Equivalence trial of proposed denosumab biosimilar GP2411 and reference denosumab in postmenopausal osteoporosis: the ROSALIA study.

Denosumab is a monoclonal antibody used to reduce risk of fractures in osteoporosis. ROSALIA was a multicenter, double-blind, randomized, integrated phase I/phase III study comparing the efficacy, pharmacokinetics (PK), pharmacodynamics (PD), immunogenicity, and safety of proposed biosimilar denosumab GP2411 with reference denosumab (REF-DMAb) (Prolia®; Amgen). Postmenopausal women with osteoporosis were randomized 1:1 to 2 60-mg doses of GP2411 or REF-DMAb, one at study start and one at week 26. At week 52, the REF-DMAb group was re-randomized 1:1 to a third dose of REF-DMAb or switch to GP2411. The primary efficacy endpoint was percentage change from baseline (%CfB) in LS-BMD at week 52. Secondary efficacy endpoints were %CfB in LS-BMD, FN-BMD, and TH-BMD at weeks 26 and 78 (and week 52 for FN-BMD and TH-BMD). Primary PK and PD endpoints were the area under the serum concentration-time curve extrapolated to infinity and maximum drug serum concentration at week 26, and the area under the effect-time curve of the %CfB in serum CTX at week 26. Secondary PK and PD endpoints included drug serum concentrations and %CfB in serum CTX and P1NP during the study period. Similar efficacy was demonstrated at week 52, with 95% CIs of the difference in %CfB in LS-BMD between treatment groups fully contained within prespecified equivalence margins. Similarity in PK and PD was demonstrated at week 26. Immunogenicity was similar between groups and was not impacted by treatment switch. The rate of new vertebral fractures was comparable. Treatment-emergent adverse events were comparable between groups (63.6% [GP2411/GP2411]; 76.0% [REF-DMAb/REF-DMAb]; 76.6% [REF-DMAb/GP2411]). In conclusion, ROSALIA showed similar efficacy, PK and PD, and comparable safety and immunogenicity of GP2411 to REF-DMAb in postmenopausal osteoporosis.

Denosumab is a biologic treatment that stops bone breakdown. This clinical trial evaluated how similar GP2411 (a denosumab biosimilar in development) is compared with European-approved reference denosumab in women with post-menopausal osteoporosis. Biosimilars are highly similar to the original treatment ('reference denosumab') and may have a lower price. 263 patients were randomly assigned to receive GP2411 and 264 to reference denosumab. Treatment was given at the study beginning, at Week 26 and at Week 52. 124 patients were re-assigned at Week 52 to test the effect of changing from reference denosumab to GP2411. The study showed similarity in how the body interacts with the treatments, what effects the treatment has (both measured over 26 weeks), and bone mineral density (measured over 78 weeks). Antibody responses to GP2411 were detected in similar proportions of patients on each treatment. Reported adverse events were similar between treatments before Week 52, and from Week 52 to 78, and <5% of patients experienced serious adverse events. A change of treatment from reference denosumab to GP2411 did not affect outcomes. These results showed similarity between GP2411 and reference denosumab in this population. In future, GP2411 may enable more patients to benefit from denosumab.

A guide to the BRAIN Initiative Cell Census Network data ecosystem.

Characterizing cellular diversity at different levels of biological organization and across data modalities is a prerequisite to understanding the function of cell types in the brain. Classification of neurons is also essential to manipulate cell types in controlled ways and to understand their variation and vulnerability in brain disorders. The BRAIN Initiative Cell Census Network (BICCN) is an integrated network of data-generating centers, data archives, and data standards developers, with the goal of systematic multimodal brain cell type profiling and characterization. Emphasis of the BICCN is on the whole mouse brain with demonstration of prototype feasibility for human and nonhuman primate (NHP) brains. Here, we provide a guide to the cellular and spatial approaches employed by the BICCN, and to accessing and using these data and extensive resources, including the BRAIN Cell Data Center (BCDC), which serves to manage and integrate data across the ecosystem. We illustrate the power of the BICCN data ecosystem through vignettes highlighting several BICCN analysis and visualization tools. Finally, we present emerging standards that have been developed or adopted toward Findable, Accessible, Interoperable, and Reusable (FAIR) neuroscience. The combined BICCN ecosystem provides a comprehensive resource for the exploration and analysis of cell types in the brain.

Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial.

BACKGROUND: Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA. METHODS: In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days). RESULTS: Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point. CONCLUSION: Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.

Intermediate-Term Survivorship of Metaphyseal Cones and Sleeves in Revision Total Knee Arthroplasty.

BACKGROUND: Both cones or sleeves have been developed to address metaphyseal bone loss in revision total knee arthroplasty (TKA), but few studies have directly compared the outcomes. The purpose of this study was to compare the survivorship and aseptic revision rates between metaphyseal cones and sleeves at intermediate follow-up. METHODS: We reviewed a consecutive series of 1,172 revision TKA patients between 2009 and 2018 with a minimum two-year follow-up on all patients. We compared demographics, surgical indication, stem fixation, constraint, rates of rerevision, and Short-Form-12 scores between patients with cones and sleeves. A multivariate analysis was performed to identify the effect of cones and sleeves on aseptic rerevision. Kaplan-Meier curves were generated to compare aseptic survivorship of cones and sleeves. RESULTS: There were 194 tibial cones (17%), 107 tibial sleeves (9%), 31 femoral cones (3%), and 135 femoral sleeves (12%) with a mean follow-up of 6.5 years (range: 2-12 years). There was no difference in demographics, indication, stem fixation, or constraint (P > .05). Although overall aseptic failure rates may be lower for tibial sleeves, there were no significant differences in survivorship over a one-year, two-year, and five-year follow-up when both tibial and femoral sleeves were directly compared to cones. CONCLUSION: Both tibial and femoral sleeves and cones perform well at an intermediate-term follow-up. Further investigation of these two are required to better understand their survivorship relative to each other.

Staged BiCompartmental Knee Arthroplasty has Greater Functional Improvement, but Equivalent Midterm Survivorship, as Revision TKA for Progressive Osteoarthritis After Partial Knee Arthroplasty.

BACKGROUND: Progressive arthritis in the unresurfaced compartments of the knee is one failure mode after partial knee arthroplasty (PKA). While progressive arthritis after PKA is typically treated with revision to TKA (rTKA), staged bicompartmental knee arthroplasty (sBiKA) -the addition of another PKA - is an alternative. This study compared outcomes of sBiKA and rTKA for progressive arthritis after PKA. METHODS: A retrospective comparative study of non-consecutive cases at four institutions were performed in patients with an intact PKA, without loosening or wear, who underwent sBiKA (n = 27) or rTKA (n = 30), for progressive osteoarthritis. Outcomes studied were new Knee Society Function and Objective Scores (KSSF, KSSO), KOOS, Jr., ROM, operative times, length of stay, complication rates and the need for reoperations. RESULTS: Mean time to conversion was 7.4 ± 6 years for sBiKA and 9.7 ± 8 for rTKA, P = .178. Patient demographics and pre-operative outcomes were similar among cohorts. At an average of 5.7 ± 3 (sBiKA) and 3.2 ± 2 years (rTKA), KOOS, Jr. significantly improved, P < .001, by an equivalent amount. Post-operative KSSO and KSSF were significantly higher in the sBiKA cohort, respectively, (90.4 ± 10 vs 72.1 ± 20, P < .001) and (80.3 ± 18 vs 67.1 ± 19, P = .011). sBiKA patients had significantly greater improvement in KSSO (30.7 ± 33 vs 5.2 ± 18, P = .003). One sBiKA patient underwent reoperation for continued pain. CONCLUSION: SBiKA has equivalent survivorship, but greater improvement in functional outcomes as rTKA at short to midterm follow-up. Given the shorter operative times and length of stay, sBiKA is a safe and cost-effective alternative to rTKA for progressive osteoarthritis following PKA. Nevertheless, further follow-up is necessary to determine whether sBiKA is a durable option.

Modern Revision Femoral Stem Designs Have No Difference in Rates of Subsidence.

BACKGROUND: Both modular and monoblock tapered fluted titanium (TFT) stems have gained popularity over fully porous-coated cylindrical (FPCC) femoral stem designs, but limited data exist comparing subsidence rates following revision total hip arthroplasty (THA). The purpose of this study is to determine differences in subsidence and clinical outcomes among 3 revision femoral stem designs. METHODS: We reviewed a consecutive series of 335 patients who underwent femoral component revision to a cementless modular TFT (n = 225), monoblock TFT (n = 63), or FPCC (n = 47) stem between 2012 and 2019. We evaluated radiographic subsidence rates, re-revision rates, and patient-reported outcomes between the 3 stems. A multivariate regression analysis was performed to determine the independent effect of stem type on the risk of subsidence >5 mm. RESULTS: At an average follow-up of 39 months (range, 12 to 96 months), there were no differences in mean subsidence rates (3.5 vs 2.4 vs 2.1 mm, P = .14), HOOS Jr scores (78 vs 74 vs 64 points, P = .15), or aseptic re-revision rates (4% vs 3% vs 0%, P = .29) between modular TFT, monoblock TFT, and FPCC stems. Although modular TFT stems were more often used in patients with extensive femoral bone loss (Paprosky III and IV), there were no differences in subsidence rates >5 mm among the 3 stems (P > .05) in multivariate analysis. CONCLUSION: Modular TFT, monoblock TFT, and FPCC femoral stem designs all perform well in revision THA with no difference in clinical outcomes or subsidence rates. Surgeons should select the stem which they feel is the most clinically appropriate.

Accuracy and Validity of Computer Adaptive Testing for Outcome Assessment in Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: Computerized adaptive test (CAT) questionnaires may allow standardization of patient-reported outcome measures and reductions in questionnaire burden. We evaluated the validity, accuracy, and efficacy of a CAT system in patients with end-stage osteoarthritis undergoing total knee arthroplasty. METHODS: CAT Knee Osteoarthritis Outcome Scores (KOOS) and CAT KOOS-JR questionnaires were applied to 1871 standard form KOOS and 1493 KOOS-JR patient responses, respectively. Mean, standard deviations, Pearson's correlation coefficients, interclass correlation coefficients (ICCs), frequency distribution plots, and Bland-Altman plots were used to compare the precision, validity, and accuracy between CAT scores and full-form scores. RESULTS: There was a mean reduction of 14 questions (33%) in the CAT KOOS and 1.4 questions (20%) with the CAT KOOS-JR version, compared with the standard KOOS and KOOS-JR surveys, respectively. There were no significant differences between KOOS and CAT KOOS scores with respect to pain (P = .66), symptoms (P = .43), quality of life (P = .99), activities of daily living (P = .68), and sports (P = .84). Similarly, there were no significant differences between the standard form KOOS-JR and CAT KOOS-JR scores (P = .94). There were strong correlations with minimal variability between the CAT KOOS and standard KOOS questionnaires for pain (r = 0.98, ICC: 0.98), symptoms (r = 0.97, ICC: 0.97), quality of life scores (r = 0.99, ICC: 0.99), activities of daily living scores (r = 0.99, ICC: 0.99), and sports scores (r = 0.99, ICC: 0.99). Similarly, there were strong correlations between the KOOS-JR and the CAT KOOS-JR scores (r = 0.99, ICC: 0.99). CONCLUSION: CAT KOOS and the CAT KOOS-JR versions are accurate and reduce questionnaire burden up to one-third compared with standard surveys. CAT versions may improve patient compliance and decrease fatigue.

Semantic segmentation of microscopic neuroanatomical data by combining topological priors with encoder-decoder deep networks.

Understanding of neuronal circuitry at cellular resolution within the brain has relied on neuron tracing methods which involve careful observation and interpretation by experienced neuroscientists. With recent developments in imaging and digitization, this approach is no longer feasible with the large scale (terabyte to petabyte range) images. Machine learning based techniques, using deep networks, provide an efficient alternative to the problem. However, these methods rely on very large volumes of annotated images for training and have error rates that are too high for scientific data analysis, and thus requires a significant volume of human-in-the-loop proofreading. Here we introduce a hybrid architecture combining prior structure in the form of topological data analysis methods, based on discrete Morse theory, with the best-in-class deep-net architectures for the neuronal connectivity analysis. We show significant performance gains using our hybrid architecture on detection of topological structure (e.g. connectivity of neuronal processes and local intensity maxima on axons corresponding to synaptic swellings) with precision/recall close to 90% compared with human observers. We have adapted our architecture to a high performance pipeline capable of semantic segmentation of light microscopic whole-brain image data into a hierarchy of neuronal compartments. We expect that the hybrid architecture incorporating discrete Morse techniques into deep nets will generalize to other data domains.

Accuracy and Validity of Computer Adaptive Testing for Outcome Assessment in Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: Probability-based computer algorithms that reduce patient burden are currently in high demand. These computer adaptive testing (CAT) methods improve workflow and reduce patient frustration, while achieving high measurement precision. In this study, we evaluated the accuracy and validity of the CAT Hip Disability and Osteoarthritis Outcome Score (HOOS) and the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR) by comparing them to the full version of these scoring systems in a subset of patients who had undergone total hip arthroplasties. METHODS: A previously developed CAT HOOS and HOOS-JR was applied to 354 and 1547 HOOS and HOOS-JR patient responses, respectively. Mean, standard deviations, Pearson's correlation coefficients, interclass correlation coefficients, frequency distribution plots, and Bland-Altman plots were used to compare the precision, validity, and accuracy between CAT scores and full-form scores. RESULTS: By modifying the questions to past responses, the CAT HOOS demonstrated a mean reduction of 30% of questions (28 vs 40 questions). There were no significant differences between the full HOOS and CAT HOOS with respect to pain (P = .73), symptoms (P = .94), quality of life (P = .99), activities of daily living (P = .82), and sports (P = .99). There were strong linear relationships between the CAT versions and the standard questionnaires (r > 0.99). The Bland-Altman plot showed that differences between CAT HOOS and full HOOS were independent of the overall scores. CONCLUSION: The CAT HOOS and HOOS-JR have high correlation and require fewer questions to finish compared to the standard full-form questionnaires. This may represent a reliable and practical alternative that may be less burdensome to patients and may help improve compliance for reporting outcome metrics.

Propionibacterium acnes Osteomyelitis after Intraosseous Cannulation in a Child.

Propionibacterium acnes osteomyelitis secondary to intraosseous (IO) cannulation is not well documented in literature. We report here an extremely rare incident of P. acnes tibial osteomyelitis at the IO access site, in a 4-year-old child, who presented 3 months after an episode of fluid resuscitation for streptococcal toxic shock syndrome necessitating irrigation and debridement and prolonged antibiotic therapy. We advocate for heightened awareness of osteomyelitis in patients with continued pain after IO cannulation. Low-grade persistent symptoms may be caused by less virulent organisms and may dictate need for early magnetic resonance imaging studies for diagnosis and treatment planning.

Prostheses for reverse total shoulder arthroplasty.

INTRODUCTION: Historically, patients with rotator cuff arthropathy had limited reconstructive options. The early generations of reverse total shoulder arthroplasty (rTSA) designs had increased failure rates due to loosening of glenoid baseplates secondary to excessive torques. In 1985, Paul Grammont introduced a prosthetic design changing the center of rotation that addressed this major complication. The Grammont principles remain the foundation of modern reverse total shoulder prostheses, although the original design has undergone several adaptations. We reviewed here the various aspects of prosthetic designs including baseplates, glenospheres, humeral components, and polyethylene bearing interfaces. AREAS COVERED: We discuss the evolution, biomechanics, prosthetic options, and future direction for rTSA. A literature search using the PubMed database including review articles, biomechanical studies, and clinical trials pertaining to rTSA prothesis and outcomes. EXPERT COMMENTARY: Despite an expansion in the understanding of the biomechanics of the rotator cuff deficient shoulder and its effect on the reverse total shoulder prostheses, Grammont principles remain the foundation of contemporary rTSA designs. Further clinical studies are needed to assess how modern prosthetic modifications effect clinical and radiographic outcomes. Additionally, implants are being used in younger individuals with expanded indications, therefore, close clinical monitoring is needed to better evaluate their prosthetic longevity.

Safe Zones for Anterior Acetabular Retractor Placement in Direct Anterior Total Hip Arthroplasty: A Cadaveric Study.

INTRODUCTION: There is paucity of literature evaluating anterior acetabular retractor proximity to the femoral nerve and external iliac vessels during total hip arthroplasty through the direct anterior approach. In this cadaveric study, we evaluated three retractor locations to identify optimal positioning of anterior retractors. METHODS: A direct anterior approach was performed in 22 hips of 15 cadavers. Anterior acetabular retractors were placed over the anterior acetabular wall in-line with the femoral neck (12-o'clock or middle position). The anterior neurovascular structures were identified through the ilioinguinal approach. Retractors were reinserted at 10-o'clock (right hip; superior) and 2-o'clock (right hip; inferior) locations marked using K-wires. Horizontal and vertical distances from retractor tip positions to neurovascular structures were measured with a digital caliper. RESULTS: Retractor tips moved significantly from lateral to the femoral nerve when placed in the superior position (mean, 2.8 mm) to medial to the femoral nerve in the middle (mean, -2.3 mm) and inferior (mean, -4.8 mm) locations. Retractor tips moved significantly medial toward the external iliac artery when retractors were moved from superior (mean, 15.3 mm) to inferior (mean, 6.6 mm) positions placing the retractor tip closer to the vessels. CONCLUSION: As retractor placements moved inferior, retractor tips moved medial to neurovascular structures. Inferior retractor positioning placed the femoral nerve and external iliac artery at the risk of injury during the initial retractor placement or adjustment. Retractors should be placed in a relative safe zone superior to the 12-o'clock position to avoid damage to neurovascular structures. LEVEL OF EVIDENCE: IV.

Advances in Wound Management.

Wound management is a notable healthcare and financial burden, accounting for >$10 billion in annual healthcare spending in the United States. A multidisciplinary approach involving orthopaedic and plastic surgeons, wound care nursing, and medical and support staff is often necessary to improve outcomes. Orthopaedic surgeons must be familiar with the fundamental principles and evidenced-based concepts for the management of acute and chronic wounds. Knowledge of surgical dressings, negative pressure wound therapy, tissue expanders, dermal apposition, biologics, and extracellular matrices can aide practitioners in optimizing wound care.

Estimating relative efficacy in acute postoperative pain: network meta-analysis is consistent with indirect comparison to placebo alone.

Network meta-analysis uses direct comparisons of interventions within randomized controlled trials and indirect comparisons across them. Network meta-analysis uses more data than a series of direct comparisons with placebo, and theoretically should produce more reliable results. We used a Cochrane overview review of acute postoperative pain trials and other systematic reviews to provide data to test this hypothesis. Some 261 trials published between 1966 and 2016 included 39,753 patients examining 52 active drug and dose combinations (27,726 given active drug and 12,027 placebo), in any type of surgery (72% dental). Most trials were small; 42% of patients were in trials with arms <50 patients, and 27% in trials with arms ≥100 patients. Response to placebo in third molar extraction fell by half in studies over 30 to 40 years (171 trials, 7882 patients given placebo). Network meta-analysis and Cochrane analyses provided very similar results (average difference 0.04 number needed to treat units), with no significant difference for almost all comparisons apart from some with small patient numbers or small effect size, or both. Network meta-analysis did not detect significant differences between effective analgesics. The similarity between network meta-analysis and Cochrane indirect analyses probably arose from stringent quality criteria in trials accepted in Cochrane reviews (with consequent low risk of bias) and consistency in methods and outcomes. Network meta-analysis is a useful analytical tool that increases our confidence in estimates of efficacy of analgesics in acute postoperative pain, in this case by providing similar results.

Tissue expanders with a focus on extremity reconstruction.

INTRODUCTION: Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. AREAS COVERED: In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. EXPERT COMMENTARY: An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

Lateral Subtalar Dislocation with Tarsometatarsal Dislocation: A Case Report of a Rare Injury.

Dislocation of the fourth and fifth tarsometatarsal joints in conjunction with lateral subtalar dislocation is a rare occurrence. Little is known about the mechanism of injury, the appropriate treatment for this condition, and its ultimate prognosis. In this report, we describe this atypical presentation in a middle aged, otherwise healthy male who sustained a trivial twisting injury to the ankle when he slipped and fell on ice. Open reduction and K-wire fixation were necessary to affix the lateral tarsometatarsal and talonavicular joints. At one year postoperatively, he was able to return to his preinjury occupation with mild to moderate pain with prolonged walking. His Foot and Ankle Disability Index and American Orthopaedic Foot and Ankle Society scores were 64 and 65 points, respectively. Surgical intervention resulted in a stable plantigrade foot; however, the patient had early radiographic evidence of posttraumatic arthritis in the midfoot joints at one-year follow-up.

Blastomycotic Osteomyelitis: An Unusual Cause of Hand Swelling.

Isolated blastomycosis hand infections are extremely rare, and are often clinically unsuspected, leading to delays in clinical diagnosis. Conclusive diagnosis often necessitates fungal cultures and histopathological demonstration of budding yeasts in tissues. In this report, we describe the rare occurrence of isolated blastomycotic hand infection, without any other organ involvement, in a 42-year-old male patient. Analyzing tissue specimens with frozen section has been shown in the past to demonstrate granulomatous inflammation and yeast forms of the organism; however, as demonstrated in this patient, the presence of pseudoepitheliomatous cells may deceptively appear as malignant, causing substantial concern and anxiety. Definitive diagnosis often necessitates fungal culture and histopathological examination with special fungal stains including polymerase chain reaction for speciation.

Ipsilateral Rupture of Quadriceps Tendon with Distal Tibia Fracture: A Case Report and Review of the Literature.

Traumatic rupture of the quadriceps tendon by itself is not an uncommon clinical condition. However, its association with concurrent ipsilateral closed distal tibia oblique fracture is exceedingly rare with only one previously reported case in English literature. The dual diagnosis of this atypical combination of injury may be masked by pain and immobilization of the more obvious fracture and may be missed, unless the treating physician maintains a high index of suspicion. Suprapatellar knee pain with or without a palpable gap in the quadriceps tendon and inability to straight leg raise in the setting of a distal tibia fracture should raise concern, but if initial treatment employs a long-leg splint the knee symptoms may be muted. In this report, we describe this unusual combination of injury in a 67-year-old male patient who sustained a trivial twisting injury to the leg. The aim of this report is to raise awareness and emphasize the importance of thorough and repeated clinical examinations in the presence of distracting injuries. Despite the complexity of the problem, standard techniques for quadriceps tendon repair using transpatellar bone tunnels following locked intramedullary rodding of the tibia fracture may lead to optimal outcomes.