Intra-Articular Pathology Associated with Acute and Chronic Anterior Cruciate Ligament Reconstruction.

Background: Concomitant meniscal and chondral pathology is common at the time of anterior cruciate ligament reconstruction (ACL-R). The purpose of the present study was to report the prevalence of concomitant intra-articular pathology for patients undergoing acute or chronic anterior cruciate ligament reconstruction. Methods: This study represents a prospective, consecutively collected cohort of 255 patients undergoing both primary and revision ACL-R between January 2012 and December 2014 at a single institution. The cohort was divided into an acute surgical group, defined as surgery within six weeks of injury, and a chronic surgical group, greater than six weeks removed from injury. The median time from injury to surgery for the entire cohort was 37 days (range: 4 days to 855 days). Variables of interest included patient demographic characteristics, concomitant meniscal and chondral pathology, and meniscus treatment. Results: Patients treated in the chronic setting were slightly older (28.7 ± 11.6 years vs. 23.1 ± 8.6 years, P=0.001), had a higher prevalence of complex tears of the medial meniscus (37.2% vs. 7.7%, P=0.012) and cartilage injury (16.5% vs. 7.8%, P=0.03). After excluding revision ACL-R procedures, complex medial meniscus tears in chronic ACL-R were higher than in acute ACL-R (medial= 27.3% vs. 3.0%, P=0.022), however when age was considered, these tears were no longer more frequent than in the acute setting (P=0.056). Similarly, the prevalence of cartilage injury was equivalent between groups after correcting for age (P=0.167). Among primary ACL-R, there were more medial meniscus repairs in the acute surgical group compared to the chronic group (60.6% vs. 24.2%, P=0.003). After excluding complex tears, medial meniscus repair rates were no longer performed more frequently in patients undergoing acute ACL-R (59.4% vs. 33.3%, P=0.054). Conclusions: Data from this prospective cohort suggest that with increasing time from ACL injury to ACL-R, medial meniscus pathology increases, with a lower likelihood of meniscal repair in all patients undergoing ACL-R. However, this finding is no longer statistically significant when considering only patients undergoing primary ACL-R. Age appears to play an important role in whether concomitant pathology develops following ACL rupture. Given these findings, early intervention may increase the ability to repair medial meniscus tears in the setting of ACL-R, but this conclusion is less supported in primary ACL-R.Level of Evidence: II.

Limited evidence that the presence of a bone bruise alone affects the clinical outcome of surgically reconstructed anterior cruciate ligaments: a systematic review.

IMPORTANCE: Anterior cruciate ligament (ACL) injury can be a devastating injury that without surgery may lead to chronic instability. Although surgical reconstruction recreates the stabilising constraint of the native ACL, postoperative pain and subsequent arthrosis may follow. OBJECTIVES: The primary objective of this systematic review is to determine whether the presence of a bone bruise following ACL rupture adversely affects the clinical outcomes following surgical reconstruction. EVIDENCE REVIEW: A standardised research protocol was used as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included for review were those of high level of evidence (I or II) and had MRI data on the presence of bone bruise and clinical outcome measures in patients who underwent surgical reconstruction of the ACL after traumatic rupture. Articles were searched using PubMed/ Medline, Cochrane Library, CINAHL and EMBASE databases using a keyword search. Article references and conference proceedings were subsequently reviewed on identification of articles found via the keyword search. Non-English literature, animal and basic science studies, studies focused on the skeletally immature and low level of evidence (III, IV, V) were excluded. A quantitative analysis of the data retrieved was summarised. FINDINGS: Five studies met the inclusion criteria. Follow-up ranged from the time of surgical reconstruction to 165 months. Although a variety of clinical outcome measures were used across studies, bone bruise cohorts did not demonstrate clinically inferior outcome scores. CONCLUSIONS AND RELEVANCE: Although osteochondral injury is frequently identified following ACL injury, the presence of a bone bruise alone does not appear to significantly adversely affect the clinical outcome of surgically reconstructed ACLs. However, factors such as articular cartilage injury and alteration in joint loading may be important variables for further research. LEVEL OF EVIDENCE: IV.

Infection following Anterior Cruciate Ligament Reconstruction: An Analysis of 6,389 Cases.

Infection following anterior cruciate ligament reconstruction (ACLR) is rare. Previous authors have concluded that diabetes, tobacco use, and previous knee surgery may influence infection rates following ACLR. The purpose of this study was to identify a cohort of patients undergoing ACLR and define (1) the incidence of infection after ACLR from a large multicenter database and (2) the risk factors for infection after ACLR. We identified patients undergoing elective ACLRs in the American College of Surgeons National Surgical Quality Improvement Program database between 2007 and 2013. The primary outcome was any surgical site infection within 30 days of surgery. We performed univariate and multivariate analyses comparing infected and noninfected cases to identify risk factors for infection. In total, 6,398 ACLRs were available for analysis of which 39 (0.61%) were diagnosed with a postoperative infection. Univariate analysis identified preoperative dyspnea, low hematocrit, operative time > 1 hour, and hospital admission following surgery as predictors of postoperative infection. Diabetes, tobacco use, age, and body mass index (BMI) were not associated with infection (p > 0.05). After multivariate analysis, the only independent predictor of postoperative infection was hospital admission following surgery (odds ratio, 2.67; 95% confidence interval, 1.02-6.96; p = 0.04). Hospital admission following surgery was associated with an increased incidence of infection in this large, multicenter cohort. Smoking, elevated BMI, and diabetes did not increase the risk infection in the present study. Surgeons should optimize outpatient operating systems and practices to aid in same-day discharges following ACLR.

Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries.

Postoperative knee stiffness can influence outcomes following operative treatment of multiligament knee injuries (MLKIs). The purpose of this study was to evaluate patient and surgical factors that may potentially contribute to stiffness following surgery for MLKIs. All surgically managed MLKIs involving two or more ligaments over a 10-year period at a single level one trauma center were included in this study. A retrospective review was performed to gather objective data related to the development of knee stiffness after surgery. Patients were classified as "stiff" postoperatively if they (1) had a flexion contracture greater than 10 degrees, (2) failed to reach 120 degrees of flexion at final follow-up, or (3) underwent a manipulation under anesthesia with or without arthroscopic lysis of adhesions to improve range of motion. Patient and surgical factors were evaluated systematically to determine factors associated with stiffness. The mean age of the cohort was 27.6 years at the time of surgery and mean follow-up was 50 weeks. Overall, 26/121 (21.5%) knees were diagnosed with postoperative stiffness. In the acute postoperative phase, 17 patients underwent manipulation under anesthesia. There were no significant differences in age, body mass index, associated injuries, mechanism, external fixation use or surgical timing (acute vs. chronic) between stiff and normal knees. Factors associated with the development of postoperative stiffness included knee dislocation (p = 0.04) and surgical intervention on three or more ligaments (p = 0.04). Careful attention to postoperative rehabilitation regimens should be given to patients with knee dislocations and/or those undergoing reconstruction or repair of three or more injured ligaments. Surgeons may utilize spanning external fixation if necessary without increasing the rate of long-term stiffness. Further, acute surgery does not appear to influence rates of postoperative stiffness or the need for manipulation.

Availability of consumer prices for bunion surgery.

BACKGROUND: Today, insurance insulates most patients from the true costs of the health care services they consume. Economists believe that the absence of price signals incentivizes patients to pursue more extensive care than they would otherwise. Reformers propose restoring price consciousness to patients as a way to tame the soaring costs of American health care. To test this idea, we decided to gauge the availability and variability of price quotes for a common elective surgery-bunion repair. METHODS: Orthopedic clinics were sorted by state and randomly selected from an online directory maintained by the American Orthopaedic Foot and Ankle Society. Each selected clinic was contacted up to 3 times in an attempt to get a full, bundled price quote using a standardized patient script. If this was unavailable, an isolated quote for the physician fee alone was solicited. RESULTS: Of the 141 clinics contacted, 56 (39.7%) could provide a physician price estimate and 12 (8.5%) could give a complete bundled estimate, including hospital fees. The overall mean bundled price quoted was $18 332, while the overall mean physician fee quoted was $2487. There was no statistically significant difference in the mean price quoted by academic and private clinics, nor was regional variation observed. CONCLUSION: We found low price availability for elective bunion procedures. CLINICAL RELEVANCE: However, the wide variation observed in the prices that were quoted suggests that a very determined patient may be able to spend substantially less on an elective surgery if they were willing to select a provider carefully.

National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes.

OBJECTIVE: To present recommendations for athletic trainers and other allied health care professionals in the conservative management and prevention of ankle sprains in athletes. BACKGROUND: Because ankle sprains are a common and often disabling injury in athletes, athletic trainers and other sports health care professionals must be able to implement the most current and evidence-supported treatment strategies to ensure safe and rapid return to play. Equally important is initiating preventive measures to mitigate both first-time sprains and the chance of reinjury. Therefore, considerations for appropriate preventive measures (including taping and bracing), initial assessment, both short- and long-term management strategies, return-to-play guidelines, and recommendations for syndesmotic ankle sprains and chronic ankle instability are presented. RECOMMENDATIONS: The recommendations included in this position statement are intended to provide athletic trainers and other sports health care professionals with guidelines and criteria to deliver the best health care possible for the prevention and management of ankle sprains. An endorsement as to best practice is made whenever evidence supporting the recommendation is available.

CAM-type impingement in the ankle.

BACKGROUND: Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion. METHODS: A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured. RESULTS: 34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus. CONCLUSIONS: Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA. LEVEL OF EVIDENCE: Level III.

Outcomes after trochleoplasty.

Trochlear dysplasia is a risk factor for patellofemoral instability. Trochleoplasty involves reshaping the trochlear groove to provide increased patellofemoral stability. We obtained post-operative radiographs, MRI, and outcome scores in 6 patients who underwent this procedure. All 6 of the patients were satisfied with their outcome following trochleoplasty with no recurrent instability events. Mean bony sulcus angles decreased from 148 degrees to 129 degrees. However, 4 of the 6 patients reported anterior knee pain. Similar to previously published studies, trochleoplasty can reliably improve patellofemoral stability in patients with severe trochlear dysplasia, but a high percentage of patients will have pain postoperatively.

Talar dome access for osteochondral lesions.

BACKGROUND: Recently, osteochondral grafting has become a popular procedure for treating challenging talar dome lesions. However, no guidelines exist for selection of the surgical approach to obtain perpendicular access to the talar dome. HYPOTHESIS: The majority of the talar dome can be accessed for perpendicular resurfacing procedures without need for osteotomy. STUDY DESIGN: Descriptive laboratory study. METHODS: Nine human cadaveric ankles were dissected in a standard fashion to expose the talar dome. Seven approaches were used, including 4 arthrotomies (anteromedial, anterolateral, posteromedial, and posterolateral) and 3 osteotomies (anterolateral [Chaput], distal fibula, and medial malleolar). The area available for perpendicular access to the dome was determined for each approach. RESULTS: On average, 17% (range, 10%-24%) of the medial talar dome and 20% (range, 16%-25%) of the lateral talar dome could not be accessed without osteotomy. On the lateral aspect of the superior talar dome surface, an anterolateral osteotomy adds a mean of 22% to sagittal plane exposure. Malleolar osteotomies, when performed using the method described, provide access to the entire medial and lateral sides; however, there remains a mean residual 15% (range, 11%-38%) of the central talar dome that cannot be accessed in a perpendicular manner with any approach. CONCLUSION: Most of the talar dome can be accessed perpendicularly for resurfacing without malleolar osteotomy. Osteotomies substantially increase the access and are needed for extensive lesions. Part of the central portion of the talar dome is inaccessible to perpendicular resurfacing techniques with any standard approach. CLINICAL RELEVANCE: This study generated clear clinical guidelines to help decision making regarding the surgical approach to resurface the talar dome with osteochondral techniques. The majority of the talar dome can be accessed without osteotomy.

Isokinetic evaluation of internal/external tibial rotation strength after the use of hamstring tendons for anterior cruciate ligament reconstruction.

BACKGROUND: Evaluation of the knee after an anterior cruciate ligament reconstruction with the use of the semitendinosus and gracilis (hamstring) autografts has primarily focused on flexion and extension strength. The semitendinosus and gracilis muscles contribute to internal tibial rotation, and it has been suggested that harvest of these tendons for the purpose of an anterior cruciate ligament reconstruction contributes to internal tibial rotation weakness. HYPOTHESIS: Internal tibial rotation strength may be affected by the semitendinosus and gracilis harvest after anterior cruciate ligament reconstruction. STUDY DESIGN: Prospective evaluation of internal and external tibial rotation strength. METHODS: Inclusion criteria for subjects (N = 30): unilateral anterior cruciate ligament reconstruction at least 2 years previously, a stable anterior cruciate ligament (<5-mm side-to-side difference) at time of testing confirmed by surgeon and KT-1000 arthrometer, no history of knee problems after initial knee reconstruction, a normal contralateral knee, and the ability to comply with the testing protocol. In an attempt to minimize unwanted subtalar joint motion, subjects were immobilized using an ankle brace and tested at angular velocities of 60 degrees /s, 120 degrees /s, and 180 degrees /s at a knee flexion angle of 90 degrees . RESULTS: The mean peak torque measurements for internal rotation strength of the operative limb (60 degrees /s, 17.4 +/- 4.5 ft-lb; 120 degrees /s, 13.9 +/- 3.3 ft-lb; 180 degrees /s, 11.6 +/- 3.0 ft-lb) were statistically different compared to the nonoperated limb (60 degrees /s, 20.5 +/- 4.7 ft-lb; 120 degrees /s, 15.9 +/- 3.8 ft-lb; 180 degrees /s, 13.4 +/- 3.8 ft-lb) at 60 degrees /s (P = .012), 120 degrees /s (P = .036), and 180 degrees /s (P = .045). The nonoperative limb demonstrated greater strength at all speeds. The mean torque measurements for external rotation were statistically similar when compared to the nonoperated limb at all angular velocities. CONCLUSIONS: We have shown through our study that patients who undergo surgical intervention to repair a torn anterior cruciate ligament with the use of autogenous hamstring tendons demonstrate with weaker internal tibial rotation postoperatively at 2 years when compared to the contralateral limb.