Editorial Commentary: Routine Use of Suture Tape Augmentation for Primary Anterior Cruciate Ligament Reconstruction Surgery Is Not Justified.

High rates of graft failure after primary anterior cruciate ligament reconstruction (ACLR) and the need for revision ACLR continue to be a challenge. Multiple studies demonstrate graft failure rates and the need for revision ACLR in 10% to 15% of young patients participating in pivot sporting activities. Currently, a wide range of strategies to mitigate this is problem being investigated, including extra-articular augmentation (with modified lateral extra-articular tenodesis or anterolateral ligament reconstruction) and intra-articular fixation (that aim for primary anterior cruciate ligament healing or augmentation of an ACLR with suture tape). While the early data on suture tape augmentation of primary ACLR seem optimistic, it does not justify its routine use.

The Anatomy of the Medial Patellofemoral Ligament.

Recurrent patellar dislocation is observed in many patients treated nonoperatively following primary dislocation. Injury to the medial patellofemoral ligament (MPFL) is reported in the majority of patients following dislocation. There is an increased interest in repair or reconstruction of the MPFL for patients experiencing recurrent instability. The femoral attachment of the MPFL is critical in determining graft behavior following reconstruction. The femoral attachment can be determined by referencing local anatomy, fluoroscopic imaging or on the basis of desired graft-length changes. This article reviews the anatomy of the MPFL, with a focus on its femoral insertion site as it pertains to anatomic, isometric, and anisometric reconstruction. [Orthopedics. 2017; 40(4):e583-e588.].

Short-term Outcomes of Femoral Neck Fractures Treated With Hemiarthroplasty Using the Anterior Approach.

The direct anterior approach has recently gained popularity for patients undergoing elective total hip arthroplasty. It is unknown whether the reported benefits of the direct anterior approach to elective total hip arthroplasty can be extrapolated to patients undergoing hemiarthroplasty after femoral neck fracture. A retrospective review of 101 patients was performed to compare the outcomes of patients treated with hemiarthroplasty using the direct anterior approach (group 1) with those of patients undergoing the procedure with the posterior, anterolateral, or lateral approach (group 2). No differences in age, American Society of Anesthesiologists classification, and preinjury ambulatory status were identified between treatment groups. No difference in operative time was found between those undergoing the anterior approach (98.7 minutes) and those undergoing other surgical approaches (96.5 minutes) (P=.76). No difference in either the need for transfusion or the number of blood products transfused was seen (P=.21) postoperatively. Patients undergoing the direct anterior approach were more likely to be discharged by postoperative day 3 (P=.004) despite no difference in the recorded number of feet ambulated in the hospital. At a mean clinical follow-up of 16 weeks, there was no difference in the rate of return to baseline ambulatory status between groups (P=.07). The overall rates of major and minor complications for all patients were 23% and 26%, respectively, with no statistically significant differences between groups. The overall dislocation rate of all patients was found to be 3%. All dislocations were observed in group 2. Larger prospective studies are needed to further define the benefits of the direct anterior approach in this patient population.

Repeat Manipulation Under Anesthesia For Persistent Stiffness After Total Knee Arthroplasty Achieves Functional Range of Motion.

Poor range of motion may decrease a patient's ability to participate in activities of daily living after total knee arthroplasty. Manipulation under anesthesia has been shown to improve range of motion; however, some patients have persistent stiffness even after manipulation. The goal of this study was to evaluate the outcomes and complications of patients who underwent a second manipulation under anesthesia for persistent stiffness after total knee arthroplasty. The review of surgical records of two joint arthroplasty surgeons identified 226 knees in 210 patients who underwent a manipulation under anesthesia for poor range of motion after total knee arthroplasty. Of these patients, 16 patients underwent a second manipulation under anesthesia. For patients undergoing two manipulations under anesthesia procedures, at latest follow up (mean 539 days), mean extension improved from 10.50° to 2.50° (p=0.001) and mean flexion improved from 87.50° to 112.69° (p=0.001) respectively. SF-12 scores were available for 12 of 16 knees with a mean score of 34.42. Two of 16 patients (12.5%) experienced a complication. Three of 16 (18.8%) patients who underwent a second manipulation required a revision arthroplasty procedure. In conclusion, a second manipulation under anesthesia can achieve functional range of motion that is sustained after total knee arthroplasty.

Retrograde Versus Antegrade Femoral Bone Graft Harvesting Using the Reamer-Irrigator-Aspirator.

OBJECTIVES: To compare retrograde versus antegrade femoral bone graft harvesting using the reamer-irrigator-aspirator system to determine whether there was any difference in intraoperative, postoperative, or patient outcome variables. DESIGN: Retrospective cohort study. SETTING: Urban Level I Trauma Center. PATIENTS/PARTICIPANTS: Ninety-four (62 antegrade and 32 retrograde procedures) consecutive adult patients who underwent femoral autologous bone graft harvesting using the Synthes reamer-irrigator-aspirator system between April 2008 and March 2013. MAIN OUTCOME MEASUREMENTS: Amount of bone graft, perioperative fractures or other complications, and postoperative hip and/or knee pain. RESULTS: There was no significant difference between demographic or medical comorbidities between the groups. There was no significant difference in the side of the graft harvest, graft volume, hospital length of stay, or the ability to ambulate on postoperative day 1. There was a significantly increased incidence of iatrogenic fracture or prophylactic nailing with antegrade reaming (4 vs. 0, P = 0.01). Average length of follow-up was 500 (range, 20-1477) days for the antegrade group and 378 (range, 19-706) days for the retrograde group. The antegrade group had a nonsignificant increased incidence of hip pain (8.1% vs. 3.1%, P = 0.66), and the retrograde group had a significantly higher incidence of knee pain (15.6% vs. 1.6%, P = 0.02) at 6-month follow-up. Neither hip nor knee complaints were present at final follow-up. No cases of delayed femur fracture, infection, or abductor and/or antalgic gait involving the donor extremity were seen at final follow-up. CONCLUSIONS: This study provides support to the safety of femoral bone graft harvesting using both antegrade and retrograde techniques. Both techniques provide reliable, high-volume, nonstructural autologous bone graft with minimal associated morbidity. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review.

OBJECTIVE: To report and compare the clinical and radiographic outcomes of patients treated with reverse shoulder arthroplasty (RSA) or hemiarthroplasty for acute complex proximal humeral fractures. DATA SOURCES: A systematic review of PubMed, Cumulative Index to Nursing and Allied Health Literature, SportDiscus, and Cochrane Central Register of Controlled Trials was conducted. All published English language studies before January 2014 were reviewed for possible inclusion. Search terms included the following: proximal humerus, fracture, arthroplasty, hemiarthroplasty, RSA, and reverse total shoulder arthroplasty. STUDY SELECTION: Studies reporting outcomes in human subjects after either RSA or hemiarthroplasty for acute proximal humeral fractures were assessed for inclusion. Additional inclusion criteria included a minimum clinical follow-up of 1 year. Level V evidence, basic science/cadaveric studies, and those studies reporting outcomes after revision arthroplasty were excluded. DATA EXTRACTION: Patient demographics, clinical/radiographic outcomes, and complications were recorded. Posttreatment weighted means were calculated and reported. Homogenous outcome measures were analyzed, and a direct comparison of outcomes between treatment groups was performed. CONCLUSIONS: Patients treated with RSA possess improved forward flexion (RSA: 118 degrees, Hemi: 108 degrees) but decreased external rotation (RSA: 20 degrees, Hemi: 30 degrees) compared with patients undergoing hemiarthroplasty after acute proximal humeral fracture. No significant clinical difference in either American Shoulder and Elbow Surgeons Shoulder Score (RSA: 64.7, Hemi: 63.0) or Constant score (RSA: 54.6, Hemi: 58.0) was identified. RSA was associated with an increased rate of clinical complications (9.6%) and a lower revision rate (0.93%) at short-term to midterm follow-up compared with hemiarthroplasty. RSA offers an acceptable surgical option for patients after complex acute proximal humeral fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing: A Case Report.

CASE: We report the case of a patient who sustained injury to the anterior tibial artery during tibiotalocalcaneal retrograde nailing and developed an acutely ischemic foot. CONCLUSION: Vascular injury during tibiotalocalcaneal arthrodesis with retrograde nailing is a rare but serious complication. While retrograde tibiotalocalcaneal arthrodesis nailing for end-stage ankle and subtalar arthritis has shown encouraging results, a high index of suspicion for postoperative complications is necessary in patients with risk factors for poor posterior collateral circulation.