Modern multiligament knee injury surgical reconstruction techniques can achieve excellent knee function and patient satisfaction, with low complication rates.

PURPOSE: To report on the recovery of strength and functional capacity symmetry following multiligament knee surgical reconstruction (MLKR), as well as the capacity of athletes to return to sport. METHODS: This prospective cohort study recruited 47 patients undergoing MLKR between February 2018 and July 2021. Forty patients had full outcome assessment postoperatively at 6, 12 and 24 months and were included in the analysis, 75% were knee dislocation one injuries and 60% were injured playing sport. Patient-reported outcome measures (PROMs) assessed included the International Knee Documentation Committee score, the Knee Outcome Survey, the Lysholm Knee Score and the Tegner Activity Scale (TAS). Patient satisfaction was also assessed. Objective assessment included assessment of active knee flexion and extension range of motion (ROM), the single (single horizontal hop for distance [SHD]) and triple (triple horizontal hop for distance [THD]) hop tests for distance and peak isokinetic knee flexor/extensor torque. RESULTS: All PROMs significantly improved (p < 0.001) from presurgery to 24 months postsurgery. At 24 months, 70% of patients were satisfied with their sports participation. Active knee flexion (p < 0.0001) and extension (p < 0.0001) ROM significantly improved over time, as did the limb symmetry indices (LSIs) for the SHD (p < 0.0001), THD (p < 0.0001), peak knee extensor (p < 0.0001) and flexor (p = 0.012) torque. While LSIs for the SHD, THD and knee flexor strength tended to plateau by 12 months, knee extensor strength continued to improve from 12 to 24 months. CONCLUSIONS: The majority of patients undergoing modern MLKR surgical techniques and rehabilitation can achieve excellent knee function, with low complication rates. LEVEL OF EVIDENCE: Level IV.

Patients undergoing multiligament knee reconstruction injured during pivoting sports demonstrate similar clinical, functional and return to sport outcomes by 2 years compared with those undergoing anterior cruciate ligament reconstruction.

PURPOSE: This study investigates the clinical and activity-based outcomes after anterior cruciate ligament reconstruction (ACLR) versus multiligamentous knee reconstruction (MLKR) following a pivoting sports injury. METHODS: Fifty MLKR patients were included, of which 20 (40%) were injured during pivoting sports. A further 50 patients undergoing ACLR following an injury during pivoting sports were consecutively recruited for comparison. Patients were assessed before the surgery and at 6-, 12- and 24 months with patient-reported outcome measures (PROMs) including the International Knee Documentation Committee (IKDC) form, Tegner activity scale (TAS) and anterior cruciate ligament return to sport after injury (ACL-RSI) score. Knee movement, the single (SHD) and triple (THD) hop tests for distance, and peak isokinetic knee extensor and flexor strength were assessed, with Limb Symmetry Indices (LSIs) calculated. Outcomes were compared across groups: (1) ACLR (n = 50), (2) MLKR (n = 50) and (3) MLKR due to pivoting sport injury (n = 20). RESULTS: IKDC, TAS and ACL-RSI scores remained lower (p < 0.05) in the full MLKR versus ACLR cohort at all timepoints. Comparing the ACLR and MLKR cohort that had injuries specifically during pivoting sports, the IKDC (p < 0.001) and TAS (p = 0.009) were higher in the ACLR group at 6 months, and the ACL-RSI was higher at 6 (p < 0.001) and 12 (p = 0.007) months, there were no further differences. Hop and knee extensor strength LSIs were lower (p < 0.05) in the full MLKR (versus ACLR) cohort at all timepoints (apart from the 24-month SHD LSI). However, the ACLR group only demonstrated greater LSIs than the pivoting sport MLKR for the SHD at 6 months (p < 0.001), and knee extensor strength at 6 (p < 0.001) and 12 (p < 0.001) months. CONCLUSIONS: While the recovery of patients undergoing MLKR due to a pivoting sports injury is delayed compared with their ACLR counterparts, the clinical outcome and activity profile are similar by 24 months. LEVEL OF EVIDENCE: Level IV.

The distance between the fibular collateral ligament tunnel and the common peroneal nerve allows a posterolateral corner reconstruction without neurolysis.

PURPOSE: The most popular knee posterolateral corner (PLC) reconstruction techniques describe that a common peroneal nerve (CPN) neurolysis must be done to safely address the posterolateral aspect of the knee. The purpose of this study was to measure the distance between the CPN and the fibular insertion of the FCL in different degrees of knee flexion in cadaveric specimens, to identify if tunnel drilling could be done anatomically and safely without a CPN neurolysis. METHODS: Ex vivo experimental analytical study. Ten fresh frozen human knees were dissected leaving FCL and CPN in situ. Shortest distance from the centre of the FCL distal tunnel and CPN was measured (antero-posterior and proximal-distal wire-nerve distances) at 90°, 60°, 30°, and 0° of knee flexion. Measurements between different flexion angles were compared and correlation between knee flexion angle and distance was identified. RESULTS: The mean distance between the FCL tunnel and the CPN at 90° were 21.15 ± 6.74 mm posteriorly (95% CI: 16.33-25.97) and 13.01 ± 3.55 mm distally (95% CI: 10.47-15.55). The minimum values were 9.8 mm posteriorly and 8.9 mm, respectively. These distances were smaller at 0° (p ≤ 0.017). At 90° of knee flexion, the mean distance from the fibular tip to the CPN distally was 23.46 ± 4.13 mm (20.51-26.41). CONCLUSION: Anatomic localization and orientation of fibular tunnels can be done safely while avoiding nerve neurolysis. Further studies should aim to in vivo measurements and results.

Utilization of the gastrocnemius flap for post-traumatic knee reconstruction: a systematic review.

PURPOSE: High-energy injuries to the knee may lead to extensive soft tissue loss, fractures, and potential loss of extensor function. The gastrocnemius flap is a prominent reconstructive option for patients with injuries involving the knee and proximal third of the lower extremity. To the best of our knowledge, there has not been an informative review that has evaluated outcomes of patients who have undergone post-traumatic knee reconstruction with a pedicled medial or lateral gastrocnemius flap. The goal of this study is to assess outcomes in patients who have undergone gastrocnemius flap reconstruction after traumatic injuries to the knee. METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gastrocnemius, flap, knee, and traum*. RESULTS: A total of 204 studies were imported for screening, from which five papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were case series followed by retrospective chart reviews. In total, 43 patients with traumatic soft tissue knee defects were included with an average patient age of 27.28 years. All patients had successful and clinical viable flaps post-operatively, and there were a total of five patients who had complications. CONCLUSION: The gastrocnemius flap has demonstrated to be an effective option for individuals undergoing post-traumatic knee reconstruction. Infection rates, loss of mobility, and scarring represent a minority of complications that may be seen when this reconstructive technique is utilized. Still, additional randomized controlled trials and retrospective studies are required in order to further evaluate for other potential complications that may occur in this patient population.

Germany has a high demand in meniscal allograft transplantation but is subject to health economic and legal challenges: a survey of the German Knee Society.

PURPOSE: To determine the current status and demand of meniscal allograft transplantation (MAT) in Germany among members of the German Knee Society (= Deutsche Kniegesellschaft; DKG). METHODS: An online survey was conducted between May 2021 and June 2021 and sent to all members of the DKG. The survey questionnaire consisted of 19 questions to determine the demand and technical aspects of MAT among the participants and to identify areas of improvement in MAT in Germany. RESULTS: Overall, 152 participants, 136 (89.5%) from Germany, 8 (5.3%) from Switzerland, 6 (4.0%) from Austria, and 2 (1.3%) from other countries completed the online survey, with the majority working in non-academic institutions. According to the regulations of the DKG, 87 (57.2%) participants were board certified as specialized knee surgeons and 97 (63.8%) worked primarily in the field of orthopedic sports medicine. MAT was considered clinically necessary in Germany by 139 (91.5%) participants. Patient age (83.6%), post-meniscectomy syndrome in isolated lateral (79.6%) and medial (71.7%) meniscus deficiency, and functional and athletic demands (43.4%) were the most important determinants to consider MAT in patients. Participants reported that reimbursement (82.9%), jurisdiction over the use of donor grafts (77.6%), and the availability of meniscal allografts (76.3%) are the main challenges in performing MAT in Germany. The most frequently used meniscal allograft types by 54 (35.5%) participants who had already performed MAT were fresh-frozen grafts (56.6%), peracetic acid-ethanol sterilized grafts (35.9%), and cryopreserved grafts (7.6%). Participants reported to perform suture-only fixation more often than bone block fixation for both medial (73.6% vs. 22.6%) and lateral (69.8% vs. 24.5%) MAT. CONCLUSION: More than 90% of the responding members of the DKG indicated that MAT is a clinically important and valuable procedure in Germany. Reimbursement, jurisdiction over the use of donor grafts, and the availability of meniscal allografts should be improved. This survey is intended to support future efforts to facilitate MAT in daily clinical practice in Germany. LEVEL OF EVIDENCE: Level V.

Analysis of Hip and Knee Reconstruction Questions on the Orthopedic In-Training Examination.

BACKGROUND: It is vital for orthopedic residents and residency programs to have a current understanding of the materials and resources utilized on the Orthopedic In-Training Examination (OITE) to tailor resident educational curricula accordingly. This study presents an updated analysis of the hip and knee section of the OITE. METHODS: All OITE questions related to hip and knee reconstruction over six examinations between 2014 and 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, resident performance, and references. RESULTS: There were 166 hip and knee reconstruction questions of 1600 OITE questions (10.4%) over a six-year period. The most commonly tested topics include mechanical properties of total knee and hip implants (10.8%), instability after THA (10.8%), periprosthetic fracture (10.2%), and prosthetic joint infection (10.2%). A total of 362 references were cited from 68 different sources. The most common sources were JOA, JBJS, JAAOS, and CORR, which were collectively responsible for 68% of all citations. There was an average publication lag of 7.1 years, with 75% of all citations falling within 10 years of the question date. Compared with a prior analysis from 2005 and 2009, there were significantly more complex multistep questions regarding treatment and fewer one-step knowledge recall questions (P = .003). Similarly, recent tests had significantly more questions involving interpretation of radiographs (55%, P < .001) and advanced imaging (9.6%, P < .001), compared with a decade ago. CONCLUSIONS: The OITE continues to evolve over time, incorporating recent literature and topics. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE hip and knee section.

Use of autogenous onlay bone graft for uncontained tibial bone defects in primary total knee arthroplasty.

BACKGROUND: The use of autogenous bone graft is a well-known technique for reconstruction of tibial bone defects in primary total knee arthroplasty (TKA). In cases where the size of the bone graft is inappropriate, the stability of bone graft fixation and subsequent bone graft to host bone incorporation may be compromised. We describe a simple and reliable technique of reconstruction in a proximal tibia bone defect at the time of primary TKA by using autogenous onlay bone graft (AOBG). METHODS: Records were reviewed of 19 patients (mean age, 72 years) who underwent primary TKA using AOBG without the additional allogenous bone or metal augments, between August 2013 and August 2014. RESULTS: Mean Knee Society score (KSS) in the 22 knees was significantly higher postoperatively than preoperatively (92 ± 4 vs. 30 ± 7, P < 0.001). The mean range of motion (ROM) in the 22 knees, which was 106 ± 12° preoperatively, improved to 112 ± 10° at last follow-up, but this difference was not significant (P = 0.32). No migration of implants and presence of radiolucent lines at the bone cement-prosthesis interface were observed. Furthermore, the serial radiographs of 19 patients had a mean time of 3.2 months (range, 2.7-4.4 months) for solid union with cross trabeculation between the proximal tibial bone and graft. CONCLUSIONS: This simple AOBG supplement technique may biologically promote graft to host bone healing by enhancing fixation stability without the additional fixatives and assist the surgeon in managing the varying nature of uncontained bone defects. TRIAL REGISTRATION: Trial registration number: KCT0002328 , May 15, 2017.

Feasibility of establishing an Australian ACL registry: a pilot study by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

PURPOSE: Rupture of the anterior cruciate ligament (ACL) is a common and debilitating injury that impacts significantly on knee function and risks the development of degenerative arthritis. The outcome of ACL surgery is not monitored in Australia. The optimal treatment is unknown. Consequently, the identification of best practice in treating ACL is crucial to the development of improved outcomes. The Australian Knee Society (AKS) asked the Australian Orthopaedic Association (AOA) to consider establishing a national ACL registry. As a first step, a pilot study was undertaken by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to test the hypothesis that collecting the required information in the Australian setting was possible. METHODS: Surgeons completed an operative form which provided comprehensive information on the surgery undertaken. Patients provided pre- and post-operative questionnaires including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Marx Activity Scale (MA Scale). The number of ACL procedures undertaken at each hospital during the recruitment period was compared against State Government Health Department separation data. RESULTS: A total of 802 patients were recruited from October 2011 to January 2013. The overall capture rate for surgeon-derived data was 99%, and the capture rate for the pre-operative patient questionnaire was 97.9%. At 6 months, patient-reported outcomes were obtained from 55% of patients, and 58.5% of patients at 12 months. When checked against State Government Health Department separation data, 31.3% of procedures undertaken at each study hospital were captured in the study. CONCLUSION: It is possible to collect surgeon-derived and pre-operative patient-reported data, following ACL reconstruction in Australia. The need to gain patient consent was a limiting factor to participation. When patients did consent to participate in the study, we were able to capture nearly 100% of surgical procedures. Patient consent would not be an issue in for a national registry where inclusion is automatic unless the patient wishes to opt out. The collection of post-operative patient-reported outcome measures (PROMs) is more problematic, due to an insufficient proportion of individuals providing patient-reported outcomes. Alternative outcome measures are required for an ACL registry in Australia to be successfully implemented. LEVEL OF EVIDENCE: Diagnostic, Level III.

Does age predict outcome after multiligament knee reconstruction for the dislocated knee? 2- to 22-year follow-up.

PURPOSE: The purpose of this study is to determine whether age is a predictor of clinical and functional outcomes in patients who sustained a knee dislocation (KD) and underwent multiligament knee reconstruction. It was hypothesized that increasing age will negatively affect patient outcome. METHODS: In total, 125 multiligament knee injuries (MLKI) associated with KD were surgically reconstructed between 1992 and 2013 and evaluated with IKDC and Lysholm scores at a median follow-up of 5 (range 2-22) years. Patient demographics including age were then analysed with respect to IKDC and Lysholm scores using rank sums and pair-wise rank sums analysis for continuous variables and Chi-square analysis for categorical variables. RESULTS: In total, 125 patients (96 males and 29 females) with a median age of 31 (range 11-62) years at the time of surgery were included. At final follow-up, patients ≤30 years old compared to >30 years old obtained higher IKDC (73.3 vs. 61.9; p = 0.01) and Lysholm scores (76.9 vs. 68.5; p = 0.04). No confounding variables including gender, injury mechanism, injury pattern, injuries to the peroneal nerve, popliteal artery, meniscus, or cartilage accounted for differences in outcome scores between the two groups. CONCLUSION: Based on current available literature, this study represents the largest cohort with the longest follow-up reported on MLKI to date. At intermediate- to long-term follow-up, patients >30 years of age that undergo multiligament knee reconstruction for KD have inferior IKDC and Lysholm scores compared to those ≤30 years of age. However, successful multiligament knee reconstruction can still be obtained in this age group. LEVEL OF EVIDENCE: IV.

Is bicortical femoral pin insertion safe for Image-based Robotic Knee Arthroplasty Surgery ? A comparative complications analysis in 970 Consecutive Cases.

OBJECTIVES: Limited data exists on complications associated with robotic image-based system in knee arthroplasty. This study aims to document complications in robotic arm-assisted knee arthroplasties, and evaluate the system's safety by comparing two femoral pin insertion methods: bicortical diaphyseal with additional stab wounds, and unicortical metaphyseal placement through the main incision. METHODS: All patients undergoing primary knee arthroplasty with the image-based robotic system (Mako, Stryker, Mako Surgical Corp., Fort Lauderdale, FL, USA) from 1st March 2021 to 31st January 2024 with a minimum follow-up of 2 months were included. Demographics, system and non-system-related complications, as well as outcomes were recorded. Complications were categorized as either major (requiring a second surgical intervention) or minor. RESULTS: A total of 970 consecutive cases (median age 69.3 years) were analyzed. The unicortical group comprised 651 cases, while the bicortical group 319. The incidence of non-system-related complications was 2.37%, with the most common being joint stiffness (10 cases; 1.03%), followed by lateral femoral condyle fracture (4;0.41%). The overall incidence of system-specific complications was 1.03%. Pin-related femoral fractures occurred in 0.2% of cases, all postoperatively and in the unicortical group. There was no statistically significant difference between the femoral pin insertion-related complication rates among the two groups (0.3% in the unicortical, compared to 0% in the bicortical group; p-value= 0.3). Complications included tibia fracture (0.1%), delayed wound healing (0.2%), superficial wound infection (0.1%), tibia osteomyelitis (0.1%), and "exostosis" (0.2%). The major complications rate was 0.3% and minor 0.7%. CONCLUSIONS: Minimal system-specific overall complications indicate that robotic arm-assisted surgery is safe. The bicortical diaphyseal femoral pin insertion method does not increase the complication rates compared to the unicortical metaphyseal method. LEVEL OF EVIDENCE: III.

Outcomes of Surgical Treatment for Multiligament Knee Injuries in a Cohort Including Competitive Athletes With Long-Term Follow-Up.

Background: There is a paucity of outcomes data on surgical reconstruction for multiligament knee injury (MLKI) in the orthopaedic literature. Purpose: To examine functional and return-to-sports (RTS) outcomes and revision rates after single-stage reconstruction for MLKIs in a cohort containing a large proportion of competitive athletes over a 20-year period. Study Design: Case series; Level of evidence, 4. Methods: We identified all patients at our institution who underwent surgical reconstruction for an anterior cruciate ligament (ACL) or bicruciate (ACL-posterior cruciate ligament) MLKI between 2001 and 2020 and had ≥2 years of postoperative outcome data. Patient-reported outcomes were evaluated using the International Knee Documentation Committee (IKDC) form, a surgical satisfaction survey, and questions about subsequent knee surgery and RTS administered via telephone. Summary statistics for all outcomes data were calculated, and predictors of IKDC scores at follow-up were examined using univariable linear regression. Results: Out of 151 patients eligible for this study, outcomes data were collected in 119 patients (79%). The mean follow-up time was 8.3 ± 4.4 years, and the mean IKDC score at follow-up was 79 ± 17. A total of 83 competitive athletes were included; 62 of these athletes attempted to return to preinjury sport. Among the 62 who attempted RTS, 50 (81%) were successful, and 12 were unable to return due to limitations from their surgery. At follow-up, 112 of the overall cohort of 119 patients (94%) were either satisfied or very satisfied with their surgical outcome, and 91% stated the surgery met or exceeded their expectations. In addition, 24% had subsequent ipsilateral knee operations after their index multiligament knee reconstruction. Older age at surgery and female sex were associated with worse IKDC scores at follow-up. Conclusion: Despite the severity of the injuries in our cohort, we found high levels of patient-reported function and a high rate of successful RTS in the competitive athletes. Older age and female sex were associated with worse patient-reported knee function at follow-up.

Long-term Outcomes of Multiligament Knee Injuries in American Football Players.

BACKGROUND: Long-term outcomes for isolated anterior cruciate ligament (ACL) reconstructions in competitive American football athletes are well reported in the literature, but little data currently exist regarding multiligament knee injury (MLKI) reconstruction outcomes. PURPOSE: To examine patient-reported and return-to-sport outcomes of competitive American football athletes who underwent primary, single-staged, multiligament knee reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We identified patients from our institution's prospectively collected data repository between 2001 and 2020 who underwent single-staged surgical reconstruction of an MLKI sustained during competitive participation in American football. We assessed patient-reported outcomes at a minimum of 2 years after surgery using the International Knee Documentation Committee (IKDC) Subjective Knee Form and questions regarding surgical satisfaction and return to sport. Successful return to sport was defined as a return to preinjury level of competition. We summarized all outcome data and compared outcomes between 2-ligament and >2-ligament groups and between ACL-only MLKI injury and bicruciate MLKI injury groups using independent t test for IKDC scores and chi-square test for return to sport. Additionally, we evaluated predictors of postoperative IKDC scores using linear regression and predictors of return to sport using logistic regression. RESULTS: Outcome data were successfully collected for 53 of 73 total eligible patients (73%; mean follow-up time, 7.7 ± 4.0 years; all male; mean age at surgery, 18.1 ± 2.7 years). The mean postoperative IKDC score was 84 ± 16. The most common level of preinjury competition was high school (n = 36; 68%), followed by college (n = 10; 19%). Seven patients did not return to sport competition at any level due to limitations from their knee surgery, and 82% of patients that attempted to return to preinjury level of sport were able to do so. A total of 50 patients (94%) were satisfied or very satisfied with their surgical outcome. The 2-ligament (n = 39) and >2-ligament (n = 14) groups did not significantly differ in IKDC scores (P = .96) or proportions with successful return to sport (P = .77). Similarly, the ACL-MLKI injury (n = 39) and bicruciate MLKI injury (n = 14) groups did not significantly differ in IKDC scores (P = .89) or proportions with successful return to sport (P = .77). Age and body mass index were not significantly associated with IKDC scores or successful return to sport at follow-up (all P > .05). CONCLUSION: This study may represent the largest cohort of competitive American football athletes evaluated for longitudinal outcomes after multiligament knee reconstruction. Despite the severity of these injuries, we found good knee-related function and that the large majority of athletes who attempted to return to sport were successful. The majority of athletes (94%) were satisfied with their operative treatment.

Validating a Novel 2D to 3D Knee Reconstruction Method on Preoperative Total Knee Arthroplasty Patient Anatomies.

BACKGROUND: As advanced technology continues to evolve, incorporating robotics into surgical procedures has become imperative for precision and accuracy in preoperative planning. Nevertheless, the integration of three-dimensional (3D) imaging into these processes presents both financial considerations and potential patient safety concerns. This study aims to assess the accuracy of a novel 2D-to-3D knee reconstruction solution, RSIP XPlan.ai™ (RSIP Vision, Jerusalem, Israel), on preoperative total knee arthroplasty (TKA) patient anatomies. METHODS: Accuracy was calculated by measuring the Root Mean Square Error (RMSE) between X-ray-based 3D bone models generated by the algorithm and corresponding CT bone segmentations (distances of each mesh vertex to the closest vertex in the second mesh). The RMSE was computed globally for each bone, locally for eight clinically relevant bony landmark regions, and along simulated bone cut contours. In addition, the accuracies of three anatomical axes were assessed by comparing angular deviations to inter- and intra-observer baseline values. RESULTS: The global RMSE was 0.93 ± 0.25 mm for the femur and 0.88 ± 0.14 mm for the tibia. Local RMSE values for bony landmark regions were 0.51 ± 0.33 mm for the five femoral landmarks and 0.47 ± 0.17 mm for the three tibial landmarks. The RMSE along simulated cut contours was 0.75 ± 0.35 mm for the distal femur cut and 0.63 ± 0.27 mm for the proximal tibial cut. Anatomical axial average angular deviations were 1.89° for the trans epicondylar axis (with an inter- and intra-observer baseline of 1.43°), 1.78° for the posterior condylar axis (with a baseline of 1.71°), and 2.82° (with a baseline of 2.56°) for the medial-lateral transverse axis. CONCLUSIONS: The study findings demonstrate promising results regarding the accuracy of XPlan.ai™ in reconstructing 3D bone models from plain-film X-rays. The observed accuracy on real-world TKA patient anatomies in anatomically relevant regions, including bony landmarks, cut contours, and axes, suggests the potential utility of this method in various clinical scenarios. Further validation studies on larger cohorts are warranted to fully assess the reliability and generalizability of our results. Nonetheless, our findings lay the groundwork for potential advancements in future robotic arthroplasty technologies, with XPlan.ai™ offering a promising alternative to conventional CT scans in certain clinical contexts.

Outcomes After Single-Stage Anatomic Multiligament Knee Reconstruction With Early Range of Motion in Adolescents.

Background: Multiligament knee injuries (MLKI), rare in adolescents, are challenging injuries that require complex surgical reconstruction. Historically, nonanatomic reconstructions have been associated with prolonged immobilization and failure to restore normal knee biomechanics, resulting in arthrofibrosis and high rates of graft failure. Purpose: To describe the clinical and patient-reported outcomes (PROs) for adolescent patients treated with single-stage anatomic multiligament knee reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A single-center retrospective study was performed of patients ≤18 years old who underwent reconstruction of MLKIs by a single surgeon between 2014 and 2019 using a single-stage anatomic technique, with protected weightbearing and early range of motion. Complications were defined as infection, arthrofibrosis, deep vein thrombosis (DVT) or pulmonary embolus, and secondary surgery. PROs, including the pediatric version of the International Knee Documentation Committee (Pedi-IKDC) and the Tegner activity score, were obtained at a minimum of 2 years postoperatively. Results: Included were 30 patients (21 male, 9 female; mean age, 15.4 years). The most common ligamentous reconstruction types were anterior cruciate ligament (ACL) + fibular collateral ligament (12 patients; 40%) and ACL + medial collateral ligament (9 patients; 30%). Three patients (10%) had secondary surgeries, including irrigation and debridement of a granuloma, a staged osteochondral allograft transplantation to a lateral femoral condyle impaction fracture, and repair of a medial meniscal tear and lateral femoral condyle fracture associated with new injuries 2 years after ACL + fibular collateral ligament reconstruction. Two patients (7%) developed arthrofibrosis and 1 patient (3%) developed DVT. PRO scores obtained at a mean of 37 months postoperatively included a mean Pedi-IKDC of 87 (range, 52-92) and a median highest Tegner score at any point postoperatively of 9 (range, 5-10). Of the patients who were athletes before their injury, 70% returned to the same or higher level of sport postoperatively. Conclusion: Reconstruction of MLKI in this series of adolescents with single-stage anatomic techniques and early range of motion resulted in low rates of secondary surgery, few complications, and good knee function as well as PRO scores at mean 3-year follow-up.

Diagnosis and management of METS-Stanmore Morse taper failure.

We describe clinical semiology in 6 cases of METS-Stanmore distal femoral Morse taper impaction failure: from obvious forms with intraprosthetic dislocation to chronic forms with less obvious symptoms: instability, piston sensation, rotational disorder in gait. The diagnostic procedure in chronic forms is described, notably with dynamic examination under fluoroscopy. Reduction and re-impaction by external maneuver can be attempted; in case of failure or of any suspicion of taper disassembly, the 2 modular implant components have to be replaced. Finally, we provide a review of the literature on this rare but serious complication. LEVEL OF EVIDENCE: IV.

Multiligament Knee Reconstruction of the ACL, PLC, and ALL in a Floating Knee: A Case Report.

Introduction: Ipsilateral fracture of the femur and tibia, known by the moniker "floating knee," is a serious injury that primarily results from high-energy trauma. Up to 53% of patients with floating knee injuries have concurrent ligamentous injuries, with the anterior cruciate ligament (ACL) as the most commonly affected ligament. Approximately 10% of multi-ligament knee injuries consist of injuries to both the ACL and posterolateral corner (PLC); however, the literature reporting the management of this patient population is sparse, particularly, with a lack of consensus on the timing and protocol of surgical treatment. Well-characterized treatment guidelines are needed for patients with concomitant floating knee and multi-ligament knee injuries. Case Report: A 26-year-old, previously healthy male involved in a high-speed motor vehicle collision presented with upper and lower extremity, skull, and facial fractures, sacropelvic dissociation, and epidural hematoma. Here we describe a rare instance of a floating knee with a multi-ligament knee injury treated through early reconstruction of the ACL, PLC, and anterolateral ligament following stabilization of long bone fractures. Post-injury day 18, the patient underwent single-stage reconstruction of his multi-ligament knee injury. The timing of this was chosen to allow for capsular scar formation to aid in arthroscopy. Conclusion: Our surgical algorithm consists of allograft reconstruction using an all-inside ACL technique and a modified anatomical PLC technique. We recommend early (1-3 weeks) surgical treatment of multi-ligament knee injuries for patients without a closed head injury; however, an individualized treatment approach should be sought, considering the severity of ligamentous injuries, pre-injury activity level, extent of soft-tissue damage, and the activity goals of the patient post-injury. In patients with floating knee injuries, the proposed surgical algorithm here may be utilized for successful multi-ligament knee injury reconstruction.

Race and Sex Disparities in Lower Extremity Total Joint Arthroplasty: A Retrospective Database Study.

INTRODUCTION: Total joint arthroplasty (TJA) is successful in improving health-related quality of life. However, outcomes vary in the literature due to modifiable and non-modifiable factors. Modifiable factors consist of body mass index (BMI), nutrition, and tobacco use. Non-modifiable risk factors include age, race, sex, and socioeconomic status. Prior literature has focused on racial disparities in terms of the utilization of lower extremity arthroplasty. The purpose of this study is to determine the effect of race and sex on the in-hospital complication rate, length of stay, and charges associated with primary TJA. METHODS: This retrospective cohort utilized complex survey data from the National Inpatient Sample (NIS) between 2016 and 2019. The use of the International Classification of Disease-10 Procedure Codes (ICD-10 PCS) for right hip, left hip, right knee, and left knee TJA yielded a preliminary total of 2,660,280 patients. The exclusion criteria were bilateral arthroplasty and concomitant unilateral hip and knee arthritis. Major complications were defined as acute myocardial infarction, cardiac arrest, pulmonary embolism, adult respiratory distress syndrome, stroke, shock, and septicemia. Odds ratio (OR) and beta coefficients were adjusted for age, sex, primary payer, hospital region, hospital teaching status, and year. Total charges were adjusted for inflation using the Consumer Price Index data reported by the US Bureau of Labor Statistics. RESULTS: A total of 2,589,510 patients met our inclusion criteria; 87.6%, 5.9%, 4.8%, 1.4%, and 0.3% of people were 'White', 'Black', 'Hispanic', 'Asian, or Pacific Islander', and 'Native American', as defined by the National (Nationwide) Inpatient Sample (NIS) Variable 'RACE'. Black individuals experienced a significantly greater major complication rate compared to White individuals (0.87% vs. 0.74%, OR 1.25, p-value = 0.0004). Black and Hispanic individuals experienced a significantly greater minor complication rate compared to White individuals (6.39% vs. 4.12%, odds ratio (OR) 1.61, p-value < 0.0001; 4.68% vs. 4.12%, OR 1.17, p-value < 0.0001). Black, Hispanic, Asian or Pacific Islander, and Native American individuals stayed, on average, 0.33, 0.19, 0.19, and 0.25 days longer than White individuals (2.78, 2.54, 2.55, 2.56 vs. 2.37 days, p<0.0001). None of these statistically significant differences exceeded the established minimal clinically important difference of two days. Black, Hispanic, and Asian or Pacific Islander patients were charged $5,751, $18,656, and $12,119 more than White patients ($72,122, $85,027, $78,490, and $59,297 vs. $66,371, p ≤ 0.0165). Native American patients were charged $7,074 less than White patients ($59,297 vs. $66,371, p < 0.0001). CONCLUSIONS: Black and Hispanic TJA patients may have higher complication rates than White TJA patients. The differences in length of stay between race groups may not affect outcomes. Hispanic patients received significantly more charges than White patients, and Native American patients received significantly fewer charges than White patients after controlling for non-modifiable risk factors. Addressing the charge disparities may reduce the total national cost burden associated with TJA. The present study highlights the need for further studies on healthcare outcomes related to race and sex.

Simultaneous ipsilateral knee dislocation and hip fracture: A case report.

Hip fracture is one of the main causes of medical attendance in trauma centers. By contrast, knee dislocation is a challenging and limb-threatening injury. We report a case of a 68-year-old male who sustained a simultaneous ipsilateral hip fracture and knee dislocation after a low-energy fall. Popliteal artery and common peroneal nerve injuries were associated. Knee dislocation treatment included closed reduction, external fixation and popliteal artery repair. Hip hemiarthroplasty was performed using a direct anterior approach. Revision multiligament knee reconstruction surgery was not considered. A rehabilitation program achieved a good long-term functional outcome. Simultaneous ipsilateral knee dislocation and associated proximal femoral injuries are rare and challenging, potentially requiring long-term staged management. The direct anterior approach to the hip is worth consideration when additional lower limb injuries are present, especially in the setting of a knee spanning external fixator.

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls.

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

Treatment of Knee Dislocation With Primary Repair and Suture Augmentation: A Viable Solution.

Background: Different surgical techniques have been described for the treatment of knee dislocation (KD). Nonoperative approaches are frequently combined with surgical reconstruction using auto- or allograft. Purpose: To evaluate the midterm results of primary surgical repair and suture augmentation to treat KD. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 patients (5 women, 17 men; mean age, 45 ± 15 years) with KD were evaluated at a mean of 49 ± 16 months after surgical treatment that included primary repair and suture augmentation. Magnetic resonance imaging, stress radiographs, and outcome scores were obtained at the follow-up. Clinical examination including hop tests and force measurements for flexion and extension was performed. Results: The mean difference in pre- to postinjury Tegner scores was -2 ± 1. The outcome scores showed mean values of 84 ± 15 (Lysholm), 73 ± 15 (International Knee Documentation Committee) and 65 ± 25 (Anterior Cruciate Ligament-Return to Sport after Injury scale). Compared with the uninjured knee, the range of motion of the injured knee was reduced by 21° ± 12°. Twelve patients felt fit enough to perform hop tests and showed a mean deficit of 7% ± 17%° compared with the uninjured leg. The mean force deficit was 19% ± 18% for extension and 8% ± 16% for flexion. Stress radiographs revealed an 11 ± 7-mm higher anteroposterior translation on the injured side. Four patients had secondary ligament reconstructions due to persistent instability and 7 underwent arthroscopic arthrolysis due to stiffness. A significant increase of osteoarthritis was found for the medial, lateral, and patellofemoral compartments (P = .007, .004, and .006, respectively). Conclusion: Primary repair and suture augmentation of KD led to satisfactory clinical midterm results despite persistent radiological instability and a significant increase in osteoarthritis. This technique allows the return to activities of daily living without subjective instability in most nonathletic patients. Secondary ligament reconstructions should be performed if relevant instability persists to decrease the risk of secondary meniscal and cartilage damage.