A randomized controlled trial of PEEK versus titanium interference screws for anterior cruciate ligament reconstruction with 2-year follow-up

Purpose: To compare the clinical performance of ACL reconstruction with PEEK and titanium interference screws at 2 years and to evaluate a novel method of measuring tunnel volume. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 133 patients underwent arthroscopic ACL reconstruction with 4-strand hamstring autografts and were randomized to have titanium or PEEK interference screws for femoral and tibial tunnel fixation. At 2 years, subjective Lysholm and International Knee Documentation Committee scores were assessed and clinical examination performed. At 12 months, MRI was performed to assess graft incorporation and cyst formation, and a novel technique was employed to measure tunnel volumes. Results: There were no significant differences in graft rerupture rate, contralateral ACL rupture rate, subjective outcomes, or objective outcomes. In the titanium and PEEK groups, MRI demonstrated high overall rates of graft integration (96%-100% and 90%-93%, respectively) and ligamentization (89% and 84%) and low rates of synovitis (22% and 10%) and cyst formation (0%-18% and 13%-15%). There was a higher proportion of patients with incomplete graft integration within the femoral tunnel in the PEEK group as compared with the titanium group (10% vs 0%, P = .03); however, the authors suggest that metal artifact precluded proper assessment of the graft in the titanium group by MRI. Tunnel volumes also appeared to be equivalent in the 2 groups and were measured with a novel technique that was highly reproducible in the PEEK group secondary to the absence of flare. Conclusion: Two-year clinical analysis of PEEK interference screws for femoral and tibial fixation of ACL reconstructions showed equivalent clinical performance to titanium interference screws. Given the excellent mechanical characteristics, biological compatibility, and absence of metal artifact on MRI, PEEK has become our material of choice for interference screw fixation in ACL reconstruction

Midterm outcomes of arthroscopic reduction and internal fixation of anterior cruciate ligament tibial eminence avulsion fractures with K-Wire fixation

Purpose: To determine the clinical and radiological outcomes of patients who underwent arthroscopic reduction and internal fixation of a tibial eminence avulsion fracture with Kirshner wires (K-wires) at a mean of 8 years following surgery. Methods: This was a retrospective study with prospectively collected data. Inclusion criteria consisted of patients who underwent arthroscopic reduction and internal fixation of tibial eminence fracture with K-wires between 1989 and 2015 at a minimum of 18 months follow-up. Assessment included the International Knee Documentation Committee Ligament Evaluation, Lysholm Knee Score, and clinical outcomes. Magnetic resonance imaging (MRI) was performed to evaluate the anterior cruciate ligament (ACL) and evidence of osteoarthritis. Results: A total of 48 participants met the inclusion criteria, and 32 were reviewed at a mean of 8 years (range, 18-260 months) after surgery. The mean age at the time of surgery was 24.5 years (10-55 years). Subsequent ACL injury occurred in 5 participants (10.4%) on the index knee and in 1 participant also on the contralateral knee; 86% had a normal examination, and no patients had \u3e5-mm side-to-side difference on instrumented testing. The mean International Knee Documentation Committee subjective score at 8 years was 86 (range, 40-100). On MRI scan assessment for osteoarthritic changes at final follow-up, 82% of participants had no evidence of chondral wear on the medial compartment and 73% had no changes in the lateral compartment according to Magnetic Resonance Image Osteoarthritis Knee Score classification. On MRI scan qualitative assessment of ACL and tibial eminence, 7 participants (32%) were found to have high signal at the fracture site. The mean medial tibial eminence height was 9.2 mm (range, 6.3 mm to 1.31 cm) and the lateral tibial eminence height was an average of 6.7 mm (range, 0.38-0.97 mm). Significant kneeling pain was reported by 8 participants (25%). Conclusions: This study indicates that internal fixation with K-wires is an acceptable approach to reduce tibial eminence avulsion fractures, providing excellent clinical and radiological outcomes at a minimum of 18 months of follow-up. Level of Evidence: Level IV, therapeutic case series

Allograft donor characteristics significantly influence graft rupture after anterior cruciate ligament reconstruction in a young active population

Background: Graft selection in anterior cruciate ligament (ACL) surgery can be difficult in a young active population given their high rates of reinjury. Allografts allow for control over graft size and reduce morbidity of autograft harvest. There are mixed results about the use of allograft in the literature; however, the influence of the properties of the allograft on outcomes has not been considered. Hypothesis: ACL reconstruction with allografts from older donors will have a higher rate of graft rupture when compared with allograft from young donors. Study Design: Cohort study; Level of evidence, 3. Methods: Patients (N = 211) aged 13 to 25 years underwent primary ACL reconstruction with fresh-frozen nonirradiated allograft. Four graft types were used: patellar tendon, Achilles tendon, tibialis anterior, and tibialis posterior. Details were collected on allograft donor age and sex. At a minimum of 24 months, patients were evaluated for any further injuries and subjective analysis by International Knee Documentation Committee (IKDC) questionnaire. Results: ACL graft rupture occurred in 23.5%. When grafts were separated into single strand (patellar and Achilles tendon) and multistrand (tibialis anterior and posterior), there was a significantly higher rate of reinjury in the single-strand grafts (29.9% vs 11%; P = .014). Grafts from female donors aged ≥50 years had significantly higher rates of ACL graft rupture (52.6%; P = .003) with increased odds by 6.7 times when compared with grafts from male donors aged donor. Conclusion: The age and sex of the allograft donor and the morphology of the graft significantly influenced the rate of ACL graft rupture in young active patients. Tendons from female donors aged ≥50 years should be avoided given the higher rerupture rates as compared with male donors of any age and younger females

Utility of preoperative blood screening before hip and knee arthroplasty

Background: It is engrained in medical training that routine blood screening prior to arthroplasty is necessary for optimal patient care. There is little evidence to support their utility and the aggregate cost to the health system. The purpose of this study was to evaluate preoperative blood screening by identifying the frequency of an abnormal result and to examine the influence of age, gender and body mass index on the frequency of abnormal blood pathology. Methods: This is a retrospective review of 1000 patients from a single centre who underwent elective primary hip or knee arthroplasty from 2015 to 2017. Abnormal blood results were identified and clinically relevant intervals were created for routine markers. Results: A total of 939 patients had available pathology results with 84% identified as having an abnormal result and 47% having a clinically important range. Abnormal liver function tests and ferritin were most common. With increasing age, there was a significant increase in rates of abnormal clinically important range, renal dysfunction, abnormal haemoglobin and erythrocyte sedimentation rate. Males and patients with body mass index \u3e40 had an increased rate of abnormal results, particularly liver function tests. Conclusion: The ordering of preoperative investigations prior to lower limb arthroplasty is recommended by the National Institute for Health and Care Excellence guidelines, alleviating concern of post-operative complications and covering medicolegal issues. Our study determined a high frequency of abnormal results, justifying routine blood screening is recommended prior to surgery, particularly for the elderly, males and obese patients

Stable lateral meniscal posterior root tears left in situ at time of anterior cruciate ligament reconstruction are of minimal long-term clinical detriment

Purpose: The purpose of this study was to compare long-term patient-reported outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction with untreated stable lateral meniscal posterior root (LMPR) tears to those with an intact meniscus. Methods: Four hundred ninety-two subjects were followed for a minimum of 15-years posteACL reconstruction and evaluated by an International Knee Documentation Committee questionnaire. The integrity of the meniscus was classified at surgery. Patients were grouped as either untreated injury to LMPR “with stable tear” (WST) group (n ¼ 52) or intact lateral meniscus “no tear” (NT) group (n ¼ 440). WST group included tears where those with a root avulsion within 9 mm of insertion and parrot beak tears with the integrity of the root attachment maintained. Outcomes were compared between groups. Results: ACL graft rupture occurred in 10% in the WST group and in 11% in the NT group (P = .78). For participants with an intact graft (n = 440), the mean International Knee Documentation Committee scores were 82, in the WST group, and 87, in the NT group (P = .03), with a small effect size of .32. The WST group had a worse mean pain severity score (P = .04) and higher frequency of pain (P = .03) than the NT group, but the effect size was small (P \u3c 0.3). There was no difference in the overall knee function (P = .209) or International Knee Documentation Committee activity level (P = .882). Conclusion: There was no adverse clinical outcome to leaving a stable LMPR tear in situ at the time of ACL reconstruction. LMPR tears left in situ were of minimal clinically significant long-term detriment, with outcomes similar to having an intact meniscus. There is an innate desire to fix the broken, but posterior meniscal root avulsions and stable parrot beak tears within 9 mm of insertion may not require intervention. At 15 years postinjury, most patients with a stable tear left in situ continue to enjoy an active lifestyle with a pain-free knee. Level of Evidence: Level III, retrospective comparative study