Delaying anterior cruciate ligament reconstruction increases the rate and severity of medial chondral injuries.

Aims: The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr). Methods: Between January 2012 and January 2022, 1,840 consecutive ACLrs were performed and included in a single-centre retrospective cohort. Exclusion criteria were partial tears, multiligament knee injuries, prior ipsilateral knee surgery, concomitant unicompartmental knee arthroplasty or high tibial osteotomy, ACL agenesis, and unknown date of tear. A total of 1,317 patients were included in the final analysis, with a median age of 29 years (interquartile range (IQR) 23 to 38). The median preoperative Tegner Activity Score (TAS) was 6 (IQR 6 to 7). Patients were categorized into four groups according to the delay to ACLr: < three months (427; 32%), three to six months (388; 29%), > six to 12 months (248; 19%), and > 12 months (254; 19%). Chondral injury was assessed during arthroscopy using the International Cartilage Regeneration and Joint Preservation Society classification, and its association with delay to ACLr was analyzed using multivariable analysis. Results: In the medial compartment, delaying ACLr for more than 12 months was associated with an increased rate (odds ratio (OR) 1.93 (95% confidence interval (CI) 1.27 to 2.95); p = 0.002) and severity (OR 1.23 (95% CI 1.08 to 1.40); p = 0.002) of chondral injuries, compared with < three months, with no association in patients aged > 50 years old. No association was found for shorter delays, but the overall dose-effect analysis was significant for the rate (p = 0.015) and severity (p = 0.026) of medial chondral injuries. Increased TAS was associated with a significantly reduced rate (OR 0.88 (95% CI 0.78 to 0.99); p = 0.036) and severity (OR 0.96 (95% CI 0.92 to 0.99); p = 0.017) of medial chondral injuries. In the lateral compartment, no association was found between delay and chondral injuries. Conclusion: Delay was associated with an increased rate and severity of medial chondral injuries in a dose-effect fashion, in particular for delays > 12 months. Younger patients seem to be at higher risk of chondral injury when delaying surgery. The timing of ACLr should be optimally reduced in this population.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear.

PURPOSE: The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender. METHODS: Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%). RESULTS: Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001). CONCLUSION: Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury. LEVEL OF EVIDENCE: Level III.

Can Patella Instability After Total Knee Arthroplasty be Treated With Medial Patellofemoral Ligament Reconstruction?

Background: The aim of this study was to describe outcomes of patients who had undergone medial patellofemoral ligament reconstruction (MPFLr) to treat patellofemoral instability (PFI) following total knee arthroplasty (TKA). Material and methods: This is a retrospective case series of consecutive patients treated for PFI after TKA. Patients were included if they had radiographic documentation of patella dislocation or subluxation and component position was adequate. MPFLr was performed using a quadriceps tendon autograft. The graft was fixed with either an interference or additional suspensory fixation. A tibial tubercle osteotomy was performed in select indications. Patients were assessed with Kujala and International Knee Score (IKS) at a minimum 12-month follow-up and radiographically with plain radiographs. Results: A total of 22 patients (23 procedures) were included. The mean follow-up period was 38 months (range 12-72). Average preoperative femoral component rotation on computed tomography was 0.10° external rotation (range 3° internal rotation to 3° external rotation). All patients had improved clinical and radiographic outcomes postoperatively. At the last follow-up, the mean IKS knee score was 77.6 ± 13.1, mean IKS function score was 75.2 ± 23.3, and mean Kujala score was 60.2/100 ± 10.9. There was 1 mechanical failure, which occurred following MPFLr with interference fixation. There were 6 complications (28.1%) postoperatively. Patients receiving double fixation of the MPFLr graft had higher clinical and radiographic scores; however, this difference was not statistically significant. MPFLr had a patella-lowering effect, 0.97 preoperatively to 0.74 postoperatively (P = .069). Conclusion: MPFLr in appropriately selected patients is a satisfactory option to treat PFI following TKA.

Tibial tuberosity osteotomy and medial patellofemoral ligament reconstruction for patella dislocation following total knee arthroplasty: A double fixation technique.

INTRODUCTION: Patella instability post total knee arthroplasty (TKA) is a rare complication. Tibial tubercle osteotomy (TTO) with medial patellofemoral ligament reconstruction (MPFLr) has not been well described for this indication. This paper describes a surgical technique to address the unique challenges faced when performing TTO and MPFLr in the prosthetic knee. TECHNIQUE: This technique and video describe a TTO and MPFLr via an extensile incision and medial sub-vastus approach. A 6 cm long TTO is performed, if indicated, to medialise the extensor mechanism up to 1 cm and fixed with ×2 4.5 mm cortical screws. For the MPFLr, a quadriceps tendon autograft is utilized, with the natural insertion to the superior pole of the patella being left undisturbed. The graft is first attached with an interference screw and then reinforced with an endobutton to provide crucial cortical fixation to overcome the problem of low bone mineral density encountered in this area of the femur following TKA. RESULTS: Five patients underwent MPFLr using the described technique. No failures or recurrence of instability occurred at the last follow-up. Pre-operative mean patella tilt and shift were 44° and 3.5 cm, respectively. Post-operatively, mean tilt and shift were 4.1° and 0.4 cm, respectively. There was one wound dehiscence requiring surgical debridement and closure. CONCLUSION: This paper describes a surgical technique to perform a TTO and MPFLr for patella instability post-TKA. The described method highlights key adaptations to address the unique challenges in this patient population.

Does meniscal repair impact muscle strength following ACL reconstruction?

PURPOSE: Meniscal lesions are commonly associated with anterior cruciate ligament (ACL) rupture. Meniscal repair, when possible, is widely accepted as the standard of care. Despite advancements in surgical and rehabilitation techniques, meniscal repair may impact muscle recovery when performed in conjunction with ACL reconstruction. The objective of this study was to explore if meniscal repairs in the context of ACL reconstruction affected muscle recovery compared to isolated ACL reconstruction. METHODS: Fifty-nine patients with isolated ACL reconstruction were compared to 35 patients with ACL reconstruction with an associated meniscal repair. All ACL reconstructions were performed using hamstring grafts with screw-interference graft fixation. Isokinetic muscle testing was performed between six and eight months of follow-up. Muscle recovery between both groups was compared. A further subgroup analysis was performed to compare muscle recovery function of gender and meniscal tear location. Tegner scores were assessed at six months' follow-up. RESULTS: No significant differences were found between the two groups regarding muscle recovery. No difference in muscle recovery was found concerning gender. Lesion of both menisci significantly increased the deficit of hamstrings muscular strength at 60°/s compared to a lesion of one meniscus (26.7% ± 15.2 vs. 18.1% ± 13.5, p = 0.018) and in eccentric test (32.4% ± 26.2 vs. 18.1% ± 13.5, p = 0.040). No significant differences were found concerning the Tegner score. CONCLUSION: Meniscal repairs performed during an ACL reconstruction do not impact muscle recovery at 6-8 months post-operatively compared to an isolated ACL reconstruction. However, reparations of both menisci appear to impact hamstring muscle recovery negatively. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Sex differences in semitendinosus muscle fiber-type composition.

Sex differences in muscle fiber-type composition have been documented in several muscle groups while the hamstring muscle fiber-type composition has been poorly characterized. This study aimed to compare the semitendinosus muscle composition between men and women. Biopsy samples were obtained from the semitendinosus muscle of twelve men and twelve women during an anterior cruciate ligament reconstruction. SDH and ATPase activities as well as the size and the proportion of muscle fibers expressing myosin heavy chain (MyHC) isoforms were used to compare muscle composition between men and women. The proportion of SDH-positive muscle fibers was significantly lower (37.4 ± 11.2% vs. 49.3 ± 10.6%, p < 0.05), and the percentage of fast muscle fibers (i.e., based on ATPase activity) was significantly higher (65.8 ± 10.1% vs. 54.8 ± 8.3%, p < 0.05) in men versus women. Likewise, men muscles exhibited a lower percentage of the area that was occupied by MyHC-I labeling (35.6 ± 10.1% vs. 48.7 ± 8.9%; p < 0.05) and a higher percentage of the area that was occupied by MyHC-IIA (38.3 ± 6.7% vs. 32.5 ± 6.5%; p < 0.05) and MyHC-IIX labeling (26.1 ± 9.6% vs. 18.8 ± 8.5%; p = 0.06) as compared with women muscles. The cross-sectional area of MyHC-I, MyHC-IIA, and MyHC-IIX muscle fibers was 31%, 43%, and 50% larger in men as compared with women, respectively. We identified sex differences in semitendinosus muscle composition as illustrated by a faster phenotype and larger muscle size in men as compared with women. This sexual dimorphism might have functional consequences.

Stiffness after unicompartmental knee arthroplasty: Risk factors and arthroscopic treatment.

INTRODUCTION: One of the principal complications after total knee arthroplasty (TKA) is stiffness. There are no publications concerning stiffness after unicompartmental knee arthroplasty (UKA). Study objectives were to describe the incidence of stiffness after UKA, to look for risk factors, and to describe safe and effective arthroscopic treatment. METHODS: There were 240 UKA performed between March 2016 and January 2019 included. Robotic-assisted surgery was performed in 164 patients and mechanical instrumentation in 76 patients. Stiffness was defined as flexion < 90° or a flexion contracture > 10° during the first 45 post-operative days. Patients with stiffness were treated with arthroscopic arthrolysis. Several factors were studied to look for risk factors of stiffness: body mass index, gender, age, mechanical or robotic instrumentation, preoperative flexion, previous meniscectomy, and anticoagulant treatment. Arthrolysis effectiveness was evaluated by flexion improvement and UKA revision rate. RESULTS: 22 patients (9%) developed stiffness. Mechanical instrumentation significantly increased the risk of stiffness with OR = 0.26 and p = 0.005. Robotic-assisted surgery decreased the risk of stiffness by five-fold. Before arthrolysis, mean knee flexion was 79°, versus 121° (53% improvement) after arthroscopic arthrolysis. Only 2 patients (9%) underwent UKA revision after arthrolysis. DISCUSSION: Stiffness after UKA is an important complication with an incidence of 9% in this study. Arthroscopic arthrolysis is a safe and effective treatment with a range of motion improvement of > 50%. Robotic-assisted surgery significantly decreases the risk of postoperative stiffness. LEVEL OF EVIDENCE: Level III, therapeutic study, retrospective cohort study.

Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients.

BACKGROUND: Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union. HYPOTHESIS: Active smoking and an initial open wound are independent risk factors for complications. MATERIALS AND METHODS: We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis. RESULTS: We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap >5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p<0.05). The same three factors were significant risk factors for non-union. Energy of the trauma, age, sex, and early or delayed weight bearing were not significantly associated with an excess risk of complications. DISCUSSION: Active smoking, a residual interfragmentary gap >5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients. LEVEL OF EVIDENCE: IV; single-centre retrospective cohort study.

Increased survival rate in extension stemmed TKA in obese patients at minimum 2 years follow-up.

PURPOSE: Total knee arthroplasty (TKA) is frequently performed for obese patients. TKA in this population shows a high rate of complication, particularly tibial component loosening. The aim of this study is to compare the survival rate of tibial components in obese population using TKA with stem versus without stem. METHODS: From a prospective database of 4216 TKA, obese patients [body mass index (BMI) > 30 kg m²] with primary TKA using a tibial short stem extension (30 mm) at a minimum follow-up of 2 years were retrospectively reviewed and compared to a matched control group (1:3 ratio) with a standard tibial stem. Inclusion criteria were BMI > 30 kg m², first knee surgery and 24 months minimum of follow-up. The primary outcome was revision for tibial aseptic loosening. Secondary outcomes were all-cause revisions and Knee Society Scores (KSS). RESULTS: The final study population consisted of 35 TKA with tibial extension stem versus 105 TKA with standard stem. The mean age was 69.2 and 69.5 years, respectively, with a mean follow-up of 52 months. Both groups were comparable before surgery. After 2 years of follow-up, we observed seven tibial loosening in the group without stem (6.6%) versus no tibial loosening in the stemmed group (p < 0.001). The difference in KSS knee score (83 versus 86; p = 0.06) and the KSS function score (73 versus 77; p = 0.84) were not statistically significant at the final follow-up. CONCLUSION: Using stemmed TKA for obese patients significantly decreased tibial loosening rate at minimum 2 years of follow-up. LEVEL OF EVIDENCE: Case-control study, Level III.

Increased survival rate for primary TKA with tibial short extension stems for severe varus deformities at a minimum of 2 years follow-up.

PURPOSE: The purpose of this study was to compare the clinical results, radiographic loosening and early complications between patients undergoing primary knee arthroplasty (TKA) with tibial short stem extension and those with standard stem for gross varus deformities at minimum two years after surgery. METHODS: From a prospective TKA database of 4216 patients, patients with a primary TKA with a tibial short stem extension (30 mm) for severe varus deformity (hip-kneeankle angle, HKA < 170°) and a minimum follow-up of 2 years, were reviewed and compared to a matched control group with tibial components with a standard stem, in a 1:3 ratio. Demographics, surgical parameters, pre- and postoperative alignment and outcome parameters were collected for all patients. The primary outcome was aseptic loosening of the tibial component. Secondary outcomes were knee society scores (KSS), postoperative HKA, general postoperative complications and implant survival rates. RESULTS: Forty-five patients with tibial short stem extensions (mean HKA 166.2°) were compared in a 1:3 ratio to a matched case-control group of 135 patients with standard stems (mean HKA 167.1°) at a mean follow-up of 57 and 64 months respectively after primary TKA. In the extension stem group, 4 patients encountered complications (8.9%) versus 12 patients in the standard stem group (8.9%). There were no cases of tibial component loosening in the short extension stem versus four cases in the standard stem group (3%). This difference was significant between groups, p = 0.04. CONCLUSION: In patients with varus deformities > 10°, undergoing primary total knee arthroplasty, prophylactic use of a tibial short extension stem may lead to less loosening of the tibial component. In this study, 3% of patient with big varus deformity without stemmed TKA had a tibial implant loosening versus 0% in the stemmed TKA group. LEVEL OF EVIDENCE: Level III, case-control study.

Clinical outcome and failure analysis of medial meniscus bucket-handle tear repair: a series of 96 patients with a minimum 2 year follow-up.

INTRODUCTION: The failure rate of meniscal repair remains significant, especially for bucket-handle tears. This study aimed to evaluate the clinical outcomes, failure rate and risk factors for failure of bucket-handle medial meniscal tear repairs performed during ACL reconstruction. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data was performed on a consecutive series of 96 ACL reconstructions with meniscal arthroscopic suture of a bucket-handle tear of the medial meniscus with a minimum 2 year follow-up. Preoperative and postoperative evaluation at last follow-up included objective IKDC rating, instrumented differential laxity and Tegner activity level. Functional outcome was evaluated with Lysholm score at last follow-up. Failure rate, survival curves and risk factor analysis using Cox proportional hazard ratio models were performed to analyze suture repair failure. RESULTS: At IKDC rating, all patients were C or D preoperatively, whereas they where all A or B at last follow-up. Instrumented differential laxity improved from 6.77 mm (1.57) to 1.02 mm (1.15) mm at last follow-up (p = 1.9 E-18). The mean Tegner score before injury was 6.79 (± 1.47) and 6.11 (± 1.75) at last follow-up (p = 0.0011). Mean Lyholm score at last follow-up was 91.53 (± 11.6). The average entire cohort failure rate was 19% at final follow-up of 35.2 ± 9.8 months. Kaplan-Meier survival analysis demonstrated that the probability of the absence of failure decreased constantly over time. No significant difference in the objective IKDC, Lysholm or Tegner scores was observed between the failure group and the success group. Multivariate analysis revealed that younger patients and a procedure of ACL revision are more at risk for suture repair failure. In the majority of cases, the meniscal lesion observed at revision was equivalent or less extensive than the initial lesion. CONCLUSION: Despite the fact that failure rate remains high for medial meniscus bucket-handle tears, suture repair of bucket-handle tears should be encouraged taking into account the long-term consequences of menisectomy.

Conservative management of anterior cruciate ligament injury in paediatric population: About 53 patients.

INTRODUCTION: The last symposium held by the French Arthroscopy Society was on anterior cruciate ligament (ACL) reconstruction on children. The first aim of this study was to analyse the tolerance of conservative management of ACL rupture in children. We also tried to find predictive factors of ACL reconstruction. MATERIAL AND METHODS: We conducted an observational, retrospective study in an academic department of paediatric orthopaedic surgery. All patients under the age of eighteen, who were treated conservatively for an acute intra-ligamentous ACL rupture confirmed by magnetic resonance imaging (MRI) between 2007 and 2017, were included. Two groups were analysed: operated patients and conservative treatment. We also analysed population according Tanner stage. RESULTS: Fifty-three patients were included in this study. The median length of follow-up was 31.5 months [interquartile range (IQR): 22.3-49.3]. The median age at the last follow-up was 14.4 years [IQR: 12.6-15.5]. All patients were allowed to practice activities without restrictions, including pivoting sports. Tegner activity level scale remains identical before injury and at last follow-up (p: n.s.). Nineteen patients (36%) described knee instability at last follow-up. On the last MRI, 9 (17%) patients had meniscal tears but only one patient (2%) needed a menisectomy. Twenty-one patients (40%) underwent ACL reconstruction. The 4-years successful conservative treatment rate was 92% (95% CI: 85-98%). Clinical instability at first examination was the only significant predictive factors of bad tolerance of conservative management (p=0.047). DISCUSSION: Conservative management of ACL rupture in paediatric population is a valuable treatment which permits return to a normal life with sports activities without major increasing of meniscal tears. The rehabilitation protocol must restore full knee stability to permit a successful conservative treatment. We must study the impact of pubertal status on larger group. LEVEL OF EVIDENCE: IV, retrospective study.