Purpose
The purpose of this study was to carefully analyse the reasons for revision ACLR failure to optimize the surgical revision technique and minimize the risk of recurrent re-rupture. Large ...studies with a minimum of 2 years of follow-up that clinically examine patients with revision ACLR are rare.
Methods
Between 2013 and 2016, 111 patients who underwent revision ACLR were included in the retrospective study. All patients were examined for a minimum of 2 years after revision surgery (35 ± 3.4 months, mean ± STD) and identified as “failed revision ACLR” (side-to-side difference ≥ 5 mm and pivot-shift grade 2/3) or “stable revision ACLR”.
Results
Failure after revision ACLR occurred in 14.5% (
n
= 16) of the cases. Preoperative medial knee instability (
n
= 36) was associated with failure; thus, patients had a 17 times greater risk of failure when medial knee instability was diagnosed (
p
= 0.015). The risk of failure was reduced when patients had medial stabilization (
n
= 24,
p
= 0.034) and extra-articular lateral tenodesis during revision surgery (
n
= 51,
p
= 0.028). Increased posterior tibial slope (
n
= 11 ≥ 12°,
p
= 0.046) and high-grade anterior knee laxity (side-to-side difference > 6 mm and pivot-shift grade 3,
n
= 41,
p
= 0.034) were associated with increased failure of revision ACLR. Obese patients had a 9 times greater risk of failure (
p
= 0.008,
n
= 30).
Conclusion
This study demonstrates the largest revision ACLR patient group with pre- and postoperative clinical examination data and a follow-up of 2 years published to date. Preoperative medial knee instability is an underestimated risk factor for revision ACLR failure. Additionally, high-grade anterior knee laxity, increased PTS and high BMI are risk factors for failure of revision ACLR, while additional medial stabilization and lateral extra-articular tenodesis reduce the risk of failure.
Level of evidence
III.
Background:
Both an elevated posterior tibial slope (PTS) and high-grade anterior knee laxity are often present in patients who undergo revision anterior cruciate ligament (ACL) surgery, and these ...conditions are independent risk factors for ACL graft failure. Clinical data on slope-correction osteotomy combined with lateral extra-articular tenodesis (LET) do not yet exist.
Purpose:
To evaluate the outcomes of patients undergoing revision ACL reconstruction (ACLR) and slope-correction osteotomy combined with LET.
Study Design:
Case series; Level of evidence, 4.
Methods:
Between 2016 and 2018, we performed a 2-stage procedure: slope-correction osteotomy was performed first, and then revision ACLR in combination with LET was performed in 22 patients with ACLR failure and high-grade anterior knee laxity. Twenty patients (6 women and 14 men; mean age, 27.8 ± 8.6 years; range, 18-49 years) were evaluated, with a mean follow-up of 30.5 ± 9.3 months (range, 24-56 months), in this retrospective case series. Postoperative failure was defined as a side-to-side difference of ≥5 mm in the Rolimeter test and a pivot-shift grade of 2 or 3.
Results:
The PTS decreased from 15.3° to 8.9°, the side-to-side difference decreased from 7.2 to 1.1 mm, and the pivot shift was no longer evident in any of the patients. No patients exhibited revision ACLR failure and all patients showed good to excellent postoperative functional scores (mean ± SD: visual analog scale, 0.5 ± 0.6; Tegner, 6.1 ± 0.9; Lysholm, 90.9 ± 6.4; Knee injury and Osteoarthritis Outcome Score KOOS Symptoms, 95.2 ± 8.4; KOOS Pain, 94.7 ± 5.2; KOOS Activities of Daily Living, 98.5 ± 3.2; KOOS Function in Sport and Recreation, 86.8 ± 12.4; and KOOS Quality of Life, 65.4 ± 14.9).
Conclusion:
Slope-correction osteotomy in combination with LET is a safe and reliable procedure in patients with high-grade anterior knee laxity and a PTS of ≥12°. Normal knee joint stability was restored and good to excellent functional scores were achieved after a follow-up of at least 2 years.
Background:
Some authors have suggested that the semimembranosus tendon is involved in the pathophysiology of ramp lesions. This led us to conduct a gross and microscopic analysis of the posterior ...horn of the medial meniscus and the structures inserted on it.
Hypothesis:
(1) The semimembranosus tendon has a tendinous branch inserting into the posterior horn of the medial meniscus, and (2) the meniscotibial ligament is inserted on the posteroinferior edge of the medial meniscus.
Study Design:
Descriptive laboratory study.
Methods:
In total, 14 fresh cadaveric knees were dissected. From each cadaveric donor, a stable anatomic specimen was harvested en bloc, including the medial femoral condyle, medial tibial plateau, whole medial meniscus, cruciate ligaments, joint capsule, and distal insertion of the semimembranosus tendon. The harvested blocks were cut along the sagittal plane to isolate the distal insertion of the semimembranosus tendon on the posterior joint capsule and the posterior horn of the medial meniscus in a single slice. Histological slides were made from these samples and analyzed under a microscope.
Results:
In all knees, gross examination revealed a direct branch of the semimembranosus and a tendinous capsular branch ending behind the posterior horn of the medial meniscus. This capsular branch protruded over the joint capsule, over the meniscotibial ligament below and the meniscocapsular ligament above, but never ended directly in the meniscal tissue. The capsular branch was 14.3 ± 4.4 mm long (mean ± SD). The direct tendon inserted 11 ± 2.8 mm below the articular surface of the tibial plateau. The meniscotibial ligament inserted on the posteroinferior edge of the medial meniscus, and the meniscocapsular ligament insertion was on its posterosuperior edge. Highly vascularized adipose tissue was found, delimited by the posterior horn of the medial meniscus, meniscotibial ligament, meniscocapsular ligament, and capsular branch of the semimembranosus tendon.
Conclusion:
In all knees, our study found a capsular branch of the semimembranosus tendon inserted behind the medial meniscus. The meniscotibial ligament was inserted on the posteroinferior edge of the medial meniscus. Histological analysis of this area revealed that this ligament inserted differently from the insertion previously described in the literature.
Clinical Relevance:
This laboratory study provides insight into the pathophysiology of ramp lesions frequently associated with anterior cruciate ligament injury. To restore anatomy, it is mandatory to reestablish meniscotibial ligament continuity in ramp repairs.
Introduction
Injuries of the posterolateral corner (PLC) of the knee lead to chronic lateral and external rotational instability and are often associated with PCL injuries. Numerous surgical ...techniques for repair and reconstruction of the PLC are established. Recently, several arthroscopic techniques have been published in order to address different degrees of PLC injuries through reconstruction of one or more functional structures. The purpose of this systematic review is to give an overview about arthroscopic techniques of posterolateral corner reconstructions and to evaluate their safeness.
Materials and methods
A systematic review of the literature on arthroscopic reconstructions of the posterolateral corner of the knee according to the PRISMA guidelines was performed using PubMed MEDLINE and Web of Science Databases on June 15th, 2020. Inclusion criteria were descriptions of surgical techniques to reconstruct different aspects of the posterolateral corner either strictly arthroscopically or minimally-invasive with an arthroscopic assistance.
Results
Arthroscopic techniques differ with regard to the extent of reconstructed units (popliteus tendon, popliteofibular ligament, lateral collateral ligament), surgical approach (transseptal, lateral) and biomechanical results (anatomic vs. non-anatomic reconstruction, restoration of rotational instability and/or lateral instability).
Conclusion
Different approaches to arthroscopic PLC reconstruction are presented, yet clinical results are scarce. Up to now good and excellent clinical results are reported. No major complications are reported in the literature so far.
Abstract Background Currently existing classifications of tibial plateau fractures do not help to guide surgical strategy. Recently, a segment-based mapping of the tibial plateau has been introduced ...in order to address fractures with a fracture-specific surgical approach. The goal of the present study was to analyze incidence and fracture specifics according to a new 10-segment classification of the tibial plateau. Methods A total of 242 patients with 246 affected knees were included (124 females, 118 males, mean age 51.9 ± 16.1 years). Fractures were classified according to the OTA/AO classification. Fracture pattern was analyzed with respect to a 10-segment classification based on CT imaging of the proximal tibial plateau 3 cm below the articular surface. Results 161 Patients suffered an OTA/AO type 41-B and 85 patients an OTA/AO type 41-C tibial plateau fracture. Females had an almost seven times higher risk to suffer a fracture due to low-energy trauma (OR 6.91, 95% CI (3.52, 13.54), p < 0.001) than males. In 34% of the patients with affection of the medial tibial plateau, a fracture comminution, primarily due to low-energy trauma (p < 0.001), was observed. In type B fractures, the postero-latero-lateral (65.2%), the antero-latero-lateral (64.6%) and the antero-latero-central (60.9%) segment were most frequently affected. Every second type C fracture showed an unique fracture line and zone of comminution. The tibial spine was typically involved (89.4%). A typical fracture pattern of high-energy trauma demonstrated a zone of comminution of the lateral plateau and a split fracture in the medial plateau. The most frequently affected segments were the postero-latero-central (85.9%), postero-central (84.7%), and antero-latero-central (78.8%) segment. Conclusion Posterior segments were the most frequently affected in OTA/AO type B and C fractures. Acknowledging the restricted visibility of posterior segments, whose reduction and fixation is crucial for long-term success, our findings implicate the use of posterior approaches more often in the treatment of tibial plateau fractures. Also, low-energy trauma was identified as an important cause for tibial plateau fractures.
Introduction
Arthroscopic reconstruction techniques of the posterolateral corner (PLC) of the knee have been developed in recent years. Reconstruction techniques for higher-grade PLC injuries have ...not yet been validated in clinical studies. This study aimed to compare clinical outcomes of two different techniques and to present results of the first prospective randomized clinical trial of patients to undergo these novel procedures.
Materials and methods
19 patients with Fanelli Type B posterolateral corner injuries and additional posterior cruciate ligament ruptures were included in this prospective study. They were randomly assigned to one of two novel arthroscopic reconstruction techniques, based on open surgeries developed by
Arciero
(group A) and
LaPrade
(group B). Follow-up was conducted at 6 and 12 months postoperatively and included clinical examinations for lateral, rotational and posterior stability, range of motion and subjective clinical outcome scores (IKDC Subjective Score, Lysholm Score, Tegner Activity Scale and Numeric Rating Scale for pain).
Results
At 6 and 12 months postoperative, all patients in both groups presented stable to varus, external rotational and posterior forces, there were no significant differences between the two groups. At 12-month follow-up, group A patients showed significantly higher maximum flexion angles (134.17° ± 3.76° vs. 126.60° ± 4.22°;
p
= 0.021) compared to patients of group B. Duration of surgery was significantly longer in Group B patients than in group A (121.88 ± 11.63 vs. 165.00 ± 35.65 min;
p
= 0.003). Posterior drawer (side-to-side difference) remained more reduced in group A (2.50 ± 0.69 mm vs. 3.27 ± 0.92 mm;
p
= 0.184). Subjective patient outcome scores showed no significant differences between groups (Lysholm Score 83.33 ± 7.79 vs. 86.40 ± 9.21;
p
= 0.621).
Conclusions
This study indicates sufficient restoration of posterolateral rotational instability, varus instability and posterior drawer after arthroscopic posterolateral corner reconstruction without neurovascular complications.
Increased postoperative range of motion and a shorter and less invasive surgical procedure could favor the arthroscopic reconstruction technique according to Arciero over LaPrade’s technique in future treatment considerations.
Background
A lateralized tibial tubercle may be a relevant anatomic factor in patients with patellar instability and can be used as an indication for a distal realignment procedure. However, ...parameter values for the tibial tuberosity–trochlear groove (TT-TG) distance in the young patient have not been defined. It also remains to be determined how this parameter contributes to patellar instability in the growing knee joint.
Purpose
The purpose of this study was to evaluate the value of the TT-TG distance in patellar instability in the young athlete.
Study Design
Case control study; Level of evidence, 3.
Methods
Knee magnetic resonance images were collected from 109 patients with lateral patellar instability and from 136 control subjects. Student t test and multiple logistic regression analysis were used to compare the absolute and relative values of the TT-TG distance between patients and controls. The relative value was defined as the ratio between the TT-TG distance and the total width of the distal femur.
Results
The TT-TG distance (absolute and relative to femur width) differed significantly between patients with patellar dislocation and the control group (both P < .01). The TT-TG distances were on average 4 mm larger in patients with patellar dislocation; TT-TG distance divided by femur width was on average 5% larger in patients with patellar dislocation. Multiple logistic regression analysis confirmed the TT-TG distance as a significant risk factor for patellar dislocation (P = .04), but showed no significant interaction with patient age or femur width (P = .95 and P = .15, respectively).
Conclusion
A lateralized tibial tubercle is a relevant anatomic factor in the young athlete and in the adult patient with lateral patel-lar instability. Its parameter values and its influence on patellar dislocation are independent of patient age and should therefore be evaluated as in adults.
Purpose
Valgus deformities of the lower extremity influence patellofemoral joint kinematics. However, studies examining the clinical outcome after treatment of patellar instability and maltracking ...due to valgus deformity are rare in recent literature. This study’s purpose is to analyze the clinical results after combined distal femoral osteotomy (DFO) for treatment of patellar instability.
Methods
From 2010 to 2016, 406 cases of patellofemoral instability and maltracking were treated. Twenty cases of recurring (≥ 2) patellar dislocations with genu valgum and unsuccessful conservative treatment were included in the study. A radiological analysis was performed, and anteroposterior (AP), lateral and long leg standing radiographs were analyzed, and the leg axis was pre- and postoperatively measured. At least 12 months postoperatively, the clinical leg axis, range of motion (ROM), apprehension sign, Zohlen sign, and J-sign were physically examined. Pain level and knee function were objectified on a visual analogue scale (VAS). The Lysholm, Kujala, and Tegner scores, re-dislocation rate, and patient satisfaction were also examined.
Results
20 combined DFOs on 18 patients with a median age of 23 years (15–55 years) were performed. The preoperative mechanical leg axis was 6.5° ± 2.0° valgus, and the mean tibial tuberosity to trochlear groove (TT-TG) distance was 19.1 ± 4.8 mm. All patients reported multiple dislocations. Intraoperatively, 71% presented III°–IV° cartilage lesions, located retropatellarly in 87% and correlating negatively with the postoperative Lysholm score (
r
= − 0.462,
p
= 0.040). The leg axis was corrected by 7.1° ± 2.6°, and in 17 cases, the tibial tubercle was additionally medialized by 10 ± 3.1 mm. All patellae were re-stabilized with medial patellofemoral ligament reconstruction. After a median period of 16 (12–64) months, the pain level decreased from 8.0 ± 1.4 to 2.3 ± 2.1 (VAS
p
≤ 0.001) and knee function improved from 40.1 ± 17.9 to 78.5 ± 16.6 (Kujala
p
≤ 0.001), 36.1 ± 19.5 to 81.6 ± 11.7 (Lysholm
p
≤ 0.001), and 2.0 (1–5) to 4.0 (3–6) (median Tegner
p
≤ 0.001). No re-dislocation was observed.
Conclusion
Combined DFO is a suitable treatment for patellar instability and maltracking due to genu valgum, as it leads to very low re-dislocation rates, a significant reduction of pain, and a significant increase of knee function with good-to-excellent results in the short-term follow-up. However, a high prevalence of substantial cartilage lesions is observed, causing postoperative limitations of knee function.
Level of evidence
IV, retrospective cohort study.
Since the introduction of widely available e-scooter rentals in Hamburg, Germany in June of 2019, our emergency department has seen a sharp increase in the amount of e-scooter related injuries. ...Despite a rising number of studies certain aspects of e-scooter mobility remain unclear. This study examines the various aspects of e-scooter associated injuries with one of the largest cohorts to date. Electronic patient records of emergency department admissions were screened for e-scooter associated injuries between June 2019 and December 2021. Patient demographic data, mechanism of injury, alcohol consumption, helmet usage, sustained injuries and utilized medical resources were recorded. Overall, 268 patients (57% male) with a median age of 30.3 years (IQR 23.3; 40.0) were included. 252 (94%) were e-scooter riders themselves, while 16 (6%) were involved in crashes associated with an e-scooter. Patients in non-rider e-scooter crashes were either cyclists who collided with e-scooter riders or older pedestrians (median age 61.2 years) who tripped over parked e-scooters. While e-scooter riders involved in a crash sustained an impact to the head or face in 58% of cases, those under the influence of alcohol fell on their head or face in 84% of cases. This resulted in a large amount of maxillofacial soft tissue lacerations and fractures. Extremity fractures and dislocations were more often recorded for the upper extremities. This study comprises one of the largest cohorts of e-scooter associated injuries to date. Older pedestrians are at risk to stumble over parked e-scooters. E-scooter crashes with riders who consumed alcohol were associated with more severe injuries, especially to the head and face. Restricted e-scooter parking, enforcement of drunk driving laws for e-scooters, and helmet usage should be recommended.
As brain and bone disorders represent major health issues worldwide, substantial clinical investigations demonstrated a bidirectional crosstalk on several levels, mechanistically linking both ...apparently unrelated organs. While multiple stress, mood and neurodegenerative brain disorders are associated with osteoporosis, rare genetic skeletal diseases display impaired brain development and function. Along with brain and bone pathologies, particularly trauma events highlight the strong interaction of both organs. This review summarizes clinical and experimental observations reported for the crosstalk of brain and bone, followed by a detailed overview of their molecular bases. While brain-derived molecules affecting bone include central regulators, transmitters of the sympathetic, parasympathetic and sensory nervous system, bone-derived mediators altering brain function are released from bone cells and the bone marrow. Although the main pathways of the brain-bone crosstalk remain 'efferent', signaling from brain to bone, this review emphasizes the emergence of bone as a crucial 'afferent' regulator of cerebral development, function and pathophysiology. Therefore, unraveling the physiological and pathological bases of brain-bone interactions revealed promising pharmacologic targets and novel treatment strategies promoting concurrent brain and bone recovery.
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