ACL Reconstruction With Quadrupled ST Graft and Mini-Invasive Anterolateral Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction with hamstring graft is the most common procedure around the world. More recently, the use of the semitendinosus (ST), in a quadrupled arrangement, has been described with great results. Having a thicker tendon instead of double gracilis, ST offers a graft with a diameter superior to 8 mm, thus more closely resembling the native ACL and decreasing the risk of graft failure. It has also been published that preservation of the ACL stump was paramount to obtain better graft vascularization and proprioception. In addition, reconstructing the anterolateral ligament is associated with better results. The aim of this technical note is to present an ACL reconstruction technique using a quadrupled ST graft with a double suspensory fixation associated with ACL stump preservation and a mini-invasive anterolateral ligament reconstruction.

The crevice sign: a new indicator of meniscal instability in ACL reconstructions.

PURPOSE: Meniscus preservation is key in knee surgery. The newly documented crevice sign indicates instability of the medial meniscus in ACL-deficient knees. Once the sign is visualised, it is imperative that the stability of the medial meniscus is assessed and potentially treated. It was hypothesized that there would be a strong correlation between the presence of an unstable medial meniscal tear in patients with the crevice sign in ACL-deficient knees. METHODS: This was a multicenter prospective study carried out to evaluate the incidence of medial meniscal tears in patients with ACL-deficient knees and their correlation with a crevice sign. All patients (128) who had undergone ACL reconstruction between May 2020 and November 2020 were assessed arthroscopically for meniscal stability and divided in to two groups: stable (n = 84) and unstable (n = 44). Thereafter, the presence of the crevice sign was determined in each case. RESULTS: The populations were comparable in terms of sex and age (Table 1). Fisher's exact test showed a significant association between the presence of the crevice sign and the instability of the medial meniscus (p < 0.001). Descriptive statistics suggest that the presence of crevice sign was associated more frequently to MM instability (38.6% vs 1.2%; p < 0.001). The specificity of this test was 98.8% and its sensitivity was 38.6%. The positive predictive value (PPV) was 94.4% and the negative predictive value (NPV) was 75.5%. Table 1 Descriptions and comparisons of internal meniscus instability of patients by presence of crevice sign Internal meniscus instability (N = 44) Internal meniscus stability (N = 84) Total (N = 128) Gender  N 44 84 128   Male 33 (75.0) 58 (69.0) 91 (71.1)   Female 11 (25.0) 26 (31.0) 37 (28.9) Fisher's exact test (n.s.) Age (years)  N 44 84 128   Mean (ET) 28.6 (9.4) 30.1 (10.2) 29.6 (9.9)   Median (IIQ) 26.5 (22.0;34.5) 27.0 (22.5;37.0) 27.0 (22.0;36.0)   [Min-Max] [14-54] [14-52] [14-54] Wilcoxon test bilateral (n.s.) Crevice sign  N 44 84 128   Absent 27 (61.4) 83 (98.8) 110 (85.9)   Present 17 (38.6) 1 (1.2) 18 (14.1) Fisher's exact test p < 0.001 CONCLUSION: The hypothesis was confirmed since medial meniscal instability was strongly correlated with the existence of the crevice sign and showed high specificity and PPV. LEVEL OF EVIDENCE: III.

Postoperative thromboprophylaxis does not reduce the incidence of thromboembolic events after ACL reconstruction.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstructive surgery is one of the most common ligament-related surgeries performed in France. The French Society of Anesthesia & Intensive Care Medicine (SFAR) recommends the systematic use of low-molecular weight heparin postoperatively to prevent venous thromboembolisms (VTE). However, these recommendations differ from one country to another; several national societies do not recommend them. To specify the benefits of such a treatment, we did a retrospective case-control study to evaluate the incidence of symptomatic VTE after ACL reconstruction. Hypothesis We hypothesized that the rate of symptomatic VTE would be the same, whether a course of postoperative anticoagulants is prescribed or not. METHODS: This was a retrospective, multicenter, multi-surgeon study. Of the four participating surgeons, two never prescribed thromboprophylaxis after surgery while the other two always prescribed a 10-day course of low-molecular weight heparin. All patients who underwent primary ACL reconstruction using an autologous graft between the 1st of January 2019 and the 15th of February 2020 were included. The 535 patients who had undergone ACL reconstruction were divided into two groups: (Group 1) 279 patients in the group without anticoagulants; 96% received a four-strand semi-tendinosus graft (ST4) and 4% received a quadriceps tendon (QT) graft; the mean age of these patients was 30 years (14-58); 41% of them were women and 22% of them were smokers; the mean body mass index was 24.4 (18-37); the mean tourniquet time was 37minutes. (Group 2) 256 patients in the group with anticoagulants; 81% received a semi-tendinosus/gracilis graft, 15% received a ST4 and 4% a QT; the mean age of these patients was 29 years (14-60); 38% of them were women and 21% of them were smokers; the mean body mass index was 25.0 (18-38); the mean tourniquet time was 34minutes. The two groups were comparable in all respects except for the type of graft used. All patients were contacted at a minimum interval of 3 months after their surgery, by telephone. Doppler ultrasonography was done solely when a VTE was suspected. RESULTS: In the group without anticoagulants, 249 of 279 patients were contacted, while in the group with anticoagulants, 221 of 256 were contacted. The two groups were comparable in terms of age, gender ratio, tourniquet time, body mass index and proportion of smokers. Two cases of deep vein thrombosis (all in the calf region) were found in each group with no associated pulmonary embolism. There was no difference between groups in the VTE rate. DISCUSSION: Our hypothesis was confirmed since the incidence of symptomatic VTE was the same whether postoperative anticoagulants were prescribed or not. The incidence of symptomatic VTE after ACL reconstruction was identical whether thromboprophylaxis was used or not. This casts doubt on the need for postoperative thromboprophylaxis, especially in younger patients who do not have risk factors, and brings into question whether the recommendations in France should be changed. LEVEL OF EVIDENCE: III (retrospective case-control study).

Minimally invasive harvesting of the quadriceps tendon: Technical note.

The quadriceps tendon is gaining preference as an autograft over conventional grafts for the primary reconstruction of the anterior and posterior cruciate ligaments and of the medial patello-femoral ligament. In the past, the use of the quadriceps tendon was associated with considerable morbidity and less favourable outcomes compared to other grafts, specifically due to post-operative weakness of the quadriceps and other complications such as patellar fracture and rupture of the extensor apparatus. These problems are partially ascribable to the graft harvesting method used (large incision, bone block>2cm, and full-thickness tendon harvesting). Recent technical advancements have made reproducible harvesting of quadriceps grafts possible, thereby largely preventing the complications. In this study we describe an original quadriceps tendon harvesting technique in which a minimally invasive approach allows the collection of a sufficiently long graft, while sparing the deep layer of the quadriceps tendon. This technique decreases intra-operative morbidity and improves the post-operative outcomes.

Total knee arthroplasty in achondroplasia without deformity correction: A case report with 11 years' follow-up.

Knee osteoarthritis in patients with achondroplasia is rare. Bowleg deformity is typical but corrective surgery is limited. Thus, primary total knee arthroplasty (TKA) might be challenging due to the particular anatomy. We report on a patient with 11 year's follow-up after a TKA performed maintaining bowleg alignment, using a posterior stabilized, fixed-bearing design. Sequential X-rays showed radiolucencies on the femoral component within two years postoperatively, slightly increasing over time but stable at last follow-up. The Oxford Knee Score showed an excellent result at 11 years. Despite the peculiarities of a case report, TKA without concomitant osteotomies might be an option for such patients. Nevertheless, a thorough discussion about pros and cons is paramount.

Gartland types IIB and III supracondylar fractures of the humerus in children: is Blount's method effective and safe?

BACKGROUND: Blount's method is controversial for the treatment of Gartland types IIB and III supracondylar fracture of the humerus (SCFH) in children. The purpose of this study was to evaluate the clinical and radiologic outcomes and the failure and complication rates. METHODS: All types IIB and III SCFH treated with Blount's method from 2003-2013 were included in this retrospective single-center study. Clinical assessment was performed according to Flynn criteria. Baumann angle, anteversion angle, anterior humeral line, and humeroulnar angle were measured for radiographic assessment. RESULTS: Among 447 children with types IIB and III SCHF, 339 were treated according to Blount's method. There were 173 boys (51%), and the mean age was 6.3 years (1-14 years); 71% were type III. Mean time to surgery was 5.7 hours. According to Flynn criteria, results were satisfactory in 91% of cases. No compartment syndrome was encountered. There were 16 (4.7%) secondary displacements requiring surgical revision. Five (1.9%) children developed a cubitus varus deformity. At latest follow-up, the mean Baumann angle was 74.7° (95% confidence interval, 74.1-75.3), the mean anteversion angle was 39.9° (95% confidence interval, 39.5-40.3), the anterior humeral line was normal in 87.6% of cases, and the mean humeroulnar angle was 8.7°. CONCLUSION: Blount's method is appropriate to manage types IIB and III SCFH, provided anatomic and stable reduction is obtained.