Comparing the Interobserver Reliability of 4 Methods Used to Measure Knee Laxity on Coronal Plane Stress Radiograph.

Background: Varus and valgus knee stress radiographs provide valuable information in the pre- and postoperative evaluation of joint laxity in patients with multiligament knee injuries (MLKIs). Purpose: To review the literature for described techniques of quantifying laxity on coronal stress radiographs of the knee and identify the most reliable method. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A thorough literature search using the MEDLINE and Embase databases identified 4 studies with distinct methods for objectively measuring laxity on varus and valgus stress radiographs: Heesterbeek et al (2008), Jacobsen (1976), LaPrade et al (2004), and Sawant et al (2004). To compare these methods, 200 coronal plane stress radiographs from 50 patients with MLKIs were retrospectively reviewed from an MLKI database at a single institution. The amount of varus and valgus laxity on each radiograph was measured independently by 4 reviewers using each method. Intraclass correlation coefficients (ICCs) with 95% CIs were calculated to assess the interobserver reliability of each method overall and the varus and valgus measurements individually. Results: For all 4 methods, the overall interobserver reliability was considered at least moderate. The method by Heesterbeek et al proved to have the highest interrater reliability in all domains-overall (ICC, 0.87 [95% CI, 0.85-0.90]), valgus (ICC, 0.83 [95% CI, 0.78-0.88]), and varus (ICC, 0.87 [95% CI, 0.83-0.90])-demonstrating good to excellent reliability both overall and in varus measurements and showing good reliability in valgus measurements. The method by Sawant et al demonstrated good reliability in valgus measurements. All other measures demonstrated moderate reliability. Conclusion: Available methods for measuring knee joint laxity on varus and valgus knee stress radiographs in patients with MLKIs demonstrated moderate to good interobserver reliability. The method described by Heesterbeek et al proved to have the highest reliability overall as well as in measurements on varus and valgus views individually.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Assessment of 30 Years of Randomized Controlled Trials in The American Journal of Sports Medicine: 1990-2020.

Background: Randomized controlled trials (RCTs) stand atop the evidence-based hierarchy of study designs for their ability to arrive at results with the lowest risk of bias. Even for RCTs, however, critical appraisal is essential before applying results to clinical practice. Purpose: To analyze the quality of reporting of RCTs published in The American Journal of Sports Medicine (AJSM) from 1990 to 2020 and to identify trends over time and areas of improvement for future trials. Study Design: Systematic review; Level of evidence, 1. Methods: We queried the AJSM database for RCTs published between January 1990 and December 2020. Data pertaining to study characteristics were recorded. Quality assessments were conducted using the Detsky quality-of-reporting index and the modified Cochrane risk-of-bias (mROB) tool. Univariate and multivariable models were generated to establish factors with associations to study quality. The Fragility Index was calculated for eligible studies. Results: A total of 277 RCTs were identified with a median sample size of 70 patients. A total of 19 RCTs were published between 1990 and 2000 (t1); 82 RCTs between 2001 and 2010 (t2); and 176 RCTs between 2011 and 2020 (t3). From t1 to t3, significant increases were observed in the overall mean-transformed Detsky score (from 68.2% ± 9.8% to 87.4% ± 10.2%, respectively; P < .001) and mROB score (from 4.7 ± 1.6 to 6.9 ± 1.6, respectively; P < .001). Multivariable regression analysis revealed that trials with follow-up periods of <5 years clearly stated primary outcomes, and a focus on the elbow, shoulder, or knee were associated with higher mean-transformed Detsky and mROB scores. The median Fragility Index was 2 (interquartile range, 0-5) for trials with statistically significant. Studies with small sample sizes (<100 patients) were more likely to have low Fragility Index scores and less likely to have a statistically significant finding in any outcome. Conclusion: The quantity and quality of published RCTs published in AJSM increased over the past 3 decades. However, single-center trials with small sample sizes were prone to fragile results.

Use of an Artificial Intelligence Conversational Agent (Chatbot) for Hip Arthroscopy Patients Following Surgery.

Purpose: The purpose of this study was to evaluate the use of an AI conversational agent during the postoperative recovery of patients undergoing elective hip arthroscopy. Methods: Patients undergoing hip arthroscopy were enrolled in a prospective cohort for their first 6 weeks following surgery. Patients used standard SMS text messaging to interact with an artificial intelligence (AI) chatbot ("Felix") used to initiate automated conversations regarding elements of postoperative recovery. Patient satisfaction was measured at 6 weeks after surgery using a Likert scale survey. Accuracy was determined by measuring the appropriateness of chatbot responses, topic recognition, and examples of confusion. Safety was measured by evaluating the chatbot's responses to any questions with potential medical urgency. Results: Twenty-six patients were enrolled with a mean age of 36 years, and 58% (n = 15) were male. Overall, 80% of patients (n = 20) rated the helpfulness of Felix as good or excellent. In the postoperative period, 12/25 (48%) patients reported being worried about a complication but were reassured by Felix and, thus, did not seek medical attention. Of a total of 128 independent patient questions, Felix handled 101/128 questions appropriately (79%), either by addressing them independently, or facilitating contact with the care team. Felix was able to adequately answer the patient question independently 31% of the time (n = 40/128). Of 10 patient questions that were thought to potentially represent patient complications, in 3 cases Felix did not adequately address or recognize the health concern-none of these situations resulted in patient harm. Conclusion: The results of this study demonstrate that the use of a chatbot or conversational agent can enhance the postoperative experience for hip arthroscopy patients, as demonstrated by high levels of patient satisfaction. Levels of Evidence: Level IV, therapeutic case series.

Predictors of Increased Fragility Index Scores in Surgical Randomized Controlled Trials: An Umbrella Review.

BACKGROUND: The fragility index (FI) is defined as the minimum number of patients or subjects needed to switch experimental groups for statistical significance to be lost in a randomized control trial (RCT). This index is used to determine the robustness of a study's findings and recently as a measure of evaluating RCT quality. The objective of this review was to identify and describe published systematic reviews utilizing FI to evaluate surgical RCTs and to determine if there were common factors associated with higher FI values. METHODS: Three databases (PubMed, MEDLINE [Ovid], Embase) were searched, followed by a subsequent abstract/title and full-text screening to yield 50 reviews of surgical RCTs. Authors, year of publication, name of journal, study design, number of RCTs, subspecialty, sample size, median FI, patients lost to follow-up, and associations between variables and FI scores were collected. RESULTS: Among 1007 of 2214 RCTs in 50 reviews reporting FI (median sample size 100), the pooled median FI was 3 (IQR: 1-7). Most reviews investigated orthopaedic surgery RCTs (n = 32). There was a moderate correlation between FI and p value (r = 0.-413), a mild correlation between FI and sample size (r = 0.188), and a mild correlation between FI and event number (r = 0.129). CONCLUSION: Based on a limited sample of systematic reviews, surgical RCT FI values are still low (2-5). Future RCTs in surgery require improvement to study design in order to increase the robustness of statistically significant findings.

Association of age, sex and race with prescription of anti-osteoporosis medications following low-energy hip fracture in a retrospective registry cohort.

BACKGROUND: Initiation of anti-osteoporosis medications after hip fracture lowers the risk of subsequent fragility fractures. Historical biases of targeting secondary fracture prevention towards certain groups may result in treatment disparities. We examined associations of patient age, sex and race with anti-osteoporosis medication prescription following hip fracture. METHODS: A cohort of patients with a hip fracture between 2016-2018 was assembled from the American College of Surgeons National Surgical Quality Improvement Program registry. Patients on anti-osteoporosis medications prior to admission were excluded. Multivariable logistic regression was used to determine adjusted associations between patient age, sex and race and their interactions with prescription of anti-osteoporosis medications within 30 days of surgery. RESULTS: In total, 12,249 patients with a hip fracture were identified with a median age of 82 years (IQR: 73-87), and 67% were female (n = 8,218). Thirty days postoperatively, 26% (n = 3146) of patients had been prescribed anti-osteoporosis medication. A significant interaction between age and sex with medication prescription was observed (p = 0.04). Male patients in their 50s (OR:0.75, 95%CI:0.60-0.92), 60s (OR:0.81, 95%CI:0.70-0.94) and 70s (OR:0.89, 95%CI:0.81-0.97) were less likely to be prescribed anti-osteoporosis medication compared to female patients of the same age. Patients who belonged to minority racial groups were not less likely to receive anti-osteoporosis medications than patients of white race. INTERPRETATION: Only 26% of patients were prescribed anti-osteoporosis medications following hip fracture, despite consensus guidelines urging early initiation of secondary prevention treatments. Given that prescription varied by age and sex, strategies to prevent disparities in secondary fracture prevention are warranted.

Wie wichtig sind psychologische Maßnahmen, um die Bereitschaft zur Rückkehr zum Sport nach der Rekonstruktion des vorderen Kreuzbandes zu bestimmen? Ergebnisse einer Online-Umfrage.

BACKGROUND: Recent studies have suggested that psychological factors are important components of a successful return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to survey physicians with respect to their criteria used to determine readiness to RTS after ACLR and to understand the significance of psychological factors on RTS. METHODS: A survey was designed to understand the practices of clinicians managing rehabilitation after ACLR, consisting of 25 questions divided into 3 different sections, including one section about psychological scores and factors affecting RTS. The survey was delivered to three North American organizations for orthopedic sports medicine. RESULTS: The total number of respondents was 113. Of the respondents, 95% considered psychological tests at least "somewhat important" (33% "important", 23% selected "very important"). Routine use of psychological tests in practice was only reported by 35% of respondents. The ACL-Return to Sport after Injury Scale was the most frequently used psychological test (23%). Fear of reinjury was considered the most common patient-cited psychological factor affecting RTS. Psychological factors ranked 8th out of 9 outcomes measures in determining readiness to RTS. CONCLUSION: This study demonstrates a discrepancy between the importance of psychological tests and the frequency of use in practice. Additional education on this topic, web-based applications, and a multidisciplinary approach may increase the usage of psychological tests to determine RTS after ACLR.

Wide Variability in Return-to-Sport Criteria used by Team Physicians After Anterior Cruciate Ligament Reconstruction in Elite Athletes-A Qualitative Study.

Purpose: The purpose of this study is to explore currently used readiness to return to sport (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) used in elite athletes to gain novel insights into the RTS decision-making process of professional team physicians. Methods: Eighteen qualitative semistructured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after ACLR. General inductive analysis and a coding process were used to identify themes and subthemes arising from the data. A hierarchical approach in coding helped to link themes. Results: The most important RTS criteria included muscle strength, followed by satisfactory functional testing including hop tests, a satisfactory clinical examination, joint stability, psychological readiness, time since the ACLR surgery, absence of joint effusion, subjective feeling of knee stability, pain-free return to sporting movements, completion of a sport-specific rehabilitation, and at last allied team support. Conclusions: This study identified 4 main themes, including (1) objective findings, (2) informative feedback of the team members, (3) subjective findings, and (4) type of sport and time to surgery as having the most influence on RTS decision after ACLR. However, interviews showed that even among professional team physicians, the main criteria to RTS in these categories were inconsistent. A definitive set of conclusive guidelines could not be established and would be a fruitful and useful area for future research through further quantitative studies and international consensus meetings along the foundation of the presenting study. Level of Evidence: V, evidence-based practices, qualitative study.

Adjuvant Medial Collateral Ligament Release at the Time of Knee Arthroscopy: A Controlled Percutaneous Technique.

The posterior horn of the medial meniscus can be challenging to view during arthroscopy because the medial femoral condyle obstructs vision, especially in tight medial compartments. Previous studies have described techniques for improving access, one being a percutaneous medial collateral ligament (MCL) release. This technique allows for increased medial compartment space, which offloads a tight medial compartment, minimizes iatrogenic chondral injury, incomplete meniscal resection, uncontrolled MCL rupture, and allows for accurate diagnosis and management. Studies have proven the safety of the controlled percutaneous MCL release, with no significant postoperative MCL laxity on stress views, no subjective patient instability, fewer iatrogenic cartilage lesions, and no saphenous neurovascular injury. Furthermore, retrospective studies have shown improved postoperative patient-reported outcomes with a controlled percutaneous MCL release in comparison to standard of care without a release. We hypothesize that a controlled percutaneous release of the MCL effectively alleviates some of the pressure within the medial compartment, which could potentially explain the improved postoperative clinical outcomes. This technique also facilitates improved visualization, a decreased risk of iatrogenic chondral injury, and a more complete meniscal resection. The purpose of this Technical Note is to describe our surgical technique and provide surgical pearls for a controlled percutaneous MCL release during knee arthroscopy.

The analgesic benefit of Pericapsular Nerve Group (PENG) block in hip arthroscopic surgery: a retrospective pragmatic analysis at an academic health center.

INTRODUCTION: The novel pericapsular nerve group (PENG) block has recently been reported to provide effective motor-sparing local anesthetic-based analgesia to the hip joint. We aimed to evaluate the analgesic efficacy and safety of a preoperative PENG block among patients undergoing ambulatory hip arthroscopic surgery where systemic analgesia is the gold standard. METHODS: We conducted a single-center, retrospective pragmatic exploratory cohort study of consecutive outpatient hip arthroscopic surgery cases from January 2017 to March 2019. We identified 164 cases in which patients received general anesthesia with or without a preoperative PENG block. The primary analgesic outcome measures were time to first postoperative analgesic request, intraoperative and postoperative opioid consumption (intravenous morphine equivalent), and postoperative pain severity (visual analog scale 10 cm scale ranging from 0=no pain to 10=severe pain) in hospital. Secondary outcomes included duration of stay in the postanesthesia care unit, opioid-related side effects, time to discharge readiness, and block-related complications. RESULTS: Seventy-five cases received a preoperative PENG block and 89 cases received systemic analgesia alone. The addition of a PENG block reduced intraoperative (6.6 mg vs 7.5 mg, difference: 0.9 mg; 95% CI 0.2 to 1.7; p=0.01) and postoperative (10.7 mg vs 13.9 mg, difference: 3.2 mg; 95% CI 0.9 to 5.5; p=0.01) intravenous morphine consumption, as well as the mean (3.5 vs 4.2, difference: 0.7; 95% CI 0.1 to 1.3; p=0.03) and highest (5.5 vs 6.5, difference: 1.0; 95% CI 0.2 to 1.7; p=0.02) postoperative pain severity scores in hospital. The PENG block did not prolong the time to first analgesic request (15.8 min vs 12.3 min, difference: 3.5 min; 95% CI -9.0 to 2.0; p=0.23). Fewer patients in the PENG group experienced postoperative nausea and vomiting compared with systemic analgesia alone (36% vs 52%, OR 1.9; 95% CI 1.0 to 3.6; p=0.02), while the PENG block expedited discharge readiness (165.0 min vs 202.8 min, difference: 37.8 min; 95% CI 2.9 to 72.3; p=0.04). No block-related complications were noted in any patient. DISCUSSION: Based on our retrospective dataset, this pragmatic exploratory cohort study suggests that a preoperative PENG block is associated with questionable improvements in postoperative in-hospital analgesic outcomes which may or may not prove to be clinically relevant when compared with systemic analgesia alone for patients undergoing hip arthroscopic surgery. This small signal should be investigated in a prospective randomized trial.

Six Percent Incidence of Graft-Tunnel Mismatch in Anatomic Anterior Cruciate Ligament Reconstruction Using Bone-Patella Tendon-Bone Autograft and Anteromedial Portal Drilling.

Purpose: The purpose of this study was to determine the incidence of graft-tunnel mismatch (GTM) when performing anatomic anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BPTB) grafts and anteromedial portal drilling. Methods: Beginning in November 2018, 100 consecutive patients who underwent ACLR by two sports fellowship-trained, orthopedic surgeons using BPTB autograft and anteromedial portal drilling were prospectively identified. The BPTB graft dimensions and the femoral tunnel distance, tibial tunnel distance, intra-articular distance, and total distance were measured. Surgeons determined the depth and angle of tunnels based on the patella tendon graft length dimensions in each case. After passage of the graft, the distance from the distal graft tip to the tibial cortex aperture was measured. GTM was defined as the need for additional measures to obtain satisfactory tibial graft fixation (<15-20 mm of bone fixation). Results: The incidence of mismatch was 6/100 (6%). Five cases involved the graft being too long, with the tibial bone plug protruding excessively from the tibial tunnel-4/5 had a patella tendon length ≥ 50 mm. Three cases were managed with femoral tunnel recession, and two were treated with a free bone plug technique. One patient with a patella tendon length of 35 mm had a graft that was too short, with the tibial bone plug recessed in the tibial tunnel. Of patients whose tibial tunnel distance was within 5 mm of the patella tendon length, only 1/46 (2%) patients had mismatch, whereas 5/54 (9%) of patients who had >5 mm difference had mismatch. Conclusions: The incidence of graft-tunnel mismatch after anatomic ACLR using BTPB and anteromedial portal drilling in this study is 6%. To limit the occurrence of GTM where the graft is too long, surgeons should drill tibial tunnel distances within 5 mm of the patella tendon length. Clinical Relevance: The results of this study provide surgeons with a technique of limiting graft tunnel mismatch when performing ACLR using BPTB and anteromedial portal drilling.

A Survey of Treatment Trends for Acute Quadriceps Tendon Ruptures Among North American Surgeons.

Background: To date, little clinical evidence exists to support a specific surgical technique or postoperative rehabilitation protocol for quadriceps tendon ruptures. With a lack of evidence-based superiority, assessment of clinical practices and surgeon preferences is pertinent. Purpose: To describe the current surgical technique and rehabilitation preferences among members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine pertaining to acute quadriceps tendon rupture. Study Design: Cross-sectional study. Methods: Orthopaedic staff members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine were invited to complete an internet-based survey composed of 26 questions assessing current trends in the management and rehabilitation of acute quadriceps tendon rupture. Survey questions were developed after a thorough review of current literature. Survey responses were analyzed and reported using descriptive statistics (absolute values, frequencies, and percentages) where appropriate. Statistical comparisons and contrasts between Canadian and American surgeons were made using chi-square analyses and Student t tests. Results: A total of 264 surgeons participated in the survey (136 Canadians; 128 Americans). Canadian surgeons were more likely to obtain a preoperative ultrasound as compared with Americans (43.0% vs 6.7%; P < .00001), while American respondents were more likely to obtain magnetic resonance imaging scans (65.8% vs 10.2%; P < .00001). The transosseous drill hole technique was the most commonly utilized (70.2%); the suture anchor technique was used 20.6% of the time. Canadian respondents trended toward a higher use of transosseous tunnels; however, this was not statistically significant (75.8% vs 64.2%; P = .068). American respondents were more likely to utilize suture anchors (27.5% vs 14.1%; P = .0096). Most respondents advanced range of motion goals stepwise in 2-week intervals of 30° (Canadians, 54.0% vs Americans, 58.5%; P = .3091); timing of range of motion initiation varied. Conclusion: Among North American surgeons who responded to this study, the transosseous technique was the most commonly used, and range of motion was generally advanced in a 2-week stepwise fashion. We found several differences in practice between Canadian and American respondents, including the type of preoperative imaging and the frequency of using the suture anchor technique.

Effect of Osteochondroplasty on Time to Reoperation After Arthroscopic Management of Femoroacetabular Impingement: Analysis of a Randomized Controlled Trial.

Background: A subset of patients with femoroacetabular impingement (FAI) fail arthroscopic management. It is not clear which patients will fail surgical management; however, several surgical and patient factors, such as type of procedure and age, are thought to be important predictors. Purpose: This time-to-event analysis with a 27-month follow-up analysis compared the effect of (1) arthroscopic osteochondroplasty with or without labral repair versus (2) arthroscopic lavage with or without labral repair on the time to reoperation in adults aged 18 to 50 years with FAI. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Eligible participants had been randomized in a previous study trial to a treatment of arthroscopic osteochondroplasty or arthroscopic lavage with or without labral repair. Using the comprehensive data set from the Multinational Femoroacetabular Impingement Randomized controlled Trial, all reoperations until 27 months after surgery were identified. The analysis was conducted using a Cox proportional hazards model, with percentage of patients with a reoperation evaluated in a time-to-event analysis as the outcome. The independent variable was the procedure, with age and impingement subtype explored as potential covariates. The effects from the Cox model were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha level of .05. Results: A total of 108 patients in the osteochondroplasty group and 106 patients in the lavage group were included. The mean age of the patients included in the study was 36 ± 8.5 years. Overall, 27 incident reoperations were identified within the 27-month follow-up, with an incidence rate of 6 per 100 person-years. Within the osteochondroplasty group, 8 incident reoperations were identified (incidence rate, 3.4 per 100 person-years), while within the lavage group, 19 incident reoperations were identified (incidence rate, 8.7 per 100 person-years). The hazard of reoperation for patients undergoing osteochondroplasty was 40% of that of patients undergoing lavage (HR, 0.40 [95% CI, 0.17-0.91] P = .029). Conclusion: This study demonstrated that for adults between the ages of 18 and 50 years with FAI, arthroscopic osteochondroplasty was associated with a 2.5-fold decrease in the hazard of reoperation at any point in time compared with arthroscopic lavage. Registration: NCT01623843 (ClinicalTrials.gov identifier).

Single and double bundle posterior cruciate ligament reconstruction yield comparable clinical and functional outcomes: a systematic review and meta-analysis.

PURPOSE: To perform a systematic review and compare the functional and objective outcomes after single-bundle (SB) vs. double-bundle (DB) posterior cruciate ligament reconstruction (PCLR). Where possible to pool outcomes and arrive at summary estimates of treatment effect for DB PCLR vs. SB PCLR via an embedded meta-analysis. METHODS: A comprehensive PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) literature search identified 13 eligible studies evaluating clinical outcomes of both techniques for PCLR. Clinical outcome measures included in the meta-analysis were functional outcomes (Lysholm Score, Tegner Activity Scale) and objective measurements of posterior laxity of the operated knee (arthrometer and stress radiographs). RESULTS: The meta-analysis included 603 patients. Three hundred and fifteen patients were treated with SB and two hundred and eighty-eight patients with DB PCLR. There were no significant differences between SB and DB PCLR in postoperative functional Lysholm Scores (CI [- 0.18, 0.17]), Tegner Activity Scales (CI [- 0.32, 0.12]) and IKDC objective grades (CI [- 0.13, 1.17]). Regarding posterior stability using KT-1000 and Kneelax III arthrometer measurements, there were no differences between the SB and DB group. However, double-bundle reconstruction provided better objective outcome of measurement of posterior laxity (CI [0.02, 0.46]) when measured with Telos stress radiography. CONCLUSION: A systematic review was conducted to identify current best evidence pertaining to DB and SB PCLR. An embedded meta-analysis arrived at similar summary estimates of treatment effect for motion, stability and overall function for both techniques. There is no demonstrable clinically relevant difference between techniques based on the currently available evidence. LEVEL OF EVIDENCE: III.

The accuracy of routine knee MR imaging in detection of acute neurovascular injury following multiligamentous knee injury.

OBJECTIVE: To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. MATERIALS AND METHODS: Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. RESULTS: Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. CONCLUSION: Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial.

BACKGROUND: Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. QUESTIONS/PURPOSES: (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? METHODS: Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. RESULTS: With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. CONCLUSION: With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. LEVEL OF EVIDENCE: Level II, therapeutic study.

Arthroscopic Medial Meniscal Posterior Root Repair With Transtibial Luggage-Tag and Horizontal Mattress Sutures.

Medial meniscal posterior root repair techniques have shown positive yet varied results in the literature. The decision to perform repair has improved clinical outcomes in many situations, although the healing rate is approximately 64% and the repair strength is roughly one-third of the native root strength, with meniscal extrusion being common. We present a technique based on biomechanical evidence to obtain a strong anatomic posterior root repair to restore nearly normal knee mechanics, combining an increased size of footprint under the lateral aspect of the medial meniscal horn for healing and a luggage-tag suture with a posteriorly placed horizontal mattress suture. The horizontal mattress suture is passed to capture the circumferential fibers of the meniscus and the luggage-tag suture is passed to capture the radial fibers of the meniscal body, through a single transtibial tunnel. The aim of this repair is to restore the normal meniscal function.

A Comparison of Quadriceps Tendon Autograft With Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Quantitative Synthesis.

OBJECTIVE: There is growing enthusiasm for the increased use of quadriceps tendon (QT) autograft for primary anterior cruciate ligament reconstruction (ACLR). The purpose of this analysis was to synthesize and quantitatively assess the available evidence comparing QT autograft with hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, regarding functional outcomes, knee stability, anterior knee pain, and revision rates. DATA SOURCES: A search in MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials for eligible studies up to May 2018 was conducted. Two reviewers selected studies based on inclusion criteria and assessed methodological quality. Outcomes analyzed were anterior knee pain, graft failure rates, knee stability, functional outcomes, and adverse events. Pooled analyses were performed for continuous and dichotomous variables where appropriate. MAIN RESULTS: Ten studies (1 randomized trial and 9 nonrandomized cohorts) met our inclusion criteria, which included 1398 patients. The analysis showed no statistical difference in anterior knee pain when comparing QT and HT autografts, but a significant difference between QT and BPTB autografts [odds ratio, 0.15 (95% confidence interval, 0.08-0.27); P < 0.001]. There were no differences between all 3 autografts in revision rates, knee stability, and patient-reported functional outcomes. CONCLUSIONS: Quadriceps tendon autograft is a suitable graft alternative for primary ACLR, as it achieves good clinical outcomes with a low incidence of anterior knee pain. Given the limited quality of the included studies, there is a need for a well-designed multicenter randomized control trial comparing QT autograft with other primary ACL autografts to confirm our findings. LEVEL OF EVIDENCE: Level IV systematic review.

Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To identify whether any patient factors, injury factors, or symptom severity scores are associated with either psychological or physical readiness to return to sport after anterior cruciate ligament reconstruction (ACLR). METHODS: Consecutive patients with an ACL injury that required surgical treatment were included in this study. All patients completed the single-legged hop testing and the Anterior Cruciate Ligament Return to Sport Index (ACL-RSI) at 1 year postoperatively. Multivariable regression analysis models were used to determine whether an independent relationship existed between baseline patient factors (age, sex, BMI, preinjury Marx Activity Score), injury factors (meniscal tear and chondral injury), physical symptoms (Knee Injury and Osteoarthritis Outcome Score [KOOS] for pain and symptoms), and the dependent variables of physical and psychological readiness to return to sport (single-legged hop and ACL-RSI). RESULTS: Of the 113 patients who were included, 37% were female, and the mean age of our population was 28.2 years (SD = 8.1). Multivariable regression models demonstrated that patient-reported pain symptoms at 1 year postoperatively, as measured by the KOOS pain subscale, was significantly associated with both ACL-RSI score (Beta estimate: 1.11 [95% CI: .62-1.60] P < .001) and the ability to pass the single-legged hop test (OR: 1.07 [95% CI: 1.004-1.142] P = .037). CONCLUSIONS: Patients with higher reported pain levels at 1 year following ACLR have lower psychological and physical readiness to return to sport. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.