Postoperative Magnetic Resonance Imaging after Anterior Cruciate Ligament Reconstruction: An Overview and Practical Step-by-step Guide.

Anterior cruciate ligament (ACL) rupture is a frequently encountered injury among athletes, often requiring surgical intervention to restore knee stability. Magnetic resonance imaging (MRI) after ACL reconstruction is common, especially in the evaluation of clinical complications leading to knee instability, decreased range of motion, or pain. This article provides a detailed overview of normal and abnormal postoperative findings including a practical step-by-step guide for MRI assessment. MRI findings must be correlated with surgical technique, time interval from surgery to imaging, and clinical examination.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method.

PURPOSE: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). METHODS: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate'). RESULTS: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). CONCLUSION: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. LEVEL OF EVIDENCE: II.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial.

BACKGROUND: For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. METHODS: This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. DISCUSSION: Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. TRIAL REGISTRATION: Registered at Netherlands Trial Register ( NL9072 ) on 25th of November 2020.

Pain Relief After Operative Treatment of an Extremity Fracture: A Noninferiority Randomized Controlled Trial.

BACKGROUND: Opioid pain medication is frequently given to patients recovering from a surgical procedure for an extremity fracture in spite of evidence that acetaminophen may be adequate. The aim of this study was to determine whether prescription of step 1 pain medication (acetaminophen) is noninferior to step 2 pain medication (acetaminophen and tramadol) after operative treatment of an extremity fracture. METHODS: Fifty-two patients with a single extremity fracture were randomized from July 2012 to March 2015 in this 2-week follow-up, noninferiority trial in a level-I trauma center in the Netherlands. Patients were randomly assigned to receive step 1 (acetaminophen) or step 2 (acetaminophen and tramadol) medication in standard doses on an as-needed basis on discharge. Intention-to-treat and per-protocol analyses were conducted. The primary outcome was self-reported satisfaction with pain relief measured on an 11-point ordinal scale. The hypothesis being tested was formulated before the collection of data. The mean differences between the groups were reported for intention-to-treat and per-protocol analyses. RESULTS: A total of 52 patients, with equal baseline characteristics, were analyzed in this study; the step 1 group consisted of 27 subjects and the step 2 group consisted of 25 subjects. The mean satisfaction with pain management was 8.3 for step 1 and 8.5 for step 2 medications. This mean difference of 0.2 point (95% confidence interval [CI], -0.78 to 1.30 points) did not exceed the noninferiority margin of 2.0 points, indicating that step 1 was noninferior to step 2. A similar result was found in the per-protocol analysis (mean difference, 0.2 point [95% CI, -1.03 to 1.57 points]). CONCLUSIONS: This study offers evidence to suggest that prescription of acetaminophen is not inferior compared with acetaminophen and tramadol in patients who underwent operative treatment for an extremity fracture. Given that tramadol has more side effects and is potentially habit-forming, acetaminophen should be considered the mainstay for pain relief in patients recovering from extremity fracture surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma.

BACKGROUND: The aim of this study was to determine factors associated with self-reported ongoing use of opioid medication one to two months after operative treatment of musculoskeletal trauma. METHODS: Operatively treated patients (n = 145) with musculoskeletal trauma were evaluated one to two months after surgery. Patients indicated if they were taking opioid pain medication and completed several psychological questionnaires: the Center for Epidemiologic Studies Depression Scale, the Pain Catastrophizing Scale, the Pain Anxiety Symptoms Scale, and the Posttraumatic Stress Disorder Checklist, civilian version. The Numeric Rating Scale was used to measure pain intensity. Disability was measured with use of the Short Musculoskeletal Function Assessment Questionnaire and injury severity was measured with use of the Abbreviated Injury Scale. RESULTS: Patients who scored higher on the catastrophic thinking, anxiety, posttraumatic stress disorder, and depression questionnaires were significantly more likely (p < 0.001) to report taking opioid pain medications one to two months after surgery, regardless of injury severity, fracture site, or treating surgeon. The magnitude of disability as measured by the Short Musculoskeletal Function Assessment score was significantly higher (p < 0.001) in the patients who reported using opioids (40 points) compared with those who reported not using opioids (24 points). A logistic regression model not including pain intensity found that the single best predictor of reported opioid use was catastrophic thinking (odds ratio, 1.12 [95% confidence interval, 1.07 to 1.18]), which explained 23% of the variance (p < 0.001). CONCLUSIONS: Patients who continue to use opioid pain medication one to two months after surgery for musculoskeletal trauma have more psychological distress, less effective coping strategies, and greater symptoms and disability than patients who do not take opioids, irrespective of injury, surgical procedure, or surgeon.

Injury complexity factors predict heterotopic ossification restricting motion after elbow trauma.

BACKGROUND: Heterotopic ossification (HO) is a common extrinsic cause of elbow stiffness after trauma. However, factors associated with the development of HO are incompletely understood. QUESTIONS/PURPOSES: We retrospectively identified (1) patient-related demographic factors, (2) injury-related factors, and (3) treatment-related factors associated with the development of HO severe enough to restrict motion after surgery for elbow trauma. We also determined what percentage of the variation in HO restricting motion was explained by the variables studied. METHODS: Between 2001 and 2007, we performed surgery on 417 adult patients for elbow fractures; of these, 284 (68%) were available for radiographs at a minimum of 4 months and clinical review at a minimum of 6 months after surgery (mean, 7.9 months; range, 6­31 months). HO was classified according to the Hastings and Graham system. Patients with HO restricting motion (defined as a Hastings and Graham Class II or III) were compared with patients without HO restricting motion in terms of demographics, fracture location, elbow dislocation, open wound, mechanism of injury, ipsilateral fracture, head trauma, time from injury to surgery, number of surgeries within 4 weeks, total number of surgeries, bone graft, and infection, using bivariate and multivariable analyses. A total of 96 patients had radiographic HO, and in 27 (10% of those available for followup), it restricted motion. RESULTS: There were no patient-related demographic factors that predicted the formation of symptomatic HO. Ulnohumeral dislocation in addition to fracture (odds ratio, 2.38; 95% CI, 1.01­5.64; p = 0.048) but not fracture location was associated with HO. Longer time from injury to definitive surgery and number of surgical procedures in the first 4 weeks were also independent predictors of HO (p = 0.01 and 0.004, respectively). These factors explained 20% of the variance in risk for HO restricting motion. CONCLUSIONS: HO restricting motion after operative elbow fracture treatment associates with factors that seem related to injury complexity, in particular, ulnohumeral dislocation, delay, and number of early surgeries; however, a substantial portion of the variation among patients with elbow fracture who develop restrictive HO remains unexplained. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Satisfaction with pain relief after operative treatment of an ankle fracture.

BACKGROUND: American patients are prescribed more opioid pain medication than Dutch patients after operative treatment of an ankle fracture, but it is possible that pain is undertreated in Dutch patients. This study tests if there is a difference in pain and satisfaction with pain relief between Dutch and American patients after operative treatment of ankle fractures. METHODS: Thirty American and 30 Dutch patients were enrolled in a prospective comparative study prior to operative treatment of ankle fractures. Patients rated pain and satisfaction with pain relief on postoperative day 1 (POD1) and at time of suture removal (SR). Pain and satisfaction scores were compared and multivariable analysis identified their predictors. RESULTS: At POD1, a third of Dutch patients used no opioids and a sixth took strong opioids. At SR, only 4 of 30 (13%) were taking tramadol and half were taking no medication. All of the American patients used strong opioid pain medication on POD1 and 19 of 30 (63%) were still taking strong opioids at SR. Patients that did not use opioids and Dutch patients had less pain and equivalent satisfaction with pain relief compared to patients that used opioids and American patients respectively. Nationality was the best predictor of pain intensity at POD1. Opioid medication was the best predictor of pain at SR and decreased satisfaction with pain management. CONCLUSIONS: Pain and satisfaction with pain relief are culturally mediated. Patients that use non-opioid pain medication report less pain and greater satisfaction with pain relief than patients managed with opioid pain medication. LEVEL OF EVIDENCE: Level I, Prognostic Study with more than 80% follow-up.

Orthogonal plating of intra-articular distal radius fractures with an associated radial column fracture via a single volar approach.

INTRODUCTION: The purpose of this study was to investigate the radiographic and functional outcome of orthogonal plating (two plates at right angles) via a single volar approach for fixation of intra-articular distal radius fractures with an associated radial column fracture. METHODS: In a retrospective, chart-based review, we identified 14 consecutive patients with an intra-articular distal radial fracture who had been treated with locked volar plate fixation and an additional radial column plate. Radial column plates were LCP Distal Radius Plates 2.4; volar plates were LCP Distal Radius Plates 2.4 (n=13) or LCP T-plate (n=1). These patients were operated on using the extended volar flexor carpi radialis (FCR) approach as described by Orbay. Radiographic measurements, healing rates, time to union, complications, range of motion, the Gartland and Werley score, and the QuickDASH questionnaire were done in order to evaluate the radiographic and functional outcomes of this technique. RESULTS: Thirteen of the 14 fractures healed within 7 weeks after surgery. Two implant removals were done. One patient had malposition of the fracture and carpal tunnel symptoms, which required a second surgery. No other complications (e.g., first dorsal compartment problems, radial plate prominence problems and radial sensory nerve problems) were observed. The average length of follow-up was 30 months (range, 12.8 months to 5.4 years). Radiographic results after healing were radial inclination 20°, radial length 11.4mm, tilt 6° volar, ulnar variance -0.5mm, articular gap 0.1mm and step-off 0.1mm. Wrist range of motion was flexion-extension arc 93°, ulnar-radial deviation arc 49° and pronation-supination arc 152°. Nine patients scored 'excellent' on the Gartland and Werley score, while the remaining five patients scored 'good'. The average QuickDASH score was 13.4. CONCLUSION: Additional fixation of a radial column process in an intra-articular distal radius fracture via the extended FCR approach using a standard volar plate and radial LCP resulted in good/excellent radiographic and functional outcome. LEVEL OF EVIDENCE: Therapeutic IV.

Predictors of diagnosis of ulnar neuropathy after surgically treated distal humerus fractures.

PURPOSE: Ulnar nerve dysfunction is a common sequela of surgical treatment of distal humerus fractures. This study addresses the null hypothesis that different types of distal humerus injuries have comparable rates of diagnosis of ulnar neuropathy. METHODS: We assessed diagnosis of ulnar neuropathy in 107 consecutive adults who had a surgically treated fracture of the distal humerus followed up at least 6 months after injury. Diagnosis of ulnar neuropathy was defined as documentation of sensory and motor dysfunction of the ulnar nerve in the medical record. Fractures were categorized as either columnar fractures or fractures of the capitellum and trochlea. The explanatory (independent) variables included age, sex, fracture type, AO type, associated wound, associated elbow dislocation, mechanism of trauma, ipsilateral skeletal injury, olecranon osteotomy, implant over or below the medial epicondyle, infection, time from injury to surgery, the number of surgeries within 4 weeks and 6 months of injury, the total number of surgeries, and whether the nerve was transposed. RESULTS: Postoperative ulnar neuropathy was diagnosed in 17 of 107 patients (16%), including 16 of 59 columnar fractures (21%). The only risk factor for ulnar neuropathy was columnar fracture. CONCLUSIONS: Patients with columnar fractures might be at higher risk for the development of postoperative ulnar neuropathy than patients with capitellum and trochlea fractures, regardless of whether the ulnar nerve was transposed. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands.

BACKGROUND: Interactions between American and Dutch surgeons suggested differences in prescription habits for pain medication after fracture treatment. METHODS: The percentages of 190 American [100 after hip open reduction and internal fixation (ORIF) and 90 after ankle ORIF] and 116 Dutch patients (69 after hip ORIF and 47 after ankle ORIF) receiving inpatient and outpatient prescriptions for narcotics were retrospectively compared between countries, to test the hypothesis that narcotics are prescribed more frequently in the United States as compared with The Netherlands after operative fracture treatment. RESULTS: Among patients with hip fractures, 85% of American and 58% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 77% of American and none of the Dutch patients were prescribed narcotics (p < 0.001). The multivariate model including country accounted for 11% of the variation in inpatient narcotic prescription (p < 0.001), and the model including country and surgeon accounted for 55% of the variation in outpatient narcotic prescription (p < 0.001). Among patients with ankle fracture, 98% of American and 64% of Dutch patients were prescribed narcotics during hospitalization (p < 0.001). After discharge, 82% of American patients and 6% of Dutch patients were prescribed narcotics (p < 0.001). Predictors included country and surgeon and they accounted for 20% of the variation in inpatient narcotics prescription (p < 0.001) and 49% of the variation in outpatient narcotic prescription (p < 0.001). CONCLUSIONS: American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients after operative treatment of hip and ankle fractures.

Subtle Essex-Lopresti lesions: report of 2 cases.

Two patients with high-energy elbow injuries were diagnosed with minimally displaced partial fractures of the radial head that subsequently displaced and were noted to be Essex-Lopresti injuries. The true complexity and instability of the fractures were not immediately obvious. High-energy partial radial head fractures may merit closer observation and evaluation for associated forearm ligament injury.