ABSTRACT
BACKGROUND: Periprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect-hereinafter termed the "Terrible Triad"-is a devastating complication following total knee arthroplasty. The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad. METHODS: From 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey's tests and Pearson's Chi-square tests or Fisher's exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed. RESULTS: The mean follow-up was 8.4 years and similar between groups (P = .064). Patients who had the Terrible Triad had a 45.5% incidence of above-knee amputation, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR = 5.8, 95% CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR = 3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR = 11.6, 95% CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome. CONCLUSIONS: This study demonstrates that the total knee arthroplasty Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis. LEVEL OF EVIDENCE: III.
ABSTRACT
BACKGROUND: Primary repair of chronic distal biceps tendon ruptures may not be possible because of tendon retraction, and there remains no clear consensus on the type of reconstruction technique used. The purpose of this study was to report the clinical outcomes and complication rates following reconstruction of chronic distal biceps tendon ruptures. METHODS: A systematic review was performed following PRISMA guidelines. The following databases were searched: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials. The primary outcomes of interest included range of motion, strength, and functional outcome scores. Secondary outcomes included complication, reoperation, and revision rates. Outcomes and complication rates of each graft type and fixation technique were aggregated and compared with nonparametric Wilcoxon signed rank and rank sum tests. Spearman rank coefficients were calculated for time from injury to surgery on all outcomes. RESULTS: There were no significant differences found between the graft type or fixation technique for postoperative range of motion, strength, and patient-reported outcomes. Postoperative complications were substantially higher in the autograft group (34%) as compared to the allograft group (14%). The fixation technique used also demonstrated a significantly increased complication rate in the weave group compared with the onlay group (34% and 9%, respectively). CONCLUSION: Our results do not reveal any statistically significant differences between groups in the primary outcomes. However, substantially higher complication rates were observed in the autograft and weave cohorts; more than half of the complications related to the use of autograft were associated with donor site morbidity. No specific graft type was identified as superior, although this may be due to the small patient numbers included within this study.
