Male sex, revision surgery, low volume of anterior cruciate ligament remnant, and significant instability are risk factors for Posterior Root Tear of the Lateral Meniscus in patients undergoing Anterior Cruciate Ligament Reconstruction.

PURPOSE: This multicenter study aimed to determine the incidence of lateral meniscus posterior root tears (LMPRTs) in patients undergoing ACL reconstruction and identify associated risk factors. METHODS: We conducted a retrospective, multicenter study using data from the Francophone Arthroscopic Society's registry. The study included all the patients in the registry who underwent ACL reconstruction surgery between June 2020 and June 2023, we excluded incomplete data. We compared delay from injury to surgery between LMPRTs group and No LMPRTs group. Variables investigated as potential risk factors for LMPRTs included age, sex, nature of surgery (primary or revision), pivot shift test result, side-to-side laxity under anesthesia, presence of ACL remnant, occurrence of medial meniscal tear, and presence of collateral ligament injury. Risk factors were analyzed using a logistic regression model. RESULTS: Among the 5359 patients analyzed, LMPRTs occurred in 7.0% (n=375) of cases during ACL reconstruction. Mean age at surgery was 29.3 +/- 10.3 years old [11-77]. Concerning delay to surgery, the mean time was 8.4 +/- 23.1 weeks [0.0-347.2] in the No LMPRTs group and 6.5 +/- 10.2 weeks [0.2-61.6] in the LMPRTs group (p = 0.109). Univariate analysis revealed that male sex (p < 0.001), revision surgery (p < 0.001), medial meniscal injury (p = 0.007), ACL remnant (0% vs > 70%, <10% vs > 70%, 10 to 30% vs > 70%, 30 to 50% vs > 70%, 50 to 70% vs > 70%; p < 0.001) and higher pivot shift grade (p = 0.011) were significantly associated with a presence of LMPRTs. Age, side-to-side laxity, and collateral ligament injury were not found to be significant risk factor In multivariate analysis : male sex, revision surgery, pivot shift test result and a low volume of ACL remnant remained significant. Side to side laxity was also a significant factor in multivariate analysis. CONCLUSION: This study identified male sex, revision surgery, low volume of ACL remnant, side to side laxity and higher grade of pivot shift as significant risk factors for LMPRTs during ACL reconstruction.

Risk factors and prevalence of ramp lesions in ACL ruptures: An analysis from the registry of the Francophone Arthroscopic Society.

PURPOSE: The study aimed to estimate the prevalence of ramp lesions among patients undergoing anterior cruciate ligament (ACL) reconstruction and identify risk factors associated with these lesions. METHODS: A retrospective, multicentre cohort study was conducted using data from the Francophone Arthroscopic Society's registry, including 5359 patients who underwent ACL reconstruction (ACLR) from June 2020 to June 2023. Potential risk factors for ramp lesion such as patient demographics, revision surgery, pivot shift, side-to-side anteroposterior laxity, medial collateral ligament (MCL) injury, lateral meniscal tear and the volume of ligament remnant were evaluated using multivariate regression analyses. BMI and delay to surgery were also assessed. RESULTS: Ramp lesions were identified in 822 patients (15.3%). Univariate analysis identified male sex, younger age, revision surgery, lateral meniscal injury, percentage of ACL remnant (all p < 0.0001) and pivot shift (p = 0.0103) as significant risk factors. MCL injury was associated with a lower risk (p < 0.0001). In multivariate analysis, male sex, younger age, revision surgery, lateral meniscal injury and percentage of ACL remnants remained significant risk factors, while MCL injury remained a protective factor. The anteroposterior laxity wasn't a significant predictor in either analysis. In subgroup analysis, there were differences concerning body mass index (n.s) and the delay to surgery (n.s). CONCLUSION: The study identified male sex, younger age, revision surgery, lateral meniscal injury and pourcentage of ACL remnant as significant risk factors for ramp lesions, with MCL injury acting as a protective factor. This will help regarding the suspicion and identification of ramp lesions. LEVEL OF EVIDENCE: Level III.

Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction With Pedicular Hamstrings Tendon Graft, Single-Strand Gracilis for ALL and Single Blind Femoral Tunnel.

Combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALL r) is a common procedure to treat rotational instability and to prevent ACL graft failure. Recent studies have described numerous combined reconstruction techniques to obtain the most anatomical procedure with the least graft donor site morbidity and the best clinical results. Hamstring (HG) grafts are the most popular graft in literature. Leaving pedicle HG can preserve enough blood supply to improve tendon-bone healing with additional mechanical fixation of the graft on the tibial side. A single femoral tunnel reduces bone loss and prevents convergence of 2 femoral tunnels. We describe an original ACL and ALL reconstruction technique that preserves hamstring tibial insertion with a single blind femoral tunnel.

Preserving the hamstring tendon insertion during ACL reconstruction with an autograft: Systematic literature review.

INTRODUCTION: The hamstring tendons (gracilis and semitendinosus) are often used as an autograft for anterior cruciate ligament (ACL) reconstruction. Healing of this graft involves a slow biological process called ligamentization. To encourage this process, some authors have proposed preserving the insertion of the hamstring tendons. HYPOTHESIS: Leaving the tibial insertion of the hamstring tendons intact will provide better early biological incorporation and superior tibial mechanical fixation resulting in various clinical advantages. MATERIALS AND METHODS: In January 2022, a systematic literature review was carried out independently by two authors of the Medline, PubMed and Embase databases. The keywords used were "pedicular" or "pedicled" or "preservation of tibial attachment" or "hamstring tibial insertion" AND "ACL reconstruction". Each author's data was analyzed separately. RESULTS: Sixteen articles were analyzed. Preserving the hamstring tibial insertion during ACL reconstruction improves the graft's biological incorporation during the initial postoperative phase according to clinical studies with MRI analysis and provides a mechanical advantage at the graft's tibial attachment according to biomechanical studies (construct up to 65% stiffer). There was no difference in the clinical and functional scores when compared to the conventional technique in which the hamstring tendons are detached from their tibial insertion. DISCUSSION: The main conclusion of this systematic literature review was that preserving the hamstring tibial insertion during ACL reconstruction appears to improve the graft's ligamentization with biological and mechanical advantages relative to detaching the hamstring tendons. The clinical and functional results were comparable to other techniques. Prospective studies with large cohorts are still needed to confirm these findings. LEVEL OF EVIDENCE: IV; Systematic review of literature.

Is the popliteal tendon sufficient for all-inside suture in lateral meniscus repair? A 22-case cadaver study.

INTRODUCTION: Arthroscopic lateral meniscus repair is performed in the "figure-of-4 position" (supine, with the affected knee flexed and the lower leg crossed over the extended contralateral leg), and anchorage is often on the popliteal tendon. Extending the limb at the end of the procedure alters the relations between the popliteal tendon and the repaired meniscus. The present study aimed to assess lateral meniscal suture fixation on the popliteal tendon after a cycle of flexion-extension. HYPOTHESIS: Extending the knee can induce suture release. TYPE OF STUDY: Cadaver study. MATERIALS AND METHODS: Twenty-two fresh adult human cadaver knee specimens were used. Under arthroscopy with all-inside implants, a vertical suture onto the popliteal tendon was performed through the lateral meniscus. Suture status was assessed under arthroscopy after a cycle of flexion-extension, and deemed defective if the suture was sufficiently loose for the arthroscope to be able to be passed through the popliteal hiatus, if the stitch had passed through the meniscus, or if the suture was broken. RESULTS: Thirteen sutures (59.1%) remained well fixed, and 9 (40.1%) were defective: 4 (18.2%) were loose, in 4 (18.2%) the stitch had passed through the meniscus, and in 1 (4.5%) the suture had broken. CONCLUSION: In a population of elderly cadaver knee specimens, arthroscopic suture of the lateral meniscus to the popliteal tendon was defective after flexion-extension in 40% of cases. Stress seems to be exerted on the suture when extension is resumed. Thus, a single stitch seems insufficient for stable lateral meniscus repair. CLINICAL IMPLICATIONS: Suture of the lateral meniscus to the popliteal tendon undergoes stress when extension is resumed, potentially causing failure of lateral meniscus repair. LEVEL OF EVIDENCE: IV.

Arthroscopic suture-fixation of anterior tibial intercondylar eminence fractures by retensioning of the ACL and hollowing of the tibial footprint: Objective and subjective clinical results in a paediatric population.

INTRODUCTION: Anterior tibial intercondylar eminence fractures (ATIEF) of the knee are rare in children. They are associated with prefracture intraligamental distention of the anterior cruciate ligament (ACL). OBJECTIVE: The objective of this study was to evaluate the subjective and objective clinical results of an arthroscopic surgical technique by suture-fixation of the fracture and tensioning of the ACL through hollowing of the tibial footprint. HYPOTHESIS: Suture-tensioning of ATIEF arthroscopically helps to achieve treatment objectives by leaving the knee joint free of any hardware. MATERIALS AND METHODS: This single-operator monocentric retrospective study involved twenty children operated on over a period of 2-years and 10 months, from March 2013, and with a minimum of one-year follow-up. Surgery was indicated for Stage II to IV fractures according to the Meyers and McKeever classification. Type I fractures were excluded. Seventeen out of 20 patients were reviewed. The median age was 12 years at the time of surgery and the mean follow-up was 28 months. The fractures were 5 of stage II, 9 of III and 3 of IV. The scores of Lysholm, objective and subjective IKDC were collected. Residual objective laxity was measured using the GNRB arthrometer at 150N. A standard X-ray evaluation permitted detection of possible growth disorders. RESULTS: At 28 months of mean follow-up, the mean scores of Lysholm and subjective IKDC were 99 (95; 100) and 97 (92; 100), respectively. As for the objective IKDC, 14 knees were rated A and 3 were rated B. The mean differential residual laxity via GNRB was 0.94mm (0; 2.4). No radiological growth disorder was observed at the last follow-up. CONCLUSION: The ACL suture-tensioning technique is simple and reliable. It also preserves the joint of the adult to remain free of any residual hardware. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature.

BACKGROUND: Ankle trauma in children and adolescents is the most common orthopedic injury encountered in pediatric trauma. It has long been recognized that a lateral ankle injury in this population is often a Salter and Harris type I fracture of the distal fibula (SH1). The purpose of this study is to confirm the existence of a lateral ankle sprain and to report the incidence of each pathology of the lateral ankle compartment: SH1 fracture, ATFL injury, and osteochondral avulsions. METHODS: A systematic review of the literature is done using the database provided by PubMed and Embase. All articles reporting the incidence of imaging modality-confirmed lateral ankle injury (SH1, ATFL injury, osteochondral avulsion) in children and adolescents were included. Exclusion criteria were the following: case reports or articles with less than ten subjects, unspecified imaging modality and articles unrelated to lateral ankle lesions. Thus, 237 titles and abstracts were selected, 25 were analyzed thoroughly, and 11 articles were included for final analysis. RESULTS: SH1 fractures were found in 0-57.5% of the cases in all series and 0-3% in the most recent series. A diagnosis of an ATFL injury was found in 3.2-80% and an osteochondral avulsion of the distal fibula in 6-28.1%. The most recent series report 76-80% and 62% for ATFL injury and osteochondral avulsion respectively. CONCLUSIONS: There is a non-negligible incidence of ATFL sprains and fibular tip avulsions in patients with a suspected SH1 fracture of the distal fibula. According to recent evidence and MRI examinations, the most common injuries of the pediatric ankle are ATFL sprain and osteochondral avulsions. This should be taken into consideration in daily practice when ordering radiological examination and deciding on treatment modalities.

Early postoperative practices following anterior cruciate ligament reconstruction in France.

INTRODUCTION: The early postoperative period after anterior cruciate ligament reconstruction (ACL) is critical for optimal functional recovery. Despite an abundance of literature, there is no consensus regarding good practices. This period is often under-considered by orthopedic surgeons. The aim of this study was to identify early postoperative practices after ACL reconstruction in France. HYPOTHESIS: The hypothesis was that there was a discrepancy between validated data in the literature and the current practices of orthopedic surgeons in France. MATERIAL AND METHODS: In 2019, a questionnaire was sent to all the members of the French Arthroscopy Society to investigate their postoperative practices after ACL reconstruction. Two hundred sixty-nine members responded. Surgeons were divided into two groups of experienced (n=137) and less experienced (n=132) surgeons, according to the number of ACL reconstructions performed per year (

Posterior cruciate ligament: Anatomy, femoral insertion and relationships with the anterior menisco-femoral ligament in 23 cadaver knees.

BACKGROUND: Abundant anatomic descriptions exist of the posterior cruciate ligament (PCL) and menisco-femoral ligaments (MFLs). There is broad agreement that the PCL is composed of two bundles and inserts on the femur near the distal cartilage. However, a different configuration with a single bundle and a complex femoral insertion has been reported. The main objective of our cadaver study was to determine the number of anatomical bundles forming the PCL. We also described the insertion of the PCL and its relationships with the anterior menisco-femoral ligament (AMFL). HYPOTHESIS: The PCL consists of a single ribbon-like bundle and inserts on the femur separately from the AMFL. MATERIAL AND METHODS: We used 23 knees of fresh unembalmed cadavers, which we dissected under a microsurgery loupe. Inclusion criteria for the knees were freedom from trauma and scars. No age limits were set. The features of the PCL were studied using the clock method. Measurements were taken using callipers with a precision of 0.01mm. RESULTS: No knees were excluded from the final analysis. Macroscopically, the PCL appeared as a single bundle forming a slender flat ribbon. With the knee flexed at 90°, the ligament footprint extended from 58min to 25min on the right and from 48min to 2min on the left. The femoral insertion of the AMFL started 2.07mm from the distal cartilage and masked the distal insertion of the PCL. After removal of the AMFL, the middle of the femoral insertion of the PCL started on average 5.99mm from the distal cartilaginous rim when the knee was flexed at 90°. DISCUSSION: Our study confirms descriptions of the PCL as a single bundle shaped as a flat ribbon. The presence of the AMFL gives the appearance of a double bundle and partially masks the femoral insertion of the PCL, which is located further back relative to the distal joint cartilage. LEVEL OF EVIDENCE IV: Experimental cadaver study.

Incidence and risk factors for cyclops syndrome after anterior cruciate ligament reconstruction: A systematic literature review.

BACKGROUND: Cyclops syndrome after anterior cruciate ligament (ACL) reconstruction is due to a fibrous nodule that develops in the anterior part of the intercondylar notch and prevents full knee extension. The primary objective of this systematic literature review was to evaluate the incidence of symptomatic cyclops lesion after ACL reconstruction. The secondary objective was to identify risk factors for cyclops syndrome. HYPOTHESIS: Cyclops syndrome is common after ACL reconstruction and has several risk factors reported in the literature. METHODS: A systematic literature review was performed by searching the PubMed, Medline, CINAHL, Cochrane, and Embase databases with the key terms 'cyclops' and 'ACL reconstruction'. The data thus retrieved were evaluated independently by two investigators. All articles in English or French that reported the incidence and risk factors of cyclops syndrome after ACL reconstruction were included. RESULTS: The search retrieved the titles and abstracts of 79 articles, of which 20 were selected to be read in full; among these, 10 were included in the study. The incidence of symptomatic cyclops lesion ranged from 1.9% to 10.9%. Identified risk factors were as follows: pre-operatively, knee inflammation and/or motion restriction at the time of ACL reconstruction; intra-operatively, narrow intercondylar notch and excessively anterior position of the tibial tunnel; and post-operatively, persistent hamstring muscle spasm. DISCUSSION: Development of a cyclops lesion is common after ACL reconstruction, occurs early, and may require further surgery. The knowledge of the risk factors provided by this study may improve the ability to devise effective preventive measures. LEVEL OF EVIDENCE: II, systematic literature review.

Acute Achilles Tendon Rupture: Ultrasonography and Endoscopy-Assisted Percutaneous Repair.

To date, there is no consensus concerning the treatment of acute Achilles tendon ruptures. Although surgical treatment decreases the risk of a recurrent rupture, it is not without complications. In particular, percutaneous sutures may cause a lesion of the sural nerve. The purpose of this Technical Note is to describe a reliable and reproducible surgical procedure for treating these lesions. The first operative phase consists of an ultrasound detection that makes it possible to identify the tendon extremities and the sural nerve, which is necessary to secure the posterolateral arthroscopic tract as well as to perform the percutaneous suture. The entry point is thus centered on the lesion and placed at a distance from any surrounding nerve risk. The second arthroscopic phase makes it possible to release the tendon lesion, control the transtendon passage of the surgical threads, and evaluate the dynamic contact of the tendon edges. At the end of the intervention, the complete disappearance from the transillumination via the rupture also makes it possible to ensure the disappearance of the tendon gap. Achilles tendon percutaneous sutures after the ultrasound detection and under arthroscopic control thus makes it possible to control the contact of the tendon edges, while at the same time decreasing the risk of a lesion of the sural nerve, with minimal scarring.

Non-anatomical or direct anatomical repair of chronic lateral instability of the ankle: A systematic review of the literature after at least 10 years of follow-up.

INTRODUCTION: A lateral ankle sprain is one of the most frequent reasons for consultation at the emergency trauma unit. Numerous surgical procedures have been described with long-term outcomes that differ. HYPOTHESIS: The long-term results of anatomical repair of the anterior talofibular ligament (ATFL) and the calcaneofibular (CFL) ligament are better, with less secondary radiological osteoarthritis than non-anatomical repair. MATERIALS AND METHODS: A review of the literature after a minimum follow-up of 10 years was performed to analyze the clinical and radiological results of direct anatomical repair (Broström, Duquennoy) and non-anatomical repair (Watson Jones, Evans, Castaing). Thirteen articles were selected. RESULTS: Eight hundred and one ankles were evaluated after a mean follow-up of 15.3 years. The functional outcome was better after anatomical repair but with recurrent instability. Loss of range of motion and secondary osteoarthritis was more frequent after non-anatomical repair. CONCLUSION: Anatomical repair of the lateral collateral ligament of the ankle resulted in a better functional outcome and less secondary osteoarthritis than non-anatomical repair. STUDY DESIGN: Review of the literature; level of proof IV.

Torsional Appearance of the Anterior Cruciate Ligament Explaining "Ribbon" and Double-Bundle Concepts: A Cadaver-based Study.

PURPOSE: To investigate the effect of the anterior cruciate ligament (ACL) torsion in 90° knee flexion on the morphological appearance of the ACL. METHODS: Sixty knees from fresh frozen anatomical specimens were dissected. Eighteen knees were excluded according to selection criteria (torn ACL, mucoid degeneration of the ACL, arthritic lesions of the notch, or knees harboring synovial inflammatory pathologies). After the removal of the synovial membrane, the morphology of the ligamentous fibers of the ACL and the twist were analyzed. Twisting of the ACL was measured using a goniometer in 90° knee flexion and defined by the angle of external rotation of the femur on the axis of the tibia required to visualize a flat ACL. The orientation of tibial and femoral footprint was described in a coronal plane for the tibia and a sagittal plane for the femur. RESULTS: In the 42 knees that were finally included, the ACL was always displayed as a single ribbon-like structure. The torsion of the fibers was on average 83.6° (± 9.4°) in 90° knee flexion. The twisting could be explained by the different orientations of the femoral (vertical in a sagittal plane) and tibial (horizontal in a coronal plane) footprints. An intraligamentous proximal cleavage area was encountered in 11 cases (i.e., 26%). CONCLUSIONS: The ACL is a twisted structure with 83.6° of external torsion of fibers in 90° knee flexion. It is the torsion in the fibers, due to the relative position of bone insertions, which gives the ACL the appearance of being double bundle. CLINICAL RELEVANCE: The concept of the torsional flat structure of the native ACL may be of importance during ACL reconstruction, both in terms of graft choice (flat rather than cylindrical) and of technical positioning (torsion).

What are the risk factors for post-operative infection after hip hemiarthroplasty? Systematic review of literature.

BACKGROUND: Femoral neck fractures are frequent in the elderly population and lead to high morbidity and mortality. Hemiarthroplasty is an established surgical procedure for displaced intracapsular femoral neck fractures. Post-operative infection is frequent and is potentially devastating for the patient and the healthcare services. The goal of this study was to identify the risk factors of infection after hemiarthroplasty and help adapt our surgical practice. METHODS: A systematic review of the literature was performed in July 2015 by two authors using the MedLine, PubMed and Cochrane databases. We used the MeSH keywords "hip hemiarthroplasty" AND "infection" to identify risk factors and methods of prevention for surgical site infection after hemiarthroplasty. Following the search, two authors independently performed the first stage based on titles and abstracts. RESULTS: Thirty-seven articles were selected. Review and analysis of the references was performed to find other articles of interest. Thirteen articles were selected to analyse. According to literature, the surgical site infection (SSI) rate after hip hemiarthroplasty (HHA) is between 1.7 and 7.3 %. Pre-operative comorbidities (obesity, liver disease, advanced age), operative conditions (junior surgeon, uncemented stems, time of surgery) and post-operative management (length of hospitalisation, haematoma, prolonged wound drainage and two urinary catheterisations) were identified as risk factors of surgical site infection. Authors describe conditions to decrease the incidence of these complications and underline the importance of "a specialised hip team" that provides fast care and helps decrease the duration of hospitalisation. CONCLUSIONS: Careful patient management for hemiarthroplasty is vital and may decrease the incidence of surgical site infection, which is associated with high morbidity and high procedure cost. Our review suggests that there are specific correctable risk factors for SSIs after HHA. Being able to identify these risk factors leads to better care because of SSI prevention in patients undergoing HHAs after femoral neck fractures. To improve the outcomes, some methods of prevention of surgical site infection are available: before, during and after the operation. STUDY DESIGN: Review of literature. LEVEL OF EVIDENCE: IV.

Acetabular reconstruction using a free fibular autograft in total hip arthroplasty revisions.

PURPOSE: Acetabular reconstruction for segmentary bone loss aims for primary stability and long-lasting integration. The use of a fibular autograft has been described after tumour resection and in traumatology. The hypothesis of this study is that it offers a mechanically reliable solution with good functional results and acceptable morbidity. METHODS: This is a two center retrospective study of 26 operated hips. Indication was mechanical loosening in every case. The operative technique included fibular grafting of a segmental bone loss associated with an acetabular metal reinforcement. RESULTS: Mean follow up was 88 months (three to 165). The PMA score increased from 8.5 (five to 12) to 15 (six to 18) (p <0.001). Acetabular migration was 2 mm (0-4) vertically and 1 mm (0-2) medially. Three graft failures were observed. No major morbidity was observed. CONCLUSION: Fibular autograft after mechanical loosening and segmentary bone loss in total hip arthroplasty revisions offers a mechanically reliable solution for acetabular reconstruction. The results seem to be at least equivalent to other techniques.