Adverse Events After Isolated Posterior Cruciate Ligament Reconstruction: A National Database Study.

Background: Optimal management after posterior cruciate ligament (PCL) injury remains an active area of research, as reconstruction is technically challenging and poses unique risks in the posterior knee. Studies have reported variable rates of complications. Purpose: To describe the rates of readmission, emergency department (ED) visits, and postoperative complications within 90 days of isolated PCL reconstruction (PCLR) in a large, national cohort to better understand the perioperative variables that influence a practitioner's decision of whether to pursue operative versus nonoperative management. Study Design: Descriptive epidemiology study. Methods: PCLRs from January 1, 2010, through August 31, 2020, were identified in PearlDiver, a national administrative database. Patients with concomitant ligament surgery and those with fewer than 90 days of postoperative database activity were excluded. Deep vein thromboses, pulmonary embolisms, surgical site infections, compartment syndrome, and vascular events within 90 days of surgery were identified, as were 90-day readmissions and ED visits. Logistic regression models were built in PearlDiver to calculate odds ratios (ORs) for ED utilization. Results: The final cohort consisted of 1154 patients with isolated PCLR (mean age, 34 ± 16 years; 62% male). Most patients were located in the Southern United States (n = 417; 36.1%), and most had commercial insurance (n = 992; 86%). The 90-day rates of adverse events were as follows: deep vein thrombosis (13; 1.1%), pulmonary embolism (19; 1.6%), surgical site infection (<11; <1%), compartment syndrome (<11; <1%), vascular event (<11; <1%), readmission (13, 1.1%), and ED utilization (99; 8.6%). The majority of emergency department visits (52%) occurred in the first 2 weeks postoperatively. Predictive factors for ED utilization included Elixhauser Comorbidity Index score (OR = 1.31 per 2-point increase) and Medicaid insurance (OR = 2.03 relative to commercial insurance). Conclusion: The current study reported rates of adverse events after isolated PCLR in a large, national cohort. The results provide important context for decisions about optimal management of PCL injury.

Patellar Tendon Rupture 12 Years after ACL Reconstruction with BPTB Autograft.

We present a case of a 33-year-old male with a history of anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and prior ipsilateral hamstring harvest, who presented with a complete patella tendon rupture (PTR) 12 years after ACLR. The patient underwent a successful patellar tendon (PT) repair augmented with Achilles tendon allograft and cerclage with nonabsorbable suture tape. PTR after ACLR with BPTB autograft is rare, particularly in patients over a decade out from the index procedure, but can occur. This case report highlights a novel technique for PT repair following BTB ACLR in a hamstring deficient knee.

Return to Sport After Multiligament Knee Injury in Young Athletes.

Background: While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI). Purpose: To assess the level of and factors associated with RTS after MLKI in young athletes. Study Design: Case series; Level of evidence, 4. Methods: We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL-Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries. Results: A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels. Conclusion: Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.

Supine Lobenhoffer Approach Optimizes PCL Reconstruction with Tibial Inlay in Knee Dislocations: A Case Report.

CASE: A 47-year-old man suffered a knee dislocation while skiing with associated damage to the anterior cruciate, posterior cruciate, medial collateral, and medial patellofemoral ligaments. The patient underwent a multiple-ligament knee reconstruction using the supine Lobenhoffer approach, which resulted in remarkable outcomes that persisted throughout the 56-month follow-up period. CONCLUSION: The utilization of this approach can prevent inappropriate graft tension and iatrogenic damage, reduce surgical time, and minimize airway complications by eliminating the need for the prone position. Optimizing these factors enhances the patient's chances for long-term outcomes; thus, surgeons should consider this approach in managing multiple-ligament knee injuries.

Establishing a Consensus Definition of a Knee Fracture-Dislocation (Schenck Knee Dislocation V) Using a Global Modified Delphi Method.

BACKGROUND: Knee fracture-dislocations are complex injuries; however, there is no universally accepted definition of what constitutes a fracture-dislocation within the Schenck Knee Dislocation (KD) V subcategory. The purpose of this study was to establish a more precise definition for fracture patterns included within the Schenck KD V subcategory. METHODS: A series of clinical scenarios encompassing various fracture patterns in association with a bicruciate knee ligament injury was created by a working group of 8 surgeons. Utilizing a modified Delphi technique, 46 surgeons from 18 countries and 6 continents with clinical and academic expertise in multiligamentous knee injuries undertook 3 rounds of online surveys to establish consensus. Consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree" for a positive consensus or "strongly disagree" or "disagree" for a negative consensus. RESULTS: There was a 100% response rate for Rounds 1 and 2 and a 96% response rate for Round 3. A total of 11 fracture patterns reached consensus for inclusion: (1) nondisplaced articular fracture of the femur; (2) displaced articular fracture of the femur; (3) tibial plateau fracture involving the weight-bearing surface (with or without tibial spine involvement); (4) tibial plateau peripheral rim compression fracture; (5) posterolateral tibial plateau compression fracture, Bernholt type IIB; (6) posterolateral tibial plateau compression fracture, Bernholt type IIIA; (7) posterolateral tibial plateau compression fracture, Bernholt type IIIB; (8) Gerdy's tubercle avulsion fracture with weight-bearing surface involvement; (9) displaced tibial tubercle fracture; (10) displaced patellar body fracture; and (11) displaced patellar inferior pole fracture. Fourteen fracture patterns reached consensus for exclusion from the definition. Two fracture patterns failed to reach consensus for either inclusion or exclusion from the definition. CONCLUSIONS: Using a modified Delphi technique, this study established consensus for specific fracture patterns to include within or exclude from the Schenck KD V subcategory. LEVEL OF EVIDENCE: Prognostic Level V . See Instructions for Authors for a complete description of levels of evidence.

Extensor Mechanism Disruption Impacts Treatment of Dislocated and Multiligament Injured Knees: Treatment and Schenck Classification Recommendations Based on a Global Delphi Method.

BACKGROUND: Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury. METHODS: Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree." RESULTS: There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery. CONCLUSIONS: In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered. CLINICAL RELEVANCE: Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.

The Impact of Implementing a Diabetic Limb-Preservation Program on Amputation Outcomes at an Academic Institution in a Majority-Minority State.

Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients' morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) (P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) (P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) (P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 (P < .001). The rate of obtaining bone biopsies increased from 32.1% (n = 45) to 72.1% (P < .001). The rate of revascularization increased from 10.7% (n = 15) to 15.2% (n = 30) (P = .299). Average hospital LOS decreased significantly from 11.6 days to 9.8 days (P = .044). Conclusion. After the implementation of a limb-preservation team, there was a precipitous drop in major limb amputations in favor of minor amputations. The average hospital LOS decreased. These findings demonstrated improved clinical care and outcomes in patients with lower extremity osteomyelitis and reinforce the importance of a diabetic foot-preservation service within healthcare institutions.

Comparative Success of Repair Versus Reconstruction for Knee Extra-articular Ligament Injuries.

Background: Surgical techniques and associated outcomes in treating acute and chronic extra-articular ligament knee injuries are in evolution, and there is question as to whether repair or reconstruction is optimal. Purpose/Hypothesis: The purpose of this study was to compare the subsequent surgery rate between surgical repair versus reconstruction for all extra-articular ligament injuries of the knee utilizing a large database. Our hypothesis was that overall surgical repair of both lateral and medial extra-articular knee injuries would have a higher revision rate than those treated by reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner data set (2010-2019), with 122 million patients, was utilized to generate 2 patient cohorts: those who underwent surgical repair and those who underwent surgical reconstruction of a knee extra-articular ligament injury. All patients had a minimum of 2 years follow-up. Rates of concomitant or subsequent cruciate ligament reconstruction and rates of secondary procedures were assessed and compared between the 2 cohorts. Results: In total, 3563 patients were identified: extra-articular ligament reconstruction was performed for 2405 (67.5%), and repair was performed for 1158 (32.5%). Cruciate ligament reconstruction was performed for 986 (27.7%), of which 888 of 986 (90.1%) were performed on the same day as their extra-articular ligament procedure. At 2-year follow-up, the reconstruction cohort had higher rates of revision surgery compared with the repair cohort (8.2% vs 2.5%; P < .001). Conclusion: Using a large national database, knee extra-articular ligamentous reconstructions (those on both the lateral and the medial side) had a 3.3 times higher rate of revision surgery compared with repair at 2-year follow-up. Further study is needed to investigate the causes leading to revision surgery and to determine the optimal surgical treatment for both medial and lateral extra-articular knee ligament injuries.

Presentation and Surgical Management of Multiple Ligament Knee Injuries: A Multicenter Study from the Surgical Timing and Rehabilitation (STaR) Trial for MLKIs Network.

BACKGROUND: Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system. METHODS: This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively. RESULTS: A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range [IQR], 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved menisci (55.6%), nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication. CONCLUSIONS: A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Synovial Fluid Inflammatory Profiles did not Differ between Isolated Anterior Cruciate Ligament and Multi-ligament Knee Injuries.

Objective and design: The purpose of this study was to compare synovial concentrations of pro- and anti-inflammatory cytokines between multiple-ligament knee injured (MLKI) and anterior cruciate ligament (ACL)-injured patients. Subjects: 14 patients with MLKI and 10 patients with isolated ACL injury. Methods: Synovial fluid was aspirated from the operative knee at the time of surgery and the concentrations of pro- and anti-inflammatory markers in the synovial fluid were determined. Structures injured, the time between injury and surgery, and demographic factors were collected. Linear regressions were used to determine the association between injury pattern and synovial inflammatory markers when controlling for age, BMI, and time between injury and surgery. Results: When adjusting for group differences in age, BMI and the time between injury and surgery, no group differences were detected (interferon gamma (p = 0.11), interleukin-1beta (IL-1b, p = 0.35), IL-2 (p = 0.28), IL-4 (p = 0.64), IL-6 (p = 0.37), IL-8 (p = 0.54), IL-10 (p = 0.25), IL-12p70 (p = 0.81), IL-13 (p = 0.31), and tumor necrosis factor-alpha (p = 0.90)). Conclusion: Synovial fluid inflammatory markers did not differ between MLKI and isolated ACL injuries. MLKIs have a greater prevalence of postoperative arthrofibrosis when compared to isolated ACL injuries; however, this may be due in part to factors other than the inflammatory status of the joint.

Tibial Supra-tubercular Deflexion Osteotomy in the Management of Failed Anterior Cruciate Ligament Reconstruction: A Surgical Technique.

Excessive posterior tibial slope (PTS) is a recognized risk factor for failure of anterior cruciate ligament reconstruction (ACLR) and should be considered when planning a revision ACLR. A tibial supra-tubercular deflexion osteotomy can correct excessive PTS with simultaneous or staged ACLR. There are only a handful of technical descriptions offering insight on the respective authors' approach at reducing PTS, all of which vary greatly in their methods. The authors describe a surgical technique using a proximal tibial supra-tubercular deflexion osteotomy in patients with persistent knee instability, a history of at least one failed ACLR, and a PTS greater than 12°. This surgery is not recommended in patients with significant genu recurvatum (>10°), significant varus, or severe tibiofemoral osteoarthritis.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: state of the art.

The ideal graft for anterior cruciate ligament reconstruction (ACLR) continues to be debated. Although first described in 1984, use of the quadriceps tendon (QT) autograft has only recently gained popularity. The biomechanical properties of the QT autograft are favourable compared to bone-patellar tendon-bone (BPTB) and doubled hamstring (HS) grafts with a higher load to failure and a modulus of elasticity that more closely approximates the native anterior cruciate ligament (ACL). The QT graft can be harvested with or without a bone plug, as either a full thickness or a partial thickness graft, and even through minimally invasive techniques. The surgeon must be aware of potential harvest risks including patellar fracture or a graft that is of insufficient length. Numerous short-term studies have shown comparable results when compared to BPTB or hamstring HS autografts with similar graft failure rates, patient-reported outcomes. A major advantage of QT ACLR is reduced donor site morbidity compared to BPTB. However, some persistent quadriceps weakness after QT ACLR has also been reported. The current literature shows that use of the QT autograft for ACLR provides equivalent clinical results compared to other autografts with less donor site morbidity. However, future studies with longer follow-up and higher level of evidence are needed to identify specific populations where the QT may have additional advantage.

A Biomechanical Comparison of the LaPrade Technique Versus a Novel Technique for Reconstruction of Medial-Sided Knee Injuries.

BACKGROUND: Medial-sided knee injuries can lead to symptomatic valgus laxity or anteromedial rotatory instability and may require surgery, particularly in the setting of cruciate tears and tibial-sided medial collateral ligament (MCL) avulsions. The LaPrade (LP) technique utilizes 2 free grafts to reconstruct the superficial MCL (sMCL) and the posterior oblique ligament (POL). An alternative MCL reconstruction devised by the senior author comprises an anatomic single-bundle reconstruction using a free graft to reconstruct the sMCL with advancement and imbrication of the posteromedial capsule/POL (MCL anatomic reconstruction with capsular imbrication [MARCI] technique). These techniques have not been biomechanically compared with one another. PURPOSE: To identify if one of these reconstruction techniques better restores valgus and rotational medial knee stability throughout the range of motion. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 20 fresh-frozen, male (mean age, 43.7 years [range, 20-63 years]), midfemur-to-toe-matched cadaveric knees were utilized. All reconstructions were performed by a single fellowship-trained sports medicine surgeon. Left and right specimens within matched pairs were randomized to 1 of the 2 treatment groups: LP or MARCI. Each specimen was tested in 3 phases: (1) intact knee, (2) destabilized (MCL and POL completely severed), and (3) reconstructed (post-LP or post-MARCI reconstruction). We quantified valgus angulation defined by medial joint line opening, as well as internal and external tibial rotation at 0°, 20°, 30°, 60°, and 90° of knee flexion under applied external moments/torques at each phase. RESULTS: There were significant differences between the MARCI and LP reconstruction groups in valgus stability compared with the intact state (P = .021), with the MARCI reconstruction more closely approximating the intact knee. There was no overall difference between the MARCI and LP reconstruction techniques for internal rotation (P = .163), with both closely resembling the intact state. For external rotation, the effect of the reconstruction technique was dependent on the knee flexion angle (P < .001). At the highest angles, there were no differences between reconstructions; however, for lower knee flexion angles, the MARCI technique more closely resembled the intact state. CONCLUSION: Although both techniques improved knee stability compared with destabilized conditions, the MARCI technique better approximated intact stability during valgus at knee flexion angles from 0° to 90° and external rotation loads at knee flexion angles ≤30° in a cadaveric model. CLINICAL RELEVANCE: The MARCI technique provides an alternative option to improve valgus stability throughout the range of motion. It utilizes a POL advancement without the potential limitations seen in the LP technique, such as multiple tunnel complexity and collision, particularly in the multiple ligament-injured knee.

Inclusion of open injuries in an updated Schenck classification of knee dislocations based on a global Delphi consensus study.

OBJECTIVES: Knee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. METHODS: A global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. RESULTS: Of the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). CONCLUSION: Consensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.

Failure of Primary Distal Biceps Repair After Cortical Button Fixation With Whipstitch Technique: A Root Cause Analysis.

Rerupture after cortical button fixation and whipstitch suture technique is a rare complication of distal biceps tendon repair. The tendon-bone fixation construct can fail for various reasons, including cortical breach, pull out or disengagement of a cortical button, suture breakage, or knot slippage. Occasionally, a cut-through of the tendon substance by the high-tensile strength suture material, called the 'cheese-wire' effect, can happen, especially with premature loading during the early postoperative period. The clinical presentation is more subtle, and the rerupture may go unnoticed. A high index of suspicion and a low threshold for ordering a magnetic resonance imaging (MRI) scan are necessary for a prompt diagnosis and early treatment. We describe the management of a reruptured distal biceps in an active male that happened in the early postoperative period, along with a critical analysis of the failure pattern and potential preventive measures.

Bucket handle meniscus tears in low-resource settings can be successfully treated with a cost-effective technique.

PURPOSE: In regions of the world where resources can limit medical care (limited-resource settings, LRS), most meniscal tears are often treated with meniscectomy. A simple, low-cost option for meniscal repair has been developed. We sought to evaluate patient reported outcomes (PROMs) and clinical failure rates of bucket handle meniscus tears (BHTs) treated with meniscal repair in a LRS. METHODS: We prospectively enrolled patients over 18 who were treated for BHT with meniscal repair in a LRS. Meniscal repair was primarily accomplished using an outside-in technique. Pre-injury and final follow-up PROMs were recorded. Clinical failure was defined as the need for re-operation or symptoms that prevented the patient from returning to recreational activities or work responsibilities. RESULTS: Nineteen patients with a mean age of 25.4 years were eligible. Two patients sustained a clinical failure (10.5%). At mean follow-up of 40.6 months, there was significant improvement in all PROMs from baseline. Subgroup analysis revealed no significant difference in the failure group compared to the success group in number of knots used, pre-injury Tegner score, number of devices used, suture type, or technique. CONCLUSION: Bucket-handle meniscal tears can be repaired using a low-cost technique resulting in satisfactory healing rates and excellent outcomes.

Silver Coatings in Reconstructive Orthopaedics: Basic Science and Clinical Rationale.

Prosthetic joint infection (PJI) is one of the most devastating complications that can occur following total hip and total knee arthroplasty. Despite the remarkable advances that have been made in surgical techniques and implant technology, the incidence of PJI has remained largely unchanged over the past two decades. One approach that has been described in the literature to minimize the risk of PJI has been the use of silver-coated prostheses. Silver has been reported to have antimicrobial properties when added to a variety of orthopaedic materials including bone cement, hydroxyapatite coatings and wound dressings. Silver is also being increasingly used as a surface coating for endoprostheses used for reconstruction around the hip and the knee with the specific aim of reducing the incidence of prosthetic joint infection. Despite the increasing adoption of this technology, the use of silver coatings remains controversial. The optimal method for preparation and the thickness of the coating, as well as the mechanism(s) of action in reducing the incidence of PJI, are unclear. The issue of silver toxicity is also an important consideration. This paper provides an overview of the use of silver coatings in reconstructive orthopaedics, as well as the types available and techniques used to coat endoprostheses. We also review the basic science as well as the clinical applications of silver coatings in the prevention of PJIs.

No Significant Difference Between Intramedullary and Extramedullary Button Fixation for Distal Biceps Brachii Tendon Rupture After Cyclic Loading in a Cadaver Model.

PURPOSE: To biomechanically compare intramedullary (IM) versus extramedullary (EM) distal biceps button fixation under cyclic loading conditions, which is most representative of postoperative physiologic status. METHODS: This controlled laboratory study used 13 fresh-frozen matched paired cadaver elbows. One specimen from each pair was randomized to either IM (unicortical) or EM (bicortical) distal biceps button fixation via onlay technique. A servohydraulic actuator was used to cycle each specimen from full extension to 90° of flexion at 0.5 Hz for 3,000 cycles. All specimens were subsequently loaded to failure to simulate an acute postoperative load. RESULTS: During cyclic loading, the mean change in force from cycle 5 to cycle 3000 was 2.1 ± 3.2 N for the IM group and 0.6 ± 4.2 N for the EM group (P = .19). The increase in tendon gap for the IM group was 1.02 mm and for the EM group was 1.83 mm (P = .37). During failure loading, the IM group had a mean failure load of 154.9 ± 44.5 N and the EM group a mean failure load of 191.1 ± 62.6 N (P = .16). CONCLUSIONS: No significant differences exist between the IM and EM techniques in loss of force and tendon gap formation under cyclic loading or load to failure conditions. Thus, IM fixation may adequately facilitate optimal bone-tendon apposition, with less risk of iatrogenic injury to the posterior interosseous nerve that can be seen with bicortical extramedullary fixation. CLINICAL RELEVANCE: The most common major complication following distal biceps repair is PIN palsy. IM fixation may be sufficient in facilitating optimal bone-tendon apposition and healing with onlay technique, while minimizing risk of iatrogenic PIN injury associated with EM fixation.