Direct On-Lay Repair of Isolated Pediatric Lateral Collateral Ligament Knee Injury with Biceps Femoris Tendon Rotation Graft Augmentation: A Case Report.

CASE: A 13-year-old male American football player sustained an isolated grade III lateral collateral ligament (LCL) rupture and underwent direct repair with biceps femoris rotation graft augmentation after failure of nonoperative management. The procedure was performed without any complications or graft site morbidity and achieved complete functional resolution. CONCLUSION: Isolated LCL injuries in the pediatric population are an extremely rare finding, with no evidence of rotation graft in the literature to date. Most of these cases involve multiligamentous knee injuries in the adult population, and therefore, there is no consensus regarding pediatric repair vs. reconstruction in this presentation.

A case series of recurrent myotendinous rotator cuff tears repaired and augmented with dermal allograft: clinical outcomes at two years.

When rotator cuff tears occur after a primary repair at the footprint, they often fail medially at the myotendinous junction, also called type II tears. These are difficult tears to treat, and little research has been published on how to address tears at the myotendinous junction and the clinical outcomes of the revised repairs. The purpose of this study is to evaluate the outcomes of type II rotator cuff tears repaired with a dermal allograft augmentation. MATERIALS AND METHODS: We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound. RESULTS: Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist. DISCUSSION: Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

ON-Q infusion pump linked to increased hospital stay after total knee arthroplasty.

PURPOSE: The purpose of this study was to evaluate immediate postoperative pain control modalities after total knee arthroplasty at the author's specific institution and compare those modalities with patient satisfaction, rehabilitation status, and length of hospital stay. METHODS: A retrospective chart review of 101 patients who underwent total knee arthroplasty from 2013 to 2016 was performed. Data was collected including the pain control modality, total pain medication consumption, physical therapy progress, length of hospital stay and Visual Analog Scores. Analysis was then performed using SAS proprietary software. Results were reported as statistically significant if p value was less than 0.05. RESULTS: Multiple variables proved to be statistically significant (p value <0.05) in this particular study. Patients who received Valium required more morphine equivalents on average and reported higher Visual Analog Scores (VAS). For those patients who received a lower extremity nerve block pre operatively, there was a decrease in morphine equivalents on postoperative day one and lower VAS. For those patients who received the continuous pain pump, ON-Q postoperatively, there was an average increase in length of hospital stay by one day and a decrease in ambulation on postoperative day one. Also, females required less overall pain medication on postoperative days two and three compared to their male counterparts. Finally, there was no statistically significant difference for those patients who received Lyrica (pregabalin) or NSAIDS for the parameters that were measured in this study. CONCLUSIONS: Postoperative pain control modalities after total knee arthroplasty are highly variable among physicians. This variability has allowed researchers to review each modality and compare and contrast the benefits with the potential adverse effects of these medications on total knee replacement outcomes. The data in this study suggests that the use of Valium is correlated with increased pain medication consumption and decreased patient satisfaction. Data from this study also reveals that patients who underwent preoperative nerve blocks experienced decreased pain on postoperative day one and greater patient satisfaction. The most notable contribution of this study was the discovery of the adverse effects of the continuous pain pump, ON-Q. Patients treated with this modality had decreased ambulation on postoperative day one and on average remained in the hospital one extra day, a variable that significantly increases the cost of a total knee arthroplasty for the hospital, the surgeon and the patient. Even though this data is significant, further studies should be performed to enhance our knowledge of postoperative pain control for these patients.

Loss of Internal Tibial Rotation After Anterior Cruciate Ligament Reconstruction.

The flexion angle of the knee and the position of the tibia need to be considered during tensioning of the anterior cruciate ligament (ACL) graft to avoid overconstraining the knee. The purpose of this report was to describe 2 cases of loss of tibial internal rotation after single-bundle anatomic ACL reconstruction with graft tensioning in flexion. Retrospective review of each patient's operative chart revealed that the graft was tensioned in flexion and placed in an anatomic position in the femoral tunnel at the time of the index operation. Primary outcome was ACL revision surgery. Secondary outcome data included Lysholm scores and Lachman and pivot shift tests. Two patients underwent revision ACL reconstruction with a more vertical tunnel placed through a transtibial technique. The graft was tensioned in full knee extension and neutral rotation of the tibia. This resulted in restoration of normal tibial internal rotation to 10°. Lysholm scores improved from 35 to 90 in patient 1 and from 12 to 61 in patient 2. Patient 1 returned to college soccer at 6 months postoperatively. Her knee was stable to Lachman and pivot shift tests. Patient 2 has been followed for 12 months and has returned to all normal activities without pain or dysfunction. Anatomic femoral placement of the ACL with improper positioning of the knee during tensioning of the graft may capture the knee and lead to loss of the normal internal rotation. The surgeon should be aware of this complication during primary ACL reconstruction. [Orthopedics. 2018; 41(1):e22-e26.].