The Effect of Tibial Tunnel Drilling Technique on Retained Intra-Articular Bone Debris Following Anterior Cruciate Ligament Reconstruction.

Purpose: To assess the effect of tibial tunnel drilling technique (retro-drilled bone socket vs full tibial tunnel) on the presence and grade of postoperative, intra-articular bone debris following primary hamstring anterior cruciate ligament (ACL) reconstruction. Methods: This was a retrospective cohort study of primary hamstring autograft ACL reconstructions performed by 2 surgeons. Two blinded independent reviewers assessed the presence and length of retained intra-articular bone debris on the immediate postoperative lateral radiograph. Debris was graded according to a predefined 5-point ordinal grading system: grade 0 (no debris) to IV (severe debris). Results were analyzed according to the type of tibial tunnel; retro-drilled socket or full tibial tunnel using Kappa statistics and the Mann-Whitney U test. Results: Sixty-five patients undergoing primary hamstring ACL were included (39 tibial socket: 26 full tibial tunnel). Bone debris was observed among the tibial socket technique in 29 of 39 instances (74.3%), compared with 14 of 26 (53.8%) instances for the full tibial tunnel technique (P = .09). Where there was measurable debris present, the tibial socket group had a mean length of bone debris of 13.7 ± 6.2 mm as compared with the full tibial tunnel, 10.0 ± 4.7 mm (P = .165). There were significant differences in bone debris gradings between the 2 treatment groups, with tibial sockets having an overall greater grade (P = .04). Conclusions: A difference in the presence of, or length of, retained bone debris on the postoperative lateral radiograph was not demonstrated between the retro-drilled bone socket and full tibial tunnel techniques. However, when bone debris was present, greater grades of debris were seen in the retro-drilled socket group. Level of Evidence: III, retrospective, comparative study.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR).

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique. METHODS: The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation. DISCUSSION: This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

Effect of Radiological Evidence of Kaplan Fiber Injury on the Clinical and Functional Outcomes After Acute Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A paucity of information is available regarding the clinical outcomes of patients with radiological evidence of Kaplan fiber (KF) injury who undergo anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose was to compare clinical and functional outcomes in patients undergoing acute primary ACLR with and without magnetic resonance imaging (MRI) evidence of KF injury. The hypothesis was that there would be no difference in clinical or functional outcomes in patients with versus those without radiological evidence of KF injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MRI analysis was conducted on patients in a longitudinal prospective study of ACL injury. Only patients who had an MRI scan and had undergone isolated primary ACLR within 60 days of injury were included. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. A total of 32 patients with KF injury (mean age, 24.2 years; 21 male, 11 female) were identified and matched for sex, age, graft type, and preinjury activity with 90 patients who had intact KF. Patients were followed up at 12 months with KT-1000 arthrometer measurements of side-to-side difference in anterior knee laxity, single- and triple-hop limb symmetry index (LSI), Marx activity and International Knee Documentation Committee (IKDC) scores, and return to sport (RTS) rates at 12 months and 24 months. RESULTS: No differences were found in anterior knee laxity and single- and triple-hop LSI values between the KF-intact and KF-injured cohorts at 12 months. No differences in Marx and IKDC scores were found between the groups at 12 months and 2 years. The overall rate of RTS within 24 months was 75% (92/122), and 5 patients (2 KF-injured; 3 KF-intact) had a subsequent graft rupture. CONCLUSION: We found no difference in clinical or functional outcomes in patients with and without radiological evidence of KF injury who underwent acute primary ACLR. Based on these findings, the radiological presence of KF injury at the time of acute ACL injury should not be regarded as a risk factor for a negative prognosis after ACLR.

Management and outcomes of proximal tibiofibular joint ganglion cysts: A systematic review.

BACKGROUND: Proximal tibiofibular joint (PTFJ) ganglion cysts are rare; however, their optimal management remains unclear. This study aimed to systematically review the surgical treatment options with a focus on recurrence rates and complications. METHODS: A systematic review of the literature was performed, searching three electronic databases, according to the PRISMA guidelines. The presentation, treatment, and outcomes of PTFJ ganglion cysts of minimum 1-year follow-up was collected. Study quality was assessed using the Modified Downs and Blacks checklist. Surgical interventions were considered ordinally from simple to more extensive as follows; cyst aspiration, cyst excision, cyst excision with an intervention to the PTFJ, either a hemi-resection or arthrodesis. RESULTS: Twenty-two studies comprising 100 patients (101 knees) met inclusion criteria. Among all patients, pain was present in 59.7%, a lateral fullness in 71.6% and symptoms of the common peroneal nerve in 57.4%. The overall rate of recurrence after primary treatment was 28.9%. Recurrence rates for aspiration, cyst excision, PTFJ hemi-resection and PTFJ arthrodesis were 81.8%, 27.4%, 8.3% and 0%, respectively. Revision excision for recurrence failed in all cases. Outcomes beyond recurrence were poorly reported. CONCLUSION: Addressing the PTFJ at the time of cyst excision reduces recurrence rates, however, the morbidity from PTFJ hemi-resection and arthrodesis are poorly reported. Whilst primary excision offers resolution in most cases (73%), revision cyst excision in isolation for the treatment of recurrent cysts is an inadequate treatment option. Cyst aspiration is ineffective. Data pertaining to patient reported outcomes for all treatment types are lacking.

Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience.

PURPOSE: To assess how meniscal repair and excision impact short term patient-reported outcome measures (PROMs), knee stability, and early graft rupture rates following primary hamstring anterior cruciate ligament reconstruction (ACLR) with or without lateral extra-articular tenodesis (LET) in a group of young active patients where meniscal repair is commonly advocated. METHODS: Six hundred and eighteen patients under 25 years of age at high-risk of graft failure following ACLR were recruited to the Stability 1 study. Multivariable regression models were developed to identify statistically and clinically significant surgical and demographic predictors of Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Form (IKDC), ACL Quality of Life Questionnaire (ACL-QOL) and Marx Activity Rating Scale (MARS) scores. Chi-Square tests of independence were used to explore the association between meniscal status (torn, not torn), meniscal treatment (excision or repair), graft rupture, and rotatory knee laxity. RESULTS: Medial meniscus repair was associated with worse outcomes on the KOOS (ß = -1.32, 95% CI: -1.57 to -1.10, p = 0.003), IKDC (ß = -1.66, 95% CI: -1.53 to -1.02, p = 0.031) and ACL-QOL (ß = -1.25, 95% CI: -1.61 to 1.02, p = n.s.). However, these associations indicated small, clinically insignificant changes based on reported measures of clinical relevance. Other important predictors of post-operative PROMs included age, sex, and baseline scores. Medial meniscus excision and lateral meniscus treatment (repair or excision) did not have an important influence on PROMs. There was no significant association between meniscal treatment and graft rupture or rotatory knee laxity. CONCLUSION: While repairing the medial meniscus may result in a small reduction in PROM scores at two-year follow-up, these differences are not likely to be important to patients or clinicians. Any surgical morbidity associated with meniscal repair appears negligible in terms of PROMs. Meniscal repair does not affect rotatory laxity or graft failure rates in the short term. Therefore, meniscal repair should likely be maintained as the standard of care for concomitant meniscal tears with ACLR. LEVEL OF EVIDENCE: III.

Combined Biplanar Medial Closing-Wedge Distal Femoral Osteotomy and Quadriceps Tendon Medial Patellofemoral Ligament Reconstruction.

Lateral patellofemoral instability is multifactorial in etiology, with bony and soft-tissue factors contributing. Coronal plane alignment, in particular genu valgum, is important to consider when evaluating lateral patellofemoral instability. When genu valgum is present and thought to be a significant contributing factor, we typically address this with an extra-articular, biplanar, medial closing-wedge distal femoral osteotomy (DFO). This can be combined with a medial patellofemoral ligament reconstruction using a partial-thickness quadriceps tendon graft via the same incision. A medial closing-wedge DFO with locking plate fixation affords a highly stable construct suitable for early weight-bearing. The locking plate is less prominent as compared with a lateral opening-wedge DFO, and it does not irritate the iliotibial band or cause tightening of the illiopatellar expansion. The biplanar nature of the osteotomy prevents extension of the osteotomy into the proximal trochlear, helps to control rotation in both axial and sagittal plane after wedge removal, and increases the bony surface area for healing. The quadriceps tendon medial patellofemoral ligament reconstruction allows a graft that can be tailored in terms of length and diameter, does not require an anchor on the patellar, and can be performed through the same incision as for the DFO.

No Difference in Ligamentous Strain or Knee Kinematics Between Rectangular or Cylindrical Femoral Tunnels During Anatomic ACL Reconstruction With a Bone-Patellar Tendon-Bone Graft.

BACKGROUND: As our understanding of anterior cruciate ligament (ACL) anatomy has evolved, surgical techniques to better replicate the native anatomy have been developed. It has been proposed that the introduction of a rectangular socket ACL reconstruction to replace a ribbon-shaped ACL has the potential to improve knee kinematics after ACL reconstruction. PURPOSE: To compare a rectangular femoral tunnel (RFT) with a cylindrical femoral tunnel (CFT) in terms of replicating native ACL strain and knee kinematics in a time-zero biomechanical anatomic ACL reconstruction model using a bone-patellar tendon-bone (BTB) graft. STUDY DESIGN: Controlled laboratory study. METHODS: In total, 16 fresh-frozen, human cadaveric knees were tested in a 5 degrees of freedom, computed tomography-compatible joint motion simulator. Knees were tested with the ACL intact before randomization to RFT or CFT ACL reconstruction using a BTB graft. An anterior translation load and an internal rotation moment were each applied at 0°, 30°, 60°, and 90° of knee flexion. A simulated pivot shift was performed at 0° and 30° of knee flexion. Ligament strain and knee kinematics were assessed using computed tomography facilitated by insertion of zirconium dioxide beads placed within the substance of the native ACL and BTB grafts. RESULTS: For the ACL-intact state, there were no differences between groups in terms of ACL strain or knee kinematics. After ACL reconstruction, there were no differences in ACL graft strain when comparing the RFT and CFT groups. At 60° of knee flexion with anterior translation load, there was significantly reduced strain in the reconstructed state ([mean ±standard deviation] CFT native, 2.82 ± 3.54 vs CFT reconstructed, 0.95 ± 2.69; RFT native, 2.77 ± 1.71 vs RFT reconstructed, 1.40 ± 1.76) independent of the femoral tunnel type. In terms of knee kinematics, there were no differences when comparing the RFT and CFT groups. Both reconstructive techniques were mostly effective in restoring native knee kinematics and ligament strain patterns as compared with the native ACL. CONCLUSION: In the time-zero biomechanical environment, similar graft strains and knee kinematics were achieved using RFT and CFT BTB ACL reconstructions. Both techniques appeared to be equally effective in restoring kinematics associated with the native ACL state. CLINICAL RELEVANCE: These data suggest that in terms of knee kinematics and graft strain, there is no benefit in performing the more technically challenging RFT as compared with a CFT BTB ACL reconstruction.

Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study.

BACKGROUND: A spectrum of anterolateral rotatory laxity exists in anterior cruciate ligament (ACL)-injured knees. Understanding of the factors contributing to a high-grade pivot shift continues to be refined. PURPOSE: To investigate factors associated with a high-grade preoperative pivot shift and to evaluate the relationship between this condition and baseline patient-reported outcome measures (PROMs). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A post hoc analysis was performed of 618 patients with ACL deficiency deemed high risk for reinjury. A binary logistic regression model was developed, with high-grade pivot shift as the dependent variable. Age, sex, Beighton score, chronicity of the ACL injury, posterior third medial or lateral meniscal injury, and tibial slope were selected as independent variables. The importance of knee hyperextension as a component of the Beighton score was assessed using receiver operator characteristic curves. Baseline PROMs were compared between patients with and without a high-grade pivot. RESULTS: Six factors were associated with a high-grade pivot shift: Beighton score (each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30; P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13; P = .005), presence of a posterior third medial (OR, 2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95% CI, 1.01-3.08; P = .048) meniscal injury, tibial slope >9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P = .049). The presence of knee hyperextension improved the diagnostic utility of the Beighton score as a predictor of a high-grade pivot shift. Tibial slope <9° was associated with only a high-grade pivot in the presence of a posterior third medial meniscal injury. Patients with a high-grade pivot shift had higher baseline 4-Item Pain Intensity Measure scores than did those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14; P = .04); however, there was no difference between groups in baseline International Knee Documentation Committee, ACL Quality of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and Osteoarthritis Outcome Score subscale scores. CONCLUSION: Ligamentous laxity, male sex, posterior third medial or lateral meniscal injury, increased posterior tibial slope, and chronicity were associated with a high-grade pivot shift in this population deemed high risk for repeat ACL injury. The effect of tibial slope may be accentuated by the presence of meniscal injury, supporting the need for meniscal preservation. Baseline PROMs were similar between patients with and without a high-grade pivot shift.

Association Between Radiological Evidence of Kaplan Fiber Injury, Intraoperative Findings, and Pivot-Shift Grade in the Setting of Acute Anterior Cruciate Ligament Injury.

BACKGROUND: Biomechanical studies have suggested that the Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotation of the knee. There is a paucity of clinical information on whether injury to the KF in the setting of anterior cruciate ligament (ACL) rupture contributes to increased rotatory laxity of the knee. PURPOSE/HYPOTHESIS: The purpose was to evaluate the association among radiological evidence of KF injury, intraoperative arthroscopic findings, and grade of pivot shift at the time of ACL reconstruction (ACLR). It was hypothesized that KF injury would be associated with increased injury to the lateral compartment of the knee and a higher grade of pivot shift. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective magnetic resonance imaging (MRI) analysis was conducted on 267 patients with ACL-injured knees who underwent primary ACLR. Patients who had MRI and surgery within 60 days of injury were included (mean age, 23.6 years); there were 158 (59.2%) male patients. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. Associations were made among MRI findings, intraoperative findings, and grade of pivot shift with the patient examined under anesthesia at the time of ACLR. A comparison was made between patients with and without radiological evidence of KF injury. RESULTS: The prevalence of KF injury was 17.6% (47/267 patients). Arthroscopic evidence of lateral meniscal injury was associated with KF injury (KF intact, 31%; KF injured, 55%; P = .010). The majority of patients in the intact and injured KF groups had a grade 2 pivot shift (75% and 70%, respectively). A minority had grade 3 pivot shift: 5% in the intact group versus 6.4% in the injured group. There was no association between radiological evidence of KF injury and pivot-shift grade (P = .600). CONCLUSION: In acute ACL injury, KF injuries were not very common (17.6%), and the rate of grade 3 pivot shift was low (5.2%). When present, KF injuries were not associated with a higher-grade pivot shift. However, there was an association between KF injury and lateral meniscal tears identified at the time of ACLR. The role of KFS in controlling anterolateral rotatory laxity in the acute ACL injury in the clinical setting may be less evident when compared with the biomechanical setting.

Single-Leg Squat After Anterior Cruciate Ligament Reconstruction: An Analysis of the Knee Valgus Angle at 6 and 12 Months.

BACKGROUND: Deficits in neuromuscular control are common after anterior cruciate ligament (ACL) reconstruction and may be associated with further knee injury. The knee valgus angle during a single-leg squat (SLS) is one measure of neuromuscular performance. PURPOSE: To determine whether the knee valgus angle during SLS changes between 6 and 12 months after ACL reconstruction and to assess how the operative knee valgus angle compares with that of the contralateral side. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A cohort of 100 patients with uninjured contralateral knees were assessed at 6 and 12 months after primary hamstring autograft ACL reconstruction. Participants performed the SLS on each leg, and the knee valgus angle was measured via frame-by-frame video analysis at 30° of flexion and at each patient's maximum knee flexion angle. RESULTS: For the operative limb at 30° of flexion, a small but statistically significant reduction was noted in the valgus angle between 6 and 12 months (5.46° vs 4.44°; P = .002; effect size = 0.24). At 6 months, a slightly higher valgus angle was seen in the operative limb compared with the nonoperative limb (5.46° vs 4.29°; P = .008; effect size = 0.27). At maximum flexion, no difference was seen between limbs in the valgus angle at either 6 or 12 months, and no change was seen in the operative limb between 6 and 12 months. At 6 months and 30° of knee flexion, 13 patients had a valgus angle greater than 10°. This group also had a higher mean valgus angle in the contralateral limb compared with the contralateral limb in the other 87 patients (8.5° vs 3.65°; P < .001). CONCLUSION: During a controlled SLS, the knee valgus angle remained essentially constant, and minimal limb asymmetries were present over the 6- to 12-month postoperative period, a time when athletes typically increase their activity levels. Whether changes or asymmetries will be seen with more dynamically challenging tasks remains to be determined. When present, high valgus angles were commonly bilateral.

Contemporary Strategies to Prevent Infection in Hip and Knee Arthroplasty.

PURPOSE OF REVIEW: Prosthetic joint infection (PJI) remains a serious concern in lower limb arthroplasty. Despite the significant consequences of PJI, the assessment of the safety and efficacy of preventative measures is challenging due to a low event rate. Notwithstanding, enormous efforts have been made in this arena, and prevention strategies continue to evolve. This review provides an update on contemporary literature (published within the last 5 years) pertaining to infection prevention in primary hip and knee arthroplasty. RECENT FINDINGS: Patient optimization has been highlighted as a critical preoperative factor in mitigating PJI risk. Recent evidence emphasizes the importance of preoperative glycaemic control, nutritional status, weight optimization and smoking cessation prior to hip and knee arthroplasty. Perioperatively, attention to detail in terms of surgical skin preparation agent and technique as well as prophylactic antibiotic agent, spectrum, dose and timing is important with statistically and clinically significant differences seen between differing strategies. Intraosseous regional antibiotic administration is an emerging technique with promising preclinical data. Dilute betadine lavage also shows promise. Data supporting bundled interventions continues to grow. A multimodal approach is required in PJI prevention, and attention to detail is important with each element. Patient optimization is critical, as is the execution of the planned perioperative infection prevention strategy.

Radiological Identification of Injury to the Kaplan Fibers of the Iliotibial Band in Association With Anterior Cruciate Ligament Injury.

BACKGROUND: Recent biomechanical studies have demonstrated that the Kaplan fibers (KFs) of the iliotibial band play a role in the control of anterolateral rotation of the knee. However, controversy exists regarding whether the KFs are injured in conjunction with anterior cruciate ligament (ACL) injury. PURPOSE: To establish the prevalence of radiological injury to the KFs in the ACL-injured knee; to evaluate the effect of the time interval between injury and magnetic resonance imaging (MRI) on diagnosis of KF injury; and to assess for any association between KF injury and other qualitative radiological findings. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Preoperative MRI scans were reviewed for 161 patients with ACL injury. Specific diagnostic criteria were developed and applied to identify KF injury. Chi-square testing was performed to look for associations among KF injury, the time from injury to MRI, and associated radiological knee injuries. RESULTS: Radiological evidence of KF injury was identified in 30 (18.6%) patients. The diagnosis of KF injury was higher in patients who had MRI scans performed within 90 days of injury as compared with ≥90 days after injury (23.7 vs 6.4%; P = .010). Patients with an MRI diagnosis of KF injury had significantly higher rates of lateral meniscal injury (40% vs 18%; P = .007), posteromedial tibial bone marrow edema (73% vs 44%; P = .003), and injury to the lateral collateral ligament (13% vs 3%; P = .019) or medial collateral ligament (23% vs 8%; P = .019). CONCLUSION: The prevalence of injury to the KF in patients with ACL injury as diagnosed by MRI was relatively low (18.6% of patients). However, the time interval from injury to MRI was relevant to diagnosis, with significantly higher rates of injury identification in patients with early (within 90 days) versus delayed (≥90 days) MRI. KF injury was associated with higher rates of injury to the lateral meniscal and collateral ligaments, as well as posteromedial tibial bone bruising.

Single-Leg Squat Performance and Its Relationship to Extensor Mechanism Strength After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Performance in strength and functional testing is important when considering return to sport after anterior cruciate ligament (ACL) reconstruction. Both knee extensor strength and the single-leg squat (SLS) have been used in this context. PURPOSE: To evaluate the relationship between knee extensor strength and SLS performance after primary ACL reconstruction. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: A prospective cohort of 100 patients was assessed 6 and 12 months after primary ACL reconstruction with a hamstring tendon autograft. Knee extensor peak torque was measured. Three sequential SLSs were performed, and the maximum flexion angle identified from frame-by-frame video analysis was used as the measure of squat performance. A limb symmetry index (LSI) was calculated and satisfactory performance defined as ≥90%. RESULTS: Extensor mechanism strength deficits were seen in 75% of patients at 6 months and 57% at 12 months postoperatively. Mean extensor mechanism strength showed a large improvement between 6 and 12 months (123.6 vs 147.8 N·m, respectively; P < .001; Cohen d = 1.10), and while there was also a statistically significant improvement in the mean maximum flexion angle, the change was small (66.1° vs 68.1°, respectively; P = .011; Cohen d = 0.26). There was a weak positive correlation between knee extensor strength and the SLS maximum flexion angle at 6 months (r = 0.342; P < .001) and 12 months (r = 0.245; P = .014). An SLS LSI <90% was 80% specific and 35% sensitive for extensor mechanism weakness at 6 months and 79% specific and 18% sensitive at 12 months. CONCLUSION: Extensor mechanism strength deficits are common after ACL reconstruction but reduce between 6 and 12 months. The SLS maximum flexion angle has a weak linear relationship to knee extensor strength. SLS performance has high specificity but low sensitivity in identifying extensor mechanism strength deficits. The SLS maximum flexion angle is therefore a suboptimal surrogate test to identify extensor mechanism strength deficits as diagnosed by isokinetic dynamometric testing. However, unsatisfactory SLS performance indicates a very high chance of underlying extensor mechanism weakness.

The Kaplan Fibers of the Iliotibial Band Can Be Identified on Routine Knee Magnetic Resonance Imaging.

BACKGROUND: The Kaplan fibers (KFs) of the iliotibial band have been suggested to play a role in anterolateral rotational instability of the knee, particularly in the setting of an anterior cruciate ligament (ACL) rupture. Description of the normal magnetic resonance imaging (MRI) anatomy of the KFs may facilitate subsequent investigation into the MRI signs of injury. PURPOSE: To assess if the KF complex can be identified on 3-T MRI using standard knee protocols. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: 3-T MRI scans of 50 ACL-intact knees were reviewed independently by a musculoskeletal radiologist and 2 orthopaedic surgeons. Identification of the KFs was based on radiological diagnostic criteria developed a priori. Identification of the KFs in the sagittal, coronal, and axial planes was recorded. Interobserver reliability was assessed using the Kappa statistic. Detailed anatomy including distance to the joint line and relationship to adjacent structures was recorded. RESULTS: The mean patient age was 43 years (range, 15-81 years), 58% were male, and 50% were right knees. The KFs were identified by at least 2 reviewers on the sagittal images in 96% of cases, on the axial images in 76% of cases, and on the coronal images in 4% of cases. The mean distance from the KF distal femoral insertion to the lateral joint line was 50.1 mm (SD, 6.6 mm) and the mean distance to the lateral gastrocnemius tendon origin was 10.8 mm (SD, 8.6 mm). The KFs were consistently identified immediately anterior to the superior lateral geniculate artery on sagittal imaging. Interobserver reliability for identification was best in the sagittal plane (Kappa 0.5) and worst in the coronal plane (Kappa 0.1). CONCLUSION: The KF complex can be identified on routine MRI sequences in the ACL-intact knee; however, there is low to moderate interobserver reliability. Imaging in the sagittal plane had the highest rate of identification and the coronal plane the lowest. There is a consistent relationship between the most distal KF femoral attachment and the lateral joint line, lateral gastrocnemius tendon, and superior lateral geniculate artery.

Clinical Results of Lateral Extra-Articular Tenodesis.

In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.

Interventions for reducing wrong-site surgery and invasive clinical procedures.

BACKGROUND: Specific clinical interventions are needed to reduce wrong-site surgery, which is a rare but potentially disastrous clinical error. Risk factors contributing to wrong-site surgery are variable and complex. The introduction of organisational and professional clinical strategies have a role in minimising wrong-site surgery. OBJECTIVES: To evaluate the effectiveness of organisational and professional interventions for reducing wrong-site surgery (including wrong-side, wrong-procedure and wrong-patient surgery), including non-surgical invasive clinical procedures such as regional blocks, dermatological, obstetric and dental procedures and emergency surgical procedures not undertaken within the operating theatre. SEARCH METHODS: For this update, we searched the following electronic databases: the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014), MEDLINE (June 2011 to January 2014), EMBASE (June 2011 to January 2014), CINAHL (June 2011 to January 2014), Dissertations and Theses (June 2011 to January 2014), African Index Medicus, Latin American and Caribbean Health Sciences database, Virtual Health Library, Pan American Health Organization Database and the World Health Organization Library Information System. Database searches were conducted in January 2014. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs), non-randomised controlled trials, controlled before-after studies (CBAs) with at least two intervention and control sites, and interrupted-time-series (ITS) studies where the intervention time was clearly defined and there were at least three data points before and three after the intervention. We included two ITS studies that evaluated the effectiveness of organisational and professional interventions for reducing wrong-site surgery, including wrong-side and wrong-procedure surgery. Participants included all healthcare professionals providing care to surgical patients; studies where patients were involved to avoid the incorrect procedures or studies with interventions addressed to healthcare managers, administrators, stakeholders or health insurers. DATA COLLECTION AND ANALYSIS: Two review authors independently assesses the quality and abstracted data of all eligible studies using a standardised data extraction form, modified from the Cochrane EPOC checklists. We contacted study authors for additional information. MAIN RESULTS: In the initial review, we included one ITS study that evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site tooth extractions. The intervention included examination of previous cases of wrong-site tooth extractions, educational intervention including a presentation of cases of erroneous extractions, explanation of relevant clinical guidelines and feedback by an instructor. Data were reported from all patients on the surveillance system of a University Medical centre in Taiwan with a total of 24,406 tooth extractions before the intervention and 28,084 tooth extractions after the intervention. We re-analysed the data using the Prais-Winsten time series and the change in level for annual number of mishaps was statistically significant at -4.52 (95% confidence interval (CI) -6.83 to -2.217) (standard error (SE) 0.5380). The change in slope was statistically significant at -1.16 (95% CI -2.22 to -0.10) (SE 0.2472; P < 0.05).This update includes an additional study reporting on the incidence of neurological WSS at a university hospital both before and after the Universal Protocol's implementation. A total of 22,743 patients undergoing neurosurgical procedures at the University of Illionois College of Medicine at Peoria, Illinois, United States of America were reported. Of these, 7286 patients were reported before the intervention and 15,456 patients were reported after the intervention. The authors found a significant difference (P < 0.001) in the incidence of WSS between the before period, 1999 to 2004, and the after period, 2005 to 2011.  Similarly, data were re-analysed using Prais-Winsten regression to correct for autocorrelation. As the incidences were reported by year only and the intervention occurred in July 2004, the intervention year 2004 was excluded from the analysis. The change in level at the point the intervention was introduced was not statistically significant at -0.078 percentage points (pp) (95% CI -0.176 pp to 0.02 pp; SE 0.042; P = 0.103). The change in slope was statistically significant at 0.031 (95% CI 0.004 to 0.058; SE 0.012; P < 0.05). AUTHORS' CONCLUSIONS: The findings of this update added one additional ITS study to the previous review which contained one ITS study. The original review suggested that the use of a specific educational intervention in the context of a dental outpatient setting, which targets junior dental staff using a training session that included cases of wrong-site surgery, presentation of clinical guidelines and feedback by an instructor, was associated with a reduction in the incidence of wrong-site tooth extractions. The additional study in this update evaluated the annual incidence rates of wrong-site surgery in a neurosurgical population before and after the implementation of the Universal Protocol. The data suggested a strong downward trend in the incidence of wrong-site surgery prior to the intervention with the incidence rate approaching zero. The effect of the intervention in these studies however remains unclear, as data reflect only two small low-quality studies in very specific population groups.

Synthetic devices for reconstructive surgery of the cruciate ligaments: a systematic review.

PURPOSE: The role of synthetic devices in the management of the cruciate ligament-injured knee remains controversial. The aim of this systematic review was to assess the safety and efficacy of synthetic devices in cruciate ligament surgery. METHODS: A systematic review of the electronic databases Medline, Embase, and The Cochrane Library (issue 1, 2014) on January 13, 2014, was performed to identify controlled and uncontrolled trials. Trials that assessed the safety and efficacy of synthetic devices for cruciate ligament surgery were included. The main variables assessed included rates of failure, revision, and noninfective effusion and synovitis. Patient-reported outcome assessments and complications were also assessed where reported. RESULTS: From 511 records screened, we included 85 articles published between 1985 and 2013 reporting on 6 synthetic devices (ligament augmentation and reconstruction system [Ligament Augmentation and Reconstruction System (LARS; Surgical Implants and Devices, Arc-sur-Tille, France)]; Leeds-Keio [Xiros (formerly Neoligaments), Leeds, England]; Kennedy ligament augmentation device [3M, St Paul, MN]; Dacron [Stryker, Kalamazoo, MI]; Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ]; and Trevira [Telos (limited liability company), Marburg, Germany]). The heterogeneity of the included studies precluded meta-analysis. The results were analyzed by device and then type of reconstruction (anterior cruciate ligament [ACL]/posterior cruciate ligament [PCL]/combined ACL and PCL). The lowest cumulative rates of failure were seen with the LARS device (2.6% for ACL and 1% for PCL surgery). The highest failure rate was seen in the Dacron ACL group (cumulative rate, 33.6%). Rates of noninfective synovitis and effusion ranged from 0.2% in the LARS ACL group to 27.6% in the Gore-Tex ACL group. Revision rates ranged from 2.6% (LARS) to 11.8% (Trevira-Hochfest; Telos). Recent designs, specifically the LARS, showed good improvement in the outcome scores. The mean preoperative and postoperative Lysholm knee scores were 54 and 88, respectively; the mean preoperative and postoperative Tegner activity scale scores were 3.3 and 6, respectively. CONCLUSIONS: Preliminary results for newer-generation devices, specifically the LARS, show lower reported rates of failure, revision, and sterile effusion/synovitis when compared with older devices. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.