Comparison of the Kinematics and Laxity of Total Knee Arthroplasty Bearing Designs Stabilized With Specimen-Specific Virtual Ligaments on a Joint Motion Simulator.

A variety of total knee arthroplasty (TKA) designs offer increased congruency bearing options, primarily to compensate for a loss of posterior cruciate ligament (PCL) function. However, their efficacy in providing sufficient stability under different circumstances requires further investigation. The preclinical testing of prosthesis components on joint motion simulators is useful for quantifying how design changes affect joint stability. However, this type of testing may not be clinically relevant because surrounding ligaments are either ignored or greatly simplified. This study aimed to assess the kinematics and stability of TKA joints during various motions using condylar-stabilized (CS) bearings without a PCL versus cruciate-retaining (CR) bearings with an intact PCL. TKA prosthetic components were tested on a joint motion simulator while being stabilized with five different sets of specimen-specific virtual ligament envelopes. In comparison to CR knees, CS knees without a PCL exhibited a greater amount of posterior tibial displacement laxity, with a mean increase of 2.7±2.1 mm (p = 0.03). Additionally, significant differences were observed in the anterior-posterior kinematics of the knee joint during activities of daily living (ADL) between the two designs. These results were consistent with previous cadaveric investigations, which indicated that CS knees without a PCL are less resistant to posterior tibial displacement than CR knees with one. This study employing virtual ligaments confirms previous findings that the raised anterior lip of some CS bearings may not completely compensate for the absence of the PCL; however, as both studies used reduced joint contact forces, the contributions of this design feature may be attenuated.

In Vitro Assessment of Knee Joint Biomechanics Using a Virtual Anterior Cruciate Ligament Reconstruction.

Understanding the biomechanical impact of injuries and reconstruction of the anterior cruciate ligament (ACL) is vital for improving surgical treatments that restore normal knee function. The purpose of this study was to develop a technique that enables parametric analysis of the effect of the ACL reconstruction (ACLR) in cadaver knees, by replacing its contributions with that of a specimen-specific virtual ACLR that can be enabled, disabled, or modified. Twelve ACLR reconstructed knees were mounted onto a motion simulator. In situ ACLR graft forces were measured using superposition, and these data were used to design specimen-specific virtual ACLRs that would yield the same ligament force-elongation behaviors. Tests were then repeated using the virtual ACLR in place of the real ACLR and following that in ACL deficient knee by disabling the virtual ACLR. In comparison to the ACL deficient state, the virtual ACLRs were able to restore knee stability to the same extent as real ACLRs. The average differences between the anterior tibial translation (ATT) of the virtual ACLR versus the real ACLR were +1.6 ± 0.9 mm (p = 0.4), +2.1 ± 0.4 mm (p = 0.4), and +1.0 ± 0.9 mm (p = 0.4) during Anterior drawer, Lachman and Pivot-shift tests, respectively, which is small in comparison to the full ATT range of motion (ROM) of these knees. Therefore, we conclude that a virtual ACLR can be used in place of real ACLR during biomechanical testing of cadaveric knees. This capability opens the door for future studies that can leverage parameterization of the ACLR for surgical design optimization.

Editorial Commentary: Locking Plate Removal Is Safe and May Improve Function 1 Year After Medial Opening Wedge High Tibial Osteotomy.

The development of angular stable locking late fixation in realignment osteotomy has resulted in the ability to be more aggressive with weight bearing and rehabilitation after high tibial osteotomy. One of the downsides of some of these plate fixators is the degree of soft-tissue irritation and discomfort that can be experienced by many patients, resulting in the need for hardware removal. Studies have shown greater than 50% of patients requiring hardware removal with no resulting loss of correction, although there may be cultural reasons for the higher number, not solely attributable to the symptom profile. It is encouraging to see that after 1 year postoperatively, hardware removal after high tibial osteotomy not only is safe but also results in a clinically important improvement in pain and function, with progressive bone healing out to 2 years.

Early Postoperative Activities of Daily Living Do Not Adversely Affect Joint Torques or Translation Regardless of Capsular Condition: A Cadaveric Study.

PURPOSE: To evaluate the impact of capsular management on joint constraint and femoral head translations during simulated activities of daily living (ADL). METHODS: Using 6 (n = 6) cadaveric hip specimens, the effect of capsulotomies and repair was then evaluated during simulated ADL. Joint forces and rotational kinematics associated with gait and sitting, adopted from telemeterized implant studies, were applied to the hip using a 6-degrees of freedom (DOF) joint motion simulator. Testing occurred after creation of portals, interportal capsulotomy (IPC), IPC repair, T-capsulotomy (T-Cap), partial T-Cap repair, and full T-Cap repair. The anterior-posterior (AP), medial-lateral (ML), and axial compression DOFs were operated in force control, whereas flexion-extension, adduction-abduction, and internal-external rotation were manipulated in displacement control. Resulting femoral head translations and joint reaction torques were recorded and evaluated. Subsequently, the mean-centered range of femoral head displacements and peak signed joint restraint torques were calculated and compared. RESULTS: During simulated gait and sitting, the mean range of AP femoral head displacements with respect to intact exceeded 1% of the femoral head diameter after creating portals, T-Caps, and partial T-Cap repair (Wilcoxon signed rank P < .05); the mean ranges of ML displacements did not. Deviations in femoral head kinematics varied by capsule stage but were never very large. No consistent trends with respect to alterations in peak joint restrain torques were observed. CONCLUSIONS: In this cadaveric biomechanical study, capsulotomy and repair minimally affected resultant femoral head translation and joint torques during simulated ADLs. CLINICAL RELEVANCE: The tested ADLs appear safe to perform after surgery, regardless of capsular status, because adverse kinematics were not observed. However, further study is required to determine the importance of capsular repair beyond time-zero biomechanics and the resultant effect on patient-reported outcomes.

Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts.

PURPOSE: To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS: A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS: Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS: R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Extrusion After Meniscal Allograft Transplantation Is Lower or Equal With Bony Compared With Soft-Tissue Root Fixation: A Systematic Review.

PURPOSE: To provide an update on the incidence and extent of graft extrusion after meniscal allograft transplantation (MAT) and to systematically review the literature to identify whether the type of root fixation or additional surgical techniques may reduce the risk of graft extrusion development. METHODS: A systematic search, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, was conducted using the MEDLINE database, EMBASE database, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL) database. Patients undergoing medial meniscal allograft transplantation (MMAT) or lateral meniscal allograft transplantation (LMAT) were included. The primary outcome measure was meniscal extrusion measured on postoperative magnetic resonance imaging scans taken more than 6 weeks after MAT. The following extrusion outcomes were investigated: absolute extrusion (AE), relative percentage of extrusion (RPE), and proportion of major extrusion (PME). Additional surgical techniques that reduced the risk of graft extrusion development in the included comparative studies were identified. RESULTS: For MMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.2 mm versus 3.36 mm and RPE of 44.43% versus 33.18%. The pooled mean PME for MMAT with soft-tissue fixation was 51.62%. For LMAT, the pooled mean extrusion outcomes for soft-tissue versus bony fixation were as follows: AE of 3.72 mm versus 2.78 mm, RPE of 31.89% versus 29.47%, and PME of 64.37% versus 35.80%. Additional capsulodesis was identified as a technique to reduce LMAT extrusion. CONCLUSIONS: This study highlights that graft extrusion is a common finding after MMAT and LMAT, independent of the root fixation technique. However, MAT extrusion with bony fixation was, depending on the outcome measurement, lower than or equal to that with soft-tissue fixation. LEVEL OF EVIDENCE: Level IV, systematic review of Level I, III, and IV studies.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate.

PURPOSE: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. METHODS: This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. RESULTS: We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001). CONCLUSIONS: At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial.

PURPOSE: A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar. METHODS: The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration. RESULTS: In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68-0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration. CONCLUSION: When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia. LEVEL OF EVIDENCE: Level 3, cohort study.

A bifactor model supports unidimensionality of the International Knee Documentation Committee Subjective Knee Form in young active patients with anterior cruciate ligament tears: a retrospective analysis of a randomized controlled trial.

BACKGROUND: The International Knee Documentation Committee Subjective Knee Form (IKDC) is the most highly recommended patient reported outcome measure for assessing patients with anterior cruciate ligament (ACL) injuries and those undergoing ACL reconstruction (ACLR) surgery. The IKDC was developed as a unidimensional instrument for a variety of knee conditions. Structural validity, which determines how an instrument is scored, has not been definitively confirmed for the IKDC in respondents with ACL injuries, and in fact an alternative two-factor/subscale structure has been proposed in this population. The purpose of this study was to determine the most appropriate structure and scoring system for the IKDC in young active patients following ACL injury. METHODS: In total, 618 young patients deemed at high risk of graft rupture were randomized into the Stability 1 trial. Of the trial participants, 606 patients (98%) completed a baseline IKDC questionnaire used for this analysis. A cross sectional retrospective secondary data analysis of the Stability 1 baseline IKDC data was completed to assess the structural validity of the IKDC using exploratory and confirmatory factor analyses. Factor analyses were used to test model fit of the intended one-factor structure, a two-factor structure, and alternative four-factor and bifactor structures (i.e., a combination of a unidimensional factor with additional specific factors) of the IKDC, in a dataset of young active ACL patients. RESULTS: The simple one-factor and two-factor structures of the IKDC displayed inadequate fit in our dataset of young ACL patients. A bifactor model provided the best fit. This model contains one general factor that is substantially associated with all items, plus four secondary, more specific content factors (symptoms, activity level, activities of daily living, and sport) with generally weaker associations to subsets of items. Although the single-factor model did not provide unambiguous support to unidimensionality of the IKDC based on fit indices, the bifactor model supports unidimensionality of the IKDC when covariance between items with similar linguistic structure, response options, or content are acknowledged. CONCLUSIONS: Overall, findings of a bifactor model with evidence of a reliable general factor well defined by all items lends support to continue interpreting and scoring this instrument as unidimensional. This should be confirmed in other samples. Clinically, based on these findings, the IKDC can be represented by a single score for young active patients with ACL tears. A more nuanced interpretation would also consider secondary factors such as sport and activity level. TRIAL REGISTRATION: The Stability 1 trial for which these data were collected was registered on ClinicalTrial.gov (NCT02018354).

Development of Multibundle Virtual Ligaments to Simulate Knee Mechanics After Total Knee Arthroplasty.

Preclinical evaluation of total knee arthroplasty (TKA) components is essential to understanding their mechanical behavior and developing strategies for improving joint stability. While preclinical testing of TKA components has been useful in quantifying their effectiveness, such testing can be criticized for lacking clinical relevance, as the important contributions of surrounding soft tissues are either neglected or greatly simplified. The purpose of our study was to develop and determine if subject-specific virtual ligaments reproduce a similar behavior as native ligaments surrounding TKA joints. Six TKA knees were mounted to a motion simulator. Each was subjected to tests of anterior-posterior (AP), internal-external (IE), and varus-valgus (VV) laxity. The forces transmitted through major ligaments were measured using a sequential resection technique. By tuning the measured ligament forces and elongations to a generic nonlinear elastic ligament model, virtual ligaments were designed and used to simulate the soft tissue envelope around isolated TKA components. The average root-mean-square error (RMSE) between the laxity results of TKA joints with native versus virtual ligaments was 3.5 ± 1.8 mm during AP translation, 7.5 ± 4.2 deg during IE rotations, and 2.0 ± 1.2 deg during VV rotations. Interclass correlation coefficients (ICCs) indicated a good level of reliability for AP and IE laxity (0.85 and 0.84). To conclude, the advancement of virtual ligament envelopes as a more realistic representation of soft tissue constraint around TKA joints is a valuable approach for obtaining clinically relevant kinematics when testing TKA components on joint motion simulators.

The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction.

CONTEXT: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. METHODS: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. RESULTS: There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval,  1.3 to 10.4; P = .01). CONCLUSION: A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

The Knee Injury and Osteoarthritis Outcome Score Does Not Have Adequate Structural Validity for Use With Young, Active Patients With ACL Tears.

BACKGROUND: The Knee Injury and Osteoarthritis Outcome Score (KOOS) is well known and commonly used to assess young, active patients with ACL injuries. However, this application of the outcome measure has been called into question. There is currently no evidence supporting the structural validity of the KOOS for this patient population. Structural validity refers to whether a questionnaire meant to provide scores on different subscales behaves as intended in the populations of interest. Structural validity should be assessed for all questionnaire measures with multiple items or subscales. QUESTIONS/PURPOSES: Does the KOOS demonstrate adequate structural validity in young, active patients with ACL tears, when evaluated using (1) exploratory and (2) confirmatory factor analyses? METHODS: Between January 2014 and March 2017, 1033 patients were screened for eligibility in the Stability 1 randomized controlled trial from nine centers in Canada and Europe. Patients were eligible if they had an ACL deficient knee, were between 14 and 25 years old, and were thought to be at higher risk of reinjury based on the presence of two or more of the following factors: participation in pivoting sports, presence of a Grade 2 pivot shift or greater, generalized ligamentous laxity (Beighton score of 4 or greater), or genu recurvatum greater than 10°. Based on this criteria, 367 patients were ineligible and another 48 declined to participate. In total, 618 patients were randomized into the trial. Of the trial participants, 98% (605 of 618) of patients had complete baseline KOOS questionnaire data available for this analysis. Based on study inclusion criteria, the baseline KOOS data from the Stability 1 trial represents an appropriate sample to investigate the structural validity of the KOOS, specifically for the young, active ACL deficient population.A cross sectional retrospective secondary data analysis of the Stability 1 baseline KOOS data was completed to assess the structural validity of the KOOS using exploratory and confirmatory factor analyses. Exploratory factor analysis investigates how all questionnaire items group together based on their conceptual similarity in a specific sample. Confirmatory factor analysis is similar but used often in a second stage to test and confirm a proposed structure of the subscales. These methods were used to assess the established five-factor structure of the KOOS (symptoms [seven items], pain [nine items], activities of daily living [17 items], sport and recreation [five items], and quality of life [four items]) in young active patients with ACL tears. Incremental posthoc modifications, such as correlating questionnaire items or moving items to different subscales, were made to the model structure until adequate fit was achieved. Model fit was assessed using chi-square, root mean square error of approximation (RMSEA) and an associated 90% confidence interval, comparative fit index (CFI), Tucker-Lewis index (TLI), as well as standardized root mean square residual (SRMR). Adequate fit was defined as a CFI and TLI > 0.9, and RMSEA and SRMR < 0.08. RESULTS: Structural validity of the KOOS was not confirmed when evaluated using (1) exploratory or (2) confirmatory factor analyses. The exploratory factor analysis, where the 42 KOOS items were allowed to group naturally, did not reflect adequate fit for a five-factor model (TLI = 0.828). Similarly, the confirmatory factor analysis used to investigate the KOOS structure as it was originally developed, revealed inadequate fit in our sample (RMSEA = 0.088 [90% CI 0.086 to 0.091]). Our analysis suggested a modified four-factor structure may be more appropriate in young, active ACL deficient patients; however, the final version presented here is not appropriate for clinical use because of the number and nature of post-hoc modifications required to reach adequate fit indices. CONCLUSION: The established five-factor structure of the KOOS did not hold true in our sample of young, active patients undergoing ACL reconstruction, indicating poor structural validity. CLINICAL RELEVANCE: We question the utility and interpretability of KOOS subscale scores for young, active patients with ACL tears with the current form of the KOOS. A modified version of the KOOS, adjusted for this patient population, is needed to better reflect and interpret the outcomes and recovery trajectory in this high-functioning group. A separate analysis with a defined a priori development plan would be needed to create a valid alternative.

Editorial Commentary: Indications for Lateral Extra-Articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction.

Lateral extra-articular tenodesis and other anterolateral procedures improve patient outcomes when combined with anterior cruciate ligament reconstruction. Failure rates are >50% lower in young patients at high risk of reinjury. We defined patients at high risk as those aged 14 to 25 years with 2 or more factors of the following criteria: 1) returning to contact pivoting sport, 2) high-grade anterolateral rotatory laxity, as measured by pivot shift test (grade 2 or higher), and 3) generalized ligamentous laxity (Beighton score greater than 4) or knee hyperextension recurvatum of greater than 10°. Other indications may include Segond fracture, chronic anterior cruciate ligament lesion, radiographic lateral femoral notch sign, and lateral coronal plane laxity. A clearer understanding of indications determined by a comprehensive clinical assessment and risk stratification is needed. As indications continue to be "stretched," we need to better understand the role of lateral extra-articular tenodesis and when to employ it in our practice.

Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up.

PURPOSE: Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. METHODS: This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. RESULTS: Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18-52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24-72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). CONCLUSION: Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. LEVEL OF EVIDENCE: IV.

Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience.

PURPOSE: To assess how meniscal repair and excision impact short term patient-reported outcome measures (PROMs), knee stability, and early graft rupture rates following primary hamstring anterior cruciate ligament reconstruction (ACLR) with or without lateral extra-articular tenodesis (LET) in a group of young active patients where meniscal repair is commonly advocated. METHODS: Six hundred and eighteen patients under 25 years of age at high-risk of graft failure following ACLR were recruited to the Stability 1 study. Multivariable regression models were developed to identify statistically and clinically significant surgical and demographic predictors of Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Form (IKDC), ACL Quality of Life Questionnaire (ACL-QOL) and Marx Activity Rating Scale (MARS) scores. Chi-Square tests of independence were used to explore the association between meniscal status (torn, not torn), meniscal treatment (excision or repair), graft rupture, and rotatory knee laxity. RESULTS: Medial meniscus repair was associated with worse outcomes on the KOOS (ß = -1.32, 95% CI: -1.57 to -1.10, p = 0.003), IKDC (ß = -1.66, 95% CI: -1.53 to -1.02, p = 0.031) and ACL-QOL (ß = -1.25, 95% CI: -1.61 to 1.02, p = n.s.). However, these associations indicated small, clinically insignificant changes based on reported measures of clinical relevance. Other important predictors of post-operative PROMs included age, sex, and baseline scores. Medial meniscus excision and lateral meniscus treatment (repair or excision) did not have an important influence on PROMs. There was no significant association between meniscal treatment and graft rupture or rotatory knee laxity. CONCLUSION: While repairing the medial meniscus may result in a small reduction in PROM scores at two-year follow-up, these differences are not likely to be important to patients or clinicians. Any surgical morbidity associated with meniscal repair appears negligible in terms of PROMs. Meniscal repair does not affect rotatory laxity or graft failure rates in the short term. Therefore, meniscal repair should likely be maintained as the standard of care for concomitant meniscal tears with ACLR. LEVEL OF EVIDENCE: III.

Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction.

PURPOSE: To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts. METHODS: This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010-2014 and 2015-2020. All collected variables were compared between three pre-defined age groups (< 20 years, 20-30 years, > 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R. RESULTS: This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (< 1%) patients, respectively. Patients age > 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age < 20 years (2.2 years, p < 0.001) and age 20-30 years (5.5 years, p < 0.05). Quadriceps tendon autograft was used significantly more often in 2015-2020 compared to 2010-2014 (49% vs. 18%, p < 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time (p < 0.05). Intact cartilage (41%, p < 0.05), concurrent medial meniscal repairs (39%, p < 0.05), and LET (35%, non-significant) were most frequently observed in patients aged < 20 years. CONCLUSION: Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R. LEVEL OF EVIDENCE: Level III.

The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study.

BACKGROUND: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS: We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.

Editorial Commentary: Return to Sport Following Extra-Articular Augmentation of Anterior Cruciate Ligament Reconstruction-Let the LET (Lateral Extra-Articular Tenodesis) Games Commence!

The debate around extra-articular augmentation (EA) of anterior cruciate ligament (ACL) reconstruction continues to provide a rich source of research articles that we ultimately hope will improve patient outcomes. When combined with ACL reconstruction, anterolateral ligament reconstruction or lateral extra-articular tenodesis procedures reduce graft failure and persistent rotatory laxity. An important metric of ACL reconstruction outcome is return to play (RTP). RTP rates are also excellent when EA procedures are used in both primary and revision ACL reconstruction. However, when it comes to RTP, EA augmentation has yet to show significant improvement over isolated ACL reconstruction.

Bone Versus All Soft Tissue Quadriceps Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To examine existing literature on objective and patient-reported outcomes and complications after anterior cruciate ligament reconstruction (ACLR) with bone-quadriceps-tendon (B-QT) or soft tissue-quadriceps tendon (S-QT) to further clarify the role of graft type in primary ACLR. METHODS: In accordance with PRISMA guidelines, PubMed, Embase, and Medline were searched in October 2019 for English-language, human studies of all evidence levels on patients undergoing primary ACLR with B-QT or S-QT autograft. RESULTS: 24 of 1,381 studies satisfied criteria, with 20 using B-QT (1,534 patients, mean age 29.6 years [range 14 to 59], mean follow-up 41.2 months [range 12 to 120]) and 5 using S-QT (181 patients, mean age 32.4 years [range 15 to 58), mean follow-up 25.5 months [range 12 to 46]). International Knee Documentation Committee (IKDC) scores were 67.3 to 89.5 with B-QT and 80.4 to 81.6 with S-QT. Lysholm scores were 85.7 to 97.4 with B-QT and 81.6 to 89.2 with S-QT. More B-QT patients demonstrated rotatory laxity on pivot shift compared with S-QT (0% to 39% versus 0%, respectively). The most common complication was graft rupture, and no differences were observed between graft choices (B-QT 0% to 9% versus S-QT 0% to 3.8%). CONCLUSIONS: The main findings from this review report that more B-QT patients demonstrated postoperative rotatory instability than S-QT patients, and that there are no differences in graft rupture between the 2 graft choices. Although statistical conclusions may not be drawn because of heterogeneity in reporting, it appears that the B-QT group featured much wider major and minor complication profiles. LEVEL OF EVIDENCE: IV, systematic review of level I-IV studies.

Five- and six-strand hamstring grafts consistently produce appropriate graft diameters for anterior cruciate ligament reconstruction.

PURPOSE: Hamstring tendon graft diameter less than 8 mm has been correlated with an increased risk of anterior cruciate ligament reconstruction (ACLR) graft failure. The purpose of this study was to measure and compare the diameter of 3-, 4-, 5-, and 6-strand gracilis and semitendinosus (ST) hamstring tendon (HT) ACLR grafts, and to determine if there is a correlation between anthropometric data, HT length, and diameter of the HT ACLR graft. METHODS: Male patients (n = 78) undergoing primary or revision ACLR with a HT autograft between July 2018 and March 2020 were recruited. Pre-operative anthropometric data was collected. Gracilis and ST tendons were harvested and the length and diameter measured. The following HT graft configurations were prepared in each patient: triple ST; double gracilis + double ST; double gracilis + triple ST; triple gracilis + triple ST. Paired t-tests and Pearson's correlation coefficients were used to assess demographics, anthropometrics, graft diameter, and tendon length. A non-parametric test was used to compare femoral and tibial ACL graft diameters of the 3-, 4-, 5-, and 6-strand HT graft configurations. RESULTS: For the femoral end, 10%, 19%, 69% and 86% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5- and 6-strand HT graft configurations respectively. For the tibial end, 27%, 10%, 83%, and 92% of the patients achieved graft diameters of equal to or greater than 8 mm in 3-, 4-, 5-, and 6-strand HT graft configurations respectively. The largest increases in HT graft diameters were noted between the femoral end of 6- vs. 3-strand grafts (mean difference 1.7 ± 0.5 mm; p < 0.001) and between the tibial end of 6- vs. 4-strand grafts (mean difference 2.0 ± 0.5 mm; p < 0.001). Height and leg length were moderately positively correlated with ST tendon length (r = 0.54-0.51) and gracilis tendon length (r = 0.52-0.45), and thigh and shank lengths were moderately positively correlated with ST tendon length (r = 0.43 and 0.40, respectively). CONCLUSION: Traditional 4-strand HT ACL autografts in male patients undergoing ACLR in the United Arab Emirates result in graft diameters less than 8 mm in the majority of patients. LEVEL OF EVIDENCE: III.