Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review.

Revision anterior cruciate ligament reconstruction remains a challenge, especially optimising outcome for patients with a compromised knee where previous autogenous tissue has been used for reconstruction. Allograft tissue has become a recognized choice of graft for revision surgery but questions remain over the risks and benefits of such an option. Allograft tendons are a safe and effective option for revision ACL reconstruction with no higher risk of infection and equivalent failure rates compared to autografts provided that the tissue is not irradiated, or any irradiation is minimal. Best scenarios for use of allografts include revision surgery where further use of autografts could lead to high donor site morbidity, complex instability situations where additional structures may need reconstruction, and in those with clinical and radiologic signs of autologous tendon degeneration. A surgeon needs to be able to select the best option for the challenging knee facing revision ACL reconstruction, and in the light of current data, allograft tissue can be considered a suitable option to this purpose.Level of evidence IV.

Technical considerations in lateral extra-articular reconstruction coupled with anterior cruciate ligament reconstruction: A simulation study evaluating the influence of surgical parameters on control of knee stability.

BACKGROUND: Surgical parameters such as the selection of tibial and femoral attachment site, graft tension, and knee flexion angle at the time of fixation may influence the control of knee stability after lateral extra-articular reconstruction. This study aimed to determine how sensitive is the control of knee rotation and translation, during simulated pivot-shift scenarios, to these four surgery settings. METHODS: A computer model was used to simulate 625 lateral extra-articular reconstructions based upon five different variations of each of the following parameters: femoral and tibial attachment sites, knee flexion angle and graft tension at the time of fixation. For each simulated surgery, the lateral extra-articular reconstruction external rotation moment at the knee joint center was computed during simulated pivot-shift scenarios. The sensitivity of the control of knee rotation and translation to a given surgery setting was assessed by calculating the coefficient of variation of the lateral extra-articular reconstruction external rotation moment. FINDINGS: Graft tension had minimal influence on the control of knee rotation and translation with less than 2.4% of variation across the scenarios tested. Control of knee rotation and translation was the least affected by the femoral attachment site if the knee was close to full extension at the time of graft fixation. The choice of the tibial attachment site was crucial when the femoral fixation was proximal and posterior to the femoral epicondyle since 15 to 67% of variation was observed in the control of knee rotation and translation. INTERPRETATION: Femoral and tibial attachment sites as well as knee flexion angle at the time of fixation should be considered by surgeons when performing lateral extra-articular reconstruction. Variation in graft tension between the ranges 20-40 N has minimal influence on the control of knee rotation and translation.

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society.

INTRODUCTION: Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. MATERIAL AND METHODS: A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. RESULTS: Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. DISCUSSION: The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. LEVEL OF EVIDENCE: IV, prospective multicenter study.

Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society.

INTRODUCTION: During anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. HYPOTHESIS: ALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. MATERIAL AND METHODS: Clinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3years' follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. RESULTS: The average follow-up was 6.8years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3mm in 66% of patients and less than 5mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. DISCUSSION: When compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. LEVEL OF EVIDENCE: IV, multicenter study.

Combined intra- and extra-articular grafting for revision ACL reconstruction: A multicentre study by the French Arthroscopy Society (SFA).

BACKGROUND: A careful analysis of the reasons for ACL reconstruction failure is essential to selection of the optimal surgical revision technique designed to ensure good rotational stability and to minimise the risk of re-rupture. OBJECTIVE: To evaluate anterolateral ligament (ALL) stabilisation during revision ACL reconstruction. HYPOTHESIS: ALL stabilisation during revision ACL reconstruction provides good rotational stability without increasing the risk of complications. MATERIAL AND METHODS: This multicentre study included 349 patients, 151 retrospectively and 198 prospectively. There were 283 males and 66 females. Inclusion criteria were an indication for revision ACL reconstruction surgery with combined intra-articular reconstruction and ALL stabilisation after failed autograft ACL reconstruction, and intact PCL. Exclusion criteria were primary ACL reconstruction and concomitant peripheral medial and/or lateral lesions. Each patient underwent a clinical and radiographic evaluation before and after revision surgery. Before revision surgery, the mean IKDC score was 56.5±15.5 and 96% of patients were IKDC C or D. RESULTS: Rates were 5.0% for early and 10.5% for late postoperative complications. Lachmann's test had a hard stop at last follow-up in 97% of patients. The pivot-shift test was positive in 1% of patients. The mean subjective IKDC score was 84.5±13.0 and 86.5% of patients were IKDC A or B. The proportions of patients with radiographic knee osteoarthritis at last follow-up was unchanged for the lateral tibio-femoral and patello-femoral compartments but increased by 9.7% to 21.2% for the medial tibio-femoral compartment. The re-rupture rate was 1.2% and the further surgical revision rate was 5.4%. CONCLUSION: Anterior laxity at last follow-up was consistent with previous studies of revision ACL reconstruction. However, rotational stability and the re-rupture risk were improved. ALL stabilisation is among the techniques that deserve consideration as part of the therapeutic options for revision ACL reconstruction. LEVEL OF EVIDENCE: IV, retrospective and prospective cohort study.

Analgesia after ACL reconstruction: Hamstring donor-site injection versus intra-articular local anaesthetic injection.

BACKGROUND: The purpose of this study was to compare hamstring donor-site injection versus intra-articular injection of a local anaesthetic for analgesia after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: The two methods provide similar pain relief. MATERIAL AND METHODS: 158 consecutive patients undergoing ACL hamstring tendon graft reconstruction (semi-tendinosus/gracilis [STG] or four-stranded semi-tendinosus [ST4]) during two periods in 2015 were included. Peripheral nerve block was not performed. At the end of surgery, 20mL of ropivacaine 7.5mg/mL was injected, intra-articularly during the early period (n=79) and into the hamstring donor site during the second period (n=79). Post-operative pain was evaluated subjectively by the patients using a visual analogue scale (VAS). We recorded patient demographics, concomitant surgical procedures, VAS pain scores, rescue analgesic use, time to discharge, and patient satisfaction. VAS pain score, side effects, and patient satisfaction were also recorded during a phone interview on the day after surgery (D1). RESULTS: Mean VAS pain scores were not significantly different between the two groups immediately after surgery (D0) or on D1 (D0: intra-articular, 2.08 and donor site, 1.88; Mann-Whitney P=0.6). Neither were the groups significantly different for rescue analgesic use, patient satisfaction, or quadriceps activation. CONCLUSION: The same local anaesthetic provides similar pain relief when injected intra-articularly or into the hamstring donor site after hamstring tendon ACL reconstruction (STG or ST4). LEVEL OF EVIDENCE: III, prospective case-control study.

Complications in posteromedial arthroscopic suture of the medial meniscus.

INTRODUCTION: All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing. HYPOTHESIS: The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates. MATERIAL AND METHODS: Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire. RESULTS: The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28-35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of "postage-stamp" effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm2). DISCUSSION: Some retears, or "partial failures", may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal. CONCLUSION: The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of painful Sinding-Larsen-Johansson syndrome in a professional handball player.

Sinding-Larsen-Johansson (SLJ) syndrome is a type of osteochondrosis of the distal pole of the patella most often caused by repeated microtrauma. Here, we describe the case of a professional athlete with painful SLJ syndrome treated arthroscopically. A 29-year-old male professional handball player presented with anterior knee pain that persisted after 4 months of an eccentric rehabilitation protocol and platelet-rich plasma injections. Despite this conservative treatment, the patient could not participate in his sport. The SLJ lesion was excised arthroscopically, which led to complete disappearance of symptoms and return to competitive sports after 5 months.

Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults.

BACKGROUND: Tibial spine avulsion fractures (TSAFs) occur chiefly in adolescents. Few published data are available on outcomes after arthroscopic surgical treatment of TSAFs in adults. OBJECTIVES: To evaluate outcomes of consecutive patients with TSAFs managed by arthroscopic bone suture followed by a standardised non-aggressive rehabilitation programme. HYPOTHESIS: Arthroscopic bone suture followed by non-aggressive rehabilitation therapy reliably produces satisfactory outcomes in adults with TSAF. METHODS: Thirteen adults were included. Outcomes were evaluated based on the Tegner score, International Knee Documentation Committee (IKDC) score, anterior-posterior knee laxity, passive and active motion ranges, and radiological appearance. RESULTS: After a mean follow-up of 41±27months (12-94months), all 13 patients had healed fractures without secondary displacement. No patient had knee instability. Post-operative stiffness was noted in 5 patients (2 with complex regional pain syndrome and 3 with extension lag), 1 of whom required surgical release. The mean IKDC score was 91.3±11.7. The mean Tegner score was 5.46±1.37 compared to 6.38±0.70 before surgery. Mean tibial translation (measured using the Rolimeter) was 1.09±1.22mm, compared to 5.9±1.85mm before surgery. CONCLUSION: The outcomes reported here support the reliability of arthroscopic bone suture for TSAF fixation. Nevertheless, a substantial proportion of patients experienced post-operative stiffness, whose contributory factors may include stunning of the quadriceps due to the short time from injury to surgery and the use of a gentle rehabilitation programme. LEVEL OF EVIDENCE: IV, retrospective study of treatment outcomes.

Partial tears of the anterior cruciate ligament.

Partial anterior cruciate ligament (ACL) tears were first described nearly fifty years ago but the optimal treatment for these injuries continues to be a subject of considerable debate. A question remains whether it is advantageous to preserve the ACL remnant and augment it with a graft, or to debride it and proceed with a standard ACL reconstruction unhindered by remnant fibers in the notch. Clinical outcomes of bundle preserving surgery are promising. An increasingly large body of scientific evidence suggests that augmenting the intact bundle is beneficial in terms of vascularity, proprioception and kinematics. With this knowledge, a number of surgeons have developed techniques to augment the intact bundle of the ACL in partial tears and to biologically enhance standard reconstruction techniques by preserving the ACL remnant. Correct tunnel placement is critical for achieving successful short and long-term outcomes after ACL reconstruction. However, published studies have several limitations including a limited number of patients and lack of control groups for direct comparison of outcomes. Concerns continue to exist with respect to an increased risk of impingement following augmentation, responsible of cyclops syndrome. The objective of this article was to outline the diagnostic approach, describe a reproducible and simple surgical procedure that allows correct femoral tunnel placement without the need for aggressive notch debridement and report the clinical outcome of partial ACL reconstruction.

Diaphyseal tibiofibular synostosis in professional athletes: Report of 2 cases.

Anterior leg pain is common in professional athletes and tibiofibular synostosis is reported to be a rare cause of anterior compartment pain or ankle pain related to sports activities. The management and appropriate treatment of this condition in professional athletes is controversial and the literature on the topic is sparse. Distal synostosis is usually related to ankle sprain and syndesmotic ligament injury, and proximal synostosis has been linked to leg length discrepancy and exostosis. Mid-shaft synostosis is even less common than proximal and distal forms. We present the treatment of mid-shaft tibiofibular synostosis in 2 cases of professional athletes (soccer and basketball player), along with a review of the literature. When diaphyseal synostosis is diagnosed, first-line conservative treatment, including ultrasound-guided steroid injection is recommended. However, if it does not respond to conservative management, surgical resection may be indicated to relieve symptoms.

Analysis of short and long-term results of horizontal meniscal tears in young adults.

INTRODUCTION: Symptomatic horizontal meniscal tears are rare but worrisome lesions in young adults. These are overuse injuries not amenable to the classic arthroscopic sutures. An open meniscal repair allows the meniscal lesion to be suture vertically, perpendicular to its in the vascularized zone. The purpose of this study was to evaluate the short and long-term clinical and radiological outcomes of the aforementioned surgical technique. MATERIAL AND METHOD: The first cohort consisted of 24 patients operated between 2009 and 2011 (6 women, 18 men; mean age 26years) having 11 lateral and 13 medial meniscal tears. The second cohort was of 10 patients operated between 2001 and 2002 (3 women, 7 men; mean age 24years) having 8 lateral and 2 medial meniscal tears. Patients were reviewed at the last follow-up using the IKDC, Lysholm and KOOS scores. Patients in the first cohort had an MRI, while those in the second cohort had X-rays. RESULTS: Eighteen patients in the first cohort were reviewed with a mean follow-up of 2 years (12-45 months) and 9 patients from the second cohort were reviewed after 10years (97-142 months). In the first cohort, one patient required secondary menisectomy. The mean Lysholm score was 90 and the subjective IKDC was 85. Every MRI examination found reduced extent and intensity of the hyperintense signal. In the second cohort, no patients required secondary meniscectomy. Two patients had joint space narrowing (less than 50%) on radiographs. The mean Lysholm score was 99 and the subjective IKDC was 91. CONCLUSION: Open repair of horizontal meniscal tears in young adults leads to good subjective and objective results in the short term, which are maintained in the long-term. LEVEL OF EVIDENCE: Level IV - retrospective study.

Meniscal survival rate after anterior cruciate ligament reconstruction.

BACKGROUND: Meniscal suture provides well-documented benefits. Integrity of the cruciate ligaments of the knee is a prerequisite for meniscal healing. Nevertheless, reconstruction of the anterior cruciate ligament (ACL) does not consistently prevent recurrent tearing of a sutured meniscus. We evaluated meniscal survival rates, 5 and 10 years after meniscal suture concomitant with an ACL reconstruction. We compared the outcomes of these repaired menisci to those in which no menisci tears were detected during ACL reconstruction. METHODS: In this multi-centric retrospective study, we included two groups. One group consists of patients who underwent a meniscal repair. This group was further divided into two subgroups based on whether follow-up was 5 years (n=76) or 10 years (n=39). The control group included 120 patients with normal menisci observed during surgery. We studied meniscal survival rates in each group, and we analyzed risk factors associated with the recurrence of meniscal lesions. RESULTS: The 5-year meniscal survival rate was significantly higher in the control group than in the meniscal-repair group (95% vs. 80%, respectively; P=0.0029). The controls group also had a higher meniscal survival rate after 10 years, although the difference was not statistically significant (88% vs. 77%, P=0.07). A difference in knee laxity greater than 4mm was associated with a 5-fold increase in the risk of recurrent meniscal tears (P=0.0057). After 5 years, the risk of recurrence was higher for the medial than for the lateral meniscus, whereas after 10 years the difference was no longer statistically significant. DISCUSSION: Although insufficient healing after meniscal suturing contributes to the risk of further meniscal tears, new lesions can develop in menisci that were undamaged at the time of ACL reconstruction. The risk of a new meniscal lesion is strongly associated with inadequate control of antero-posterior and rotational laxity. Some apparently "new menisci lesions" seems to have been missed during ACL reconstruction. LEVEL OF EVIDENCE: IV, retrospective study.

Meniscectomy versus meniscal repair: 10 years radiological and clinical results in vertical lesions in stable knee.

INTRODUCTION: Surgical management of meniscal lesion consists of either a meniscectomy or meniscal repair. Although repair offers immediate recovery after surgery, it is also associated with higher rates of revision. A meniscectomy, on the other hand is known to be associated with an early onset of osteoarthritis. The present study compared clinical and radiological results at 10 years between meniscectomy and meniscal repair in isolated vertical lesion in an otherwise stable knee. The hypothesis was that repair shows functional and radiological benefit over meniscectomy. PATIENTS AND METHOD: A multi-centric retrospective comparative study of 32 patients (24 male, 8 female). Mean follow-up was 10.6 years (range, 10-13 years). There were 10 meniscal repairs (group R) and 22 meniscectomies (group M), in 17 right and 15 left knees. Mean age at surgery was 33.45±12.3 years (range, 9-47 years). There were 28 medial and 4 lateral meniscal lesions; 26 were in the red-red zone and 6 in red-white zone. RESULTS: Functional score: KOOS score was significantly higher in group R than M on almost all parameters: 98±4.69 versus 77.38±21.97 for symptoms (P=0.0043), 96.89±7.20 versus 78.57±18.9 for pain (P=0.0052), 99.89±0.33 versus 80.88±19.6 for daily life activities (P=0.0002), 96.11±9.83 versus 54.05±32.85 for sport and leisure (P=0.0005), but 91±16.87 versus 68.15±37.7 for quality of life (P=0.1048). Radiology score: in group R, 7 patients had no features of osteoarthritis, and 2 had grade 1 osteoarthritis. In group M, 5 patients had grade 1 osteoarthritis, 10 grade 2, 3 grade 3 and 3 grade 4. Mean quantitative score was 0 (mean, 0.22±0.44) in-group R and 2 (mean, 2.19±0.98) in group M (P<0.0001). DISCUSSION: At more than 10year's follow-up, functional scores were significantly better with meniscal repair than meniscectomy on all parameters of the KOOS scale except quality of life. Functional and radiological scores correlated closely. These results show that meniscal repair for vertical lesions in stable knees protects against osteoarthritis and is therefore strongly recommended. LEVEL OF EVIDENCE: IV; retrospective study.

Behavior of the anterolateral structures of the knee during internal rotation.

INTRODUCTION: Since the recent descriptions of the anterolateral ligament (ALL), the role played by the anterolateral peripheral structures in the rotational control of the knee is again being debated. The objective of this study was to identify the structures during internal tibial rotation and then to define their anatomical characteristics. We hypothesized that internal rotation would tighten several anatomical formations, both superficial and deep, with the ALL one part of these structures. MATERIAL AND METHODS: Nine fresh-frozen cadaver knee specimens were studied. The anterolateral structures tightened were identified from superficial to deep at 30° of flexion. Each was selectively dissected, identifying its insertions and orientations, and measuring its size. The length variations of the ALL during internal tibial rotation were measured by applying a 30-N force using a dynamometric torque wrench at the tibiofibular mortise. RESULTS: The superficial structures tightened were the iliotibial tract and the Kaplan fibers. In internal tibial rotation, the Kaplan fibers held the iliotibial tract against the lateral epicondyle, allowing it to play the role of a stabilizing ligament. The Kaplan fibers were 73.11±19.09mm long (range, 63-82mm) and at their femoral insertion they were 12.1±1.61mm wide (range, 10-15mm). The deep structures tightened covered a triangular area including the ALL and the anterolateral capsule. The ALL was 39.11±3.4mm long (range, 35-46mm) in neutral rotation and 49.88±5.3mm long (range, 42-58mm) in internal rotation (p<0.005). Its femoral insertion area was narrow at 5.27±1.06mm (range, 3.5-7mm) and was mainly proximal and posterior at the lateral epicondyle. Its tibial insertion zone was wide, with a clearly differentiated anterior limit but a posterior limit confused with the joint capsule. In the vertical plane, this insertion was located 6.44±2.37mm (range, 2-9) below the joint space. DISCUSSION: This study demonstrates two distinct anterolateral tissue planes tightened during internal rotation of the tibia: a superficial plane represented by the iliotibial tract and the Kaplan fibers, which acts as a ligament structure, and a deep plane represented by a triangular capsular ligament complex within which the ALL and the anterolateral capsule are recruited. LEVEL OF EVIDENCE: Descriptive cadaver study IV.

Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results?

INTRODUCTION: Management of combined anterior or posterior cruciate ligament and posterolateral corner tears is still poorly codified. The aim of this study was to evaluate functional outcome after complete surgical treatment. MATERIALS AND METHODS: This retrospective multicenter study included 53 patients. Mean age was 29.8 yrs. (15-49). The anterior and posterior cruciate ligaments were involved in respectively 48 and 5 cases. Mean time to surgery was 25.6 months (0-184), and in 10 cases less than 21 days. Nine patients were sedentary workers and 29 non-sedentary (13 laborers). All ligament injuries were treated surgically. Mean follow-up was 49 months (12-146). Last follow-up assessment used IKDC, Lysholm and KOOS scores. RESULTS: At last follow-up, IKDC score graded 14 patients A, 25 B, 8 C and 6 D, versus 0 A, 4 B, 25 C, 22 D and 2 ungraded preoperatively. Mean subjective IKDC and Lysholm scores were respectively 72.8 (11.5-100) and 77.5 (37-100). Mean KOOS scores (pain, symptoms, daily life, sports, quality of life) were respectively 78 (3-100), 70 (25-100), 88 (47-100), 53 (0-100) and 50 (0-100). Posterolateral laxity was corrected in all but two cases. All sedentary workers and 86.7% of non-sedentary workers could return to work. The job had to be changed in 10% of cases overall, but in 25% of cases for laborers. DISCUSSION: The present results are comparable with those of the literature. The strategy of combined surgical treatment showed functional efficacy, usually associated with return to work except for some laborers. There was a non-significant trend in favor of acute-phase ligament reconstruction. LEVEL OF EVIDENCE: IV (retrospective series).

Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: a systematic review.

BACKGROUND: Combined injuries to the posterolateral corner and cruciate ligaments are uncommon. The heterogeneity of injury patterns in many studies complicates the assessment of outcomes. OBJECTIVE: To assess the prognosis and functional outcomes after surgery for combined injuries to the posterolateral corner and to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). MATERIAL AND METHODS: We systematically reviewed the literature for articles reporting outcomes 1 year or more after surgery for combined injuries to the posterolateral corner and ACL (n=4) or PCL (n=9). Patients with bicruciate injuries were not studied. RESULTS: Overall, 65% of patients were IKDC A or B after surgery. The mean Lysholm score improved from 67 to 90. Mean time to surgery was 4.43 months in the group with ACL tears and 18.4 months in the group with PCL tears, and mean follow-up was 34.4 and 40.7 months in these two groups, respectively. In the groups with ACL and PCL tears, the proportions of patients classified as IKDC A or B at last follow-up were 81.6% and 81.0%, respectively, whereas 88% and 99% of patients, respectively, were IKDC grade C or D before surgery. The mean Lysholm score improved from 77 to 92 in the group with ACL tears and from 65 to 89 in the group with PCL tears. Improvements in laxity ranged from 28% to 79% in the group with PCL tears. DISCUSSION: Most of the articles selected for our review provided level III or IV evidence. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. Full reconstruction seems the best strategy in patients with combined ACL/posterolateral corner injuries. Outcomes were also good but more variable in the group with PCL/posterolateral corner injuries. The time to surgery, which reflected the time to diagnosis, was shorter in patients with ACL than with PCL tears in addition to the posterolateral corner injury. LEVEL OF EVIDENCE: Level III (systematic literature review).

Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique.

Arthroscopy is becoming an essential tool for the treatment of chronic lateral ankle instability. It allows the surgeon to determine which ligaments are injured and choose the most appropriate surgical repair technique, and also to assess and treat any associated injuries. Several arthroscopic techniques for lateral ankle ligament repair have recently been developed. As a consequence, it may be possible to carry out complete lateral ligament reconstruction with an all-arthroscopic procedure. Such an arthroscopic lateral ankle ligament reconstruction technique is described in this article.

Rapid chondrolysis following an unoperated lateral meniscus tear in a young professional rugby player.

Rapid chondrolysis following a lateral meniscectomy is a rare complication. We present the first reported case of rapid chondrolysis of the lateral compartment, which developed 6 months after a meniscus tear that was not surgically treated in a young 18-year-old professional rugby player. The possible hypotheses to explain this complication are presented, and certain previously published causes were excluded (iatrogenic during surgery, undiagnosed increased rotatory instability, chondrotoxicity of bupivacaine). Overloading of the cartilage surface of the lateral compartment from meniscal extrusion can cause cartilage necrosis.

The arcuate ligament revisited: role of the posterolateral structures in providing static stability in the knee joint.

PURPOSE: To determine the involvement of the posterolateral structures including the lateral collateral ligament, the popliteus muscle-tendon unit, the arcuate ligament (popliteofibular ligament, fabellofibular ligament, popliteomeniscal fascicles, capsular arm of short head of the biceps femoris and anterolateral ligament) and the posterior cruciate ligament in providing restraint to excessive recurvatum, tibial posterior translation and external tibial rotation at 90° of flexion. METHODS: Ten fresh-frozen cadaveric knees were tested with dial test, posterior drawer test and recurvatum test. The values were collected, using a surgical navigation system, on intact knees, following a serial section of the posterolateral corner (lateral collateral ligament, arcuate ligament and popliteus muscle-tendon unit), followed by the additional section of the posterior cruciate ligament. RESULTS: The mean tibial external rotation, recurvatum and posterior drawer were, respectively, measured at 9° ± 4°, 2° ± 3° and 9 ± 1 mm on intact knees. These values increase to 12° ± 5°, 3° ± 2° and 9 ± 1 mm after cutting the lateral collateral ligament; 17° ± 6° (p < 0.05), 3° ± 2° and 10 ± 1 mm after sectioning the arcuate ligament; 18° ± 7°, 3° ± 2° and 10 ± 1 mm after sectioning the popliteus muscle-tendon unit and 27° ± 6° (p < 0.05), 5° ± 3° (p < 0.05) and 28 ± 2 mm (p < 0.05) after the additional section of the posterior cruciate ligament. CONCLUSION: Among the different structures of the posterolateral corner, only the arcuate ligament has a significant role in restricting excessive primary and coupled external rotation. The popliteus muscle-tendon unit is not a primary static stabilizer to tibial external rotation at 90° of knee flexion. The posterior cruciate ligament is the primary restraint to excessive recurvatum and posterior tibial translation. The posterior cruciate ligament and the arcuate ligament have predominant role for the posterolateral stability of the knee. The functional restoration of these ligaments is an important part of the surgical treatment of posterolateral ligamentous injuries.