Woodmass, Jarret Murray

Background: Patellar height has long been considered a risk factor for patellofemoral instability. However, recent pediatric literature demonstrated a reduction in patellar height measurements following medial patellofemoral ligament (MPFL) reconstruction. Purpose: To assess the mean change in patellar height and the percentage of skeletally mature patients with patellar height ratios reduced to within-normal limits following MPFL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Adult patients undergoing primary MPFL reconstruction for recurrent lateral patellar instability between 2005 and 2013 were identified. Pre- and postoperative (within 1 year of surgery) lateral knee radiographs were assessed for patellar height indices, including Caton-Deschamps, Blackburne-Peel, and Insall-Salvati ratios. The change in patellar height and the number of patients reduced from abnormal to normal patellar height ratios following MPFL reconstruction were assessed. Results: Overall, 32 adult patients were included in the study, with a mean age of 25.7 years (range, 18-55 years). There were 21 women (66%) and 11 men (34%). Insall-Salvati, Blackburne-Peel, and Caton-Deschamps ratios all demonstrated significant reductions in patellar height between pre- and postoperative lateral knee radiographs ( P < .001). All 3 indices showed a reduction in the number of patients meeting the criteria for patella alta following MPFL reconstruction. A total of 64% of patients had an abnormal preoperative Caton-Deschamps ratio reduced to within normal limits postoperatively. Conclusion: MPFL reconstruction provides a consistent reduction in patellar height measurements. The Caton-Deschamps ratio was reduced to the reference range following MPFL reconstruction in 64% of patients with preoperative patella alta. Surgeons treating patellofemoral instability should expect a reduction in patellar height after ligament reconstruction, which may affect the need for more invasive distalization procedures.

Purpose To (1) assess clinical outcomes of revision multiligament knee injury (MLKI) reconstruction at a minimum of 2 years' follow‐up and (2) present a standardized treatment algorithm used in treating revision MLKI patients. Methods A retrospective review of our institution's MLKI database was performed to identify all patients who underwent revision MLKI reconstructions (≥2 ligaments reconstructed) after implementation of a standardized treatment algorithm in 2000 and had a minimum of 2 years' follow‐up. Patient demographic information, injury description (mechanism of injury, neurovascular status, knee dislocation grade, associated chondral or meniscal injury), surgical technique (repair vs reconstruction, staged vs nonstaged, concomitant procedures), mechanism of failure, knee stability, and range of motion, as well as International Knee Documentation Committee and Lysholm scores, were obtained. Results We assessed 23 patients (8 female and 15 male patients), with an average age of 26.7 ± 11.5 years at primary surgery and 30.8 ± 11.0 years at revision surgery. The mean follow‐up period was 7.5 ± 5.3 years. Of the 23 patients, 10 (43.4%) underwent staged revision procedures: isolated bone grafting in 3, osteotomy in 4, hardware removal with osteochondral allograft in 1, hardware removal with bone grafting in 1, and meniscus repair for a locked knee in 1. The average International Knee Documentation Committee and Lysholm scores were 74.5 ± 22.3 and 79.4 ± 20.2, respectively. High‐energy injury and increasing age at revision surgery were the only risk factors found to be associated with significantly worse outcomes ( P < .05). Conclusions Patients with recurrent instability after MLKI reconstruction present with many concomitant pathologies, including limb malalignment, bone tunnel widening, retained hardware, meniscal incompetence, and cartilage defects. Revision MLKI reconstruction can provide these patients with modest functional outcomes when a standardized treatment algorithm is used focusing on identification and treatment of the concomitant pathology, often in a staged manner. Level of Evidence Level IV, case series.

Abstract Patellar tendon ruptures are rare but potentially devastating injuries. Acute repair after patellar tendon rupture affords the best opportunity for tension‐free restoration of the extensor mechanism. Biological augmentation of primary repair is believed to decrease strain across the repair site and reduce the risk of rerupture. We present a technique for primary patellar tendon repair with bidirectional fixation using transosseous tunnels, suture anchor fixation, and ipsilateral hamstring autograft augmentation in a distal patellar pole socket. Technique Video video See video under supplementary data.

Abstract A varus‐producing distal femoral osteotomy (DFO) is an effective technique for the treatment of lateral patellar instability (LPI) in patients with concomitant moderate to severe valgus malalignment. Patellar maltracking and subluxation are corrected via neutralization of some of the laterally directed forces on the patella due to the valgus deformity. This can be accomplished with a distal femoral lateral opening‐wedge or medial closing‐wedge osteotomy and medial soft tissue stabilization. A medial closing‐wedge osteotomy offers the advantages of immediate weight bearing and a single incision in cases requiring patellofemoral soft tissue stabilization. In this article, we describe our preferred operative technique for a medial closing‐wedge DFO using a femoral locking plate and medial patellofemoral ligament imbrication for the correction of LPI. Technique Video video See video under supplementary data.

Abstract Isolated cartilage defects can lead to significant pain and disability, prompting the development of a number of options for restorative treatment. Each method has advantages and limitations, and no single technique has gained widespread use. We present a technique for implantation of a cryopreserved osteochondral allograft (Cartiform) for the treatment of full‐thickness cartilage defects. Cartiform is a cryopreserved osteochondral allograft composed of chondrocytes, chondrogenic growth factors, and extracellular matrix proteins. This implant allows for regenerative treatment of full‐thickness cartilage lesions in a single surgical procedure. Technique Video video See video under supplementary data.

Abstract Horizontal cleavage meniscus tears are a common orthopedic injury often treated with partial or total meniscectomy versus repair. This Technical Note presents a technique for all‐inside repair with uniform compression of the superior and inferior leaflets by placement of multiple circumferential compression stitches using an all‐inside self‐retrieving suture passing device. The currently described technique provides several advantages for all‐inside repair of a horizontal cleavage tear: (1) eliminates the need for a posterior incision, (2) minimizes the risk of neurovascular injury, (3) uses standard arthroscopy portals (or small modifications), and (4) requires only a single suture deployment with a self‐retrieving device for each circumferential compression stitch. The resulting circumferential stitch provides uniform compression to the superior and inferior leaflets, promoting meniscal healing. This configuration has been shown to have the highest load to failure of all repair patterns. Technique Video video See video under supplementary data.

Abstract Lateral meniscus tears are commonly encountered by orthopaedic surgeons. Despite efforts to repair and preserve the meniscus, meniscectomy is occasionally required to treat irreparable tears. The resulting lateral meniscus deficiency leads to increased tibiofemoral contact pressures and ultimately early osteoarthritic changes in the knee. Lateral meniscal allograft transplant (LMAT) has been proposed as a way to restore the lateral meniscus–deficient knee to its native form. Although several techniques for LMAT have been proposed, osseous fixation has demonstrated increased stability, improved outcomes, and improved long‐term survival. This article presents a technique for LMAT using bone plugs and standard arthroscopic portals. Technique Video video See video under supplementary data.

➤ The medial and lateral menisci have an important role in load-bearing and shock absorption and contribute to knee stability, with meniscectomy resulting in increased anterior translation of the femoral condyle on the tibia. ➤ Meniscal repair provides improved long-term outcomes, better clinical outcome scores, and less severe degenerative changes seen radiographically compared with partial meniscectomy. ➤ Given the potential long-term sequelae of meniscal pathology, patients with symptomatic meniscal tears warrant a thorough assessment with surgical consultation to determine the optimal treatment strategy. ➤ Advancements in surgical techniques and biologic augmentation have expanded the indications for meniscal repair to include tear patterns previously considered irreparable.

Abstract The meniscal roots are critical in maintaining the normal shock absorbing function of the meniscus. If a meniscal root tear is left untreated, meniscal extrusion can occur rendering the meniscus nonfunctional resulting in degenerative arthritis. Two main repair techniques are described: (1) suture anchors (direct fixation) and (2) sutures pulled through a tibial tunnel (indirect fixation). Meniscal root repair using a suture anchor technique is technically challenging requiring a posterior portal and a curved suture passing device that can be difficult to manipulate within the knee. We present a technique for posterior medial meniscus root repair using 3 sutures (1 leader, 2 cinch), standard arthroscopy portals, and transtibial fixation. Overall, this technique simplifies a challenging procedure and allows for familiarity and efficiency. Technique Video video See video under supplementary data.