Single-bundle ACL combined with ALL reconstruction yields comparable outcomes in patients with varied anatomical risk factors for ACL graft failure.

BACKGROUND: Anterior cruciate ligament (ACL) graft failure is influenced by factors such as meniscal tears and tibial plateau slope. Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has reduced failure rates; however, its efficacy in high-risk patients remains unclear. This study hypothesized that combined ACL and ALL reconstruction would yield similar clinical outcomes in patients with varying risks of ACL failure. PATIENTS AND METHODS: A total of 76 patients who underwent primary single-bundle ACL reconstruction combined with ALL reconstruction between June 2018 and June 2021 were included. The medial tibial slope (MTS), lateral tibial slope (LTS), and anterior tibial translation (ATT) were measured using magnetic resonance imaging and plain radiography of the knee joint. The meniscal lesions were assessed during surgery. Preoperative clinical assessments and final follow-up were conducted using patient-reported outcome measurements (PROMs), including the International Knee Documentation Committee (IKDC) evaluation, Lysholm knee scoring scale, and Tegner Activity scale. PROMs were collected at least two years postoperatively. RESULTS: The average follow-up was 32.5 ± 7.4 months. There were no significant differences in postoperative IKDC score, Lysholm score, or Tegner activity score between patients with or without medial meniscus injury (p = 0.155, 0.914, and 0.042, respectively), with or without lateral meniscus injury (p = 0.737, 0.569, and 0.942, respectively), medial tibial slope > 12° or ≤ 12° (p = 0.290, 0.496, and 0.988, respectively), or lateral tibial slope > 7.4° or ≤ 7.4° (p = 0.213, 0.625, and 0.922, respectively). No significant correlations were found between anterior tibial translation and postoperative IKDC (R = -0.058, p = 0.365), Lysholm (R = -0.017, p = 0.459), or Tegner activity scores (R = -0.147, p = 0.189). CONCLUSION: Our study demonstrates that single-bundle ACL reconstruction combined with ALL reconstruction provides reliable and comparable clinical outcomes in patients with high-risk factors for ACL graft failure, such as increased tibial slope or meniscal injury. Our results suggest that the indications for ALL reconstruction may be expanded to include patients with a high tibial slope or meniscal injury, because these factors have been shown to contribute to increased rotational instability and high rates of ACL graft failure. Future prospective randomized controlled trials with large patient cohorts and long follow-up periods are needed to validate these findings and establish clear guidelines for patient selection and surgical decision-making. LEVEL OF EVIDENCE: Level 3.

Double-bundle ACL combined with ALL reconstruction for patients at high risk of ACL failure: clinical and radiological results.

BACKGROUND: We investigated whether double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (ACLR) combined with anterolateral ligament reconstruction (ALLR) improved clinical and radiological outcomes in patients at high risk of ACL failure. The primary outcome was graft failure, and secondary outcomes included knee stability and patient-reported outcome measures (PROMs). PATIENTS AND METHODS: Fifty-two patients who underwent DB ACLR combined with ALLR were included in this retrospective cohort study. Preoperative risk factors, including femorotibial angle (FTA), lateral tibial slope (LTS), medial tibial slope (MTS), and meniscal tears, were assessed using X-ray and magnetic resonance imaging (MRI). The grade of post-operative pivot shift, Lysholm score, and Tegner activity score were used to assess clinical outcomes. The minimum follow up duration was 2 years. RESULTS: The cohort (mean age, 26.1 ± 9.4 years; 51.9% male) had a mean follow-up duration of 28.9 ± 3.4 months. Preoperatively, 57.8% had lateral meniscus (LM) tears, and 61.0% had a grade 2-3 pivot shift. Postoperatively, no graft failures or revision cases occurred during follow-up. Approximately 90.4% of the patients exhibited a negative pivot shift (p < 0.001), with Lysholm and Tegner activity scores of 92.5 ± 6.1 and 5.1 ± 2.0. The medial meniscus (MM) tear group had a significantly smaller FTA than the intact group (p = 0.043). No significant differences in PROMs were found between the LM tear and intact LM groups or between the high and low MTS or LTS groups (p = n.s.). CONCLUSION: DB ACLR combined with ALLR had satisfactory clinical outcomes in patients at high risk of ACL failure, with no graft failures observed during a mean follow-up duration of 2.4 years. The technique effectively reduced the postoperative pivot shift, regardless of preoperative risk factors. STUDY DESIGN: Level IV, retrospective therapeutic case-series. TRAIL REGISTRATION: ethical approval number, 202300134B0; ethical committee, the Institutional Review Board of Chang Gung Medical Foundation.

Anatomic versus Low Tibial Tunnel in Double-Bundle Posterior Cruciate Ligament Reconstruction: Clinical and Radiologic Outcomes with a Minimum 2-Year Follow-Up.

There is currently no consensus on the optimal placement of the tibial tunnel for double-bundle posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare the clinical and radiologic outcomes of double-bundle PCL reconstruction utilizing anatomic versus low tibial tunnels. We conducted a retrospective cohort study involving patients who underwent double-bundle PCL reconstruction between Jan 2019 and Jan 2022, with a minimum follow-up of 2 years (n = 36). Based on the tibial tunnel position on postoperative computed tomography, patients were categorized into two groups: anatomic placement (group A; n = 18) and low tunnel placement (group L; n = 18). We compared the range of motion, stability test, complications, and side-to-side differences in tibial posterior translation using kneeling stress radiography between the two groups. There were no significant differences between the groups regarding clinical outcomes or complication rates. No significant differences in the posterior drawer test and side-to-side difference on kneeling stress radiography (2.5 ± 1.2 mm in group A vs. 3.7 ± 2.0 mm in group L; p = 0.346). In conclusion, the main findings of this study indicate that both anatomic tunnel and low tibial tunnel placements in double-bundle PCL reconstruction demonstrated comparable and satisfactory clinical and radiologic outcomes, with similar overall complication rates at the 2-year follow-up.

Arthroscopic Lower Trapezius Tendon Transfer for a Patient with Axillary Nerve Injury and Concomitant Rotator Cuff Tear: A Case Report and Technical Notes.

Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

Using Single Peroneal Longus Tendon Graft for Segmental Meniscus Transplantation and Revision Anterior Cruciate Ligament Combined Anterolateral Reconstruction.

This case report describes a new approach to segmental meniscal reconstruction using a peroneal longus autograft in a patient with recurrent traumatic medial meniscus tear and anterior cruciate ligament reconstruction (ACLR) failure. While allograft meniscal transplantation is the preferred method for treating meniscal deficiency, its high cost and various legal regulations have limited its widespread use. Autologous tendon grafts have been proposed as a substitute for allograft meniscus transplantation, but their initial results were poor, leading to little progress in this area. However, recent animal experiments and clinical studies have demonstrated promising results in using autologous tendon grafts for meniscal transplantation, including improvements in pain and quality of life for patients. Further research is needed to evaluate the effectiveness of segmental meniscal reconstruction using autologous tendon grafts, but it could potentially lead to more accessible and cost-effective treatment options for patients with meniscal deficiency.

Reconstruction of High-Grade Trochlea Dysplasia in a Young Female with Recurrent Patella Dislocation: A Case Report.

The patellofemoral joint involves a combination of bony structures and soft tissues to maintain stability. Patella instability is a disabling condition, and the cause is multifactorial. The main risk factors include patella alta, trochlea dysplasia, excessive tibial tuberosity to trochlea grove (TT-TG) distance, and excessive lateral patella tilt. In this case report, we highlight the thinking process of diagnosis and method for selecting the optimal treatment in accordance with the guidelines by Dejour et al. when we are presented with a patient with patella instability. A 20-year-old Asian woman without underlying medical conditions, presented with recurrent (>3 episodes) right patella dislocation for 7 years. Investigations revealed a type D trochlea dysplasia, increased TT-TG distance, and excessive lateral tilt angle. She underwent trochlea sulcus deepening, sulcus lateralization and lateral facet elevation, lateral retinacular release, and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction. Due to the complexity behind the anatomy and biomechanics of patella instability, an easy-to-follow treatment algorithm is essential for the treating surgeon to provide effective and efficient treatment. MQTFL reconstruction is recommended for recurrent patella dislocation due to satisfactory clinical and patient reported outcomes and a reduced risk of iatrogenic patella fracture. Controversies for surgical indication in lateral retinacular release, and whether the sulcus angle is an accurate parameter for diagnosis of trochlea dysplasia, remain, and further research is required.

Outcomes of Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction According to GNRB Arthrometer Measurement.

Background and Objectives: To investigate the prognosis of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction, we used a GNRB (Genourob, Laval, France) arthrometer to measure surgical outcomes. Materials and Methods: This retrospective study reviewed patients who underwent combined ACL and ALL reconstruction and had a minimum follow-up of 2 years. Subjective outcomes, namely the International Knee Documentation Committee (IKDC) evaluation form scale scores and Lysholm scores, were evaluated preoperatively and postoperatively. We used a GNRB arthrometer to test the side-to-side laxity under pressures of 134 and 200 N, and we calculated the differential of the slope of the curves. We also recorded complications. Results: Our study examined 18 patients (mean age: 30.56 ± 8.9 years, range: 19-53) with a mean follow-up of 27.37 ± 3.4 months (range: 24-36). Both Lysholm and IKDC scores were significantly improved following the operation. The GNRB arthrometer measured mean anteroposterior laxity side-to-side as 0.76 ± 0.78 mm and 0.82 ± 0.8 mm under pressures of 134 and 200 N, respectively. The mean side-to-side differential slope under 200 N was 3.52 ± 2.17 µm/N. These values indicated that patients displayed no graft tear or low functional knee instability. All patients had a grade 3 pivot shift preoperatively; only two patients had a grade 1 pivot shift postoperatively, with the rest having a negative pivot shift. Conclusions: Our study revealed that combined ACL and ALL reconstruction has an excellent prognosis. GNRB measurement demonstrated excellent stability, and most patients had no residual pivot shift.

Difference analysis of the glenoid centerline between 3D preoperative planning and 3D printed prosthesis manipulation in total shoulder arthroplasty.

INTRODUCTION: Excessive version and inclination of the glenoid component during total shoulder arthroplasty can lead to glenohumeral instability, early loosening, and even failure. The orientation and position of the central pin determine the version and inclination of the glenoid component. The purpose of this study was to compare the differences in centerline position and orientation obtained using "3D preoperative planning based on the best-fit method for glenoid elements" and the surgeon's manipulation. MATERIALS AND METHODS: Twenty-nine CT images of glenohumeral osteoarthritis of the shoulder were reconstructed into a 3D model, and a 3D printer was used to create an in vitro model for the surgeon to drill the center pin. The 3D shoulder model was also used for 3D preoperative planning (3DPP) using the best-fit method for glenoid elements. The in vitro model was scanned and the version, inclination and center position were measured to compare with the 3DPP results. RESULTS: The respective mean inclinations (versions) of the surgeon and 3DPP were -2.63° ± 6.60 (2.87° ± 5.97) and -1.96° ± 4.24 (-3.21° ± 4.00), respectively. There was no significant difference in the inclination and version of the surgeon and 3DPP. For surgeons, the probability of the inclination and version being greater than 10° was 13.8% (4/29) and 10.3% (3/29), respectively. Compared to the 3DPP results, the surgeon's center position was shifted down an average of 1.63 mm. There was a significant difference in the center position of the surgeon and 3DPP (p < 0.05). CONCLUSION: The central pin drilled by surgeons using general instruments was significantly lower than those defined using 3D preoperative planning and standard central definitions. 3D preoperative planning prevents the version and inclination of the centerline from exceeding safe values (± 10°).

Comparison of hook plate alone, hook plate augmented with suture anchor, and arthroscopically-assisted tightrope fixation in the treatment of patients with acute type v acromioclavicular joint dislocations.

INTRODUCTION: The best treatment for Rockwood type V acromioclavicular (AC) joint dislocation is unknown. HYPOTHESIS: Hook plate augmented with suture anchor (HA) may have different clinical and radiological results than hook plate alone (H), and arthroscopically assisted TightRope (TR) techniques in treating acute type V AC joint dislocations. MATERIAL AND METHODS: This retrospective study included 71 patients with acute type V AC joint dislocations between December 2010 and August 2018. Patients were categorized into three groups: H group (n=22), HA group (n=23) and TR group (n=26). We measured the coracoclavicular distance (CCD) differences and CCD ratio compared to uninjured side pre-operatively, immediately post-operatively, at 3-month and 2-year after operation. Clinical outcomes were assessed as well at the same time points. Loss of correction was determined by the CCD difference and ratio between surgical and uninjured sides. RESULTS: The mean age and follow-up period were 41.8±24.7 years and 30.2±4.3 months, respectively. No significant differences were found in the demographic data between the three groups. The HA group presented a trend of less overcorrection but without significance compared with the H group at immediately post-operation, 3-month, and 2-year follow-up. (CCD difference: -2.4mm vs. -3.7mm, -1.6mm vs. -1.8, and 0.2mm vs -1.9mm, CCD ratio: 67.7% vs. 40.9%, 79.3% vs. 70.1%, and 100.6% vs. 86.5%, respectively). The HA group also had significantly less loss of correction compared with the TR group at 3-month and 2-year after the operation (CCD difference: -1.6mm vs. 1.6mm, 0.2mm vs. 2.4mm; CCD ratio: 79.3% vs. 122.2%, 100.6% vs. 136.1%, all p<0.05). All three methods achieved significant improvement in function and pain without inter-group differences. No coracoid-related or tunnel complications occurred. DISCUSSION: The hook plate alone, and hook plate with suture anchor augmentation techniques provided less residual vertical instability compared to TightRope fixation at 2-year follow-up. The patient-reported functional outcomes were promising and comparable among the three groups. LEVEL OF EVIDENCE: III, Retrospective comparative therapeutic trial.

Recurrent Shoulder Instability after Arthroscopic Bankart Repair in an Elite Baseball Pitcher-A Case Report.

A 16-year-old right-handed male pitcher had a first-time right anterior shoulder dislocation during a baseball game. X-ray and MRI revealed no apparent glenoid bone loss or Hill-Sachs lesion, but an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion with mild posterolateral decompression of the humerus head. His instability severity index score (ISIS score) was 5 with an on-track lesion. He had an arthroscopic Bankart repair using two all-suture anchors and returned to pitching 6 months after the index surgery. However, he had an unstable sensation after 50 pitches during a game one year postoperatively. This time, he presented with a significant Hill-Sachs lesion and a recurrent APLSA lesion. His ISIS score was 6 with an on-tract lesion. During the arthroscopic examination, the previous suture was stable, while anterior capsuloligament tissues were dislodged from sutures, and a Hill-Sachs lesion was observed. This time, a revision arthroscopic Bankart repair and Remplissage procedure were done on him with four double-loaded soft tissue anchors. Pitchers often develop more external rotation in their throwing arm because of a repetitive stretch of the anterior shoulder capsule and ligaments during pitching. The decrease in external rotation after surgery may limit the pitching speed of the pitcher, making a return to play (RTP) more difficult. There is still a paucity of best evidence to revise a failed arthroscopic Bankart repair in the dominant arm of a pitcher. Arthroscopic Bankart repair and Remplissage procedure have gained increasing popularity because they can provide a stable shoulder without harvesting the coracoid. The Latarjet procedure provides a high RTP rate; however, we did not perform it in the revision surgery and decided to revise the Bankart lesion again on its own with a Remplissage procedure, even with his ISIS score being 6 before the revision surgery. A salvage Latarjet procedure is left as a bailout procedure.

Pneumothorax, an Uncommon but Devastating Complication following Shoulder Arthroscopy: Case Reports.

Shoulder arthroscopy is a mature and widely used treatment to deal with various shoulder disorders. It enables faster recovery and decreases postoperative complications. However, some complications related to shoulder arthroscopy cannot be neglected because they could be life threatening. We presented three cases of various clinical manifestations of pneumothorax after shoulder arthroscopy. The first case was a 65-year-old female who underwent arthroscopic rotator cuff repair under general anesthesia and interscalene nerve block in the beach-chair position. The second case was a 58-year-old male undergoing arthroscopic rotator cuff repair and reduction in glenoid fracture under general anesthesia in the lateral decubitus position. The third case was a 62-year-old man receiving arthroscopic rotator cuff repair under general anesthesia in the lateral decubitus position. Each case's operation time was 90, 240, and 270 min. The pressure of the irrigation pumping system was 30, 50, and 70 mmHg, respectively. The second and third cases did not undergo interscalene nerve block. Although the incidence of pneumothorax following shoulder surgery and interscalene nerve block was only 0.2%, it is one of the most life-threatening complications following shoulder arthroscopy. In these cases, multifactorial factors, including patient positioning, interscalene nerve block, long surgical time, size of rotator cuff tears, and the pressure of the irrigation and suction system, can be attributed to the occurrence of pneumothorax. It is crucial to fully comprehend the diagnosis and management of pneumothorax to reduce the risk for patients receiving shoulder arthroscopy.

Arthroscopic Superior Capsule Reconstruction With Fascia Lata Autograft And In-Situ Biceps Tendon Augmentation: Feasible Outcomes After Minimum Two-Year Follow-Up.

Purpose: To investigate the preliminary functional and radiographic outcomes after arthroscopic superior capsule reconstruction (SCR) with long head of biceps tendon (LHBT) augmentation for irreparable rotator cuff tears (RCTs). Methods: Retrospective review of medical records was conducted in patients receiving unilateral SCR with fascia lata autograft and LHBT augmentation for irreparable RCTs between January 2016 and March 2019. LHBT was adopted when the integrity was intact or partial tear was less than 50% in width. We used all-suture anchors for folded graft patch fixation with 2 in supraglenoid fossa and another 2 plus two knotless anchors via compression suture-bridging technique in greater tuberosity. Reinforced fixation with side-to-side suture was added between infraspinatus tendon and graft patch, and between proximal LHBT and graft to improve force coupling. Clinical and radiographic outcomes including magnetic resonance imaging analysis at 2-year follow-up were investigated and compared with preoperative status. Results: Consecutive 18 patients (mean age, 66.1 years) were included. Mean active forward elevation significantly improved from 75.6° to 157.2° (P < .0001), and external rotation from 33.3° to 53.3° (P < .01). Mean acromiohumeral distance increased from 6.1 ± 2.5 mm to 8.5 ± 2.1 mm (P < .001). The American Shoulder and Elbow Surgeons score improved from 33.8 ± 5.6 to 93.4 ± 5.92 points (P < .00001). Comparable outcomes were found in patients with intact LHBT and those with partial tear. Nine patients had partial tear of graft patch (5, tuberosity side; 4 posterior glenoid); 2 patients had complete tear (tuberosity side) showing inferior outcomes. Conclusions: The index surgery restored superior glenohumeral stability and function of the shoulder with irreparable RCTs. Despite high incidence of partial graft tear, favorable outcomes suggest SCR with biceps tendon augmentation is a feasible treatment for irreparable RCTs. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Autologous Semitendinosus Tendon and Long Head of Biceps Superior Capsule Reconstruction for Massive Irreparable Posterosuperior Rotator Cuff Tears.

We present a surgical technique combining arthroscopic-assisted lower trapezius tendon (LTT) transfer with autologous semitendinosus tendon and long head of biceps tendon (LHBT) superior capsule reconstruction (SCR) for massive irreparable posterosuperior rotator cuff tears. The patients are placed in the beach-chair position with the ipsilateral lower leg prepared simultaneously. After both tendons are harvested, 1 limb of a semitendinosus graft is fixed with the LTT via a Krakow suture. The LHBT is then fixed by an anchor 5 to 8 mm posterior to the bicipital groove and tenotomized distally. The transverse humeral ligament is released afterward to provide better visualization. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove, and drilled posteriorly until it exits at the infraspinatus footprint. Next, 4.5- and 8-mm cannulated drills are used sequentially to create a humeral tunnel. A shuttle suture passed through infraspinatus fascia in the back brings the EndoButton and looped semitendinosus graft from posterior to anterior of the humerus, until the EndoButton flips and is fixed inside the bicipital groove. The shoulder is placed in 45° abduction and 30° external rotation. The free limb of semitendinosus tendon is then sutured with LTT with the desired tension.

Midterm Outcomes After Revision Posterior Cruciate Ligament Reconstruction With a Single-Bundle Transtibial Autograft.

Background: There is a lack of consensus regarding the optimal technique for revision posterior cruciate ligament (PCL) reconstruction. Purpose: To evaluate midterm outcomes after revision PCL reconstruction using a single-bundle transtibial autograft. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 17 patients who underwent revision PCL reconstruction performed in our medical center by a single surgeon from 2003 to 2016. The cohort included 12 male and 5 female patients with a mean age of 31.3 years (range, 17-48 years). All of the patients underwent single-bundle transtibial reconstruction using the same surgical technique and were reviewed at a minimum of 4 years postoperatively. Preoperative and postoperative posterior stress radiography was performed. The preoperative tibial slope and tibiofemoral angle were also measured. Preoperative and postoperative functional outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective and objective scores as well as the Lysholm score. Results: The most common factor that contributed to the failure of primary surgery was misplaced tunnels, especially on the femoral side. There were 2 patients who had grade 2 laxity preoperatively, and 15 patients had grade 3 laxity preoperatively. At the latest follow-up, all 17 patients had grade 1 laxity. On posterior stress radiography, posterior displacement improved from 10.8 ± 2.1 mm preoperatively to 2.9 ± 1.1 mm at the latest follow-up (P < .001). The IKDC subjective score improved from 34.9 ± 6.8 preoperatively to 75.3 ± 15.7 postoperatively (P < .001), and the Lysholm score improved from 38.1 ± 10.0 preoperatively to 88.5 ± 7.6 postoperatively (P < .001). All patients reached the minimal clinically important difference (MCID) for the Lysholm score, and 94% reached the MCID for the IKDC subjective score, with 65% reaching the Patient Acceptable Symptom State. Conclusion: According to the findings of this study, arthroscopic revision PCL reconstruction with a single-bundle transtibial autograft offered satisfactory outcomes at midterm follow-up.

Outcomes of Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years and Younger Than 30 Years.

Background: Few studies have compared the outcomes of anterior cruciate ligament (ACL) reconstruction between older patients and younger patients. Purpose: To evaluate the clinical and functional outcomes of ACL reconstruction with autologous hamstring tendon in patients >50 years and <30 years. It was hypothesized that the outcomes would be comparable between these age groups. Study Design: Cohort study; Level of evidence, 3. Methods: Patients >50 years (older group) or <30 years (younger group) who underwent ACL reconstruction surgery with autologous hamstring tendon between 2012 and 2015 at the authors' hospital were retrospectively enrolled in this study. All patients had a minimum of 2 years of follow-up. Intraoperative findings, including cartilage and meniscal injury, were recorded, and clinical and functional outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores. We used the paired-samples t test for statistical analysis between the 2 age groups. Results: A total of 67 patients and 459 patients were included in the older and younger groups, respectively. Both groups achieved significant preoperative to postoperative improvement in IKDC (older group, from 41.4 to 88.9; younger group, from 49 to 91.2), Lysholm (older group, from 49.8 to 86.1; younger group, from 50.2 to 91.8), and Tegner (older group, from 2.7 to 4.4; younger group, from 4.6 to 6.9) (P < .05 for all) scores. The change in Tegner score from preinjury to postoperatively was not statistically significant in the older group (from 4.5 to 4.4; P = .471), although it was significant in the younger group (from 7.5 to 6.9; P < .05). No between-group differences were noted in preoperative or postoperative IKDC or Lysholm scores. Both age groups reached a high rate of return to sports activity, and no major complications or ACL retears were noted in either group. Conclusion: Comparable results after ACL reconstruction were achieved in patients >50 years compared with patients <30 years, with a high rate of return to sports activity and a low rate of complications at the 2-year follow-up. The younger group returned to a higher Tegner score, while the older group did not.

Clinical and functional outcomes of isolated posterior cruciate ligament reconstruction in patients over the age of 40 years.

BACKGROUND: To assess clinical and functional outcomes of patients aged 40 years or older receiving PCL reconstruction surgery. METHODS: All patients older than 40 years with isolated PCL rupture who underwent PCL reconstruction surgery were enrolled into the retrospective study. Associated meniscal injuries, osteochondral lesions, postoperative complications, and the rate of return to the preinjury level of activity were extracted. Outcomes included International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used to evaluate the clinically relevant value of PCL reconstruction in this population. RESULTS: In total, 41 patients with a mean age of 51.7 years were included. The mean follow-up time was 32.8 months. Associated lesions included meniscal injuries (48.8%) and osteochondral lesions (97.6%). Improvement in the IKDC score (from 46.5 preoperatively to 79.0 postoperatively, p < 0.0001), Lysholm score (from 65.5 to 88.3, p < 0.0001), and Tegner activity score (from 2.3 to 4.0, p < 0.0001) was recorded. The clinically relevant value based on the MCID showed that 34 of 41 patients (82.9%) had a ΔIKDC score exceeding 16.8; all patients (100%) showed a ΔLysholm score exceeding 8.9; and 35 of 41 patients (85.4%) showed a ΔTegner activity score exceeding 0.5. Regarding the PASS, none of the patients had an IKDC score exceeding 75.9 preoperatively, whereas 27 of 41 patients (65.9%) had a score of more than 75.9 postoperatively. All patient had ≥ grade II knee instability preoperatively. Postoperatively, 36 patients (87.8%) had no significant joint translation, and 5 patients (12.2%) had grade I instability. Twenty-one patients (51.2%) returned to their preinjury level of activity. Five patients (12.2%) developed Ahlbäck grade I radiographic osteoarthritis. No rerupture or other major perioperative complications were reported. CONCLUSIONS: PCL reconstruction is a reliable surgery for middle-aged patients suffering from persistent instability even after failed conservative treatment, with significant improvement in patient-reported outcomes that exceeded MCID in the majority of patients, restoration of subjective instability, and approximately half of the patients returned to preinjury activity levels. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Older age and varus alignment lead to early failure in treating patellofemoral osteoarthritis with Fulkerson osteotomy.

Background: It is unclear the risk factors for the failure of modified Fulkerson osteotomy. Methods: We retrospectively reviewed 40 patients who underwent the modified Fulkerson osteotomy from 1998 to 2015. There were 4 males and 36 females. The mean age of the study group was 50.2 ± 11.2 years. We used standard anteriorization measuring 10-15 mm and medialization measuring 10 mm while maintaining an intact periosteal sleeve. Results: Both the patellofemoral angle and the congruence angle improved significantly after 5.9 years. Preoperatively, the mean preoperative Lysholm score was 56.12, and the Knee Society score was 60.52. At the final follow-up, these scores improved significantly to 88.75 and 86.49, respectively. However, eight patients (20%) underwent total knee arthroplasty in the follow-up period, five of whom underwent the operation within 5 years. Comparing the survival and non-survival groups, there was a significant difference of an older age in the TKA conversion group (survival: 48.3 ± 11.1; non-survival: 57.8 ± 8.7, p = 0.03). For knee alignment, the non-survival group had a mean valgus femorotibial angle of 1.8° ± 4.9° preoperatively, and the survival group had a mean valgus angle of 6.4° ± 4.5° (p = 0.03). Conclusions: we found that patients with older age and those with varus alignment have an increased risk of deteriorated medial femorotibial cartilage.

Anatomical Dermal Allograft and Autologous Biceps Long Head Superior Capsule Reconstruction for Irreparable Posterosuperior Rotator Cuff Tears.

Superior capsule reconstruction (SCR) can be performed using fascia lata, dermal allograft, and long head of the biceps tendon (LHBT). We present a Technical Note combining dermal allograft and autologous LHBT, reconstructing the superior capsule's actual anatomical thickness and augmenting with single-stranded LHBT. The glenoid side consists of intact LHBT insertion and is covered with dermal allograft. The lateral side comprises posteriorly transpositioned LHBT, dermal allograft, and repairable remnant cuff. First, 1 suture-based anchor is used to fix the biceps 5 to 8 mm posterior to the bicipital groove, and tenotomy is done distal to it, while the glenoid side of the biceps is preserved. Second, 2 suture-based anchors are used to fix the dermal allograft at the glenoid side by 1 double-pulley and 2 mattress sutures. Third, 2 SwiveLock anchors are used to fix allograft's lateral side by 2 reverse mattress sutures. The tension and coverage of the graft can be determined by the position of the SwiveLock anchors. In this way, fewer anchors are needed than the conventional dermal allograft SCR and larger footprint coverage can be achieved than LHBT SCR. A better spacer effect may be achieved by combining both biological grafts' thickness, mimicking the intact shoulder's true anatomy.

Using MRI Measurement to Improve Accuracy of Femoral Component Sizing in Oxford Unicompartmental Knee Arthroplasty.

Unicompartmental knee arthroplasty (UKA) can achieve better kinematics and faster recovery than total knee arthroplasty. The Phase III Oxford UKA system has five sizes of femoral components to approximate the normal knee geometry. However, these different sizes may also induce problems, such as the misselection of component size. Different criteria have been proposed to predict the ideal size preoperatively. However, no single method can be applied universally. Therefore, this study aimed to develop a preoperative measurement using knee magnetic resonance imaging (MRI) to predict femoral component size. A total of 68 patients who underwent UKA were investigated from June 2019 to April 2020. 16 knees using a different MRI protocol were excluded. We developed an MRI measurement method to determine femoral size instead of gender- and height-based methods. The accuracy of different methods was compared using postoperative true lateral view radiographs. Three different kinds of gender- and height-based criteria, preoperative templating and intraoperative spoon measurement were compared. The accuracy of MRI measurement was 90.3%. Therefore, a significant difference was found between MRI measurements and all other methods, such as templating or gender- and height-based methods. In conclusion, the MRI measurement method can be concluded to accurately predict femoral component size in UKA. This method could be used regardless of different ethnic groups, individual knee geometry, or soft tissue tension.

Clinical Outcomes of Meniscus Repair with or without Multiple Intra-Articular Injections of Platelet Rich Plasma after Surgery.

Preservation of the meniscal volume is crucial in meniscus repair. The goal of this study was to evaluate the clinical outcome of repeated intra-articular platelet-rich plasma (PRP) injections after arthroscopic repair of a traumatic meniscal tear. We retrospectively reviewed 61 primary meniscal repairs in 61 patients (PRP group: 30; non-PRP: 31) from 2017 to 2018. Patients in the PRP group received repeated intra-articular PRP injections in week 2,4,6 after the primary meniscus repair. Subsequent meniscal repair treatment or meniscectomy, knee arthroplasty, and IKDC changes of less than 11.5 points were defined as healing failures. After following up for at least 24 months, the IKDC score was 75.1 ± 13.6, and the Lysholm score was 80.6 ± 14.9 in the PRP group and 72.6 ± 15.8 (IKDC) and 77.7 ± 17.2 (Lysholm) in the non-PRP group. Healing rates of the PRP and the non-PRP groups were 93.3% (Kaplan-Meier 91.6%) and 87.1% (Kaplan-Meier 84.7%), respectively (log rank test p = 0.874). Our study is the first to use multiple intra-articular PRP injections to facilitate meniscal healing after meniscal repair. Though selection bias may be present in this study, the PRP group had similar functional outcome and healing rate compared to non-PRP group.