Low re-dislocation rate following Bereiter trochleoplasty for recurrent patellar instability with severe trochlear dysplasia.

PURPOSE: Trochlear dysplasia is an independent risk factor for recurrent patellar instability with evidence demonstrating its presence in up to 85% of patients with patellar instability. Severe trochlear dysplasia can be treated with trochleoplasty to improve engagement of the patella in the trochlear groove and prevent future dislocations. The aim of this study was to determine the clinical outcome of Bereiter trochleoplasty in patients with recurrent patellar instability and severe trochlear dysplasia. METHODS: This was a retrospective case series of all trochleoplasties performed in our institution from 2008-2019. All clinical records and pre-operative MRI scans were reviewed to assess for trochlear dysplasia, tibial tuberosity to trochlear groove distance (TTTG) and patella height using patella trochlear index (PTI). Trochlear dysplasia was classified using Dejour classification. Incidence of re-dislocation, infection, arthrofibrosis, chondral necrosis and re-operation were recorded. All patients were invited to complete a post-operative visual analog score for pain (VAS-P) and Banff Patella Instability Instrument (BPII). RESULTS: Fifty-eight trochleoplasties were performed in fifty patients during this period. All trochleoplasties were combined with additional procedures. 93% had concomitant medial patellofemoral ligament (MPFL) reconstructions and 47% had tibial tuberosity transfer. The mean follow-up period was 36.8 months. The rate of dislocation and arthrofibrosis were 5% each. There were no chondral necrosis or nonunion. The mean post-operative BPII was 58.4 and VAS-P was 30.4. CONCLUSIONS: Bereiter trochleoplasty, often combined with MPFL reconstruction and/or tibial tuberosity transfer results in low re-dislocation and complication rate. LEVEL OF EVIDENCE: IV.

Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris.

We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.

Excellent outcomes with combined single stage Physica ZUK medial unicompartment knee replacement and anterior cruciate ligament reconstruction results in young, active patients with instability and osteoarthritis with a mean follow up of 5 years.

BACKGROUND (INCLUDING THE AIM OF THE STUDY): Young and more active patients with medial compartment osteoarthritis (OA) in conjunction with anterior cruciate ligament (ACL) deficiency are difficult to treat. The aim of this study was to explore the outcomes of combined fixed bearing Physica ZUK medial unicompartmental knee replacement (UKR) (Lima Corporate, Udine Italy) with ACL reconstruction for patients presenting with isolated medial compartment OA and symptomatic ACL deficiency. METHODS: Patients who underwent simultaneous single stage ACL reconstruction and medial UKR between 2012 and 2020 by a single surgeon (GG) were included. Preoperative outcome measures including Lysholm, Tegner, Oxford Knee Score and VAS pain score were evaluated and were repeated postoperatively at the most recent follow up appointment. RESULTS: Twenty four patients underwent simultaneous combined ACL and ZUK Medial UKR with a mean follow up of 5.1 years. Significant improvements in Lysholm (p < 0.001), Tegner (p < 0.001), Oxford Knee Score (p < 0.001) and VAS pain scores (p < 0.001) were seen with this combined approach with all patients returning to sport. Two patients had a minor peri-operative complication, which was treated conservatively. There were no revision procedures, and no evidence of implant loosening, however one patient had deceased due to an unrelated illness. CONCLUSION: UKR combined with ACL reconstruction can be an effective treatment option for selected patients suffering from medial unicompartmental knee osteoarthritis and symptomatic ACL deficiency. This allowed active patients to return to sports, addressing both instability and OA pain in a specific patient population.

Management of mucoid degeneration of the anterior cruciate ligament: a systematic review.

PURPOSE: The purpose of this study was to investigate the outcomes of management of mucoid degeneration of the anterior cruciate ligament (MDACL) by performing a systematic review of methods of treatment that have been reported. METHODS: A systematic literature search in the databases MEDLINE, Embase, Google Scholar, Cochrane, ISI web of science and Scopus was performed through July 2020 by three independent reviewers. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42018087782). Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of nine studies were eligible for review. All nine studies assessed the outcome of arthroscopic debridement of MDACL. A total of 313 knees in 292 patients were included. The mean follow up ranged from 13 to 72 months. There was strong association between MDACL and chondral lesions (82%) and between MDACL and meniscal tears (69%). The rate of simultaneous meniscectomy ranged from 13 to 44%. Postoperative pain relief ranged from 53.8 to 95%. There was an improvement in postoperative range of motion and outcome scores (Lysholm and International Knee Documentation Committee scores and the Knee Injury and Osteoarthritis Outcome Score). Postoperative Lachman test was positive in 40% of patients, and 6% of patients had symptomatic instability. The mean MINORS score was 9.5 out of 16 (4-12). CONCLUSIONS: Arthroscopic debridement of the anterior cruciate ligament (ACL) results in satisfactory pain relief and improvement in knee outcome scores. Postoperative ACL laxity is common after arthroscopic ACL debridement, however, symptomatic instability is not. The need for delayed ACL reconstruction should be discussed preoperatively, especially if complete resection of the ACL is to be performed. LEVEL OF EVIDENCE: IV.

Does additional reconstruction of the anterolateral ligament during a primary anterior cruciate ligament reconstruction affect tibial rotational laxity - A case series.

BACKGROUND: The current evidence suggests that rotational stability in not restored in patients with anterior cruciate ligament (ACL) ruptures, despite reconstructive surgery. The graded pivot-shift is a useful clinical test to delineate extent of ligamentous laxity within the knee. Given its lateralised position, we hypothesized that reconstruction of the anterolateral ligament (ALL) would provide restraint to excessive internal rotation, restoring rotational stability. METHODS: 10 patients with MRI confirmed diagnosis of an isolated ACL rupture were included. Patients assigned a grade-3 pivot-shift underwent dual-ligament reconstruction for the ACL and ALL (Group 2), whilst patients with an absent pivot-shift, grade-1 or grade-2 underwent single ligament reconstruction for just the ACL (Group 1). Total range of rotation (TRR) was measured using a 3D-kinematic system at 30°,60°and 90° of knee flexion. Data was collected on the pathology-free contralateral normal knee (CNK), ACL-deficient knee (ADK) and the ACL-reconstructed knee (ARK). RESULTS: A statistically significant pre-operative difference in TRR between the CNK and ADK was noted between Group 1 and 2 (4.04° vs. 1.53°; p < 0.05). Postoperatively, both groups achieved a TRR that was either equivalent, or surpassed values that were observed on the CNKs. The absolute and percentage reduction in TRR at 30° of knee flexion was significantly higher in Group-2 compared to Group-1 (-8.15° vs. -2.96°; p < 0.001) and (28.04% vs. 13.31%; p < 0.001) respectively. CONCLUSION: Our findings are based primarily in anaesthetized patients, with kinematic values at time-zero postoperatively. Patients presenting with significant rotational instability following a primary ACL injury and assessed to have a grade-3 pivot-shift may benefit from dual-ligament reconstruction. Further research is required to assess long-term patient-centered clinical outcomes.

Failure of meniscal repair association with late anterior cruciate ligament reconstruction.

INTRODUCTION: Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It would be ideal to repair all meniscus tears but failure rate is high. AIM: Our objective was to assess the success of meniscus repair. METHOD: All consecutive patients between Jan 2009 to Dec 2013 were retrospectively analysed. RESULTS: 85 meniscus repairs were performed: 64 patients presented after 3 months (Group 1) and 21 patients had meniscus repair within 2 weeks. The failure rate group 1 was 23%-4.8% group 2 at a mean follow up of 11 months. CONCLUSION: Early meniscal repair had a higher success rate. Level III evidence.

All-inside meniscal repair surgery: factors affecting the outcome.

BACKGROUND: Meniscal injury is currently a well-recognized source of knee dysfunction. While it would be ideal to repair all meniscus tears, the failure rate is significantly high, although it may be reduced by careful selection of the patients. Our objective was to assess the outcome of meniscal repair surgery and the role of simultaneous reconstruction of the anterior cruciate ligament (ACL). MATERIALS AND METHODS: Retrospectively, all consecutive patients between January 2008 and 2011 who underwent meniscal repair were included. Patients were identified using the hospital database with diagnosis and procedure codes. Patient notes were reviewed, including details of the type of tear, chronicity, location, and surgery. We used symptomatic resolution as the outcome measure. RESULTS: 136 Meniscal repairs were performed in 122 patients with a mean age of 26.8 years. Mean follow-up duration was 9 months. 63 % of the patients underwent medial and 37 % underwent lateral meniscal repair, with failure rates of 19 % for medial and 12 % for lateral menisci. Ligament injuries were found in 61 % of the patients (n = 83). Failure of meniscal repair occurred in 14.5 % (n = 12) of the patients who had early ACL reconstruction and in 27 % (n = 22) of the patients who had delayed ACL reconstruction (p = 0.0006). The failure rate was found to be 13 % in patients who were younger than 25 years (61 %) and 15 % in patients who were older than 25 years (39 %). CONCLUSION: The success rate of meniscal repair was found to be significantly better when ACL reconstruction was performed simultaneously with meniscal repair. LEVEL OF EVIDENCE: Level IV.

Time delay between diagnosis and arthroscopic lavage in septic arthritis. Does it matter?

PURPOSE: Septic arthritis is a life-threatening emergency with high mortality of up to 11 %. We investigated if delay of arthroscopic lavage of infected major joints would have a bearing on the mortality and morbidity such as admission to an intensive care unit (ICU). METHODS: We retrospectively reviewed patients presenting with septic arthritis to two regional hospitals over a period of seven years from 1 January 2005 to 31 December 2011. We divided our sample of 82 patients into four groups based on the time delay between clinical diagnosis and arthroscopic lavage ranging from less than six hours to more than 24 hours. RESULTS: We determined that 35.4 % of patients had prosthetic joints. Knee joints were predominantly involved (74.4 %). Staphylococcus aureus was the most commonly isolated pathogen (41.5 %). There were ten (12.2 %) deaths and the same number of admissions to an ICU. Our study revealed there was no statistical significance between the time delay and mortality (P = 0.25) or ICU admission (P = 0.74) or the number of washouts (P = 0.08) in all four groups. CONCLUSIONS: Up to 48 hours delayed arthroscopic lavage for septic arthritis does not increase the risk of mortality. Further prospective large sample studies are recommended to investigate this and the risk of long-term morbidity.

Hip extension strength following hamstring tendon harvest for ACL reconstruction.

Hamstring autograft harvest for ACL reconstruction may have an effect on hip extension strength and this may be important especially in sports that involve high speed running such as soccer, rugby, American football and the sprint disciplines of track and field. This aspect of hamstring tendon harvesting has not been looked at before. We have performed a non-randomised prospective case control study comparing isokinetic hip extension strength following four strand semitendinosus and gracilis tendons (4SHS) and bone-patellar tendon-bone (BPTB) autografts in ACL reconstruction. Isokinetic hip extension was assessed at 3 and 12 months post-operatively using a Kin-Com machine at a speed of 30 degrees per second. Three months post-operatively there was a significant decrease (p<0.05) in the peak force of concentric hip extension in the 4SHS group. There was no evidence that hip extension is weaker following ACL reconstruction with 4SHS tendon autograft than ACL reconstruction with BPTB autograft at 12 months post-operatively. We find no contra-indication to the use of 4SHS tendon autografts in ACL reconstruction in patients who wish to preserve hip extension strength for their sporting activities.

Total knee arthroplasty after failed high tibial osteotomy long-term follow-up of matched groups.

Forty patients with 51 knee arthroplasties after high tibial osteotomy were compared with a matched group of patients with primary knee arthroplasties. Patients were matched according to length of follow-up, age, sex, prosthetic design, and surgeon. At an average of 12.6 years, the patients were reviewed and assessed clinically using the Hospital for Special Surgery scoring system. Radiologic assessment was also performed. Although the overall Hospital for Special Surgery scores showed no significant difference between the 2 groups, there were more patients in the osteotomy group with a poor result (P = .027), significantly reduced flexion (P = .006), and higher reoperation rate. There were more failures after high tibial osteotomy. Failures tend to occur in the medium to long term, emphasizing the importance of long-term follow-up.

Arthroscopically assisted ACL reconstruction. Is a drain necessary?

We report on the results of a prospective randomised controlled trial to evaluate the use of an intra-articular drain following arthroscopically assisted ACL reconstruction using patellar tendon autograft. Forty-nine patients were recruited for the trial and randomised into receiving or not receiving a drain following surgery. An independent observer who was blinded for the use of the drain assessed the knees for swelling, range of movement (ROM) and pain at 2, 4 and 6 weeks postoperatively. Muscle strength was assessed at 12 weeks following surgery using the KIN COM III isometric dynamometer. We found that the knees that were drained following surgery initially had less swelling and a better ROM. However, at 4 weeks this difference had disappeared. At 3 and 6 months, there was no functional difference between the two groups. We recommend that no drain be used following ACL reconstruction as removal of the drain is uncomfortable and carries theoretical and avoidable risks.