Quadriceps Tendon Autograft ACL Reconstruction With Suture Tape Augmentation: Safe Results Based on Minimum 2-Year Follow-up MRI.

Background: The potential intra-articular effects of ≥1 year after anterior cruciate ligament reconstruction (ACLR) with independent suture tape augmentation (STA) are not fully understood. Purpose: To investigate whether incorporating suture tape in an all-soft tissue quadriceps tendon autograft (QTA) ACLR leads to satisfactory patient outcomes while having no intra-articular side effects as determined by magnetic resonance imaging (MRI). Study Design: Case series; Level of evidence, 4. Methods: Included were 25 patients with a mean age of 19.9 years (95% CI, 17.3-22.5 years) who underwent QTA ACLR with STA between 2016 and 2019. All patients underwent MRI at ≥1 year postoperatively and had at least a 2-year follow-up (mean, 28 months [95% CI, 26.5-29.5 months]) that included physical examination with anterior laxity testing with KT-1000 arthrometer, radiographs, and patient-reported outcome measures (PROMs). At the final follow-up, the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for applicable PROMs were applied to each patient. Postoperative graft and joint integrity were assessed using the Howell classification and the MRI Osteoarthritis Knee Score (MOAKS) joint effusion/synovitis grade. The Mann-Whitney U test for continuous variables and the chi-square or the Fisher exact test for categorical variables were used for statistical analyses. Results: The MRI assessment of the grafts demonstrated intact grafts in all patients. Overall, 96% of patients demonstrated grades 0 or 1 MOAKS for joint effusion/synovitis. All patient outcomes significantly improved from preoperatively to the final follow-up (P < .001), except for the Marx score, which decreased significantly (14.2 [95% CI, 12.7-15.8] vs 9.72 [95% CI, 7.3-12.2]; P = .0014). At least 68% of the patients achieved the MCID threshold, and 92% achieved the PASS threshold for all applicable PROMs. Conclusion: QTA ACLR with STA did not demonstrate adverse intra-articular changes on MRI at ≥1 year postoperatively. In addition, STA did not appear to negatively affect PROMs.

Prospective Consecutive Clinical Outcomes After Transtibial Root Repair for Posterior Meniscal Root Tears: A Multicenter Study.

BACKGROUND: Prospective evaluation of clinical outcomes after posterior meniscal root repair utilizing a transtibial pullout technique is limited, and factors that may contribute to outcomes are unclear. HYPOTHESIS: It was hypothesized that there would be an overall significant improvement in outcomes after root repair and that differences in clinical outcomes would correlate with age, body mass index (BMI), sex, and meniscal extrusion. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients undergoing transtibial medial or lateral meniscal root repair were enrolled prospectively at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) were obtained to assess for meniscal healing, quantification of extrusion, articular cartilage grade, and subchondral bone changes. Patient-reported outcomes including International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and visual analog scale (VAS) for pain were collected preoperatively and 2 years postoperatively. Patients were then subdivided by clinical and demographic characteristics to determine factors associated with clinical outcomes. RESULTS: Included were 45 patients (29 female, 16 male; mean age, 42.3 ± 12.9 years; mean BMI, 31.6 kg/m2) who underwent 47 meniscal root repairs (29 medial and 16 lateral; 2 had both). Significant improvements at 2-year follow-up were seen in IKDC score (41.1 vs 78.4; P < .001), Tegner activity level (3 vs 4; P < .001), and VAS pain (2.8 vs 0.7; P < .001). BMI, preoperative malalignment, cartilage status, and progressive meniscus extrusion (Δ = 0.7 mm) did not have a negative impact on IKDC and Tegner scores 2 years postoperatively. Age greater than or equal to 50 years and extrusion pre- and postoperatively were associated with decreased Tegner scores. Progressive meniscal extrusion was associated with a decreased overall improvement in Tegner scores. CONCLUSION: Transtibial root repair for medial and lateral posterior meniscal root tears demonstrated significantly improved clinical outcomes at 2 years postoperatively. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes (IKDC), but age greater than or equal to 50 years and extrusion negatively influenced patient activity level (Tegner). REGISTRATION: NCT03037242 (ClinicalTrials.gov identifier).

Good Surgical Outcomes After Concomitant Repair of Double Radial Tears of the Lateral Meniscus and Anterior Cruciate Ligament Reconstruction.

PURPOSE: To describe double radial tears of the lateral meniscus (LM), report early clinical treatment outcomes, and determine reoperation and failure rates. METHODS: Twenty-one (N = 21) consecutive cases of arthroscopic-treated lateral meniscus double radial tears treated between 2012 and 2018 were reviewed, including 15 males (71.4%) and 6 females (28.6%). Meniscus repairs were all performed at the time of anterior cruciate ligament (ACL) reconstruction. Patients with associated fractures or prior surgeries were excluded. Concomitant injuries were reported, as were preinjury and postoperative Tegner scores, preoperative and postoperative visual analogue pain scale (VAS) scores, and postoperative International Knee Documentation Committee (IKDC) subjective scores. Reoperation and failure rates were documented. RESULTS: Twenty-one (N = 21) tears were located in the posterior horn of the meniscus near the root attachment; 15 (71.4%) underwent all-inside repair, 4 (19.0%) underwent transtibial pull-through repair, 1 (4.8%) was partially debrided, and 1 (4.8%) was left untreated. Twenty-one tears (N = 21) were in the body of the meniscus; 7 (33.3%) were repaired, 7 (33.3%) were partially debrided, and 7 (33.3%) were left untreated. Thirteen patients (62%) had associated medial collateral ligament (MCL) injuries. Mean follow-up was 2.6 years. VAS at rest and with activity improved by 2.1 points (P < .001) and 3.1 points (P = .017) after surgery. The mean postoperative Tegner activity score was 6.4, and the mean IKDC score was 83.2 at final follow-up. Reoperation was required in 5 patients (23.8%), and the surgical treatment failed in 1 patient (4.7%). CONCLUSIONS: Double radial tears of the LM are uncommon injuries that occur in the setting of ACL tears, usually combined with MCL injury. The variety of surgical treatment techniques have a low failure rate at short-term follow-up. Patients tend to have good clinical outcomes with improvement in pain and overall function after surgically treating these injuries with simultaneous ACL reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series.

Association Between Transtibial Meniscus Root Repair and Rate of Meniscal Healing and Extrusion on Postoperative Magnetic Resonance Imaging: A Prospective Multicenter Study.

BACKGROUND: Prospective studies evaluating second-look imaging of meniscus root repair using a transtibial pull-out technique are limited; therefore, optimal surgical indications and the technique for meniscus root repair remain uncertain. HYPOTHESIS: It was hypothesized that there would be a high rate of healing, improvement in meniscal extrusion, and prevention of articular cartilage degeneration and subchondral bone abnormalities after meniscus root repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients undergoing transtibial root repair were prospectively enrolled at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) scans were reviewed by a musculoskeletal radiologist in a blinded fashion for meniscal healing, quantification of extrusion, articular cartilage grade, subchondral bone changes, and coronary/meniscotibial ligament abnormalities. Given persistent extrusion observed on postoperative MRI scans, an additional 10 patients gave consent and were enrolled for immediate (before weightbearing) postoperative MRI scans. RESULTS: A total of 45 patients (16 male, 29 female; mean ± standard deviation age, 42.3 ± 12.9 years; body mass index, 31.6) were prospectively enrolled in the study; there were 47 meniscus root repairs: 29 medial and 18 lateral (2 with both). Postoperative MRI was obtained at an average of 6.3 months (range, 5.1-8 months); 98% of meniscal repairs had evidence of healing. Mean extrusion increased significantly, from 1.9 ± 1.5 mm preoperatively to 2.6 ± 1.4 mm postoperatively (P = .03). There was no significant progression of chondromalacia grade, subchondral edema, insufficiency fracture, subchondral cysts, or subchondral collapse. In the additional 10-patient cohort, the mean preoperative extrusion (1.6 ± 1.2 mm) was not significantly different from that immediately postoperatively (2.0 ± 1.0 mm; P = .23). CONCLUSION: Prospective MRI analysis of transtibial meniscus root repair confirmed a high rate of meniscal healing and no observable progression of cartilage degeneration or subchondral bone abnormalities at the short-term follow-up. However, meniscal extrusion worsened in the first 6 months after surgery. REGISTRATION: NCT03037242 (ClinicalTrials.gov identifier).

Knotless Primary Anterior Cruciate Ligament Repair with Adjustable Loop Device and Internal Brace Augmentation.

With the recent resurgence of primary anterior cruciate ligament repair, it is important to strive for optimal patient outcomes. This knotless primary repair procedure takes advantage of the use of an adjustable loop device, which allows for intraoperative retensioning by the surgeon. This technical advancement combined with augmentation with an internal brace could potentially minimize gap formation at the repair site, thereby increasing repair stability and ultimate outcome.

Lateral Meniscal Oblique Radial Tears Are Common With ACL Injury: A Classification System Based on Arthroscopic Tear Patterns in 600 Consecutive Patients.

BACKGROUND: Meniscal root tears and ramp lesions have been rigorously characterized in recent literature. However, one of the most common lateral meniscal injuries identified with an acute anterior cruciate ligament (ACL) disruption, a posterior horn lateral meniscal oblique radial tear (LMORT), has not been thoroughly described. PURPOSE: To determine the incidence of all meniscal tears and, more specifically, the incidence of posterior horn LMORTs in a multicenter cohort of consecutive, acute ACL reconstructions. Additionally, the authors aimed to develop a new classification system to help guide treatment of posterior horn LMORTs. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A multicenter retrospective cohort design was used to analyze 200 consecutive cases of acute ACL reconstruction from each of 3 different surgeons, for a total of 600 patients. The operative notes and intraoperative photos were analyzed to determine the incidence and laterality of all meniscal tears. A classification system based on tear characterization was then used to categorize tear patterns into similar groups. RESULTS: A total of 396 (66%) of the 600 patients with acute ACL disruption had concomitant meniscal tears. Specifically, 187 (31%) had a lateral meniscal injury, 89 (15%) had a medial meniscal injury, and 122 (20%) had both medial and lateral meniscal injuries. The most common lateral meniscal tear was an LMORT; 71 (18%) patients with meniscal tears had a posterior horn LMORT. Overall, the incidence of ACL injury with a concomitant posterior horn LMORT was 12%. A classification was developed, which included type 1 tear (partial thickness <10 mm from the root attachment), type 2 tear (complete radial oblique tear that extended <10 mm from root), type 3 tear (incomplete LMORT that extended >10 mm from root), and type 4 tear (complete LMORT >10 mm from root). CONCLUSION: In 600 consecutive acute ACL reconstructions, the incidence of concomitant ACL injury with meniscal injury was 66%, and posterior horn LMORTs represented a large proportion of all meniscal tears (12%). A classification scheme was developed for posterior horn LMORTs to aid reporting and clinical decision making for these common tears.

All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger.

PURPOSE: To compare clinical outcomes of knee anterior cruciate ligament (ACL) autograft reconstruction using all-inside quadrupled semitendinosus (AIST) versus bone-patellar tendon-bone (BPTB) in a high-risk athletic population 24 years or younger. METHODS: Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the AIST (n = 32) or BPTB (n = 32) group and were followed for 2 years. Magnetic resonance imaging scans were obtained at 1-year follow-up, and radiographs were obtained at 2-year follow-up. All surgeries were performed by a single surgeon using an anteromedial portal to establish the femoral tunnel. The primary outcome measure was KT-1000 stability testing. Secondary outcome measures included International Knee Documentation Committee (IKDC) Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx Activity Scale, visual analog pain scale, and SF-12 (Mental and Physical). RESULTS: At 2-year follow-up, no statistical difference existed with KT-1000-measured side-to-side laxity between AIST (0.3 ± 0.7 mm, 95% confidence interval 0.0-1.0 mm) and BPTB (0.0 ± 0.8 mm, confidence interval CI -0.3 to 1.1 mm) (P = .197). In addition, no statistical differences between the groups were found for IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx, SF-12 Mental, SF-12 Physical, or with regards to imaging findings. Patients with BPTB reported significantly greater postoperative pain scores at days 2 (P = .049), 3 (P = .004), and 7 (P = .015) and had significantly greater kneeling pain at 2 years (P < .019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% AIST, 74% BPTB; P = .415). Two graft retears (7%; P = .222) occurred in the AIST group. Three patients in the BPTB group experienced ACL tears in the contralateral knee (9%; P = .239). CONCLUSIONS: ACL reconstruction with an all-inside quadrupled semitendinosus autograft construct is equivalent to patellar BPTB autograft based on KT-1000 stability testing in athletes 24 years or younger. LEVEL OF EVIDENCE: randomized controlled trial with 92% 2-year follow-up, Level I.

Clinical Update: Why PRP Should Be Your First Choice for Injection Therapy in Treating Osteoarthritis of the Knee.

PURPOSE OF REVIEW: The purpose of this review is to update the reader on the current applications of platelet-rich plasma (PRP) in the treatment of knee osteoarthritis (KOA). This review will focus on PRP's effect on the osteoarthritic joint, how PRP compares to traditional treatments of KOA, and provide clinical feedback on the use of PRP in an orthopedic and sports medicine practice. RECENT FINDINGS: Recent research into the applications of PRP for KOA has further indicated both the efficacy and safety of PRP treatment. Although research has shown a tendency toward better efficacy at earlier stages of osteoarthritis (OA), evidence exists to indicate positive effects at all stages of OA. In summary, since KOA is an extremely prevalent condition that can be a challenge to treat, it is imperative that safe and effective nonoperative treatment methods be available to individuals that are suffering from this condition.

Update on Internet-Based Orthopedic Registries.

With healthcare costs rising and healthcare value being emphasized, physicians now, more than ever, must capture and track patient care outcomes. Already burdened with electronic medical records, they must now collect outcomes data, as this information ultimately will be tied to reimbursement. Advances in Internet-based systems can facilitate the process. Not only is outcomes collection better for patient care, but the feedback that physicians receive from peer comparisons can enhance quality improvement.