Younger age, hyperextended knee, concomitant meniscectomy and large prerevision anterior tibial translation are associated with graft failure after the revision anterior cruciate ligament reconstruction.

Purpose: Graft failure following revision anterior cruciate ligament (ACL) reconstruction is higher than after primary ACL reconstruction. However, data regarding revision surgery is scarce. We aimed to evaluate the associated factors for failure after revision ACL reconstruction. Methods: Fifty-four patients (mean age: 24.7 ± 10.0 years) who underwent revision ACL reconstruction at our hospital with ≥1 year follow-up were retrospectively examined. Patients were divided into Group F (graft failure) and Group N (no graft failure) groups. Univariate analysis was conducted to identify factors associated with graft failure. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal thresholds for differentiating between the two groups. Results: Graft failure was observed in 7 of 54 patients (13.0%). In the univariate analysis, significant differences were observed for age at the initial surgery (Group F: 15.6 ± 1.5, Group N: 20.9 ± 8.1), age at the revision surgery (Group F: 18.0 ± 2.8, Group N: 25.7 ± 10.3), presence of hyperextended knee (Group F: 85.7%, Group N: 14.9%), concomitant meniscectomy (Group F: 42.9%, Group N: 14.9%), prerevision space for the ACL (sACL) (Group F: 7.2 ± 3.4 mm, Group N: 13.4 ± 4.7 mm) and preoperative anterior tibial translation (ATT) (Group F: 5.0 ± 1.4 mm, Group N: 2.7 ± 3.1 m). ROC analysis of preoperative sACL and preoperative ATT on one-leg standing plain radiograph showed that cutoff values of 6.9 and 4.2 mm were the optimal thresholds, respectively. Conclusion: Younger patients with a hyperextended knee, concomitant meniscectomy, small sACL and large ATT before revision ACL reconstruction are predisposed to graft failure. Level of Evidence: Level IV.

Morphological analysis of the distal femur as a surgical reference in biplane distal femoral osteotomy.

Distal femoral osteotomy (DFO) is performed alone or with high tibial osteotomy (HTO) for patients with osteoarthritis and distal femur deformities. DFO is technically demanding, particularly when creating an anterior flange. Herein, we examined the morphological characteristics of the distal femur based on the cortical shape as a surgical reference for biplanar DFO. Computed tomography images of 50 valgus and 50 varus knees of patients who underwent biplanar DFO or total knee arthroplasty were analyzed. Axial slices at the initial level of the transverse osteotomy in the DFO and slices 10 mm proximal and 10 mm distal to that level were selected. The medial and lateral cortical angles and heights (MCLA, LCLA, MCH, and LCH) were measured on axial slices. Statistical comparisons were performed between the medial and lateral cortices and valgus and varus knees. MCLA and MCH were significantly smaller and lower, respectively, than LCLA and LCH (P < 0.01). The MCLA and MCH of varus knees were significantly smaller and lower, respectively, than those of valgus knees (P < 0.01). Surgeons should carefully observe morphological differences in the distal femur cortex, distinguishing between medial and lateral knees and varus and valgus knees during the creation of the anterior flange in the DFO.

Injuries to both anterolateral ligament and Kaplan fiber of the iliotibial band do not increase preoperative pivot-shift phenomenon in ACL injury.

Background: To assess the incidence of anterolateral ligament (ALL) and Kaplan fiber of the iliotibial band (KF) injuries in patients with acute anterior cruciate ligament (ACL) injury on magnetic resonance imaging (MRI), and to investigate the association between these injuries and the magnitude of preoperative pivot-shift test. Method: One-hundred and five patients with primary ACL injury were retrospectively reviewed. ALL injury and KF injury were assessed by preoperative MRI, and subjects were allocated into four groups: Group A, neither injury; Group B, only ALL injury; Group C, only KF injury; Group D, simultaneous ALL and KF injuries. Before ACL reconstruction, tibial acceleration during the pivot-shift test was measured by an electromagnetic measurement system, and manual grading was recorded according to the International Knee Documentation Committee (IKDC) guideline. Results: In MRI, the ALL was identified in 104 patients (99.1%) and KF in 99 patients (94.3%). ALL and KF injuries were observed in 43 patients (43.9%) and 23 patients (23.5%), respectively. Patient distribution to each group was as follows; Group A: 43 patients (43.9%), Group B: 32 patients (32.7%), Group C: 12 patients (12.2%), Group D: 11 patients (11.2%). No significant differences were observed in tibial acceleration, and manual grading among the four groups. Conclusion: Simultaneous injury to both ALL and KF was uncommon, and preoperative pivot-shift phenomenon did not increase even in those patients. The finding suggests that the role of ALL and KF in controlling anterolateral rotatory knee laxity may be less evident in the clinical setting compared to a biomechanical test setting.

Ampicillin/sulbactam versus cefazolin plus aminoglycosides for antimicrobial prophylaxis in management of Gustilo type IIIA open fractures: A retrospective cohort study.

BACKGROUND: The antibiotic regimens for prophylaxis in the management of open fractures remain controversial. Although the use of aminoglycosides is widely accepted for treatment of Gustilo type III open fractures, aminoglycosides are often avoided in patients with risk factors. This study aimed to compare efficacy and safety of two regimens, cephazolin plus aminoglycoside (amikacin or gentamicin) and ampicillin/sulbactam (ABPC/SBT), in patients with Gustilo type IIIA open fractures. METHODS: A total of 95 Gustilo type IIIA fractures in 90 patients were retrospectively reviewed in this study. The cohort was categorized into two groups that were treated in accordance with the institutional prescribed regimen in different periods: (1) cefazolin plus aminoglycoside (January 1, 2014-September 30, 2017) and (2) ABPC/SBT monotherapy (October 1, 2017-September 30, 2020). Cefazolin was used at 1-2 g every 8 h, aminoglycoside (amikacin or gentamicin) was used daily depending on body weight, and ABPC/SBT was used at 3 g every 8 h The antibiotic administration was continued within 3 days or until successful soft tissue coverage was achieved. The infection rate and the incidence of acute kidney injury (AKI) in both groups were assessed. RESULTS: ABPC/SBT was used in 34 patients (36 fractures), and 56 patients (59 fractures) received cefazolin plus aminoglycoside for antibiotic prophylaxis. Infection developed in 2 of 36 fractures in ABPC/SBT group and 4 of 59 fractures in the cefazolin plus aminoglycoside group (p > 0.99). The average serum creatinine levels on admission, baseline, and peak during the hospital stay were not significantly different between the two groups. One case of AKI was identified in each group, indicating that incidence rate of AKI was not significantly different between the two groups. CONCLUSION: We demonstrated the non-inferiority of ABPC/SBT therapy over cefazolin plus aminoglycoside regimen for type IIIA open fractures. The ABPC/SBT regimen may be an alternative option for managing Gustilo type IIIA open fractures. Further prospective studies with larger samples are needed to verify these results.