Medial patellar ligament reconstruction in combination with derotational distal femoral osteotomy for treating recurrent patellar dislocation in the presence of increased femoral anteversion: a systematic review.

BACKGROUND: Medial patellar ligament reconstruction (MPFL-R) in combination with derotational distal femoral osteotomy (DDFO) for treating recurrent patellar dislocation (RPD) in the presence of increased femoral anteversion is one of the most commonly used surgical techniques in the current clinical practice. However, there are limited studies on the clinical outcomes of MPFL-R in combination with DDFO to treat RPD in the presence of increased femoral anteversion. PURPOSE: To study the role of MPFL-R in combination with DDFO in the treatment of RPD in the presence of increased femoral anteversion. METHODS: A systematic review was performed according to the PRISMA guidelines by searching the Medline, Embase, Web of Science, and Cochrane Library databases through June 1, 2023. Studies of patients who received MPFL-R in combination with DDFO after presenting with RPD and increased femoral anteversion were included. Methodological quality was assessed using the MINORS (Methodological Index for Nonrandomized Studies) score. Each study's basic characteristics, including characteristic information, radiological parameters, surgical techniques, patient-reported outcomes, and complications, were recorded and analyzed. RESULTS: A total of 6 studies with 231 patients (236 knees) were included. Sample sizes ranged from 12 to 162 patients, and the majority of the patients were female (range, 67-100%). The mean age and follow-up ranges were 18 to 24 years and 16 to 49 months, respectively. The mean femoral anteversion decreased significantly from 34° preoperatively to 12° postoperatively. In studies reporting preoperative and postoperative outcomes, significant improvements were found in the Lysholm score, Kujala score, International Knee Documentation Committee score, and visual analog scale for pain. Postoperative complications were reported in all studies, with an overall reported complication rate of 4.7%, but no redislocations occurred during the follow-up period. CONCLUSION: For RPD with increased femoral anteversion, MPFL-R in combination with DDFO leads to a good clinical outcome and a low redislocation rate. However, there was no consensus among researchers on the indications for MPFL-R combined with DDFO in the treatment of RPD.

Delaying anterior cruciate ligament reconstruction for more than 3 or 6 months results in lower risk of revision surgery.

BACKGROUND: The objective of this study is to investigate the risk of revision surgery when delaying anterior cruciate ligament reconstruction (ACLR) past 3 months or 6 months after injury. MATERIALS AND METHODS: A total of 30,280 patients with isolated ACLR were identified in the Danish Knee Ligament Reconstruction Registry and divided into four groups; ACLR < 3 months, > 3 months, < 6 months, or > 6 months after injury. Primary outcome was revision surgery and secondary outcome were objective and subjective clinical outcome. The 2 year relative risk, crude, and adjusted hazard ratio (HR) were calculated. RESULTS: Comparing ACLR < 3 months to ACLR > 3 months of injury the 2 year relative risk of revision surgery was found to be 1.81 (95% CI 1.46-2.23; P < 0.001) with an adjusted hazard ratio (HR) of 1.27 (95% CI 1.12-1.44; P < 0.001). Comparing ACLR < 6 months to ACLR > 6 months of injury the 2 year relative risk of revision surgery was found to be 1.61 (95% CI 1.34-1.92; P < 0.001) with an adjusted HR of 1.27 (95% CI 1.15-1.40; P < 0.001). CONCLUSION: The risk of revision ACLR surgery was found to be increased when ACLR was performed within 3 months or 6 months of injury compared with later surgery. The 1 year postoperative objective knee laxity and the subjective patient-related outcome was found to be without a clinically significant difference; however, those with early ACLR (< 3 months or < 6 months) were found to have a higher activity level 1 year postoperatively. The information about increased risk of revision when having early surgery should be informed to patients when deciding timing of ACLR treatment. LEVEL OF EVIDENCE: II.

Description of WALANT technique in open bone and ligament wrist surgery.

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release.

PURPOSE: Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. METHODS: We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. RESULTS: A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). CONCLUSIONS: Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Reconstruction of the medial patellofemoral ligament through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation.

PURPOSE: The present study aimed to assess the clinical efficacy and imaging results of reconstruction of the medial patellofemoral ligament through a double bundle of single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation. METHODS: Twenty-three patients with recurrent patellar dislocation, including ten males and 13 females, with 23 knee joints were enrolled according to the relevant criteria. Reconstruction of the medial patellofemoral ligament was performed through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity. Knee function was evaluated using visual analog scale (VAS) score, International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner score, and Kujala score at pre- and postoperative stages. Patellar stability was assessed by CT scans measuring tibial tuberosity-trochlear groove (TT-TG) distance, lateral patella displacement (LPD), congruence angle (CA), and patellar tilt angle (PTA). RESULTS: All 23 patients were effectively followed up for 13-28 months (mean: 21.91 ± 4.14 months). At the last follow-up, the postoperative VAS score, IKDC score, Lysholm score, Tegner score, and Kujala score of 23 patients were 1.13 ± 0.82, 87.35 ± 3.17, 90.22 ± 1.28, 4.35 ± 0.65, and 89.26 ± 1.96, respectively, as compared to the preoperative values of 5.91 ± 1.13, 30.96 ± 5.09, 30.30 ± 2.98, 1.26 ± 0.62, and 27.87 ± 3.46, respectively, and these differences were statistically significant (P < 0.001). At the last follow-up, the postoperative TT-TG, LPD, CA, and PTA values of the 23 patients were 8.80 ± 1.85 mm, 6.01 ± 1.77 mm, 11.32 ± 6.18°, and 9.35 ± 2.88°, respectively, compared to the preoperative values of 18.77 ± 1.74 mm, 14.90 ± 4.07 mm, 37.82 ± 5.71°, and 23.58 ± 3.24°, respectively, and the differences were statistically significant (P < 0.001). No relevant complications were observed in the 23 patients. CONCLUSIONS: Reconstruction of the medial patellofemoral ligament through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation showed satisfactory medium-term efficacy, and further investigations are required to confirm the long-term efficacy of this approach.

Comparing Outcomes of Bicruciate-Stabilized and Cruciate-Retaining Total Knee Arthroplasty.

Background: Bicruciate-stabilized (BCS) total knee arthroplasty (TKA) aims to restore normal kinematics by replicating the function of both cruciate ligaments. Conventional cruciate-retaining (CR) design in TKA has shown previous clinical success with lower complication rates. This study compared the patient-reported outcomes between the BCS and CR TKA designs. Methods: This retrospective study examined patients who underwent primary TKA using a CR or a BCS implant. Patient demographics, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), and Forgotten Joint Score (FJS) were compared between two cohorts. Patient-reported outcome measures were analyzed using independent samples t-tests. Results: There were no significant preoperative demographic differences between groups. The CR cohort (n = 756) had significantly higher average KOOS, JR Scores compared to the BCS cohort (n = 652) at 3 months (59.7 ± 3.8 vs. 53.0 ± 3.9, p < 0.001) and 2 years (62.6 ± 8.0 vs. 53.8 ± 6.7, p = 0.001) after TKA. Within the cohort, KOOS, JR delta differences were not significant for CR when comparing patient scores 3 months to 1 year after surgery. Meanwhile, the BCS patients did show significant delta improvement (4.1 ± 1.9, p = 0.030) when compared 3 months to 1 year after surgery. One year postoperatively, the BCS cohort (n = 134) showed a significantly higher average FJS score (49.5 ± 31.4, vs. 36.8 ± 28.5, p = 0.028) than the CR cohort (n = 203). Both cohorts displayed a significant difference in delta improvements within their respective cohort when measuring FJS from 3 months to 1 year, 2 years, and 3 years after surgery. Conclusions: The CR cohort performed better on average, compared to the BCS cohort in measures of KOOS, JR scores at the 2-year follow-up. The BCS cohort performed marginally better regarding FJS only at 1-year follow-up.

Functional reconstruction of chronic acromioclavicular joint separation using a double suture technique combined with semitendinosus autograft.

PURPOSE: We present the functional and clinical results of a combined surgical technique that functionally restores chronic Acromioclavicular Joint Instability (AJI). The method combines a double-looped suture fixation augmented with a semitendinosus autograft. METHODS: Between 2017 and 2021, 15 patients were treated using the surgical technique. All patients suffered an Acromioclavicular Joint Separation that remained untreated for at least 6 (6-16) weeks after the initial injury. Four Ethibond sutures were passed below the coracoid process and through a 4.5 drill hole in the clavicle. The sutures provided adequate horizontal and vertical reduction and stabilization of the clavicle. A semitendinosus autograft was passed below the coracoid process and looped around the clavicle. The remaining graft limbs were used to reconstruct the acromioclavicular capsule. Patients were radiologically evaluated with bilateral anteroposterior (AP), Zanca, and Alexander views. The clinical evaluation was based on the Acromioclavicular Joint Instability Score and the Constant-Murley Score. RESULTS: The mean follow-up period was 31.2 months (17-61). The mean last ACJIS and CMS scores were 96 (90-100) and 97.67 (87-100), respectively. Reduction of the clavicle was radiologically confirmed in all cases throughout the follow-up period. AC arthritis was reported in 1 case without associated clinical symptoms. No significant complications were reported, and all patients returned to the pre-injury activity level. CONCLUSION: The presented functional reconstruction of the AC joint disruption in chronic cases is an effective and secure method with low complication rates and good clinical results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint.

PURPOSE: The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS: Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS: The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS: For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE: Level IV, cadaveric study.

[Anatomical and biomechanical characteristics of plantaris tendon and its application in ligament reconstruction].

Objective: To improve the clinical utility of the plantaris tendon mainly by summarizing its anatomical characteristics, biomechanical properties, harvesting methods, and its applications in ligament reconstruction. Methods: The relevant literature from domestic and international databases regarding the anatomical and biomechanical characteristics of the plantaris tendon and its applications in ligament reconstruction was comprehensively reviewed and systematically summarized. Results: The plantaris tendons have an absence. The majority of plantaris tendon forms a fan-shape on the anterior and medial sides of the Achilles tendon and terminates at the calcaneal tuberosity. There are significant differences in biomechanical parameters between plantaris tendon with different numbers of strands, and multi strand plantaris tendon have significant advantages over single strand tendon. The plantaris tendon can be harvested through proximal and distal approaches, and it is necessary to ensure that there are no obvious anatomical variations or adhesions in the surrounding area before harvesting. The plantaris tendon is commonly utilized in ligament reconstruction around the ankle joint or suture reinforcement for Achilles tendon rupture, with satisfactory effectiveness. There is limited research on the use of plantar tendon in the reconstruction of upper limb and knee joint ligaments. Conclusion: The plantaris tendon is relatively superficial, easy to be harvested, and has less impact on local function. The plantaris tendon is commonly utilized in ligaments reconstruction around the ankle joint or suture reinforcement for Achilles tendon rupture. The study on the plantaris tendon for upper limbs and knee joints ligament reconstruction is rarely and require further research.

The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) is a valid and reliable measure to assess psychological readiness before returning to sport following peroneal tendon pathology surgery.

PURPOSE: The objective of this study was to validate a scale that could help surgeons evaluate patients' psychological readiness to return to sport (RTS) after peroneal tendon pathology surgery. METHODS: The Ankle Ligament Reconstruction-Return to Sport after Injury (ALR-RSI) scale, which had previously been validated in ankle ligament reconstruction patients, was adapted to evaluate the psychological preparedness for RTS in athletic patients who underwent peroneal tendinopathy surgery. The Foot and Ankle Outcome Score (FAOS) and Foot Ankle Ability Measurement (FAAM) scores were employed as patient-related outcome measurement (PROM) instruments. RESULTS: This study included 57 patients. There was a strong correlation between ALR-RSI and both FAOS and FAAM (r = -0.68 and 0.74, respectively). ALR-RSI was considerably higher in patients who returned to sports than in those who did not. The mean score was 72.9 ± 19.0 in patients who returned to the same preinjury level, 48.5 ± 24.0 in those who returned to a lower level and 53.6 ± 31.1 in patients who changed their athletic activity (p < 0.0001). Furthermore, ALR-RSI showed at least a similar discrimination ability when compared to FAOS and FAAM. The test-retest intraclass correlation coefficient was 0.95. The Cronbach's α statistic used to measure the internal consistency was high (0.95). A Youden index of 0.65 was observed for a cut-off score of 68 points. CONCLUSION: ALR-RSI is a valid instrument for assessing psychological readiness to RTS in an athletic population following peroneal tendon surgery. When compared to the most commonly used PROMs, it was strongly correlated and demonstrated at least similar discrimination capacity. This could assist surgeons in identifying athletes who will have poor postoperative results and advising them on their capability to RTS. LEVEL OF EVIDENCE: Level III.

[Imaging of posterolateral rotational instability of the knee joint]. / Bildgebung bei posterolateraler Rotationsinstabilität des Kniegelenks.

Posterolateral instability of the knee joint typically occurs with injuries to the posterolateral corner of the joint or with additional combined injuries involving the anterior and posterior cruciate ligaments. In addition to numerous, smaller anatomical structures, the most important are the lateral collateral ligament (LCL), the popliteus muscle with its tendon, and the popliteofibular ligament (PFL), which can usually be assessed using magnetic resonance imaging (MRI). On the contrary, small structures like the arcuate ligament and fabellofibular ligament cannot always be identified. However, they are also of lesser importance in the development of posterolateral rotational instability. Overlooked injuries to the posterolateral joint corner promote instability with the complication of inadequate ligament reconstruction and early onset posttraumatic osteoarthritis. Knowledge of MRI morphology of the anatomical structures involved, taking into account their biomechanical significance, is crucial to recognize and use the corresponding imaging findings.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Biomechanical Effects of Subtalar Joint Fusion and Medial Ligament Reconstruction in Simulated Progressive Collapsing Foot Deformity.

BACKGROUND: The purpose of this study is to investigate the biomechanical effect of medial displacement calcaneal osteotomy (MDCO), subtalar joint fusion (SF), and medial ligament reconstruction (MLR: deltoid-spring ligament) in a severe flatfoot model. We hypothesized that (1) combination of MDCO and SF improves the tibiotalar and foot alignment in severe progressive collapsing foot deformity (PCFD) cadaver model. (2) However, if a residual valgus heel alignment remains after MCDO and SF, it can lead to increased medial ligament strain, foot malalignment, and tibiotalar valgus tilt, which will be mitigated by the addition of MLR. METHODS: Ten fresh-frozen cadaveric foot specimens were used to create a severe flatfoot model. The foot alignment changes, including the talo-first metatarsal angle in the axial and sagittal planes, subtalar angle, and tibiotalar angle in the coronal plane, were measured. The angles were measured at the initial condition, after creating the severe flatfoot model, and after each successive reconstructive procedure in the following order: (1) MDCO, (2) SF, and (3) MLR. RESULTS: Tibiotalar valgus tilt was decreased with the MDCO procedure: 4.4 vs 1.0 degrees (P = .04). Adding in situ SF to the MDCO led to increased tibiotalar tilt to 2.5 degrees was different from the initial condition (P = .01). Although the tibiotalar valgus tilt was significantly decreased after adding the MLR to the MDCO/SF procedure compared with the severe flatfoot model (0.8 vs 4.4 degrees, P = .03), no significant difference in the tibiotalar valgus tilt was observed between MDCO/SF and MDCO/SF with MLR. CONCLUSION: Our results demonstrated that MDCO significantly improved forefoot abduction and medial arch alignment, with no significant additional improvement observed with addition of SF. Following SF, a residual valgus heel alignment can contribute to subsequent tibiotalar valgus tilt. The addition of MLR did not show significantly decreased tibiotalar valgus tilt following SF. CLINICAL RELEVANCE: Residual valgus heel alignment after subtalar joint fusion in the surgical treatment of PCFD can lead to increased medial ligament strain. Although MLR might be considered for providing medial stability, it may not necessarily prevent the development of tibiotalar valgus tilt.

Patients who undergo tibial tubercle anteromedialization with medial patellofemoral ligament reconstruction demonstrate similar rates of return to sport compared to isolated MPFL reconstruction.

PURPOSE: To investigate the rate of return to sports and sport psychological readiness between patients who underwent isolated MPFLR (iMPFLR) compared to a matched cohort of patients who underwent MPFLR with anteromedializing tibial tubercle osteotomy (MPFLR/TTO). METHODS: Patients who underwent primary MPFLR with or without TTO for recurrent patellar instability were retrospectively reviewed from 2012 to 2020 at a single institution. Preinjury sport and work information, Kujala, Tegner, Visual Analogue Score for pain, satisfaction and MPFL-Return to Sport after Injury (MPFL-RSI) score were collected. Two readers independently measured the tibial tuberosity-trochlear groove distance, Caton-Deschamps index and Dejour classification for trochlear dysplasia. Patients in iMPFLR and MPFLR/TTO groups were matched 1:1 on age, sex, body mass index and follow-up length. Multivariate regression analysis was performed to determine whether the MPFL-RSI was associated with a return to sport. RESULTS: This study included 74 patients at mean follow-up of 52.5 months (range: 24-117). These groups returned to sport at similar rates (iMPFLR: 67.6%, MPFLR/TTO: 73.0%, not significant [ns]), though iMPFLR patients returned more quickly (8.4 vs. 12.8 months, p = 0.019). Rates of return to preinjury sport level were also similar (45.9% vs. 40.5%, ns). Patients with Dejour B/C took more time to return to sport compared to patients with mild/no trochlear pathology (13.8 vs. 7.9 months, p = 0.003). Increasing MPFL-RSI score was significantly predictive of the overall return to sport (odds ratio [OR]: 1.08, 95% confidence interval [CI] [1.03, 1.13], p < 0.001) and return to preinjury level (OR: 1.07, 95% CI [1.04, 1.13], p < 0.001). Most patients in iMPFLR and MPFLR/TTO groups resumed work (95.7% vs. 88.5%, ns), though iMPFLR patients who returned to preinjury work levels did so more quickly (1.7 vs. 4.6 months, p = 0.005). CONCLUSION: Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. Patients with more severe trochlear pathology required more time to return to sports. LEVEL OF EVIDENCE: Level III.

Editorial Commentary: When Managing Patellofemoral Instability, Mind Your P's and Q's: Medial Patellofemoral Ligament Versus Medial Quadriceps Tendon Femoral Ligament Versus Medial Patellofemoral Complex.

Our understanding of patellar instability and the medial patellofemoral complex (MPFC) has evolved over the past 15 years. Despite advancements and appreciation of the anatomy and biomechanics of the MPFC, the best surgical treatment for recurrent patellar instability has yet to be determined. The goals of medial patellofemoral ligament (MPFL), medial quadriceps tendon femoral ligament (MQTFL), or MPFC reconstructions (with grafts from both the patella and quad to the femur) are to return patients back to activity and avoid complications such as recurrent instability, overconstraint, secondary arthrosis, and potential patellar fracture from surgical drill holes. Other considerations when managing recurrent instability include patella alta, hypermobility, and whether an osteotomy procedure is indicated. Although we always need to make good choices and mind our P's and Q's, the big question remains: Is MPFL, MQTFL, or MPFC the best choice for our patients?

Combination of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for patellofemoral instability provides good middle- to long-term outcomes in adolescents.

PURPOSE: There are limited studies that have reported the middle- to long-term outcomes of combined procedures consisting of more than two procedures for patellofemoral instability. The current study aims to investigate and report the middle- to long-term outcomes of a combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for patellofemoral instability in patients aged 18 years and below. METHODS: In the cohort study, all patients aged 18 years old or younger who underwent a combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release for recurrent patellofemoral instability were included. RESULTS: A total of 21 patients were included in the study. All patients had no further patellofemoral dislocation, pain and apprehension following the 4-in-1 surgery (p < 0.01). There was a significant improvement in the Kujala score from 36.1 (SD 12.9) pre-operatively to 93.1 (SD 3.6) post-operatively (p < 0.001). The patients also had a statistically significant improvement in their radiological factors, including the patellar tilt angle (p < 0.001), sulcus angle (p = 0.001), trochlear groove depth (p = 0.041), tibial tubercle-trochlear groove distance (p < 0.001) and Caton-Deschamps index (p = 0.001). CONCLUSION: A combination procedure of tibial tubercle transfer, medial patellofemoral ligament reconstruction, trochleoplasty and lateral release leads to good middle- to long-term subjective, functional and radiographic outcomes for patients with recurrent patellofemoral instability and underlying predisposing factors of increased TT-TG distance of more than 20 mm, Dejour B or D trochlear dysplasia and medial patellofemoral ligament rupture. LEVEL OF EVIDENCE: IV.

Clinical outcomes of derotational femoral osteotomy combined with medial patellofemoral ligament reconstruction in patients with patellar dislocation and increased femoral anteversion unaffected by the pattern of distribution of femoral torsion.

PURPOSE: The aim of this study was to evaluate the clinical effect of derotational femoral osteotomy combined with medial patellofemoral ligament reconstruction for patellar dislocation and the effect of the distribution of femoral torsion at different segments on postoperative function. METHODS: Forty-two patients with patellar dislocation who underwent derotational femoral osteotomy from 2017 to 2021 were retrospectively analysed. All patients received computed tomography scans from the hip to the knee to evaluate correction of the femoral anteversion (FA) angle, patellar tilt angle (PTA) and congruence angle (CA) after derotational femoral osteotomy. Subjective scores, such as the Kujala, Lysholm, International Knee Documentation Committee (IKDC), Tegner and visual analog scale (VAS) scores, were used to evaluate knee function before and after the operation. Patients with supracondylar torsion > distal torsion were categorized into the supracondylar torsion group and patients with distal torsion > supracondylar torsion were categorized into the distal torsion group. Subgroup analyses were performed. RESULTS: No presentation of redislocation occurred in these patients at the minimum 2-year follow-up visit. The mean preoperative FA angle in the supracondylar torsion group was 30.2° ± 4.2°, and the mean postoperative FA angle was 14.5° ± 2.5° (p < 0.001). The mean preoperative FA angle was 26.7° ± 1.4° and the mean postoperative FA angle was 14.1° ± 1.4° in the distal torsion group. In addition, postoperative PTA and CA were significantly corrected in both groups (p < 0.001). The postoperative Kujala, Lysholm, IKDC, Tegner and VAS scores were significantly improved in both groups (p < 0.001). Subgroup analyses showed a higher preoperative FA in the supracondylar torsion group and a higher occurrence of high-grade trochlear dysplasia in the distal torsion group. However, there was no significant difference in their postoperative clinical outcomes. CONCLUSION: Through a minimum of 2-year follow-up visits of patients with patellar dislocation and increased FA, it was found that derotational femoral osteotomy could significantly reduce FA and improve subjective knee function. The pattern of torsion distribution did not significantly affect the clinical outcomes of derotational femoral osteotomy. These findings readvised orthopaedic surgeons that derotational femoral osteotomy remains the preferred procedure for correcting rotational malalignment, but that they should be more cautious about its indications. LEVEL OF EVIDENCE: Level IV.

Derotational distal femoral osteotomy improves subjective function and patellar tracking after medial patellofemoral ligament reconstruction in recurrent patellar dislocation patients with increased femoral anteversion: A systematic review and meta-analysis.

PURPOSE: The purpose of this study is to systematically review and quantitatively analyse the clinical outcomes of combined derotational distal femoral osteotomy (D-DFO) and medial patellofemoral ligament reconstruction (MPFL-R) in the treatment of recurrent patellar dislocation (RPD) with increased femoral anteversion angle (FAA). METHODS: This study was performed in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the Methodological Quality Of Systematic Reviews) Guidelines. PubMed, Embase, Web of Science and Cochrane Library databases were searched to identify studies reporting clinical outcomes of combined D-DFO and MPFL-R in RPD patients with increased FAA. Data on patient-reported outcome measures, radiological parameters, patellar tracking as revealed by J-sign and complications were extracted based on the inclusion criteria. The Methodological Index for Non-Randomized Study score was used for quality assessment. Review Manager and R statistical software were used to perform the statistical analysis. RESULTS: Eleven studies with a total of 569 knees in 553 patients were included. Patients were predominantly female (79%). The weighted mean of FAA decreased from 33.6° to 13.0° (weighted mean difference = 20.59; p < 0.00001) after the combined procedure. Significant improvements (p < 0.00001) were identified in the Lysholm score (weighted mean: 55.5 vs. 80.4), International Knee Documentation Committee (IKDC) score (weighted mean: 52.8 vs. 78.6) and Kujala score (weighted mean: 54.5 vs. 80.6). The incidence of residual J-sign ranged from 14.3% to 38.3% with an overall pooled rate of 28.2% (95% confidence interval = 22.8%-33.6%). The overall redislocation rate was 1.1%. No patients experienced surgical site infection or bone nonunion. Two studies compared the clinical outcomes of MPFL-R with and without D-DFO. Compared with isolated MPFL-R, the combined procedure yielded a better Lysholm score (weighted mean: 84.9 vs. 79.3, p < 0.0001), IKDC score (weighted mean: 84.1 vs. 79.9, p = 0.001), Kujala score (weighted mean: 84.3 vs. 79.4, p < 0.0001) and a lower residual J-sign rate (26/97 [26.8%] vs. 44/105 [41.9%], p = 0.02), respectively. CONCLUSION: The combination of D-DFO and MPFL-R led to improved clinical outcomes and a low redislocation rate in patients with RPD and increased FAA. Additional D-DFO can achieve more favourable results in subjective function and patellar tracking than isolated MPFL-R in the setting of excessive FAA. LEVEL OF EVIDENCE: Level IV.

Scapholunate Ligament Rupture and Coincident Fracture Proximal Pole Scaphoid Presenting Late with Osteonecrosis: A Rare Case Report with Unique Management.

CASE: A 29-year-old young active man with ununited necrosed proximal fifth of scaphoid with chronic scapholunate ligament disruption was managed by excision of proximal pole fragment and interosseous scapholunate reconstruction using modified Brunelli triple ligament tenodesis technique with satisfying outcome at 6 months and return to sports instructor job by the end of 1 year. CONCLUSION: Meticulous understanding and algorithmic itemwise approach of injury components can lead to optimal management of complex unstable wrist injuries such as scapholunate dissociation. To the best of our knowledge, this is the first report on excision of proximal pole of scaphoid coupled with scapholunate ligament reconstruction.

Could medial malleolus fracture be combined with deltoid ligament injury?: A rare case report.

RATIONALE: Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously. PATIENT CONCERNS: In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident. DIAGNOSIS: The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation. INTERVENTION: As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital. OUTCOMES: During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital. LESSONS: The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.