Patients With More Than 6.5° of Knee Hyperextension are 14.6 Times More Likely to Have Anterior Cruciate Ligament Hamstring Graft Rupture and Worse Knee Stability and Functional Outcomes.

PURPOSE: To create a cut-off point for hyperextension that best discriminates retear and to verify whether this cut-off point can predict retear regardless of other characteristics after primary anterior cruciate ligament (ACL) reconstruction with hamstrings autograft. METHODS: A cohort of patients submitted to primary isolated ACL reconstruction with hamstrings autografts was retrospectively evaluated. Patients were stratified according to the degree of passive knee hyperextension measured in the normal contralateral knee. The following data were collected: patient age and sex, time from injury to surgery, knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury, intra-articular graft size, follow-up time, graft failure, and postoperative Lysholm and subjective International Knee Documentation Committee scores. RESULTS: Data from 457 patients were evaluated. Median age was 31 years. Thirty-two (7.0%) presented with retear. There was a significant difference in hyperextension between patients with and without retear (P < .001), with the cut-off point established by the receiver operating characteristic curve from 6.5°. Patients with greater hyperextension had a statistically greater frequency of women, longer injury time, greater intra-articular graft diameter, greater postoperative KT-1000, and greater frequency of retear, whereas the subjective International Knee Documentation Committee and Lysholm scores were statistically lower in patients with greater hyperextension. Only hyperextension showed a statistically significant association with re-rupture (P < .001). The odds of retear in patients with hyperextension greater than 6.5 was 14.65 times the odds of patients with hyperextension less than 6.5. CONCLUSIONS: Patients with more than 6.5° of hyperextension are 14.6 times more likely to have a graft rupture than patients with lower hyperextension when submitted to ACL reconstruction with hamstring tendons. Also, they present worse knee stability by the KT-1000 test and worse functional outcomes. Therefore, patients with this degree of hyperextension should not have isolated reconstruction with hamstrings as their first choice. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Extensor mechanism injury, infection, and an extended time between trauma and surgical approach are related to the need for total knee arthroplasty removal after traumatic dehiscence.

BACKGROUND: Surgical wound-related traumatic complications are rarely reported in the literature. Traumatic dehiscence is unpredictable because of the trauma magnitude and the potential of associated injuries. This study aims to report the clinical outcomes and complications of a case series due to traumatic dehiscence after total knee arthroplasty (TKA) and establish possible criteria for prognosis for maintaining the implant. METHODS: Patients admitted to an emergency room due to traumatic dehiscence after TKA were retrospectively evaluated. Patient data was analyzed and patients who maintained or not the arthroplasty were compared to establish prognosis factors. RESULTS: Thirty-two patients with traumatic dehiscence after TKA were evaluated. The trauma occurred on a mean of 14.3 +/- 25.0 days after the surgical procedure, and debridement in the operating room was performed on a mean of 6.2 +/- 4.9 hours after the trauma. Twenty patients maintained the arthroplasty until the end of follow-up and did not require revision. Factors related to arthroplasty removal were associated extensor mechanism injury (p = 0.026), time from trauma to surgical debridement (p = 0.035), and infection (p = 0.0001) CONCLUSION: Traumatic dehiscence after total knee arthroplasty is an event with a high rate of complications. Extensor mechanism Injury, infection, and extended time between trauma and surgical intervention were poor prognostic factors for arthroplasty maintenance.

Small Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction Combined With Anterolateral Ligament Reconstruction Results in the Same Failure Rate as Larger Hamstring Tendon Graft Reconstruction Alone.

PURPOSE: To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter. METHODS: We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group). RESULTS: We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P < .001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P = .717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P = .114), as were postoperative pivot-shift grades (P = .652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P = .058 and P = .280, respectively). CONCLUSIONS: Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts. LEVEL OF EVIDENCE: Level III, retrospective, comparative therapeutic trial.

The Addition of Either an Anterolateral Ligament Reconstruction or an Iliotibial Band Tenodesis Is Associated With a Lower Failure Rate After Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Comparative Trial.

PURPOSE: To compare the failure rate in patients who underwent revision anterior cruciate ligament (ACL) reconstruction alone or associated with an extra-articular procedure. Secondary objectives were to compare ACL laxity, patient-reported outcome measures, and complication rates in these patients and, subsequently, to compare the outcomes of patients who underwent revision ACL reconstruction associated with anatomical anterolateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET). METHODS: This was a retrospective comparative study. Patients were classified into 2 groups, according to whether (group 2) or not (group 1) an extra-articular reconstruction was performed. Patients who underwent an extra-articular procedure were further divided into ALL reconstruction (group 2A) and LET (group 2B). Baseline demographic variables, operative data and postoperative data were evaluated. RESULTS: The groups with (86 patients) and without (88 patients) an associated extra-articular reconstruction had similar preoperative data. Group 2 had a lower failure rate (4.6% vs 14.7%; P = .038), better KT-1000, better pivot-shift, and better Lysholm. There was no difference regarding complications, except more lateral pain in group 2. Regarding the groups who underwent ALL reconstruction (41 patients) and LET (46 patients), group 2A showed better Lysholm scores. Both groups had similar failure rates and complications. CONCLUSIONS: Patients who underwent revision ACL reconstruction with a laterally based augmentation procedure had a lower failure rate than patients who underwent isolated revision ACL reconstruction. KT-1000 and pivot-shift examination were also significantly better when a lateral augmentation was performed. Complications were similar except for an increase in lateral pain in the augmented group. No clinically important differences were found when comparing the LET group to the ALL group other than a statistical improvement in the Lysholm functional scale, likely not clinically meaningful, favoring the ALL group and an increased duration of post-operative lateral pain in the LET group. LEVEL OF EVIDENCE: III, retrospective comparative therapeutic trial.

Comparative study of superficial medial collateral ligament reconstruction combined with posterior oblique ligament reconstruction or posteromedial capsule advance in grade III injuries of the medial compartment in a complex knee injury scenario.

BACKGROUND: The purpose of this study was to compare the combined reconstruction of the superficial medial collateral ligament (sMCL) and the posterior oblique ligament (POL) with the reconstruction of the sMCL associated with the advancement of the posteromedial capsule in a complex knee injury scenario. We hypothesized that both techniques would present similar knee stability and failure rates. METHODS: This is a retrospective case-control study designed to compare the results of the two reported techniques for grade III MCL instability. Patients undergoing MCL reconstruction associated with anterior cruciate ligament, posterior cruciate ligament, or both, from 2010 to 2019, were included. The following parameters were evaluated: demographic data, type of graft, time from injury to surgery, associated meniscus injuries, follow up time, mechanism of trauma, postoperative objective IKDC, subjective IKDC and Lysholm scales, range of motion, reconstruction failure and complications. RESULTS: Seventy-eight patients were evaluated, 37 of whom underwent reconstruction of the sMCL and POL, and 41 of whom underwent reconstruction of the sMCL with advancement of posteromedial structures. There was no difference in any preoperative variable. Patients undergoing reconstruction of the sMCL + advancement had greater loss of flexion (Group 1 3.4 ± 4.6 vs Group 2 8.4 ± 7.9; P = 0.002) and more individuals with flexion loss greater than 10° (Group 1, seven patients (18.9%) vs Group 2, 17 patients (41.5%); P = 0.031). Postoperative knee stability, failures and complications were similar between groups. CONCLUSION: Both techniques presented good functional results and low rates of complications. However, the advancement technique showed greater flexion loss, which should be considered when choosing the best surgical option.

Functional results of multiple revision anterior cruciate ligament with anterolateral tibial tunnel associated with anterolateral ligament reconstruction.

BACKGROUND: Revision anterior cruciate ligament (ACL) reconstructions are usually complex owing to previous tunnels. The objective of this study is to report the results of a revision ACL reconstruction technique with a tibial tunnel performed from the anterolateral plateau associated with an anterolateral ligament (ALL) reconstruction. METHODS: Patients with at least two ACL reconstructions that failed and who had significant enlargement and confluence of tunnels in the medial tibial plateau and underwent revision ACL reconstruction associated with ALL reconstruction with the tibial tunnel for the ACL performed from the lateral plateau between 2017 and 2019 were evaluated. All patients were evaluated by physical examination, International Knee Documentation Committee (IKDC), and Lysholm functional scales. RESULTS: Six patients who underwent this surgical procedure were evaluated. All patients were sports practitioners and presented a grade 3 pivot shift. The mean age was 28.5 ± 8.2 years, and the mean follow-up time was 34.1 ± 12.8 months. No patient had a new graft rupture, but three (50%) had grade 1 pivot shift. Four patients had minor complications with no clinical impact on the final result. All except one patient were able to return to pre-injury type of sports, at a mean time of 14.6 ± 2.3 months after surgery. CONCLUSION: The anterolateral tibial tunnel technique using an Achilles tendon allograft for revision ACL reconstruction after multiple failures associated with an ALL reconstruction showed good results and no major complications. The anterolateral tunnel can be considered a good alternative in cases of medial tibial confluence or significant enlargement of the medial tunnels in re-revision procedures.

High Incidence of Osteoarthritis Observed in Patients at Short- to Midterm Follow-Up after Delayed Multiligament Knee Reconstruction.

The aim of this study was to evaluate the incidence of knee osteoarthritis, failure rate of reconstruction, and clinical outcomes of patients with chronic multiligament knee injuries subjected to surgical treatment. Sixty-two patients with chronic knee dislocation subjected to multiligament reconstruction between April 2008 and July 2016 were evaluated, with a minimum follow-up of 24 months. Anteroposterior and lateral radiographs were performed in the pre- and last postoperative evaluation; the progression of degenerative changes according to the Kellgren-Lawrence classification (KL) was assessed. The Schenck classification, Knee Injury and Osteoarthritis Outcome Score (KOOS), time between injury and surgery, type of postoperative rehabilitation protocol (brace vs. external fixator), and physical examination for ligament instability were also evaluated. Univariate and multivariate analysis were performed, p <0.05 was considered significant. Fifty-two (83.9%) patients were men and 16.1% (n = 10) were women, with a mean age of 38.8 ± 1.3 years. The time from injury to surgery was 31.1 ± 6.1 months, and the follow-up time was 6.1 ± 0.5 years. The mean final KOOS was 79.3 ± 10.4 and the overall reconstruction failure occurred in 25.8%. Of all patients, 64.5% (n = 40) presented a KL classification of ≥2 and were defined as having radiographic osteoarthritis (OA). As 11.7% (n = 7) also presented arthritis in the contralateral knee, in 53.2% (n = 33) the progression was most likely due to the initial injury. The failure of ligament reconstruction or residual instability was present in 15 (35.7%) of patients with OA, and only one patient (4.5%) without OA. In the multivariate analysis, only reconstruction failure was an independent predictor of OA (odds ratio = 13.2 [p = 0.028]). There is a high incidence of knee OA following ligament reconstruction for chronic multiligament knee injuries. Ligament reconstruction failure was the only independent predictor for the development of OA in our study.

Knee Hyperextension Greater Than 5° Is a Risk Factor for Failure in ACL Reconstruction Using Hamstring Graft.

BACKGROUND: The degree of knee hyperextension in isolation has not been studied in detail as a risk factor that could lead to increased looseness or graft failure after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To analyze whether more than 5° of passive knee hyperextension is associated with worse functional outcomes and greater risk of graft failure after primary ACL reconstruction with hamstring tendon autograft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of patients who had primary ACL reconstruction with hamstring tendon autografts was divided into 2 groups based on passive contralateral knee hyperextension greater than 5° (hyperextension group) and less than 5° (control group) of hyperextension. Groups were matched by age, sex, and associated meniscal tears. The following data were collected and compared between the groups: patient data (age and sex), time from injury to surgery, passive knee hyperextension, KT-1000 arthrometer laxity, pivot shift, associated meniscal injury and treatment (meniscectomy or repair), contralateral knee ligament injury, intra-articular graft size, follow-up time, occurrence of graft failure, and postoperative Lysholm knee scale and International Knee Documentation Committee subjective form scores. RESULTS: Data from 358 patients initially included in the study were analyzed; 22 were excluded because the time from injury to surgery was greater than 24 months, and 22 were lost to follow-up. From the cohort of 314 patients, 102 had more than 5° of knee hyperextension. A control group of the same size (n = 102) was selected by matching among the other 212 patients. Significant differences in the incidence of graft failure (14.7% vs 2.9%; P = .005) and Lysholm knee scale score (86.4 ± 9.8 vs 89.6 ± 6.1; P = .018) were found between the 2 groups. CONCLUSION: Patients with more than 5° of contralateral knee hyperextension submitted to single-bundle ACL reconstruction with hamstring tendons have a higher failure rate than patients with less than 5° of knee hyperextension.

ANATOMICAL STUDY OF THE POSTEROLATERAL LIGAMENT COMPLEX OF THE KNEE: LCL AND POPLITEUS TENDON.

OBJECTIVE: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. METHODS: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. RESULTS: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. CONCLUSION: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

OBJETIVO: Analisar as distâncias entre as inserções femorais do tendão poplíteo (TP) e o ligamento colateral lateral (LCL) através de dissecções de espécimes cadavéricos em uma população miscigenada. MÉTODOS: Cadáveres frescos foram dissecados. Foram registrados dados antropométricos e foi avaliada a distância da origem do TP e do LCL na região femoral com auxílio de paquímetro digital. Foi também avaliado o diâmetro do footprint femoral do TP e do LCL. RESULTADOS: Foram dissecados 11 joelhos não pareados, 8 homens e 3 mulheres com uma idade média de 71,5 ± 15,2 anos, pesando em média 57,2 ± 15,6 kgs e com altura de 170,5 ± 8,2 cm. A distância do centro do footprint femoral do LCL e do TP foi de 10,0 ± 2,4 mm. As distâncias das bordas mais próximas entre si e das mais distantes entre si foram de 3,1 ± 1,1 mm e 16,3 ± 2,4 mm, respectivamente. CONCLUSÃO: A distância entre o ponto central do TP e do LCL em nossa população mais miscigenada demonstrou um valor absoluto menor do que é, frequentemente, relatado na literatura. Uma reconstrução ligamentar do CPL com túneis separados para o LCL e o TP pode não ser tecnicamente possível para indivíduos de qualquer população. Nível de Evidência III, Estudos diagnósticos.

Anatomical study of the posterolateral ligament complex of the knee: lcl and popliteus tendon / Estudo anatômico do complexo ligamentar posterolateral do joelho: lcl e tendão poplíteo

ABSTRACT Objective: To analyse the distances between the femoral insertions of the popliteus tendon (PT) and the lateral collateral ligament (LCL) through dissections of cadaveric specimens in a mixed population. Methods: Fresh cadavers were dissected, and the anthropometric data of all specimens were recorded. The distances from the origin of the PT to the LCL in the femoral region and the diameter of each structure were measured using a digital calliper. Results: In total, 11 unpaired knees were dissected, eight men and three women, with an average age of 71.5 ± 15.2 years, weight of 57.2 ± 15.6 kg, and a mean height of 170.5 ± 8.2 cm. The distance from the center of the femoral footprint of the LCL to the PT was 10.0 ± 2.4 mm. The distances between the edges closest to each other and those more distant from each other were 3.1 ± 1.1 mm and 16.3 ± 2.4 mm, respectively. Conclusion: The distance between the midpoints of the PT and the LCL in our mixed population is smaller than the distances often reported in the literature. PLC reconstruction with separate tunnels for the LCL and PT may not be technically possible for individuals of any population. Level of Evidence III, Diagnostic studies.

RESUMO Objetivo: Analisar as distâncias entre as inserções femorais do tendão poplíteo (TP) e o ligamento colateral lateral (LCL) através de dissecções de espécimes cadavéricos em uma população miscigenada. Métodos: Cadáveres frescos foram dissecados. Foram registrados dados antropométricos e foi avaliada a distância da origem do TP e do LCL na região femoral com auxílio de paquímetro digital. Foi também avaliado o diâmetro do footprint femoral do TP e do LCL. Resultados: Foram dissecados 11 joelhos não pareados, 8 homens e 3 mulheres com uma idade média de 71,5 ± 15,2 anos, pesando em média 57,2 ± 15,6 kgs e com altura de 170,5 ± 8,2 cm. A distância do centro do footprint femoral do LCL e do TP foi de 10,0 ± 2,4 mm. As distâncias das bordas mais próximas entre si e das mais distantes entre si foram de 3,1 ± 1,1 mm e 16,3 ± 2,4 mm, respectivamente. Conclusão: A distância entre o ponto central do TP e do LCL em nossa população mais miscigenada demonstrou um valor absoluto menor do que é, frequentemente, relatado na literatura. Uma reconstrução ligamentar do CPL com túneis separados para o LCL e o TP pode não ser tecnicamente possível para indivíduos de qualquer população. Nível de Evidência III, Estudos diagnósticos.

Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis.

OBJECTIVES: To compare the clinical outcomes of isolated anterior cruciate ligament (ACL) reconstruction with combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. METHODS: A search was conducted on the PubMed, Medline, Google Scholar, EMBASE, and Cochrane library databases, in line with the PRISMA protocol. The indexation terms used were "anterior cruciate ligament" OR "acl" AND "anterolateral ligament" AND "reconstruction." Articles that compared patients submitted to combined ACL and ALL reconstruction with those submitted to isolated reconstruction of the ACL, with levels of evidence I, II, and III, were included. Studies with follow-up of less than 2 years and articles that did not use "anatomical" techniques for ALL reconstruction, such as extraarticular tenodesis, were excluded. A meta-analysis with R software was conducted, with a random effects model, presented as risk ratio (RR) or mean difference (MD), with a 95% confidence level (CI) and statistically significant at p < 0.05. RESULTS: Ten articles were selected, with a total of 1495 patients, most of whom were men, of whom 674 submitted to ACL and ALL reconstruction and 821 to isolated ACL reconstruction. Combined ACL and ALL reconstruction exhibited a statistically significant advantage in residual pivot shift (RR 0.34, 95% CI 0.24-0.47, I2 = 0%, p < 0.01), rerupture rate (RR 0.34, 95% CI 0.19-0.62, I2 = 0%, p < 0.01), Lachman test (RR 0.59, 95% CI 0.40-0.86, I2 = 21%, p < 0.01), and postoperative Lysholm score (MD 2.28, CI 95% 0.75-3.81, I2 = 73%, p < 0.01). CONCLUSIONS: Combined ACL and ALL reconstruction obtained better postoperative clinical outcomes when compared with isolated ACL reconstruction, especially in reducing residual pivot shift and rerupture rate.

Lever sign test for chronic acl injury: a comparison with lachman and anterior drawer tests / Teste da alavanca para lesão crônica do lca: comparação com os testes de lachman e gaveta anterior

ABSTRACT Objective: This study aims to evaluate the sensitivity and specificity of the lever sign test in patients with and without chronic Anterior Cruciate Ligament (ACL) injuries in an outpatient setting and the inter-examiner agreement of surgeons with different levels of experience. Methods: 72 consecutive patients with a history of previous knee sprains were included. The Lachman, anterior drawer, and Lever Sign tests were performed for all subjects in a randomized order by three blinded raters with different levels of experience. Sensitivity, specificity, positive predictive value, negative predictive value, and inter-rater agreement were estimated for all tests. Results: Among the 72 patients, the prevalence of ACL injuries was 54%. The lever test showed sensitivity of 64.1% (95% CI 0.47-0.78) and specificity of 100% (95% CI 0.87-1.00) for the senior examiner. For the less experienced examiner the sensitivity was 51.8% and the specificity was 93.7%. Positive predictive values (PPV) and negative predictive values (NPV) were 100% and 70.2%, respectively. Conclusion: Lever Sign test shows to be a maneuver of easy execution, with 100% specificity and 100% PPV. Moderate agreement between experienced examiners and low agreement among experienced and inexperienced examiners was found. This test may play a role as an auxiliary maneuver. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.

RESUMO Objetivo: O objetivo deste estudo foi avaliar a sensibilidade e a especificidade do teste da alavanca em pacientes ambulatoriais com e sem lesões crônicas do LCA e a concordância entre examinadores com diferentes níveis de experiência. Métodos: Setenta e dois pacientes consecutivos com histórico de entorse de joelho foram incluídos. O teste de lachman, gaveta anterior e teste de alavanca foram realizados para todos os indivíduos em ordem randomizada por 3 examinadores cegados com diferentes níveis de experiência. Sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e concordância interavaliadores foram calculados para todos os testes. Resultados: Entre os 72 pacientes, a prevalência de lesões do LCA foi de 54%. O teste da alavanca mostrou sensibilidade de 64,1% (IC95% 0,47-0,78) e especificidade de 100% (IC95% 0,87-1,00) para o examinador sênior. Para o examinador menos experiente, a sensibilidade foi de 51,8% e a especificidade, de 93,7%. Valores preditivos positivos (VPP) e valores preditivos negativos (VPN) foram de 100% e 70,2%, respectivamente. Conclusão: O teste da alavanca mostra ser uma manobra de fácil execução, com 100% de especificidade e 100% de PPV. Foi encontrada concordância moderada entre examinadores experientes e baixa concordância entre examinadores experientes e inexperientes. Este teste pode desempenhar um papel como uma manobra adjuvante. Nível de Evidência I, Estudos Diagnósticos - Investigação de um Exame para Diagnóstico.

LEVER SIGN TEST FOR CHRONIC ACL INJURY: A COMPARISON WITH LACHMAN AND ANTERIOR DRAWER TESTS.

OBJECTIVE: This study aims to evaluate the sensitivity and specificity of the lever sign test in patients with and without chronic Anterior Cruciate Ligament (ACL) injuries in an outpatient setting and the inter-examiner agreement of surgeons with different levels of experience. METHODS: 72 consecutive patients with a history of previous knee sprains were included. The Lachman, anterior drawer, and Lever Sign tests were performed for all subjects in a randomized order by three blinded raters with different levels of experience. Sensitivity, specificity, positive predictive value, negative predictive value, and inter-rater agreement were estimated for all tests. RESULTS: Among the 72 patients, the prevalence of ACL injuries was 54%. The lever test showed sensitivity of 64.1% (95% CI 0.47-0.78) and specificity of 100% (95% CI 0.87-1.00) for the senior examiner. For the less experienced examiner the sensitivity was 51.8% and the specificity was 93.7%. Positive predictive values (PPV) and negative predictive values (NPV) were 100% and 70.2%, respectively. CONCLUSION: Lever Sign test shows to be a maneuver of easy execution, with 100% specificity and 100% PPV. Moderate agreement between experienced examiners and low agreement among experienced and inexperienced examiners was found. This test may play a role as an auxiliary maneuver. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.

OBJETIVO: O objetivo deste estudo foi avaliar a sensibilidade e a especificidade do teste da alavanca em pacientes ambulatoriais com e sem lesões crônicas do LCA e a concordância entre examinadores com diferentes níveis de experiência. MÉTODOS: Setenta e dois pacientes consecutivos com histórico de entorse de joelho foram incluídos. O teste de lachman, gaveta anterior e teste de alavanca foram realizados para todos os indivíduos em ordem randomizada por 3 examinadores cegados com diferentes níveis de experiência. Sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e concordância interavaliadores foram calculados para todos os testes. RESULTADOS: Entre os 72 pacientes, a prevalência de lesões do LCA foi de 54%. O teste da alavanca mostrou sensibilidade de 64,1% (IC95% 0,47-0,78) e especificidade de 100% (IC95% 0,87-1,00) para o examinador sênior. Para o examinador menos experiente, a sensibilidade foi de 51,8% e a especificidade, de 93,7%. Valores preditivos positivos (VPP) e valores preditivos negativos (VPN) foram de 100% e 70,2%, respectivamente. CONCLUSÃO: O teste da alavanca mostra ser uma manobra de fácil execução, com 100% de especificidade e 100% de PPV. Foi encontrada concordância moderada entre examinadores experientes e baixa concordância entre examinadores experientes e inexperientes. Este teste pode desempenhar um papel como uma manobra adjuvante. Nível de Evidência I, Estudos Diagnósticos - Investigação de um Exame para Diagnóstico.

Degenerative Medial Meniscus Tear With a Displaced Flap Into the Meniscotibial Recess and Tibial Peripheral Reactive Bone Edema Presents Good Results With Arthroscopic Surgical Treatment.

PURPOSE: To report the arthroscopic treatment results of a degenerative medial meniscus tear with a displaced flap into the meniscotibial recess, tibial peripheral reactive bone edema, and focal knee medial pain. As a secondary objective, we propose to identify possible factors associated with a good or poor prognosis of the surgical treatment of this lesion. METHODS: From 2012 to 2018, patients who had this specific meniscus pathology and underwent arthroscopic surgical treatment were retrospectively evaluated. Patients with Kellgren-Lawrence (KL) classification greater than 2 were excluded. KL classification, the presence of an Outerbridge grade III/V chondral lesion of the medial compartment, limb alignment, body mass index, and smoking were evaluated. The subjective outcomes included the International Knee Documentation Committee score, improvement in the pain reported by patients, and the Global Perceived Effect (GPE) scale score. RESULTS: A total of 69 patients were evaluated. The mean age was 58.6 ± 7.1 years. The follow-up time was 48.7 ± 20.8 months. Fifty-five (79.7%) patients reported pain improvement. The postoperative International Knee Documentation Committee was 62.6 ± 15.4, and the mean GPE was 2.3 ± 2.6. Fourteen patients (20.3%) showed no improvement in pain, and 7 patients (10.2%) presented complications. Groups that improved (GPE > 0) and did not improve (GPE < 0) did not present differences regarding age, sex, follow-up time, chondral lesions, or body mass index. Patients without improvement had a greater incidence of smoking (P = .001), varus alignment (P = .008), and more advanced KL classification (P < .001). In the multivariate analysis based on the GPE score, KL classification (P = .038) and smoking (P = .003) were significant. CONCLUSIONS: Arthroscopic surgical treatment of degenerative medial meniscal tears with a meniscal flap displaced into the meniscotibial recess and adjacent focal bone edema in the tibia shows good results in approximately 80% of cases. Smoking and KL grade 2 were factors associated with poor prognosis of surgical treatment. LEVEL OF EVIDENCE: Level IV (case series).

Surgical Timing Does Not Interfere on Clinical Outcomes in Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament: A Comparative Study With Minimum 2-Year Follow-Up.

PURPOSE: To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases. METHODS: Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated. RESULTS: Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups. CONCLUSIONS: Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Clinical Outcomes of Posterolateral Complex Reconstruction Performed with a Single Femoral Tunnel.

The objective of this study is to report the functional outcomes, complications, and reconstruction failure rate of patients undergoing posterolateral complex reconstruction with a single femoral tunnel technique. Patients with posterolateral complex injuries associated with injury of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), or both undergoing surgical treatment with the single femoral tunnel technique were included in the study. The International Knee Documentation Committee (IKDC) and Lysholm's scales were evaluated, in addition to age, gender, time between trauma and surgery, trauma type, range of motion (ROM) restrictions, peroneal nerve injury, and reconstruction failure. Sixty-six patients were included. Eighteen underwent ACL and posterolateral complex (PLC) reconstruction (group 1), 24 underwent ACL, PCL, and PLC reconstruction (group 2), and 24 underwent PCL and PLC reconstruction (group 3). The mean follow-up was 63 months. The subjective IKDC was 83.7 ± 14.6 for group 1, 74.3 ± 12.6 for group 2, and 66.3 ± 16.0 for group 3 (p < 0.001). The Lysholm's score was 87.1 ± 12.8 for group 1, 79.5 ± 15.0 for group 2, and 77.7 ± 15.2 for group 3 (p = 0.042). There were six reconstruction failures among the patients (9.1%) with no differences among the groups (p = 0.368). Female gender and reconstruction failure were associated with worse outcomes. Patients undergoing reconstruction of PLC structures with the single femoral tunnel technique achieved good functional outcomes and a failure rate similar to literature. Patients undergoing only combined ACL reconstruction showed better outcomes than patients undergoing combined PCL reconstruction. Female gender was associated with a worse functional outcome irrespective of the injury type.

Outcomes After Isolated Acute Anterior Cruciate Ligament Reconstruction Are Inferior in Patients With an Associated Anterolateral Ligament Injury.

BACKGROUND: Isolated reconstruction of the anterior cruciate ligament (ACL) does not reestablish the normal knee biomechanics in cases of associated injuries to the anterolateral structures. Studies evaluating the potential clinical effect of anterolateral ligament (ALL) injury on the treatment of ACL injuries are necessary to validate the findings of biomechanical studies. PURPOSE: To evaluate the clinical outcomes and failure rate of ACL reconstruction in patients with and without ALL injury diagnosed using magnetic resonance imaging. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective cohort of patients with acute ACL injury was divided into 2 groups based on the presence (ALL group) or absence (no-ALL group) of ALL injury on preoperative magnetic resonance imaging scans. Both groups underwent anatomic reconstruction of the ACL with autologous hamstring tendon grafts. The Lysholm and subjective IKDC scores (International Knee Documentation Committee), KT-1000 arthrometer and pivot-shift test results, reconstruction failure rate, incidence of contralateral ACL injury, presence of associated meniscal injury, and presence of knee hyperextension were evaluated. RESULTS: A total of 182 patients were evaluated. Postoperative mean ± SD follow-up was 33.6 ± 7.1 and 36.1 ± 8.1 months for the ALL and no-ALL groups, respectively. No significant differences were found between the groups in terms of age, sex, knee hyperextension, duration of injury before reconstruction, follow-up time, or associated meniscal injuries. In the preoperative evaluation, the pivot-shift grade was similar, and the ALL group had worse KT-1000 arthrometer values (7.9 ± 1.2 mm vs 7.2 ± 1.1 mm; P < .001). In the postoperative evaluation, patients in the no-ALL group had a lower reconstruction failure rate (10.2% vs 1.4%; P = .029) and better clinical outcomes according to the IKDC subjective (85.5 ± 10.7 vs 89.1 ± 6.6; P = .035) and Lysholm scores (85.9 ± 10.1 vs 92.0 ± 6.3; P < .001). There was no postoperative difference in the KT-1000 or pivot-shift results. CONCLUSION: Combined ACL and ALL injuries were associated with significantly less favorable outcomes than were isolated ACL injuries at a minimum follow-up of 2 years after ACL reconstruction. Patients with concomitant ALL injury showed a higher rerupture rate and worse functional scores.

High Potential for Complications After Traumatic Exposure in Patients With a Total Knee Replacement.

OBJECTIVE: The purpose of this study is to describe cases of traumatic exposure during the early postoperative period in patients with a total knee replacement (TKR) and to report the treatments instituted and complications of this adverse event. METHODS: A retrospective review of postoperative patients with TKR performed at the Universidade de São Paulo from 2001 to 2017 who subsequently were treated at the emergency room due to trauma to the TKR region accompanied by surgical wound dehiscence in deep planes and implant exposure was conducted. The initial treatment, evolution, and complications of each patient were reported. RESULTS: In 16 years, there were 3224 TKRs performed at the study institution. Among this population, 4 (0.1%) patients had trauma dehiscence of the surgical wound during the immediate postoperative period. All patients were women between the ages of 64 and 88 years with comorbidities (eg, diabetes mellitus and/or hypertension). The mean time between the surgery and trauma was 6.7 ± 6.2 days. All patients underwent surgical cleaning, debridement with polyethylene exchange, and primary closure of the surgical wound and received adjuvant treatment with broad-spectrum antibiotic therapy. Of the 4 patients affected, 3 developed an infection, 3 required new surgery after initial cleaning, 2 lost their prostheses, and 1 lost a limb, requiring a transfemoral amputation. CONCLUSIONS: Traumatic dehiscence with implant exposure during the initial postoperative period of TKR is an infrequent event (0.1%) with a high potential for complications (75%), which may lead to loss of the prosthesis and even the limb. Measures should be taken to prevent falls and gather reports from several centers to broaden the knowledge of this rare event, identify prognostic factors, and define the best treatment algorithm.

The use of negative-pressure wound therapy after total knee arthroplasty is effective for reducing complications and the need for reintervention.

BACKGROUND: Wound healing complications are causal factors of prosthesis infection and poor postoperative evolution of patients after total knee arthroplasty (TKA). Negative-pressure wound therapy (NPWT) can be an option to minimize these complications. The aim of this study is to compare the complications of patients undergoing TKA who used a portable NPWT device in the immediate postoperative period with those of a control group. METHODS: A total of 296 patients were evaluated. Patients were divided into two groups: those who used NPWT for seven days in the postoperative period (Group 1 - prospective evaluated) and those who used conventional dressings (Group 2 - historical control group). Epidemiological data, comorbidities, local parameters related to the surgical wound and complications were evaluated. RESULTS: The groups did not differ in regard to sex, age and clinical comorbidities. Overall, 153 (51.7%) patients had at least one risk factor for wound complications. Patients who used NPWT had a lower rate of complications (28.5% vs. 45.7%, p = 0.001) and a lower rate of reintervention in the operating room (2% vs. 8.5%, p = 0.001). Patients in group 1 had a lower incidence of hyperaemia (14.7% vs. 40.2%, p = 0.01), skin necrosis (2.1% vs. 8.5%, p = 0.04) and wound dehiscence (3.1% vs 10.1%, p = 0.03). The use of NPWT was a protective factor for the presence of complications, with an odds ratio of 0.36 (95% CI 0.206-0.629). CONCLUSION: The number of complications related to the wound after TKA is high; however, most of them are minor and have no impact on the treatment and clinical evolution of patients. The use of NPWT decreased the number of surgical wound complications, especially hyperaemia, dehiscence and necrosis, and reduced the need for reintervention.

Alternative Techniques for Lateral and Medial Posterior Root Meniscus Repair Without Special Instruments.

Improved understanding and treatment of posterior medial and lateral meniscus root tears have attracted increasing interest. These lesions significantly compromise meniscal function, which can result in an outcome resembling total meniscectomy, and are also a potential cause of knee instability. Despite facilitating repair procedures and reducing the operative time for these lesions, all-inside meniscal repair devices are not available in all circumstances or registered for use in all countries worldwide. Furthermore, all-inside arthroscopic devices can be expensive. Therefore, low-cost alternatives for the treatment of these lesions must be identified. We present 2 efficient and safe techniques: an outside-in technique for repairing medial meniscus root tears and a technique using a simple needle inserted through the transtibial tunnel for lateral meniscal root repairs, neither of which requires the use of specific instruments, thus enabling appropriate treatment of posterior medial and lateral meniscus root tears.