The aim of this study was to investigate differences in concomitant injury patterns and their treatment in patients undergoing early (≤ 12 weeks) and delayed (> 12 weeks) primary multiligament ...posterior cruciate ligament (PCL) reconstruction (PCL-R).
This study was a retrospective chart review of patients undergoing primary multiligament PCL-R at a single institution between 2008 and 2020. Multiligament PCL-R was defined as PCL-R and concurrent surgical treatment of one or more additional knee ligament(s). Exclusion criteria included isolated PCL-R, PCL repair, and missing data for any variable. Patients were dichotomized into early (≤ 12 weeks) and delayed (> 12 weeks) PCL-R groups based on the time elapsed between injury and surgery. Between-group comparison of variables were conducted with the Chi-square, Fisher's exact, and independent samples t-tests.
A total of 148 patients were eligible for analysis, with 57 (38.5%) patients in the early and 91 (61.1%) patients in the delayed multiligament PCL-R groups. Concomitant LCL/PLC reconstruction (LCL-R/PLC-R) was performed in 55 (60%) of delayed multiligament PCL-Rs and 23 (40%) of early PCL-Rs (p = 0.02). Despite similar rates of meniscus injury, concomitant meniscus surgery was significantly more prevalent in the early (n = 25, 44%) versus delayed (n = 19, 21%) multiligament PCL-R group (p = 0.003), with a significantly greater proportion of medial meniscus surgeries performed in the early (n = 16, 28%) compared to delayed (n = 13, 14%) PCL-R group (p = 0.04). The prevalence of knee cartilage injury was significantly different between the early (n = 12, 24%) and delayed (n = 41, 46%) multiligament PCL-R groups (p = 0.01), with more frequent involvement of the lateral (n = 17, 19% vs. n = 3, 5%, respectively; p = 0.04) and medial (n = 31, 34% vs. n = 6, 11%, respectively; p = 0.005) femoral condyles in the delayed compared to the early PCL-R group.
Given higher rates of chondral pathology and medial meniscus surgery seen in delayed multiligament PCL-R, early management of PCL-based multiligament knee injury is recommended to restore knee stability and potentially prevent the development of further intraarticular injury.
Level III.
Background:
Multiple-revision anterior cruciate ligament reconstruction (ACLR) presents several technical challenges, often due to residual hardware, tunnel widening, malposition, or staged ...surgeries.
Purpose:
To compare failure and complication rates between the over-the-top (OTT) and transportal drilling (TD) techniques in patients undergoing surgery for failed revision ACLR.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
The medical records of patients with at least 2 revision ACLRs using either the OTT or TD technique were reviewed retrospectively. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications, and failures were collected. Between-group comparisons of continuous and categorical variables were conducted with the independent-samples t test and the Fisher exact or chi-square test, respectively.
Results:
A total of 101 patients undergoing multiple-revision ACLR with OTT (n = 37, 37%) and TD (n = 64, 63%) techniques were included for analysis. The mean follow-up time was 60 months (range, 12-196 months). There were no significant differences in age, sex, body mass index, laterality, or follow-up length between groups (P > .05). Allograft was the graft used most frequently (n = 64; 67.3%) with no significant differences between groups in graft diameter (P > .05). There were no statistically significant differences between groups regarding rate of concurrent medial and lateral meniscus, cartilage, or lateral extra-articular procedures (P > .05). There was also no significant66 between-group difference in complication rate (OTT: n = 2 5.4%; TD: n = 8 13%) or graft failure rate (OTT: n = 4 11%; TD: n = 14 22%) (P > .05 for both).
Conclusion:
The results of this study showed notably high failure and complication rates in challenging multiple-revision ACLR. Complication and failure rates were similar between techniques, demonstrating that the OTT technique is a valuable alternative that can be used in a revision ACLR, particularly as a single-stage approach when the single-stage TD technique is not possible.
Background:
Due to difficult-to-access location and complex tear patterns, the management of meniscus injuries in isolation and in conjunction with anterior cruciate ligament injury may be ...challenging. The aim of this video is to present techniques and tips that may help surgeons perform arthroscopic all-inside repair of complex meniscus tears.
Indications:
Indications for the presented repair techniques are young patients with high activity demands, symptomatic lateral and medial meniscus lesions, ligamentous knee instability, chondral changes grade 2 or less, neutral joint alignment, and body mass index below 35 kg/m2.
Technique Description:
High anterolateral, low anteromedial, and accessory anterolateral portals are used for the arthroscopic assessment of meniscus tear quality and pattern, and to ensure adequate access to the lesion. Horizontal mattress, vertical mattress, and cerclage sutures are passed using a range of all-inside devices to approximate tear edges with the aim of restoring native hoop stresses along the circumferential meniscus collagen fibers. Tear edges are abraded to enhance healing potential. Two separate cases and complex tear configurations are presented to illustrate these all-inside meniscus repair techniques.
Results:
Meniscus repair yields superior long-term outcomes compared with partial meniscectomy. Improvements in subjective knee function and lower rates of progression to long-term knee osteoarthritis are reported in patients treated with meniscus repair versus resection. Advantages of all-inside meniscus repair include the reduced risk of iatrogenic neurovascular lesions, decreased operative time, restoration of native contact surfaces, and repair without fixation of the menisci to the surrounding soft tissue.
Discussion/Conclusion:
Arthroscopic all-inside meniscus repair enables the safe and efficient management of complex meniscus tears in active patients with symptomatic meniscus pathology, and can be performed concurrent with knee ligament surgery. Consequently, all-inside meniscus repair techniques are a versatile addition to the toolkit of complex knee surgeons.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Graphical Abstract
This is a visual representation of the abstract.
Objectives:
Multiple-revision anterior cruciate ligament reconstruction (ACL-R) presents several technical challenges, often due to residual hardware, tunnel widening, or malposition. The aim of this ...study was to compare complication rates between over-the-top (OTT) and anteromedial portal drilling (AMD) techniques in patients undergoing multiple-revision ACL-R.
Methods:
A retrospective cohort study comprised of patients undergoing multiple-revision ACL-R was performed by four sports medicine fellowship trained surgeons in a single institute. Patients with two or more revision ACL-Rs performed with the OTT or AMD techniques were included. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications (arthrofibrosis, septic arthritis, cyclops lesion), and failures were collected. Between- group comparisons of continuous and categorical variables were conducted with independent samples t- tests and Fisher’s exact or the chi-squared test, respectively. Level of significance was set at p < 0.05.
Results:
A total of 101 patients undergoing multiple revision ACL-R with OTT (n=37, 37%) and AMD (n=64, 63%) techniques were identified. The mean follow-up period was 60 months (range: 12-196). No statistically significant differences were found in age, gender, body mass index, laterality, or follow-up length (p > 0.05, Table 1) between the groups. Allograft was the most frequently used graft (n=64, 67.3%) with no significant differences between groups in terms of graft diameter. There were no statistically significant differences between groups regarding rate of concurrent medial meniscus, lateral meniscus, cartilage, or lateral extra-articular tenodesis procedures (p > 0.05; Table 2). As displayed in Table 3, there was also no statistically significant difference in complication rate (OTT: n=2 (5.4%); AMD: n=8 (13%); p > 0.05) or graft failure rate (OTT: n=4 (11%); AMD: n=14 (22%); p > 0.05) between groups.
Conclusions:
The results of this study showed notably elevated failure and complication rates in challenging multiple-revision ACL-R. Complication and failure rates were lower in the OTT compared to the AMD technique, however, there were no significant between group differences in these outcomes. In the setting of multiple-revision ACL-R, surgeons may consider the use of the OTT technique.
This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the ...exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.
Artificial intelligence (AI) has the potential to transform medical research by improving disease diagnosis, clinical decision-making, and outcome prediction. Despite the rapid adoption of AI and ...machine learning (ML) in other domains and industry, deployment in medical research and clinical practice poses several challenges due to the inherent characteristics and barriers of the healthcare sector. Therefore, researchers aiming to perform AI-intensive studies require a fundamental understanding of the key concepts, biases, and clinical safety concerns associated with the use of AI. Through the analysis of large, multimodal datasets, AI has the potential to revolutionize orthopaedic research, with new insights regarding the optimal diagnosis and management of patients affected musculoskeletal injury and disease. The article is the first in a series introducing fundamental concepts and best practices to guide healthcare professionals and researcher interested in performing AI-intensive orthopaedic research studies. The vast potential of AI in orthopaedics is illustrated through examples involving disease- or injury-specific outcome prediction, medical image analysis, clinical decision support systems and digital twin technology. Furthermore, it is essential to address the role of human involvement in training unbiased, generalizable AI models, their explainability in high-risk clinical settings and the implementation of expert oversight and clinical safety measures for failure. In conclusion, the opportunities and challenges of AI in medicine are presented to ensure the safe and ethical deployment of AI models for orthopaedic research and clinical application.
Level of evidence
IV
The Triple Varus Knee: A Case Presentation Grandberg, Camila; Kaarre, Janina; Keeling, Laura E. ...
Video journal of sports medicine,
01/2024, Volume:
4, Issue:
1
Journal Article
Open access
Background:
Knee instability due to posterior cruciate ligament (PCL) and posterolateral corner (PLC) deficiency is a devastating condition that negatively affects patient quality of life. This video ...presents the surgical management of a triple varus knee, including combined high tibial osteotomy (HTO), revision PCL and PLC reconstruction, and meniscus root repair.
Indications:
Combined HTO and revision PCL and PLC reconstruction is indicated for patients with previously failed PCL and PLC reconstruction in the setting of varus malalignment.
Technique Description:
The procedure begins with a medial opening-wedge biplanar HTO, which is fixed with a patient-specific locking plate. The PCL femoral tunnel is drilled via a low anterolateral portal, and the tibial insertion is debrided via a posteromedial portal. The medial meniscus is carefully freed from the posterior capsule, and 2 luggage tag sutures are placed through the posterior root. The PCL tibial tunnel and meniscus root tunnels are drilled via their respective guides. The meniscal sutures are passed through the tunnel but not fixed. An Achilles bone-block allograft is passed through the PCL tibial tunnel and fixed with suspensory fixation and an interference screw on the femoral side, while the tibial side is left free. A peroneal nerve neurolysis is performed. A fibular tunnel is drilled, and a semitendinosus allograft is whip-stitched on both sides and passed through the tunnel. A Beath pin is inserted into the femur, and the tunnel is over drilled. Both limbs of the graft are passed deep to the iliotibial band and into the tunnel. The tibial side of the PCL is fixed with an interference screw at 90° of knee flexion. The PLC grafts are fixed with an interference screw at 30° of knee flexion with slight valgus. The medial meniscus root sutures are tied over a button, with 60° of knee flexion. Screws from osteotomy fixation are replaced as needed.
Results:
Although outcomes following the combined procedure are lacking, good to excellent clinical outcomes have been reported in isolation following each procedure.
Conclusion:
A combination of HTO and revision PCL and PLC reconstruction should be considered for patients with persistent instability and/or pain in the setting of triple varus knee.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Graphical Abstract
This is a visual representation of the abstract.
Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for ...the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity.
Level of evidence
V.
The posterior cruciate ligament (PCL) represents an intra-articular structure composed of two distinct bundles. Considering the anterior and posterior meniscofemoral ligaments, a total of four ...ligamentous fibre bundles of the posterior knee complex act synergistically to restrain posterior and rotatory tibial loads. Injury mechanisms associated with high-energy trauma and accompanying injury patterns may complicate the diagnostic evaluation and accuracy. Therefore, a thorough and systematic diagnostic workup is necessary to assess the severity of the PCL injury and to initiate an appropriate treatment approach. Since structural damage to the PCL occurs in more than one third of trauma patients experiencing acute knee injury with hemarthrosis, background knowledge for management of PCL injuries is important. In Part 1 of the evidence-based update on management of primary and recurrent PCL injuries, the anatomical, biomechanical, and diagnostic principles are presented. This paper aims to convey the anatomical and biomechanical knowledge needed for accurate diagnosis to facilitate subsequent decision-making in the treatment of PCL injuries.
Level of evidence
V.
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