Citations

Purpose To evaluate both the potential causes and resultant outcomes in patients in whom subchondral insufficiency fracture of the knee (SIFK) develops after arthroscopy. Methods We performed a retrospective review of all patients with a magnetic resonance imaging diagnosis of SIFK after arthroscopic meniscectomy and chondroplasty over a 12‐year period. Results A total of 28 patients were included, with a mean age of 61 years and mean follow‐up period of 5.7 years. SIFK showed a predilection for the medial compartment (n = 25, 89%), specifically the medial femoral condyle (n = 21, 75%). In 7 patients (25%), SIFK developed in both the femoral condyle and tibial plateau in the ipsilateral compartment. Fifteen patients (54%) went on to conversion to arthroplasty at a mean of 0.72 years. The rate of survival free of conversion to arthroplasty was 57%, 45%, and 40% at 1 year, 2 years, and 5 years, respectively. Furthermore, 63% of patients with a meniscal tear and SIFK in the same compartment went on to arthroplasty ( P = .04). There was an increased risk of conversion to arthroplasty if SIFK was present in both the femur and tibia in the same compartment ( P = .04). A higher Kellgren‐Lawrence grade at the time of the SIFK diagnosis increased the likelihood of eventual arthroplasty ( P = .03). The presence of SIFK in both the femur and tibia in the ipsilateral compartment, an increased Kellgren‐Lawrence grade, and a meniscal tear or prior meniscectomy in the same compartment as SIFK were associated with an increased risk of eventual arthroplasty. Conclusions Post‐arthroscopic SIFK most commonly occurs in the medial compartment, particularly in patients who underwent a prior meniscectomy. The presence of meniscal root and radial tears in these patients is notable (75%). Ultimately, there is a high rate of progression of arthrosis (33%) and eventual conversion to arthroplasty. Level of Evidence Level IV, case series.

Abstract The brain vital signs framework is a portable, objective, neurophysiological evaluation of brain function at point-of-care. We investigated brain vital signs at pre- and post-season for age 14 or under (Bantam) and age 16–20 (Junior-A) male ice hockey players to (i) further investigate previously published brain vital sign results showing subconcussive cognitive deficits and (ii) validate these findings through comparison with head-impact data obtained from instrumented accelerometers. With a longitudinal study design, 23 male ice hockey players in Bantam (n = 13; age 13.63 ± 0.62) and Tier II Junior-A (n = 10; age 18.62 ± 0.86) divisions were assessed at pre- and post-season. None were diagnosed with a concussion during the season. Cognitive evoked potential measures of Auditory sensation (N100), Basic attention (P300) and Cognitive processing (N400) were analysed as changes in peak amplitudes and latencies (six standard scores total). A regression analysis examined the relationship between brain vital signs and the number of head impacts received during the study season. Significant pre/post differences in brain vital signs were detected for both groups. Bantam and Junior-A players also differed in number of head impacts (Bantam: 32.92 ± 17.68; Junior-A: 195.00 ± 61.08; P < 0.001). Importantly, the regression model demonstrated a significant linear relationship between changes in brain vital signs and total head impacts received (R = 0.799, P = 0.007), with clear differences between the Bantam and Junior-A groups. In the absence of a clinically diagnosed concussion, the brain vital sign changes appear to have demonstrated the compounding effects of repetitive subconcussive impacts. The findings underscored the importance of an objective physiological measure of brain function along the spectrum of concussive impacts.

ObjectivePatients with meniscal tears reporting meniscal symptoms such as catching or locking have traditionally undergone arthroscopy. The present study was undertaken to investigate whether patients with meniscal tears who report meniscal symptoms have greater improvement with arthroscopic partial meniscectomy (APM) than physical therapy (PT).MethodsWe used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, which randomized participants with knee osteoarthritis (OA) and meniscal tear to APM or PT. The frequency of each meniscal symptom (clicking, catching, popping, intermittent locking, giving way, swelling) was measured at baseline and 6 months. We used linear regression models to determine whether the difference in improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score at 6 months between patients treated with APM versus PT was modified by the presence of each meniscal symptom. We also determined the percentage of participants with resolution of meniscal symptoms by treatment group.ResultsWe included 287 participants. The presence (versus absence) of any of the meniscal symptoms did not modify the improvement in KOOS pain score between APM versus PT by >0.5 SD (all P interaction >0.05). APM led to greater resolution of intermittent locking and clicking than PT (locking 70% versus 46%, clicking 41% versus 25%). No difference in resolution of the other meniscal symptoms was observed.ConclusionMeniscal symptoms were not associated with improved pain relief. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of meniscal symptoms in isolation should not inform clinical decisions surrounding APM versus PT in patients with meniscal tear and knee OA.

Background: Posterior cruciate ligament (PCL) reconstruction is commonly performed to restore joint stability and prevent posterior tibial translation at higher flexion angles. However, persistent knee laxity after reconstruction is often reported. Purpose: To biomechanically evaluate the effect of independent suture tape (ST) reinforcement on different PCL reconstruction techniques. Study Design: Controlled laboratory study. Methods: PCL reconstruction using porcine bones and quadrupled bovine tendons was performed using 2 techniques: (1) an all-inside method using suspensory adjustable loop devices (ALDs) in the tibia and femur and (2) a method using an interference screw on the tibial and an ALD on the femoral site. Both were tested with and without an additional ST for 4 groups (n = 8 per group). Each construct underwent biomechanical testing involving 3000 loading cycles in 3 stages. After position-controlled cycles simulating full range of motion, force-controlled loading from 10 to 250 N and then from 10 to 500 N were performed before pull-to-failure testing. Elongation, stiffness, and ultimate strength were evaluated. Results: The highest ultimate load (1505 ± 87 N), a small total elongation (2.60 ± 0.97 mm), and stiffness closest to the native human ligament (156.3 ± 16.1 compared with 198.9 ± 33.5 N/mm; P = .192) was seen in the all-inside technique using ST. Intragroup comparison revealed that reinforcement with ST produced a smaller total elongation for the screw fixation (Screw-ALD, 6.06 ± 3.60 vs Screw-ALD ST, 2.50 ± 1.28 mm; P = .018) and all-inside techniques (ALD-ALD, 4.77 ± 1.43 vs ALD-ALD ST, 2.60 ± 0.97 mm; P = .077), albeit the latter was not significantly different. Elongation for constructs without ST increased more rapidly at higher loads compared with elongation for ST constructs. The ultimate strength was significantly increased only for constructs using the all-inside technique using ST (ALD-ALD, 1167 ± 125 vs ALD-ALD ST, 1505 ± 87 N; P = .010). Conclusion: Adding an independent ST to PCL reconstruction led to improvement in the studied metrics by reducing the total elongation and increasing the ultimate strength, independent of the technique used. Clinical Relevance: PCL reconstruction using additional ST reinforcement was biomechanically favorable in this study. ST reinforcement in the clinical setting could decrease knee laxity after PCL reconstruction, providing better joint stability and improved functional outcomes.

AbstractMany different techniques with multiple graft types have been described for the reconstruction of the injured posterior cruciate ligament (PCL); autograft versus allograft, single- versus double-bundle, open inlay versus arthroscopic inlay versus arthroscopic transtibial, and recently described the arthroscopic “all-inside” socket technique. Reported clinical outcomes have demonstrated no significant difference in any of these PCL reconstruction techniques, likely because of the heterogeneity in injury characteristics and patient population. The ideal surgical technique should be safe, simple, and reproducible while allowing treatment of concomitant knee injuries resulting and return to function.

Background: Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort. Purpose: To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 4. Methods: All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores. Results: Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation ( P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively ( P < .001). Conclusion: The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.

Debate remains regarding the utility of mechanical axis alignment as a predictor of durability after total knee arthroplasty (TKA). Our study aimed to assess the effects of coronal alignment on implant durability, clinical outcomes, and radiographic results with a single fixed-bearing TKA design. All patients undergoing primary cemented TKA of a single design (Stryker Triathlon) from 2005–2007 with >10 years of follow-up and available pre-operative and post-operative hip–knee–ankle radiographs were included (n = 89). Radiographs were measured to determine coronal alignment and assessed for loosening. Mean preoperative mechanical axis alignment was −6° ± 6.7° (varus, range, −16°–23°), while mean post-operative alignment was −1° ± 2.7° (varus, range, −3°–15°). The aligned group was defined as knees with a post-operative mechanical axis of 0° ± 3° (n = 73) and the outlier group as those outside this range (n = 16). No patients underwent revision. Ten-year survivorship free from any reoperation was 99% and 100% in the aligned and outlier groups, respectively (p = 0.64). Knee Society scores improved significantly in both groups (p < 0.001) and did not differ at final follow-up (p = 0.15). No knees demonstrated radiographic evidence of loosening. Post-operative mechanical axis alignment within 3° of neutral was not associated with improved implant durability, clinical outcomes, or radiographic results at 10 years following primary TKA.

Abstract Posterolateral corner injuries are complex injuries, and their therapeutic management varies from one individual to another. Biomechanical studies demonstrate that anatomic posterolateral corner reconstruction restores knee kinematics better than nonanatomic reconstruction. The purpose of this report is to describe an all‐arthroscopic procedure for anatomic posterolateral corner reconstruction. Technique Video video See video under supplementary data.

Abstract Arthroscopic assessment of posterior compartments of the knee and the posterior aspect of the proximal tibial and fibula is challenging because of the relative proximity of the neurovascular bundle. This Technical Note describes a reproducible arthroscopic surgical approach in a cadaveric model that aims to identify and expose the popliteus tendon, posterior fibular head, fibular collateral ligament popliteal fibular ligament, biceps femoris tendon, and peroneal nerve. Technique Video video See video under supplementary data.

Abstract Tears of the posterior medial meniscus root commonly result in extrusion of the meniscus and disruption of tibiofemoral contact mechanics. Transtibial pull‐through repair of the root often results in healing of the tear, but postoperative extrusion may persist. In this scenario, the meniscus is unlikely to be chondroprotective. Therefore, an additional centralization procedure is necessary to improve the extrusion. Biomechanical studies have demonstrated that centralization can improve meniscus mechanics and potentially reduce the risk of osteoarthritis. This Technical Note describes an arthroscopic technique for medial meniscus posterior root repair that combines transtibial pullout and centralization sutures. Technique Video video See video under supplementary data.