Jeremy M. Burnham

Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL Injury: a roundtable discussion

AbstractPersistent rotatory knee laxity is increasingly recognized as a common finding after anterior cruciate ligament (ACL) reconstruction. While the reasons behind rotator knee laxity are multifactorial, the impact of the anterolateral knee structures is significant. As such, substantial focus has been directed toward better understanding these structures, including their anatomy, biomechanics, in vivo function, injury patterns, and the ideal procedures with which to address any rotatory knee laxity that results from damage to these structures. However, the complexity of lateral knee anatomy, varying dissection techniques, differing specimen preparation methods, inconsistent sectioning techniques in biomechanical studies, and confusing terminology have led to discrepancies in published studies on the topic. Furthermore, anatomical and functional descriptions have varied widely. As such, we have assembled a panel of expert surgeons and scientists to discuss the roles of the anterolateral structures in rotatory knee laxity, the healing potential of these structures, the most appropriate procedures to address rotatory knee laxity, and the indications for these procedures. In this round table discussion, KSSTA Editor-in-Chief Professor Jón Karlsson poses a variety of relevant and timely questions, and experts from around the world provide answers based on their personal experiences, scientific study, and interpretations of the literature. Level of evidence V.

The anterolateral complex of the knee: a pictorial essay

AbstractInjuries to the anterolateral complex of the knee can result in increased rotatory knee instability. However, to diagnose and treat patients with persistent instability properly, surgeons need to understand the multifactorial genesis as well as the complex anatomy of the anterolateral aspect of the knee in its entirety. While recent research focused primarily on one structure (anterolateral ligament—ALL), the purpose of this pictorial essay is to provide a detailed layer-by-layer description of the anterolateral complex of the knee, consisting of the iliotibial band with its superficial, middle, deep, and capsulo-osseous layer as well as the anterolateral joint capsule. This may help surgeons to not only understand the anatomy of this particular part of the knee, but may also provide guidance when performing extra-articular procedures in patients with rotatory knee instability. Level of evidence V.

Technical Considerations in Revision Anterior Cruciate Ligament Reconstruction for Operative Techniques in Orthopaedics

As the incidence of anterior cruciate ligament (ACL) reconstruction continues to increase, the rate of revision surgery continues to climb. Revision surgery has inherent challenges that must be addressed in order to achieve successful results. The cause of the primary ACL reconstruction failure should be determined, and careful preoperative planning should be performed to address the cause(s) of failure. Each patient undergoing revision surgery should undergo a thorough history and physical examination, receive full length alignment radiographs, lateral radiographs, 45-degree flexion weight-bearing postero-anterior radiographs, and patellofemoral radiographs. 3-dimensional computed topography (CT) scan should be performed to assess tunnel position and widening. Magnetic resonance imaging (MRI) should be used to assess for intra-articular soft tissue pathology. Meniscal tears, meniscal deficiency, anterolateral capsule injuries, bony morphology, age, activity level, connective tissue diseases, infection, graft choice, and tunnel position can all impact the success of ACL reconstruction surgery. Meniscal lesions should be repaired, and in cases of persistent rotatory instability, extra-articular procedures may be indicated. Furthermore, osteotomies may be needed to correct malalignment or excess posterior tibial slope. Depending on the placement and condition of the original femoral and tibial tunnels, revision surgery may be performed in a single procedure or in a staged manner. In most cases, the surgery can be performed in one procedure. Regardless, the surgeon must communicate with the patient openly regarding the implications of revision ACL surgery and the treatment plan should be developed in a shared fashion between the surgeon and the patient.

Refractory pain following hip arthroscopy: evaluation and management

ABSTRACT With increased knowledge and understanding of hip pathology, hip arthroscopy is rapidly becoming a popular treatment option for young patients with hip pain. Despite improved clinical and radiographic outcomes with arthroscopic treatment, some patients may have ongoing pain and less than satisfactory outcomes. While the reasons leading to failed hip arthroscopy are multifactorial, patient selection, surgical technique and rehabilitation all play a role. Patients with failed hip arthroscopy should undergo a thorough history and physical examination, as well as indicated imaging. A treatment plan should then be developed based on pertinent findings from the workup and in conjunction with the patient. Depending on the etiology of failed hip arthroscopy, management may be nonsurgical or surgical, which may include revision arthroscopic or open surgery, periacetabular osteotomy or joint arthroplasty. Revision surgery may be appropriate in settings including, but not limited to, incompletely treated femoroacetabular impingement, postoperative adhesions, heterotopic ossification, instability, hip dysplasia or advanced degeneration.

Ethical Issues in Return to Play: How to Deal with Parents and Coaches

Return-to-play decisions for any group of athletes can be challenging and subject to multiple competing interests. These decisions can be even more complex when they involve not just players and coaches but also the parents. Parental involvement in youth athletic participation is important, but over-involvement or the wrong types of parental intervention can hinder the athlete’s experience. It is also important to realize that the athlete’s health is paramount, despite economic and social pressures otherwise. While parents, coaches, teammates, and even team physicians may benefit from early return to play, the athlete shoulders nearly all the risks should premature return to play result in detrimental health effects. For these reasons, sports medicine professionals must ignore competing interests and focus only on the patient’s best interest. The keys to successful return to play in these settings are to initiate clear communication with all involved parties early in the process, to implement objective return-to-play guidelines and assessment criteria, to maintain strict ethical standards, to reinforce the priority on the patient’s health, and to make sure that the player, parents, and coach buy in to these principles as well.

Editorial Commentary: MRI Findings Are Only One Part of the Equation in National Football League Athletes: Shoulder Instability in Contact Athletes

Shoulder instability is a common problem in contact sports such as the National Football League. Although many elite level football athletes will have shoulder magnetic resonance imaging (MRI) findings consistent with labral tearing on MRI, these imaging findings are not always correlated with symptomatic instability or functional limitations. It is crucial in all patients, not just National Football League athletes, to treat the patient, and not the MRI.

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)

Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment

Purpose of reviewThe purpose of this study is to review the basic concepts of healthcare value, patient outcome measurement, and cost-effectiveness analyses as they relate to the introduction of new surgical techniques and technologies in the field of orthopedic surgery.Recent findingsAn increased focus on financial stewardship in healthcare has resulted in a plethora of cost-effectiveness and patient outcome research. Recent research has made great progress in identifying orthopedic technologies that provide exceptional value and those that do not meet adequate standards for widespread adoption.SummaryAs the pace of technological innovation advances in lockstep with an increased focus on value, orthopedic surgeons will need to have a working knowledge of value-based healthcare decision-making. Value-based healthcare and cost-effectiveness analyses can aid orthopedic surgeons in making ethical and fiscally responsible treatment choices for their patients.