Bilateral Tibial Tubercle Avulsion Fractures With an Associated Patellar Tendon Avulsion in an Adolescent Patient.

Tibial tubercle fractures in pediatric patients are increasing in frequency as more children participate in sports. These injuries are often seen in boys engaging in jumping activities before closure of their proximal tibial physis. Bilateral tibial tubercle fractures have been reported in the literature, but less frequent are associated patellar tendon ruptures with fracture of the tubercle. In this case report, we present an 11-year-old girl who sustained bilateral tibial tubercle fractures, including an associated patellar tendon rupture from the tubercle on the right lower extremity. We describe our technique for the management of both injuries, which included a primary patellar tendon repair for the right leg and Kirschner wire fixation of the displaced tubercle for the left leg. The patient ultimately had a successful outcome at the final follow-up with healed fractures and full range of motion of both knees. In this case report, we also present similar cases from the literature and the differing treatment strategies.

An Improved Transosseous Pullout Suture Technique for Arthroscopic Repair of a Meniscus Root Tear.

OBJECTIVE: This study aimed to explore the clinical efficiency of an improved transosseous pullout suture technique for arthroscopic repair of a meniscus root tear. METHODS: From January 2017 to January 2021, 53 patients with posterior meniscus root tears combined with anterior cruciate ligament (ACL) and/or posterior cruciate ligament (PCL) tears were collected. Totally, in 29 patients (group A), the 2.0 mm modified pullout tunnel method was used to suture the posterior meniscus root, while 24 patients (group B) were treated with the traditional 4.5 mm pullout tunnel method. In group A, 20 patients had lateral meniscus posterior root (LMPR) combined with ACL tears, 5 patients had LMPR combined with ACL and PCL tears, and 4 patients had medial meniscus posterior root (MMPR) combined with ACL tears. In group B, 19 patients had LMPR combined with ACL tears, 3 patients had LMPR combined with ACL and PCL tears, and 2 patients had MMPR combined with ACL tears. The improvement of the Lysholm and VAS scores and the incidence of complications in group A and group B before the operation, 1 month and 3 months after the operation, and after the final follow-up were compared. RESULTS: Preoperative Lysholm score was 26.0±5.6 in group A and 26.7±5.8 in group B (P>0.05). One-month postoperative Lysholm score was 66.5±5.7 in group A and 54.3±2.4 in group B (P<0.001). Three-month postoperative Lysholm score was 81.1±7.2 in group A and 73.2±9.7 in group B (P<0.05). Lysholm scores after the final follow-up was 90.3±5.6 in group A and 90.0±5.0 in group B (P>0.05). Preoperative VAS score was 6.3±1.4 in group A and 6.3±1.2 in group B (P>0.05). One-month postoperative VAS score was 1.8±0.7 in group A and 2.4±0.9 in group B (P<0.05). Three-month postoperative VAS score was 0.7±0.6 in group A and 0.8±0.6 in group B (P>0.05). VAS score after the final follow-up was 0.2±0.4 in group A and 0.3±0.5 in group B (P>0.05). CONCLUSION: The improved transosseous pullout suture technique using a smaller 2.0 mm bone tunnel can virtually eliminate the risk of conflict with other bone tunnels and facilitate the management of bone tunnels in multiple ligament injuries, while also diminishing suture abrasion caused by the windshield wiper effect. The technique achieves good clinical efficacy.

Resultados de un programa de descolonización de Staphylococcus aureus en cirugía protésica primaria de cadera y rodilla / Results of a preoperative screening and decolonization program for Staphylococcus aureus in primary hip and knee arthroplasty

Introducción: La detección y descolonización del Staphylococcus aureus previo a la cirugía, se postula como la opción para disminuir el riesgo de infección en artroplastias. El objetivo de este estudio fue evaluar la efectividad de un programa de cribado de S. aureus en la artroplastia total de rodilla (ATR) y en la artroplastia total de cadera (ATC), la incidencia de infección respecto a una cohorte histórica y su viabilidad económica. Material y métodos: Estudio pre-postintervención en pacientes intervenidos de ATR y ATC en al año 2021. Se realizó protocolo de detección de colonización nasal por S. aureus y erradicación si procedía, con mupirocina intranasal, cultivo postratamiento con el resultado de 3 semanas entre cultivo postratamiento y cirugía. Se evalúan medidas de eficacia, se analizan costes y se comprara la incidencia de infección respecto a una serie histórica de pacientes intervenidos entre enero y diciembre de 2019, realizando análisis estadístico descriptivo y comparativo. Resultados: Los grupos fueron comparables estadísticamente. Se realizó el cultivo en el 89%, siendo 19 (13%) pacientes positivos. Se confirmó el tratamiento en 18, cultivo control en 14, todos descolonizados; ninguno sufrió infección. Un paciente con cultivo negativo sufrió infección por S. epidermidis. En cohorte histórica: 3 sufrieron infección profunda por S. epidermidis, E. cloacae y S. aureus. El coste del programa fue de 1.661,85€. Conclusión: El programa de cribado detectó el 89% de los pacientes. La prevalencia de infección en el grupo intervención era menor que en la cohorte, siendo S.epidermidis el microorganismo causante, diferente a S. aureus descrito en la literatura y en la cohorte. Consideramos que este programa es económicamente viable, siendo sus costes reducidos y asumibles.(AU)

Introduction: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening program for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. Material and methods: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. Results: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: 3 suffered deep infection by S. epidermidis, Enterobacter cloacae, S. aureus. The cost of the program is €1661.85. Conclusion: The screening program detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main microorganism, different from S. aureus described in the literature and in the cohort. We believe that this program is economically viable, as its costs are low and affordable.(AU)

[Translated article] Results of a preoperative screening and decolonization programme for Staphylococcus aureus in primary hip and knee arthroplasty / Resultados de un programa de descolonización de Staphylococcus aureus en cirugía protésica primaria de cadera y rodilla

Introducción: La detección y descolonización del Staphylococcus aureus previo a la cirugía, se postula como la opción para disminuir el riesgo de infección en artroplastias. El objetivo de este estudio fue evaluar la efectividad de un programa de cribado de S. aureus en la artroplastia total de rodilla (ATR) y en la artroplastia total de cadera (ATC), la incidencia de infección respecto a una cohorte histórica y su viabilidad económica. Material y métodos: Estudio pre-postintervención en pacientes intervenidos de ATR y ATC en al año 2021. Se realizó protocolo de detección de colonización nasal por S. aureus y erradicación si procedía, con mupirocina intranasal, cultivo postratamiento con el resultado de 3 semanas entre cultivo postratamiento y cirugía. Se evalúan medidas de eficacia, se analizan costes y se comprara la incidencia de infección respecto a una serie histórica de pacientes intervenidos entre enero y diciembre de 2019, realizando análisis estadístico descriptivo y comparativo. Resultados: Los grupos fueron comparables estadísticamente. Se realizó el cultivo en el 89%, siendo 19 (13%) pacientes positivos. Se confirmó el tratamiento en 18, cultivo control en 14, todos descolonizados; ninguno sufrió infección. Un paciente con cultivo negativo sufrió infección por S. epidermidis. En cohorte histórica: 3 sufrieron infección profunda por S. epidermidis, E. cloacae y S. aureus. El coste del programa fue de 1.661,85€. Conclusión: El programa de cribado detectó el 89% de los pacientes. La prevalencia de infección en el grupo intervención era menor que en la cohorte, siendo S.epidermidis el microorganismo causante, diferente a S. aureus descrito en la literatura y en la cohorte. Consideramos que este programa es económicamente viable, siendo sus costes reducidos y asumibles.(AU)

Introduction: Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening program for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability. Material and methods: Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis. Results: The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: 3 suffered deep infection by S. epidermidis, Enterobacter cloacae, S. aureus. The cost of the program is €1661.85. Conclusion: The screening program detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main microorganism, different from S. aureus described in the literature and in the cohort. We believe that this program is economically viable, as its costs are low and affordable.(AU)

Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis.

¼ Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.¼ An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.¼ Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.

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

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

Management of comminuted patellar fractures using suture reduction technique combined with the modified Kirschner-wire tension band.

OBJECTIVES: Surgical management of comminuted patella fractures remains a major challenge for the surgeon. We developed a suture reduction (SR) technique to better preserve the comminuted patella. The study aimed to compare the suture reduction technique with conventional reduction (CR) technique in the management of comminuted patellar fractures using the modified Kirschner-wire (K-wire) tension band. METHODS: From May 2016 to September 2020, a total of 75 patients with comminuted patellar fracture were reviewed retrospectively. Among these cases, 35 patients were in the suture reduction group with a mean age of 52 years, while 40 patients were in the conventional reduction group with a mean age of 53 years. All cases were closed fractures. Comminuted patellar fractures were classified as type 34-C3 according to the AO/OTA classification. Radiographs of the knee were obtained at routine follow-up to evaluate the reduction quality and fracture union. Clinical outcomes including range of motion (ROM), visual analog scale (VAS), Lysholm, and Böstman grading scales were measured at the last follow-up. Postoperative complications were also recorded. RESULTS: The average time from injury to surgery was 5.4 days in suture reduction group and 3.7 days in conventional reduction group (p < 0.05). The surgical time of suture reduction group was less than that of conventional reduction group, but there was no significant difference (p = 0.110) regarding surgical time between the two groups. The average blood loss in suture reduction group was 42.9 ml, while the average blood loss in conventional reduction group was 69.3 ml (p < 0.001). There was no difference regarding fracture union, ROM and knee function score (Lysholm score and Böstman scale) between the two groups. The complication rates were 17.1% in suture reduction group and 12.5% in conventional reduction group respectively (p > 0.05). CONCLUSIONS: In the treatment of comminuted patellar fractures with modified K-wire tension band, the use of suture reduction technique can shorten the surgical time, reduce the surgical trauma, and obtain satisfactory results. This new surgical technique may be particularly effective in management of comminuted patellar fractures when patellectomy would otherwise be considered.

Major Increase in Incidence of Pediatric ACL Reconstructions From 2005 to 2021: A Study From the Norwegian Knee Ligament Register.

BACKGROUND: The incidence of pediatric and adolescent anterior cruciate ligament reconstruction (ACLR) is increasing in several countries. It is uncertain whether this trend applies to countries that traditionally prefer an initial nonoperative treatment approach whenever possible, like Norway. Nationwide, long-term patient-reported outcomes and revision rates after ACLR in the pediatric population are also lacking. PURPOSE: To determine the incidence of pediatric ACLR in Norway since 2005, as well as to detect trends in surgical details and describe patient-reported outcomes up to 10 years after ACLR. STUDY DESIGN: Descriptive cohort study. METHODS: This study is based on prospectively collected data on girls ≤14 years and boys ≤16 years, registered in the Norwegian Knee Ligament Register at the time of their primary ACLR, between 2005 and 2021. The main outcome was the incidence of ACLR, adjusted to the corresponding population numbers for each year. The time trend was analyzed by comparing the mean of the first and last 3-year period (2005-2007 and 2019-2021). Patient-reported outcomes were assessed using the Knee injury and Osteoarthritis Outcome Score preoperatively and at 2, 5, and 10 years postoperatively. RESULTS: A total of 1476 patients (1484 cases) were included, with a mean follow-up of 8.1 years (range, 1-17). The incidence of pediatric ACLRs per 100,000 population increased from 18 to 26, which corresponds to an increase of 40% for boys and 55% for girls. Concurrent meniscal procedures increased significantly from 45% to 62%, and the proportion of meniscal repairs increased from 19% to 43% when comparing the first and last time period. The mean Knee injury and Osteoarthritis Outcome Score values for the Sport and Recreation and Quality of Life subscales were between 72 and 75 at the 2-, 5- and 10-year follow-up. The 5-year revision rate was 9.9%. CONCLUSION: There was a major increase in incidence of pediatric ACLR in Norway during the study period. There was a shift in the approach to concomitant meniscal procedures from resection to repair, with more than a doubling of the proportion of meniscal repairs. Patient-reported outcomes revealed long-lasting reduced knee function.

Lateral Meniscal Root Displacement into the Popliteal Hiatus in a Multiligamentous Knee Injury: A Case Report.

CASE: A 45-year-old female patient presented with left knee pain after a ski accident. Magnetic Resonance Imaging (MRI) showed complete rupture of the anterior cruciate ligament, posterior cruciate ligament, proximal Medial Collateral Ligament (MCL), and medial patellofemoral ligament. The lateral meniscal root was torn with the posterior horn incarcerated superiorly into the popliteal hiatus, rendering high risk of plastic deformation. An unconventional 2-staged surgical approach was performed. CONCLUSION: Where risk of meniscal plastic deformation is high in the setting of multiligamentous knee injury (MLKI), diagnosis and careful surgical planning are central to a successful outcome. Treatment of intra-articular structures in operative stage 1 in MLKI is possible and was necessary in this case.

Reconstructing a Patellar Tendon Rupture Neglected for 14 Years When Anatomic Restoration Is Not Possible: A Case Report.

CASE: This case highlights the utility and outcomes of an Achilles tendon bone-block allograft in reconstructing the patellar tendon of a 44-year-old man in the setting of a high-riding, irreducible patella after a chronic patellar tendon rupture of 14 years. CONCLUSION: In cases of a neglected patellar tendon rupture with an irreducible high-riding patella, an Achilles tendon bone-block allograft can provide the length and tissue necessary to reconstruct the extensor mechanism. Although reconstruction may not be anatomic, patients can still experience great subjective and objective functional improvement with restoration of the extensor mechanism even after delayed reconstruction.

Improving the quality of rehabilitation following anterior cruciate ligament reconstruction surgery, in an outpatient physiotherapy department.

Anterior cruciate ligament reconstruction (ACLR) is a type of orthopaedic knee surgery and physiotherapy rehabilitation is undertaken for several months postoperatively, often with the aim of returning the patient to sport. Variations in postoperative protocols to guide rehabilitation exist between National Health Service (NHS) Trusts. Although there is no single guideline to guide clinicians, strong evidence does support several clinical measures to be included post-ACLR, to improve outcomes and reduce the need for revision surgery. This project aimed to align our NHS Trust's ACLR physiotherapy care with best-evidence.A literature review was completed to establish key quality standards for ACLR rehabilitation. A retrospective notes audit was then undertaken to quantify the baseline quality of care, measured against these standards. Quality improvement methods were used to improve the quality of care and postoperative rehabilitation processes for ACLR patients. A new evidence-based, postoperative rehabilitation protocol was created, a core group of clinicians was formed to see ACLR patients and a rehabilitation class, solely for ACLR patients was also implemented.The key process measure for the project was patients engaging in 'criteria-driven progressions of rehabilitation'. This 'criteria-driven progressions' rate increased from 0% at baseline to 100% during the project period. Overall, non-attendance rates maintained at a similar level from 5.4% at baseline to a final rate of 4.8%. There was also an increase in mean 'return to sport' times, from 6 to 9.9 months, which is in line with best-evidence recommendations.The previous rehabilitation provided in our trust was not aligned with current evidence. This quality improvement project has led to improvements in patient care and lessons from the project will allow other trusts to learn from the changes made, to improve their own care pathways.

Editorial Commentary: Traumatic and Atraumatic Meniscal Root Injuries Can Occur Both Medially and Laterally: No Rule Without Exceptions!

It took a long time for meniscal root injuries to slowly gain scientific and clinical attention some 40 years after the first arthroscopic meniscal resection. Medial root injuries are mostly degenerative in nature and often are associated with obesity and varus deformity. However, lateral root injuries are more commonly traumatic in origin and are associated with anterior cruciate ligament injuries. But, there is no rule without an exception. Laterally, there are isolated root injuries without anterior cruciate ligament involvement and also nontraumatic root injuries that can be associated with a valgus leg axis. Traumatic medial root injuries, on the other hand, occur in the context of knee dislocations. Therefore, the therapeutic concepts should not be based strictly on the localization medial or lateral but on the etiology, traumatic and not traumatic. Even though it has been shown that many patients benefit from refixation of the meniscus root, it seems sensible to search for the etiology of nontraumatic root injuries and to integrate this into the therapeutic concept (e.g., additional osteotomy to correct the varus or valgus deformity). However, the degenerative changes in the relevant compartment must also be taken into account. Recent biomechanical results on the influence of the meniscotibial (medial) or meniscofemoral (lateral) ligaments on extrusion are also relevant with regard to the success of root refixation. These results can provide the rationale for carrying out additional centralization.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis.

PURPOSE: To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness. METHODS: This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries. RESULTS: Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3 weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3 weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.). CONCLUSION: Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured. LEVEL OF EVIDENCE: Level IV.

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.

First revision ACL reconstruction combined with tibial deflexion osteotomy improves clinical scores at 2 to 7 years follow-up.

PURPOSE: To report outcomes of first revision anterior cruciate ligament reconstruction (ACLR) with tibial deflexion osteotomy (TDO) in patients with posterior tibial slope (PTS) >10° at >2 years. METHODS: The authors studied outcomes of a consecutive series of 16 patients that underwent first revision ACLR with TDO, including Lysholm score, IKDC subjective and objective scores, Lachman test, PTS, and signs of osteoarthritis. One woman was excluded because of early signs of knee arthritis, as the first revision ACLR took place 27 years following the primary ACLR. This left a final cohort of 15 patients assessed at minimum follow-up of 2 years. RESULTS: The final cohort comprised 14 men and 1 woman aged 25.3 ± 6.6 years (range 16-39) at first revision ACLR. At final follow-up of 4.4 ± 1.5 years (range, 2-7), PTS was corrected from 12.5 ± 1.8° (range 8-15°) to 1.9 ± 3.6° (range - 4 to 8°), and none of the knees had radiographic signs of osteoarthritis. Lysholm score was 83.8±12.5, IKDC subjective score was 80.3±16.2, and IKDC objective score was A in 5 (33%), and B in 10 (67%). The net improvement exceeded the minimal clinically important difference (MCID) in 93% of patients for the IKDC subjective score and in 80% of patients for the Lysholm score. None of the knees had any retears, and only one required a reoperation to re-suture a medial meniscal tear due to trauma. CONCLUSION: At 2-7 years following revision ACLR combined with TDO, net improvement exceeded the MCID in 93% of patients for IKDC subjective score and in 80% of patients for Lysholm score, with no retears or major complications. These results suggest that TDO is a safe technique to protect the ACL graft and might be considered as of first revision ACLR to correct excessive PTS. LEVEL OF EVIDENCE: Level IV.

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.

Difference in Bioimpedance Across the Knee in Un-Injured Young Adults.

Background: Knee injuries induce swelling and resolution of swelling may be a useful factor in identifying states of healing and time to return to sports activities. Recent work has suggested that bioimpedance can provide an objective measure of swelling following total knee arthroplasty (TKA) and therefore may also provide guidance for clinical decision-making following knee injury. This study measures knee bioimpedance in young, active people to help define baseline variability and factors that influence limb to limb differences. Methods: Bioimpedance was measured via sensors placed at the foot/ankle and thigh, in positions similar to those suggested for monitoring post-TKA swelling. Initial tests were performed to verify method repeatability, then bioimpedance was measured in a convenience sample of 78 subjects (median age 21yrs). The influence of age, BMI, thigh circumference, and knee function (KOOS-JR) on the impedance measures and difference in impedance between the subject's knees were examined using a generalized multivariable linear regression. Results: The repeatability study measurements were highly consistent with a COV of 1.5% for resistance and an ICC of 97.9%. Women exhibited significantly larger dominant limb impedance and larger limb to limb difference in impedance than men. Regression analysis indicated that subject sex and BMI significantly influenced bioimpedance but joint score and age did not. The limb to limb differences in impedance were small on average (<5%), with larger magnitudes of difference associated with female sex, lower knee function scores, and larger limb to limb differences in thigh circumference. Conclusion: Bioimpedance measurements across right and left knees of healthy young people were similar, supporting use of bioimpedance measures from a patient's uninjured knee as a benchmark to monitor healing of a contralateral injured knee. Future work should focus on understanding how knee function scores and bioimpedance are related, and further explore how sex and side to side anatomic differences impact the measurement. Level of Evidence: IV.

Return to Sport After Knee Injuries in Collegiate Wrestling.

Background: Wrestling is known to be a sport of relatively high injury incidence, and knee injuries account for a large percentage of those injuries. Treatment of these injuries varies considerably depending on injury and wrestler characteristics, leading to variability in complete recovery and return to sport (RTS). The purpose of this study was to evaluate injury trends, treatment strategies, and RTS characteristics after knee injuries in competitive collegiate wrestling. Methods: NCAA Division I collegiate wrestlers who sustained knee injuries between January 2010 and May 2020 were identified using an institutional Sports Injury Management System (SIMS). Wrestling-related knee, meniscus, and patella injuries were identified, and treatment strategies were documented to investigate potential recurrent injury trends. Descriptive statistics were used to quantify the number of days, practices, and competitions missed, return to sport times, and recurrent injuries among wrestlers. Results: Overall, 184 knee injuries were identified. After excluding non-wrestling injuries (n=11), 173 injuries remained (77 wrestlers). The mean age at time of injury was 20.8 ± 1.4 years, and the mean BMI was 25.9 ± 3.8 kg/m2. There were 135 primary injuries (74 wrestlers), which consisted of 72 (53%) ligamentous injuries, 30 (22%) meniscus injuries, 14 patellar injuries (10%), and 19 other injuries (14%). The majority of ligamentous injuries (93%) and patellar injuries (79%) were treated non-operatively, while the majority of meniscus tears (60%) underwent surgery. Twenty-three wrestlers (22%) sustained recurrent knee injuries, of which 76% were treated non-operatively after their initial injury. Recurrent injuries consisted of 12 (32%) ligamentous injuries, 14 (37%) meniscus injuries, eight (21%) patellar injuries, and four (11%) other injuries. Fifty percent of recurrent injuries were treated operatively. When comparing recurrent injuries to primary injuries, recurrent injuries had a significantly longer return to sport time (Recurrent 68.3 ± 96.0 days vs. Primary 26.0 ± 56.4 days, p=0.01). Conclusion: The majority of NCAA Division I collegiate wrestlers who sustained knee injuries were initially treated non-operatively, and approximately one in five wrestlers sustained recurrent injuries. Return to sport time was significantly increased after a recurrent injury. Level of Evidence: IV.

Predictors of postoperative complications of tension band wiring techniques for patella fracture: A retrospective multicenter (TRON group) study.

OBJECTIVE: The relationship between postoperative complications and operative techniques of tension band wiring (TBW) is not well studied. We aimed to evaluate the incidence of implant breakage, implant migration, and loss of reduction in patellar fractures treated with TBW and identify radiographic factors associated with these postoperative complications. METHODS: This multicenter (named, TRON group) retrospective study included 224 patients who underwent open reduction and internal fixation of patella fractures using TBW from January 2016 to December 2020. Radiographic findings were evaluated by experienced orthopedic surgeons, and radiographic outcomes were assessed for K-wire migration, implant breakage, and loss of reduction. Logistic regression analysis was performed to identify radiographic factors associated with postoperative complications. RESULTS: Implant migration occurred in 44 cases (19.6%), with bending of a single K-wire end identified as a significant risk factor (OR: 12.90; 95% CI: 4.99-33.30; P < 0.001). Implant breakage occurred in 43 cases (19.2%), with a large patella-tension band ratio (OR: 291.0; 95% CI: 19.60-4330; P < 0.001) and a wide distance between K-wires (OR: 1.15; 95% CI: 1.060-1.250; P = 0.001) identified as significant risk factors. Loss of reduction occurred in 5 cases (2.0%), but no significant risk factors were identified. CONCLUSION: This study highlights the importance of bending both ends of the K-wires and proper placement of the tension band and K-wires in reducing postoperative complications in patellar fractures treated with TBW. Further research is needed to better understand the risk factors associated with loss of reduction.

The side hop test: Validity, reliability, and quality aspects in relation to sex, age and anterior cruciate ligament reconstruction, in soccer players.

OBJECTIVE: To study the side hop test regarding validity, reliability, and quality in relation to sex, age and ACL-reconstruction in soccer players. DESIGN: Cohort study. PARTICIPANTS: 117 females with a primary ACL-reconstruction, and 119 females, 46 males (age 16-26 years), 49 girls and 66 boys (age 13-16 years) without injury. MAIN OUTCOME MEASURES: For convergent validity, one physiotherapist analysed side hops live and later on video. One physiotherapist and two physiotherapy students analysed side hops from 92 players for interrater reliability (video). For intrarater reliability, side hops from 35 players were analysed twice (video). Quality aspects (flaws), i.e. number of times the hopping limb touched the strips, the non-hopping limb touched the floor, and double hops/foot turns with the hopping limb, were registered (video). RESULTS: Convergent validity was excellent; the intraclass correlation coefficient (ICC) was 0.93-1.0. All reliability measures were excellent (ICC 0.92-1.0). Adult male players had fewest and girls had most flaws, especially double hops/foot turns with the hopping limb, compared with all other players (mean, 11-12 vs 1-6, η2 = 0.18, large effect size). No differences were reported between knee-healthy and ACL-reconstructed females. CONCLUSION: The side hop test is valid and reliable. Quality aspects differ between sexes and ages.