Anterior Cruciate Ligament Reconstruction Basics: Quadriceps Tendon (All-Soft Tissue) Autograft Preparation-Part 2.

Anterior cruciate ligament reconstruction with quadriceps tendon autograft is a reliable graft option that has recently increased in use. Varying harvesting and graft preparation techniques available and improved technology and implant design continue to make quadricep tendon preparation more efficient and reproducible. In this Technical Note, we describe our preferred technique for all-soft tissue quadriceps tendon autograft preparation after harvest for anterior cruciate ligament reconstruction.

Anterior Cruciate Ligament Reconstruction Basics: Quadriceps Tendon (All-Soft Tissue) Autograft Harvest-Part 1.

Anterior cruciate ligament reconstruction with quadriceps tendon autograft has become increasingly popular for primary and revision anterior cruciate ligament reconstruction surgery. Although there are a variety of techniques available for performing quadriceps tendon autograft harvest for anterior cruciate ligament reconstruction, a minimally invasive, all-soft tissue harvest technique can result in a reproducible, reliable graft while minimizing donor-site morbidity. In this Technical Note, we describe our preferred technique for quadriceps tendon autograft harvest for anterior cruciate ligament reconstruction.

Posterior Meniscus Root Repair Using a Retensionable Knotless All-Suture Anchor.

Meniscus root injuries lead to increased tibiofemoral contact pressures and rapid progression of osteoarthritis. Early recognition and treatment with a meniscal root repair can restore biomechanics and help preserve the joint. The transtibial pullout repair and suture anchor repair are the most commonly used techniques to achieve anatomic fixation of the meniscal root.

Pediatric Multidrug-Resistant Disseminated Tuberculosis Presenting as Small Finger Tuberculous Osteomyelitis: A Case Report.

Case: We report a case in the United States of a 12-year-old girl with multidrug-resistant tuberculous (MDR-TB) osteomyelitis of the hand managed with surgical debridement and second-line anti-TB therapy. The disease course was complicated by dissemination and multifocal progression.

Conclusion: Despite early intervention, multidrug resistance makes TB treatment challenging and facilitated progression to disseminated disease in this case.

Arthroscopic Repair and Reconstruction of Coracoclavicular Ligament.

Acromioclavicular joint separations are common shoulder injuries that require prompt recognition, diagnosis, and treatment. Deciding on a treatment algorithm relies on a detailed knowledge of anatomy and a thorough understanding of the specific functional demands of the patient in question. When a repair or reconstruction is indicated, arthroscopic assistance can be a helpful tool to ensure a safe, anatomic reconstruction that minimizes morbidity and maximizes the potential return to high-level function.

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial.

Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear.

Purpose/hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups.

Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients.

Background: Outcomes after sports-related multiple-ligament knee reconstructions are limited.

Purpose: To evaluate outcomes after single-stage surgical treatment of sports-related multiple-ligament knee injuries and to compare outcomes after anterior cruciate ligament (ACL)-based and posterior cruciate ligament (PCL)-based multiple-ligament knee reconstructions.

Study Design: Case series; Level of evidence, 4.

Axial-Oblique Versus Standard Axial 3-T Magnetic Resonance Imaging for the Detection of Trochlear Cartilage Lesions: A Prospective Study.

Background: Imaging of the femoral trochlea has been inherently difficult because of its convex anatomy.

Purpose/hypothesis: The purpose of this study was to compare the diagnostic utility of a standard axial magnetic resonance imaging (MRI) sequence with an axial-oblique MRI sequence of the knee for the detection of trochlear articular cartilage lesions on a high-field 3-T MRI scanner. We hypothesized that axial-oblique MRI scans of the knee obtained along the true axis of the trochlea would significantly improve the detection of high-grade cartilage lesions.

Partial Controlled Early Postoperative Weightbearing Versus Nonweightbearing After Reconstruction of the Fibular (Lateral) Collateral Ligament: A Randomized Controlled Trial and Equivalence Analysis.

Background: While early weightbearing protocols have been advocated after anterior cruciate ligament (ACL) reconstruction, early weightbearing after fibular (lateral) collateral ligament reconstruction has not been well defined.

Purpose: (1) To determine if early partial controlled weightbearing after fibular collateral ligament (FCL) reconstruction resulted in an objective difference in laxity on varus stress radiographs at postoperative 6 months as compared with nonweightbearing, and (2) to determine if there was a difference in pain, edema, range of motion, and subjective patient-reported outcomes between these groups at 3 time points.

Study Design: Randomized controlled trial; Level of evidence, 1.

Kinematic and neuromuscular relationships between lower extremity clinical movement assessments.

Lower extremity injuries have immediate and long-term consequences. Lower extremity movement assessments can assist with identifying individuals at greater injury risk and guide injury prevention interventions. Movement assessments identify similar movement characteristics and evidence suggests large magnitude kinematic relationships exist between movement patterns observed across assessments; however, the magnitude of the relationships for electromyographic (EMG) measures across movement assessments remains largely unknown.

Medial Patellar Instability: Treatment and Outcomes.

Background: Historically, a lateral retinacular release was one of the primary surgical interventions used to treat lateral patellar instability. However, disruption of the lateral structures during this procedure has been associated with medial instability of the patella.

Hypothesis: We hypothesize that good to excellent outcomes can be achieved at midterm follow-up after lateral patellotibial ligament reconstruction.

Overlap Between Anterior Cruciate Ligament and Anterolateral Meniscal Root Insertions: A Scanning Electron Microscopy Study.

Background: The anterolateral meniscal root (ALMR) has been reported to intricately insert underneath the tibial insertion of the anterior cruciate ligament (ACL). Previous studies have begun to evaluate the relationship between the insertion areas and the risk of iatrogenic injuries; however, the overlap of the insertions has yet to be quantified in the sagittal and coronal planes.

Purpose: To investigate the insertions of the human tibial ACL and ALMR using scanning electron microscopy (SEM) and to quantify the overlap of the ALMR insertion in the coronal and sagittal planes.

Varus-Producing Lateral Distal Femoral Opening-Wedge Osteotomy.

Valgus knee alignment in excess of physiological valgus leads to excessive loading of the lateral compartment, which can potentially increase the risk of osteoarthritis and can place the medial knee structures at risk of chronic attenuation. Varus-producing distal femoral osteotomies have been proposed for correction of valgus malalignment, to relieve tension on medial-sided structures, as well as to off-load the lateral compartment. Understanding that symptomatic valgus deformity of the knee represents a complex problem that is magnified in the setting of lateral compartment arthritis or medial ligamentous incompetence, we present our preferred technique for a varus-producing distal femoral osteotomy using plate osteosynthesis and cancellous bone allograft.

Posterior Wall Blowout During Anterior Cruciate Ligament Reconstruction: Suspensory Cortical Fixation With a Screw and Washer Post.

Posterior wall blowout can be a devastating intraoperative complication in anterior cruciate ligament reconstruction. This loss of osseous containment can cause difficulty with graft fixation and can potentially lead to early graft failure if unrecognized and left untreated. If cortical blowout occurs despite careful planning and proper surgical technique, a thorough knowledge of the local anatomy and surgical salvage options is paramount to ensure positive patient outcomes.

Posteromedially placed plates with anterior staple reinforcement are not successful in decreasing tibial slope in opening-wedge proximal tibial osteotomy.

Purpose: To document the effectiveness of a novel technique to decrease tibial slope in patients who underwent a proximal opening-wedge osteotomy with an anteriorly sloped plate placed in a posteromedial position. The hypothesis was that posteromedial placement of an anteriorly sloped osteotomy plate with an adjunctive anterior bone staple on the tibia would decrease, and maintain, the tibial slope correction at a minimum of 6 months following the osteotomy.

Methods: All patients who underwent biplanar medial opening-wedge proximal tibial osteotomy with anterior staple augmentation to decrease sagittal plane tibial slope were included, and data were collected prospectively and reviewed retrospectively.

Meniscal Ramp Lesions: Anatomy, Incidence, Diagnosis, and Treatment.

Meniscal ramp lesions are more frequently associated with anterior cruciate ligament (ACL) injuries than previously recognized. Some authors suggest that this entity results from disruption of the meniscotibial ligaments of the posterior horn of the medial meniscus, whereas others support the idea that it is created by a tear of the peripheral attachment of the posterior horn of the medial meniscus. Magnetic resonance imaging (MRI) scans have been reported to have a low sensitivity, and consequently, ramp lesions often go undiagnosed.

Posterior Wall Blowout in Anterior Cruciate Ligament Reconstruction: A Review of Anatomic and Surgical Considerations.

Violation of the posterior femoral cortex, commonly referred to as posterior wall blowout, can be a devastating intraoperative complication in anterior cruciate ligament (ACL) reconstruction and lead to loss of graft fixation or early graft failure. If cortical blowout occurs despite careful planning and adherence to proper surgical technique, a thorough knowledge of the anatomy and alternative fixation techniques is imperative to ensure optimal patient outcomes. This article highlights anatomic considerations for femoral tunnel placement in ACL reconstruction and techniques for avoidance and salvage of a posterior wall blowout.

Direct versus indirect ACL femoral attachment fibres and their implications on ACL graft placement.

Purpose: To further elucidate the direct and indirect fibre insertion morphology within the human ACL femoral attachment using scanning electron microscopy and determine where in the footprint each fibre type predominates. The hypothesis was that direct fibre attachment would be found centrally in the insertion site, while indirect fibre attachment would be found posteriorly adjacent to the posterior articular cartilage.

Methods: Ten cadaveric knees were dissected to preserve and isolate the entirety of the femoral insertion of the ACL.

Anatomic Reconstruction of the Proximal Tibiofibular Joint.

Proximal tibiofibular joint (PTFJ) instability can be easily missed or confused for other, more common lateral knee pathologies such as meniscal tears, fibular collateral ligament injury, biceps femoris pathology, or iliotibial band syndrome. Because of this confusion, some authors believe that PTFJ instability is more common than initially appreciated. Patients with PTFJ subluxation may have no history of inciting trauma or injury, and it is not uncommon for these patients to have bilateral symptoms and generalized ligamentous laxity.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction: Bone Grafting Technique Using an Allograft Bone Matrix.

Outcomes of primary anterior cruciate ligament (ACL) reconstruction have been reported to be far superior to those of revision reconstruction. However, as the incidence of ACL reconstruction is rapidly increasing, so is the number of failures. The subsequent need for revision ACL reconstruction is estimated to occur in up to 13,000 patients each year in the United States.

Patellofemoral Joint Reconstruction for Patellar Instability: Medial Patellofemoral Ligament Reconstruction, Trochleoplasty, and Tibial Tubercle Osteotomy.

Recurrent patellar instability can be very debilitating and may require surgical intervention. A thorough workup must be completed in this subset of patients. Risk factors for recurrent instability include patella alta, trochlear dysplasia, an increased tibial tubercle-trochlear groove distance, and insufficiencies in the medial retinacular structures.

Inside-Out Meniscal Repair: Medial and Lateral Approach.

Preservation of meniscal tissue has been proven to be the best approach in most cases of meniscal tears. Currently available techniques for treating a peripheral meniscal tear include inside-out, outside-in, and all-inside techniques. Each of these techniques present potential advantages and disadvantages.

Radiographic Identification of Arthroscopically Relevant Proximal Femoral Structures.

Background: Anatomic landmarks located on the proximal femur have only recently been defined, and there is a lack of radiographic guidelines for their locations presented in the literature. With the confident identification of these landmarks, radiographs could provide more assistance in preoperative evaluations, intraoperative guidance, and postoperative assessments.

Purpose: To quantify the radiographic locations of endoscopic landmarks of the proximal femur.

Radiographic Identification of Arthroscopically Relevant Acetabular Structures.

Background: The anatomy of the acetabulum has been described extensively in the literature, but radiographic acetabular guidelines have not been well established. This study provides a radiographic map of acetabular landmarks in the hip.

Purpose/hypothesis: The purpose of this study was to quantify the precise radiographic location of arthroscopic landmarks around the acetabulum.

Medial and Lateral Meniscal Inside-Out Repairs.

Meniscal tears differ in terms of pattern and location. If left untreated, a meniscal tear can lead to the development of osteoarthritis and increased pain, swelling, and functional limitations. Tears in the vascularized outer two-thirds of the meniscus can often be successfully repaired with use of an inside-out technique.