Ajay C. Kanakamedala

High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques

IntroductionAlthough it is well known from cadaveric and biomechanical studies that transtibial femoral tunnel (TT) positioning techniques are associated with non-anatomic tunnel positions, controversial data exist as so far no clinical differences could have been found, comparing transtibial with anteromedial techniques (AM). The purpose of the study was to analyze if graft failure following TT ACL reconstruction was more commonly associated with non-anatomic tunnel position in comparison with the AM technique. We hypothesized that, compared to AM techniques, non-anatomic tunnel positions correlate with TT tunnel positioning techniques.Materials and methodsA total of 147 cases of ACL revision surgery were analyzed retrospectively. Primary ACL reconstructions were analyzed regarding the femoral tunnel drilling technique. Femoral and tibial tunnel positions were determined on CT scans using validated radiographic measurement methods. Correlation analysis was performed to determine differences between TT and AM techniques.ResultsA total of 101 cases were included, of whom 64 (63.4%) underwent the TT technique and 37 (36.6%) the AM technique for primary ACL reconstruction. Non-anatomic femoral tunnel positions were found in 77.2% and non-anatomical tibial tunnel positions in 40.1%. No correlations were found comparing tunnel positions in TT and AM techniques, revealing non-anatomic femoral tunnel positions in 79.7 and 73% and non-anatomic tibial tunnel positions in 43.7 and 35.1%, respectively (pxa0>xa00.05).ConclusionsConsiderable rates of non-anatomic femoral and tibial tunnel positions were found in ACL revisions with both transtibial and anteromedial femoral drilling techniques. Despite the potential of placing tunnels more anatomically using an additional AM portal, this technique does not ensure anatomic tunnel positioning. Consequently, the data highlight the importance of anatomic tunnel positioning in primary ACL reconstruction, regardless of the applied drilling technique.

IKDC Subjective Knee Form and Marx Activity Rating Scale are suitable to evaluate all orthopaedic sports medicine knee conditions: a systematic review

Importance Given the increasing importance and number of knee-related patient-reported outcome measures (PROMs), it would be desirable to have one PROM for assessing the outcomes of all patients with orthopaedic sports medicine knee conditions. Objective The purpose of this review was to evaluate whether the existing literature supports the use and interpretation of the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and Marx Activity Rating Scale (MARS) as the primary PROMs in the setting of orthopaedic research or clinical practice. We hypothesised that the reported data for the psychometric properties of the IKDC-SKF and MARS would meet accepted standards for interpretation and use of PROMs. Evidence review A systematic search of MEDLINE was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify articles reporting the development and psychometric properties of the IKDC-SKF and MARS. References of included articles were hand-searched to identify additional articles for inclusion. The results of these studies were extracted to determine if the reported psychometric properties for the IKDC-SKF and MARS met established standards. Findings The reported test–retest intraclass correlations (ICCs) for the IKDC-SKF and the MARS respectively range from 0.85 to 0.99 and 0.81 to 0.97 (ICC>0.70 considered acceptable). The reported effect sizes (ES) and standardised response means (SRM) ranged from 0.76 to 2.11 for the IKDC-SKF and from 0.57 to 1.5 for the MARS (ES/SRM >0.5 or >0.8 are respectively considered moderate and large). The IKDC-SKF has been reported to show moderate/excellent correlations with 60/72 (83%) concomitantly administered measures of physical health and poor/fair correlations with 28/31 (90%) measures of mental health, thus demonstrating its convergent and divergent validity. The MARS has shown moderate/excellent correlations with 3/3 (100%) concomitantly administered measures of level of sports activities, which demonstrates its convergent validity. Standards for interpreting the IKDC-SKF, including the minimal detectable change, minimum clinically important difference, normative data and the patient acceptable symptom state, are also summarised. Conclusions and relevance This review suggests that the IKDC-SKF and MARS have acceptable psychometric properties to support their use and interpretation to assess the clinical response of patients with a variety of knee conditions in clinical practice and research settings.

Female sex is associated with greater rotatory knee laxity in collegiate athletes

AbstractPurpose/hypothesisnThe purpose of this observational study was to determine which factors, including sex, are associated with increased rotatory knee laxity in collegiate athletes with no history of knee injuries. It was hypothesized that increased rotatory knee laxity, measured by a quantitative pivot shift test, would correlate with female sex, increased anterior translation during the Lachman test, generalized ligamentous laxity, and knee hyperextension.MethodsnNinety-eight collegiate athletes with a median age of 20 (range 18–25) years with no history of knee injuries were tested. IKDC and Marx activity scores were obtained and subjects underwent measurement of anterior translation during the Lachman test with a Rolimeter and measurement of knee hyperextension with a goniometer for both knees. A standardized pivot shift test was performed in both knees and quantified using image analysis technology. Generalized ligamentous laxity was assessed using the modified Beighton score.ResultsThe average anterior translation of the lateral compartment during the pivot shift test was 1.6xa0mm (range 0.1–7.1) with a mean side-to-side difference of 0.6xa0mm (range 0–2.7). The average anterior translation during the Lachman test was 9.0 (range 2–15). The anterior translation of the lateral compartment during the pivot shift test was significantly higher in females (median, 1.6; range 0.3–4.9) than in males (1.1, 0.1–7.1xa0mm) (pxa0<xa00.05). Anterior translation of the lateral compartment during the pivot shift test was significantly correlated with anterior translation during the Lachman test (rxa0=xa00.34; pxa0<xa00.05). There was no significant correlation between anterior translation of the lateral compartment during the pivot shift test and knee hyperextension or modified Beighton score (n.s).ConclusionThe data from this study show that female sex is associated with increased rotatory knee laxity measured during the pivot shift test and anterior translation during the Lachman test in collegiate athletes. In the future, these data may be helpful in diagnosing and managing ACL injuries in athletes and could be used in the clinic as a baseline by which to compare and identify patients who might exhibit increased rotatory laxity.Level of evidenceDiagnostic level II.

Lateral femoral notch depth is not associated with increased rotatory instability in ACL-injured knees: a quantitative pivot shift analysis

PurposeA deep lateral femoral notch (LFN) on lateral radiographs is indicative of ACL injury. Prior studies have suggested that a deep LFN may also be a sign of persistent rotatory instability and a concomitant lateral meniscus tear. Therefore, the purpose of this study was to evaluate the relationship between LFN depth and both quantitative measures of rotatory knee instability and the incidence of lateral meniscus tears. It was hypothesized that greater LFN depth would be correlated with increased rotatory instability, quantified by lateral compartment translation and tibial acceleration during a quantitative pivot shift test, and incidence of lateral meniscus tears.MethodsACL-injured patients enrolled in a prospective ACL registry from 2014 to 2016 were analyzed. To limit confounders, patients were only included if they had primary ACL tears, no concurrent ligamentous or bony injuries requiring operative treatment, and no previous knee injuries or surgeries to either knee. Eighty-four patients were included in the final analysis. A standardized quantitative pivot shift test was performed pre-operatively under anesthesia in both knees, and rotatory instability, specifically lateral compartment translation and tibial acceleration, was quantified using tablet image analysis software and accelerometer sensors. Standard lateral radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for LFN depth.ResultsThere were no significant correlations between LFN depth on either imaging modality and ipsilateral lateral compartment translation or tibial acceleration during a quantitative pivot shift test or side-to-side differences in these measurements. Patients with lateral meniscus tears were found to have significantly greater LFN depths than those without on conventional radiograph and MRI (1.0 vs. 0.6xa0mm, pu2009<u20090.05; 1.2 vs. 0.8xa0mm, pu2009<u20090.05, respectively).ConclusionThere was no correlation between lateral femoral notch depth on conventional radiographs or MRI and quantitative measures of rotatory instability. Concomitant lateral meniscus injury was associated with significantly greater LFN depth. Based on these findings, LFN depth should not be used as an indicator of excessive rotatory instability, but may be an indicator of lateral meniscus injury in ACL-injured patients.Level of evidencePrognostic level IV.

No difference between full thickness and partial thickness quadriceps tendon autografts in anterior cruciate ligament reconstruction: a systematic review

PurposeThe purpose of this review was to compare outcomes and complication profiles of anterior cruciate ligament reconstruction (ACL-R) between full thickness (FT-Q) and partial thickness (PT-Q) quadriceps tendon (QT) autografts.MethodsAs per PRISMA guidelines, PubMed, EMBASE, and MEDLINE were searched in September 2017 for English language, human studies of all levels of evidence on patients undergoing primary ACL-R with FT-Q or PT-Q. This search was repeated in March 2018 to capture additional articles. Data regarding postoperative outcomes and complications were abstracted. Due to heterogeneous reporting, data were not combined in meta-analysis and were summarized descriptively.ResultsUpon screening 3670 titles, 18 studies satisfied inclusion/exclusion criteria. The second search identified an additional two studies for a total of 20 studies (50% case–control, 50% case series). These studies examined 1212 patients (1219 knees) of mean age 29.8xa0years (range 15–59) followed a mean of 42.2xa0months (range 12–120). FT-Q and PT-Q autografts were used in eight studies (50.5% of knees), and thirteen studies (49.5% of knees), respectively. Only one study directly compared FT-Q to PT-Q. Instrumented laxity was less than 3xa0mm in 74.8 and 72.4% of the FT-Q and PT-Q groups, respectively. Postoperative IKDC Subjective Knee Form scores were similar between the FT-Q (82.5) and PT-Q (82.1) groups. Postoperative quadriceps strength, measured as a percentage of the contralateral side, were similar in the FT-Q (89.5%) and PT-Q (85.1%) groups. Graft failure rates for the FT-Q and PT-Q groups were 3.7 and 3.0%, respectively.ConclusionAcross the 20 studies included in this review, there appeared to be no difference in outcomes or complications between either FT-Q or PT-Q in primary ACL-R. Moreover, primary ACL-R using QT autografts appears to have successful outcomes with a low rate of graft failure, irrespective of tendon thickness. While further comparative studies are needed to better delineate the optimal thickness of quadriceps tendon for primary ACL-R, these data suggest that, in primary ACL-R, either FT-Q or PT-Q is efficacious and, in the clinical setting, surgeons may be justified in using either graft thickness.Level of evidenceIV, Systematic Review of Level III and IV studies.

Intraoperative fluoroscopy during MPFL reconstruction improves the accuracy of the femoral tunnel position

PurposeReconstruction of the medial patellofemoral ligament (MPFL) has been established as standard of care for patellofemoral instability. An anatomic femoral tunnel position has been shown to be a prerequisite for restoration of patellofemoral stability and biomechanics. However, the incidence of malpositioning of the femoral tunnel during MPFL reconstruction continues to be notable. Palpation of anatomic landmarks and intraoperative fluoroscopy are the two primary techniques for tunnel placement. The aim of this study was to compare the accuracy of these two methods for femoral tunnel placement.MethodsFrom 2016 to 2017, 64 consecutive patients undergoing MPFL reconstruction for patelllofemoral instability were prospectively enrolled. During surgery, the presumed femoral MPFL insertion was identified by both palpation of anatomic landmarks and using fluoroscopy, both of these points were separately documented on true lateral radiographs. They were then analysed and deviations from the Schoettle’s Point were measured as anterior–posterior and proximal–distal deviations. A tunnel position within a radius of 7xa0mm around the Schoettle’s Point was designated as an “accurate tunnel position”.ResultsCompared to the method of palpation, fluoroscopy led to significantly more anatomic femoral tunnel positoning (pu2009<u20090.0001). The mean proximal–distal and anterior–posterior distances between the femoral insertion site identified by palpation and the Schoettle’s Point were 5.7u2009±u20094.5xa0mm (0.3–20.3xa0mm) and 4.1u2009±u20093.7xa0mm (0.1–20.3xa0mm), respectively, versus 1.7u2009±u20090.9xa0mm (0.1–3.6xa0mm) and 1.8u2009±u20091.3xa0mm (0.1–4.8xa0mm) for fluoroscopy, respectively. Using fluoroscopy, all femoral insertion sites were identified within a 7xa0mm radius around the centre of the Schoettle’s Point. In contrast, only 52% (33) of femoral insertion sites identified by palpation were within this radius. These data were independent of patients’ age, gender and BMI. No improvement in accuracy of femoral tunnel positions was detected over time.ConclusionsThe main finding of this study was that, compared to the method of palpation of anatomic landmarks, the use of intraoperative fluoroscopy in MPFL reconstruction leads to more accurate femoral tunnel positioning. Based on these results, the use of intraoperative fluoroscopy has to be recommended for femoral tunnel placement in daily surgical practice to minimize the incidence of malpositioning and to restore native patellofemoral biomechanics.Study designLevel III Case-control study.

The Use of Fluoroscopy Leads to Improved Identification of the Femoral Lateral Collateral Ligament Origin Site When Compared With Traditional Tactile Techniques

PURPOSEnTo determine whether a fluoroscopic technique can be used to improve the accuracy of the determination of the femoral origin of the lateral collateral ligament (LCL).nnnMETHODSnA 1-cm incision was made over the lateral epicondyle in 13 fresh-frozen cadaveric knee specimens, and the LCL origin was determined first by palpation and then with a previously described fluoroscopic method. Both points for the LCL origin were marked with 2-mm Kirschner wires. The distances between the center of the anatomic LCL origin and the LCL origin points determined by palpation and fluoroscopic imaging were calculated. An independent t-test was used to compare the distances between the anatomic LCL origin center and the determined LCL origin points.nnnRESULTSnThe LCL origin points determined by fluoroscopic imaging were significantly (Pxa0= .005) closer to the anatomic center of the LCL origin point than the ones determined by palpation (3.2xa0mm ± 1.6xa0mm vs 5.0xa0mm ± 1.6xa0mm, respectively). A total of 92.7% fluoroscopically determined LCL origin points were within a 5xa0mm radius surrounding the anatomic LCL origin point. In contrast, only 53.8% LCL origin points determined by palpation were within a 5xa0mm radius surrounding the anatomic LCL origin point.nnnCONCLUSIONSnThe use of palpation to identify the LCL origin may not be an accurate method for performing an isometric and anatomic LCL reconstruction. The use of fluoroscopic imaging appears to be a feasible method for identifying the LCL origin in clinical practice and may increase the accuracy of LCL origin identification. Fluoroscopic guidance improves accuracy in determining the anatomic LCL origin, which may help avoiding tunnel malplacement during LCL reconstruction. CLINICALxa0RELEVANCE: The use of a previously described radiographic method for identifying the LCL origin may be used to achieve a more anatomic LCL reconstruction.

Increased medial and lateral tibial posterior slopes are independent risk factors for graft failure following ACL reconstruction

PurposeTo analyze the contribution of increased lateral (LTPS) and medial tibial slopes (MTPS) as independent risk factors of graft failure following anterior cruciate ligament (ACL) reconstruction.Materials and methodsFifty-seven patients with graft failure after ACL reconstruction who underwent revision surgery between 2009 and 2014 were enrolled and matched to a control group of 69 patients with primary anatomic successful ACL reconstruction. Patients were matched based on age, sex, date of primary surgery and graft type. LTPS and MTPS were measured on MRI in a blinded fashion. Tibial and femoral tunnel positions were determined on CT scans. Independent t test was used to compare the MTPS and LTPS between subgroups. Risks of graft failure associated with an increasing MTPS and LTPS were analyzed using binary logistic analysis.ResultsThe means of LTPS (7.3°) and MTPS (6.7°) in the graft failure group were found to be significantly greater than in the control group (4.6° and 4.1°, respectively; pu2009=u2009<u20090.001). Non-anatomic and anatomic tunnel positions were found in 42 cases (73.7%) and 15 cases (26.3%), respectively. There were no significant differences in MTPS or LTPS between patients with anatomic and non-anatomic tunnel positions within the graft failure group. An increase of the MTPS of 1° was associated with an 1.24 times increased likelihood of exhibiting graft failure [95% CI 1.07–1.43] (pu2009=u20090.003) and an increase of the LTPS of 1° was associated with an 1.17 times increased likelihood of exhibiting graft failure [95% CI 1.04–1.31] (pu2009=u20090.009). The increased risk was most evident in patients with a lateral tibial posterior slope of ≥u200910°.ConclusionsIncreased LTPS and MTPS are independent risk factors for graft failure following ACL reconstruction regardless whether tunnel position is anatomic or non-anatomic. This information may be helpful to clinicians when considering slope correction in selected revision ACL reconstruction procedures.

Differences between traumatic and non-traumatic causes of ACL revision surgery

PurposeThe purpose of this study was to evaluate and classify causes for anterior cruciate ligament (ACL) reconstruction failure. It was hypothesized that specific technical and biological reconstruction aspects would differ when comparing traumatic and non-traumatic ACL reconstruction failures.Materials and methodsOne hundred and forty-seven consecutive patients who experienced ACL reconstruction failure and underwent revision between 2009 and 2014 were analyzed. Based on a systematic failure analysis, including evaluation of technical information on primary ACL reconstruction and radiological assessment of tunnel positions, causes were classified into traumatic and non-traumatic mechanisms of failure; non-traumatic mechanisms were further sub-divided into technical and biologic causes. Spearman’s rank correlation coefficient and chi-squared tests were performed to determine differences between groups based on various factors including graft choice, fixation technique, technique of femoral tunnel positioning, tunnel malpositioning, and time to revision.ResultsNon-traumatic, i.e., technical, and traumatic mechanisms of ACL reconstruction failure were found in 64.5 and 29.1% of patients, respectively. Biological failure was found only in 6.4% of patients. Non-anatomical femoral tunnel positioning was found the most common cause (83.1%) for technical reconstruction failure followed by non-anatomical tibial tunnel positioning (45.1%). There were strong correlations between non-traumatic technical failure and femoral tunnel malpositioning, transtibial femoral tunnel drilling techniques, femoral transfixation techniques as well as earlier graft failure (pu2009<u20090.05).ConclusionsTechnical causes, particularly tunnel malpositioning, were significantly correlated with increased incidence of non-traumatic ACL reconstruction failure. Transtibial femoral tunnel positioning techniques and femoral transfixation techniques, showed an increased incidence of non-traumatic, earlier graft failure.

Is Lateral Femoral Notch Depth Associated with Rotatory Instability in ACL Deficient Knees: A Quantitative Pivot Shift Analysis

Objectives: Persistent rotatory knee instability after anterior cruciate ligament (ACL) reconstruction is relatively common. While the causes of this persistent instability are multifactorial, bony morphologic characteristics have been proposed to play a role. Therefore, the purpose of this study was to evaluate the relationship between the well-described lateral femoral notch (LFN) depth and quantitative measures of rotatory knee stability. We hypothesized that greater LFN depth would be associated with increased rotatory knee instability. Methods: A consecutive series of patients undergoing primary ACL reconstruction at our university medical center from June 2014 to April 2016 were analyzed. Inclusion criteria included primary ACL tear, no concurrent ligamentous or bony injury requiring operative treatment, no history of previous knee injury or surgery to the ACL-injured extremity, and no history of injury or surgery to the contralateral knee. A standardized pivot shift test was performed by the senior surgeon preoperatively under anesthesia in both knees and quantified using tablet image analysis software and accelerometer sensors as previously described and validated. Lateral knee radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for depth of the LFN as previously described. A line tangent to the lateral femoral condyle articular surface was drawn across the notch. Notch depth was measured perpendicular from this line to the deepest point of the LFN. Pearson correlation coefficient was used to analyze correlations between continuous variables. Chi-square test was used to analyze relationships between notch depth and presence/absence of medial or lateral meniscus tears. Analyses were performed with SPSS 22.0 and significance was set at a p<0.05. Results: Fifty patients met inclusion criteria and were included in this study (mean age 24 years, range 13-45; 28 females, 22 males). Mean LFN depth as measured via x-ray was 0.8 mm (SD=0.63, n=50) and via MRI was 1.0 mm (SD=0.73, n=47). Twenty-two (44%) patients had a medial meniscus tear and 27 (54%) had a lateral meniscus tear. LFN on x-ray had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.402, p=0.004) and acceleration side-to-side differences (r=0.407, p=0.003). LFN depth on MRI had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.334, p=0.022) and acceleration side-to-side differences (r=0.363, p=0.012). LFN depth on x-ray was significantly associated with the presence of a lateral meniscus tear (p=0.014). There were no significant associations between LFN depth (x-ray or MRI) on ipsilateral or contralateral lateral compartment translation, contralateral lateral compartment acceleration, or the presence of medial meniscus tears. Conclusion: The results from this study demonstrated that a well described bony morphologic feature - LFN depth - was correlated with higher lateral compartment acceleration as measured by quantitative pivot shift analysis. Furthermore, greater LFN depth was associated with an increased incidence of lateral meniscus tears, which supports findings from previous studies. Assessment of LFN depth may help clinicians identify patients with greater rotatory instability prior to ACL reconstruction and potentially direct surgical treatment to account for additional rotatory knee instability. Table 1: Mean Quantitative Pivot Shift Values of the Injured and Uninjured Knee Injured Uninjured Side-to-Side Difference Compartment Acceleration (m/s2) 5.14 (SD=0.73) 3.45 (SD=0.95) 1.68 (SD=2.09) Lateral Compartment Translation (mm) 3.67 (SD=2.30) 1.22 (SD=0.75) 2.46 (SD=2.24)