Prince, Matthew

AbstractPatellar sleeve fractures primarily occur in the adolescent population from a rapid contraction of the quadriceps with the knee in a flexed position. Several small case reports describe operative reduction and fixation for displaced fractures. However, there is sparse literature on nonoperative management of these injuries. Retrospective review and prospective follow-up of all patients diagnosed with patellar sleeve fracture between 1991 and 2014 at a single institution. Patients with superior pole avulsion fractures, history of prior knee surgery, and fractures managed operatively were excluded. Patients with a clinical diagnosis without support of advanced imaging were also excluded. Radiographs and magnetic resonance imaging (MRI) were reviewed for initial fracture displacement, time until fracture union, and the presence of patellar tendon ossification. Outcome was assessed using the Tegner's activity scale, Kujala's Score and the International Knee Documentation Committee (IKDC) subjective knee evaluation score at final follow-up. Eighteen nonoperatively treated distal patellar pole sleeve fractures were identified, while five patients had advanced imaging to support their diagnosis. All were males with a mean age of 15.1 (range: 12–18). Traumatic and sport-related injuries were noted in the majority of patients. Only one patient had any appreciable displacement, but still < 2 mm. Final radiographic evaluation revealed fracture healing without patellar tendon ossification in all patients. All five patients had full terminal knee extension and symmetric range of motion. Mean IKDC score was 96.4 (range: 82–100) mean Tegner's activity score was 60 (range: 5–8), and mean Kujala's score was 89.7 (range: 63–100) at final follow-up. Of the five cases, three patients presented in a delayed fashion, and all went on to have surgical treatment. Two required arthroscopic loose body removal, while the other had an open patellar debridement and platelet-rich plasma (PRP) injection. Minimally displaced patellar sleeve fractures can be successfully managed nonoperatively with excellent clinical outcomes. However, delayed in presentation may be associated with worse outcome. This study of case series reflects level of evidence IV.

Purpose To compare clinical and functional outcomes of surgically treated medial and lateral knee dislocations. Methods A retrospective review of the medical records of patients who presented with knee dislocations was conducted. We identified patients who underwent surgical treatment of KDIII‐M (anterior cruciate ligament/posterior cruciate ligament/medial collateral ligament) or KDIII‐L (anterior cruciate ligament/posterior cruciate ligament/lateral collateral ligament) knee dislocation as documented by the Schenck classification. Minimum 2‐year follow‐up with Lysholm and International Knee Documentation Committee (IKDC) outcome scores was required for inclusion. Postoperative range of motion, ligamentous examination, and conversion to total knee arthroplasty were also collected. Data were analyzed using univariate and multivariate statistical models with P < .05 considered significant. Results A total of 56 patients met the inclusion criteria, 24 with the KDIII‐M injury pattern (43%) and 32 with the KDIII‐L injury pattern (57%), with a mean age of 34 years (range, 16 to 62 years) and a mean follow‐up of 6.5 years (range, 2 to 20 years). Patients undergoing medial repairs had worse outcomes for both the Lysholm score ( P = .008) and IKDC score ( P = .003). In addition, female sex was linked to worse outcomes (Lysholm score, 58.8 ± 21.5 v 77.8 ± 21.1, P < .01; IKDC score, 54.9 ± 23.7 v 75.2 ± 20.2, P < .01). No differences in outcome were found between patients with and patients without peroneal nerve injury (Lysholm score, P = .81; IKDC score, P = .77). No difference in laxity testing was found between the 2 groups. Conclusions In patients undergoing multiligament knee reconstruction, our data suggest that those who undergo medial repair for knee dislocations are not as likely to achieve positive results as those who undergo reconstruction or lateral reconstruction/repair, regardless of the status of the peroneal nerve. In addition, medial reconstruction had comparable outcomes to those in patients treated with lateral reconstruction/repair. Lastly, female patients showed less favorable clinical outcomes than male patients. Level of Evidence Level III, retrospective comparative study.

Abstract Injuries to the medial collateral ligament (MCL) and posteromedial corner can occur in isolation or in the setting of multiligamentous knee injuries. Reconstruction of the MCL and posteromedial corner is indicated in the setting of a multiligamentous knee injury. Isolated cases failing nonoperative treatment may also undergo surgical treatment. Our preferred technique for anatomic medial‐sided knee reconstruction is an open anatomic MCL reconstruction using an Achilles tendon allograft along with direct repair of all associated medial and posteromedial structures. Technique Video video See video under supplementary data.

Abstract Posterior cruciate ligament (PCL) injuries account for nearly 20% of knee ligament injuries. PCL injuries can occur in isolation or, more commonly, in the setting of multiligamentous knee injuries. Isolated PCL disruptions are commonly treated nonoperatively; however, symptomatic grade III injuries, as well as PCL injuries found in multiligamentous injuries, are frequently treated surgically. Several reconstructive techniques exist for the treatment of PCL deficiency without a clear optimal approach. We describe our preferred operative technique to reconstruct the PCL using an all‐inside arthroscopic approach with a quadrupled tibialis anterior or peroneus longus allograft with both tibial and femoral suspensory fixation. Technique Video video See video under supplementary data.