Background:
The lateral tibial posterior slope (LTPS) has been reported in multiple studies to correlate with an increased risk for native anterior cruciate ligament (ACL) tearing. To date, no study ...has examined the effect of an increased LTPS as measured on magnetic resonance imaging (MRI) on the likelihood of ACL graft failure.
Hypothesis:
An increased LTPS as measured on MRI would correlate with an increased risk for ACL graft failure.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Fifty-eight patients were initially identified who experienced graft failure after primary ACL reconstruction and underwent revision between 1998 and 2009. Exclusion criteria were clinical follow-up of less than 4 years, graft failure occurring greater than 2 years after primary surgery, skeletal immaturity, deep infection, lack of available preoperative MRI, and history of trauma to the proximal tibia. This left 35 patients with early (within 2 years) failure of primary ACL reconstruction. These patients were matched to 35 control participants who had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, sex, date of primary surgery, and graft type. The LTPS was then determined on MRI in a blinded fashion.
Results:
The mean time to failure in patients in the study group was 1 year (range, 0.6-1.4 years). The mean follow-up of those in the matched control group was 6.9 years (range, 4.0-13.9 years). The mean LTPS in the early ACL failure group was found to be 8.4°, which was significantly larger than that in the control group at 6.5° (P = .012). The odds ratio for graft failure considering a 2° increase in the LTPS was 1.6 (95% CI, 1.1-2.2) and continued to increase to 2.4 (95% CI, 1.2-5.0) and 3.8 (95% CI, 1.3-11.3) with 4° and 6° increases in the LTPS, respectively. No significant association was identified between graft type and graft failure.
Conclusion:
An increased LTPS is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring the LTPS as part of the preoperative assessment of ACL-injured patients.
Purpose To determine whether the amount of pain relief after preoperative intra-articular (IA) anesthetic injection predicts clinical and functional outcomes after hip arthroscopy, especially when ...controlling for the presence of chondral degeneration. Methods We identified patients who underwent IA injection and subsequent hip arthroscopy for labral pathology between 2007 and 2013 performed by a single surgeon. Inclusion criteria were ultrasound- or fluoroscopic-guided IA anesthetic injection performed at our institution, prospectively documented pre- and postinjection numerical rating scale pain scores, and minimum 1-year follow-up postoperatively. Patients were divided into 2 groups, those who received >50% pain relief from preoperative IA anesthetic injection and those who received ≤50% relief. Preoperative radiographs were reviewed, and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome. Results Of the 319 arthroscopic hip surgeries performed between 2007 and 2013, 115 (37%) patients were lost to follow-up, 16 (5%) patients did not receive an IA injection, 16 (5%) patients had an injection containing gadolinium, and 40 (13%) patients completed injections at an outside institution. Five (2%) patients were excluded for a history of ipsilateral hip surgery, and 3 (1%) for a history of contralateral hip surgery, leaving 96 hips in 96 patients. There were 71 females (74%) and 25 males (26%) with a mean age of 37.6 ± 14.0 years. Tonnis was grade 0, 1, and 2 for 26 (27%), 55 (56%), and 16 (17%) patients, respectively. Fifty-one (53%) of the injections contained a corticosteroid. The mean pain relief after IA injection was 73% ± 36% (range, 0% to 100%). Twenty-six hips (26%) had ≤50% pain relief, whereas 70 (73%) had >50% pain relief, and the median time interval from injection to surgery was 3 (range, <1 to 20) months. Outcome scores were obtained at a mean 14.8 (range, 11 to 30) months after arthroscopic surgery. Postoperative mean Modified Harris Hip Score, HOS activities of daily living, and HOS-Sport scores were 79.2 ± 17.3, 82.6 ± 17.3, and 67.4 ± 28.2, respectively. There was no statistical correlation between percent pain relief and outcome. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. Multivariate regression analysis showed no significant predictors of outcome, including age, gender, Tonnis grade, percent relief with IA injection, or type of surgery. Conclusions In this study of patients undergoing hip arthroscopy for labral pathology, our data indicate that the amount of pain relief from IA injection may be a poor predictor of short-term outcome, even when adjusting for chondral degeneration. Although anesthetic injections can be an important diagnostic tool in select patients, a combination of the clinical history, physical examination, and imaging findings is fundamental. Level of Evidence Level IV, therapeutic case series.
Background: Sesamoid pathology can lead to significant pain and disability both with activities of daily living and high-impact athletic movements. Sesamoidectomy is a widely used procedure for ...patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain, but complications were reported. A proposed alternative medial approach using a burr may provide many advantages compared with traditional approaches. This study presents patient outcomes and complications for this technique. Methods: This was a retrospective chart review of patients undergoing sesamoidectomy (tibial, peroneal, or both) using a burr through a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Results: Twenty-seven patients (29 feet) were included. The mean age was 38.4 years followed up for a mean of 30.9 months. VR-12 physical component improved from 35.98 ± 7.86 to 51.34 ± 8.01 ( P < .001), FAAM ADL and sport improved from 58.33 ± 16.61 to 83.27 ± 18.28 ( P < .001) and 26.37 ± 20.31 to 63.75 ± 29.74 ( P < .001), respectively. Patient satisfaction with the treatment was 80.59% ± 27.06%. The overall complication rate was 11 (37.9%) whereas the overall reoperation rate was 4 (13.7%) of 29 feet. Complications included 1 arthrofibrosis, 1 flexor hallucis longus subacute rupture, and 1 asymptomatic hallux valgus. There were no sesamoid excision revisions. Conclusion: Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, with a relatively acceptable complications rate including 20% persistent pain. The medial approach is familiar to orthopaedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar scar while avoiding disruption of the plantar plate, flexor hallucis brevis tendon, and ligamentous structures attached to the sesamoids. Larger studies with long-term follow-up from other centers are needed.
Purpose
Knee dislocations can cause significant damage to intra-articular knee structures, but currently there are limited data reporting articular cartilage and meniscal injuries in this setting. ...The purpose of this study is to (1) report the rate of concomitant intra-articular injuries at the time of multiligament reconstruction for knee dislocation, (2) determine whether the pattern of ligament injury is associated with the presence of chondral and meniscal injuries, and (3) assess the relationship between timing of surgery and incidence of chondral and meniscal injuries.
Methods
The records of patients who sustained a knee dislocation between 1992 and 2013 were retrospectively reviewed. Patients included for further review had a PCL-based multiligament knee injury or a minimum of three disrupted ligaments, both indicative of knee dislocation. Patient demographics, ligament injury patterns, meniscal tears and chondral injuries at arthroscopy, and interval from injury to surgery were recorded. Early surgical intervention was defined as <3 months, delayed was between 3 and 12 months, and chronic was >12 months. Data analysis compared ligament injury pattern with chondral and meniscal injuries, as well as the rates of intra-articular injury by timing of surgery.
Results
One-hundred and twenty-one patients (122 knees) were included (93 males, 28 females) with a median age at time of surgery of 31 years (range 15–62). Ninety-three knees (76 %) had associated chondral or meniscal injury. Sixty-seven knees (55 %) presented with meniscal tears (26 isolated medial, 27 isolated lateral, and 14 combined medial/lateral), while 52 knees (48 %) had chondral damage, most commonly in the medial compartment. Schenck classification as well as side of injury did not demonstrate consistent relationships with intra-articular injury. A higher incidence of damage to the lateral femoral condyle (20 % vs 3 %;
p
= 0.02), lateral tibial plateau (20 % vs 2 %;
p
< 0.01), and patella (40 % vs 13 %;
p
= 0.01) was found in the chronic group compared to the early group. The chronic group contained significantly more patients with bicompartmental and tricompartmental chondral lesions (25 % vs 6 %;
p
= 0.03 and 10 % vs 0 %;
p
= 0.02, respectively).
Conclusion
Meniscal tears and chondral damage occur frequently in patients with a knee dislocation. A longer interval from injury to surgical reconstruction is associated with higher rates of articular cartilage lesions, especially in multiple compartments.
Level of evidence
IV.
Purpose
Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. ...Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data.
Methods
All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS).
Results
Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16–59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12–15) months were 80.1 ± 19.9 (0–100), 83.6 ± 19.2 (13.2–100), and 70.3 ± 27.0 (0–100), respectively.
Conclusion
This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.
Level of evidence
Case series, Level IV.
For the younger, more active patient with flexible symptomatic progressive collapsing foot deformity (PCFD), joint-sparing procedures may be preferred to preserve functional motion. Isolated ...talonavicular (TN) arthrodesis has been described for treatment of rigid and flexible PCFD for patients that are older and less active whose deformity is still correctable through the TN joint. The purpose of this study was to evaluate radiographic and clinical outcomes in patients with PCFD treated with isolated triplanar correction with a TN joint arthrodesis.
Forty-nine patients (53 feet) with flexible PCFD underwent isolated TN arthrodesis. Weightbearing radiographs were performed pre- and postoperatively, and measurements included lateral talar-first metatarsal angle, calcaneal pitch, TN coverage angle, and the anteroposterior (AP) talar-first metatarsal angle. The Foot and Ankle Ability Measure (FAAM) and Veterans-Rand 12-Item Health Survey (VR-12) scores were also collected.
Thirty-five females and 14 males were evaluated with a mean age of 63 years, at an average follow-up of 41.3 months. Significant improvements were found radiographically. Lateral radiographs demonstrated improvements in lateral talar-first metatarsal angle from 25.2 degrees preoperatively to 9.5 degrees postoperatively (
< .001) and calcaneal pitch from 14.9 degrees preoperatively to 17.5 degrees postoperatively (
< .001). AP radiographs showed the TN coverage angle improving from 35.0 degrees to 4.9 degrees postoperatively (
< .001) and AP talar-first metatarsal angle improving from 17.3 degrees to 5.9 degrees postoperatively (
< .001). Clinical outcomes were improved in the FAAM pain score (48.6 to 39.2,
= .130), FAAM ADL score (53.8 to 69.2,
= .002), FAAM Sport score (29.5 to 40.7,
= .099), and the overall FAAM score (47.7 to 63.1,
= .006). Patient satisfaction with medical care was 85.2/100 postoperatively.
Isolated TN arthrodesis is a viable surgical option for older, lower-demand patients with flexible PCFD. This study demonstrated significant improvements in radiographic alignment and FAAM scores. Comparative studies with other surgical procedures should be performed to determine which is the best technique for older, lower-demand patients with flexible PCFD.
Level III, retrospective cohort study.
Category:
Hindfoot; Other
Introduction/Purpose:
Progressive collapsing foot deformity (PCFD) remains a challenging condition for foot and ankle surgeons to treat. While there exists more clarity on ...the treatment for end-stage rigid deformities involving PCFD, there is still significant debate over different surgical treatment options for the flexible collapsing foot. Common surgical corrections for flexible PCFD include the 'All-American Procedure' popularized by Manoli in the 1990s. Isolated talonavicular (TN) arthrodesis has also been described for the treatment of flexible PCFD. The primary objective of this study was to evaluate clinical and radiographic outcomes in patients with AAFD treated with isolated tri-planar corrective TN arthrodesis. A secondary objective was to establish whether there is a correlation between radiographic outcomes and clinical outcomes.
Methods:
Fifty-four patients (59 feet) from July 2013 to October 2020 with flexible PCFD underwent surgical treatment with isolated TN arthrodesis. Patients with other arthrodesis or hindfoot osteotomies were excluded. Concomitant gastrocnemius lengthening and toe deformity correction procedures were not an exclusion criterion. Weight-bearing radiographs were performed pre- and postoperatively, with Meary angle (or lateral talo-first metatarsal angle) and calcaneal pitch measured on lateral view. The degree of TN coverage on antero-posterior (AP) radiographs were measured with the TN coverage angle and the degree of first ray angular deformity was measured using Simmon angle (or AP talo-first metatarsal angle). Angles were measured by a foot and ankle fellow. The Foot & Ankle Ability Measure (FAAM) and Veterans-Rand 12 Item Health Survey (VR- 12) were used to clinically evaluate the patient.
Results:
Thirty-seven females and seventeen males were evaluated with a mean age 61 years at the time of surgery and an average length of follow up of 19 months. There were significant improvements in deformity correction found in this study. Radiographically, the lateral radiographs demonstrated Meary angle correction from 27 degrees pre-operatively to 9 degrees post- operatively (p<0.001) and calcaneal pitch improving from 15 degrees pre-operatively to 18 degrees post operatively (p<.001). AP radiographic analysis demonstrated TN coverage angle improving from 35 degrees pre-operatively to 5 degrees post-operatively (p<0.001) and Simmon angle improving from 20 degrees pre-operatively to 6 degrees, post-operatively (p<.001). The only statistically significant improvement in clinical outcomes was in the FAAM score (pre-operative score 48.48, post-operative score 58.45 (p<.001)).
Conclusion:
Isolated TN arthrodesis is a viable option for multi-planar deformity correction in patients with flexible PCFD. Not only did it provide significant improvements in radiographic alignment, it also provided improved functional outcomes as demonstrated on FAAM scores. Comparative studies with other surgical treatment techniques such as the 'All-American Procedure' should be performed to determine which is the best technique for patients with flexible PCFD.
Purpose
To determine changes in tibial slope, patellar height, and coronal plane alignment after medial opening wedge proximal tibial osteotomy (PTO) using a modern osteotomy system.
Methods
Patients ...undergoing medial opening wedge PTO for any indication with follow-up until radiographic union were identified. Pre- and post-operative tibial slope (referenced off the anterior tibial cortex, proximal tibial anatomic axis, and posterior tibial cortex), patellar height (Caton–Deschamps, Blackburne–Peel, and Insall–Salvati indices), and coronal plane mechanical axis and weight-bearing line (WBL) ratio measurements were taken by two observers and compared.
Results
Review of 27 patients demonstrated unchanged tibial slope and slightly decreased patellar height post-operatively (Caton–Deschamps: −0.10 ± 0.09; Blackburne–Peel: −0.11 ± 0.10). Coronal plane measurements showed 6.4° ± 1.8° mean change in mechanical axis. Mean post-operative WBL ratio was significantly lower (51.6 ± 11.5 %) than mean goal WBL ratio (62.2 ± 2.5 %). Preoperative mechanical axis >6° varus and osteoarthritis alone as the surgical indication were risk factors for undercorrection >10 %.
Conclusions
Medial opening wedge PTO using a recently developed instrumentation system was found to have no effect on tibial slope. Patellar height was decreased after osteotomy using this system, although clinical significance of these findings is unknown. Coronal plane undercorrection of 10.6 % of the target WBL ratio was seen in the group as a whole, although secondary analysis of these results indicated that patients with medial compartment osteoarthritis and/or preoperative mechanical axis of >6° varus accounted for the majority of the cases of undercorrection.
Level of evidence
Retrospective case series, Level IV.
Abstract This study aims to report the incidence of patellar fracture after patellofemoral arthroplasty (PFA) and to determine associated factors as well as outcomes of patients with and without this ...complication. 77 knees in 59 patients with minimum two-year follow-up were included. Seven (9.1%) patients experienced a patellar fracture at a mean of 34 (range 16–64) months postoperatively. All were treated nonoperatively. Lower BMI (P = 0.03), change in patellar thickness (P < 0.001), amount of bone resected (P = 0.001), and larger trochlear component size (P = 0.01) were associated with a greater incidence of fracture. Fewer fractures occurred when the postoperative patellar height exceeded the preoperatively measured height. No statistically significant differences were found in outcome scores between groups at mean four-year follow-up.
Category:
Midfoot/Forefoot; Sports
Introduction/Purpose:
Patients with pathology of the sesamoids can have significant pain and disability both with activities of daily living and high impact ...athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain but complications are noted, including hallux varus deformity, painful plantar incision, and clawing of the hallux. Additionally, the dorsal approach is technically difficult because of poor visualization, which can lead to unnecessary disruption of important plantar ligamentous structures. An alternative medial approach using a bur provides many advantages compared to traditional approaches.
Methods:
This was a retrospective chart review of patients undergoing sesamoidectomy using a bur with a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), Visual Analog Scale (VAS), patient satisfaction, and complications.
Results:
In patients (10 feet) with an average age of 36.5 (range, 13-77) years were analyzed. Six patients underwent medial sesamoidectomy, three underwent lateral sesamoidectomy, and one patient underwent excision of both medial and lateral sesamoids using a bur. The average latest follow up was 11.9 months. Scores were improved from pre-operatively to most recent follow-up for VR-12 Physical (29.43 vs 53.86), FAAM ADL (48.8 vs 94.1 points), FAAM Sports (7.8 vs 87.4 points), and VAS (57.8 vs 8.6). Patient satisfaction with the treatment was 96.4%. There were zero complications or additional procedures performed.
Conclusion:
In this series, sesamoidectomy utilizing a medial approach with a bur provided excellent pain relief, zero complications, and significantly improved outcome scores at early follow up. The medial approach is familiar to orthopedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar incision. Furthermore, this technique allows for maintenance of the plantar plate, flexor hallucis brevis (FHB) tendon, and all other ligamentous structures that attach to the sesamoids. Larger studies with longer term follow up are needed to further our knowledge on this surgical technique.
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