Incidence of and Risk Factors for Medial Meniscal Lesions at the Time of ACL Reconstruction: An Analysis of 4697 Knees From the SANTI Study Group Database.

BACKGROUND: Medial meniscal (MM) lesions (MMLs) are a common finding at the time of anterior cruciate ligament reconstruction (ACLR). It is recognized that evaluation of the posteromedial compartment reduces the rate of missed MML diagnoses. PURPOSE: To determine the incidence of MMLs in patients undergoing ACLR, when using a standardized arthroscopic approach that included posteromedial compartment evaluation, as well as to determine how the incidence of MMLs changed with increasing time intervals between injury and surgery, and to investigate what risk factors were associated with their presence. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis of prospectively collected data was performed. All patients who underwent primary ACLR between January 2013 and March 2023 were considered for study eligibility. The epidemiology was defined by categorizing and reporting the incidence and categorizing the spectrum of MM tear types. Risk factors associated with MMLs were analyzed using a logistic regression model. RESULTS: MMLs were identified in 1851 (39.4%) of 4697 consecutive patients undergoing ACLR. The overall incidence of MMLs was 33.1% for the period of 0 to 3 months, 38.7% for the period of 3 to 12 months, and 59.6% for the period of >12 months. The overall incidence of MMLs increased with longer durations of time between injury and surgery, along with significant increases in complex, bucket-handle, ramp, and/or flap lesions. The largest increase in incidence of MMLs was observed for complex MM tear patterns. Risk factors associated with MMLs included time between injury and surgery >3 months (odds ratio [OR], 1.320; 95% CI, 1.155-1.509; P < .0001) and >12 months (OR, 3.052; 95% CI, 2.553-3.649; P < .0001), male sex (OR, 1.501; 95% CI, 1.304-1.729; P < .0001), body mass index (BMI) ≥25 (OR, 1.193; 95% CI, 1.046-1.362; P = .0088), and lateral meniscal lesion (OR, 1.737; 95% CI, 1.519-1.986; P < .0001). CONCLUSION: Overall, MMLs were identified in 39.4% of 4697 patients undergoing ACLR when posteromedial compartment evaluation was performed in addition to standard anterior viewing. The incidence of MMLs and the complexity of tear types increased significantly with increasing time intervals between the index injury and ACLR. Secondary risk factors associated with an increased incidence of medial meniscal tears include male sex, increased BMI, and lateral meniscal lesions.

Is Heterotopic Ossification Associated With Surgical Approach in Total Hip Arthroplasty?

BACKGROUND: Although risk factors for heterotopic ossification (HO) have been defined, the effect from surgical approach is not fully understood. The primary objective of our study was to evaluate the effect that surgical approach has on the risk for developing severe HO after total hip arthroplasty (THA) and compare this with other known risk factors. We hypothesized that there would be no difference in HO formation based on the surgical approach. METHODS: We retrospectively reviewed all patients who underwent primary THA at our hospital between March 2011 and March 2021. Patients with HO documented in the radiology reports were cross-referenced with our THA data set and manually reviewed to determine Brooker classification. Patient demographics, medical comorbidities, surgical details, and medication information were collected from the electronic medical record and compared. RESULTS: Of 3,427 patients who underwent THA, 677 (19.8%) developed HO postoperatively. A multivariable analysis confirmed that surgical approach was independently associated with increased odds for HO development. The anterolateral (odds ratio [OR], 3.43; P < 0.001) and posterior (OR, 2.24; P < 0.001) approaches had increased odds for developing HO compared with the direct anterior approach. However, only the anterolateral approach (OR, 1.85; P = 0.033) demonstrated an increased association with the development of severe HO (Brooker 3, 4) postoperatively. CONCLUSION: Although the use of the direct anterior approach had the lowest overall OR for developing HO after THA, this is likely only clinically notable when compared with the anterolateral approach. LEVEL OF EVIDENCE: III.

Routine immediate postoperative radiographs rarely identify unknown complications after shoulder arthroplasty.

BACKGROUND: Intraoperative complications after shoulder arthroplasty (SA) are uncommon, yet surgeons continue to obtain immediate postoperative radiographs despite prior literature questioning the efficacy of these images. There is a paucity of literature describing the role of immediate postoperative radiographs in revision SA. This study aimed to evaluate the utility of immediate postoperative radiographs in identifying intraoperative complications leading to a change in care after primary or revision SA. We hypothesized that routine postoperative ("survey") radiographs would not provide a high diagnostic yield in identifying early complications requiring a change in postoperative management. METHODS: A retrospective review of 4063 SAs (1298 primary anatomic total shoulder arthroplasties [aTSAs], 2162 primary reverse shoulder arthroplasties [RSAs], 129 revision aTSAs, and 474 revision RSAs) was performed from a multi-institutional arthroplasty database. All shoulders were evaluated with a single immediate postoperative (survey) radiograph that was read by a musculoskeletal radiologist and by the treating orthopedic surgery team. The radiology reports of all 4063 immediate postoperative radiographs were reviewed to determine whether complications had been identified. For patients in whom complications were identified, the medical record was then reviewed to determine whether the survey radiograph resulted in a return to the operating room or a change in management between the surgical procedure and the first postoperative clinic visit with radiographic evaluation. RESULTS: Complications were reported by a radiologist on the basis of immediate postoperative radiographs in 10 of 4063 shoulders (0.2%, or 1 of every 500 arthroplasties). Complications were reported after 4 primary RSAs, 4 revision aTSAs, and 2 revision RSAs; no complication was reported after any of the primary aTSAs. Of the 10 complications, only 3 were unknown to the treating surgeon following the operation and none altered immediate postoperative management. Early complications were reported at a rate of 1% after revision arthroplasty vs. 0.1% after primary arthroplasty (P = .001). Additionally, revision aTSA was found to have a higher rate of complications reported on radiographs, with a rate of 3.1%, compared with revision RSA, at 0.4% (P = .021). CONCLUSION: The radiology reports of routine immediate postoperative radiographs rarely identified postoperative complications (0.2%). In all cases, postoperative management remained unaltered until the time of the first postoperative visit. The value and medicolegal implications of immediate postoperative radiographs may inform the decision to abandon obtaining these studies routinely.

Does Metabolic Syndrome Impact the Risk of Reoperation, Revision, or Complication After Primary Total Knee Arthroplasty?

BACKGROUND: Metabolic syndrome (MetS) is an increasingly frequent condition characterized by insulin resistance, abdominal obesity, hypertension, and dyslipidemia. This study evaluated implant survivorship, complications, and clinical outcomes of primary TKAs performed in patients who have MetS. METHODS: Utilizing our institutional total joint registry, 2,063 primary TKAs were performed in patients with a diagnosis of MetS according to the World Health Organization criteria. MetS patients were matched 1:1 based on age, sex, and surgical year to those who did not have the condition. The World Health Organization's body mass index (BMI) classification was utilized to evaluate the effect of obesity within MetS patients. Kaplan-Meier methods were utilized to determine implant survivorship. Clinical outcomes were assessed with Knee Society scores. The mean follow-up was 5 years. RESULTS: MetS and non-MetS patients did not have significant differences in 5-year implant survivorship free from any reoperation (P = .7), any revision (P = .2), and reoperation for periprosthetic joint infection (PJI; P = .2). When stratifying, patients with MetS and BMI >40 had significantly decreased 5-year survivorship free from any revision (95 versus 98%, respectively; hazard ratio = 2.1, P = .005) and reoperation for PJI (97 versus 99%, respectively; hazard ratio = 2.2, P = .02). Both MetS and non-MetS groups experienced significant improvements in Knee Society Scores (77 versus 78, respectively; P < .001) that were not significantly different (P = .3). CONCLUSION: MetS did not significantly increase the risk of any reoperation after TKA; however, MetS patients with BMI >40 had a two-fold risk of any revision and reoperation for PJI. These results suggest that obesity is an important condition within MetS criteria and remains an independent risk factor. LEVEL OF EVIDENCE: Level 3, Case-control study.

A retrospective case series of prophylactic neurectomy during total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is a common operation performed to relieve pain and restore functional activity. While overall widely successful, a subset of patients has continued pain postoperatively with no identifiable cause. Neuroma formation has been identified as a possible contributor to this unexplained pain, often necessitating an additional procedure for neuroma removal. The purpose of our study was to evaluate if prophylactic neurectomy could reduce the occurrence of postoperative pain. METHODS: A total of 112 patients were compared, 44 control patients and 68 neurectomy patients. Demographic information, Numerical rating pain scale (NRS) and Knee Society Scores (KSS) were collected pre- and post-operatively. Patients were additional asked if they were overall satisfied with the operation. RESULTS: There were no differences between groups with respect to age (Median: 71 vs 69 years, p = 0.28), male sex (41% vs 44%, p = 0.85), or body mass index (Median: 32.2 vs 31.3, p = 0.80). When comparing the degree of change following surgery there were no statistically significant differences observed in NRS pain scores (Median change: -7 vs -6, p = 0.89) or KSS scores (Median change: +44 vs +40, p = 0.14). Similarly, there was no statistically significant difference in overall patient-reported satisfaction with the knee replacement (82.5% vs 86.6%, p = 0.59). CONCLUSION: We did not find a statistically significant difference in NRS, KSS, or overall patient satisfaction between the prophylactic neurectomy and control patient groups. Larger studies with evaluation of the nerve diameter will be needed to determine which patients are at risk for symptomatic neuroma development following total knee arthroplasty.

Primary Total Hip Arthroplasty in Patients With Ehlers-Danlos Syndrome: A Retrospective Matched-Cohort Study.

BACKGROUND: Ehlers-Danlos syndromes (EDSs) are connective-tissue disorders resulting in joint laxity. Soft-tissue stability is a concern in these patients when they undergo total hip arthroplasty (THA). Our purpose was to compare THAs in the population with EDS with a matched control undergoing THA for osteoarthritis. METHODS: Thirteen patients with EDS underwent THA from 1997 to 2017. Matching was 1:3 with a control group of patients who underwent THA for osteoarthritis. Matching was based on the gender, age, and length of follow-up. RESULTS: We found no difference in demographics or postoperative Harris Hip Scores between the cohorts (P > .05). Two patients (15.4%) with EDS and 2 patients (5.1%) in the control group suffered a dislocation. We found no difference in the reoperation or revision rate between the groups (P = .28). CONCLUSION: Patients with EDS have a significant improvement in postoperative Harris Hip Scores after THA. These patients also have a high dislocation rate after surgery, and alternative approaches and technologies such as dual-mobility components should be considered to reduce the rate of dislocation in this population.

The impact of bone morphology on the outcome of the pivot shift test: a cohort study.

BACKGROUND: The presence of a positive pivot shift after surgical repair of the ACL is considered an important indicator of a failed reconstruction. The ability to predict the result of a pivot shift test after an ACL reconstruction using variables that can be measured prior to surgery could provide an indication of which patients may be at-risk of a poor surgical outcome.The purpose of this study was to determine whether structural characteristics of the femur and tibia, measured using plain radiographs, were associated with the result of the pivot shift test in unilateral ACL reconstructed patients. METHODS: Sixteen patients who had undergone unilateral ACL reconstruction were divided into two groups based on the results of manual pivot shift testing: 1) Pivot group; and 2) No pivot group. All patients had standing true lateral radiographs of both knees. Structural measurements of the tibia and femur were made on both knees. In addition, two new variables were created to describe the tibiofemoral mismatch: 1) Femur Tibia Size Ratio (FTSR); and 2) Tibia to Posterior Femoral Condyle Ratio (TPFCR). These measures were compared within groups and between groups. RESULTS: None of the individual structural characteristics were significantly different when compared between groups. No individual structural characteristics had a significant association with the presence of a positive pivot shift. When a between-group analysis was performed, both the FTSR (p < 0.03) and the TPFCR (p < 0.01) were significantly different between the Pivot group and the No Pivot group. A larger FTSR ratio, or a larger femur relative to the tibia, was associated with a positive pivot shift. A smaller TPFCR ratio, or a smaller tibial depth relative to the depth of the lateral posterior femoral condyle, was associated with a positive pivot shift. CONCLUSIONS: Structural characteristics in the lateral femoral condyle and lateral tibial plateau were found to be associated with the presence of a positive pivot shift. These characteristics could separate between patients in the Pivot group and the No Pivot group. Two indices, the FTSR and the TPFCR, provided better predictive value than individual characteristics in identifying patients with a knee that was structurally "at-risk" for developing a positive pivot shift.

Robotic axial lower leg testing: repeatability and reproducibility.

PURPOSE: The purpose of this study was to determine the test-retest reliability and the repeatability over multiple days of a robotic testing device when used to measure laxity of the lower leg during a simulated dial test. METHODS: Ten healthy subjects were evaluated using an instrumented robotic lower leg testing system over 4 days. Three testing cycles were performed each day. Each leg was rotated into external and then internal rotation by servomotors until a torque threshold of 5.65 N m was reached. Load-deformation curves were generated from torque and rotation data. Both average-measure and single-measure intraclass correlation coefficients (ICC) were compared across the curves. ICC scores were also compared for features of the curves including: maximum external rotation at -5.65 N m of torque, maximum internal rotation at 5.65 N m of torque, rotation at torque 0, compliance (slope of load-deformation curve) at torque 0, endpoint compliance in external rotation, endpoint compliance in internal rotation, and play at torque 0. Play at torque 0 was defined as the width of the hysteresis curve at torque 0. RESULTS: Average-measure ICC scores and test-retest scores were >0.95 along the entire load-deformation curve except around zero torque. ICC scores at maximum internal and external rotation ranged from 0.87 to 0.99 across the left and right knees. ICC scores for the other features of the curves ranged from 0.61 to 0.98. The standard error of the mean ranged from 0.0497 to 1.1712. CONCLUSIONS: The robotic testing device in this study proved to be reliable for testing a subject multiple times both within the same day and over multiple days. These findings suggest that the device can provide a level of reliability in rotational testing that allows for clinical use of test results. Objective laxity data can improve consistency and accuracy in diagnosing knee injuries and may enable more effective treatment.

Single-bundle ACL reconstruction with and without extra-articular reconstruction: evaluation with robotic lower leg rotation testing and patient satisfaction scores.

PURPOSE: The purpose of this study was to compare the biomechanical characteristics and patient outcomes after either isolated intraarticular ACL reconstruction or intraarticular reconstruction with lateral extra-articular tenodesis. In addition, we aimed to evaluate biomechanical parameters of the entire uninjured, contralateral knee as a baseline during the analysis. METHODS: Eighteen patients were evaluated at an average of 9.3 years after ACL reconstruction. Twelve patients had an intraarticular reconstruction (BTB), and six had an additional lateral extraarticular procedure (BTB/EAR). Patients were selected for the additional procedure by the operating surgeon based on clinical and radiological criteria. At the time of review, each patient was assessed using subjective patient questionnaires, manual laxity testing, and instrumented laxity testing. Each knee was also evaluated using a robotic lower leg axial rotation testing system. This system measured maximum internal and external rotations at 5.65 Nm of applied torque and generated load deformation curves and compliance data. Pointwise statistical comparisons within each group and between groups were performed using the appropriate paired or unpaired t test. Features were extracted from each load deformation curve for comparative analysis. RESULTS: There were no significant differences between the two groups with respect to the patient satisfaction scores or to laxity testing (manual or instrumented). Robotic testing results for within-group comparisons demonstrated a significant reduction in maximum external rotation (8.77°) in the reconstructed leg when compared to the healthy leg (p < 0.05) in the BTB/EAR group, with a non-significant change in internal rotation. The slope of the curve at maximum internal rotation was also significantly greater in the reconstructed legs for the BTB/EAR group (p < 0.05), indicating reduced endpoint compliance or a harder endpoint. Finally, the leg that received the extra-articular tenodesis had a trend towards a reduced total leg axial rotation. Conversely, patients in the BTB group demonstrated no significant differences between their legs. For between-group comparisons, there was a significant increase in maximum internal rotation in the healthy legs in the BTB/EAR group compared with the healthy legs in the BTB group (p < 0.05). If the injured/reconstructed legs were compared, the significant difference at maximum internal rotation disappeared (p < 0.10). Similarly, the healthy legs in patients in the BTB/EAR group had a significantly more compliant or softer endpoint in internal rotation, greater maximum internal rotation, and more internal rotation at torque 0 in their healthy legs compared with the healthy legs in the BTB group (p < 0.05). These same differences were not noted in the reconstructed knees. The only identifiable significant difference between the injured/reconstructed legs was rotation at 0 torque (p < 0.05). CONCLUSIONS: In this group of patients who were at an average of 9 years from surgery, the addition of a lateral extra-articular reconstruction to a standard bone-tendon-bone intraarticular ACL reconstruction does reduces internal rotation of the tibia with respect to the femur when compared to intraarticular reconstruction alone. It appears that the selection process for inclusion into the BTB/EAR group included an increase in total axial rotation of the healthy knee during the examination along with a decrease in endpoint stiffness at maximum internal rotation. LEVEL OF EVIDENCE: II.

The evolution of ACL reconstruction over the last fifty years.

Anterior cruciate ligament (ACL) reconstruction has evolved considerably over the past 30 years. This has largely been due to a better understanding of ACL anatomy and in particular a precise description of the femoral and tibial insertions of its two bundles. In the 1980s, the gold standard was anteromedial bundle reconstruction using the middle third of the patellar ligament. Insufficient control of rotational laxity led to the development of double bundle ACL reconstruction. This concept, combined with a growing interest in preservation of the ACL remnant, led in turn to selective reconstruction in partial tears, and more recently to biological reconstruction with ACL remnant conservation. Current ACL reconstruction techniques are not uniform, depending on precise analysis of the type of lesion and the aspect of the ACL remnant in the intercondylar notch.

Elevated intraocular pressure and myopic shift linked to topiramate use.

PURPOSE: The purpose of this report is to describe acute myopia as an ocular adverse reaction to topiramate (Topamax, Ortho-McNeil, Raritan, NJ) and discuss the importance of recognizing this syndrome. METHODS: Retrospective case report and brief review of the literature. RESULTS: A 27-year-old female patient developed decreased vision in both eyes due to acute myopia 2 weeks of after initiating therapy with topiramate. Emergency department evaluation revealed visual acuities of 20/400 right eye and 20/200 left eye. Intraocular pressures were 33 mm Hg right eye and 26 mm Hg left eye. The anterior chambers were shallow. Retinal striae were present in the maculae. The patient stated no previous need for optical correction. However, after initiating treatment with topiramate, she refracted to approximately -5.00 D bilaterally. Ultrasound testing revealed that the patient had suprachoroidal effusions in both eyes. The symptoms and clinical findings resolved completely with discontinuation of topiramate, administration of topical atropine 1% and prednisolone acetate 1%. CONCLUSIONS: An acute myopic shift may be the presenting sign of an idiosyncratic drug reaction that can include secondary bilateral angle closure glaucoma. This condition can occur in patients who do not have a history of anterior chamber abnormalities. Recognizing this condition and discontinuing the use of the causative drug may prevent angle closure and associated vision loss.

Purtscher-like retinopathy in a patient with HELLP syndrome.

PURPOSE: To report the antepartum presentation of Purtscher-like retinopathy and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome that resulted in severe permanent visual loss. DESIGN: Interventional case report. METHODS: A 25-year-old primigravida patient at 38.5 weeks gestation presented with severe bilateral loss of vision. Immediate hospitalization with complete evaluation, urgent medical treatment, and cesarean section was performed. RESULTS: Ophthalmoscopic evaluation showed bilateral Purtscher-like retinopathy. Laboratory studies revealed elevated liver enzymes, thrombocytopenia, and evidence of intravascular coagulation consistent with HELLP syndrome. Despite the successful delivery of a healthy baby, the patient developed permanent visual loss. CONCLUSION: Purtscher-like retinopathy with permanent visual loss can occur antepartum in patients with HELLP syndrome.

Polypoidal choroidal vasculopathy.

BACKGROUND: Polypoidal choroidal vasculopathy (PCV) is a unique form of occult choroidal neovascular membrane. The clinical presentation and angiographic findings distinguish idiopathic PCV from other known neovascular and choroidal degenerative disorders. The characteristic morphology of PCV includes the presence of a branching network of inner choroidal vessels with terminal aneurysmal dilations. Other key findings include subtle nodular protrusions, which may precede multiple serosanguineous retinal pigment epithelial detachments. If Bruch's membrane is compromised, there is an additional risk of exudative retinopathy or vitreal hemorrhage. CASE REPORTS: Three patients with polypoidal choroidal vasculopathy are described with visual impairment secondary to irregular choroidal vascular lesions producing recurrent subretinal hemorrhages and exudative retinopathy. CONCLUSIONS: The characteristic presentation and clinical course of polypoidal choroidal vasculopathy distinguish it from the typical presentation of age-related macular degeneration and other causes of hemorrhagic and exudative retinopathy. Imaging techniques such as fluorescein angiography, indocyanine green angiography, and optical coherence tomography may assist in the accurate diagnosis of PCV, so that appropriate treatment and management can be provided. In patients who manifest exudative, hemorrhagic retinopathy, with no signs of active inflammation or an anatomic predisposition to choroidal neovascularization, PCV should be considered.

Comparison of three standard radiologic techniques for screening of patellar subluxations.

The presence of many "abnormal" types of PF joints in asymptomatic cases and the frequent unilateral complaints in morphologically symmetric joints indicate that emphasis must be placed on factors that cause "abnormal" PF joints to decompensate, rendering them symptomatic. These factors include hyperlaxity, puberty, overuse, or athletic activities. It is our conviction that full understanding of PF problems needs dynamic, three-dimensional motion analysis of patellofemoral relationships. At the present time these imaging techniques do not exist, as they require more powerful computer capacities. The absence of strict and reliable relationships between radiographic anomalies and clinical symptoms brings two reflections about the treatments in symptomatic cases: It is common sense to treat PPS by conservative methods first. Our study indicates that the goal should be to turn the symptomatic patella into an asymptomatic one, rather than correcting maltracking by vastus medialis training. The high failure rates at long-term follow-up of patellar maltracking correction by surgical methods such as lateral release and tibial tubercle transfer show us that correction of part or all of the anomalies does not always make the symptoms disappear. A nice lesson in humility for the orthopedist.