Jonathan A. Godin

Transtibial Versus Independent Drilling Techniques for Anterior Cruciate Ligament Reconstruction A Systematic Review, Meta-analysis, and Meta-regression

Background: While numerous cadaveric, in vivo, and clinical studies have compared transtibial and independent drilling of femoral tunnels during anterior cruciate ligament reconstruction, there is no evidence-based consensus on which technique affords the best outcome. Hypothesis: There is no difference in clinical outcome between transtibial and independent drilling of femoral tunnels. Study Design: Systematic review with meta-analysis and meta-regression. Methods: Cadaveric, in vivo, and clinical studies comparing transtibial and independent drilling techniques were systematically identified. A qualitative synthesis of nonrandomized studies and meta-analysis of randomized controlled trials (RCTs) were performed. In addition, a meta-regression analysis of RCTs that did not directly compare drilling techniques was performed. Results: A total of 49 studies were included in the qualitative review, and 15 were included in the meta-analysis; 22 studies were included in the meta-regression. In biomechanical studies, independent drilling placed the center of the femoral tunnel closer to the center of the femoral footprint (mean difference, 2.69 mm; 95% CI, 0.46-4.92; P < .00001). Independent drilling reduced anterior tibial translation with the Lachman examination (mean difference, 2.2 mm; 95% CI, 0.34-4.07; P = .02), 134 N of anterior load (mean difference, 1 mm; 95% CI, 0.29-1.71; P = .006), and simulated pivot shift (mean difference, 3.36 mm; 95% CI, 1.88-4.85; P < .00001). The meta-analysis showed improved Lysholm scores with independent drilling (mean difference, −0.62 points; 95% CI, −1.09 to −0.55; P = .009), although the clinical relevance of this small difference is questionable. There were no significant differences in International Knee Documentation Committee (IKDC) objective scores or Tegner scores between groups. With the meta-regression, there were no significant differences in failure rates or IKDC objective scores. Conclusion: While there are biomechanical data suggesting improved knee stability and more anatomic graft placement with independent drilling, no significant clinical differences were found between the 2 techniques. Clinical Relevance: The current evidence shows that transtibial and independent drilling techniques have equivalent clinical outcomes at short-term to midterm follow-up. The long-term effects of subtle differences in tunnel position and postoperative knee kinematics should be further studied in dedicated, prospective cohort and randomized studies.

The Association of ASA Class on Total Knee and Total Hip Arthroplasty Readmission Rates in an Academic Hospital

Total hip and knee arthroplasties are two of the most successful orthopaedic procedures. However, with the increasing demand, estimated future costs for these procedures are enormous. Recent data suggest post-discharge care may account for up to 35% of total episode payments. Yet, little is known about targets that can help improve quality and reduce cost. This retrospective study shows an ASA score of ≥ 3 is associated with a 2.9 times (P = 0.0082) greater risk of re-admission in total joint arthroplasty patients. The current literature corroborates this finding by demonstrating an increase risk of post-operative complications in patients with an ASA of ≥ 3. Therefore, the ASA score is a potential target for interventions designed to increase quality and lower cost in arthroplasty patients.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury

Background: Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. Methods: We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients’ preoperative and postoperative sports involvement (primary and secondary sports, number of sports). Results: A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). Conclusions: Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Comprehensive Reanalysis of the Distal Iliotibial Band: Quantitative Anatomy, Radiographic Markers, and Biomechanical Properties:

Background: The qualitative anatomy of the distal iliotibial band (ITB) has previously been described. However, a comprehensive characterization of the quantitative anatomic, radiographic, and biomechanical properties of the Kaplan fibers of the deep distal ITB has not yet been established. It is paramount to delineate these characteristics to fully understand the distal ITB’s contribution to rotational knee stability. Purpose/Hypothesis: There were 2 distinct purposes for this study: (1) to perform a quantitative anatomic and radiographic evaluation of the distal ITB’s attachment sites and their relationships to pertinent osseous and soft tissue landmarks, and (2) to quantify the biomechanical properties of the deep (Kaplan) fibers of the distal ITB. It was hypothesized that the distal ITB has definable parameters concerning its anatomic attachments and consistent relationships to surgically pertinent landmarks with correlating plain radiographic findings. In addition, it was hypothesized that the biomechanical properties of the Kaplan fibers would support their role as important restraints against internal rotation. Study Design: Descriptive laboratory study. Methods: Ten nonpaired, fresh-frozen human cadaveric knees (mean age, 61.1 years; range, 54-65 years) were dissected for anatomic and radiographic purposes. A coordinate measuring device quantified the attachment areas of the distal ITB to the distal femur, patella, and proximal tibia and their relationships to pertinent bony landmarks. A radiographic analysis was performed by inserting pins into the attachment sites of relevant anatomic structures to assess their location relative to pertinent bony landmarks with fluoroscopic guidance. A further biomechanical assessment of 10 cadaveric knees quantified the load to failure and stiffness of the Kaplan fibers’ insertion on the distal femur after a preconditioning protocol. Results: Two separate deep (Kaplan) fiber bundles were identified with attachments to 2 newly identified femoral bony prominences (ridges). The proximal and distal bundles inserted on the distal femur 53.6 mm (95% CI, 50.7-56.6 mm) and 31.4 mm (95% CI, 27.3-35.5 mm) proximal to the lateral epicondyle, respectively. The centers of the bundle insertions were 22.5 mm (95% CI, 19.1-25.9 mm) apart. The total insertion area of the distal ITB on the proximal tibia was 429.1 mm2 (95% CI, 349.2-509.1 mm2). A distinct capsulo-osseous layer of the distal ITB was also identified that was intimately related to the lateral knee capsule. Its origin was in close proximity to the lateral gastrocnemius tubercle, and it inserted on the proximal tibia at the lateral tibial tubercle between the fibular head and the Gerdy tubercle. Radiographic analysis supported the quantitative anatomic findings. The mean maximum load during pull-to-failure testing was 71.3 N (95% CI, 41.2-101.4 N) and 170.2 N (95% CI, 123.6-216.8 N) for the proximal and distal Kaplan bundles, respectively. Conclusion: The most important finding of this study was that 2 distinct deep bundles (Kaplan fibers) of the distal ITB were identified. Each bundle of the deep layer of the ITB was associated with a newly identified distinct bony ridge. Radiographic analysis confirmed the measurements previously recorded and established reproducible landmarks for the newly described structures. Biomechanical testing revealed that the Kaplan fibers had a strong attachment to the distal femur, thereby supporting a role in rotational knee stability. Clinical Relevance: The identification of 2 distinct deep fiber (Kaplan) attachments clarifies the function of the ITB more definitively. The results also support the role of the ITB in rotatory knee stability because of the fibers’ vectors and their identified maximum loads. These findings provide the anatomic and biomechanical foundation needed for the development of reconstruction or repair techniques to anatomically address these deficiencies in knee ligament injuries.

Quantitative and Qualitative Analysis of the Medial Patellar Ligaments: An Anatomic and Radiographic Study

Background: The qualitative and quantitative anatomy of the medial patellar stabilizers has been reported; however, a quantitative analysis of the anatomic and radiographic attachments of all 4 ligaments relative to anatomic and osseous landmarks, as well as to one another, has yet to be performed. Purpose: To perform a qualitative and quantitative anatomic and radiographic evaluation of the medial patellofemoral ligament (MPFL), medial patellotibial ligament (MPTL), medial patellomeniscal ligament (MPML), and medial quadriceps tendon femoral ligament (MQTFL) attachment sites, with attention to their relationship to pertinent osseous and soft tissue landmarks. Study Design: Descriptive laboratory study. Methods: Ten nonpaired fresh-frozen human cadaveric knees were dissected, and the MPFL, MPTL, MPML, and MQTFL were identified. A coordinate measuring device quantified the attachment areas of each structure and its relationship to pertinent bony landmarks. Radiographic analysis was performed through ligament attachment sites and relevant anatomic structures to assess their locations relative to pertinent bony landmarks. Results: Four separate medial patellar ligaments were identified in all specimens. The center of the MPFL attachments was 14.3 mm proximal and 2.1 mm posterior to the medial epicondyle and 8.3 mm distal and 2.7 mm anterior to the adductor tubercle on the femur and 8.9 mm distal and 19.9 mm medial to the superior pole on the patella. The MQTFL had a mean insertion length of 29.3 mm on the medial aspect of the distal quadriceps tendon. The MPTL and MPML shared a common patellar insertion and were 9.1 mm proximal and 15.4 mm medial to the inferior pole. The MPTL attachment inserted on a newly identified bony ridge, which was located 5.0 mm distal to the joint line. The orientation angles of the MPTL and MPML with respect to the patellar tendon were 8.3° and 22.7°, respectively. Conclusion: The most important findings of this study were the correlative anatomy of 4 distinct medial patellar ligaments (MPFL, MPTL, MPML, MQTFL), as well as the identification of a bony ridge on the medial proximal tibia that consistently served as the attachment site for the MPTL. The quantitative and radiographic measurements, while comparable with current literature, detailed the meniscal insertion of the MPML and defined a patellar insertion of the MPTL and the MPML as a single attachment. The data allow for reproducible landmarks to be established from previously known bony and soft tissue structures. Clinical Relevance: The findings of this study provide the anatomic foundation needed for an improved understanding of the role of medial-sided patellar restraints. This will help to further refine injury patterns and/or soft tissue deficiencies that result in lateral patellar instability, which can then be addressed with an anatomic-based reconstruction or repair technique and potentially lead to improved outcomes.

All-Arthroscopic Superior Shoulder Capsule Reconstruction With Partial Rotator Cuff Repair

Massive irreparable rotator cuff tears are difficult to treat. Although several treatment options exist, none provides superior long-term results. There is no consensus on optimal surgical technique. Superior capsular reconstruction is an operative treatment option aimed at restoring native biomechanics of the glenohumeral joint by providing a restraint to superior subluxation. Partial rotator cuff repair for massive tears has also been shown to improve shoulder kinematics and can be performed in conjunction with superior capsule reconstruction. The authors describe a technique for arthroscopic superior capsular reconstruction with a dermal allograft with concomitant partial rotator cuff repair. [Orthopedics. 2017; 40(4):e735-e738.].

Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis

Background: Persistent clinical instability after anterior cruciate ligament (ACL) reconstruction may be associated with injury to the anterolateral structures and has led to renewed interest in anterolateral extra-articular procedures. The influence of these procedures on knee kinematics is controversial. Purpose/Hypothesis: The purpose was to investigate the biomechanical properties of anatomic anterolateral ligament (ALL) reconstruction and a modified Lemaire procedure (lateral extra-articular tenodesis [LET]) in combination with ACL reconstruction as compared with isolated ACL reconstruction in the setting of deficient anterolateral structures (ALL and Kaplan fibers). It was hypothesized that both techniques would reduce tibial internal rotation when combined with ACL reconstruction in the setting of anterolateral structure deficiency. Study Design: Controlled laboratory study. Methods: A 6 degrees of freedom robotic system was used to assess tibial internal rotation, a simulated pivot-shift test, and anterior tibial translation in 10 paired fresh-frozen cadaveric knees. The following states were tested: intact; sectioned ACL, ALL, and Kaplan fibers; ACL reconstruction; and an anterolateral extra-articular procedure (various configurations of ALL reconstruction and LET). Knees within a pair were randomly assigned to either ALL reconstruction or LET with a graft tension of 20 N and a randomly assigned fixation angle (30° or 70°). ALL reconstruction was then repeated and secured with a graft tension of 40 N. Results: In the setting of deficient anterolateral structures, ACL reconstruction was associated with significantly increased residual laxity for tibial internal rotation (up to 4°) and anterior translation (up to 2 mm) laxity as compared with the intact state. The addition of ALL reconstruction or LET after ACL reconstruction significantly reduced tibial internal rotation in most testing scenarios to values lower than the intact state (ie, overconstraint). Significantly greater reduction in laxity with internal rotation and pivot-shift testing was found with the LET procedure than ALL reconstruction when compared with the intact state. Combined with ACL reconstruction alone, both extra-articular procedures restored anterior tibial translation to values not significantly different from the intact state with most testing scenarios (usually within 1 mm). Conclusion: Residual laxity was identified after isolated ACL reconstruction in the setting of ALL and Kaplan fiber deficiency, and the combination of ACL reconstruction in this setting with either ALL reconstruction or the modified Lemaire LET procedure resulted in significant reductions in tibiofemoral motion at most knee flexion angles, although overconstraint was also identified. ALL reconstruction and LET restored anterior tibial translation to intact values with most testing states. Clinical Relevance: ALL reconstruction and lateral extra-articular tenodesis have been described in combination with intra-articular ACL reconstruction to address rotational laxity. This study demonstrated that both procedures resulted in significant reductions of tibial internal rotation versus the intact state independent of graft tension or fixation angle, although anterior tibial translation was generally restored to intact values. The influence of overconstraint with anterolateral knee reconstruction procedures has not been fully evaluated in the clinical setting and warrants continued evaluation based on the findings of this biomechanical study.

Clinical Outcomes and Failure Rates of Osteochondral Allograft Transplantation in the Knee: A Systematic Review:

Background: Cartilage lesions are a significant cause of morbidity and impaired knee function; however, cartilage repair procedures have failed to reproduce native cartilage to date. Thus, osteochondral allograft (OCA) transplantation represents a 1-step procedure to repair large chondral defects without the donor site morbidity of osteochondral autograft transplantation. Purpose: To perform a systematic review of clinical outcomes and failure rates after OCA transplantation in the knee at a minimum mean 2 years’ follow-up. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA transplantation in the knee joint was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1980 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCAs for the treatment of chondral defects in the knee joint, English language, mean follow-up of 2 years and minimum follow-up of 18 months, minimum study size of 20 patients, and human studies. The methodological quality of each study was assessed using a modified version of the Coleman methodology score. Results: The systematic search identified 19 studies with a total of 1036 patients. The mean 5-year survival rate across the studies included in this review was 86.7% (range, 64.1%-100.0%), while the mean 10-year survival rate was 78.7% (range, 39.0%-93.0%). The mean survival rate was 72.8% at 15 years (range, 55.8%-84.0%) and 67.5% at 20 years (range, 66.0%-69.0%). The weighted mean patient age was 31.5 years (range, 10-82 years), and the weighted mean follow-up was 8.7 years (range, 2-32 years). The following outcome measures showed significant improvement from preoperatively to postoperatively: d’Aubigné-Postel, International Knee Documentation Committee, Knee Society function, and Lysholm scores. The weighted mean reoperation rate was 30.2% (range, 0%-63%). The weighted mean failure rate was 18.2% (range, 0%-31%). Of note, revision cases, patellar lesions, and bipolar lesions demonstrated worse survival rates. Conclusion: Improved patient-reported outcomes can be expected after OCA transplantation, with a survival rate of 78.7% at 10 years. Revision cases, patellar lesions, and bipolar lesions were associated with worse survival rates; therefore, utilization of the most appropriate index cartilage restoration procedure and proper patient selection are key to improving results.

Posterior Tibial Translation Measurements on Magnetic Resonance Imaging Improve Diagnostic Sensitivity for Chronic Posterior Cruciate Ligament Injuries and Graft Tears

Background: Magnetic resonance imaging (MRI) of the knee is a highly sensitive and specific method for diagnosing acute posterior cruciate ligament (PCL) tears, with a reported accuracy of 96% to 100%. In chronic and revision settings, these injuries may be missed on MRI because of the apparent continuity of nonfunctional PCL fibers. Posterior tibial translation (PTT) of the medial compartment has been identified as a potential secondary finding of PCL tear on routine MRI. Purpose/Hypothesis: The purpose of this study was to evaluate the sensitivity of PTT on MRI associated with PCL injuries and compare it with the sensitivity of a radiologist’s MRI interpretation with preoperative posterior knee stress radiographs as the gold standard. Our hypothesis was that the MRI measurement of PTT of the medial compartment would improve diagnostic sensitivity as compared with the diagnosis made by the interpreting radiologist’s evaluation of the continuity of the PCL fibers for chronic and postrecostruction graft injuries. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Cases of patients who underwent a primary or revision PCL reconstruction, without anterior cruciate ligament injury, by a single surgeon between 2010 and 2016 were retrospectively analyzed. Measurements of medial and lateral compartment PTT were performed with the MRI of PCL-injured cases and controls without clinical or MRI evidence of ligamentous injury. The sensitivity of this technique was compared with the preoperative MRI diagnosis determined by review of the musculoskeletal radiologist’s report and confirmed by the gold standard of posterior knee stress radiographs. The sensitivity of medial compartment PTT was determined by receiver operator characteristic (ROC) analysis and compared with the MRI sensitivity for chronic PCL and PCL graft tears. Results: One hundred patients (80 males and 20 females) with a mean age of 31.1 years (range, 15-66 years) met the inclusion criteria: 57 acute primary tears, 32 chronic primary, and 11 PCL graft tears. MRI sensitivity was 100% for acute primary PCL tears, 62.5% for chronic primary PCL tears, and 18.1% for PCL graft tears. There were significant differences in medial compartment PTT on MRI for acute versus chronic injuries (P = .025) and acute versus graft injuries (P = .007). ROC curve analysis indicated that the most accurate cutoff point for the detection of chronic PCL tears was 2.0 mm of medial compartment PTT on MRI, with a sensitivity and specificity of 0.80 and 0.89, respectively. For PCL graft injuries, the ROC curve indicated that the most accurate medial compartment PTT cutoff for the detection of PCL graft failure was 3.6 mm (sensitivity, 0.92; specificity, 0.72). Conclusion: MRI evaluation of the PCL fibers had poor sensitivity for chronic PCL tears and PCL reconstruction graft tears. The sensitivity for diagnosing chronic PCL tears and PCL reconstruction graft failures was improved by measuring posteromedial tibial translation.

Comparable Outcomes After Bucket-Handle Meniscal Repair and Vertical Meniscal Repair Can Be Achieved at a Minimum 2 Years’ Follow-up

Background: Meniscal tears can lead to significant pain and disability, necessitating surgical treatment. Nondisplaced vertical tears are usually smaller in size and can be repaired in most cases; however, bucket-handle tears are usually larger and displaced, and the repair of these tears can be challenging. Purpose/Hypothesis: The purpose was to report the outcomes after inside-out vertical mattress suture meniscal repair of bucket-handle tears and to compare these outcomes with those of patients who underwent repair of nondisplaced vertical meniscal tears with a minimum of 2 years’ follow-up. The hypothesis was that the outcomes of bucket-handle tear repair would be comparable with those of nondisplaced vertical meniscal tear repair. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent inside-out repair of a bucket-handle meniscal tear or a nondisplaced vertical meniscal tear with a minimum 2 years’ follow-up were included in this study. Patients were excluded if they had a diagnosis of a meniscal root tear, underwent a concomitant procedure for a chondral injury, or underwent previous surgical treatment of the same meniscus. Subjective questionnaires were administered preoperatively and postoperatively, including the Lysholm score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short Form–12 (SF-12) physical component summary (PCS) and mental component summary (MCS), the Tegner activity scale, and patient satisfaction. Results: Thirty-two patients underwent repair for vertical meniscal tears (mean, 7 sutures), while 38 patients underwent repair for bucket-handle meniscal tears (mean, 11 sutures), with a mean follow-up of 3.1 years (range, 2-6 years). There were no significant differences in the preoperative outcome scores between the 2 groups. Significant improvements in patient-reported outcome scores from preoperatively to postoperatively were found in both groups. A direct comparison of the bucket-handle tear group to the vertical tear group did not exhibit significantly different SF-12 PCS scores (54.0 vs 51.6, respectively; P = .244), SF-12 MCS scores (55.3 vs 52.5, respectively; P = .165), WOMAC scores (8.1 vs 9.0, respectively; P = .729), Lysholm scores (84.6 vs 80.8, respectively; P = .276), Tegner scores (5.5 vs 5.5, respectively; P = .970), and patient satisfaction scores (7.4 vs 7.7, respectively; P = .570). Additionally, a comparison of acute and chronic bucket-handle tears demonstrated no significant difference in outcome scores. Conclusion: The repair of bucket-handle meniscal tears with multiple vertical mattress sutures using an inside-out technique yielded improved results and low failure rates, comparable with outcomes after repair of nondisplaced vertical meniscal tears. The findings of this study support repairing bucket-handle meniscal tears with multiple vertical mattress sutures when possible.