Anterior Cruciate Ligament Reconstruction With a Partial-Thickness Quadriceps Tendon Graft Secured With a Continuous-Loop Fixation Device

Anterior cruciate ligament reconstruction using quadriceps tendon (QT) autograft has recently gained popularity because newer techniques allow harvest of a robust graft with little soft-tissue dissection or donor-site morbidity. The QT graft can provide a safe, reproducible, and versatile option for primary and revision anterior cruciate ligament reconstruction with equivalent outcomes and failure rates to those of bone–patellar tendon–bone and hamstring tendon grafts. Therefore, continued improvement in surgical technique may help to further improve patient outcomes. This study introduces a modification of current QT techniques using a partial-thickness graft with continuous-loop EndoButton fixation (Smith & Nephew, Andover, MA)

Reefing of the Posteromedial Capsule in Anteromedial Rotatory Instability

The posterior oblique ligament (POL) is the main component of the posteromedial corner (PMC) of the knee and plays a crucial role in acting as a secondary restraint against translation, rotation, and valgus forces. Injuries to the PMC often occur in association with acute or chronic deficiency of the anterior cruciate ligament and may result in anteromedial rotatory instability. A surgical technique for treatment of acute and chronic injuries of the posteromedial structures was first established by Hughston in 1973. This procedure involves an advancement and reefing of the POL and adherent posterior capsule to the stout tissue of the intact medial collateral ligament, potentially using suture anchors if the POL tissue is detached from bone. Additionally, in cases of residual laxity, the semimembranosus tendon may be advanced anteriorly to improve dynamic stabilization. This procedure appears to be useful in cases of moderate posteromedial insufficiency and avoids retrieval of a medial tendon graft from the region of the medially stabilizing hamstrings or from the healthy contralateral side

Intercondylar Notch Measurement During Arthroscopy and on Preoperative Magnetic Resonance Imaging

Small intercondylar notch size is associated with increased risk of anterior cruciate ligament (ACL) injuries and increased difficulty of ACL reconstruction. When encountering a small notch during surgery, some surgeons may resort to a notchplasty, which has been shown to have associated morbidity. The ability to predict notch size on preoperative imaging could allow the orthopaedic surgeon to anticipate surgical difficulty such as an oversized graft and graft impingement and possibly avoid a notchplasty. Many methods have been proposed for measuring intercondylar notch size, but they do not correlate with intraoperative measurements or they utilize computed tomography scanning, which is not readily obtained before ACL reconstruction. The purpose of this study was to develop a method of notch measurement on preoperative radiography and magnetic resonance imaging that match intraoperative arthroscopic measurements. The method presented here can be used to identify narrow intercondylar notches, prepare for potential intraoperative challenges, and formulate surgical plans such as for graft choice in individualized ACL reconstruction

Anatomic Flat Double-Bundle Medial Collateral Ligament Reconstruction

Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL

Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction

Purpose: To characterize contemporary pain management strategies after anterior cruciate ligament reconstruction (ACLR) within the US and international orthopaedic community. Methods: This was a cross-sectional survey-based study disseminated to a consortium of expert orthopaedic surgeons in the management of anterior cruciate ligament injuries. The survey was a 27-question, multiple choice–style questionnaire with question topics ranging from demographic characteristics and practice characteristics to surgeon-specific pain management strategies in the postoperative period after ACLR. Specific topics of interest included the use of preoperative opioid education and/or counseling sessions, implementation of standardized pain management regimens, use of pain tracking systems, and use of any adjunct non-narcotic analgesic modalities. Results: A total of 34 completed surveys were collected, representing a 73.9% response rate. Over 85% of respondents reported prescribing opioids as a standardized postoperative regimen after ACLR. Surgeons reported prescribing 5- to 10-mg doses, with the tablet count ranging anywhere from fewer than 10 tablets to more than 20 tablets, often instructing their patients to stop opioid use 2 to 4 days postoperatively. Prescribed dosages remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents reported using standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Conclusions: Over 85% of respondents prescribe opioids as a standardized postoperative regimen after ACLR, with only 15% providing non-narcotic pain regimens. However, prescribed dosages have remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents use standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. Clinical Relevance: The ongoing opioid epidemic has created an urgent need to identify the most effective pain management strategies after orthopaedic procedures, especially ACLR. This study provides important information about current pain management practices for patients who have undergone ACLR