Graft choice or drilling technique does not influence outcomes of ACL reconstruction in patients over forty-five.

PURPOSE: To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45. METHODS: From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes. RESULTS: Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24-60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45-66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability. CONCLUSIONS: In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up. LEVEL OF EVIDENCE: Therapeutic IV, Case Series.

Novel repair of a quadriceps tendon rupture after a total knee arthroplasty using gracilis and semitendinosus autografts.

BACKGROUND: Multiple techniques have been described for repair of quadriceps tendon rupture after total knee arthroplasty (TKA) with unsatisfactory outcomes. We present a novel technique for repair using hamstring tendon autografts. METHODS: A 54 year-old morbidly obese patient presented five months after quadriceps tendon rupture. Direct repair was performed using two anchors in the patella in addition to augmentation with semitendinosus and gracilis tendon autografts. RESULTS: Satisfactory outcomes were achieved with no residual pain and ability to perform a straight leg raise at three weeks postoperatively. There was no extensor lag at five weeks postoperatively. CONCLUSIONS: Most previous reports of a similar complication were treated using synthetic materials. Using hamstring tendon autografts as described in this report provides an alternative surgical option for reconstruction of quadriceps tendon rupture in the setting of TKA, with potentially favorable outcomes and minimal donor site morbidity. Further studies are needed to evaluate long-term outcome of this procedure and to delineate the gold standard of treatment.

A Case Report of Acute Exertional Compartment Syndrome with Peroneal Nerve Palsy in an Adolescent Athlete.

INTRODUCTION: Acute following a chronic exertional compartment syndrome (CECS) is a known but uncommonly encountered complication of sports activity and its physiologic profile remains unclear to date. Failure to recognize and promptly treat this condition can lead to disastrous sequelae. CASE REPORT: We present the case of a 13-year-old lacrosse player with a history of CECS who developed unprovoked acute compartment syndrome. Despite emergent fasciotomy, she experienced intermittent episodes of peroneal nerve deficits. A peroneal nerve neurolysis was later performed which resulted in full resolution of her symptoms. CONCLUSION: This case stresses the importance of a high index of suspicion for compartment syndrome which if not treated in a timely fashion can have devastating consequences.

Risk factors associated with ACL registry compliance: can we predict who will follow-up?

PURPOSE: The purpose of this study was to determine patient factors that influence patient compliance to fill out anterior cruciate ligament reconstruction (ACLR) registry forms. METHODS: Patients prospectively enrolled in the ACLR registry at a single institution were retrospectively reviewed. Patients who were followed up for at least 6 months were included. Patients who did not fill out initial registry forms were excluded. Patients were asked to fill out forms preoperatively and at 6, 12 and 24 months postoperatively. The impacts of age, race, employment status, medical insurance, smoking status, driving distance to the hospital and importance to return to the same level of sporting activity were analyzed against patient compliance (yes/no) to complete registry forms at the respective follow-ups. Multivariate analysis was performed to analyze variables at 6 and 12 months postoperatively. The numbers of patients who were followed up for more than 24 months were too low to run a multivariate analysis, so only univariate analysis was performed on this cohort. RESULTS: A total of 221 patients filled out the initial preoperative forms at least 6 months before data gathering was commenced and were included. At 6 months postoperatively, none of the variables significantly influenced patient compliance. At 12 months, younger age and longer driving distance to the hospital had a significant negative impact on compliance [OR per year: 0.92 (0.85-0.99), p = 0.0237; OR per mile: 1.01 (1, 1.01), p = 0.0297]. Patients who filled out registry forms at 6 months were significantly more compliant at 12 months postoperatively (p < 0.0001). At 24 months, the influence of age remained significant (p = 0.0262) and, additionally, patients who initially noted that it was important for them to return to the same level of sports were significantly less compliant (p = 0.0367). CONCLUSION: Younger age and longer driving distance to the hospital were significantly associated with less compliance to fill out ACLR registry forms at 12 months postoperatively. Patient perspectives on the importance to return to the same level of sports were inversely related to compliance at 24 months postoperatively. This information can be utilized to improve compliance in future studies as we have potentially identified patients that can be viewed as "at-risk" for registry noncompliance.

Indications for Two-Incision (Outside-In) Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure. Drilling the femoral tunnel independent of the tibial tunnel has become popular as surgeons strive to create tunnels in the anatomic locations of the femoral and tibial attachments of the native ligament. The 2-incision technique effectively and reproducibly accomplishes this goal. The 2-incision technique for ACL reconstruction is a valuable tool in the skillset of the reconstructive knee surgeon. Indications for the 2-incision surgery are reviewed in detail. Furthermore, technical tips, complications, and outcomes are discussed.

"Retrograde technique" for drilling the femoral tunnel in an anterior cruciate ligament reconstruction.

Recent literature has led some surgeons to drill the femoral tunnel in an anterior cruciate ligament reconstruction through an accessory anteromedial portal. Several techniques have been reported for the safe, effective drilling of the femoral tunnel by this approach. This technical note presents a new "retrograde technique" in which all instruments are passed independently into the notch and across the medial compartment. This technique is safe and reproducible and allows for meticulous evaluation and creation of the femoral tunnel(s) while minimizing steps.

Allografts in knee surgery.

The use of musculoskeletal allograffs in knee surgery is expanding as outcome studies continue to delineate roles for ligament, meniscal, and osteochondral allouraffs.

Resurfacing arthroplasty versus silicone arthroplasty for proximal interphalangeal joint osteoarthritis.

PURPOSE: To compare the outcomes of silicone proximal interphalangeal joint (PIPJ) arthroplasties to pyrolytic carbon implants in patients with osteoarthritis. METHODS: This study is a retrospective review of 41 arthroplasties in 22 patients with severe PIPJ osteoarthritis performed by a single surgeon. There were 13 patients and 22 joints in the silicone group with an average follow-up of 45 months. There were 9 patients and 19 joints in the pyrolytic carbon group with an average follow-up of 19 months. Clinical assessment included range of motion, grip strength, and deformity. Radiographs were evaluated for alignment, subsidence, and implant fracture. Patients filled out a subjective questionnaire with respect to pain, appearance of the finger, and satisfaction. Complications were recorded. RESULTS: In the silicone group, the average preoperative PIPJ range of motion (ROM) was 11 degrees /64 degrees (extension/flexion) and the average postoperative ROM was 13 degrees /62 degrees . In the pyrolytic carbon group, the average preoperative PIPJ ROM was 11 degrees /63 degrees and the average postoperative ROM was 13 degrees /66 degrees . Eleven of 20 joints in the silicone group and 4 of 19 joints in the pyrolytic carbon group had a coronal plane deformity as defined by angulation of the PIPJ > or =10 degrees . The average coronal plane deformity was 12 degrees in the silicone group and 2 degrees in the pyrolytic carbon group. The difference was statistically significant. In the silicone group, 3 of 22 joints required additional surgery. Two implants in one patient were removed and the PIPJ fused, and one implant was permanently removed for sepsis. In the pyrolytic carbon group, 8 of 19 joints squeaked, and there were 2 early postoperative dislocations and 2 implants with radiographic loosening. To date, there has been no revision surgery. Both groups had good pain relief. Patients were generally satisfied with the appearance of their joints in the pyrolytic carbon arm; however, satisfaction with appearance was variable in the silicone group. Nine of 13 patients in the silicone group and 6 of 7 patients in the pyrolytic carbon group would have the procedure again. CONCLUSIONS: Both implants provide excellent pain relief and comparable postoperative ROM. Complications were implant specific. The results of this series show promise for the pyrolytic carbon PIPJ resurfacing arthroplasty but did not clearly demonstrate superiority compared with the silicone implant.

Atypical lumbar disc herniation: a case report.

BACKGROUND CONTEXT: This is a case report of a right posterolateral L5-S1 disc herniation that migrated to the left cephalad level to impinge on the left L5 nerve root as it exited the dura. The resultant free fragment migration is a rare variation of a posterolateral disc disruption. PURPOSE: The purpose is to report a rare variation of lumbar disc herniation not previously reported in the literature. STUDY DESIGN/SETTING: Case report. PATIENT SAMPLE: A 60-year-old white woman. OUTCOME MEASURES: Resolution of the patient's left lower extremity symptoms. METHODS: Not applicable. RESULTS: The patient experienced resolution of most of her left lower extremity symptoms after a slightly modified microscopically assisted lumbar hemilaminectomy, discectomy and nerve root decompression. CONCLUSIONS: This is a rare right to left migration of a sequestrated disc herniation, which was effectively treated with surgery.