Arthroscopic Repair of Proximal Posterior Cruciate Ligament Injuries in Pediatric Patients.

A renewed interest in arthroscopic knee ligament repair is emerging as a result of diagnostic and technical improvements. In pediatric patients with posterior cruciate ligament (PCL) injury, surgical reconstruction is rarely considered as an option because of the risk of iatrogenic physeal injury. In this Technical Note, we describe an arthroscopic surgical repair technique of PCL proximal avulsions in pediatric patients. The main reasons to consider arthroscopic PCL repair in this population include minimal surgical morbidity, preservation of the complex biomechanical properties of the native ligament, the small diameter of the bone tunnels, the physeal respecting nature of the procedure, the absence of graft harvesting, and the absence of fixation devices. The indications for this technique are limited to patients with an acute proximal PCL avulsion. Investigation performed from at Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France

Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament–injured knees from the SANTI study group database: a risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs

Background: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of ACL reconstruction has been shown to improve knee biomechanics. Hypothesis/Purpose: Primary objectives of this study were to evaluate the incidence and risk factors for ramp lesions in a large series of patients undergoing ACL reconstruction, Secondary objectives were to determine the re-operation rate for failure of ramp repair, defined by subsequent re-operations for partial medial meniscectomy Study Design: Case series Methods: All patients underwent trans-notch posteromedial compartment evaluation of the knee during ACL reconstruction. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of two years was undertaken in order to determine the secondary partial meniscectomy rate for failed ramp repair. Results: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions in 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male gender, patients aged under 30 years, revision ACLR, chronic injuries, pre-operative side-to-side laxity >6 mm and the presence of concomitant lateral meniscus tears. The secondary meniscectomy rate was 10.8% at a mean follow up of 45.6 months (24.2-66.2). Patients who underwent ACLR + ALLR had a greater than 2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95%CI, 0.226-0.864; P = .021). Conclusion: There is a high incidence of ramp lesions in patients undergoing ACLR. The identification of important risk factors for ramp lesions in this study in an individual patient should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates

Combined Anatomic Anterior Cruciate and Anterolateral Ligament Reconstruction With Quadriceps Tendon Autograft and Gracilis Allograft Through a Single Femoral Tunnel.

Despite technical advances in anterior cruciate ligament (ACL) reconstruction surgery, there remains a need to improve postoperative outcomes with respect to graft failure rates. Recently, it has been shown that combined ACL-anterolateral ligament (ALL) reconstruction (using a graft composed of a tripled semitendinosus and single-strand gracilis tendon) is associated with a significant reduction in graft rupture rates compared with isolated ACL reconstruction. It is recognized that the hamstring tendons are not always available (revision scenario) or are not always the primary ACL graft choice. Some surgeons prefer to use quadriceps tendon ACL grafts because of the suggestion that these grafts may be associated with equal or better functional scores. However, if surgeons wish to try to reduce the risk of graft failure by performing an ALL reconstruction, either a combined reconstruction or the use of an independent ALL graft, with a separate femoral socket, could be considered. The disadvantage of an independently performed extra-articular procedure is the risk of femoral socket collision with the femoral ACL tunnel. This Technical Note therefore describes the use of a combined ACL-ALL reconstruction using quadriceps tendon autograft (ACL graft), gracilis allograft (ALL graft), and a single femoral tunnel

Risk factors for lateral meniscus posterior root tears in the anterior cruciate ligament injured knee: an epidemiological analysis of 3956 patients from the SANTI database

Background: Lateral meniscal posterior root tears (LMPRT) result in loss of hoop forces and significant increases in tibiofemoral contact pressures. Pre-operative imaging lacks reliability and therefore holding an appropriate index of suspicion, based on the epidemiology and risk factors for LMPRT, may reduce the rate of missed diagnoses. Hypothesis/Purpose: The primary objectives of this study were to evaluate the incidence and risk factors for lateral meniscus root lesions in a large series of patients undergoing anterior cruciate ligament (ACL) reconstruction. Study Design: Case series. Methods: All patients who underwent primary or revision ACL reconstruction, between January 2011 to April 2018 were considered for study eligibility. From this overall population, all patients who underwent repair of a lateral meniscus posterior root tear (LMPRT) were identified. The epidemiology of LMPRT was defined by the incidence within the study population, stratified by key demographic parameters. Potentially important risk factors for the presence of LMPRT were evaluated in multivariate logistic regression analysis. Results: 3956 patients undergoing ACL reconstruction were included in the study. A LMPRT was identified and repaired in 262 patients (6.6%). Multivariate analyses demonstrated that significant risk factors for LMPRT included a contact sports injury mechanism (7.8% incidence with contact sports mechanism vs 4.5% with non-contact mechanism 4.5%; OR = 1.69, IC95% 1.266 - 2.285; P <.001) and the presence of a medial meniscal tear (7.9% incidence with medial meniscal tear vs 5.8% in those without; OR = 1.532, IC95% 1.185 - 1.979; P <.001). Although the incidence of LMPRT in male patients (7.3%) was higher than females (4.8%) this was not significant in multivariate analysis (P = 0.270). Patient age, revision ACL reconstruction and a pre-operative side to side laxity difference of ≥ 6mm were not found to be significant risk factors for LMPRT. Conclusion: The incidence of LMPRT was 6.6% in a large series of patients undergoing ACL reconstruction. Participation in contact sports and the presence of a concomitant medial meniscal tear were demonstrated to be important independent risk factors. Their presence should raise the index of suspicion of this injury pattern

Elimination of the Pivot-Shift Sign After Repair of an Occult Anterolateral Ligament Injury in an ACL-Deficient Knee

Several biomechanical studies have demonstrated the importance of the anterolateral ligament (ALL) in rotational instability of the knee.1,10,12,14 Despite this, the precise role of the ALL in eliminating the pivot shift remains controversial.9,11,13 This disparity exists secondary to the nature of cadaveric research and the subsequent creation of artificial injury patterns that are not a true representation of in vivo characteristics. This case report provides clinical evidence of the important role that the anterolateral structure plays in anterolateral rotational instability, as demonstrated by the pivot-shift sign

Arthroscopic Dissection of the Distal Semimembranosus Tendon: An Anatomical Perspective on Posteromedial Instability and Ramp Lesions.

Ramp lesions are increasingly recognized as a hallmark of posteromedial knee instability. Although the precise mechanisms through which these lesions occur is not completely understood, the distal semimembranosus complex has been implicated in their pathogenesis due to its attachment to the posterior horn of the medial meniscus (PHMM). Arthroscopic dissection of the distal semimembranosus tendon, and the application of traction to it, results in posterior translation of the PHMM and stretching of the meniscocapsular region. This demonstrates a mechanism through which ramp lesions can occur. Furthermore, the subsequent open dissection highlights the complex anatomical relationships of the distal semimembranosus tendon complex, particularly its tensioning effect on the posterior oblique ligament. The clinical relevance of this is that when a ramp lesion occurs, it is likely to be part of a spectrum of posteromedial injury and it should be considered a hallmark of posteromedial instability rather than an isolated meniscocapsular injury

Presoaking ACL Grafts in Vancomycin Decreases the Frequency of Postoperative Septic Arthritis : A Cohort Study of 29,659 Patients, Systematic Review, and Meta-analysis From the SANTI Study Group

Presoaking anterior cruciate ligament (ACL) grafts in vancomycin has been reported to reduce the occurrence of septic arthritis (SA). However, strong recommendations for its universal use have been precluded by concerns regarding the fragility of previous meta-analyses. The primary objective was to investigate whether presoaking ACL grafts in vancomycin was associated with a reduction in the rate of SA in a large series of patients. The secondary objective was to perform an updated systematic review and meta-analysis to determine the efficacy of vancomycin in reducing the rate of SA. Cohort study and systematic review; Level of evidence, 3. A retrospective analysis of patients who underwent primary ACL reconstruction (ACLR) at our institution was undertaken. Rates of postoperative SA were determined and analyzed according to whether patients had received grafts presoaked in vancomycin. A systematic review of the literature and meta-analysis was performed. Odds ratios (ORs) for the risk of SA were calculated according to the inverse variance approach. Results were presented using forest plots, funnel plots, and the fragility index. A total of 5300 patients underwent primary ACLR during the study period. The rate of SA was 0.34% (11/3228) in the control group and 0.05% (1/2072) in the presoaked group. There was a 5-fold greater risk of SA in patients who did not receive grafts presoaked in vancomycin (OR, 5.13 [95% CI, 1.16-48.30]; P =.04). Overall, 11 studies were included in the systematic review (29,659 ACLR procedures). The meta-analysis demonstrated a significantly greater risk of SA in those patients who did not receive grafts presoaked in vancomycin (OR, 14.39 [95% CI, 5.90-35.10]; fragility index = 23). This finding held true for the subpopulation receiving hamstring tendon grafts (fragility index = 16), but only a trend was demonstrated for bone-patellar tendon-bone grafts. The meta-analysis demonstrated that presoaking ACL grafts in vancomycin was associated with significant reductions in the rates of SA when all graft types were analyzed together. This finding held true specifically for hamstring tendon autografts. The fragility index of these findings allows for a strong recommendation for the universal use of vancomycin presoaking. However, it should be noted that only a trend toward reduced SA rates was demonstrated with presoaking bone-patellar tendon-bone autografts in vancomycin

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Reconstruction.

There has been a renewed interest in anterior cruciate ligament (ACL) repairs over the last decade with some early promising results in the right patient population. Additionally, the anterolateral ligament has been extensively studied and has recently been shown to have a protective effect on standard ACL reconstructions in a clinical trial. Given its protective effect on ACL reconstructions, we believe this phenomenon is also relevant to ACL repairs and can decrease rerupture rates. In this publication, we demonstrate a surgical technique for ACL repair using an internal brace combined with an anterolateral ligament reconstruction using a gracilis autograft

Segond fractures are not a risk factor for anterior cruciate ligament reconstruction failure: Letter to the Editor

Germanium nanowires (NWs) have attractive properties for a variety of applications, including micro- and optoelectronics, memory devices, solar energy conversion, and energy storage, among others. For applications that involve exposure to air, the poor chemical stability and electronic surface passivation of native oxides have remained a long-standing concern. Termination by sulfur-rich surface layers has emerged as a promising strategy for passivation of planar Ge surfaces. Here we discuss experiments on solid-state sulfurization of Ge nanowires in sulfur vapor at near-ambient pressures and at different temperatures. Combined transmission electron microscopy imaging and chemical mapping establishes that Ge NWs remain intact during vapor-phase reaction with S at elevated temperatures, and show the formation of sulfur-rich shells with T-dependent morphology and thickness on the Ge NW surface. Photoluminescence of ensembles of such core-shell nanowires is dominated by strong emission at approximate to 1.85 eV, consistent with luminescence of GeS. Cathodoluminescence spectroscopy on individual NWs establishes that this luminescence originates in thin GeS shells formed by sulfurization of the NWs. Our work establishes direct sulfurization as a viable approach for forming stable, wide-bandgap surface terminations on Ge NWs

Anterolateral Ligament Reconstruction Does Not Delay Functional Recovery, Rehabilitation, and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI (Scientific ACL Network International) Study Group.

PurposeTo determine whether the addition of an anterolateral ligament reconstruction (ALLR) resulted in delayed functional recovery (based on the Knee Santy Athletic Return to Sport [K-STARTS] score) at 6 months after anterior cruciate ligament reconstruction (ACLR).MethodsA retrospective analysis of prospectively collected data from consecutive patients who underwent an ACLR between September 2017 and December 2020 was conducted. Patients who received an isolated hamstring autograft (isolated ACLR group) were propensity matched in a 1:1 ratio to patients who received a hamstring autograft ACLR combined with an ALLR (ACLR-ALLR group). Outcome measures included the Tegner Activity Scale and the K-STARTS test-a validated composite return-to-sports test (including the Anterior Cruciate Ligament-Return to Sport After Injury scale, Qualitative Assessment of Single-Leg Landing tool, limb symmetry index, and ability to change direction using the Modified Illinois Change of Direction Test).ResultsThe study included 111 matched pairs. At 6 months postoperatively, there were no significant differences between groups in the overall K-STARTS score (65.4 for isolated ACLR vs 61.2 for ACLR-ALLR, P = .087) or the Tegner Activity Scale score (3.7 for isolated ACLR vs 3.8 for ACLR-ALLR, P = .45). In addition, an evaluation of the subscales of the K-STARTS score revealed no disadvantage across the domains of neuromuscular control, limb symmetry index, agility, or psychological readiness to return to sport when an ALLR was performed.ConclusionsThe addition of ALLR at the time of ACLR does not delay functional recovery. Specifically, at 6 months postoperatively, there was no disadvantage in patients undergoing ALLR-ACLR, when compared with those undergoing isolated ACLR, with respect to neuromuscular control, limb symmetry indices (hop tests), agility, or psychological readiness to return to sport.Level of evidenceLevel III, retrospective comparative study