Distal Triceps Tendon Injury

Background: Triceps tendon ruptures typically result from a forceful elbow eccentric contraction. The goal of a distal triceps tendon repair is to reattach the torn tendon back to the olecranon. Surgery is indicated for patients with complete rupture of the triceps tendon or symptomatic partial tears with failed conservative management. The complication rate occurs in 22% of patients postoperatively; however, only 0% to 4% of patients suffer a re-rupture of the tendon. Indications: We present a case of a highly active 38-year-old right-hand dominant man with acute onset of left posterior elbow pain following 1-handed pushup resulting in a complete distal triceps avulsion with 1.5 cm retraction. Technique: The distal triceps avulsion was repaired in a double row fashion using 2 double-loaded all-suture anchors in the medial row and anchor in the lateral row through a posterior approach. Results: Full anatomic footprint coverage was able to be achieved intraoperatively, and gentle range of motion from 0 to 90 degrees of flexion did not result in gap formation. Discussion/Conclusion: Successful outcomes with full anatomic footprint coverage of the distal triceps tendon can be achieved through a double row repair configuration.

Complex Patellofemoral Reconstruction for Recurrent Instability

Background: Patellofemoral instability is due to a combination of bony and soft tissue factors. While recurrent patellar dislocations are rare, evaluation and treatment of these conditions require addressing patellar height and lateralization of the tibial tubercle (TT), restraint to lateral patellar subluxation, and trochlear dysplasia. Other factors to consider are coronal limb-length alignment outside of the physiologic 5 to 8° of valgus, which may significantly alter the Q angle and contribute to lateral instability. Other ligaments around the patella contribute to soft-tissue restraint, including the medial and lateral patellotibial ligaments, patellomeniscal ligaments, and the medial quadriceps tendon femoral ligament. Patellar tilt is assessed with and without quadriceps contraction to further evaluate the patella’s relationship to the trochlear groove. The Caton-Deschamps Index, as well as patellar trochlear index (PTI), are used to measure patellar height for patella alta or baja. Technique Description: The technique is to surgically manage a patient in neutral mechanical alignment on standing limb radiographs, with moderate-to-severe DeJour type B trochlear dysplasia and a trochlear sulcus angle of around 145°, patella alta with a Caton-Deschamps Index of 1.6 and PTI of 0.22, a TT to trochlear groove (TT-TG) distance of 8 mm, and a deficient medial patellofemoral ligament (MPFL). The MPFL reconstruction is done first, with harvesting of the ipsilateral quadriceps tendon and maintenance of its distal attachment on the superior patellar pole. The quadriceps tendon graft is folded medially upon its distal attachment and fixed in this position with suture anchors. Tibial tubercle osteotomy is accomplished by spacing drill holes 2 mm apart, medially and laterally, on the TT and connecting the drill holes with an osteotome and reciprocating saw. A distalized location to secure the TT is selected and superficial bone is excised. A medial parapatellar arthrotomy is performed, and bur attachments are used to drill into the subchondral bone beneath the femoral articular surface to create a V-shaped flap of trochlear cartilage. An arthroscope is inserted under the trochlear flap during this process to visualize the appropriate depth. The trochlear flap is then secured with screws passed over guide pins to secure the flap to the desired location. Cannulated screws and washers are then used to secure the TT to its distalized and/or medialized position, with fluoroscopic verification of screw depth and location. The arthrotomy is then closed with the knee at 45°. The quadriceps graft is passed through a subretinacular channel and secured with suture anchors, adjacent to the adductor tubercle, to complete the MPFL reconstruction. Before closure, appropriate tracking and translation of the patella is verified. Results: Sulcus-deepening trochleoplasty, with or without MPFL reconstruction, has been reported to obtain satisfactory outcomes at 2 years, with close to 85% return to sport and 100% return to work, with improvements in International Knee Documentation Committee (IKDC) scores from 50.8 to 79.1 in some studies. MPFL reconstruction with tibial tubercle osteotomy (TTO) has yielded a 94.5% patient satisfaction rate in the literature. Discussion/Conclusion: In patients with recurrent patellar instability and DeJour types B-D trochlear dysplasia, MPFL reconstruction with TTO and sulcus-deepening trochleoplasty provides excellent subjective outcomes and restores patellar tracking with elimination of recurrent subluxation.

Arthroscopic Patellar Tendon Debridement and Distal Pole Osteoplasty for Recalcitrant Patellar Tendinopathy

Background: Chronic patellar tendinosis is an overuse injury of the patellar tendon that commonly afflicts jumping athletes. Indications: For patients with refractory symptoms that do not respond to extensive physical therapy and rest, surgical management may be considered. Although both open and arthroscopic treatments have been described, arthroscopic treatment allows for more direct access to the diseased dorsal portion of the tendon and allows for faster return to activities and sport. Technique Description: Arthroscopic treatment involves debridement of the diseased portion of the patella tendon and osteoplasty of the distal pole of the patella. The infrapatellar fat pad is first debrided using an arthroscopic shaver and radiofrequency ablation device to the level of the dorsal surface of the patellar tendon. Under direct arthroscopic visualization and corresponding to the location of edema noted on the magnetic resonance image, the diseased portion of the patellar tendon is gently debrided with an arthroscopic shaver. Next, an osteoplasty of the distal pole of the patella is performed to facilitate bleeding and healing of the diseased tendon as well as eliminate any mechanical impingement. Any calcifications within the enthesis can be removed using an arthroscopic biter and resector. An arthroscopic resector is then used to decorticate and smoothen the distal pole of the patella to the level of healthy, bleeding cancellous bone. Results: Significant improvements in pain and function have been reported with arthroscopic treatment for chronic patellar tendinosis. Patients can expect a 90% return to sport rate following the procedure, with return to preinjury function as soon as 3 to 5 months. This procedure is well tolerated with minimal complications reported. Discussion: Arthroscopic patellar tendon debridement and distal pole osteoplasty can be used to treat chronic patellar tendinosis refractory to nonoperative treatment. Improvements in pain and function have been reported with this technique, along with a faster return to sport compared with traditional open techniques.

Patellar MACI With Tibial Tubercle Osteotomy

Background: Chondral pathology is frequently encountered during knee arthroscopies with a prevalence rate of 63% to 66%. Prior studies have demonstrated that unaddressed or excised fragments result in poor knee function and arthritis. As a result, chondral-related procedures have increased in popularity, and now more than 200,000 procedures are performed annually. Indications: We present a case of an active 32-year-old woman, prior collegiate basketball player, with persistent left knee pain noted to have a full-thickness patellar articular cartilage defect and maltracking. Technique: A patellar autologous matrix-induced chondrocyte is implanted with a concomitant tibial tubercle osteotomy (TTO) and lateral retinacular lengthening. Results: At 9 weeks, the patient had no knee pain with full range of motion symmetric to the contralateral side while slowly progressing with quadriceps strengthening. Discussion/Conclusion: Successful outcomes addressing large patellar chondral defects and maltracking can be achieved with matrix autologous chondrocyte implantation and concomitant TTO with lateral retinacular lengthening.

Anatomic Multiple Ligament Reconstructions of the Knee

Background: Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage. Indications: After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (<3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis. Technique: We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary. Results: Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed. Discussion/Conclusion: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.

Revision Quadriceps Tendon Repair With Bone-Achilles Allograft Augmentation

Background: Surgical repair of chronic quadriceps tendon ruptures can be daunting, especially after failure of a prior repair. In this setting, tissue quality is usually poor, necessitating graft augmentation. In this video, we describe our technique for Achilles tendon allograft augmentation for revision quadriceps tendon repair. Indications: Failed quadriceps tendon repair defined as ongoing extensor mechanism deficit including patella baja, functional deficit, or palpable quadriceps defect with confirmed retear on advanced imaging. Technique Description: Patient is placed in the supine position, and a midline incision is extended to the tibial tubercle. Full thickness medial and lateral flaps are raised, nonviable scar tissue is excised, and suprapatellar adhesions are released to ensure full mobilization of the viable remnant quadriceps. A plane is then developed deep to the patellar tendon paratenon from proximal to distal. A reamer is used to prepare a socket just medial to the tibial tubercle. The calcaneal bone block of the Achilles allograft is fashioned to match the recipient site on the tibia with a sagittal saw. The graft is shuttled deep to the paratenon, and the bone plug is fixed to the tibia with an interference screw. Suture from the patellar anchors is then used to place 2 running Krackow stitches spanning the remnant quadriceps tendon proximally. The remnant tissue is subsequently reduced and tied with an anchor pull-through technique. The soft tissue component of the Achilles graft is laid over the repair and oversewn with free nonabsorbable suture. Patient is placed in a brace locked in extension for 6 weeks and allowed to be weight bearing as tolerated. Results: Long-term patient-reported outcomes of Achilles allograft reconstruction for revision extensor mechanism repairs are limited. Two studies of 17 reconstructions each reported this to be a reliable and durable option at a mean follow-up of 65 and 52 months, respectively. Discussion/Conclusion: Revision surgery for extensor mechanism deficits can be a challenging procedure. Our preference is to perform augmentation with Achilles allograft with bone plug fixation on the tibial side. This allows for augmentation of the entire extensor mechanism, as well as bone-to-bone healing on the tibial side.

Double-Level Osteotomy in Severe Varus Malalignment to Optimize Knee Joint Restoration

Background: Lower extremity alignment-correcting procedures for unicompartmental osteoarthritis are experiencing a rapid rise. Medial open-wedge high tibial osteotomy (MOW-HTO) thereby represents the most common technique among osteotomies but is limited in cases of severe malalignment. Some cases make a double-level osteotomy necessary. Indications: If planning of malalignment correction using a MOW-HTO results in a mechanical medial proximal tibial angle (mMPTA) of more than 93° (causing an oblique joint line), double-level osteotomy is indicated to avoid nonphysiological knee kinematics. Technique Description: After clinical examination and detailed analysis of malalignment (full-weight-bearing long-leg radiograph: hip-knee-angle [HKA], mMPTA, mechanical lateral distal femoral angle [mLDFA], joint line convergence angle [JLCA]), as well as individualized planning of the correction, the surgical procedure starts with an arthroscopy to evaluate the cartilage conditions and eventually treat intraarticular pathologies. Then, the femoral supracondylar correction is performed (closed wedge, biplanar osteotomy [ to increase bony healing]) according to the presurgical planning by resecting the osteotomy wedge with the measured length. K-wires are placed to check the correction. An angle-stable plate is used for osteosynthesis. The wedge taken out will be used as bone stock for the MOW-HTO afterward. The biplanar open-wedge tibial osteotomy is then performed subsequently using a medial tibial approach and an angle-stable plate. Opening of the osteotomy is then performed and double checked with intraoperative fluoroscopy using an alignment rod. Postoperative partial weight bearing for 6 weeks is recommended. Results: In recent literature, only few publications report on results of double-level osteotomies. Babis et al reports that it is a valuable procedure for patients with large varus deformity. Nakayama et al noted a significant improvement in patient-registered clinical outcomes in early postoperative evaluation of 20 patients. Schröter et al reports on 37 knees and findings include good clinical results, despite progressive osteoarthritis. Discussion/Conclusion: In cases of severe malalignment, adequate axis correction may require a double-level osteotomy. Exact preoperative planning is essential. Results reported in recent publications are promising. By splitting 1 large correction into 2 smaller ones, complications like hinge fracture and delayed bone healing are lowered.

Meniscal Root Repair

Background: Meniscal root tears typically result from a hyperflexion/squatting injury or are in conjunction with ligamentous knee injury. Once a complete tear occurs, the meniscus is unable to convert axial loads to transverse hoop stresses which result in increased tibiofemoral contact pressure and osteoarthritis. The goal of a meniscal root repair is to anatomically reattach the meniscal root to the tibia plateau. Complete and partial healing occurs in over 93% of cases with retear rates ranging from 0% to 7%. Indications: We present a case of a highly active 21-year-old male collegiate soccer play that sustained a medial meniscal root tear after slipping on ice. Technique: An anatomic medial meniscal root repair was performed using a transtibial guide and 2 loop sutures tied over a button. Results: Full anatomic footprint coverage was able to be achieved intraoperatively and gentle range of motion from 0 to 90° of flexion did not result in gap formation. Discussion/Conclusion: Successful outcomes with full anatomic footprint coverage of the medial meniscal root can be achieved with 2-loop suture button configuration.

Open Posterior Glenoid Reconstruction Using a Distal Tibial Allograft

Background: Posterior instability is less common than anterior instability but can be seen in contact athletes and posttraumatically. Distal tibial allograft reconstruction for glenoid bone loss was first described by Provencher and colleagues in 2009 and an arthroscopic technique for posterior glenoid reconstruction using a distal tibial allograft was later described by Gupta et al in 2013. Indications: The primary indications for posterior distal tibial allograft include the failure of conservative management, recurrent instability after an arthroscopic stabilization, or glenoid bone loss > 20% to 25%. Technique Description: The patient is positioned in lateral decubitus, and examination under anesthesia is performed. Following arthroscopic evaluation, an incision is made medial to the posterolateral aspect of the acromion at the glenohumeral joint level. Electrocautery is carried to the deltoid, which is split in line with its fibers. A split between the infraspinatus and teres minor is performed. Vertical capsulotomy is performed, and deep retractors are placed. Attention is turned to the back table for graft preparation. The graft is measured, marked on the lateral aspect of the articular surface, and cut accordingly. Two 3.5-mm holes are drilled 1 cm apart, and the graft is thoroughly irrigated before being placed into the wound. A 2.5-mm drill is used in the 3.5-mm holes, and two 3.5-mm solid fully threaded screws are placed under power and tightened by hand. The wound is closed in the traditional fashion. Results: Graft nonunion and/or resorption are the primary concerns following posterior distal tibial allograft. Amar et al found no cases of nonunion or partial unions on 6-month computerized tomography (CT) scan, most patients having no or <50% resorption. Millet et al also found bony union by CT scan and improved patient-reported outcome measures. A case series by Gilat et al found 90% of patients reported restoration of stability. Discussion/Conclusion: Posterior distal tibial allograft is a successful surgical intervention for patients with recurrent posterior shoulder instability with glenoid bone loss.

Lateral Patellofemoral Ligament Reconstruction With a Hamstring Allograft

Background: Medial patellar instability is rare but may occur after lateral retinacular release. The lateral patellofemoral ligament is a significant stabilizer for medial and lateral patellar displacement, and soft tissue–based reconstruction may restore its stabilizing effect. Indications: Lateral patellofemoral ligament reconstruction (LPFLR) is indicated for patellar instability failing exhaustive nonoperative measures. Technique Description: Diagnostic arthroscopy for medial patellofemoral ligament (MPFL) status, patellar tracking, chondral status, and postoperative changes of lateral retinacular release is conducted. A 5-cm incision is made between the midpoint of the patella and the lateral epicondyle, or a single midline incision can be used if performing a concomitant MPFL reconstruction. Dissection is carried down to the lateral retinaculum and capsule, and two 1-cm incisions are made at the distal and proximal patella through the patellar and quadriceps tendon, respectively. The lateral epicondyle is then directly palpated, and two 1-cm incisions are made directly anterior and posterior to the epicondyle into the iliotibial band in full extension. A hamstring allograft is then shuttled in a V-shaped configuration from the quadriceps tendon through the iliotibial band and finally to the patellar tendon. Excess graft is trimmed and doubled over proximally and distally to replicate the normal (or contralateral) 0° to 15° of patellar eversion. Trial resting length and tension is set with temporary sutures through the proximal and distal doubled graft in full extension. The knee is taken through full range of motion to ensure there is no graft tightening in flexion or loosening in full extension. Eversion and patellar translation are then examined. Heavy nonabsorbable sutures are used to set length of the doubled allograft proximally and distally. Results: Case series of LPFLR have demonstrated significant improvements in patients’ pain, Lysholm score and Knee Injury and Osteoarthritis Outcome Score, and kinesiophobia with no instability events and normal range of motion at short-term follow-up. Discussion/Conclusion: Medial patellar instability can occur following lateral retinacular release and patients experiencing instability despite nonoperative treatment are likely to benefit from a soft tissue–based LPFLR. Although other nongraft-based techniques may confer similar outcomes, the authors find it more reliable to perform a lateral reconstruction as described.