The anteromedial retinaculum in ACL-injured knees: An overlooked injury?

PURPOSE: The purpose of this study was to retrospectively analyse the pattern of injury to the medial knee structures in anterior cruciate ligament (ACL) injured patients. It was hypothesised that anteromedial injuries would be more common than posteromedial lesions. METHODS: One hundred and twenty subjects aged 18-25 years with a primary ACL injury were included. Patients were excluded if the time between injury and magnetic resonance imaging (MRI) was more than 28 days or if a knee dislocation or fracture was present. The MRIs were analysed with particular emphasis on injuries to the medial knee structures, menisci and bone bruise patterns. Injuries to the ligaments and anteromedial retinaculum (AMR) were graded according to severity, ranging from periligamentous oedema (grade I), partial fibre disruption of less or more than 50% (grade IIa or IIb) to complete tears (grade III). RESULTS: AMR injury was seen in 87 subjects (72.5%) on the coronal plane and in 88 (73.3%) on the axial plane, with grade III lesions observed in 27 (22.5%) and 29 knees (24.2%). Injuries to the superficial medial collateral ligament (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL) were detected in 60 patients (50%), 93 patients (77.5%) and 38 patients (31.6%). However, grade III injuries to the POL were observed in only seven knees (5.8%). Medial meniscus injuries were associated with lesions of the sMCL and AMR (p < 0.05), while lateral meniscus injuries were significantly more common in patients with dMCL rupture (p < 0.05). CONCLUSION: Data from this study suggest that injuries to the AMR are much more common than posteromedial lesions in subjects with ACL injuries. LEVEL OF EVIDENCE: Level IV.

Clinical and Functional Outcomes of Documented Knee Dislocation Versus Multiligamentous Knee Injury: A Comparison of KD3 Injuries at Mean 6.5 Years Follow-up.

BACKGROUND: Previous research has found that the incidence of neurovascular injury is greatest among multiligamentous knee injuries (MLKIs) with documented knee dislocation (KD). However, it is unknown whether there is a comparative difference in functional recovery based on evidence of a true dislocation. PURPOSE: To determine whether the knee dislocation-3 (KD3) injury pattern of MLKI with documented tibiofemoral dislocation represents a more severe injury than KD3 MLKI without documented dislocation, as manifested by poorer clinical outcomes at long-term follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter retrospective cohort study was performed of patients who underwent surgical treatment for KD3 MLKI between May 2012 and February 2021. Outcomes were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, and visual analog scale (VAS) for pain. Documented dislocation was defined as a radiographically confirmed tibiofemoral disarticulation, the equivalent radiology report from outside transfer, or emergency department documentation of a knee reduction maneuver. Subgroup analysis was performed comparing lateral (KD3-L) versus medial (KD3-M) injuries. Multivariable linear regression was conducted to determine whether documented dislocation was predictive of outcomes. RESULTS: A total of 42 patients (25 male, 17 female) were assessed at a mean 6.5-year follow-up (range, 2.1-10.7 years). Twenty patients (47.6%) were found to have a documented KD; they reported significantly lower IKDC (49.9 vs 63.0; P = .043), Lysholm (59.8 vs 74.5; P = .023), and Tegner activity level (2.9 vs 4.7; P = .027) scores than the patients without documented dislocation. VAS pain was not significantly different between groups (36.4 vs 33.5; P = .269). The incidence of neurovascular injury was greater among those with documented dislocation (45.0% vs 13.6%; P = .040). Subgroup analysis found that patients with KD3-L injuries experienced a greater deficit in Tegner activity level than patients with KD3-M injuries (Δ: -3.4 vs -1.2; P = .006) and had an increased incidence of neurovascular injury (41.7% vs 11.1%; P = .042). Documented dislocation status was predictive of poorer IKDC (ß = -2.15; P = .038) and Lysholm (ß = -2.85; P = .007) scores. CONCLUSION: Patients undergoing surgical management of KD3 injuries with true, documented KD had significantly worse clinical and functional outcomes than those with nondislocated joints at a mean 6.5-year follow-up. The current MLKI classification based solely on ligament involvement may be obscuring outcome research by not accounting for true dislocation.

Patellar Tendon Rupture During Postoperative Physiotherapy for Crouch Gait: A Case Report.

INTRODUCTION: A 14-year-old adolescent girl with spastic diplegic cerebral palsy underwent bilateral distal femur extension osteotomy and patellar tendon plication. Two and a half months after surgery, during physiotherapy, she sustained mid-substance tear of the left patellar tendon. The girl was successfully managed with patellar tendon repair and augmentation with tensor fascia lata autograft. CONCLUSION: Patellar tendon rupture during rehabilitative physiotherapy after patellar tendon plication surgery is rare. Postoperative protocols in patients with cerebral palsy are crucial and should progress gradually to improve knee range of motion. This report highlights that patellar tendon repair with fascia lata augmentation yields good outcome.

Acute sport-related knee injuries.

BACKGROUND: Australia has a high rate of sporting participation. Although this has many benefits, knee injuries are common, particularly in pivoting and contact sports. OBJECTIVE: This article reviews the management of common sport-related knee injuries, including injuries to the collateral and cruciate ligaments, menisci and the extensor mechanism. DISCUSSION: Some sport-related knee injuries can be treated non-operatively with physiotherapy-led rehabilitation. These include the majority of isolated medial collateral ligament, lateral collateral ligament and posterior cruciate ligament injuries. Other knee injuries might require surgical intervention. These include anterior cruciate ligament ruptures in young patients aiming to return to pivoting sports, certain meniscal tears and extensor mechanism disruptions. A multidisciplinary approach to these injuries will facilitate optimal patient care.

Impact of Environmental Factors on the ACL Injury Risk in Recreational Alpine Skiing.

In recreational alpine skiing, an ACL injury represents the most common injury. Skiing is a complex activity where the skier interacts with the environment, such as weather, snow conditions, temperature, etc. Thus, the aim of this study was to evaluate the potential impact of environmental factors on ACL injury risk in recreational alpine skiers. Among a cohort of 392 ACL-injured skiers and 392 uninjured controls matched for sex and skiing skill, environmental factors were collected by questionnaire. Factors included weather conditions, snow conditions, perceived temperature, and slope difficulty at the time-point of the accident (ACL-injured skiers) or of questioning during the ski day (uninjured controls).Multiple logistic regression revealed that in addition to age, five environmental factors were significantly predictive of an ACL injury: fresh snow (OR 10.5), grippy snow (OR 7.8), icy slope condition (OR 12.4), very cold/cold perceived temperature (OR 1.6), and skiing on easy slopes (OR 6.9). In conclusion, besides age, environmental factors such as fresh and grippy snow, icy slope conditions, low temperatures, and flat slopes are associated with an increased ACL injury risk in recreational alpine skiing. Those factors are at least partly modifiable and should be taken into consideration for preventive strategies.

Factors Associated With Meniscal and Articular Cartilage Injury in the PLUTO Cohort.

BACKGROUND: Anterior cruciate ligament (ACL) injuries in adults are frequently accompanied by meniscal and articular cartilage damage. However, little is known regarding the association, if any, between physical maturity, hypermobility, or bone bruising and these associated injuries in skeletally immature patients with ACL tears. PURPOSE: To determine if physical maturity, hypermobility, and/or bone bruising is associated with concomitant meniscal and articular cartilage injury in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: At 10 institutions in the United States, consecutive skeletally immature patients with complete ACL tears were enrolled between January 2016 and June 2020. Univariable and multivariable logistic regression analysis was used to assess the effect of variables on the likelihood of articular cartilage and meniscal injury. RESULTS: A total of 748 patients were analyzed. Of these, 85 patients (11.4%) had articular cartilage injuries. These patients had a higher bone age (13.9 vs 13.1 years; P = .001), a higher Tanner stage (P = .009), and increased height (162.9 vs 159.9 cm; P = .03) and were heavier (57.8 vs 54.0 kg; P = .02). For each additional Tanner stage, the odds of articular cartilage injury increased approximately 1.6 times (P < .001). Of the total patients, 423 (56.6%) had meniscal tears. Those with meniscal tears were older (12.6 vs 12.0 years; P < .001), had a higher bone age (13.5 vs 12.8 years; P < .001), had a higher Tanner stage (P = .002), had increased height (162.2 vs 157.6 cm; P < .001), and were heavier (56.6 vs 51.6 kg; P < .001). For each additional Tanner stage, the odds of a meniscal tear increased approximately 1.3 times (P < .001). No association was detected between hypermobility or bone bruising and the likelihood of articular cartilage or meniscal injury. Multivariable regression revealed that increasing Tanner stage was associated with an increasing risk of articular cartilage injury, while weight was associated with an increasing risk of meniscal injury. CONCLUSION: Increasing physical maturity is associated with increased risks of concomitant articular cartilage and meniscal injury in skeletally immature patients with ACL tears. Hypermobility and bone bruising are not associated with articular cartilage or meniscal injury, suggesting that physical maturity, rather than ligamentous laxity, is the primary risk factor for associated injuries in skeletally immature patients with an ACL tear.

Prevention of knee joint injuries in winter sports training / Prevenção de lesões articulares do joelho no treino dos esportes de inverno / Prevención de las lesiones articulares de la rodilla en el entrenamiento de los deportes de invierno

ABSTRACT Introduction: With the 2022 Winter Olympic Games launch, ice and snow sports have come into the spotlight, receiving government incentives to encourage their practice. Objective: Examine the causes of knee injury in skiers, proposing preventive measures for joint injury. Methods: The current situation of joint injury in skiers' knees, joint movement in skiing, the cause of joint injury, and the prevention of joint injury were analyzed, and scientific prevention and corresponding treatment plan were developed according to the results of the analysis. Results: The injury rate among skiers is high. Ligament injury, tendon injury, and muscle strain are the three main types of injury. There are 57 mild injuries of various types to the knee joint - 53.27% of all injuries; 41 moderate injuries, representing 38.32% of all injuries; 9 serious injuries, representing 8.41% of all injuries, with minor injuries. Conclusion: This article examines knee motion and the causes of knee injury in skiers and proposes preventive measures for joint injury. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

RESUMO Introdução: Com o lançamento dos Jogos Olímpicos de Inverno de 2022, os esportes de gelo e neve entraram em evidência, recebendo incentivos governamentais para encorajamento de sua prática. Objetivo: Examinar as causas da lesão no joelho em esquiadores, propondo medidas preventivas para a lesão articular. Métodos: Foram analisadas a situação atual de lesão articular nos joelhos dos esquiadores, o movimento articular no esqui, a causa das lesões articulares e a prevenção de lesões articulares, além de um plano de prevenção científica e tratamento correspondente, de acordo com os resultados da análise. Resultados: A taxa de lesões em esquiadores é alta. Lesão ligamentar, lesão tendinosa e tensão muscular são os três principais tipos de lesão. Há 57 lesões leves de vários tipos na articulação do joelho - 53,27% de todas as lesões; 41 lesões moderadas, representando 38,32% de todas as lesões; 9 lesões graves, representando 8,41% de todos os ferimentos, com ferimentos menores. Conclusão: Este artigo examina o movimento do joelho e as causas da lesão no joelho em esquiadores, e propõe medidas preventivas para lesão articular. Nível de evidência II; Estudos terapêuticos - investigação dos resultados do tratamento.

RESUMEN Introducción: Con la puesta en marcha de los Juegos Olímpicos de Invierno de 2022, los deportes de hielo y nieve han pasado a ser el centro de atención, recibiendo incentivos gubernamentales para fomentar su práctica. Objetivo: Examinar las causas de las lesiones de rodilla en los esquiadores, proponiendo medidas preventivas de las lesiones articulares. Métodos: Se analizó la situación actual de las lesiones articulares en las rodillas de los esquiadores, el movimiento articular en el esquí, la causa de las lesiones articulares y la prevención de las mismas, y se elaboró un plan científico de prevención y tratamiento correspondiente según los resultados del análisis. Resultados: El índice de lesiones en los esquiadores es alto. Las lesiones de ligamentos, las lesiones de tendones y las distensiones musculares son los tres tipos principales de lesiones. Hay 57 lesiones leves de diversos tipos en la articulación de la rodilla, el 53,27% de todas las lesiones; 41 lesiones moderadas, que representan el 38,32% de todas las lesiones; 9 lesiones graves, que representan el 8,41% de todas las lesiones, con lesiones leves. Conclusión: Este artículo examina el movimiento de la rodilla y las causas de las lesiones de rodilla en los esquiadores, y propone medidas preventivas para las lesiones articulares. Nivel de evidencia II; Estudios terapéuticos - investigación de los resultados del tratamiento.

Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study.

BACKGROUND: This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach. METHODS: The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves. RESULTS: The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively. CONCLUSION: Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study. TRIAL REGISTRATION: The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).

Lesiones ligamentarias de rodilla asociadas a fracturas de diáfisis femoral: epidemiología y diagnóstico: revisión narrativa de la bibliografía / Knee ligamentous injury associated to femoral shatf fracture: epidemiology and diagnosis: narrative review of the literatur / Lesões ligamentares do joelho associadas a fraturas diafisárias do fêmur: epidemiologia e diagnóstico: revisão narrativa da literatura

Introducción: Las fracturas de la diáfisis femoral son lesiones que requieren gran energía y a menudo asocian otras lesiones. Este es el caso de las lesiones ligamentarias de rodilla, las cuales pueden pasar desapercibidas por el equipo médico tratante. El objetivo de nuestro trabajo es revisar la literatura existente sobre esta asociación lesional. Dentro de la misma se buscará la metodología diagnóstica utilizada y la incidencia de las lesiones ligamentarias. Materiales y métodos: Se realizó una búsqueda bibliográfica de forma sistematizada a través de los portales de búsqueda PubMed y Timbó. La búsqueda alcanzó un total de 3099 artículos y de acuerdo a los criterios de inclusión y exclusión se seleccionaron 15 trabajos. Resultados: Los diferentes artículos utilizaron examen físico bajo anestesia, radiografías en estrés, artroscopía o resonancia nuclear magnética para establecer el diagnóstico de las lesiones ligamentarias asociadas a las fracturas de diáfisis femoral. Un 22,5% de las fracturas femorales asoció lesión ligamentaria de rodilla, siendo la lesión del ligamento cruzado anterior el 34% de las lesiones reportadas. Discusión: Se evidencia una gran variabilidad en la incidencia de lesiones ligamentarias y de cuál es el ligamento más frecuentemente lesionado, yendo desde 5,3% a 52,5% en estudios tanto retrospectivos como prospectivos con bajos números de pacientes. Se plantea un algoritmo diagnóstico para los pacientes que puedan presentar esta asociación lesional, para evitar que los mismos pasen desapercibidos al equipo médico tratante. Logrando un diagnóstico precoz se puede mejorar el pronóstico de estos pacientes. Conclusión: De nuestra revisión se desprende que en el contexto de una fractura de diáfisis femoral un 22,5% de los pacientes presenta lesiones ligamentarias de rodilla con un 34% de compromiso del LCA. Sin embargo, estas cifras son muy variables en los distintos trabajos. Por esta razón, creemos necesario llevar a cabo un estudio prospectivo con mayor número de pacientes para lograr valorar la verdadera epidemiología de estas lesiones.

Introduction: Femoral shaft fractures require great energy and are often associated with other injuries. This is the case of knee ligament injuries, which can go unnoticed by the treating physician The objective of our work is to review the existing literature on this injury association. Within it, the diagnostic methodology used and the incidence of ligamentous injuries will be sought. Materials and methods: A bibliographic search was carried out in a systematic way through the search portals PubMed and Timbó. The search reached a total of 3099 articles and according to the inclusion and exclusion criteria, 15 works were selected. Results: The different articles used physical examination under anesthesia, stress radiographs, arthroscopy or magnetic resonance imaging to establish the diagnosis of ligamentous injuries associated with femoral diaphysis fractures. 22.5% of femoral fractures were associated with knee ligament injury, with anterior cruciate ligament accounting for 34% of reported injuries. Discussion: There is evidence of a great variability in the incidence of ligament injuries and which is the most frequently injured ligament, ranging from 5.3% to 52.5% in both retrospective and prospective studies with low numbers of patients. A diagnostic algorithm is proposed for patients who may present this lesional association, to prevent them from going unnoticed by the treating medical team. Achieving an early diagnosis can improve the prognosis of these patients. Conclusion: Our review shows that in the context of a femoral diaphysis fracture, 22.5% of patients present knee ligament injuries with 34% of ACL involvement. However, these figures are highly variable in the different studies. For this reason, we believe it is necessary to carry out a prospective study with a larger number of patients in order to assess the true epidemiology of these lesions.

Introdução: As fraturas da diáfise do fêmur são lesões que requerem grande energia e muitas vezes estão associadas a outras lesões. É o caso das lesões ligamentares do joelho, que podem passar despercebidas pela equipe médica que o trata. O objetivo do nosso trabalho é revisar a literatura existente sobre essa associação lesional. Dentro dele, será buscada a metodologia diagnóstica utilizada e a incidência de lesões ligamentares. Materiais e métodos: Foi realizada uma busca bibliográfica de forma sistemática através dos portais de busca PubMed e Timbó. A busca atingiu um total de 3099 artigos e de acordo com os critérios de inclusão e exclusão, 15 trabalhos foram selecionados. Resultados: Os diferentes artigos utilizaram o exame físico sob anestesia, radiografias de estresse, artroscopia ou ressonância magnética para estabelecer o diagnóstico de lesões ligamentares associadas às fraturas da diáfise do fêmur. 22,5% das fraturas do fêmur foram associadas à lesão ligamentar do joelho, sendo a lesão do ligamento cruzado anterior responsável por 34% das lesões relatadas. Discussão: Há evidências de uma grande variabilidade na incidência de lesões ligamentares e qual é o ligamento mais frequentemente lesado, variando de 5,3% a 52,5% em estudos retrospectivos e prospectivos com baixo número de pacientes. Um algoritmo diagnóstico é proposto para os pacientes que podem apresentar essa associação lesional, para evitar que passem despercebidos pela equipe médica responsável. O diagnóstico precoce pode melhorar o prognóstico desses pacientes. Conclusão: Nossa revisão mostra que no contexto de fratura da diáfise do fêmur, 22,5% dos pacientes apresentam lesões ligamentares do joelho com 34% de envolvimento do LCA. No entanto, esses números são altamente variáveis ​​nos diferentes estudos. Por esse motivo, acreditamos ser necessário realizar um estudo prospectivo com um número maior de pacientes para avaliar a verdadeira epidemiologia dessas lesões.

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. METHODS: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. FINDINGS: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. INTERPRETATION: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. FUNDING: The UK National Institute for Health Research Health Technology Assessment Programme.

The meniscal tear outcome (METRO) review: A systematic review summarising the clinical course and outcomes of patients with a meniscal tear.

BACKGROUND: Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. METHOD: A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. RESULTS: 35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant. CONCLUSIONS: Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications.

Treatment of displaced intra-articular calcaneal fractures: A single-center experience study with 20 years follow-up.

INTRODUCTION: This study was conducted to identify the patient characteristics, classification, treatment, complications, and functional outcomes of operatively treated displaced intra-articular calcaneal fractures (DIACFs) in a level-I trauma center over a 20-year period. METHODS: Patients with a DIACF classified as Sanders ≥2 and operatively treated with percutaneous reduction and screw fixation (PSF) or open reduction and internal fixation (ORIF) between 1998 and 2017 were identified. Pre- and postoperative radiological assessments were performed. Functional outcomes were evaluated using the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). General health and patient satisfaction were assessed using the Short Form-36 Health Survey (SF-36) and the visual analog scale (VAS). RESULTS: In total, 120 patients with a DIACF that were operatively treated with PSF or ORIF. Of these patients, 72 with a total of 80 DIACFs completed the questionnaires (60%). The average follow-up was 130 months. Mean scores for PSF and ORIF were 74 and 75 for AOFAS, 78 and 78 for MFS, 68 and 61 for SF-36, and 7.7 and 7.5 for VAS, respectively. An infection was the most common complication associated with ORIF (31%), and hardware removal (58%) was the most common complication in patients treated with PSF. Overall, 36 patients (68%) were able to return to work after a median time 6 months (IQR, 3-7) and 6 months (IQR, 3,25-6,75) for PSF and ORIF treated, respectively CONCLUSION: This long-term follow-up study reviews ORIF using ELA and PSF in the treatment of DIACFs. This study shows that both treatments are capable of restoring the Böhler angle and yield relatively good long-term functional outcomes. Differences in complication rates were apparent, infectious problems are inherent to ORIF using ELA, and hardware removal is associated with PSF.

The radiographic soft tissue thickness is associated with wound complications after open reduction and internal fixation of patella fractures.

BACKGROUND: Displaced patella fracture is commonly treated with open reduction and internal fixation (ORIF). Wound complications after surgery often lead to prolonged hospitalization and dissatisfaction of patients. Periarticular adiposity and swelling may be associated with wound complications. The purpose of this study is to determine the relationship between periarticular soft tissue thickness and wound complications after ORIF of patella fractures. METHODS: We retrospectively studied 237 patients undergoing ORIF for patella fractures from June 2017 to February 2021 at our institution. We established periarticular soft tissue thickness ratio (PSTTR) to evaluate soft tissue status on lateral knee X-ray radiographs. Univariate analysis was performed to identify the association between PSTTR and postoperative wound complication. A receiver-operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PSTTR. RESULTS: The incidence of postoperative wound complication was 10.5%. Minor wound complication occurred in 24 patients, and major wound complication occurred in one patient. The average femoral PSTTR (fPSTTR) was 0.94 ± 0.17 and the average tibial PSTTR (tPSTTR) was 0.66 ± 0.16. fPSTTR proved to be associated with postoperative wound complication. In the ROC analysis of fPSTTR predicting postoperative wound complication, the area under curve (AUC) was 0.676, which indicated a moderate predictive value. CONCLUSIONS: PSTTR was a feasible method to assess periarticular soft tissue. The increased fPSTTR was associated with wound complications after ORIF of patella fractures.

[When the pig escaped, the cattle gun hit the knee].

Injuries sustained from a cattle gun are typically more severe than they appear. Fractures and infection are the primary concerns due to a coupling of a sustained penetrating impact, contamination of the bolt and residual foreign material left after penetration. This is a case report of an injury caused by a cattle gun. The initial assessment did not match the actual magnitude of the injury. Due to the severity of injuries of this kind they require a thorough assessment as well as specialized treatment in terms of debridement and high-yield antibiotics, as well as the possible fracture treatments.

Anterior Cruciate Ligament Rupture in Skeletally Immature Patients.

In the past 20 years, sports injuries in pediatric and adolescent athletes have increased dramatically, with anterior cruciate ligament (ACL) injuries accounting for more than 25% of all knee injuries at this age. Diagnosis is based on detailed clinical history, physical examination, and imaging assessment, where magnetic resonance imaging plays a central role. The growing immature skeleton presents specific characteristics, which require unique methods for surgical reconstruction, ideally avoiding the physes or minimizing the risk of damaging them. Specific rehabilitation protocols are needed, and these patients face a higher risk of recurrent and contralateral ACL injury. Nonsurgical treatment or delayed reconstruction has been associated with persistent instability, activity modifications, worst functional outcomes, and increased risk of irreparable injuries to menisci and articular cartilage. Consequently, surgical stabilization is the preferred treatment for most patients, despite the eventual risk of angular deformities or limb-length discrepancies due to iatrogenic physeal injury. A variety of surgical techniques have been described, depending on the skeletal maturity and growth remaining. Targeted prevention programs play a key role in reducing the risk of ACL injury, are easy to implement, and require no additional equipment. High-quality evidence supports its use in all pediatric athletes.

An individualized decision between physical therapy or surgery for patients with degenerative meniscal tears cannot be based on continuous treatment selection markers: a marker-by-treatment analysis of the ESCAPE study.

PURPOSE: Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears. METHODS: Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments. RESULTS: Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. While some marker-based thresholds could be identified at 3, 12, and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. CONCLUSION: This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics. LEVEL OF EVIDENCE: II.

Spontaneous Healing of a Posteriorly Displaced Lateral Meniscus Bucket-Handle Tear in a Multiligament Knee Injury: A Case Report.

CASE: Bucket-handle meniscus tears (BHMTs) typically involve the medial meniscus and often occur with concomitant rupture of the anterior cruciate ligament. We report an unusual case of a polytrauma patient who sustained a bicruciate multiligament knee injury (MLKI) with a posteriorly displaced lateral BHMT that spontaneously healed after reduction of the fragment. At the 2-year follow-up, the lateral meniscus was clinically stable without pain. CONCLUSION: A lateral BHMT with a posteriorly displaced fragment produced an atypical magnetic resonance imaging presentation in a bicruciate MLKI. Meniscal repair was aborted because of extravasation and concerns of compartment syndrome, but spontaneous healing occurred after fragment reduction.

Ski-geometric parameters do not differ between ACL injury mechanisms in recreational alpine skiing.

PURPOSE: It is not known so far if ski-equipment-related factors differ between the ACL injury mechanisms, potentially influencing the circumstances and causes of falling, finally resulting in ACL injury. More specifically focusing on the injury mechanisms will provide a deeper understanding of injury causation. The aim of the study was to evaluate whether ACL injury mechanisms in recreational alpine skiing differ with regard to ski-geometric parameters, self-reported circumstances and causes of accident and injury severity. METHODS: Among a cohort of 392 ACL-injured (57.9% females) skiers, age, sex, height, weight, skill level, risk-taking behavior, circumstances and causes of accident, and ACL injury severity were collected by questionnaire. Additionally, patients had to recall their type of fall (ACL injury mechanism) by classifying forward and backward falls with and without body rotation. Ski length, side cut radius and widths of the tip, waist and tail were directly notated from the ski. RESULTS: The forward fall with body rotation was the most common reported ACL injury mechanism (63%). A riskier behavior was associated with forward falls without body rotation. Ski-geometric parameters did not significantly influence the type of ACL injury mechanism. Regarding accident characteristics, catching an edge of the ski was more frequent (p < 0.001) the cause for forward falls (75% and 67%) when compared to the backward falls (46 and 15%) and executing a turn was the most frequent action in all falls (39-68%). A complete rupture of the ACL (66-70%) was more commonly reported than a partial tear (30-34%) among all four non-contact ACL injury mechanisms (n.s.). CONCLUSION: In contrast to risk-taking behavior and accident characteristics, ski-geometric parameters and injury severity do not significantly differ between ACL injury mechanisms in recreational skiing. Thus, an individual skiing style seems to have more impact on ACL injury mechanisms than ski equipment. Future studies should evaluate potential effects of ski geometry on the incidence of ACL injury. LEVEL OF EVIDENCE: III.

Increased occurrence of ACL injuries for football players in teams changing coach and for players going to a higher division.

PURPOSE: To identify football-specific factors associated with ACL injuries that can be targeted for sport-specific injury prevention. METHODS: A study-specific questionnaire was developed to study the characteristics of ACL injuries in football including intrinsic, extrinsic, and injury specific factors. The questionnaire was available at the Swedish national knee ligament registry's website for the football players to voluntarily fill out. Data are presented on group level for all football players in total and for females and males separate to examine gender-specific differences. The results are based on answers collected over a 3-year period from 2875 football players, 1762 (61%) males and 1113 (39%) females. RESULTS: ACL were more frequently sustained during games 66% than during practices 25%. The injury mechanism was non-contact in 59% and contact in 41%. For the contact injuries during games, no action was taken by the referee in 63% of the situation and a red card was shown in 0.5%. The risk of ACL injury was highest early in the football game with 47% sustained during the first 30 min and 24% in the first 15 min. Players changing to a higher level of play 15% had a higher rate of ACL injuries than players changing to a lower level 8%. This difference was especially seen in female football players with 20% of ACL injuries being sustained by players going to a higher division compared to 7% for those going to a lower division. 15% of the male and 21% of the female ACL injuries occurred in teams with a coach change during the season. Knee control exercises to warm up was used by 31% of the female players and 16% of the males. 40% of the players reported that they did not plan on returning to football. CONCLUSION: Neuromuscular training programs have proven to reduce ACL injuries, but greater adherence to these remains a challenge as only 1 in 5 of the ACL-injured football players report using them. Teams changing coach and players going to a higher division appear to have an increased risk of ACL injury warranting attention and further investigations. LEVEL OF EVIDENCE: IV.

Effect of tourniquet application on postoperative outcomes in sinus tarsi approach for intra-articular calcaneus fractures.

INTRODUCTION: Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and increase surgical comfort, despite the potential risks associated with it. This study compared postoperative outcomes of tourniquet-assisted and non-tourniquet-assisted operative fixation of calcaneal fractures via the sinus tarsi approach. MATERIALS AND METHODS: A retrospective study from March 2015 to December 2018 revealed 131 patients with closed calcaneal fractures who underwent minimally invasive surgery at our hospital. Visualization, operating time, blood loss, and postoperative pain were collected. Patients in the tourniquet group (n = 62) were compared with patients in the non-tourniquet group (n = 69). RESULTS: The visibility of the surgical field was fair/poor in 2 cases in the tourniquet group and fair/poor in 19 cases in the non-tourniquet group (P < 0.05). The mean operative time was 64.7 ± 3.5 min in the tourniquet group and 76.0 ± 6.1 min in the non-tourniquet group (P < 0.05). The estimated intraoperative and postoperative blood loss was 56.6 ± 33.3 and 100.0 ± 25.3 mL, respectively, in the tourniquet group and 205.0 ± 31.6 and 38.3 ± 19.8 mL, respectively, in the non-tourniquet group (P < 0.05). The VAS pain scores 24 h, 48 h, and 72 h postoperatively were 4.3 ± 1.8, 3.1 ± 1.2, and 2.0 ± 0.5 points, respectively, in the tourniquet group and 2.1 ± 1.1, 1.6 ± 1.0, and 1.0 ± 0.3 points, respectively, in the non-tourniquet group (P < 0.05). CONCLUSION: Tourniquet application during the sinus tarsi approach for calcaneal fractures can significantly improve surgical visualization and reduce intraoperative blood loss. However, adverse events associated with the use of tourniquets include increased postoperative pain and bleeding. Due to increased postoperative bleeding and pain, more attention should be given to the postoperative phase in patients treated with tourniquets.