Analysis of the reliability of KEOPS version 2 for the measurement of coronal and sagittal parameters in spinal deformity.

BACKGROUND: The purpose of the study is to evaluate the updated version of this software in patients with various spinal deformity. METHODS: Sixty patients were included in this study and were divided into three categories: 20 patients with AIS, 20 patients with ASD, and 20 patients having undergone corrective surgery for spinal deformity. The measurements were performed by two senior and two junior orthopedic surgery residents, and were done at two points in time separated by a 3-week interval with the cases being randomized every time to reduce the risk of memory bias. Measured parameters included coronal, sagittal, global alignment parameters, and pelvic parameters. RESULTS: When assessing the inter- and intra-observer reliability across all the groups of patients, none of the coefficients was smaller than 0.8 with a very high level of agreement. The standard error ranged from 0.7° to 1.5° demonstrating a high level of accuracy. Fairly similar results were seen when the groups were divided into the three categories except for the post-operative groups where a strong and not perfect level of agreement was reported. CONCLUSION: This is the first study to assess the reproducibility of the new version of KEOPS, showing a very high agreement in all measurements. In the post-operative group, although it showed a strong agreement, the lower performance can be explained by the presence of surgical material making it harder to identify the anatomical landmarks accurately. Nevertheless, we can recommend the usage of this software in a clinical setting.

Ultrasound-guided electrocoagulation of neovascularisation for persistent patellar tendinopathy in athletes: a cohort study of 25 patients with a mean follow-up of 5 years from the SANTI Study Group.

Background: Patellar tendinopathy (PT) is a common condition characterised by persistent patellar tendon pain and dysfunction, particularly in athletes. Neovascularisation is frequently observed in the PT and is associated with increased pain. Ultrasound-guided electrocoagulation of neovascularisation has emerged as a minimally invasive alternative treatment for recalcitrant PT. Hypothesis/purpose: The purpose of this study was to evaluate the clinical outcomes of ultrasound-guided electrocoagulation of neovascularisation in athletes with persistent PT. Study design: Case series; level of evidence, IV. Methods: A retrospective analysis of prospectively collected data was performed on 25 athletes who underwent ultrasound-guided electrocoagulation of neovascularisation for recalcitrant PT. Clinical outcomes including complications, reinterventions and patient-reported outcome measures were recorded. Comparisons between variables were assessed using χ2 test or Fisher's exact test for categorical variables and Student's t-test or Wilcoxon test for quantitative variables. Results: 25 patients were included in the final analysis. 96% returned to their preoperative activity level at a mean of 3.8 months. At a mean follow-up of 5 years 4% did not receive significant benefit from electrocoagulation therapy. Significant improvements were observed in outcome measures, including the Victorian Institute of Sport Assessment Questionnaire for Patients with Patellar Tendinopathy, Kujala score, modified Blazina score and Visual Analogue Scale for pain. Conclusion: Ultrasound-guided electrocoagulation of neovascularisation for persistent PT in elite athletes resulted in a low complication rate, a high rate and rapid return to sport and a significant improvement in outcome measures.

Posterolateral Bundle Resection for an Anterior Cruciate Ligament Ganglion Cyst.

The incidence of intra-articular ganglion cysts of the anterior cruciate ligament (ACL) is low and symptomatic presentation of this pathology is even lower. Nevertheless, symptomatic cases pose a real challenge for the orthopaedic community, as no general consensus exists regarding the most appropriate treatment. The purpose of this Technical Note is to describe the surgical treatment of an ACL ganglion cyst by arthroscopic resection of the entire posterolateral bundle of the ACL in a figure-of-four position after conservative treatment has failed.

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

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

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

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

Single AnteroMedial Bundle Biological Augmentation: SAMBBA Plus Technique for Combined ACL Repair and Reconstruction.

This technical note presents the single-anteromedial bundle biological augmentation (SAMBBA)-plus technique, which is a combined anterior cruciate ligament (ACL) repair and ACL reconstruction. Preservation of the native ACL fibers improves vascularity by encircling the ACL graft with synovium that is abundant in vascular-derived stem cells. Retaining the proprioceptive fibers of the native ACL can improve the recovery of joint positioning.

Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group.

BACKGROUND: Bone-patellar tendon-bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS: The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non-graft rupture-related reoperation rates. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records. RESULTS: A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged <20 years were at a particularly high risk of graft ruptures compared with patients aged >30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar. CONCLUSION: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are among the most common knee injuries sustained in elite sport, and athletes generally undergo ACL reconstruction (ACLR) to facilitate their return to sport. ACL graft rupture is a career-threatening event for elite athletes. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the risk factors for graft failure in professional athletes undergoing ACLR. It was hypothesized that athletes who underwent combined ACLR with a lateral extra-articular procedure (LEAP) would experience significantly lower rates of graft rupture in comparison with those who underwent isolated ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Professional athletes who underwent primary ACLR with a minimum follow-up of 2 years were identified from the Santy database. Patients were excluded if they underwent major concomitant procedures, including multiligament reconstruction surgery or osteotomy. Further ipsilateral knee injury, contralateral knee injury, and any other reoperations or complications after the index procedure were identified by interrogation of the database and review of the medical notes. RESULTS: A total of 342 athletes with a mean follow-up of 100.2 ± 51.9 months (range, 24-215 months) were analyzed. Graft failures totaling 31 (9.1%) were reported, requiring revision surgery because of symptomatic instability. The rate of graft failure was significantly higher when ACLR was not combined with a LEAP (15.5% vs 6.0%; P = .0105) and in athletes aged 21 years or younger (13.8% vs 6.6%; P = .0290). A multivariate analysis was performed using the Cox model and demonstrated that athletes undergoing an isolated ACLR were at >2-fold risk of ACL graft rupture (hazard ratio [HR], 2.678 [1.173; 4.837], P = .0164) when compared with those undergoing a combined ACLR with a LEAP. Additionally, athletes aged ≤21 years were also at >2-fold risk of graft failure (HR, 2.381 [1.313; 5.463]; P = .0068) than those aged >21 years. Sex, sport, and graft type were not found to be significant risk factors for graft failure. CONCLUSION: Professional athletes undergoing isolated ACLR and aged ≤21 years are at >2-fold greater risk of graft failure. Orthopaedic surgeons treating elite athletes should combine an ACLR with a LEAP to improve ACL graft survivorship.

Management of the Failed First Revision ACL Reconstruction: Clinical Outcomes of Nonsurgical Management Versus Second Revision ACL Reconstruction From the SANTI Group.

BACKGROUND: The optimum management strategy after failure of revision anterior cruciate ligament reconstruction (RACLR) is not clearly defined. The literature evaluating differences in outcomes between surgical and nonsurgical management is sparse. PURPOSE/HYPOTHESIS: The purpose was to evaluate the outcomes of surgical versus nonsurgical management of failed first RACLR. It was hypothesized that the long-term clinical outcomes of second RACLR would be superior with respect to knee stability, return to sport, and patient-reported outcome measures when compared with nonsurgical treatment. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who experienced failure of first RACLR were evaluated. All participants followed the same rehabilitation protocol regardless of whether they underwent nonsurgical treatment or a second RACLR. Follow-up comprised regular clinical review and a standardized telephone interview at the end of the study period. Patient-reported outcome measures were recorded at the final follow-up. RESULTS: A total of 41 patients with a mean follow-up of 104 ± 52.7 months (range, 40-140 months) were evaluated. Of these, 31 underwent a second RACLR, and 10 patients chose nonsurgical treatment. There was a high rate of return to sport in both groups, but patients undergoing second RACLR had significantly better Tegner (6.35 vs 4.8; P = .012), Lysholm (88.5 vs 78.3; P = .0353), Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (72.6 vs 56.3; P = .0490), and KOOS Sport and Recreation scores (81.4 vs 62.5; P = .0033). Significantly more patients undergoing second RACLR achieved the Patient Acceptable Symptom State for KOOS Sport and Recreation than those who underwent nonsurgical management (74.2% vs 30%; P = .015). The most important predictor of failure to achieve a good/excellent Lysholm score in multivariate analysis was nonsurgical management (P = .0095). CONCLUSION: Both second RACLR and nonsurgical management of failed first RACLR were associated with high rates of return to sport. However, second RACLR was associated with significantly better functional outcome scores with respect to Tegner, Lysholm, KOOS Quality of Life, and KOOS Sport and Recreation scores compared to nonsurgical management. In addition, nonsurgical treatment was the only significant predictor of failure to achieve a good/excellent Lysholm score at the final follow-up, and this was likely a function of inferior knee stability in that group.

Combined Revision Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction.

There has been a substantial increase in the number of revision anterior cruciate ligament (ACL) reconstructions performed in the past decade. This Technical Note describes combined revision ACL and anterolateral ligament reconstruction using outside-in drilling, which avoids the need for 2-stage revision ACL reconstruction because it allows unconstrained anatomic placement.

How to Avoid Knee Tunnel Convergence When Performing a Modified Lemaire Extra-Articular Tenodesis.

There has been a significant increase in the number of anterior cruciate ligament (ACL) reconstruction (ACLR) procedures being performed with a lateral extra-articular procedure (LEAP). However, tunnel convergence in combined ACLR and LEAP techniques has been described and can lead to damage to the graft or graft failure. This technical note describes how to avoid knee tunnel convergence when performing a modified Lemaire extra-articular tenodesis using a knotless suture anchor.

Injury patterns among national-level athletes in Lebanon: a retrospective study.

OBJECTIVES: This study aims to assess the annual prevalence, associated factors, and characteristics of musculoskeletal disorders among Lebanese national-level athletes. METHODS: Lebanese athletes aged 18 and over and who competed in a top-level national championship during an entire athletics season were invited to participate in the study. Data were collected through questionnaire assessing self-reported injury during the past year. Injury, dependent variable of the study, was defined as a musculoskeletal condition that made the athlete partially or completely abstains from training or competition for a 1-week minimum injury period. RESULTS: Among the 250 eligible athletes, 210 (84.0%) (25.5±6.7 years) completed the questionnaire. The 1-year retrospective injury prevalence was 51.9% (95% confidence interval, 45.1%-58.7%). Injured athletes reported 150 injuries: 128 (85.3%) affected the lower extremities, and 111 (74.0%) occurred during training. The most common type was muscle cramps/spasm (n=53; 35.3%); and overuse (n=121; 80.7%) was the predominant cause. Athletes who mainly practiced endurance disciplines (-p-value=0.042), who participated in international athletics championships (-p-value=0.047), and who were taking chronic medications (-p-value=0.049) had more injuries in the past year. CONCLUSION: These findings may help inform potential injury prevention programs, which should target injuries affecting the lower extremities, and consider the factors associated with injury risk among Lebanese athletes.

Measurement of biceps tendon retraction after arthroscopic tenotomy.

BACKGROUND: One of the treatment options for long head of the biceps tendon (LHBT) pathology is tenotomy. To our knowledge, no study in the literature has evaluated the degree of retraction after tenotomy. The goals of this study were to determine the distance of this retraction and to identify its relationship with patient characteristics. METHODS: We conducted an observational prospective survey over a 3-month period among 30 patients operated on arthroscopically by the same surgeon between August 2018 and April 2019. A radiopaque device was introduced inside the LHBT before tenotomy. Radiographs were obtained to evaluate the distance of retraction on day 1, day 30, and day 90. RESULTS: Thirty patients were included, of whom 63.3% (19) were women. Surgery was performed for a rotator cuff tear in 10 patients (33.3%) and for subacromial impingement in the remainder of patients (66.7%) after failure of conservative management. The mean retraction of the LHBT (distance between the glenoid and clip) increased from 1.9 cm (day 1) to 3.5 cm (day 90). Three radiographic measurements were performed, and all 3 showed significant increases from day 1 to day 90. According to the Student t test, the mean retraction in the subacromial impingement group was significantly higher than that in the rotator cuff tear group on day 1, day 30, and day 90. Body mass index, younger age, sex, and dominant hand did not show any relation with LHBT retraction (P > .05). The mean LHBT retraction was significantly higher on day 90 in patients presenting with a positive Popeye sign (P < .05). CONCLUSION: At 3 months of follow-up, the mean LHBT retraction was 3.5 cm from the glenoid and 2.5 cm from the greater tuberosity. It dynamically increased from day 1 to day 90. The LHBT will retract and sit beyond the transverse humeral ligament in the bicipital groove. The LHBT retracts significantly more when early mobilization of the shoulder is allowed.