Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement.

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Orthopedic Surgery in Ambulatory Surgery Centers During the COVID-19 Pandemic: Low Incidence of Infection Among Patients, Surgeons, and Staff.

Background and objective The coronavirus disease 2019 (COVID-19) pandemic has presented tremendous challenges to the healthcare systems worldwide. Consequently, ambulatory surgery centers (ASCs) have been forced to find new and innovative ways to function safely and maintain operations. We conducted a study at a large United States (US) private orthopedic surgery practice, where a universal screening policy and testing protocol for COVID-19 was implemented for patients and ASC personnel including surgeons, in order to examine the incidence of COVID-19 in patients scheduled for orthopedic surgery in ASC settings as well as the incidence among the surgeons and ASC personnel. Methods The universal screening protocol was implemented in the ASCs of the facility during the early stage of the pandemic for an eight-month period from April 28, 2020, to December 31, 2020. All ASC personnel including surgeons had their symptoms tracked daily and were rapid-tested every two weeks. All patients were screened and tested before they entered the ASC. Results A total of 70 out of 12,115 patients and 41 out of 642 ASC personnel tested positive for COVID-19, resulting in infection rates of 0.6% and 6.4%, respectively. Individual symptoms, age, the American Society of Anesthesiologists (ASA) scores, and comorbidities were documented, and no single factor was found to be common among positive (+) tests. Conclusions The implementation of universal screening and symptom-reporting procedures was associated with a very low rate of infections among ASC patients, staff, and surgeons, and it offers a reproducible framework for other facilities to continue to provide orthopedic outpatient operations in ASC settings during the ongoing iterations of the COVID-19 pandemic.

Tibial Tubercle Preserving Anterior Closing Wedge Proximal Tibial Osteotomy and ACL Tunnel Bone Grafting for Increased Posterior Tibial Slope in Failed ACL Reconstructions.

Anterior cruciate ligament reconstruction (ACLR) failure is multifactorial, but it is known that increased posterior tibial slope (PTS) leads to a greater likelihood of ACLR failure. This technical note describes the senior author's technique for performing an anterior closing wedge proximal tibial osteotomy, in which the osteotomy is made proximal to the tibial tubercle. This procedure is the first part of a staged surgery for patients with multiple failed ACLRs and increased sagittal plane PTS. Debridement of osteolytic reconstruction tunnels with bone grafting is also undertaken in preparation for a second-stage revision ACLR.

The Natural History of Medial Meniscal Root Tears: A Biomechanical and Clinical Case Perspective.

Posterior medial meniscus root tears (PMMRTs) make up a relatively notable proportion of all meniscus pathology and have been definitively linked to the progression of osteoarthritis (OA). While known risk factors for development of OA in the knee include abnormal tibial coronal alignment, obesity and female gender, PMMRTs have emerged in recent years as another significant driver of degenerative disease. These injuries lead to an increase in average contact pressure in the medial compartment, along with increases in peak contact pressure and a decrease in contact area relative to the intact state. Loss of the root attachment impairs the function of the entire meniscus and leads to meniscal extrusion, thus impairing the force-dissipating role of the meniscus. Anatomic meniscus root repairs with a transtibial pullout technique have been shown biomechanically to restore mean and peak contact pressures in the medial compartment. However, nonanatomic root repairs have been reported to be ineffective at restoring joint pressures back to normal. Meniscal extrusion is often a consequence of nonanatomic repair and is correlated with progression of OA. In this study, the authors will describe the biomechanical basis of the natural history of medial meniscal root tears and will support the biomechanical studies with a case series including patients that either underwent non-operative treatment (5 patients) or non-anatomic repair of their medial meniscal root tears (6 patients). Using measurements derived from axial MRI, the authors will detail the distance from native root attachment center of the non-anatomic tunnels and discuss the ongoing symptoms of those patients. Imaging and OA progression among patients who were treated nonoperatively before presentation to the authors will be discussed as well. The case series thus presented will illustrate the natural history of meniscal root tears, the consequences of non-anatomic repair, and the findings of symptomatic meniscal extrusion associated with a non-anatomic repair position of the meniscus.

Medial Patellofemoral Reconstruction Using Quadriceps Tendon Autograft, Tibial Tubercle Osteotomy, and Sulcus-Deepening Trochleoplasty for Patellar Instability.

Recurrent patellar dislocations have been correlated with an elevated risk of further patellar dislocations, often requiring surgical treatment. Risk factors include medial patellofemoral ligament (MPFL) tears, patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance. Surgical management must be based on a patient's unique joint pathoanatomy and may require MPFL reconstruction with tibial tubercle osteotomy or trochleoplasty either alone or in combination. This article discusses our preferred technique for surgical treatment of recurrent patellar instability with MPFL reconstruction using a quadriceps tendon autograft, an open trochleoplasty, and a tibial tubercle osteotomy for patients with patella alta, trochlear dysplasia, and an increased tibial tubercle-trochlear groove distance.

Arthroscopic Excision of Bipartite Patella.

A bipartite patella usually presents as an incidental finding on radiographs because most cases are asymptomatic. However, some patients may present with pain and functional limitations. Conservative treatment is sufficient to resolve symptoms in most cases; however, a small minority of patients may require surgical management. Recent studies have reported excellent results with an arthroscopic approach. This Technical Note details our procedure for treating a symptomatic bipartite patella that has not resolved with conservative care.

Multiple Ligament Reconstructions of the Knee and Posterolateral Corner.

Injuries to the knee involving multiple ligaments occur in a variety of circumstances and require careful assessment and planning. A wide constellation of injuries can occur with causes sufficiently traumatic to produce bicruciate ligament deficiency, and this technical report will describe diagnosis, treatment and rehabilitation for a knee dislocation with lateral injury (KD-III-L on the Schenk classification). Reconstruction in the acute setting is preferred, with anatomic-based, single-bundle anterior cruciate ligament reconstruction, double-bundle posterior cruciate ligament reconstruction, and anatomic reconstruction of the posterolateral corner using two grafts for the 3 primary posterolateral corner stabilizers. Tunnel orientation to prevent convergence and sequence of graft tensioning and fixation are discussed as well. Successful outcomes have been achieved using these anatomic-based reconstruction techniques along with appropriate rehabilitation and bracing.

Medial Patellofemoral Ligament Reconstruction Using a Quadriceps Tendon Autograft in a Patient with Open Physes.

Recurrent patellar dislocations are correlated with an elevated risk for further patellar dislocations. Chronic patellar instability is a disabling issue for some patients and may require surgical intervention for proper treatment. Risk factors for recurrent dislocations include medial patellofemoral ligament (MPFL) tears, patella alta, trochlear dysplasia, and increased tibial tubercle to trochlear groove distance. Surgical management must be based on a patient's unique joint pathoanatomy and typically requires medial patellofemoral ligament reconstruction, with or without accompanying procedures such as tibial tubercle osteotomy or sulcus-deepening trochleoplasty. Chronic patellar instability in minors with open growth plates, requires alternative MPFL reconstruction techniques to prevent physeal injury, because of the close proximity of the femoral physis to the MPFL insertion. This article discusses the authors' preferred technique for surgical treatment of recurrent patellar instability with a medial patellofemoral ligament reconstruction using a quadriceps tendon autograft.

The Oblique Meniscomeniscal Ligament: A Case Report of a Rare Obstruction to Meniscal Root Repair.

CASE: The authors present a case of a 41-year-old woman who was treated for a chronic type 2 posterior horn tear of the medial meniscal root. During an arthroscopic repair, a broad, thick ligament coursing through the intercondylar notch caused difficulty in visualizing the posterior joint space and necessitated creation of an accessory portal. Given its course and attachments, this structure was an example of a rare variant of anatomy, an oblique meniscomeniscal ligament. CONCLUSION: An oblique meniscomeniscal ligament may complicate surgery in the posterior knee by presenting a visual and physical impediment to the surgeon.

Multiple Ligament Knee Reconstructions.

Patients with multiligament knee injuries require a thorough examination (Lachman, posterior-drawer, varus, valgus, and rotational testing). Diagnoses are confirmed with magnetic resonance imaging as well as stress radiographs (posterior, varus, and valgus) when indicated. Multiple systematic reviews have reported that early (<3 weeks after injury) single-stage surgery and early knee motion improves patient-reported outcomes. Anatomic-based reconstructions of the torn primary static stabilizers and repair of the capsular structures and any tendinous avulsions are performed in a single-stage. Open anteromedial or posterolateral incisions are preferentially performed first to identify the torn structures and to prepare the posterolateral corner (PLC) and medial knee reconstruction tunnels. Next, arthroscopy allows preparation of the anterior cruciate ligament (ACL) and double-bundle (DB) posterior cruciate ligament (PCL) tunnels. Careful attention to tunnel trajectory minimizes the risk for convergence. Meniscal tears are preferentially repaired (root and ramp tears are commonly seen in this patient group). Graft passage is performed after all tunnels are reamed. The graft tensioning and fixation sequence is as follows: anterolateral bundle of the PCL to restore the central pivot, posteromedial bundle of the PCL, ACL, PLC (including fibular [lateral] collateral ligament), and posteromedial corner (including medial collateral ligament). Graft integrity and full knee range of motion should be verified before closure. Physical therapy commences on postoperative day 1 with immediate knee motion (flexion from 0°-90°; prone for DB-PCL reconstruction) and quadriceps activation. Patients are nonweightbearing for 6 weeks. Patients with ACL-based reconstructions wear an immobilizer for 6 weeks then transition to a hinged ACL brace. Patients with PCL-based reconstructions transition into a dynamic PCL brace once swelling subsides and wear it routinely for 6 months. Functional testing and stress radiography are performed to validate return to sports.

Meniscal repair: The current state and recent advances in augmentation.

Meniscal injuries represent one of the most common orthopedic injuries. The most frequent treatment is partial resection of the meniscus, or meniscectomy, which can affect joint mechanics and health. For this reason, the field has shifted gradually towards suture repair, with the intent of preservation of the tissue. "Save the Meniscus" is now a prolific theme in the field; however, meniscal repair can be challenging and ineffective in many scenarios. The objectives of this review are to present the current state of surgical management of meniscal injuries and to explore current approaches being developed to enhance meniscal repair. Through a systematic literature review, we identified meniscal tear classifications and prevalence, approaches being used to improve meniscal repair, and biological- and material-based systems being developed to promote meniscal healing. We found that biologic augmentation typically aims to improve cellular incorporation to the wound site, vascularization in the inner zones, matrix deposition, and inflammatory relief. Furthermore, materials can be used, both with and without contained biologics, to further support matrix deposition and tear integration, and novel tissue adhesives may provide the mechanical integrity that the meniscus requires. Altogether, evaluation of these approaches in relevant in vitro and in vivo models provides new insights into the mechanisms needed to salvage meniscal tissue, and along with regulatory considerations, may justify translation to the clinic. With the need to restore long-term function to injured menisci, biologists, engineers, and clinicians are developing novel approaches to enhance the future of robust and consistent meniscal reparative techniques.

Patellar Tendon Revision Reconstruction With Hamstring Tendon Autografts.

Patellar tendon rupture is an infrequent cause of disability in patients younger than 40 years, with chronic injury and repeat procedures creating difficulty in facilitating healing. Use of hamstring autograft to reinforce the repair has been reported to strengthen the repair construct in patients with previous failure or chronic injury. This technique describes utilization of gracilis and semitendinosus tendon autografts to reconstruct the patellar tendon in a case of primary repair failure.

Arthroscopic-Assisted Lateral Meniscal Allograft Transplantation With Open Ligamentous Extra-Articular Tenodesis.

Lateral meniscus allograft transplantation is performed in predominantly young, active patients and is an option to stabilize the joint in lateral meniscus-deficient patients after anterior cruciate ligament reconstruction. The lateral meniscus functions as an important restraint to anterior tibial translation, and meniscal transplant in such a patient may improve survivability of the graft in addition to preserving the patient's articular cartilage in the long term. A ligamentous extra-articular tenodesis procedure may be performed simultaneously to augment rotational stability of the joint, particularly in a patient with underlying ligamentous hyperlaxity.

Acetabular Rim Disorders/Pincer-type Femoroacetabular Impingement and Hip Arthroscopy.

Femoroacetabular impingement (FAI) can lead to acetabular impaction, chondral injury, and labral pathology secondary to deformities of the proximal femur (CAM-type FAI), acetabulum (pincer-type FAI), or with combined FAI. While the majority of cases are of the combined type, this paper focuses on acetabular overcoverage/pincer-type deformities. Various pincer subtypes include focal anterior overcoverage, global retroversion, global overcoverage/profunda, protrusio, subspine impingement, and os acetabuli/rim fracture variants. A thorough history and physical examination, plain radiographs, magnetic resonance imaging, 3-dimensional computerized tomography, and diagnostic injections can lead to an accurate assessment of pincer-type variants. Appropriately indicated arthroscopic management techniques and pearls for the various pincer subtypes can lead to improved patient-related outcome measures and a high rate of return to athletic activity for the majority of these patients.