Project description:The popliteus tendon plays a critical role in restraining the tibia against external rotation. It is often injured in the setting of posterolateral corner injuries. However, it is rarely injured in isolation from other structures of the posterolateral corner. This Technical Note describes an open anatomic reconstruction of the popliteus tendon. Although several techniques exist, this technique has been biomechanically validated and shown to have good outcomes. An early rehabilitation protocol focused on protected range of motion, edema control, quadriceps strengthening, and pain control is essential for maximizing patient outcomes. Technique Video Video 1 A standard lateral hockey-stick incision is made over the inferior border of the iliotibial band and carried distally bisecting Gerdy’s tubercle and the anterior border of the fibular head. A 6-cm long CPN neurolysis is performed with extreme care to minimize the risk of footdrop postoperatively due to swelling. Attention is then turned to the tibia for creation of the tibial tunnel. A Chandler retractor is then placed in the developed interval along the posterior tibia to protect the neurovascular structures, and an ACUFEX guide is used to drill a guide wire from anterior to posterior. The surgeon then splits the iliotibial band and enters the lateral capsule to identify the injured popliteus tendon. A pin is placed through the center of the femoral attachment of the popliteus, and the guide pin is angled to exit the thigh anteromedially. This is then over-reamed using a 6-mm reamer and is followed with a 7-mm tap. The semitendinosus tendon is then obtained using an open hamstring harvester tool. The graft is prepared by an assistant on the back table by whipstitching each end with #2 nonabsorbable sutures The popliteus tendon graft is then shuttled into the femoral tunnel and held in place with a 7 × 20-mm bioabsorbable screw. The graft is then fixed within the tibia using a 7 × 20-mm bioabsorbable screw with the knee at 60° of flexion and the foot in neutral rotation and traction on the graft The dial test and posterolateral corner test now return to normal. (CPN, common peroneal nerve.)

Project description:PurposeTo assess the clinical outcomes comparing rectangular bone-tendon-bone (BTB) grafts and double-bundle hamstring tendon (HM) grafts used for anatomic anterior cruciate ligament (ACL) reconstruction in young female athletes.MethodsFrom January 2014 to November 2017, young female athletes 20 years or younger who underwent primary ACL reconstructions by a single surgeon were identified. Patients with concomitant injuries, not being a regular sports participant, the existence of contralateral ACL reconstruction, and who did not have a minimum of 1-year follow-up were excluded. We searched the rate and time for return-to-play, clinical outcomes including chronological instrumental side-to-side tibial translation difference, and muscle strength. Second ACL injury rates between the 2 groups during follow-up period were evaluated.ResultsTwenty-seven BTB ACL reconstructions and 29 HM ACL reconstructions were performed. The mean follow-up periods were 35.2 months in the BTB group and 33.8 months in the HM group. The BTB group showed better knee stability in mean side-to-side translational difference via arthrometric testing of 0.6 mm in the BTB versus 1.7 mm in the HM group at 5 months (P = .01) and 1.1 mm and 2.0 mm at 12 months, respectively (P = .02). There was no significant side-by-side difference in quadriceps muscle strength ratio, but the hamstring muscle strength was significantly better in the BTB group. The graft reinjury rate in the BTB group and the HM group was 0% (0/27) and 10.3% (3/29) (P = .09), respectively. In contrast, contralateral ACL injuries occurred in 17.3% (4/27) of the BTB group and 3.5% (1/29) of the HM group (P = .12).ConclusionsFor young female athletes aged 20 years or younger, the BTB group had better knee instrumental stability than the HM group without range of motion loss or knee extensor muscle strength deficit. Although there was no statistical significance in terms of second ACL injury, we observed fewer graft rerupture and an increasing rate of contralateral ACL injuries in the BTB group.Level of evidenceLevel III, retrospective comparative study.

Project description:Purpose To evaluate whether preoperative magnetic resonance imaging (MRI) measurements of multiple tendon autograft sources could be used to improve estimates of intraoperative hamstring tendon autograft (HTA) diameter. Methods Patients who underwent anterior cruciate ligament reconstruction with HTA at our institution were identified through electronic health records. Preoperative MRI tendon measurements of the patellar tendon (PT) length, PT width, PT thickness, quadriceps tendon thickness, semitendinosus tendon (ST) cross-sectional area (CSA), and gracilis tendon (GT) CSA were conducted by 2 independent evaluators using digital imaging measurement tools. Results A total of 53 patients met the inclusion criteria, with a mean HTA diameter of 7.98 ± 0.7 mm. Height greater than 1.63 m, weight greater than 63.4 kg, PT length greater than 4.2 cm, PT thickness greater than 0.33 cm, ST CSA greater than 10.8 mm2, and GT CSA greater than 6.3 mm2 were associated with an HTA of 8 mm or greater (P < .005). Female sex was associated with an HTA of less than 8 mm (P < .05). PT length, PT thickness, and GT CSA were the strongest predictors of an HTA of 8 mm or greater and were combined into an additive logistic regression model: Score = –23.24 + (1.68 × PT length) + (20.104 × PT thickness) + (1.48 × GT CSA). If the score was greater than 0.237, the HTA graft diameter was predicted to be 8 mm or greater with 83% specificity, 91% sensitivity, and 87% accuracy. Conclusions By combining PT length and PT thickness measurements with GT CSA measurements in a logit function model, we were able to show improved overall specificity, sensitivity, and accuracy of estimated HTA diameters in our data set when compared with assessments of anthropometric, ST CSA, GT CSA, or combined ST-GT CSA measurements in isolation. Clinical Relevance Preoperative MRI measurements may be used to screen whether a patient is likely to have an 8-mm graft in the setting of anterior cruciate ligament reconstruction with HTA and thus may help guide graft choice.

Project description:BackgroundBone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice.Questions/purposesWhich graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity?MethodsWe performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000™ testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months.ResultsTwo hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84).ConclusionsIn this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection.Level of evidenceLevel III, therapeutic study.

Project description:BackgroundInfection following Achilles tendon surgery is a devastating complication and can be difficult to treat and often leads to poor outcomes. A number of treatments have been described, but there is little information concerning outcomes of these treatments. Our purpose was to evaluate the clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon after acute and chronic midsubstance repair.MethodsWe retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range, 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture-specific intravenous (IV) antibiotics for 3 to 6 weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale.ResultsAll wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. Fourteen patients participated in the FAAM ADL survey. There were 6 patients lost to follow-up. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as "normal" or "nearly normal." Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture-specific IV antibiotics.Level of evidenceLevel IV, retrospective case series.

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Hamstring Autograft Applications for Treatment of Achilles Tendon Pathology.

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