001). The IKDC score increased from 49 ± 17 pre-operatively to 68 ± 14 one-year post-operatively in the Immediate group (p < 0.0001) and from 44 ± 16 to 69 ± 19 in the Delayed group (p < 0.001). The average VAS for pain 2 months after surgery was 3 ± 3 in the Immediate group and 3 ± 2 in the Delayed (n.s.). There was no significant difference between the two groups in any of the outcome measures. The mean mechanical femorotibial angle changed from 6° of varus (0°-15° of varus, SD = 3°) to 4° of valgus (5°-11° of valgus, SD = 3°) in the Immediate group and from 5° of varus (0°-10° of varus, SD = 3°) to 3° of valgus (2° of varus to 8° of valgus, SD = 3°) in the Delayed group. No difference was seen between groups, and no loss of correction was observed in any patient. Two cases of non-union occurred, one in each group. One infection and one deep vein thrombosis occurred in the Immediate group. CONCLUSION: Immediate weight bearing after medial opening wedge high tibial osteotomy had no effect on functional scores at 1 year follow-up and did not significantly increase the complication rate. Immediate weight bearing after medial opening wedge high tibial osteotomy appears to be safe and can allow some patients a quicker return to activities of daily living and a decreased convalescence period. LEVEL OF EVIDENCE: II.

A novel posteromedial approach for tibial inlay PCL reconstruction in KDIIIM injuries: avoiding prone patient positioning.

BACKGROUND: Treatment of traumatic knee dislocations remains controversial and challenging. Current techniques for PCL reconstruction utilize either a transtibial approach with potential risk of vascular injury from drilling toward the popliteal artery or a tibial inlay technique with prone patient positioning, which is cumbersome and adds operative time. We therefore developed a surgical technique using a supine posteromedial approach for PCL tibial inlay reconstruction for the treatment of Schenck KDIIIM (ACL/PCL/medial collateral ligament) knee dislocations. In patients undergoing this technique, we evaluated patient-reported outcome scores, ROM, stability, and complications. DESCRIPTION OF TECHNIQUE: Tibial inlay PCL reconstructions were performed through a posteromedial approach with the patient supine, knee flexed, and hip externally rotated, thus avoiding prone patient positioning. The inlay approach uses the interval between the medial head of the gastrocnemius and the pes anserinus (gracilis and semitendinosus), with release of the semimembranosus tendon approximately 1 cm from its insertion on the tibia. Retraction of the medial gastrocnemius and semimembranosus allows access to the posteromedial aspect of the proximal tibia while protecting the neurovascular bundle. METHODS: All 11 patients sustaining a KDIIIM multiligamentous knee injury treated between 2002 and 2011 with a three-ligament reconstruction received this posteromedial approach. Seven patients were available for complete evaluation, and one completed telephone followup only. Mean followup was 6.0 years (range, 2.0-11.2 years). Clinical evaluation included Lysholm and Tegner activity scores and measurements of ROM and knee laxity. We also recorded complications. RESULTS: Mean Lysholm and Tegner activity scores were 81 and 4.9, respectively, with three patients returning to recreational or competitive sports. Mean knee flexion was 120° (range, 106°-137°); however, two patients had stiffness in flexion, lacking greater than 20° of flexion compared to the contralateral side. Five had less than 3 mm of translation. Three returned to the operating room, two for arthrofibrosis or painful hardware and a third for ACL reinjury requiring revision reconstruction; there were no vascular injuries. CONCLUSIONS: Outcome scores, stability, and complications using this surgical technique were comparable to those found in other studies. The posteromedial approach for tibial inlay avoids prone positioning and the incisions are minimized, allowing safe exposure for combined medial and posterior ligament reconstruction. Further studies are needed to compare this method with others in the treatment of KDIIIM knee dislocations.

Outcomes of isolated patellofemoral arthroplasty.

Osteoarthritis of the patellofemoral compartment can cause significant functional impairment. Isolated patellofemoral osteoarthritis affects greater than 10% of males and females over the age of 60. Patellofemoral arthroplasty (PFA) was developed as a joint-preserving procedure that maintains natural knee kinematics in those with isolated patellofemoral disease. First-generation implants were fraught with complications, a high rate of revision, and early conversion to total knee arthroplasty (TKA). Second-generation implants have demonstrated significant improvements in patient-reported outcome measures, complication rates and implant survivorship. Factors that can affect outcomes include surgical indications, patient selection, and PFA prosthesis design. Modern PFA for isolated patellofemoral osteoarthritis has comparable outcomes to TKA for isolated patellofemoral osteoarthritis. In this article, we discuss the use of PFA, implant design, the indications and factors affecting outcomes, and comparison to TKA.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries.

Background: Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis: The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results: In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Conclusion: Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: state of the art.

The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.

Differentiation in Posterior Tibial Slope by Sex, Age, and Race: A Cadaveric Study Utilizing 3-Dimensional Computerized Tomography.

BACKGROUND: Posterior tibial slope (PTS) has recently gained increased attention for its possible role in anterior cruciate ligament and posterior cruciate ligament injury. The possible differences among age, sex, and ethnicity in PTS have not yet been reported. PURPOSE: To describe demographic variances of proximal tibial anatomy and to detect differences in regard to ethnicity, sex, and age. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: In total, 250 cadaveric specimens with full-body computerized tomography scans from the New Mexico Descendant Imaging Database were randomly selected (inclusion/exclusion criteria: older than 18 years, complete imaging of the knee without previous surgery or arthroplasty) and reviewed by 3 independent observers measuring medial posterior tibial slope (MPTS), lateral posterior tibial slope (LPTS), and global posterior tibial slope (PTS), which was calculated as the mean of the MPTS and LPTS. Individuals were evenly divided among male and female and ethnicities/races: African American/Black, Asian American, Hispanic, Native American, and White. Intraclass correlation coefficient was calculated for interobserver reliability and analysis of variance statistical testing to determine statistical significance between groups. Fisher exact test was also used to understand PTS differences among ethnicities when looking at clinically significant values for potential ligamentous injury. RESULTS: Measurements were obtained from 250 specimens with a mean age of 49.4 years (range, 19 to 103 years). The mean PTS was 8.92° (range, -9.4° to 14.95°). Asian Americans had a 1.7° greater mean MPTS than Whites (P = .016), and African Americans/Blacks had a 1.6° greater mean PTS than Whites (P = .022). No difference in mean PTS was seen between age and sex. When looking at clinically significant PTS, 61 (24.4%) individuals had tibial slopes <6° or >12°, 32 (12.8%) and 29 (11.6%), respectively. Statistically significant differences were seen among ethnicities with PTS <6° (P = .017) but not with PTS >12° (P = .106). No sex-based differences were seen in the percentage of specimens with a PTS of >12° or <6°. CONCLUSION: Among ethnicities, African Americans/Blacks and Asian Americans have increased PTS in comparison with Whites. Nearly 25% of individuals have clinically significant slopes of <6° or >12°, with no difference in tibial slope among sex or age groups.

Tibial Supra-tubercular Deflexion Osteotomy in the Management of Failed Anterior Cruciate Ligament Reconstruction: A Surgical Technique.

Excessive posterior tibial slope (PTS) is a recognized risk factor for failure of anterior cruciate ligament reconstruction (ACLR) and should be considered when planning a revision ACLR. A tibial supra-tubercular deflexion osteotomy can correct excessive PTS with simultaneous or staged ACLR. There are only a handful of technical descriptions offering insight on the respective authors' approach at reducing PTS, all of which vary greatly in their methods. The authors describe a surgical technique using a proximal tibial supra-tubercular deflexion osteotomy in patients with persistent knee instability, a history of at least one failed ACLR, and a PTS greater than 12°. This surgery is not recommended in patients with significant genu recurvatum (>10°), significant varus, or severe tibiofemoral osteoarthritis.

Inclusion of open injuries in an updated Schenck classification of knee dislocations based on a global Delphi consensus study.

OBJECTIVES: Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. METHODS: A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. RESULTS: Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). CONCLUSION: Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.

Simultaneous Bilateral Latissimus Dorsi Tendon Ruptures: A Case Report.

CASE: We report a case of a 55-year-old man who sustained bilateral, complete latissimus dorsi tendon ruptures during a water-skiing accident. Physical examination and magnetic resonance imaging confirmed the patient's diagnosis but also revealed a tear of the teres major on the left side. Staged primary repair was performed on each side, with a 6-week interval between procedures. At 1-year follow-up, the patient had an excellent clinical outcome. CONCLUSION: Staged surgical repair of bilateral latissimus dorsi tendon ruptures can be performed, leading to excellent clinical and functional outcomes for patients.

No Significant Difference Between Intramedullary and Extramedullary Button Fixation for Distal Biceps Brachii Tendon Rupture After Cyclic Loading in a Cadaver Model.

PURPOSE: To biomechanically compare intramedullary (IM) versus extramedullary (EM) distal biceps button fixation under cyclic loading conditions, which is most representative of postoperative physiologic status. METHODS: This controlled laboratory study used 13 fresh-frozen matched paired cadaver elbows. One specimen from each pair was randomized to either IM (unicortical) or EM (bicortical) distal biceps button fixation via onlay technique. A servohydraulic actuator was used to cycle each specimen from full extension to 90° of flexion at 0.5 Hz for 3,000 cycles. All specimens were subsequently loaded to failure to simulate an acute postoperative load. RESULTS: During cyclic loading, the mean change in force from cycle 5 to cycle 3000 was 2.1 ± 3.2 N for the IM group and 0.6 ± 4.2 N for the EM group (P = .19). The increase in tendon gap for the IM group was 1.02 mm and for the EM group was 1.83 mm (P = .37). During failure loading, the IM group had a mean failure load of 154.9 ± 44.5 N and the EM group a mean failure load of 191.1 ± 62.6 N (P = .16). CONCLUSIONS: No significant differences exist between the IM and EM techniques in loss of force and tendon gap formation under cyclic loading or load to failure conditions. Thus, IM fixation may adequately facilitate optimal bone-tendon apposition, with less risk of iatrogenic injury to the posterior interosseous nerve that can be seen with bicortical extramedullary fixation. CLINICAL RELEVANCE: The most common major complication following distal biceps repair is PIN palsy. IM fixation may be sufficient in facilitating optimal bone-tendon apposition and healing with onlay technique, while minimizing risk of iatrogenic PIN injury associated with EM fixation.

Open approaches for cruciate ligament reconstruction in knee dislocations: A technical note and case series.

INTRODUCTION: Arthroscopic surgery is the gold standard for cruciate ligament reconstruction in multi-ligament knee injuries. However, hospitals in limited-resource settings often lack arthroscopic-trained surgeons or equipment. Open approaches for treating knee dislocations can overcome many of these limitations. METHODOLOGY: This study aims to describe techniques for open approaches in a supine patient to address the cruciate ligaments in multi-ligament knee injuries and to review associated complications and clinical outcomes in a retrospective case series. RESULTS: Ten patients with multi-ligament knee injuries who had undergone open cruciate ligament reconstruction between July 2016 and November 2018 were retrospectively identified. Open approaches were performed owing to the extravasation of arthroscopy fluid into the posterior compartment (3) or a large traumatic arthrotomy (7). Complications and patient-reported outcomes were analysed. Eight of the 10 patients were followed up at 10 months postoperatively (range, 5-23 months). None had iatrogenic neurovascular damage. Median outcomes scores were: visual analogue scale, 45 (range, 0-100); Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, 81.4 (range, 75-100); Lysholm, 85 (range, 67-92). DISCUSSION: Open approaches were safe and useful in treating cruciate ligaments and should be considered in arthroscopy fluid extraversion and large traumatic arthrotomies.

Is Diagnostic Arthroscopy at the Time of Medial Patellofemoral Ligament Reconstruction Necessary?

BACKGROUND: Although medial patellofemoral ligament (MPFL) reconstruction is well described for patellar instability, the utility of arthroscopy at the time of stabilization has not been fully defined. PURPOSE: To determine whether diagnostic arthroscopy in conjunction with MPFL reconstruction is associated with improvement in functional outcome, pain, and stability or a decrease in perioperative complications. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent primary MPFL reconstruction without tibial tubercle osteotomy were reviewed (96 patients, 101 knees). Knees were divided into MPFL reconstruction without arthroscopy (n = 37), MPFL reconstruction with diagnostic arthroscopy (n = 41), and MPFL reconstruction with a targeted arthroscopic procedure (n = 23). Postoperative pain, motion, imaging, operative findings, perioperative complications, need for revision procedure, and postoperative Kujala scores were recorded. RESULTS: Pain at 2 weeks and 3 months postoperatively was similar between groups. Significantly improved knee flexion at 2 weeks was seen after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and reconstruction with targeted arthroscopic procedures (58° vs 42° and 48°, respectively; P = .02). Significantly longer tourniquet times were seen for targeted arthroscopic procedures versus the diagnostic and no arthroscopic procedures (73 vs 57 and 58 min, respectively; P = .0002), and significantly higher Kujala scores at follow-up were recorded after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and targeted arthroscopic procedures (87.8 vs 80.2 and 70.1, respectively; P = .05; 42% response rate). There was no difference between groups in knee flexion, recurrent instability, or perioperative complications at 3 months. Diagnostic arthroscopy yielded findings not previously appreciated on magnetic resonance imaging (MRI) in 35% of patients, usually resulting in partial meniscectomy. CONCLUSION: Diagnostic arthroscopy with MPFL reconstruction may result in findings not previously appreciated on MRI. Postoperative pain, range of motion, and risk of complications were equal at 3 months postoperatively with or without arthroscopy. Despite higher Kujala scores in MPFL reconstruction without arthroscopy, the relationship between arthroscopy and patient-reported outcomes remains unclear. Surgeons can consider diagnostic arthroscopy but should be aware of no clear benefits in patient outcomes.

Initial Evaluation and Classification of Knee Dislocations.

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.