Higher odds of meniscectomy compared with meniscus repair in a young patient population with increased neighbourhood disadvantage.

OBJECTIVES: To investigate the impact of demographic and socioeconomic factors on the management of isolated meniscus tears in young patients and to identify trends in surgical management of meniscus tears based on surgeon volume. METHODS: Data from a large healthcare system on patients aged 14-44 years who underwent isolated meniscus surgery between 2016 and 2022 were analysed. Patient demographics, socioeconomic factors and surgeon volume were recorded. Patient age was categorised as 14-29 years and 30-44 years old. Area Deprivation Index (ADI), a measure of neighbourhood disadvantage with increased ADI corresponding to more disadvantage, was grouped as <25th, 25-75th and >75th percentile. Multivariate comparisons were made between procedure groups while univariate comparisons were made between surgeon groups. RESULTS: The study included 1552 patients treated by 84 orthopaedic surgeons. Older age and higher ADI were associated with higher odds of undergoing meniscectomy. Patients of older age and with non-private insurance were more likely to undergo treatment by a lower-volume knee surgeon. Apart from the year 2022, higher-volume knee surgeons performed significantly higher rates of meniscus repair compared with lower-volume knee surgeons. When controlling for surgeon volume, higher ADI remained a significant predictor of undergoing meniscectomy over meniscus repair. CONCLUSION: Significant associations exist between patient factors and surgical choices for isolated meniscus tears in younger patients. Patients of older age and with increased neighbourhood disadvantage were more likely to undergo meniscectomy versus meniscus repair. While higher-volume knee surgeons favoured meniscus repair, a growing trend of meniscus repair rates was observed among lower-volume knee surgeons. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Editorial Commentary: Early Outcomes of Suture Tape Augmentation in Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction Are Promising but Require Long-term Proof.

The management of anterior cruciate ligament (ACL) injuries continually evolves, with new interest in all-soft tissue quadriceps tendon autograft, as well as new interest in suture tape augmentation of the graft, particularly in high-risk patients with young age; female sex; lower-limb alignment, tibial, or femoral abnormalities; hyperlaxity; concomitant meniscal and/or additional ligamentous injuries; or participation in high-risk sports. Load-sharing suture tape enhances the biomechanical stability of the reconstructed ACL, especially during the initial ingrowth and ligamentization phase, and biomechanical evidence highlights a reduced risk of graft elongation and failure under the loads encountered during daily physical activities and sport. Optimal tape tensioning could be achieved in knee hyperextension, when the ACL is at maximal length, to avoid overconstraint. The published 2-year outcomes of this technique are excellent. Current comparative studies, however, have not shown superiority. Additional controlled studies and studies with longer-term follow-up are needed, as well as comparison to extra-articular tenodesis augmentation.

Both Hamstring and Quadriceps tendon autografts offer similar functional outcomes after arthroscopic ACL reconstruction in patients over 50 years of age.

PURPOSE: The purpose of this study was to compare the outcomes of hamstring tendon (HT) and quadriceps tendon (QT) autografts for anterior cruciate ligament (ACL) reconstruction in patients older than 50 years in terms of patient-reported functional outcomes, graft failure rates, complications, return to sports activity and the preference for sports. METHODS: Between 2010 and 2022, prospectively collected data were obtained from an institutional database. Patients older than 50 years with primary arthroscopic ACL reconstruction using either HT or QT autograft and a minimum of 2 years of follow-up were included. Patients with concomitant meniscus, cartilage and MCL injury were also included. Patients undergoing a revision ACL reconstruction or undergoing a primary ACL reconstruction using a graft other than HT or QT autograft, and patients with a contralateral knee injury or ipsilateral osteoarthritis (Ahlback stage 2 or higher) were excluded. Patients were evaluated for pre-injury and 2-year follow-up Lysholm knee score, Tegner activity level, Visual Analog Scale (VAS) for pain, graft failure, quadriceps tendon rupture, and return to sport. Mann-Whitney test was used for unpaired samples, whereas the Friedman test was used for analyzing variables over time. The chi-square statistic test was used to determine differences in categorical data between groups RESULTS: The number of patients in the QT and HT groups was 85 and 143 respectively. The mean age was 54.4 [50-65] and 56.4 [50-65] for the QT and HT groups respectively, 49% and 51% were males in the QT and HT groups respectively. The two groups did not differ significantly in terms of age, gender, time from injury to surgery and concomitant injuries. No significant differences were found in the pre-injury patient-reported outcome scores (PROMs) as Lysholm, Tegner activity level and VAS for pain between the two groups (p>0.05). At the 2-year follow-up, Lysholm knee score, Tegner activity level and VAS for pain improved to pre-injury level and no significant difference was noted between pre-injury and 2-year follow-up functional scores between the two groups (p>0.05). Furthermore, at the 2-year follow-up, Lysholm score, and VAS didn't show significant differences between QT and HT groups. (p=.390; p= .131). Similarly, no differences have been reported in Tegner activity level scores between HT and QT groups at 2 years of follow-up. No significant differences in terms of minimal clinically important difference (MCID) have been detected between the two groups for Lysholm and Tegner activity scores (p = 0.410 and p = 0.420 for Lysholm score and Tegner activity level score respectively). The two groups did not differ in terms of patient's percentage of sports participation at baseline, and 2 years of follow-up (p>0.05). A significant decrease (p=0.01) in skiing/snowboarding was reported in the HT group at a 2-year follow-up compared to baseline [116 (81%) vs 98 (69%)]. No case of graft failures and quadriceps tendon rupture was reported in either of the groups. CONCLUSION: Arthroscopic ACL reconstruction by using HT or QT autograft in athletically active older than 50 years patients provide satisfactory patient-reported functional outcomes and allows recovery of the pre-injury level of activity.

Conversion to knee arthroplasty is more common after meniscectomy than meniscus repair in patients older than age 40.

PURPOSE: To describe rates of conversion to unicompartmental or total knee arthroplasty (KA) in patients over the age of 40 years (at initial surgery) after partial meniscectomy (ME) or meniscal repair (MR). METHODS: Patients over the age of 40 undergoing isolated ME or MR between 2016 and 2018 were extracted from a single healthcare provider database. Data on patient characteristics, type of initial surgery, number of returns to the operating room, as well as performed procedures, including conversion to KA, were recorded. Comparative group statistics as well as a Kaplan-Meier survival rate analysis were performed. RESULTS: A total of 3638 patients (47.8% female) were included, with 3520 (96.8%) undergoing ME and 118 (3.2%) MR. Overall, 378 (10.4%) patients returned to the OR at an average of 22.7 ± 17.3 months postoperatively. Conversion to KA was performed more frequently in patients after primary ME (n = 270, 7.7%) compared to those with MR (2.5%, n = 3, odds ratio [OR]: 3.2, p = 0.03). Compared to ME (2.3%, n = 82), two times as many patients undergoing MR returned for subsequent meniscus surgery (MR: 5.9%, n = 7, OR: 2.6, p = 0.02). Time from primary surgery to KA (ME: 22 ± 17 months, MR: 25 ± 15 months, p = 0.96) did not differ between the treatment groups. Survivorship was 95% for ME and 98.2% for MR after 24 months (p = 0.76) and 92.5% and 98.2% after 60 months (p = 0.07), respectively. CONCLUSION: The overall reoperation rate after meniscal surgery was 10.4% in patients over the age of 40 years. Patients treated with primary ME have over three times higher odds to undergo subsequent KA compared to those treated with MR. However, patients with primary MR have a higher rate of subsequent meniscus surgery compared to those undergoing primary ME. This information is important when considering and treating a patient over the age of 40 and meniscal injury. LEVEL OF EVIDENCE: Level III study.

Retrospective evaluation of radiological and clinical outcomes after surgical treatment of proximal femoral fractures utilizing PFNA and PFNA augmented.

INTRODUCTION: The primary aim of this study was to evaluate the clinical and radiological outcomes after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA), with the main focus on complications and reoperations. The secondary aim was to compare the outcomes of patients with and without cement augmentation of the cephalomedullary nails. MATERIALS AND METHODS: All patients with an acute proximal femoral fracture consequently treated with a PFNA between January 2011 and Dezember  2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative radiographs were used to determine the position of the implant, and any migration, via Tip-Apex-Distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated according to Baumgaertners criteria. RESULTS: Two hundred sixty-four consecutive patients (mean age 78.8 ± 12.0; 73.1% female) were included. The predominant OTA/AO fracture classification was 31A1 (153 cases, 58.0%). The average duration of surgery was 63.1 ± 28.0 min and showed no significant differences between PFNA and PFNA with augmentation. The implant positioning was rated as good in 222 cases (84.1%). Two hundred sixty-three patients (99.6%) showed evidence of healing within the time frame of three months postoperatively, one case of delayed union healed after secondary dynamization. During the observational period, 18 patients (6.8%) required a total of 23 additional surgeries. Overall, a lower reoperation rate was observed following the use of the augmentation option (2/86 patients (2.3%) vs. 16/178 patients (9.0%), p = 0.04). In particular, there were no cases of cut-out or cut-through among patients who underwent augmentation as part of osteosynthesis. CONCLUSIONS: Overall reoperation rate after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA) was 6.8%, with 23 additional surgeries performed in 18 patients. The usage of the PFNA with augmentation showed equally good implant positioning, excellent healing rates and fewer postoperative complications compared to the PFNA implant alone with a similar overall duration of surgery.

PEEK Interference Screws Show Significant Tunnel Enlargement After ACL Reconstruction and is Comparable to Adjustable-Length Loop Cortical Button Fixation.

Background: It is unclear whether the use of polyetheretherketone (PEEK) interference screws for anterior cruciate ligament (ACL) reconstruction leads to postoperative tunnel enlargement. Femoral tunnel enlargement was further compared with adjustable-length loop cortical fixation. Methods: Eighteen patients with ACL reconstruction using hamstring grafts were retrospectively divided into two groups. Eleven patients were treated with the ACL reconstruction technique using a PEEK interference screw for femoral graft fixation. Seven patients received adjustable-length loop cortical buttons for femoral fixation. Tibial ACL graft fixation was performed using PEEK interference screws. Tunnel volume changes were assessed using computed tomography (CT) scans performed after surgery (100%) and after 1 year. The maximal tunnel diameter was measured. Results: The group with femoral screw fixation showed a mean tunnel volume change of 108.15 ± 13.7% on the tibial side and 124.07 ± 25.38% on the femoral side. The group with femoral button fixation showed a tunnel volume change of 111.12 ± 12.72% on the tibial side and 130.96 ± 21.71% on the femoral side. The differences in femoral tunnel volume changes were not significant (P = 0.562). Femoral tunnels with PEEK screw fixation showed significantly larger diameter after 12 months in comparison with button fixation (13.02 ± 1.43 mm vs. 10.46 ± 1.29 mm, P < 0.001). Conclusions: PEEK interference screws were associated with significant tibial and femoral tunnel enlargement. Femoral tunnel enlargement was comparable between PEEK interference screws and button fixation. Final femoral tunnel diameter was significantly larger with PEEK screw fixation in comparison to button fixation.

Noninvasive and Reliable Quantification of Anteromedial Rotatory Knee Laxity: A Pilot Study on Healthy Individuals.

BACKGROUND: Anteromedial rotatory instability (AMRI) of the knee is a complex and severe condition caused by injury to the anterior cruciate ligament and/or the medial collateral ligament. Clinical studies dealing with AMRI are rare, and objective measurements are nonexistent. PURPOSE/HYPOTHESIS: The objectives of this study were, first, to quantify anteromedial rotatory knee laxity in healthy individuals using a noninvasive image analysis software and, second, to assess intra- and interrater reliability and equivalence in measuring anteromedial knee translation (AMT). It was hypothesized that AMT could be reliably quantified using a noninvasive image analysis software. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This prospective proof-of-concept study included healthy individuals aged 16 to 40 years with no history of knee injury or surgery. Three adhesive surface markers were placed on predefined landmarks on the medial side of the knee. Three independent investigators examined anteromedial rotatory knee laxity with an anterior drawer test in different tibial rotations (neutral tibial rotation, 15° of external tibial rotation, and 15° of internal tibial rotation). The entire examination of each knee was recorded, and AMT including the side-to-side difference (SSD) was assessed using a freely available and validated image analysis software (PIVOT iPad application). Group comparisons were performed using a 1-way analysis of variance with Bonferroni-adjusted post hoc analysis. Intraclass correlation coefficients (ICCs) were calculated to assess inter- and intrarater reliability of AMT measurements. Equivalence of measurements was evaluated using the 2 one-sided t-test procedure. RESULTS: Anteromedial rotatory knee laxity was assessed in 30 knees of 15 participants (53% male) with a mean age of 26.2 ± 3.5 years. In all 3 raters, the highest AMT was observed in neutral tibial rotation (range of means, 2.2-3.0 mm), followed by external tibial rotation (range of means, 2.0-2.4 mm) and internal tibial rotation (range of means, 1.8-2.2 mm; P < .05). Intrarater reliability of AMT (ICC, 0.88-0.96) and SSD (ICC, 0.61-0.96) measurements was good to excellent and moderate to excellent, respectively. However, interrater reliability was poor to moderate for AMT (ICC, 0.44-0.73) and SSD (ICC, 0.12-0.69) measurements. Statistically significant equivalence of AMT and SSD measurements was observed between and within raters for almost all testing conditions. CONCLUSION: Anteromedial rotatory knee laxity could be quantified using a noninvasive image analysis software, with the highest AMT observed during neutral tibial rotation in uninjured individuals. Reliability and equivalence of measurements were good to excellent within raters and moderate between raters.

Revision ACL reconstruction in female athletes: current concepts.

The challenge of revision anterior cruciate ligament (ACL) reconstruction lies in its complexity, varied presentation, and technical intricacies. A successful ACL reconstruction should allow patients to safely return to preinjury activities. However, it is only sometimes simple, and many risk factors and concurrent pathologies come into play. Evaluating and analysing the cause of failure and associated conditions is paramount to addressing them effectively. Despite a plethora of research and improvements in knowledge and technology, e gaps exist in issues such as optimal techniques of revision surgery, graft options, fixation, concurrent procedures, rehabilitation and protocol for return to sports of high-level athletes. Female athletes need additional focus since they are at higher risk of re-injury, suboptimal clinical outcomes, and lower rates of return to sport following revision reconstruction. Our understanding about injury prevention and the protection of ACL grafts in female athletes needs to be improved. This review focuses on the current state of revision ACL surgery in female athletes and provides recommendations and future directions for optimising outcomes in this high-risk group.

Slope Osteotomies in the Setting of Anterior Cruciate Ligament Deficiency.

➤ Posterior tibial slope (PTS) of ≥12° represents an important risk factor for both anterior cruciate ligament (ACL) injury and ACL reconstruction failure.➤ PTS measurements can significantly differ on the basis of the imaging modality and the measurement technique used. PTS should be measured on strictly lateral radiographs, with a recommended proximal tibial length of 15 cm in the image. The PTS measurement can be made by placing 2 circles to define the proximal tibial axis, 1 just below the tibial tubercle and another 10 cm below it. PTS measurements are underestimated when made on magnetic resonance imaging and computed tomography.➤ Slope-reducing osteotomies can be performed using a (1) supratuberosity, (2) tubercle-reflecting transtuberosity, or (3) infratuberosity method. The correction target remains a topic of debate. Although it is controversial, some authors recommend overcorrecting the tibial slope slightly to a range of 4° to 6°. For instance, if the initial slope is 12°, a correction of 6° to 8° should be performed, given the target tibial slope of 4° to 6°.➤ Clinical outcomes following slope-reducing osteotomies have been favorable. However, potential complications, limited data with regard to the impact of slope-reducing osteotomies on osteoarthritis, and uncertainty with regard to the effects on the patellofemoral joint are notable concerns.➤ Patients with complex deformities may need biplanar osteotomies to comprehensively address the condition.

Injury Incidence, Outcomes, and Return to Competition Times after Sports-Related Concussions during One Professional Ice Hockey Season: A Prospective Cohort Study.

OBJECTIVE: The objective of this study was to analyze the incidence and characteristics of sports-related concussions (SRCs) for a professional ice hockey team during one regular season in the International Central European Hockey League. BACKGROUND: Repeated concussions are a common cause of long periods of absence in team contact sports, with a wide range of potential short- and long-term consequences for the affected athlete. Questions mainly regarding early diagnosis and ideal follow-up treatment remain unanswered, especially regarding the timing of return to sports (RTS). METHOD: A prospective data analysis for a professional ice hockey team during a regular season was conducted. Firstly, concussions per 1000 athlete exposure (AE) and average time loss due to SRC were calculated. Secondly, the data from ImPACT Applications were analyzed for those players who were diagnosed with an SRC. RESULTS: Five SRCs were evaluated during the regular season, which resulted in 1.35 concussions/1000 AEs, a maximum of 17 missed games, and a median of three games per SRC. The average symptom count was 9.6, with the most common symptoms being headache, sensitivity to light, and dizziness. CONCLUSIONS: SRCs sustained in professional ice hockey are a common in-competition injury, while practices play a subsidiary role. The duration of RTS is highly individual and can be associated with symptoms lasting days to months.

Triple Hybrid Tibial Anterior Cruciate Ligament Graft Fixation.

Optimal graft fixation in anterior cruciate ligament reconstruction is critical. Several direct and indirect methods of graft fixation exist, each with advantages and disadvantages. This Technical Note describes a tibial hybrid anterior cruciate ligament graft fixation technique combining direct and indirect fixation methods, including autologous bone augmentation of the drill tunnel using cancellous bone fragments.