Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction

© 2021, The Author(s). Purpose: To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts. Methods: This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010–2014 and 2015–2020. All collected variables were compared between three pre-defined age groups (\u3c 20 years, 20–30 years, \u3e 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R. Results: This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (\u3c 1%) patients, respectively. Patients age \u3e 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age \u3c 20 years (2.2 years, p \u3c 0.001) and age 20–30 years (5.5 years, p \u3c 0.05). Quadriceps tendon autograft was used significantly more often in 2015–2020 compared to 2010–2014 (49% vs. 18%, p \u3c 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time (p \u3c 0.05). Intact cartilage (41%, p \u3c 0.05), concurrent medial meniscal repairs (39%, p \u3c 0.05), and LET (35%, non-significant) were most frequently observed in patients aged \u3c 20 years. Conclusion: Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R. Level of evidence: Level III

Oral Contraceptive Pills Are Not a Risk Factor for Deep Vein Thrombosis or Pulmonary Embolism After Arthroscopic Shoulder Surgery

Background: Worldwide, more than 100 million women between the ages of 15 and 49 years take oral contraceptive pills (OCPs). OCP use increases the risk of venous thromboembolism (VTE) through its primary drug, ethinylestradiol, which slows liver metabolism, promotes tissue retention, and ultimately favors fibrinolysis inhibition and thrombosis. Purpose: To evaluate the effects of OCP use on VTE after arthroscopic shoulder surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A large national payer database (PearlDiver) was queried for patients undergoing arthroscopic shoulder surgery. The incidence of VTE was evaluated in female patients taking OCPs and those not taking OCPs. A matched group was subsequently created to evaluate the incidence of VTE in similar patients with and without OCP use. Results: A total of 57,727 patients underwent arthroscopic shoulder surgery from 2007 to 2016, and 26,365 patients (45.7%) were female. At the time of surgery, 924 female patients (3.5%) were taking OCPs. The incidence of vascular thrombosis was 0.57% (n = 328) after arthroscopic shoulder surgery, and there was no significant difference in the rate of vascular thrombosis in male or female patients (0.57% vs 0.57%, respectively; P \u3e .99). The incidence of VTE in female patients taking and not taking OCPs was 0.22% and 0.57%, respectively (P = .2). In a matched-group analysis, no significant difference existed in VTE incidence between patients with versus without OCP use (0.22% vs 0.56%, respectively; P = .2). On multivariate analysis, hypertension (odds ratio [OR], 2.00; P \u3c .001) and obesity (OR, 1.43; P = .002) were risk factors for VTE. Conclusion: OCP use at the time of arthroscopic shoulder surgery is not associated with an increased risk of VTE. Obesity and hypertension are associated with a greater risk for thrombolic events, although the risk remains very low. Our findings suggest that patients taking OCPs should be managed according to the surgeon’s standard prophylaxis protocol for arthroscopic shoulder surgery

Does the lateral intercondylar ridge disappear in ACL deficient patients?

The aim of this study was to determine whether there is a difference in the presence of the lateral intercondylar ridge and the lateral bifurcate ridge between patients with sub-acute and chronic ACL injuries. We hypothesized that the ridges would be present less often with chronic ACL deficiency. Twenty-five patients with a chronic ACL injury were matched for age and gender to 25 patients with a sub-acute ACL injury. The lateral intercondylar ridge and lateral bifurcate ridge were scored as either present, absent, or indeterminate due to insufficient visualization by three blinded observers. The kappa for the three observers was .61 for the lateral intercondylar ridge and .58 for the lateral bifurcate ridge. The lateral intercondylar ridge was present in 88% of the sub-acute patients and 88% of the chronic patients. The lateral bifurcate ridge was present in 48% of the sub-acute and 48% of the chronic patients. This matched-pairs case–control study was unable to show a difference in the presence of the femoral bony ridges between patients with acute and chronic ACL injuries. The authors would suggest looking for the ridges as a landmark of the native ACL insertion site during ACL reconstruction in both acute and chronic ACL injuries

ACL graft re-rupture after double-bundle reconstruction: factors that influence the intra-articular pattern of injury

To determine the most common rupture patterns of previously reconstructed DB-ACL cases, seen at the time of revision surgery, and to determine the influence of age, gender, time between the initial ACL reconstruction and re-injury, tunnel angle and etiology of failure. Forty patients who presented for revision surgery after previous double-bundle ACL reconstruction were enrolled. Three orthopedic surgeons independently reviewed the arthroscopic videos and determined the rupture pattern of both the anteromedial and posterolateral grafts. The graft rupture pattern was then correlated with the previously mentioned factors. The most common injury pattern seen at the time of revision ACL surgery was mid-substance AM and PL bundle rupture. Factors that influenced the rupture pattern (proximal vs. mid-substance and distal rupture vs. elongated, but in continuity) were months between ACL reconstruction and re-injury (P = 0.002), the etiology of failure (traumatic vs. atraumatic) (P = 0.025) and the measured graft tunnel angle (P = 0.048). The most common pattern of graft re-rupture was mid-substance AM and mid-substance PL. As the length of time from the initial DB-ACL reconstruction to revision surgery increased, the pattern of injury more closely resembled that of the native ACL. Evaluation of patients who have undergone double-bundle ACL reconstruction, with a particular focus on graft maturity, mechanism of injury and femoral tunnel angles, and graft rupture pattern assists in preoperative planning for revision surger

Factors that influence the intra-articular rupture pattern of the ACL graft following single-bundle reconstruction

The number of revision anterior cruciate ligament (ACL) surgeries performed annually continues to rise. The purpose of this study was to determine the most common rupture pattern in ACL revision cases after previous single-bundle reconstruction. The second aim was to determine the relationship between rupture pattern and patient-specific factors (age, gender, time between the initial ACL reconstruction and re-injury, and etiology/mechanism of failure) and surgical factors (graft type, tunnel angle). This was a cohort study of 60 patients that underwent revision ACL surgery after previous single-bundle ACL reconstruction. Three sports medicine-trained orthopedic surgeons reviewed the arthroscopic videos and determined the rupture pattern of the grafts. The rupture pattern was then correlated to the above-mentioned factors. The inter-observer agreement had a kappa of 0.7. The most common rupture pattern after previous single-bundle ACL reconstruction is elongation of the graft. This is different from the native ACL, which displays more proximal ruptures. With the use of autograft tissue and after a longer period of time, the rupture pattern in revision surgery is more similar to that of the native ACL. The most common rupture pattern after previous single-bundle reconstruction was elongation of the graft. Factors that influenced the rupture pattern were months between ACL reconstruction and re-injury and graft type. Cohort study, Level I

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

© 2020, The Author(s). Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results: In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of evidence: V

Symptomatic intratendinous ganglion cyst of the patellar tendon

Ganglion cysts have been previously described throughout the body, most commonly about the wrist, hand, knee, ankle, and feet. When symptomatic, they may interfere with joint mechanics, resulting in snapping, catching, and locking. Intratendinous ganglion cysts lack a synovial epithelial lining and are thought to develop from the mucoid degeneration of connective tissue caused by chronic irritation, chronic repetitive injury, and chronic ischemia. On magnetic resonance imaging, ganglion cysts originating from tendons, ligaments, tendon sheaths, menisci, or joint capsules appear as well-defined lobulated masses that follow simple or complex fluid signal intensity on all pulse sequences, with enhancing walls and internal septations on post-contrast images. There may be appreciable degeneration and partial tearing of the structure of origin, particularly if associated with tendons. On ultrasonography, they present as hypoechoic masses, with internal septations and lobulations of varying sizes, without significant vascularity on power or color Doppler sampling. A thin fluid neck extending from the structure of origin (tail sign), when present, is a reliable sign of a ganglion cyst. This article describes a sonographically guided technique to treat symptomatic ganglion cysts within the patellar tendon. Complete evacuation of the ganglion cyst, with disappearance of the tail sign, is considered the determining factor for a successful procedure. A similar technique can be used for the treatment of other symptomatic intratendinous ganglion cysts elsewhere in the body. To our knowledge, symptomatic intratendinous ganglion cysts within the patellar tendon and their treatment have not been previously reported

Magnetic resonance imaging double popliteus tendon sign: a case report

The double popliteus tendon sign is seen on sagittal magnetic resonance imaging (MRI) of the knee as a low-signal-intensity band parallel to the popliteus tendon at the level of the popliteus hiatus. It is the result of a displaced complex flap tear of the lateral meniscus. This type of displaced meniscal tear can be easily missed on MRI, unless the clinician is aware of its existence and significance and is familiar with its MRI appearance

Sonographically guided therapeutic injection for primary medial (tibial) collateral bursitis

The purpose of this article is to describe a sonographically guided technique to perform therapeutic injection into the medial collateral ligament bursa. Scans are performed using a high-frequency linear transducer with the scan plane corresponding to the anatomic coronal plane. The transducer is positioned along the medial aspect of the knee; a 25-gauge needle is placed along the inferior border of the bursa; and a standardized therapeutic mixture (anesthetic and long-active corticosteroid) is injected. Distention of the bursa is the determining factor for a successful injection. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes

Magnetic Resonance Imaging Double Popliteus Tendon Sign: A Case Report

The double popliteus tendon sign is seen on sagittal magnetic resonance imaging (MRI) of the knee as a low-signal-intensity band parallel to the popliteus tendon at the level of the popliteus hiatus. It is the result of a displaced complex flap tear of the lateral meniscus. This type of displaced meniscal tear can be easily missed on MRI, unless the clinician is aware of its existence and significance and is familiar with its MRI appearance