The Dejour classification for trochlear dysplasia shows slight interobserver and substantial intraobserver reliability.

PURPOSE: Trochlear dysplasia is one of the main risk factors for recurrent patellar dislocation. The Dejour classification identifies four categories that can be used to classify trochlear dysplasia. The purpose of this study is to evaluate the inter- and intraobserver reliability of the Dejour classification for trochlear dysplasia. The hypothesis was that both intra- and interobserver reliability would be at least moderate. METHODS: This is a cross-sectional, reliability study. Twenty-eight examiners from the International Patellofemoral Study Group 2022 meeting evaluated lateral radiographs of the knee and axial magnetic resonance images from 15 cases of patellofemoral instability with trochlear dysplasia. They classified each case according to Dejour's classification for trochlear dysplasia (A-D). There were three rounds: one with only computed radiograph (CR), one with only magnetic resonance imaging (MRI) and one with both. Inter- and intraobserver reliability were calculated using κ coefficient (0-1). RESULTS: The mean age of patients was: 14.6 years; 60% were female and 53% had open physis. The interobserver reliability κ probabilities were 0.2 (CR), 0.13 (MRI) and 0.12 (CR and MRI). The intraobserver reliability κ probabilities were 0.45 (CR), 0.44 (MRI) and 0.65 (CR and MRI). CONCLUSION: The Dejour classification for trochlear dysplasia has slight interobserver reliability and substantial intraobserver reliability. LEVEL OF EVIDENCE: Level I.

Tibial tubercle to trochlear groove and the roman arch method for tibial tubercle lateralisation are reliable and distinguish between subjects with and without major patellar instability.

PURPOSE: Patellofemoral (PF) instability recurrence depends on several factors including the relative lateralisation of tibial tubercle (TT) regarding the trochlear groove (TG). TT relative lateralisation quantification has long been a topic of debate. Multiple measuring techniques have been described including TT-trochlear groove (TT-TG), TT-posterior cruciate ligament (TT-PCL) and TT-roman arch (TT-RA), with no clear consensus regarding the most reliable index or pathologic threshold. We set out to determine the normal value range of each index and their association with age, sex and PF instability status. Also, this study aims to determine a reliable pathologic distance threshold to effectively predict patellar dislocation. METHODS: Skeletally mature patients up to 45 years of age who presented a CT Scan and an MRI of the same knee between 2014 and 2018 were included and divided into subgroups based on history of PF instability. Three indexes (TT-TG, TT-PCL and TT-RA) were assessed by two independent observers blinded to instability history. ROC curves were performed for each index to obtain the cut point that better predicts instability. Univariate and multivariate models adjusted by age, sex, instability history and type of imaging technique were performed to test the influence of these variables. RESULTS: 208 patients were included. Mean age was 27.93 â€‹± â€‹8.48 years, 67.3% were female and 71 patients (34.1%) presented major instability history. Good or excellent inter and intraobserver reliability was found for all three indexes. All indexes presented significantly different distributions between subjects with and without major instability (p â€‹< â€‹0.001), except for TT-PCL. Different cut point values differing between imaging modalities were found: 11.4 â€‹mm for MRI TT-TG, 17 â€‹mm for CT TT-TG, 15.6 â€‹mm for MRI TT-RA and 18.2 â€‹mm for CT TT-RA. CONCLUSIONS: All indexes studied had good or excellent inter and intraobserver reliability. Measurements between imaging techniques (CT and MR) are not interchangeable. Both TT-TG and TT-RA correctly distinguish between subjects with and without major instability, while TT-PCL does not, recommending caution when evaluated on its own. Specific threshold values depending on imaging technique should be considered for surgical decision-making. LEVEL OF EVIDENCE: Level IV, Diagnostic Test.

Tibial spine fractures: State of the art.

Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8-14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.

Current trends in anterior cruciate ligament surgery. A worldwide benchmark study.

OBJECTIVES: To benchmark current trends on anterior cruciate ligament reconstruction (ACLR) surgery. METHODS: The largest worldwide ACLR survey to date was performed during May 2020, targeted to reach representation of all continents. It was submitted electronically to all International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports surgeons (n = 3,026), asking those who perform ACLR to respond. RESULTS: With a final sample size of 2,107, the overall response rate was 69.6%. Median years of practice as orthopaedic surgeon was 15 (range 1-52) and 49.6% of all respondents were defined as high-volume surgeons (>50 ACLR annually). Hamstrings tendon autograft was the preferred graft for primary ACLR (80.3%) and the medial portal femoral drilling was the most frequently used technique (78.5%). Cortical buttons (82.7%) and bioabsorbable screws (62.7%) were the preferred fixation methods for hamstring tendon autograft ACLR in femur and tibia, respectively. Metallic screws (45.2%) were the preferred fixation methods for bone patellar tendon bone autograft in femur and tibia. Most of the respondents routinely used pre-tensioning techniques for their graft preparation (63.8%), but less than half of surgeons preferred antibiotic soaking of the grafts (45.3%). The preferred knee position for graft fixation was 10-30° of knee flexion and neutral rotation (57.0%). The addition of anterolateral augmentation (or extra-articular tenodesis) was infrequent in primary and isolated ACLR (10.0%), but a statistically significant raise was seen for revision surgeries (20.0%). Most used brace in the initial postoperative rehabilitation (54.9%) and the time to allow patients to fully resume sports was at an average of 8.9 ± 2.0 months. Treatment algorithm of paediatric ACL injuries exhibited a low consensus among the respondents. CONCLUSION: This worldwide survey benchmarks the current trends in ACL reconstruction, achieving the largest participation of surgeons to date. Among the great variety of options available for ACL reconstructions, surgeons' preferences showed some differences according to their location and expertise. Reporting trends in practice, and not only the evidence, is important to medical education and providing patients the safest care possible. This is a Level V, expert opinion study.

Anterior Cruciate Ligament Rupture in Skeletally Immature Patients.

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

Guided growth: indications and techniques for correction of knock knees and bowlegs.

PURPOSE OF REVIEW: Lower extremities axis alterations are a frequent cause for consultation in the medical practice of the care of paediatric patients. When it corresponds to pathological situations, guided growth surgery has been positioned as a possibility of well tolerated, reproducible and predictable resolution. For this reason, its use has increased significantly in recent years. In this review, its current indications, preoperative study, results and complications described in the updated literature will be discussed. RECENT FINDINGS: The success of the technique remains high in the current literature, expanding the technique to other segments and disorders, and describing new ways of performing tension band with sutures. In addition, there is an increase in its incidence and a decrease in the associated hospitalized days, which can associate with techniques of lower morbidity. SUMMARY: As guided growth surgery allows for successful correction of axis alterations, to achieve this, it is important to know the main indications, preoperative analysis and theoretical bases on which this technique is based, to carry it out in an adequate and timely manner, seeking an adequate resolution of the child's problem.

Stenotic Intercondylar Notch as a Risk Factor for Physeal-Sparing ACL Reconstruction Failure: A Case-Control Study.

INTRODUCTION: Identifying risk factors is crucial for developing strategies that minimize reinjury after anterior cruciate ligament reconstruction (ACLR). This study aims to determine whether certain features of intercondylar notch geometry are associated with failure of physeal-sparing ACLRs in skeletally immature athletes. METHODS: Nine failed physeal-sparing ACLRs were compared with a control subject group of 15 age- and sex-matched intact physeal-sparing ACLRs. Notch width index (NWI), notch angle (NA), and intercondylar notch roof inclination angle (RA) were measured on preoperative MRIs. RESULTS: Median NWI was smaller in the failed ACLR versus control subject group in coronal (0.23 versus 0.27; P < 0.05) and axial planes (0.25 versus 0.27; P = 0.055). Median NA was smaller in the failed ACLR versus control subject group in coronal (49.6 versus 61.0°; P < 0.05) and axial planes (48.6° versus 54.9°; P < 0.05). Median RA was steeper in the failed ACLR versus control subject group (132.0° versus 125.7°; P < 0.05). CONCLUSION: NWI, NA, and RA were associated with ACLR failure in skeletally immature patients undergoing physeal-sparing reconstruction. A smaller, narrower, and steeper notch may predispose these patients to reinjury.

Lesiones traumáticas de rodilla en niños y adolescentes / traumatic knee injury in children and adolescents

Durante las últimas décadas, hemos visto un aumento exponencial de las lesiones traumáticas alrededor de la rodilla en niños y adolescentes. La rodilla pediátrica tiene características particulares, que la diferencian de los adultos, y la predisponen a lesiones distintivas que requieren un manejo acorde. El aumento de su incidencia obliga a los médicos a verse enfrentados con mayor frecuencia a patologías como la luxación patelar, la avulsión de espinas tibiales, la avulsión de la tuberosidad anterior de la tibia y la lesión meniscal en probable contexto de un menisco discoideo. Es fundamental conocer los diferentes diagnósticos diferenciales y su enfrentamiento inicial para realizar una derivación oportuna con el fin de que estos pacientes obtengan un tratamiento adecuado

Over the past few decades, we have seen an exponential increase in traumatic injuries around the knee in children and adolescents. The pediatric knee is different from the adult knee, with special characteristics that predispose it to certain types of injuries that require a specific management. The increase in its incidence has faced attendants more frequently with pathologies such as patellar dislocation, tibial eminence fracture, tibial tubercle fractures and meniscal injury in the setting of a discoid meniscus. It is essential to know the differential diagnoses of this age-group, how to obtain an adequate study for a prompt referral

Multiligamentary Reconstruction in a Below-Knee Amputation Patient.

Multiligament injuries in below-knee amputation patients are a severe condition, and its treatment is controversial. Its incidence is unknown, and it is highly underdiagnosed, representing a challenge for the physician. The case presented is about a patient with a left transtibial amputation secondary to a severe crushing of the ipsilateral lower limb to which during the process of physiotherapy, a multiligament injury was diagnosed. The patient underwent a tibiofibular fixation with a multiligament reconstruction with good functional results. In this complex situation, delay in diagnosis is frequent, ligament instability should always be suspected and explored further, allowing for proper rehabilitation and early treatment.

Fracturas avulsivas tibiales del ligamento cruzado posterior fijadas con tornillos: un estudio clínico y radiológico / Screw fixation of posterior cruciate ligament tibial avulsion fractures: a clinical and radiographic study

OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.

OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.

Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates.

PURPOSE: In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch. METHODS: Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student's t test and one-way ANOVA. RESULTS: Maximum physeal damage (5.35% [4.47-6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07-0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. CONCLUSION: Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.

Valor diagnóstico de las clasificaciones outerbridge e ICRS para la clasificación artroscópica de lesiones condrales de rodilla / Diagnostic value of outerbridge and ICRS classifications for arthroscopic grading of chondral lesions in the knee

OBJETIVOS: Determinar el rendimiento de las clasificaciones de Outerbridge (OB) e International Cartilage Repair Society (ICRS). MÉTODO: Estudio de test diagnóstico, diseño y recolección de datos prospectivo. Siete traumatólogos sub-especialistas observaron un mismo video donde se exponían 30 lesiones condrales bajo visión artroscópica, para luego clasificarlas según OB e ICRS y consignar el tratamiento de elección para cada una de las lesiones, eligiendo entre 6 alternativas: observación, debridamiento mecánico o térmico, microfractura, OATS o terapias biológicas. Tras 7 días, los evaluadores debían repetir el mismo procedimiento. RESULTADOS: La concordancia entre los observadores fue débil para clasificación de ICRS (k 0,25 p < 0,001) y moderada para la clasificación de OB (k 0,45 p < 0,001). La concordancia intra-observador para ICRS oscilaba entre moderada y excelente (k promedio de 0,67), y para la clasificación de OB entre buena y excelente (k promedio 0,83). Ninguna de las dos clasificaciones mostró correlación con la experiencia del cirujano. En la elección de tratamiento, la concordancia entre observadores fue débil (k 0,33 p < 0,001), sin embargo, la concordancia intra-observador fue en todos los casos buena o excelente (k 0,82), mostrando una correlación directamente proporcional a la experiencia del cirujano. La capacidad de discriminación terapéutica, evaluada mediante una regresión logística, mostró un área bajo la curva roc en el rango del no-efecto. CONCLUSIÓN: Ambas clasificaciones mostraron una baja correlación inter-observador y una elevada concordancia intra-observador. En ambas categorías, Outerbridge fue más concordante que ICRS. En cuanto al tratamiento, ninguna de las dos clasificaciones logra unificar criterios quirúrgicos. NIVEL DE EVIDENCIA: Nivel I (test diagnóstico).

OBJECTIVES: Assess de diagnostic accuracy of Outerbridge (OB) and ICRS (International Cartilage Repair Society) classifications. METHODS: We performed a diagnostic test study, with a prospective design and data collection. Seven knee surgeons were asked to observe a video were the 30 chondral lesions were shown through arthroscopic view. Simultaneously they were asked to classify them according to OB and ICRS. Besides, they had to define how they would manage the chondral lesion, choosing among six treatment options (observation, mechanical or thermic chondroplasty, microfracture, osteochondral autologous transfer system (OATS) or biological therapies). A week later, they repeated the same procedure. Intra and interobserver agreement were characterized by κ statistical analysis, and a logistic regression was used to assess the ability of both classifications to discriminate among treatment options. P values < 0,05 were considered significant. RESULTS: Interobserver agreement was weak (κ 0.25 p < 0.001) for ICRS classification and moderate for OB classification (κ 0.45 p < 0.001). Intraobserver agreement for ICRS ranged from moderate to excellent (average κ of 0.67), and for the OB classification ranged from good to excellent (average kappa 0.83). Neither classification correlated with the surgeon's experience. Interobserver agreement for therapeutic choice was poor (κ 0.33 p < 0.001). However, intraobserver agreement was good to excellent (κ 0.82) in all cases, showing a direct correlation with the surgeon's experience. Logistic regression used to assess the ability of both classifications to discriminate among treatment options, showed in both cases an area under the roc curve in the no-effect range. CONCLUSION: Both classifications showed low interobserver and high intraobserver agreements for arthroscopic grading of chondral lesions. In both, Outerbridge was more reliable than ICRS. As for guiding therapeutic management, none of the classifications could unify surgical criteria.

Discoid meniscus: current concepts.

Discoid meniscus is the most frequent congenital malformation of the menisci, and primarily affects the lateral meniscus; it is highly prevalent in the Asian population.The anatomic, vascular, and ultrastructural features of the discoid meniscus make it susceptible to complex tears.Discoid meniscus anomalies are described according to their shape; however, there is consensus that peripheral stability of the meniscus should also be defined.Initial workup includes plain X-rays and magnetic resonance imaging, while arthroscopic evaluation confirms shape and stability of the meniscus.Clinical presentation is highly variable, depending on shape, associated hypermobility, and concomitant meniscal tears.Treatment seeks to re-establish typical anatomy using saucerization, tear reparation, and stable fixation of the meniscus. Cite this article: EFORT Open Rev 2020;5:371-379. DOI: 10.1302/2058-5241.5.190023.

Fracture of the anterior tibial tuberosity in children.

Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.This fracture is more commonly seen in children 12-14 years old.It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability. Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026.

Tendencias en reconstrucción en ligamento cruzado anterior: encuesta a 103 cirujanos / Anterior cruciate ligament reconstruction tendencies among 103 surgeons

OBJETIVO: Describir las tendencias en reconstrucción de LCA (R-LCA) entre los traumatólogos ejerciendo en Chile, delineando sus preferencias en cuanto a la técnica quirúrgica. MÉTODO: encuesta online de selección múltiple y recolección anónima de datos, dirigida a todos aquellos cirujanos que realizan R-LCA en Chile. Fue enviada por correo electrónico desde la Sociedad Chilena de Ortopedia y Traumatología a todos sus afiliados. RESULTADOS: 103 cirujanos completaron la encuesta, realizando su práctica quirúrgica en Santiago (53%) y regiones (47%). En el 53% de los encuestados la cirugía de rodilla representaba más del 75% de su práctica, mientras que sólo en 9 ellas eran menos del 25%. El autoinjerto de isquiotibiales es utilizado en el 70% de R-LCA, seguido por el autoinjerto de tendón patelar (27%). En cuanto a la preparación de túneles, 33% utiliza técnica transtibial y 67% túneles independientes (13% fresado retrógrado, 54% portal medial). Para la fijación de injerto isquiotibiales, botones corticales es lo más utilizado en el fémur (73%), y tornillos interferenciales en la tibia (82%). Para la fijación femoral y tibial de injerto de tendón patelar, los tornillos metálicos son los más utilizados (75%). Un 41% realiza un pretensado del injerto, un 59% lo ciclan una vez fijo, y sólo 8 aplican una solución antibiótica sobre el injerto. La mayoría (89%) realiza la fijación en 10°-20° de flexión, ya sea con rotación externa (36%) o neutra (53%). En un 7% de las R-LCA primarias y en un 27% de las revisiones agregan una reconstrucción anterolateral. CONCLUSIÓN: la tendencia en R-LCA en Chile es el uso de autoinjerto de isquiotibiales, con fresado independiente del túnel femoral y fijación en flexión con botones corticales y tornillos interferenciales.

OBJECTIVE: To describe the trends in anterior cruciate ligament reconstruction (ACL-R) among Orthopaedic surgeons working in Chile, outlining their preferences regarding surgical technique. METHOD: An online, multiple choice, anonymous survey was sent via email from the Chilean Orthopaedic and Trauma Society to all its members, with instructions to be completed by surgeons who perform ACL-R. RESULTS: 103 surgeons completed the survey from Santiago (53%) and other regions (47%). For 53% of the surgeons, knee surgeries represented more than 75% of their practice, and in only 9 cases it was less than 25% of it. The autologous hamstring tendon graft was in 70% of the ACL-R, while patellar tendon graft in 27%. For tunnel drilling, 33% of surgeons use transtibial technique, and 67% prefer independent tunnel drilling (13% retrodrill, 54% medial portal). Fixation method for hamstring tendon graft is mostly with cortical buttons on femur (73%), and interference screws for the tibia (82%). Patellar graft was fixed with metal screws (75%) in both femur and tibia. 41% of surgeons pretensed the graft, 59% cycle it once, and only 8 coated the graft with antibiotic solutions. Most (89%) fixate de graft in 10°-20° of knee flexion, with either external rotation (36%) or neutral (53%). Antero-lateral reconstruction is used in 7% of primary ACL-R and in 27% of revision surgeries. CONCLUSION: the chilean tendency for ACL-R is to use an autologous hamstring tendon graft, with independent drilling technique, and fixation with cortical buttons and interference screws for femur and tibia respectively.

Juvenile Osteochondritis Dissecans of the Trochlea: A Cohort Study of 34 Trochlear Lesions Associated With Sporting Activities That Load the Patellofemoral Joint.

BACKGROUND: Juvenile osteochondritis dissecans (JOCD) lesions are rarely located in the trochlea and few studies have focused on the causes and outcomes of JOCD lesions in this part of the knee. The purpose of this study is to (1) evaluate the clinical characteristics and outcomes of patients who undergo surgery for JOCD in this unusual location as well as (2) assess the association between trochlear JOCD and participation in sporting activities that load the patellofemoral joint. METHODS: We conducted a retrospective cohort study of 34 trochlear JOCD lesions in 30 patients. Cases that involved traumatic cartilage shear or patella instability were excluded. Preoperative and postoperative magnetic resonance images and x-rays were evaluated and demographic data, sports played, comorbidities, surgical procedures, and clinical data were extracted from medical records. A case-control cohort of 102 femoral condyle lesions was used to assess the correlation between sports played and lesion location. RESULTS: The cohort comprised 34 consecutive trochlear JOCD lesions in 30 patients (26 males, 4 females). Average age at surgery was 13.8 years (9.3 to 18.0 y). In total, 27 (90%) patients were active, and of these active patients, soccer and basketball were the most common sports played. In the case-control comparison, the correlation between playing either basketball or soccer and the presence of a trochlear JOCD lesion was statistically significant (P=0.017). In total, 21 knees (62%) received operative treatment. Sixteen of the surgical patients underwent repair and fixation with bioabsorbable nails. The average length of clinical and radiographic follow-up was 21.1 months. All patients who underwent fixation showed radiographic and/or clinical indications of healing at most recent follow-up. Thirteen of the patients who underwent fixation were active, and all of these patients reported successful return to sports. Thirteen knees underwent nonoperative treatment, and the majority of these patients had limited follow-up. CONCLUSIONS: We report a significant association between pediatric athletes who play basketball and soccer and the development of trochlear JOCD, suggesting that repetitive loading of the patellofemoral joint may play a role in the development of JOCD lesions. Patients with trochlear JOCD lesions were likely to undergo surgery, and repair and fixation of the lesions produced good outcomes at short-term follow-up. LEVEL OF EVIDENCE: Level III-case-control study.

Tibial tubercle avulsion fractures in children.

PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.

Sutura meniscal en niños. ¿En qué hemos avanzado? / Meniscal repair in children

La real incidencia de las lesiones meniscales en niños y adolescentes sigue siendo desconocida, aunque se estima que estas han aumentado en los últimos años. En este grupo de pacientes, tanto el examen físico como la resonancia magnética han reportado un menor rendimiento, por lo que la sospecha clínica debe ser alta. Aunque la literatura es escasa en niños y las bases del manejo de estas lesiones se extrapolan del manejo en adultos, la tendencia actual es la preservación meniscal. Dado el alto potencial de cicatrización y la mayor vascularización del menisco pediátrico, se extiende la indicación de sutura meniscal a toda aquella lesión reparable, independiente del patrón, extensión o tiempo de evolución en este grupo étareo. La literatura reporta buenos resultados tras la reparación meniscal en pacientes pediátricos, con tasas de cicatrización promedio por sobre el 70%, que son al menos comparable a lo reportado en adultos. A la fecha, la técnica todo-dentro es la más utilizada por su fácil utilización y menor tiempo quirúrgico. Sin embargo, debemos ser especialmente cuidadosos para evitar una lesión neurovascular iatrogénica dado el menor tamaño y proximidad del paquete neurovascular en rodillas pediátricas. La principal complicación es la falla de la sutura, reportándose tasas comparables a la población adulta a pesar de su indicación extendida en niños y adolescentes. Se han identificado como factores protectores para la reparación meniscal la menor edad, la fisis abierta, roturas de patrones simples y la reconstrucción concomitante de ligamento cruzado anterior. En el presente artículo realizamos una detallada revisión de la literatura disponible sobre reparación meniscal en niños y adolescentes, enfatizando las diferencias versus población adulta. También presentamos nuestra experiencia y protocolo de rehabilitación para sutura meniscal en pacientes pediátricos

The true incidence of meniscal injuries in children and adolescents remains unknown, though estimated to have increased during the last years. Clinical suspicion must remain high since physical examination and magnetic resonance imaging have reported less accuracy for meniscal tears in pediatric patients. Although literature is scarce in children and adolescents and the basis for managing these lesions is extrapolated from adult population, the current trend is meniscal preservation. Considering the greater healing potential and vascularization of the pediatric meniscus, indications for meniscal suture are extended to all those tears amenable to repair in spite of their size, tear pattern and time to repair. Literature has demonstrated good outcomes for meniscal repair in children, with healing rates above 70%, comparable to those reported for adults. To date, the all-inside technique is the most frequently used for meniscal repair thanks to its simplicity and shorter operative time. However, we must be especially careful to avoid iatrogenic neurovascular injury given the smaller size and proximity of the neurovascular package in the pediatric knee. Suture failure is the main complication, with rates comparable to adult population despite widespread indication of repair in children. Younger age, open physis, simple tear patterns and simultaneous anterior cruciate ligament reconstruction appear to benefit meniscal repair in children. This article summarizes the available literature regarding meniscal repair in children and adolescents, emphasizing the differences with adult population. We also present our experience in the treatment of these injuries and our preferred rehabilitation protocol

A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever.

PURPOSE: Tibial spine fractures (TSFs) are graded according to the Meyers and McKever (MM) classification system, which is based on a qualitative evaluation of plain radiographs. However, although MRI images can provide important information about these fractures, there is no MRI-based classification system. This study aims to (1) establish the intra- and inter-rater reliability of the MM system for use with radiographs, (2) propose a quantitative, MRI-based system and compare its reliability to the MM system, and (3) assess how often using the MRI-based system changes the classification and potential treatment plan as previously determined using MM. METHODS: The MRI-based system was designed with three grades based on quantitative displacement patterns of the fractured fragment and tissue entrapment. Four raters from a tertiary care center evaluated 20 fractures according to the MM and MRI-based systems. Observers graded images at two time points at least 2 weeks apart, after which we compared the intra- and inter-rater reliability of each system (using Fleiss' kappa and weighted kappa, respectively) and assessed how often using the MRI-based system changed the fracture grade. RESULTS: Both the MM and MRI-based systems exhibit fair to moderate intra- and inter-rater reliability (average kappa values ranged from 0.38 to 0.66). Use of the MRI-based system changed the fracture grade and as a result modified the treatment recommendations in 32.5% of cases: 6.9% were previously unnoticed fractures, 13.1% underwent a raise in grade, and 12.5% were graded as lower than before. CONCLUSION: The MRI-based system is as reliable as the MM system and provides specific, quantitative criteria for classifying fractures according to fragment displacement and tissue entrapment. The new MRI-based system potentially clarifies treatment indications for TSFs. LEVEL OF EVIDENCE: Diagnostic Study, Level II.

Tibial spine avulsion fractures: treatment update.

PURPOSE OF REVIEW: The purpose of this review is to summarize and clarify the current framework for treating tibial spine avulsion fractures (TSAFs). We will discuss how these fractures are classified both on plain radiographs and MRI as well as report the incidence of concomitant soft tissue injury, an important consideration that guides treatment. We will also compare guidelines for nonsurgical versus surgical treatment and summarize frequently used surgical techniques. Finally, we will review outcomes following treatment, including common complications. RECENT FINDINGS: Although TSAFs only constitute 2-5% of all pediatric knee injuries, the incidence is increasing. A recently developed MRI-based system for evaluating TSAFs is another tool that aids in the treatment of these injuries. SUMMARY: TSAFs can be classified using plain radiographs as well as MRI. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. Type III fractures are indicated directly for arthroscopic surgery and both suture and screw fixation produce good clinical outcomes. All-epiphyseal or transphyseal approaches can minimize the risk of physeal injury in skeletally immature patients. Common complications following TSAF injury and treatment are residual laxity, knee stiffness, and nonunion or malunion.