Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries.

Background: Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis: The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results: In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Conclusion: Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

Long-term National Trends of Arthroscopic Meniscal Repair and Debridement.

BACKGROUND: Optimal treatment of meniscal pathology continues to evolve in orthopaedic surgery, with a growing understanding of which patients benefit from which procedure and which patients might be best treated nonsurgically. In 2002, Moseley et al found no difference between arthroscopic procedures, including meniscal debridement and sham surgery, in patients with osteoarthritis of the knee. This called into question the role of routine arthroscopic debridement in these patients. Additionally, an increased interest in understanding and maintaining the function of the meniscus has more recently resulted in a greater focus on meniscal preservation procedures. STUDY DESIGN: Descriptive epidemiology study. PURPOSE/HYPOTHESIS: The purpose was to evaluate the trends of arthroscopic meniscal debridement and repair and the characteristics of the patients receiving these treatments, compare the differences in practice between newly trained orthopaedic sports medicine specialists and those of other specialties, and analyze if there are differences in practice by region. It was hypothesized that the American Board of Orthopaedic Surgery (ABOS) database would evaluate practice patterns of recent graduates as a surrogate for current treatment and training and, consequently, demonstrate a decreased rate of meniscal debridement. METHODS: Data from ABOS Part II examinees from 2001 to 2017 were obtained from the ABOS Case List. Current Procedure Terminology (CPT) codes related to arthroscopic meniscal treatment were selected. The examination year, age of the patient, practice region, and examinee subspecialty were analyzed. Patient age was stratified into 4 groups: <30, 30 to 50, 51 to 65, and >65 years. Examinee subspecialty was stratified into sports medicine and non-sports medicine. Statistical regression analysis was performed. RESULTS: Between 2001 and 2017, ABOS Part II examinees submitted 131,047 cases with CPT codes 29880 to 29883. Meniscal debridement volume decreased for all age groups during the study period, while repair increased. Sports medicine subspecialists were more likely than their counterparts to perform repair over debridement in patients aged younger than 30 years (P = .0004) and between 30 and 50 years (P = .0005). CONCLUSION: This study provides insights into arthroscopic meniscal debridement and repair practice trends among ABOS Part II examinees. Meniscal debridement is decreasing and meniscal repair is increasing. Younger patient age and treatment by a sports medicine subspecialty examinee are associated with a higher likelihood of repair over debridement.

Is Diagnostic Arthroscopy at the Time of Medial Patellofemoral Ligament Reconstruction Necessary?

BACKGROUND: Although medial patellofemoral ligament (MPFL) reconstruction is well described for patellar instability, the utility of arthroscopy at the time of stabilization has not been fully defined. PURPOSE: To determine whether diagnostic arthroscopy in conjunction with MPFL reconstruction is associated with improvement in functional outcome, pain, and stability or a decrease in perioperative complications. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent primary MPFL reconstruction without tibial tubercle osteotomy were reviewed (96 patients, 101 knees). Knees were divided into MPFL reconstruction without arthroscopy (n = 37), MPFL reconstruction with diagnostic arthroscopy (n = 41), and MPFL reconstruction with a targeted arthroscopic procedure (n = 23). Postoperative pain, motion, imaging, operative findings, perioperative complications, need for revision procedure, and postoperative Kujala scores were recorded. RESULTS: Pain at 2 weeks and 3 months postoperatively was similar between groups. Significantly improved knee flexion at 2 weeks was seen after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and reconstruction with targeted arthroscopic procedures (58° vs 42° and 48°, respectively; P = .02). Significantly longer tourniquet times were seen for targeted arthroscopic procedures versus the diagnostic and no arthroscopic procedures (73 vs 57 and 58 min, respectively; P = .0002), and significantly higher Kujala scores at follow-up were recorded after MPFL reconstruction without arthroscopy versus reconstruction with diagnostic and targeted arthroscopic procedures (87.8 vs 80.2 and 70.1, respectively; P = .05; 42% response rate). There was no difference between groups in knee flexion, recurrent instability, or perioperative complications at 3 months. Diagnostic arthroscopy yielded findings not previously appreciated on magnetic resonance imaging (MRI) in 35% of patients, usually resulting in partial meniscectomy. CONCLUSION: Diagnostic arthroscopy with MPFL reconstruction may result in findings not previously appreciated on MRI. Postoperative pain, range of motion, and risk of complications were equal at 3 months postoperatively with or without arthroscopy. Despite higher Kujala scores in MPFL reconstruction without arthroscopy, the relationship between arthroscopy and patient-reported outcomes remains unclear. Surgeons can consider diagnostic arthroscopy but should be aware of no clear benefits in patient outcomes.

Initial Evaluation and Classification of Knee Dislocations.

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.

Critical Evaluation of the Methodologic Quality of the Top 50 Cited Articles Relating to Knee Dislocation and Multiligamentous Knee Injury.

BACKGROUND: Many studies have evaluated the management of knee dislocations (KDs) and multiligamentous knee injuries (MLKIs). However, no study to date has analyzed the quality of the most cited articles in this literature. HYPOTHESIS: There is a positive correlation between the number of article citations in the KD and MLKI literature and their methodologic quality. STUDY DESIGN: Systematic review. METHODS: The Web of Science online database was searched to identify the top 50 cited articles in KD and MLKI care. Demographic data were recorded for each study. The Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS) were used to analyze the methodological quality of each article. Spearman correlation coefficients (r s) were then calculated. RESULTS: The articles identified were published between 1958 and 2015 in a wide variety of peer-reviewed journals (n = 16). The majority of study level of evidence (LOE) was of low quality (level 5, 16%; level 4, 54%; level 3, 16%; level 2, 14%). There were no studies of level 1 evidence. The mean MCMS and MINORS scores were 29.0 (SD, 19.1; range, 3-72) and 6.1 (SD, 3.7; range, 0-14), respectively. No significant correlation was identified between the number of citations and the publication year, LOE, MCMS, or MINORS (r s = 0.123 [P = .396]; r s = 0.125 [P = .389]; r s = 0.182 [P = .204]; and r s = 0.175 [P = .224], respectively). Positive correlations were observed between improved MCMS and MINORS scores and more recent year of publication (r s = 0.43 [P = .002]; r s = 0.32 [P = .022]) as well as improved study LOE (r s = 0.65 [P < .001]; r s = 0.67 [P < .001]). CONCLUSION: The top 50 cited articles on KD and MLKI care consisted of low LOE and methodological quality, with no existing level 1 articles. There was no significant correlation between the number of citations and publication year, LOE, or study methodological quality. Positive correlations were observed between later publication date and improved methodological quality.

A Biomechanical Comparison of the Arciero and LaPrade Reconstruction for Posterolateral Corner Knee Injuries.

BACKGROUND: Injury to the posterolateral corner (PLC) of the knee requires reconstruction to restore coronal and rotary stability. Two commonly used procedures are the Arciero reconstruction technique (ART) and the LaPrade reconstruction technique (LRT). To the authors' knowledge, these techniques have not been biomechanically compared against one another. PURPOSE: To identify if one of these reconstruction techniques better restores stability to a PLC-deficient knee and if concomitant injury to the proximal tibiofibular joint or anterior cruciate ligament affects these results. STUDY DESIGN: Controlled laboratory study. METHODS: Eight matched-paired cadaveric specimens from the midfemur to toes were used. Each specimen was tested in 4 phases: intact PLC (phase 1), PLC sectioned (phase 2), PLC reconstructed (ART or LRT) (phase 3), and tibiofibular (phase 4A) or anterior cruciate ligament (phase 4B) sectioning with PLC reconstructed. Varus angulation and external rotation at 0º, 20º, 30º, 60º, and 90º of knee flexion were quantified at each phase. RESULTS: In phase 3, both reconstructions were effective at restoring laxity back to the intact state. However, in phase 4A, both reconstructions were ineffective at stabilizing the joint owing to tibiofibular instability. In phase 4B, both reconstructions had the potential to restrict varus angulation motion. There were no statistically significant differences found between reconstruction techniques for varus angulation or external rotation at any degree of flexion in phase 3 or 4. CONCLUSION: The LRT and ART are equally effective at restoring stability to knees with PLC injuries. Neither reconstruction technique fully restores stability to knees with combined PLC and proximal tibiofibular joint injuries. CLINICAL RELEVANCE: Given these findings, surgeons may select their reconstruction technique based on their experience and training and the specific needs of their patients.

Knee Dislocation (KD) IV Injuries of the Knee: Presentation, Treatment, and Outcomes.

"KDIV ligamentous injuries of the knee are frequently high-energy injuries with significant soft tissue disruption, gross knee instability, and rarely are treated nonoperatively. KDIVs frequently require external fixation, but when presenting in an isolated fashion can be reconstructed in one setting. Five presentations of KDIV injury are described: closed with multitrauma/closed head injury requiring external fixation, irreducible KDIV requiring semi-emergent open reduction and repair, isolated KDIV without arterial injury undergoing 4-ligament reconstruction after regaining motion, KDIV with varus and slight thrust undergoing medial opening osteotomy before ligament reconstruction, and KDIV with failed ligaments requiring revision and posterior tibial tendon transfer."

Distal tibia allograft for glenohumeral instability: does radius of curvature match?

BACKGROUND: A distal tibia osteochondral allograft is a potential graft option for glenoid reconstruction because the distal tibia may have a similar radius of curvature (ROC) as the glenoid. This study evaluated ROC mismatch as measured on computed tomography (CT) scans between the glenoid, distal tibia, and humeral head. METHODS: Bilateral CT images were formatted for 10 decedents from the Office of the Medical Investigator database, giving 20 specimens per anatomic location. The ROCs of the glenoid, distal tibia, and humeral head were measured. A statistical model was generated to assess ROC mismatch of randomly paired distal tibias and glenoids. RESULTS: The mean ± standard deviation ROC was 2.9 ± 0.25 cm for the glenoid, 2.3 ± 0.21 cm for the distal tibia, and 2.5 ± 0.12 cm for the humeral head. No differences were found in laterality, intraobserver, or interobserver measurements. The least-squares difference in the ROC between the glenoid and tibia was 0.57 cm, glenoid and humerus was 0.40 cm, and humerus and tibia was 0.17 cm. Only 22% of randomly paired distal tibias and glenoids had a difference in ROC of 0.3 cm or less. CONCLUSION: CT measurement of the ROC of the glenoid, distal tibia, and humeral head is reliable and reproducible. The probability of obtaining a random distal tibia allograft with a similar ROC to the glenoid is low. Obtaining ROC measurements of the injured glenoid and the distal tibia allograft specimen before use for glenoid reconstruction may be useful.

Meniscal repair using an all-inside, rapidly absorbing, tensionable device.

PURPOSE: The purpose of this study was to evaluate the clinical success rate of all-inside meniscal repairs using a rapidly absorbing device in patients undergoing concurrent anterior cruciate ligament (ACL) reconstructions. METHODS: Patients with menisci repaired using the polydioxanone Mitek RapidLoc (Depuy Mitek, Raynham, MA) during concurrent ACL reconstruction were evaluated clinically 2 years following index surgery. We performed examinations on 38 meniscal tears in 30 patients using the International Knee Documentation Committee form and the Knee Disorders Subjective History visual analog scale. We also performed physical examinations for an effusion, joint line tenderness, McMurray's testing, and KT-1000 arthrometry (MEDmetric, San Diego, CA). RESULTS: The clinical success rate for meniscal repair was 86.8% (33 of 38) at a mean follow-up of 30.4 months (range, 21 to 56 months). Univariate analysis revealed sex as the only predictive variable for failure; all failures occurred in male patients. Nonpredictive variables included tear length, type, and configuration; a duration of more than 3 months, compartment, zone, ligament graft choice, age, follow-up, Tegner score, and visual analog scale score. CONCLUSIONS: The polydioxanone RapidLoc device was found to have a clinical success rate of 86.8%. These data suggest that the more rapidly absorbing polydioxanone device is effective for all-inside meniscal repair during concurrent ACL reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction.

The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.