Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition in ACL reconstruction.

PURPOSE: The purpose of this study was to determine whether direct arthroscopic control of femoral buttons can prevent improper deployment and soft tissue interposition in anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective analysis of prospectively collected data from the SANTI study group database was performed. All patients who underwent ACL reconstruction using suspensive femoral fixation between 01/01/2017 and 31/12/2019 were included. Patient assessment included demographics, sports metrics, reoperations performed and femoral button-related specific complications such as iliotibial band (ITB) irritation and/or septic arthritis. Proper deployment of the button and soft tissue interposition were assessed on postoperative radiographs. RESULTS: A total of 307 patients underwent ACL reconstruction using adjustable femoral button fixation and were analyzed after a mean follow-up of 35.2 ± 11.0 months (14.3-50.2). The mean age was 39.5 ± 10.9-years old (range 13.3-70.6). Postoperative radiographs showed a correctly deployed femoral button without soft tissue interposition for all patients. No septic arthritis was reported. Nine patients (2.9%) suffered from lateral pain related to ITB irritation due to the button. Five of them had their symptoms resolve during rehabilitation. Ultrasound-guided corticosteroid infiltration was necessary for four patients after an average delay of 14.5 ± 4.8 months (11.7-21.7). Three patients were then symptom-free, but one required surgical removal of the implant 27.5 months after the surgery. Regarding unrelated femoral button complications, 15 patients (4.9%) underwent secondary arthroscopic procedures, including meniscectomy (1.6%), surgery for cyclops syndrome (2.6%) and revision ACLR (0.7%). CONCLUSION: Arthroscopic confirmation of femoral button deployment prevents soft tissue interposition without specific complications. LEVEL OF EVIDENCE: Level IV.

Partial and complete repairs of massive rotator cuff tears maintain similar long-term improvements in clinical scores.

PURPOSE: The authors have previously published early outcomes of arthroscopic repairs of 86 massive rotator cuff tears (mRCTs) and aimed to determine whether their clinical scores are maintained or deteriorate after 5 more years. METHODS: Of the initial series of 86 shoulders, 2 had deceased, 16 lost to follow-up and 4 reoperated, leaving 64 for assessment. The repairs were complete in 44 and partial in 20, and 17 shoulders had pseudoparalysis. Preoperative assessment included absolute Constant score, shoulder strength, tear pattern, tendon retraction, and fatty infiltration. Patients were evaluated at 8.1 ± 0.6 years (range 7.1-9.3) using absolute and age-/sex-adjusted Constant score, subjective shoulder value (SSV), and simple shoulder test (SST). RESULTS: Absolute Constant score was 80.0 ± 11.7 at first follow-up (at 2-5 years) but diminished to 76.7 ± 10.2 at second follow-up (at 7-10 years) (p < 0.001). Adjusted Constant score was 99.7 ± 15.9 at first follow-up and remained 98.8 ± 15.9 at second follow-up (ns). Comparing other outcomes revealed a decrease in strength over time (p < 0.001) but no change in pain, SSV or SST. Partially-repaired shoulders had lower strength at both follow-ups (p < 0.05). Pseudoparalytic shoulders had lower absolute and adjusted Constant score at second follow-up (p < 0.05), but their net improvements in absolute Constant score were higher (p = 0.014). CONCLUSIONS: Both partial and complete arthroscopic repairs grant satisfactory long-term outcomes for patients with mRCTs, regardless of their tear pattern, fatty infiltration and presence of pseudoparalysis. Absolute Constant score decreased over time for both repair types, but adjusted Constant score remained stable, suggesting that decline is due to aging rather than tissue degeneration. The clinical relevance of this study is that arthroscopic repair should be considered for mRCTs, even if not completely repairable, rather than more invasive and/or risky treatments, such as reverse shoulder arthroplasty. LEVEL OF EVIDENCE: IV.

No difference between single and staged posterolateral corner surgical procedures in the multiligament injured/dislocated knee.

PURPOSE: Posterolateral corner (PLC) injuries commonly occur in the setting of a dislocated knee and often require multiple procedures due to concomitant vascular, nerve, and soft tissue involvement. Debate persists regarding single vs staged surgery. The purpose of this study was to compare knee function after single and staged surgery for PLC injury. METHODS: Patients who underwent surgery for a PLC injury (KD I, IIIL, IV) with minimum follow-up of 2 years were included. Patients treated with staged and single surgery were matched according to age, sex, and KD grade. Lysholm and International Knee Documentation Committee (IKDC) subjective scores were obtained. Risk factors for poor knee function were assessed, including age, nerve, vascular, meniscal and articular cartilage injuries. RESULTS: Twenty single-surgery patients with a median age of 24 years (median follow-up 5.3 years, range 2-18.3) and 20 staged surgery patients with a median age of 26 years (median follow-up 4.3 years, range 2-19.8) were studied. The mean Lysholm score was 78.7 (± 20.3) in the single surgery and 84.2 (± 17.8) in the staged surgery cohort (n.s.). The mean IKDC score was 80.8 (± 21.1) in the single and 74.9 (± 18.9) in the staged surgery cohort (n.s.). Age at injury, peroneal, vascular, meniscal or cartilage injury were not associated with poor knee outcome. CONCLUSION: This study demonstrates similar knee function among patients with PLC injuries treated with single or staged surgical procedures. The need for staged surgery for the dislocated knee with PLC involvement should be individualized based on specific knee and patient-related factors. LEVEL OF EVIDENCE: III.

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE: (1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score. METHODS: From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value. RESULTS: The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears. CONCLUSIONS: The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy. LEVEL OF EVIDENCE: Comparative case series, Level IV.

Isometric Characteristics of the Anterolateral Ligament of the Knee: A Cadaveric Navigation Study.

PURPOSE: To measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion. METHODS: Twelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle. RESULTS: During IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location. CONCLUSIONS: The ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°. CLINICAL RELEVANCE: Clinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Evaluating the Reliability of YouTube as a Source of Information for Meniscal Ramp Lesions.

Background: Videos uploaded to YouTube do not go through a review process, and therefore, videos related to medial meniscal ramp lesions may have little educational value. Purpose: To assess the educational quality of YouTube videos regarding ramp lesions of the meniscus. Study Design: Cross-sectional study. Methods: A standard search was performed on the YouTube website using the following terms: "ramp lesion" and "posterior meniscal detachment" and "ramp" and "meniscocapsular" and "meniscotibial detachment," and the top 100 videos based on the number of views were included for analysis. The video duration, publication data, and number of likes and views were retrieved, and the videos were categorized based on video source (health professionals, orthopaedic company, private user), the type of information (anatomy, biomechanics, clinical examination, overview, radiologic, surgical technique), and video content (education, patient support, patient experience/testimony).The content analysis of the information on the videos was evaluated with the use of the DISCERN instrument (score range, 16-80), the Journal of the American Medical Association (JAMA) benchmark criteria (score range, 0-4), and the Global Quality Score (GQS; score range, 1-5). Results: A total of 74 videos were included. Of these videos, 70 (94.6%) were published by health professionals, while the remaining 4 (5.4%) were published by orthopaedic companies. Most of the videos were about surgical technique (n = 36; 48.6%) and all had an educational aim (n = 74; 100%). The mean length of the videos was 10.35 ± 17.65 minutes, and the mean online period was 18.64 ± 13.85 months. The mean DISCERN score, JAMA benchmark score, and GQS were 31.84 ± 17.14 (range, 16-72), 1.65 ± 0.87 (range, 1-4), and 2.04 ± 1.21 (range, 1-5), respectively. Videos that reported an overview about ramp lesions were the best in terms of quality for DISCERN and JAMA benchmark score, while biomechanics videos were the best according to GQS. The worst category of videos was about surgical technique, with all having lower scores. Conclusion: The educational content of YouTube regarding medial meniscal ramp lesions showed low quality and validity based on DISCERN score, JAMA benchmark score, and GQS.

Incidence of and Risk Factors for Arthrogenic Muscle Inhibition in Acute Anterior Cruciate Ligament Injuries: A Cross-Sectional Study and Analysis of Associated Factors From the SANTI Study Group.

BACKGROUND: Arthrogenic muscle inhibition (AMI) is a process in which neural inhibition after injury or surgery to the knee results in quadriceps activation failure and knee extension deficit. PURPOSE: To determine the incidence and spectrum of the severity of AMI after acute anterior cruciate ligament (ACL) injury using the Sonnery-Cottet classification, to determine the interobserver reliability of the classification system, and to investigate potential important factors associated with AMI after ACL injury. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients who had an acute ACL injury between October 2021 and February 2022 were considered for study inclusion. Eligible patients underwent a standardized physical examination at their first outpatient appointment. This included an assessment of quadriceps inhibition, identification of any extension deficits, and grading of AMI and its reversibility according to the Sonnery-Cottet classification. RESULTS: A total of 300 consecutive patients with acute ACL ruptures were prospectively enrolled in the study. Of them, 170 patients (56.7%) had AMI. Patients evaluated with AMI showed a significantly inferior Lysholm score, International Knee Documentation Committee score, Simple Knee Value, and Knee injury and Osteoarthritis Outcome Score than patients without AMI (P < .0001). Multivariate analysis revealed that the presence of effusion, concomitant injuries, and high pain scores were associated with a significantly greater risk of AMI. Additional associations with the presence of AMI included a short duration between injury and evaluation, the use of crutches, and using a pillow as a support at night. In contrast, a previous ACL injury was associated with significantly lower odds of developing AMI (OR, 0.025; 95% CI, 0-0.2; P = .014). Among the 170 patients with AMI, 135 patients (79%) showed a resolution of their inhibition at the end of the consultation after application of simple exercises; the remaining 35 patients required specific rehabilitation. Interobserver reliability of the classification system was almost perfect (95% CI, 0.86-0.99). CONCLUSION: AMI occurs in over half of patients with acute ACL injuries. When it occurs, it is easily reversible in the majority of patients with simple exercises targeted at abolishing AMI. The presence of "red flags" should increase the index of suspicion for the presence of AMI, and these include the presence of an effusion, high pain scores, a short time between injury and evaluation, multiligament injuries, the use of crutches, and using a pillow as a support at night. Patients with a history of ipsilateral or contralateral ACL injury are at a significantly lower risk of AMI than those with a first-time ACL injury.

Postoperative regular use of a self-rehabilitation mobile application for more than two weeks reduces extension deficit and cyclop syndrome after anterior cruciate ligament reconstruction.

PURPOSE: To investigate the minimum use that correlates with the best outcomes in term of complications associated with self-directed rehabilitation mobile application and to explore the user profile and usage habits. METHODS: This was a single-center retrospective study of 356 patients who underwent ACL reconstruction surgery between November 2019 and August 2020. Complications were defined as the presence of an extension deficit ≥ 5° after 6 weeks and/or the presence of cyclops syndrome. The demographics, sports competition level and number of connections were collected by the application. RESULTS: The complication rate was reduced 4.2-fold with at least 2 weeks of use (2.4% (3/123) (with 0.8% (1/123) of cyclops syndrome) versus 10.8% (23/212) (with 3.3% (7/212) cyclops syndrome), p = .04). The mean duration of use was 20 ± 23 days with a frequency of 2.1 ± 2.3 connections per day. The usage rate was 50% in week 1, 35% in week 2, and 24% in week 3. There was one peak in the abandon rate during the first few days of use and a second peak at Day 10 when physiotherapy sessions started. There were two dips in the abandon rate associated with the follow-up visits at Days 21 and 45. Greater use was found in older patients (p = .0001) and female patients (p = .04). CONCLUSIONS: When using the application for a minimum of 2 weeks, the risk of complications was reduced 4.2-fold. The typical users of a self-directed rehabilitation application after ACL surgery in this study were women and patients over 30 years of age. LEVEL OF EVIDENCE: IV, retrospective.

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown.

BACKGROUND: Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application. HYPOTHESIS: Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction. MATERIAL AND METHODS: We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome. RESULTS: We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]). DISCUSSION: The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists. LEVEL OF EVIDENCE: IV, single-centre retrospective case-control study.

Radiographic Incidence of Knee Osteoarthritis After Isolated ACL Reconstruction Versus Combined ACL and ALL Reconstruction: A Prospective Matched Study From the SANTI Study Group.

BACKGROUND: Combined anterior cruciate ligament (ACL) reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) have demonstrated reduced risk of graft rerupture as compared with isolated ACLR. However, concerns remain that the risk of osteoarthritis (OA) may be increased by the addition of ALLR. PURPOSE/HYPOTHESIS: The aim of this study was to evaluate the incidence of OA with isolated ACLR in comparison with ACLR + ALLR at medium-term follow-up. We hypothesized that there would be no differences between the groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent ACLR + ALLR with hamstring tendon autograft between January 2011 and March 2012 were propensity matched to patients who underwent isolated ACLR with bone-patellar tendon-bone (BPTB) or hamstring tendon autograft in the same period. Medium-term radiographic evaluation was performed using the International Knee Documentation Committee (IKDC) radiographic OA grading scale, modified Kellgren-Lawrence grade, and the surface fit method to assess percentage of joint space narrowing. Clinical outcomes were assessed with the following measures: IKDC, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and ACL Return to Sport after Injury. RESULTS: A total of 80 patients (42 ACLR + ALLR and 38 isolated ACLR) were analyzed with a mean follow-up of 104 months. There was no significant difference between groups for joint space narrowing in the medial or lateral tibiofemoral or lateral patellofemoral (PF) compartment. However, 36.8% in the isolated ACLR group versus 11.9% in the ACLR + ALLR group had narrowing of the medial PF compartment (P = .0118). A lateral meniscal tear increased the risk of lateral tibiofemoral narrowing by nearly 5 times (odds ratio, 4.9; 95% CI, 1.547-19.367; P = .0123). The risk of medial PF narrowing was >4-fold with an isolated ACLR (odds ratio, 4.8; 95% CI, 1.44-19.05; P = .0179). Between the isolated ACLR group and the ACLR + ALLR group, the secondary meniscectomy rate was 13.2% versus 11.9% (not significantly different). There was no difference between groups in KOOS, Tegner, or IKDC scores. There was also no difference between groups for grades of osteoarthritic change for any classification system. Patients who received a BPTB graft had medial PF joint narrowing in 66.7% of cases as compared with 11.9% in those who received ACLR + ALLR (P = 0.118). CONCLUSION: ACLR + ALLR did not increase the risk of OA in the lateral tibiofemoral compartment when compared with an isolated ACLR at medium-term follow-up. Isolated ACLR using BPTB was associated with a significantly increased risk of medial PF joint space narrowing. REGISTRATION: NCT05123456 (ClinicalTrials.gov identifier).

Failure Rates of Repaired Bucket-Handle Tears of the Medial Meniscus Concomitant With Anterior Cruciate Ligament Reconstruction: A Cohort Study of 253 Patients From the SANTI Study Group With a Mean Follow-up of 94 Months.

BACKGROUND: Failure rates of repaired bucket-handle medial meniscal tears (BHMMTs) concomitant with anterior cruciate ligament reconstruction (ACLR) are as high as 20%. The outcomes of posteromedial portal suture hook repair have not been compared with all-inside repair techniques for this subtype of meniscal lesion. PURPOSE/HYPOTHESIS: The aim of this study was to evaluate the outcomes and failure rates of patients who underwent BHMMT repair concomitant with ACLR using an all-inside technique, suture hook + all-inside technique, or suture hook + outside-in technique. It was hypothesized that no significant differences in failure rates would be found between the groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was performed on patients diagnosed with a BHMMT who underwent meniscal repair during primary ACLR and had a minimum follow-up of 2 years. Patients were grouped based on the meniscal repair technique used: all-inside repair, suture hook + all-inside repair, or suture hook + outside-in repair. At the end of the study period, secondary medial meniscectomy rates were determined. RESULTS: The study population comprised 253 patients who underwent repair of a BHMMT with concomitant ACLR with a mean follow-up of 94.0 ± 47.6 months. A total of 114 patients (45.1%) underwent all-inside repair, 61 patients (24.1%) underwent suture hook + all-inside repair, and 78 patients (30.8%) underwent suture hook + outside-in repair. Overall, there were 36 failures. The failure rates were 20.2%, 14.8%, and 5.1%, respectively (P = .0135). All-inside repairs were >4 times more likely to fail than suture hook + outside-in repairs (hazard ratio [HR], 4.103; 95% CI, 1.369-12.296; P = .0117). Failure was also 3 times higher (HR, 2.943; 95% CI, 1.224-7.075; P = .0159) for patients <30 years of age compared with those aged ≥30 years. An additional anterolateral ligament reconstruction (ALLR) was also found to reduce the failure rate of repaired BHMMTs concomitant with ACLR. CONCLUSION: Combined suture hook + outside-in repair of BHMMTs resulted in significantly fewer failures than all other techniques. Furthermore, age <30 years and no additional ALLR were associated with higher failure rates.

Rehabilitation protocol after suturing the medial meniscus of a stable knee, a retrospective series of the Francophone Arthroscopy Society.

INTRODUCTION: Surgical meniscal lesions are common and 80% of cases involve the medial meniscus of a stable knee. There is a lack of consensus regarding postoperative rehabilitation protocols and a wide variation between restrictive and accelerated rehabilitation protocols exists. The main objective of this study was to report the functional results and the failure rate of the various rehabilitation protocols of the retrospective series of the French Society of Arthroscopy (SFA) after suturing the medial meniscus of a stable knee, considering whether the tear is stable or unstable. HYPOTHESIS: Our hypothesis was that accelerated rehabilitation was not associated with an increased risk of failure. MATERIALS AND METHODS: This retrospective, multicenter study was conducted across 10 centers (6 private hospitals and 4 public hospitals) including all patients tested for a medial meniscus suture in a stable knee between January 1, 2005 and November 31, 2017 for a minimum follow-up of 5years. Demographic, imaging, suturing, rehabilitation protocol, and functional TEGNER and KOOS scores were collected. Failure was defined as performing a secondary meniscectomy. RESULTS: Three hundred and sixty-seven patients were analyzed with an average follow-up of 82months. Immediate weight bearing was allowed in 85% of cases, the wearing of a brace was present in almost 74% of cases and flexion was limited in 97% of cases. Inter-group comparisons found a higher suture failure rate in the group with immediate weight bearing (35.6% vs. 20%, p=0.011) and in the group with a brace (36.9% vs. 22.4%, p<0.001). There was no difference in the 90° flexion group. The TEGNER score was higher in the non-weight bearing group (6.5 vs. 5.4, p=0.028) and the KOOS QOL score was higher in the group without a brace (82.2 vs. 66.8, p=0.025). According to a multivariate analysis, immediate weight bearing (OR=3.6, [1.62; 7.98], p=0.0016) and wearing a brace (OR=2.83, [1.54; 5.02], p<0.001) were associated with a higher failure rate. In the group of stable lesions, the use of a brace (OR=3.73, [1.62; 8.56], p=0.0019) was associated with a higher failure rate. CONCLUSION: No consensus regarding rehabilitation protocols has been established to date and the results of this retrospective series of the SFA affirm the great variability of practices at a national level. Although accelerated rehabilitation protocols are presently favored, the resumption of immediate full weight bearing should be considered with caution, being associated with a higher risk of failure in this series. Deferring weight bearing for 1 month can be considered in the event of a large tear or in the event of damage to the circumferential fibers. Wearing a brace does not seem to have any influence, while limited flexion achieved a consensus. LEVEL OF EVIDENCE: IV, retrospective study.

Return to sport after surgery for osteochondral lesions of the talar dome. Results of a multicenter prospective study on 58 patients.

INTRODUCTION: Osteochondral lesions of the talar dome (OLTD) are most often found in patients for whom the return to sports activities is the main issue. Two types of surgery have been distinguished at present, bone marrow stimulation techniques and mosaicplasty techniques. The size of the lesion indicating the need for bone marrow stimulation as the required surgical procedure has recently been decreased (<1cm). The main objective of this study was therefore to evaluate the return to sport after OLTD surgery. Our hypothesis is that surgery of osteochondral lesions of the talar dome allows the resumption of sports activities in the majority of cases. MATERIAL AND METHODS: This multicenter prospective study was conducted across 10 French centers specializing in foot and ankle surgery. All patients aged 18 to 65 with symptomatic OLTD resistant to thorough medical treatment for at least 6 months, justifying surgery, were included from June 2018 to September 2019. In addition to the usual demographic data, the practice of sport and level (professional, competitive, leisure) were systematically investigated preoperatively. A common protocol for surgical management and postoperative follow-up had previously been established according to the arthrographic stage of the lesion. The most recent recommendations based on size, but also depth, were taken into account. The primary endpoint was return to sport. RESULTS: A final functional evaluation with the AOFAS (American Orthopedic Foot & Ankle Society) score was performed at a minimum of 12 months. Of 58 sports patients, 70.6% returned to sport (41/58) with an average delay of 4.3 months. A high AOFAS functional score (p=0.02) and a stage 1 lesion (p=0.006) were the only preoperative criteria significantly associated with a return to sport. No other factor was predictive of a return to sport. CONCLUSION: Our prospective study shows that 70.6% of sports patients returned to sport after OLTD surgery according to a surgical protocol and standardized follow-up. LEVEL OF EVIDENCE: II.

The frequency of medial meniscal repairs in stable knees during one year of arthroscopic activity (2021-2022) - comparison with a retrospective study (prior to 2017).

INTRODUCTION: There has been a significant increase in the use of conservative treatment for meniscal lesions due to raised awareness around the need for meniscal preservation. However, sutures of the medial meniscus (MM) in stable knees remain less frequently used. The objective of this study was to, firstly, identify the MM suture rate over one year of activity; secondly, to identify and compare the distribution of MM sutures in stable, and stabilized, knees on this prospective series; and thirdly, to compare the evolution of practices with a retrospective series of more than 5 years follow-up. HYPOTHESIS: The number of MM sutures in stable knees represents a small percentage of annual arthroscopic activity. MATERIAL AND METHODS: This multicenter study was carried out in 10 reference centers participating in the 2022 symposium of the Francophone Society of Arthroscopy (Bordeaux, Caen, Lille, Lille Louvière, Lyon, Marseille, Toulouse, Saint-Étienne, Strasbourg, Versailles). This study included a prospective series on interventions performed under arthroscopy during one year of activity. The inclusion criteria were patients operated on via an arthroscopic technique and aged over 18 at the time of the operation. Demographic data, as well as the circumstances leading to the injury, were collected. A register of the lesions found was established in order to list the lesions of the MM, the lateral meniscus (LM), the anterior cruciate ligament (ACL), the associated chondral lesions; as well as the treatment performed: meniscal suture of the MM and/or LM, meniscectomy of the MM and/or LM and ligamentoplasty of the ACL. This study also included a retrospective series comprised of only MM sutures in stable knees at more than 5 years of follow-up. RESULTS: Of the 4154 patients included, 1919 patients (46.2%) underwent surgery for ACL reconstruction and 2235 for arthroscopy without associated ligament surgery. MM sutures (in stable knees and in knees with ACL reconstruction) represented 14% of the overall arthroscopic activity (583 MM sutures) versus 8.6% for LM (360 sutures). In cases of ACL surgery, there were 895 associated meniscal lesions (337 LM and 558 MM) and 66% of MM tears (371 MM sutures) were sutured. In stable knees, MM tears were weaker (212 MM sutures out of 1359 lesions, i.e. 15%). Of all the arthroscopic procedures performed over the course of a year, MM suturing in stable knees represented 5.1% of the activity. Compared to the retrospective series (n=367), the patients were older (37 years versus 28 years) and the management of ramp lesions or root tears was noted. In both series, these tears were related to sports trauma in more than 70% of cases. CONCLUSION: MM suturing in stable knees represents a small part of annual arthroscopic activity and it occurs less frequently than during ACL reconstruction surgery. LEVEL OF EVIDENCE: IV.

Medial meniscal repair in stable knees: Survival rate and risk factors for failure at a minimum of 5 years.

INTRODUCTION: The menisci play a major role in the protection of the knee against osteoarthritis. A medial meniscus (MM) tear occurring in a stable knee is more at risk of repair failure than a suture concomitant with reconstruction of the anterior cruciate ligament. HYPOTHESIS: The survival of MM sutures in stable knees depends on the type of lesion. MATERIALS AND METHODS: This retrospective study was carried out as part of the 2022 Francophone Arthroscopy Society's symposium, across 10 centers (Bordeaux-Mérignac, Caen, Lille, Lille Louvière, Lyon, Marseille, Toulouse, Saint-Étienne, Strasbourg and Versailles) including medial meniscus sutures in stable knees performed before the end of 2017 (minimum 5 years of follow-up) with a collection of demographic, imaging, suture and postoperative protocol data, and a functional evaluation using the Knee injury and Osteoarthritis Outcome score (KOOS). The aim of this study was to analyze the medial meniscus sutures in stable knees and to evaluate their survival and their risk factors for failure according to the type of lesion; failure being defined by the use of a meniscectomy. RESULTS: Three-hundred and sixty-seven MM sutures, including 122 bucket-handle tears, were included. The KOOS score was improved by the meniscal suture by an average of 22.2 points for each sub-score (p<0.05), with an improvement, which was more marked for the bucket-handle tears. The failure rate, defined by revision surgery by meniscectomy, was 33% on average (42% for bucket-handles tears, 26% for others). The probability of survival was reduced for bucket-handle tears (62% at 5 years versus 77% for the other types). For all lesions, the main risk factor identified for failure was immediate weight-bearing [OR=3.6 (1.62; 7.98), p=0.0016]. Smoking was a failure risk factor for bucket-handle tears [OR=5.76 (1.81; 18.35), p=0.003]. CONCLUSION: MM sutures in stable knees improve knee function but present a different risk of failure depending on the type of lesion treated with a higher risk of failure for bucket-handle tears with the need for caution to be applied with regards to weight-bearing and smoking. LEVEL OF EVIDENCE: IV; retrospective series.

All-Arthroscopic Treatment of Combined Posterior Cruciate Ligament and Posterolateral Corner Instability.

Injuries to the posterolateral corner (PLC) of the knee are uncommon, and usually associated with other ligamentous injuries. A combined posterior cruciate ligament (PCL) and PLC tear is the most frequent combination. Several studies describe anatomic reconstructive techniques using an open approach with large incisions and extensive exploration of the posterolateral structures. This Technical Note describes an all-arthroscopic technique as a safe and efficient treatment of combined PCL and PLC instability using the trans-septal approach.

Revision Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft Combined With Modified Lemaire Technique Versus Hamstring Graft Combined With Anterolateral Ligament Reconstruction: A Clinical Comparative Matched Study With a Mean Follow-up of 5 Years From The SANTI Study Group.

BACKGROUND: Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved clinical outcomes and reduced failure rates in revision anterior cruciate ligament (ACL) reconstruction (ACLR). However, no data are available on clinical outcomes and reoperation after revision ACLR using different LET procedures. PURPOSE: To compare the clinical outcomes of ACL + anterolateral ligament (ALL) reconstruction using hamstring tendon graft (HT-ALL) and a bone-patellar tendon-bone (BPTB) graft + modified Lemaire tenodesis procedure (BPTB-Lemaire) in the setting of revision ACLR and to determine whether ALL reconstruction is associated with an increased rate of adverse outcomes when compared with a modified Lemaire tenodesis procedure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with LET between 2009 and 2018 with a minimum follow-up of 2 years. Patients with an HT autograft combined with ALL reconstruction (HT-ALL group) were matched in a 1:1 propensity ratio to patients with a BPTB autograft combined with a modified Lemaire LET procedure (BPTB-Lemaire group). The evaluated parameters included complications and reoperations; knee laxity tests; return to sports; and various scores, including the Lysholm knee score, Tegner activity scale, Anterior Cruciate Ligament Return to Sport After Injury scale, Marx activity rating scale, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. RESULTS: In total, 36 matched pairs were included in the analysis. The mean follow-up durations for the BPTB-Lemaire and HT-ALL groups were 56 ± 35 and 57 ± 23 months, respectively (P = .91). No significant differences were found in graft rupture rate (HT-ALL, 0%; BPTB-Lemaire, 11.1%; P = .13) or reoperations (HT-ALL, 8.3%; BPTB-Lemaire, 22.2%; P = .23). No specific complications with regard to LET were noted in either group. Additionally, there were no significant differences in knee laxity parameters, return to sports, or clinical scores between the groups at the final follow-up, except for the Tegner activity scale score (HT-ALL, 6.4; BPTB-Lemaire, 7.3; P = .03). HT-ALL was associated with a shorter surgical time (41.4 vs 59.8 minutes; P < .0001). CONCLUSION: HT-ALL was at least equivalent, in terms of clinical outcomes, to the more commonly performed procedure, BPTB-Lemaire. Performing ALL reconstruction in the setting of revision ACLR is therefore safe and effective.

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate.

Purpose: To analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children. Methods: This study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated. Results: Thirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID. Conclusions: This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions. Level of Evidence: IV, therapeutic case series.

Long-term Graft Rupture Rates After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction: A Matched-Pair Analysis From the SANTI Study Group.

BACKGROUND: Clinical studies have demonstrated significant advantages of combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) over isolated ACL reconstruction (ACLR) with respect to reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to sports. However, no long-term studies exist. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the outcomes of isolated ACLR versus ACL+ALLR at long-term follow-up. The hypothesis was that patients who underwent combined procedures would experience significantly lower rates of graft rupture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing primary ACL+ALLR between January 2011 and March 2012 were propensity matched in a 1:1 ratio to patients who underwent isolated ACLR during the same period. A combination of face-to-face and telemedicine postoperative follow-up was undertaken. At the end of the study period (March 2020), medical notes and a final telemedicine interview were used to determine whether patients had experienced any complications or reoperations. The Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, Lysholm score, and Tegner score were collected for all patients. Graft survivorship was assessed using Kaplan-Meier analysis. Logistic regression was performed to account for the potential effect of activity level on graft rupture rates. RESULTS: A total of 86 matched pairs were included in the study. The mean ± SD age was 32.2 ± 8.8 years (range, 22-67 years) in the ACL+ALLR group and 34.7 ± 8.5 years (range, 21-61 years) in the isolated ACLR group. The mean duration of follow-up was 104.33 ± 3.74 months (range, 97-111 months). Patients who underwent combined ACL+ALLR versus isolated ACLR experienced significantly better ACL graft survivorship (96.5% vs 82.6%, respectively; P = .0027), lower overall rates of reoperation (15.3% vs 32.6%; P < .05), and lower rates of revision ACLR (3.5% vs 17.4%; P < .05). Patients undergoing isolated ACLR were at >5-fold greater risk of graft rupture (odds ratio, 5.549; 95% CI, 1.431-21.511; P = .0132), regardless of their preinjury activity level. There were no significant differences between groups with respect to other complications or any clinically important differences in patient-reported outcome measures. CONCLUSION: Patients who underwent combined ACL+ALLR experienced significantly better long-term ACL graft survivorship, lower overall rates of reoperation, and no increase in complications compared with patients who underwent isolated ACLR. Further, patients who underwent isolated ACLR had a >5-fold increased risk of undergoing revision surgery at a mean follow-up of 104.3 months.

Risk Factors for Rapid Chondrolysis After Partial Lateral Meniscectomy: A Scoping Review of the Literature.

BACKGROUND: The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established. PURPOSE: The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment. STUDY DESIGN: Systematic (scoping) review. METHODS: A scoping review of the literature was conducted in accordance with the framework of Arksey and O'Malley. A search strategy based on the terms "chondrolysis" AND "knee," "chondrolysis" AND "meniscus," and "chondral damage" AND "lateral meniscus" was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis. RESULTS: Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee. CONCLUSION: Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.