Revision Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft Combined With Modified Lemaire Technique Versus Hamstring Graft Combined With Anterolateral Ligament Reconstruction: A Clinical Comparative Matched Study With a Mean Follow-up of 5 Years From The SANTI Study Group

Background: Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved clinical outcomes and reduced failure rates in revision anterior cruciate ligament (ACL) reconstruction (ACLR). However, no data are available on clinical outcomes and reoperation after revision ACLR using different LET procedures. Purpose: To compare the clinical outcomes of ACL + anterolateral ligament (ALL) reconstruction using hamstring tendon graft (HT-ALL) and a bone–patellar tendon–bone (BPTB) graft + modified Lemaire tenodesis procedure (BPTB-Lemaire) in the setting of revision ACLR and to determine whether ALL reconstruction is associated with an increased rate of adverse outcomes when compared with a modified Lemaire tenodesis procedure. Study Design: Cohort study; Level of evidence, 3. Methods: Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with LET between 2009 and 2018 with a minimum follow-up of 2 years. Patients with an HT autograft combined with ALL reconstruction (HT-ALL group) were matched in a 1:1 propensity ratio to patients with a BPTB autograft combined with a modified Lemaire LET procedure (BPTB-Lemaire group). The evaluated parameters included complications and reoperations; knee laxity tests; return to sports; and various scores, including the Lysholm knee score, Tegner activity scale, Anterior Cruciate Ligament Return to Sport After Injury scale, Marx activity rating scale, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Results: In total, 36 matched pairs were included in the analysis. The mean follow-up durations for the BPTB-Lemaire and HT-ALL groups were 56 ± 35 and 57 ± 23 months, respectively ( P = .91). No significant differences were found in graft rupture rate (HT-ALL, 0%; BPTB-Lemaire, 11.1%; P = .13) or reoperations (HT-ALL, 8.3%; BPTB-Lemaire, 22.2%; P = .23). No specific complications with regard to LET were noted in either group. Additionally, there were no significant differences in knee laxity parameters, return to sports, or clinical scores between the groups at the final follow-up, except for the Tegner activity scale score (HT-ALL, 6.4; BPTB-Lemaire, 7.3; P = .03). HT-ALL was associated with a shorter surgical time (41.4 vs 59.8 minutes; P < .0001). Conclusion: HT-ALL was at least equivalent, in terms of clinical outcomes, to the more commonly performed procedure, BPTB-Lemaire. Performing ALL reconstruction in the setting of revision ACLR is therefore safe and effective.

Laxity measurement of internal knee rotation after primary anterior cruciate ligament rupture versus rerupture

Purpose The aim of the current study was to objectify the rotational laxity after primary anterior cruciate ligament (ACL) rupture and rerupture after ACL reconstruction by instrumented measurement. It was hypothesized that knees with recurrent instability feature a higher internal rotation laxity as compared to knees with a primary rupture of the native ACL. Study design Cross-sectional study, Level of evidence III. Methods In a clinical cross-sectional study successive patients with primary ACL rupture and rerupture after ACL reconstruction were evaluated clinically and by instrumented measurement of the rotational and antero-posterior laxity with a validated instrument and the KT1000®, respectively. Clinical examination comprised IKDC 2000 forms, Lysholm Score, and Tegner Activity Scale. Power calculation and statistical analysis were performed (p value < 0.05). Results 24 patients with primary ACL rupture and 23 patients with ACL rerupture were included. There was no significant side-to-side difference in anterior translation. A side-to side difference of internal rotational laxity ≥ 10° was found significantly more frequent in reruptures (53.6%) compared to primary ruptures (19.4%; p < 0.001). A highly significant relationship between the extent of the pivot-shift phenomenon and side-to-side difference of internal rotation laxity could be demonstrated (p < 0.001). IKDC 2000 subjective revealed significantly better scores in patients with primary ACL tear compared to patients with ACL rerupture (56.4 ± 7.8 vs. 50.8 ± 6.2; p = 0.01). Patients with primary ACL tears scored significantly better on the Tegner Activity Scale (p = 0.02). No significant differences were seen in the Lysholm Score (p = 0.78). Conclusion Patients with ACL rerupture feature significantly higher internal rotation laxity of the knee compared to primary ACL rupture. The extend of rotational laxity can be quantified by instrumented measurements. This can be valuable data for the indication of an anterolateral ligament reconstruction in ACL revision surgery.

Internal Fixation of Lateral Trochlear Groove Osteochondritis Dissecans With Simultaneous Lateral Retinacular Lengthening in Adolescent Athletes

Background: The goals of operative treatment for the adolescent athlete with unstable osteochondritis dissecans (OCD) lesion are rigid fixation and prevention of recurrence. Purpose: To evaluate clinical and radiological outcomes of internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening. Study Design: Case series; Level of evidence, 4. Methods: Adolescent athletes who had undergone internal fixation and simultaneous lateral retinacular lengthening for an unstable OCD lesion of the lateral trochlear groove were retrospectively reviewed. Subjective assessments included the Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Tegner activity scale, and an athletic questionnaire. Functional tests included isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance. Pre- and postoperative radiographs and magnetic resonance images were reviewed. Results: The mean ± SD age of the 17 patients included in this study was 15.9 ± 0.9 years; last clinical follow-up duration was 37.7 ± 8.1 months. At the last follow-up, the Lysholm score improved from 68.7 ± 15.3 to 93.4 ± 12.4 and the IKDC subjective score from 60.2 ± 14.7 to 88.7 ± 12.7 ( P < .001). The mean Tegner activity scale score was 9.4 ± 0.5 before injury and 8.9 ± 1.2 at the last follow-up ( P = .059). The limb symmetry indices of isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance improved at the last follow-up; the mean limb symmetry index was ≥85% in each functional test. Regarding the athletic questionnaire, 16 (94.1%) patients were satisfied with the surgery. At the last follow-up, 2 patients had higher ability after returning to sports, 11 had the same ability, and 3 had lower ability than the preinjury level. Postoperative magnetic resonance imaging at 12-month follow-up showed that the OCD lesion appeared healed in 7 (41.2%) patients and partially healed in 9 (52.9%). Conclusion: Internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening in adolescent athletes achieved satisfactory clinical and radiological outcomes. Therefore, this combined surgical technique could be considered an effective treatment for lateral trochlear groove OCD, with a high rate of return to sport.

Reliability of the MOCART score: a systematic review

Background The present systematic review analysed the available literature to assess reliability of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score in the evaluation of knee and ankle osteochondral lesions. Methods All the studies using the MOCART score for knee and/or talus chondral defects were accessed in March 2021. A multivariate analysis was performed to assess associations between the MOCART score at last follow-up and data of patients at baseline, clinical scores and complications. A multiple linear model regression analysis was used. Results The MOCART score evidenced no association with patient age (P = 0.6), sex (P = 0.1), body mass index (P = 0.06), defect size (P = 0.9), prior length of symptoms (P = 0.9) or visual analogue scale (P = 0.07). For chondral defects of the knee, no statistically significant association was found between the MOCART score and the International Knee Documentation Committee (P = 0.9) and with the Lysholm Knee Scoring Scales (P = 0.2), Tegner Activity Scale (P = 0.2), visual analogue scale P = 0.07), rate of failure (P = 0.2) and revision (P = 0.9). For chondral defect of the talus, no statistically significant associations were found between the MOCART score and the American Orthopedic Foot and Ankle Score (P = 0.3), Tegner Activity Scale (P = 0.4), visual analogue scale (P = 0.1), rate of failure (P = 0.1) and revision (P = 0.7). Conclusion The MOCART score demonstrated no association with patient characteristics and with the surgical outcome in patients who underwent surgical management for knee and talus chondral defects. Level of evidence Level IV.

Muscle strength after the anterior cruciate ligament reconstruction via contralateral bone-tendon-bone autograft

Purpose The anterior cruciate ligament (ACL) reconstruction via a contralateral bone-tendon-bone (C-BTB) autograft was introduced to encourage early return to sports. The purpose of this study is to evaluate whether primary contralateral BTB ACL reconstruction can be adapted for early return-to-sports modification by investigating the chronological changes of muscle strength after surgery. Methods Fifteen patients who had underwent C-BTB ACL reconstruction were compared with a matched group of 15 patients of ipsilateral BTB (I-BTB) ACL reconstruction. The clinical outcomes of the time of return-to-sports, Tegner activity scale and the rate of second ACL injuries, the tibial anterior translation measurement, and knee extension and flexion muscle strength were assessed. Results Within 12 months after surgery, 14 of 15 patients from both groups returned to preinjury sports. The median time to return to sports after surgery was 6.5 months in the C-BTB group and 8.0 months in the I-BTB group (p = 0.021). No significant difference was noted with regard to the Tegner activity scale, reinjury rate or mean instrumental anterior tibial translation. The quadriceps muscle strength in the ACL-reconstructed knee compared with the opposite knee in both groups at 5 months after surgery was 120.6% in the C-BTB group and 70.0% in the I-BTB group (p < 0.001). However, the quadriceps muscle strength of the non-reconstructed limb, which instructed the graft harvested knee in the C-BTB and the intact knee in the I-BTB group, compared with that of the preoperative uninjured limb, was 74.5% in the C-BTB group and 118.7% in the I-BTB group (p = 0.0021) 5 months after surgery. Moreover, the quadriceps muscle strength of the reconstructed knee compared with the preoperative normal limb was 88.8% and 81.5% in the C-BTB and I-BTB groups, respectively (p = 0.38). Conclusions ACL reconstruction via the C-BTB autograft indicated better quadriceps muscle strength from early stage after surgery compared with I-BTB ACL reconstruction. However, the ostensible rapid symmetrical muscle strength recovery was attributed to strength deficits compared to the preoperative condition at the donor site limb and ACL-reconstructed limb. Level of evidence Level: Level: 4.

Joint effusion, anteroposterior stability, muscle strength and degree of patellofemoral osteoarthritis significantly impact outcome following revision ACL reconstruction

Purpose: Effusion, impaired muscle function and knee instability are considered as some of the most important factors effecting outcome following anterior cruciate ligament reconstruction (ACL-R) but the impact on revision ACL-R remains unclear. It was hypothesized that these factors will significantly worsen clinical outcome following revision ACL-R. Methods Seventy knees (13 female and 57 male) were followed retrospectively after revision ACL-R at a mean follow-up of 47.8 ± 20.7 months. Clinical examination was based on the International Knee Documentation Evaluation Form-2000 (IKDC), Tegner activity scale. Instrumented measurement of anterior tibial translation was performed using the Rolimeter® (DJO Global, Freiburg, Germany). Bilateral circumference of the thigh was measured 10 and 20 cm proximal to the medial joint space. Cartilage was assessed according to Outerbridge classification during both primary and revision ACL-R. Results Tegner activity scale decreased significantly from 7.8 ± 1.4 points at primary ACL-R to 7 ± 1.8 points at revision ACL-R, and 5.8 ± 1.7 points at the time of follow up (p < 0.001). Joint effusion (r = − 0.47, p < 0.01) and side to side differences in single leg hop test (r = − 0.48, p < 0.1) significantly correlated with inferior outcome. Cartilage lesions were found in 67% of the patients at the time of revision ACL-R compared to 38% at the time of primary ACL-R. According to the IKDC classification A was graded in three patients (4.3%), B in 35 (50%), C in 29 (41.4%) and D in three (4.3%). Joint effusion was measured in 35% of patients at the time of follow-up. Degeneration at the patellofemoral compartment of > grad 2 was responsible for IKDC grade C and D (p = 0.035). Instrumented anteroposterior site-to-site difference of ≥3 mm showed significant impact on clinical outcome (p < 0.019). Conclusion The study has shown that chronic effusion, quadriceps dysfunction, cartilage lesions especially at the patellofemoral compartment and side to side difference in anteroposterior stability significantly influences patient outcome after revision ACL-R. These factors require special attention when predicting patient’s outcome. Level of evidence Level-IV, case-controlled study.

Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures

Purpose To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports. Methods Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities. Results A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF. Conclusion Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II–IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort. Level of Evidence Level IV.

Efficacy of Autologous Platelet-Rich Plasma Injections for Grade 3 Symptomatic Degenerative Meniscal Lesions: A 1-Year Follow-up Prospective Study

Background: Platelet-rich plasma (PRP) injections have been proposed as a biologic option to provide symptomatic relief and delay surgery in patients with degenerative joint disease of osteoarthritis (OA). The efficacy of autologous PRP on symptomatic degenerative meniscal lesions (DMLs) has never been investigated. Hypothesis: We hypothesized that patients with symptomatic DMLs without OA undergoing autologous PRP injections experience a significant clinical improvement at 12 months. Study Design: Prospective case series. Level of Evidence: Level 4. Methods: A total of 69 patients with symptomatic DMLs without radiographic evidence of knee OA (Kellgren-Lawrence radiographic grading scale 0-1) received 4 autologous PRP injections once a week. Patients were prospectively evaluated before the injection and then at 1, 3, 6, and 12 months. Evaluation was based on Lysholm knee scoring scale (primary outcome), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Tegner activity scale, and visual analogue scale scores. Results: Patients treated with PRP injections demonstrated an improving knee function and symptoms over the duration of the study. A significant improvement from baseline to 12 months was observed in all the outcome measures, and no patients experienced failure or required surgery during the follow-up. Patients younger than 50 years reported lower subjective level of pain and higher Tegner activity scale at baseline and had significantly better Lysholm knee scoring scale ( P = 0.03) and WOMAC ( P = 0.03) scores at 6 months, as well as better range of motion at 3, 6, and 12 months ( P < 0.001). Thirty-three (47.8%) patients were very satisfied, 26 (37.7%) satisfied, 8 (11.6%) partially satisfied, and 2 (2.9 %) not satisfied, with 62 (89.8%) patients willing to repeat the same treatment. No patient was lost to follow-up and no patient experienced adverse reaction, infection, failure, recurrence or underwent further surgery. Conclusion: PRP injections provide short-term benefits in symptomatic DMLs. Although promising results were evident at 12 months, this is a preliminary study and no definitive recommendation can be made based, for example, on longer follow-up. Clinical Relevance: This research supports the use of autologous PRP injections for symptomatic DMLs.

Evaluation of the ‘Spaarne soft tissue procedure’ as a treatment for recurrent patellar dislocations: a four-in-one technique

Purpose The ‘Spaarne soft tissue procedure’, is a 4-in-1 soft tissue procedure that treats recurrent patellar dislocations in the young and active population. The procedure has not yet described elsewhere. The purpose of this study is to analyse the redislocation rate and to evaluate the postoperative knee function and patient satisfaction. Methods Twenty-seven patients (34 knees) underwent the four-in-one SST-procedure. The 4-step technique required a minor change in 2010, including the use of a smaller strip of the patellar tendon for transposition. After a median follow-up of 10.4 years, the redislocation rate was evaluated as the primary outcome measure. Secondary outcome measures were functional outcome (IKDC, Kujala, Lysholm and Tegner activity scale) and Numeric Rating Scales for satisfaction and pain. Results Redislocation occurred in 8 cases (23.5%) and subluxation occurred in 13 cases (38.2%) post-surgery. A significant higher number of redislocations and subluxations were seen before 2010 (p = 0.04, p = 0.03). The median postoperative IKDC, Lysholm and Kujala scores for the total group were 54, 76 and 81 respectively. Pre- and postoperative Tegner activity scale were both level 3. Median NRS scores during rest, walking and sports were 1, 3 and 5 respectively. Satisfaction with the procedure was reported as ‘excellent’ or ‘good’ by 79% of the patients. Conclusion Despite the high overall redislocation rate and increased pain scores, the SST-procedure shows to be a safe procedure in patients with recurrent patellar dislocations based on the cases after 2010. Mid- and long-term results show moderate to good functional outcomes and satisfaction. Level of evidence Therapeutic retrospective cohort study, LEVEL III