Supratubercle Anterior Closing Wedge Osteotomy: No Changes in Patellar Height and Significant Decreases in Anterior Tibial Translation at 6 Months Postoperatively.

BACKGROUND: Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope on increased anterior tibial translation and increased ACL graft forces. One potential concern in supratubercle anterior closing wedge proximal tibial osteotomy (ACW-PTO) for decreasing the posterior tibial slope is the risk of altering the patellar height. PURPOSE: To radiographically assess changes in (1) patellar height, (2) anterior tibial translation, and (3) posterior tibial slope after supratubercle ACW-PTO. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent supratubercle ACW-PTO by a single surgeon between July 2019 and June 2023 were included. Standardized lateral knee weightbearing radiographs to assess patellar height (via the Caton-Deschamps index), anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle, and posterior tibial slope were obtained at 4 time points (preoperatively and 1 day, 3 months, and 6 months postoperatively). Paired t test was used to compare differences between preoperative, 1-day, and 3- and 6-month values for patellar height as measured using the Caton-Deschamps index and for posterior tibial slope. Paired t test was also used to compare differences in the preoperative and 6-month postoperative values for anterior tibial translation. RESULTS: In 20 patients after ACW-PTO, the Caton-Deschamps index demonstrated a significant increase in patellar height on postoperative day 1 (P < .001) but no significant differences at 3 (P = .057) and 6 (P = .176) months postoperatively. Anterior tibial translation on standing lateral knee radiographs was significantly decreased by a mean of 8.9 mm from preoperatively to 6 months postoperatively (P < .001). Posterior tibial slope was significantly decreased by a mean of 11.2° from preoperatively to 6 months postoperatively (P < .001). CONCLUSION: Supratubercle ACW-PTO performed for ACL reconstruction failure in the setting of an increased posterior tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, after ACW-PTO, there was a significant decrease in anterior tibial translation and posterior tibial slope.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques.

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Symptomatic rib fracture nonunion: a systematic review of the literature.

INTRODUCTION: Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions. MATERIALS AND METHODS: We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles. RESULTS: One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting. CONCLUSION: Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject.

Combined Rip-Stop and Transtibial Pull-out Technique for Lateral Meniscus Radial Repairs.

Radial tears of the meniscus disrupt circumferential fibers that allow for the dispersion of axial tibiofemoral forces. Both nonoperative treatment and meniscectomy carry increased risk of early-onset degeneration of the joint because of decreased contact surface area and increased point-loading of the chondral surfaces. Radial type tears are also notable for the relatively high failure rate associated with repair. The purpose of this technical note is to demonstrate our surgical technique for a radial lateral meniscus repair construct that allows for good apposition and anatomic reduction of the meniscus with less risk of residual postoperative extrusion through use of a combination inside-out rip-stop and transtibial pull-out suturing repair.

Concurrent Repair of Medial Meniscal Ramp Lesions and Lateral Meniscus Root Tears in Patients Undergoing Anterior Cruciate Ligament Reconstruction: The "New Terrible Triad".

Recent studies have suggested that up to 8% of patients with anterior cruciate ligament (ACL) tears can present with a combined medial meniscal ramp lesion (MMRL) and lateral meniscus root tear (LMRT). MMRLs and LMRTs often are missed preoperatively and can increase the risk of ACL graft failure if left untreated. Given the potential synergistic biomechanical consequences and challenging repair techniques used for treatment, our group commonly refers to this presentation (MMRL-LMRT-ACL) as the "new terrible triad" of ACL pathology. This Technical Note aims to describe a systematic approach for arthroscopic assessment and our preferred inside-out and transtibial pull-out repair techniques to efficiently diagnose and treat a combined MMRL and LMRT at the time of ACL reconstruction surgery.

Treatment of a Failed Posterior Cruciate Ligament Avulsion Fracture Fixation in a Skeletally Immature Patient: A Case Report.

CASE: A 12-year-old skeletally immature girl presented with 1 year of persistent instability after an open reduction and internal fixation (ORIF) for a posterior cruciate ligament (PCL) avulsion fracture. With a period of nonoperative management, her PCL stress radiographic measurements significantly decreased and her posterior tibial slope increased because the primary ORIF effectively led to growth arrest with an early fusion of the posterior tibial physis. At age 13 years when she was skeletally mature, revision PCL and fibular collateral ligament (FCL) reconstructions were performed. Promising clinical outcomes were observed at age 17 years. CONCLUSION: Pediatric patients with a failed PCL ORIF can successfully be managed with a period of nonoperative bracing and a revision PCL reconstruction once skeletally mature.

Combined Repair of Medial Meniscal Ramp Lesions and Posterior Root Tears of the Lateral Meniscus During Anterior Cruciate Ligament Reconstruction: A Case Report.

CASE: This case report describes the clinical outcomes for 2 patients who underwent a primary or revision anterior cruciate ligament (ACL) reconstruction with a combined inside-out and transtibial pullout repair for a medial meniscal ramp lesion (MMRL) and a lateral meniscus root tear (LMRT), respectively. Promising short-term outcomes were seen at the one-year follow-up for both patients. CONCLUSIONS: Utilization of these repair techniques can successfully treat a combined MMRL and LMRT injury at the time of primary or revision ACL reconstruction.