Anterior Cruciate Ligament Reconstruction Using a 4-Strand Semitendinosus Tendon Graft or a Doubled Semitendinosus and Gracilis Tendon Graft: A 4.5-Year Prospective, Randomized, Double-Blind, Parallel-Group Study.

BACKGROUND: Hamstring tendon grafts are the most common choice for anterior cruciate ligament (ACL) reconstruction (ACLR). Previous studies have provided evidence that offers conflicting opinions concerning the most favorable graft choice. PURPOSE: To identify whether the use of a quadrupled semitendinosus tendon (ST) or doubled semitendinosus tendon and gracilis tendon (ST/G) graft provides comparable anterior tibial translation (ATT) with similar functional results and similar donor site morbidity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a prospective, patient- and surgeon-blinded, randomized trial set in a busy orthopaedic and traumatology department at a university hospital. Between 2015 and 2017, a total of 162 patients with ACL lesions were randomized to undergo ACLR with either a quadrupled ST or doubled ST/G graft. The primary endpoint was ATT assessed with the KT-1000 arthrometer. Clinical outcomes were assessed using the patient-reported outcome measures (PROMs) of the visual analog scale (VAS), International Knee Documentation Committee (IKDC) subjective evaluation form, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, and Lysholm knee scoring scale. RESULTS: Preoperative demographic data, ATT, and PROM scores showed no significant differences. At 4.5 years, no significant differences were found between the ST and ST/G groups with respect to PROM scores and KT-1000 arthrometer, Lachman test, and pivot-shift test findings. Differences in functional results between groups were significant (muscle strength). Subgroup analysis revealed significantly increased ATT in female patients undergoing ACLR with a quadrupled ST graft during the 4.5-year observation period, as assessed by the KT-1000 arthrometer, as well as inferior KOOS, IKDC, Lysholm, and VAS scores. CONCLUSION: This study showed a significant increase in ATT as well as inferior results on PROMs during a 4.5-year observation period in female patients undergoing ACLR with a quadrupled ST graft. In male patients, the study provided evidence of the noninferiority of ACLR with an ST graft, with no influence on donor site morbidity. TRIAL REGISTRATION: clinicaltrials.gov: NCT03626883.

Outcomes of Treatment of Monteggia Fractures with Reduction and Internal Titanium Elastic Nail Fixation of the Ulna.

BACKGROUND: The purpose of this paper is to evaluate the usefulness of radiographic indices of humero-radial joint instability in order to predict treatment outcomes in Monteggia fractures. MATERIAL AND METHODS: A retrospective analysis was conducted in a group of patients who underwent closed reduction and internal titanium elastic nail (TEN) fixation of the ulna and closed reduction of a dislocation of the radial head between 2016 and 2018. The indications for intrame-dullary fixation comprised transverse or short oblique fractures. The direction of the dislocation was classified according to Bado. The following radiographic indies were assessed: Radiocapitellar Line, Lateral Humeral Line, Proximity Index, and Radial Head Displacement Index. RESULTS: Treatment outcomes were assessed with the Oxford Elbow Score and Mayo Elbow Performance Score, and com-plications were assessed with a modified Clavien-Dindo-Sink scale. No coincidence between poor functional and radio-graphic outcomes was demonstrated. CONCLUSIONS: 1. Regardless of the severity of the injury, eligibility for surgery and correctly performed surgical treatment guarantee a good final outcome. 2. Patients treated with TEN regain their preoperative mobility. 3. There was no coincidence between poor functional and radiographic outcomes, except for one patient in whom subluxation of the radial head persisted despite surgery and was confirmed radiographically and functionally. 4. It would be beneficial for clinical practice to introduce simple, reproducible radiographic parameters for unambiguous assessment of the effectiveness of treatment and predicting treatment outcomes; unfortunately none of the parameters we investigated were sufficiently reliable. 5. The radiographic parameters analysed in this paper are dependent on the quality of the radiological examinations performed.

Total Hip Arthroplasty in Patients With Osteoarthritis Associated With Legg-Calve-Perthes Disease: Perioperative Complications and Patient-Reported Outcomes.

BACKGROUND: Complications and patient-reported outcomes (PROs) of total hip arthroplasty (THA) in patients with Legg-Calve-Perthes disease (LCPD) have demonstrated variable results. The purpose of this study was to use a validated grading scheme to analyze complications associated with THA in patients with residual LCPD deformities. Second, we report PROs and intermediate-term survivorship in this patient population. METHODS: A retrospective, single-center review was performed on 61 hips in 61 patients who underwent THA for residual Perthes disease. Average patient age was 42 years and 26% of hips had previous surgery. Complications were determined and categorized using a validated grading scheme that included five grades based on the treatment required to manage the complication and on persistent disability. PROs were compared from preoperative to most recent follow-up time points. RESULTS: Major complications (grade III) occurred in three patients (5%) which each required a second surgical intervention. The most common minor grade I or II complications (11.5%) were asymptomatic heterotopic ossification (3.3%). Patients were lengthened on the surgical side an average of 1.4 cm with no nerve palsies. All patient PROs improved from preoperative to postoperative time points with the modified Harris Hip Score improving from 46.9 preoperatively to 85.4 postoperatively (P < .01). Patients free from revision for any reason at final follow-up (5.6 years; range 2-13 years) was 98.4% with one patient needing a revision of their femoral component. CONCLUSIONS: THA for the sequelae of the LCPD has an acceptable complication rate and provides excellent patient reported outcomes at mid-term follow-up.

Repair Augmentation of Unstable, Complete Vertical Meniscal Tears With Bone Marrow Venting Procedure: A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study.

PURPOSE: To compare the effectiveness and safety of meniscal repair in 2 groups of patients: meniscal repair with biological augmentation using a bone marrow venting procedure (BMVP) of the intercondylar notch versus meniscal repair only. METHODS: This single-center, prospective, randomized, double-blind, placebo-controlled, parallel-arm study included 40 patients (21 menisci in control, 23 in BMVP group) with complete vertical meniscus tears. Patients underwent all-inside and outside-in meniscal repair and a concomitant BMVP of the intercondylar notch or meniscal repair alone during an index arthroscopy. The primary endpoint was the rate of meniscus healing in the 2 groups assessed during a second-look arthroscopy (at week 35). The secondary endpoints were changes in the International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale in the 2 groups at 30 months. RESULTS: After 36 weeks, the meniscus healing rate was significantly higher in the BMVP-treated group than in the control group (100% vs. 76%, P = .0035). Functional outcomes were significantly better 30 months after treatment than at baseline in both groups. The International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and visual analog scale scores were significantly better in the BMVP-treated group than in the control group. No adverse events were reported during the study period. CONCLUSIONS: Our blinded, prospective, randomized, controlled trial on the role of BMVP augmentation in meniscus repair, indicates that BMVP augmentation results in a significant improvement in the rate of meniscus healing (100% vs. 76%, P = .0035). The risk of adverse events related to augmentation with BMVP of the arthroscopic meniscal repair is very low. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Psychometric Properties of Patient-Reported Outcome Measures for Periacetabular Osteotomy.

BACKGROUND: Appropriate patient-reported outcome measures are paramount to determine the clinical relevance of change experienced by patients after a surgical procedure. The purpose of this study was to evaluate the psychometric properties of 3 patient-reported outcome measures (Hip disability and Osteoarthritis Outcome Score [HOOS], modified Harris hip score, and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) in a large population of patients treated with periacetabular osteotomy for symptomatic developmental dysplasia of the hip. METHODS: Patients who underwent a periacetabular osteotomy for acetabular dysplasia between October 2011 and October 2016 completed multiple questionnaires preoperatively and at the 1-year follow-up. Internal consistency for subscores was evaluated with the Cronbach alpha. Validity was assessed against the Short Form-12. Interpretability included the calculation of the distribution of scores, floor and ceiling effects, and the minimal clinically important difference. Responsiveness was assessed by correlating the score changes with the Global Perceived Effect score. RESULTS: Of 294 patients, 246 (84%) were female. The median age was 21 years (interquartile range, 17 to 29 years). All WOMAC and HOOS subscores demonstrated adequate internal consistency, and none of the modified Harris hip score components did. All scores except the WOMAC stiffness score exhibited adequate validity and interpretability, with no floor and ceiling effects over 15%. For the HOOS subscores, the minimal clinically important difference was 10.3 for pain, 10.2 for symptoms, 12.6 for sports and recreation, 11.2 for quality of life, and 10.8 for activities of daily living. The minimal clinically important difference for the modified Harris hip score was 7.4. For the WOMAC subscores, the minimal clinically important difference was 10.8 for pain, 12.9 for stiffness, 10.8 for physical, and 10.4 for total. All scores demonstrated adequate responsiveness. CONCLUSIONS: The HOOS, WOMAC, and modified Harris hip score have adequate psychometric properties for use in patients undergoing periacetabular osteotomy, with minor shortcomings. Among the scores analyzed, the HOOS appears to be the most appropriate measure of patient-reported outcome in patients undergoing periacetabular osteotomy. CLINICAL RELEVANCE: By establishing the psychometric properties of patient-reported outcome measures for periacetabular osteotomy, this study enables a more informed choice of measures for clinical practice and research. The estimated minimal clinically important difference values will facilitate understanding the importance of change in patient-reported outcomes after a surgical procedure in a clinical setting and sample size calculation for further studies.

Neglected Iatrogenic Elbow Joint Dislocation. Didactic Case Report.

We present a case of a neglected dislocation of the elbow joint. A 28-year-old patient suffered elbow joint dislocation with fracture of the radial head after a fall from a considerable height. Following a failed attempt at manual repositioning, the dislocation was reduced surgically and free fragments of the radial head were removed without stabilisation with a Kirschner wire. The joint was immobilised for 6 weeks in an arm-to-hand plaster cast, followed by two weeks during which an elbow joint orthosis with adjustable flexion was worn. The patient then attended rehabilitation. The first follow-up radiograph was obtained as late as 5 months following the operation and revealed a neglected dislocation and periarticular ossifications. Subsequent procedures did not improve limb function and the course was also complicated by a joint infection. The ultimate functional outcome is unsatisfactory. According to the principles of trauma care, all repositioning procedures need to be confirmed with a follow-up radiograph.

A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study Evaluating Meniscal Healing, Clinical Outcomes, and Safety in Patients Undergoing Meniscal Repair of Unstable, Complete Vertical Meniscal Tears (Bucket Handle) Augmented with Platelet-Rich Plasma.

OBJECTIVE: The present study aimed to investigate the effectiveness and safety of platelet-rich plasma (PRP) application in arthroscopic repair of complete vertical tear of meniscus located in the red-white zone. METHODS: This single center, prospective, randomized, double-blind, placebo-controlled, parallel-arm study included 37 patients with complete vertical meniscus tears. Patients received an intrarepair site injection of either PRP or sterile 0.9% saline during an index arthroscopy. The primary endpoint was the rate of meniscus healing in the two groups. The secondary endpoints were changes in the International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and analog scale (VAS) in the two groups at 42 months. RESULTS: After 18 weeks, the meniscus healing rate was significantly higher in the PRP-treated group than in the control group (85% versus 47%, P = 0.048). Functional outcomes were significantly better 42 months after treatment than at baseline in both groups. The IKDC score, WOMAC, and KOOS were significantly better in the PRP-treated group than in the control group. No adverse events were reported during the study period. CONCLUSIONS: The findings of this study indicate that PRP augmentation in meniscus repair results in improvements in both meniscus healing and functional outcome.

D-dimer Levels are not a Good Marker for Venous Thromboembolism in Patients Before and After Total Hip Replacement.

BACKGROUND: Total hip replacement activates the coagulation and fibrinolysis systems. The aim of this paper is to describe the concentrations of these proteins following elective total hip replacement. MATERIAL AND METHODS: This prospective laboratory study enrolled 30 patients (including 18 women) who had been qualified for primary total hip replacement due to idiopathic osteoarthritis. Mean age was 70 years (range: 45-86 years). All patients received venous thromboembolism (VTE) prophylaxis according to the current guidelines (enoxaparin 40 mg SC s.i.d. from the day of the procedure). An immunoenzymatic assay (ACL TOP 500 CTS analyser, Beckman Coulter, Brea, CA, USA) was used to determine D-dimer levels before the surgical procedure, 6 hours after the procedure, and on the 2nd, 4th, and 6th post-operative day. RESULTS: No patients showed signs and symptoms of VTE during the hospital stay. The mean D-dimer level before the procedure was 1 mg/ml, with a highest mean value of 11.8 mg/ml at 6 hours after the procedure; the levels would then decrease but would remain above the normal range for 6 days after surgery. Elevated baseline D-dimer levels (>0.5 mg/ml) were found in 80% of the study patients. CONCLUSIONS: 1. D-dimers act like acute phase proteins, with levels increasing several-fold following total hip repla-cement. 2. D-dimer levels cannot be used to diagnose venous thromboembolism even before the procedure and hospi-talisation in patients with idiopathic coxarthrosis and no clinical manifestations of thrombosis.

Radiological Outcomes of Overhead Traction Therapy for Developmental Dysplasia of the Hip in Non-ambulatory Children.

BACKGROUND: Infants with a dislocated and unstable hip that does not lend itself to stabilisation may be treated using overhead traction to achieve gradual reduction of the hip joint. The aim of this paper was to analyse the radiological outcomes of overhead traction therapy and the effect of duration of traction on the occurrence of complications and final treatment outcomes. Material and methodd. A retrospective analysis of medical records of 26 children (34 affected hips) involved three independent observers assessing radiological parameters before the surgery and at follow-up visits at least two years after the therapy. RESULTS: Overhead traction was used for an average of 35 days (range: 15-43 days). Twenty six hips were treated solely with reduction and immobilisation in a 'human position' plaster cast. Three hips were qualified for surgery immediately after a preliminary traction period. Five hips showed a suboptimal result following the immobilisation period. A MANOVA model revealed that the following factors had a significant effect on the treatment outcome: superior centring ratio of Smith (with the lowest values recorded in patients with residual hip dysplasia, p = 0.001) and acetabular angle of Sharp (with the lowest values found in patients requiring surgery, p = 0.01). Statistical tests did not show a correlation between the duration of traction and disturbance of proximal femoral metaphysis growth assessed according to Bucholz and Ogden classification. Fifteen hips were classified as type I, eight hips were graded as type II and also eight hips as type III. CONCLUSIONS: The lowest values of acetabular angle of Sharp were recorded in patients requiring surgery and the lowest superior centring ratio of Smith was found in those with residual hip dysplasia. The duration of overhead traction did not directly correlate with the final outcome; it only seemed to be an indicator of the severity of hip dysplasia. Routine use of overhead traction before undertaking closed reduction does not probably decrease the incidence of proximal femoral growth disturbance.

Emperor's new clothes: Is particle disease really infected particle disease?

Aseptic loosening remains the most significant long-term complication of total hip replacement. The current paradigm points to an inflammatory response to wear particles as its main trigger. Recently, there have been increasing numbers of positive bacterial isolates reported among patients with clinically absent infection. This paper reviews existing evidence on possible involvement of bacteria and microbial-associated molecular patterns in the pathology of so-called "aseptic loosening." © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1497-1504, 2016.

Posttraumatic Oedema in Lower Limbs. Advances in Understanding Etiopathogenesis and Treatment. Review Article.

Mechanical injury to soft tissues and bones of the lower limbs may be complicated by thrombosis and oedema. Treatment of posttraumatic oedema in the lower limbs can be difficult and protracted and rarely leads to complete recovery. The pathogenesis of posttraumatic oedema has not been fully elucidated. This paper presents the aetiopathogenesis of posttraumatic oedema in the lower limbs and a review of relevant literature in English and Polish of the last 5 years, describing therapy outcomes and potential perspectives for develop ment.

Custom-Made Antibiotic Cement Nails in Orthopaedic Trauma: Review of Outcomes, New Approaches, and Perspectives.

Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection.