Uncommon Complications after Anterior Cruciate Ligament Reconstruction

Platelet rich plasma and anterior cruciate ligament repair: A new frontier, or a short term adjunct

Platelet rich plasma (PRP) is an autologous blood product rich in platelets, showing promise in reducing inflammation and accelerating healing. While extensively utilized in plastic surgery, dermatology, and osteoarthritis treatment, its application in anterior cruciate ligament (ACL) injuries is limited. This article examines PRP's potential in ACL reconstruction (ACLR), exploring its history, current usage, controversies and future directions. PRP has demonstrated significant early benefits in ligamentisation and vascularisation post-ACLR, though its long-term efficacy is inconsistent. Studies suggest that PRP may serve as both an adjunct therapy in ACLR to enhance initial healing and reduce postoperative complications, and as a non-surgical alternative for small ACL tears. Despite these promising findings, outcome variability necessitates further high-quality research to optimize PRP formulations and determine its most effective applications. The exploration of PRP as a treatment modality in ACLR offers promising but varied outcomes. PRP holds considerable promise as both an adjunct and alternative to traditional ACLR. This article underscores the need for targeted research to fully realize PRP's therapeutic potential in ACL treatment, aiming to inform future studies and clinical practices. By understanding PRP's mechanisms of efficacy and identifying the most beneficial patient populations, PRP could significantly impact orthopaedics and sports medicine, improving recovery pathways and patient outcomes.

C-reactive Protein Levels After Anterior Cruciate Ligament Reconstruction

Introduction Understanding standard changes in C-reactive protein (CRP) after Anterior cruciate ligament reconstruction (ACLR) is important for early detection of septic arthritis. Methods We conducted a prospective two-center comparative study to clarify changes in postoperative CRP levels after ACLR, as well as factors that influence the changes, in a large sample of Asian patients. A total of 439 ACLR cases were included in this study. CRP tests were performed before and one, seven, and 14 days after ACLR. Results The mean CRP level was 0.06 ± 0.19 mg/dl (range: 0-2.69) preoperatively, increased to 0.54 ± 0.58 (range: 0-4.38) mg/dl at one day postoperatively and 0.92 ± 1.22 (range: 0-11.48) mg/dl at seven days postoperatively, and decreased to 0.23 ± 0.35 (range: 0-3.11) mg/dl at 14 days postoperatively. Multivariate multiple regression analysis revealed that sex, BMI, and which facility the surgery was performed significantly affect CRP levels after one day postoperatively, and sex, BMI, and age significantly affect CRP levels after seven days postoperatively. Only sex was found to significantly affect CRP levels at 14 days postoperatively. Conclusion The present study provides a standard change in CRP after ACLR in a sufficient number of patients without postoperative complications, which would be helpful to rule out the complications. Moreover, the multivariate analysis revealed that sex, age, BMI, and facility are factors that significantly affect CRP levels after ACLR.

Navigating Post-operative Challenges: A Comprehensive Review of Complications Following Anterior Cruciate Ligament (ACL) Tear Surgery

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating sports-related injuries, often necessitating surgical intervention to restore knee stability and function. ACL reconstruction surgery, which has evolved significantly over the years, aims to enable patients, particularly those who are young and physically active, to return to their pre-injury activity levels. However, despite advancements in surgical techniques and rehabilitation protocols, post-operative complications remain a significant concern that can adversely affect patient outcomes. This comprehensive review explores the spectrum of complications that can arise following ACL tear surgery, ranging from common issues such as infection, graft failure, and knee stiffness to less frequent but clinically significant complications like osteoarthritis and neurological injuries. The review also delves into the various factors influencing the likelihood of these complications, including patient-related variables, surgical techniques, and the effectiveness of rehabilitation protocols. By providing an in-depth analysis of these post-operative challenges, this review aims to enhance the understanding of ACL reconstruction outcomes and guide healthcare professionals in implementing preventive strategies and optimizing patient care. Through a multidisciplinary approach, the goal is to minimize the risk of complications, improve surgical outcomes, and ultimately enhance the quality of life for patients undergoing ACL reconstruction.

Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures, and huge variation exists in the surgical technique. Single bundle hamstrings autograft reconstruction is a common method and has good clinical outcomes. A criticism of the hamstrings autograft is a small graft diameter, often less than 8-mm, which has been associated with increased re-rupture rates. Several graft preparation techniques for single bundle hamstrings autograft exist. Perioperative decisions include the number of tendons utilized, number of graft strands, graft configuration, and femoral and tibial fixation methods. Awareness of the minimum tendon and graft length required to produce each graft variation is necessary to avoid common pitfalls. However, intraoperative graft modification is possible to maximize graft diameter, and obtain proper fixation. The objective of this current concepts review is to describe the indications, surgical anatomy, technique, intraoperative tips, clinical outcomes, and complications for single bundle hamstrings autograft preparation techniques in ACLR.

Use of Unidirectional Porous β-Tricalcium Phosphate in the Tibial Tunnel for Anterior Cruciate Ligament Reconstruction: A Case Series

Bone defects in the tibial tunnel for anterior cruciate ligament (ACL) reconstruction can cause adverse events. The unidirectional porous tricalcium β-phosphate (UDPTCP) has the potential to be used as a filling substitute for bone defects. In this case series, we present the first nine cases in which UDPTCP was used as a bone substitute in the tibial tunnel during ACL reconstruction. The patients comprised six males and three females, with an average age of 32 years (range: 16-50 years). A cylindrical UDPTCP measuring 10 x 20 mm was molded to fit the tibial tunnel and then implanted. At the one-year postoperative follow-up, none of the patients demonstrated any complications, and bone remodeling was observed on radiographs. Therefore, UDPTCP may provide a safe and reliable filling substitute for the tibial tunnel in ACL reconstruction.

Effects of Weight Bearing on Marrow Adipose Tissue and Trabecular Bone after Anterior Cruciate Ligament Reconstruction in the Rat Proximal Tibial Epiphysis

The effects of mechanical unloading after anterior cruciate ligament (ACL) reconstruction on bone and marrow adipose tissue (MAT) are unclear. We investigated weight bearing effects on bone and MAT after ACL reconstruction. Rats underwent unilateral knee ACL transection and reconstruction, followed by hindlimb unloading (non-weight bearing), no intervention (low-weight bearing, the hindlimb standing time ratio (STR; operated/contralateral) during treadmill locomotion ranging from 0.55 to 0.91), or sustained morphine administration (moderate-weight bearing, STR ranging from 0.80 to 0.95). Untreated rats were used as controls. At 7 or 14 days after surgery, changes in trabecular bone and MAT in the proximal tibial were assessed histologically. Histological assessments at 7 or 14 days after surgery showed that ACL reconstruction without post-operative intervention did not significantly change trabecular bone and MAT areas. Hindlimb unloading after ACL reconstruction induced MAT accumulation with adipocyte hyperplasia and hypertrophy within 14 days, but did not significantly affect trabecular bone area. Increased weight bearing through morphine administration did not affect trabecular bone and MAT parameters. Our results suggest that early weight bearing after ACL reconstruction is important in reducing MAT accumulation, and that reduction in weight bearing alone is not sufficient to induce bone loss early after ACL reconstruction.

Deep Infection After Anterior Cruciate Ligament Reconstruction Diagnosed by Intratunnel Suspensory Fixation Device Migration: A Case Report

CASE

A 43-year-old woman sustained an anterior cruciate ligament injury while kickboxing and underwent anterior cruciate ligament reconstruction with hamstring autograft with suspensory fixation. Lateral thigh wound was superficially infected at 2 weeks postoperatively with resolution of signs and symptoms after debridement. Three months later, posterolateral knee pain developed and radiographs revealed intratunnel migration of the device. That observation with abnormal magnetic resonance imaging and serology results led to the diagnosis of deep infection. Immediate device removal and debridement were performed. Consequently, the grafts were preserved, and the patient could perform kickboxing 2 years thereafter.

CONCLUSIONS

Intratunnel migration of suspensory fixation devices can support a diagnosis of infection.

Management of ACL Reconstruction Complicated by MRSA Osteomyelitis Requiring a Gastrocnemius Perforator Flap: A Case Report

CASE

A 21-year-old woman presented with sepsis from methicillin-resistant Staphylococcus aureus, patellar osteomyelitis, and 6 × 4 × 2-cm proximal anteromedial soft-tissue defect 1 week after bone-tendon-bone autograft anterior cruciate ligament reconstruction (ACL-R). She underwent multiple irrigation and debridement (I&Ds), hardware removal, bone grafting with antibiotic-loaded tricalcium phosphate beads, and medial gastrocnemius perforator flap with plastic surgery. At 18 months after her initial ACL-R, single-stage revision ACL-R with quadriceps autograft was performed.

CONCLUSION

When acute ACL-R infection does not respond to initial I&D and Intravenous (IV) antibiotics, retained hardware and graft tissue must be removed expeditiously to prevent sepsis, osteomyelitis, and soft-tissue defects.

Smaller diameter femoral tunnel biocomposite interference screws provide adequate fixation strength in anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to evaluate the effect of bioabsorbable interference screw diameter on the pullout strength and failure mode for femoral tunnel fixation in primary anterior cruciate ligament reconstruction (ACLR) at time zero fixation using bone-patellar tendon-bone (BTB) autograft in a cadaveric model.

METHODS

Twenty-four fresh-frozen cadaveric knees were obtained from 17 different donors. Specimens were allocated to three different treatment groups (n = 8 per group) based on interference screw diameter: 6 mm, 7 mm, or 8 mm biocomposite interference screw. All specimens underwent dual energy X-ray absorptiometry (DEXA) scanning prior to allocation to ensure no difference in bone mineral density among groups (n.s.). All specimens underwent femoral-sided ACLR with BTB autograft. Specimens subsequently underwent mechanical testing under monotonic loading conditions to failure. The load to failure and failure mechanism were recorded.

RESULTS

The mean pullout force (N) at time zero for each group was 309 ± 213 N, 518 ± 313 N, and 541 ± 267 N for 6 mm, 7 mm, and 8 mm biocomposite interference screw diameter, respectively (n.s.). One specimen in the 6 mm group, two specimens in the 7 mm group, and one specimen in the 8 mm group failed by screw pullout. The remainder in each group failed by graft failure (n.s.).

CONCLUSION

Biocomposite interference screw diameter did not have a significant influence on fixation pullout strength or failure mode following femoral tunnel fixation using BTB autograft at time zero. A 6 mm interference screw can improve preservation of native bone stock, increase potential for biologic healing, and decrease the risk of damage to the graft during insertion without significantly compromising fixation strength. This study supports the use of smaller 6 mm interference screw diameter options for femoral tunnel fixation in ACLR.

PATELLAR FRACTURE IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: IN VITRO ANALYSIS

Objective

To determine, by biomechanical analysis, safe patellar cut limits in anterior cruciate ligament (ACL) reconstruction that minimize fracture risks.

Methods

From three-dimensional reconstruction, triangular cuts were made in the patella, with a depth of 6.5 mm and variable width and length (10 to 20 mm and 8 to 12 mm, respectively, both with an interval of 1 mm). The combinations of cuts constituted 55 models for tests, with five variations in width and 11 variations in length, tested with the finite element method (FEM).

Results

The mean of the localized principal maximum (traction force) values was 4.36 Pa (SD 0.87 ± 0.76) and the localized principal minimum (compression force) was -4.33 Pa (SD 1.05 ± 1.11). Comparing width and length to the tension force of the values of the main maximum, we found statistical significance from 11 mm for width and 13 mm for length.

Conclusion

In ACL reconstruction, the removal of the patellar bone fragment is safe for fragments smaller than 11 mm in width and 13 mm in length, which corresponds to 24% of the width and 28% of the length of the patella used. Level of Evidence II, Comparative Prospective Study.

A Squeaking Knee Is a Rare Complication of ACL Surgery: A Case Report

CASE

We report a rare case of a 36-year-old woman who underwent anterior cruciate ligament surgery (ACL), which was complicated by a squeaking knee postoperatively. The squeaking noise was likely due to migrating nonabsorbable suture engaging with the articular surface and created significant psychological stress but had no impact on the functional outcome of the patient. We eliminated the noise with an arthroscopic debridement of the suture that had migrated from the tibial tunnel.

CONCLUSION

A squeaking knee after ACL surgery due to migrating suture is a rare complication that, in this case, improved with surgical debridement and diagnostic imaging seems to have a limited role.

Elective transfemoral amputation and simultaneous implantation of a transcutaneous osseointegrated prosthesis stem as salvage treatment after knee joint arthrodesis with poor function: A case report

Background

Surgical reconstruction of anterior cruciate ligament ruptures is a well-established procedure, and although it is for the vast majority of patients without severe complications, total knee joint arthroplasty, arthrodesis of the knee, and finally transfemoral amputation have to be considered in the worst-case scenario.

The case

We report a case of a patient with a 13-year history of recurrent failure after anterior cruciate ligament reconstruction. She claimed she had severely impaired mobility secondary to a knee joint arthrodesis via an Ilizarov circular frame 2 years ago and chronic immobilizing pain, making a permanent medication with opioids necessary. She was aware of the therapeutic options and asked for transfemoral amputation and concomitant supply with a transcutaneous osseointegrated prosthesis system (TOPS).

Procedures

After careful evaluation and clinical work-up, the indication for transfemoral amputation and concomitant implantation of the prosthetic stem into the femoral cavity was secured. Six weeks after the creation of the stoma for coupling of the artificial limb and onset of physiotherapy, balance and gait training were scheduled. Full weight-bearing and walking without crutches were allowed 12 weeks after the index procedure. This sequence of events was paralleled by a series of pre-defined examinations, that is, questionnaires and mobility scores addressing the situation of transfemoral amputees, as well as standardized clinical gait analysis. The latter was performed before surgery and 6, 9, and 18 months after the index procedure.

Outcome

At the time of the index procedure, opioids could be tapered to zero, and the patient quickly regained her walking abilities during the rehabilitation period. Clinical gait analysis confirmed the restoration of bilateral symmetry by mutual approximation of kinematics and kinetics to a standard gait pattern.

Conclusion

The outcome of our patient strengthens the therapeutic potential of a unilateral transfemoral amputation in combination with TOPS. Nevertheless, long-term follow-up is necessary to detect future complications of this approach.

Complication of lengthening and the role of post-operative care, physical and psychological rehabilitation among fibula hemimelia

There is a clear clinical need for efficient physiotherapy and rehabilitation programs during and after bone lengthening and reconstruction for gaining the optimal effect and also prevention or treatment of lengthening side effects. Pin tract infection is the most prevalent side effect during lengthening which could be prevented and treated initially via proper wound care. Muscle contractures are typically a consequence of the generated tension on the distracted muscle. It can be managed by physiotherapy initially and surgically in later severe stages. Furthermore, it is essential to avoid muscle contracture development, which is the demonstration of the imbalanced muscle appeals on the joint to inhibit the following subluxation. The knee is the furthermost affected joint by the aforementioned problem due to the inherent lack of ligamentous and bony stability. Joint stiffness is the other possible unfavorable effect of lengthening. It happens because of extensive muscle contractures or may possibly be attributed to rigidity of the joint following the amplified pressure on the joint surface during the process of lengthening. Physiotherapy and occupational therapy including endurance and strength exercise as well as stretching play an important role during the rehabilitation periods for the prevention and also the treatment of muscle contracture and the following deformity and also joint stiffness. Likewise, the effect of mental and physical rehabilitation programs should not be overlooked.

Distance to the Neurovascular Bundle for Iliotibial Band Graft Passage During Anterior Cruciate Ligament Reconstruction: A Pediatric Cadaveric Study

Background:

The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients.

Purposes:

To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery.

Study Design:

Descriptive laboratory study.

Methods:

Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90° to 100°. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure.

Results:

The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of ≤8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for ≤8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005).

Conclusion:

The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances <1 cm in many specimens in this study. When passing the graft through the knee for an over-the-top position, surgeons should consider these small distances between the path of graft passage and critical neurovascular structures.

Clinical Relevance:

As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.

Anterior cruciate ligament reconstruction related complications: 2D and 3D high-resolution magnetic resonance imaging evaluation

Anterior cruciate ligament (ACL) injury is a common indication for sports-related major surgery and accounts for a large proportion of ligamentous injuries in athletes. The advancements in 2D and 3D MR imaging have provided considerable potential for a one-stop shop radiation-free assessment with an all-in-one modality examination of the knee, for both soft-tissue and bone evaluations. This article reviews ACL injuries and types of surgical managements with illustrative examples using high resolution 2D and 3D MR imaging. Various complications of ACL reconstruction procedures are highlighted with a focus on the use of advanced MR imaging and relevant arthroscopic correlations.

Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction

BACKGROUND

Muscle atrophy is common after an injury to the knee and anterior cruciate ligament reconstruction (ACLR). Blood flow restriction therapy (BFR) combined with low-load resistance exercise may help mitigate muscle loss and improve the overall condition of the lower extremity (LE).

PURPOSE

To determine whether BFR decreases the loss of LE lean mass (LM), bone mass, and bone mineral density (BMD) while improving function compared with standard rehabilitation after ACLR.

STUDY DESIGN

Randomized controlled clinical trial.

METHODS

A total of 32 patients undergoing ACLR with bone-patellar tendon-bone autograft were randomized into 2 groups (CONTROL: N = 15 [male = 7, female = 8; age = 24.1 ± 7.2 years; body mass index [BMI] = 26.9 ± 5.3 kg/m2] and BFR: N = 17 [male = 12, female = 5; age = 28.1 ± 7.4 years; BMI = 25.2 ± 2.8 kg/m2]) and performed 12 weeks of postsurgery rehabilitation with an average follow-up of 2.3 ± 1.0 years. Both groups performed the same rehabilitation protocol. During select exercises, the BFR group exercised under 80% arterial occlusion of the postoperative limb (Delfi tourniquet system). BMD, bone mass, and LM were measured using DEXA (iDXA, GE) at presurgery, week 6, and week 12 of rehabilitation. Functional measures were recorded at week 8 and week 12. Return to sport (RTS) was defined as the timepoint at which ACLR-specific objective functional testing was passed at physical therapy. A group-by-time analysis of covariance followed by a Tukey's post hoc test were used to detect within- and between-group changes. Type I error; α = 0.05.

RESULTS

Compared with presurgery, only the CONTROL group experienced decreases in LE-LM at week 6 (-0.61 ± 0.19 kg, -6.64 ± 1.86%; P < 0.01) and week 12 (-0.39 ± 0.15 kg, -4.67 ± 1.58%; P = 0.01) of rehabilitation. LE bone mass was decreased only in the CONTROL group at week 6 (-12.87 ± 3.02 g, -2.11 ± 0.47%; P < 0.01) and week 12 (-16.95 ± 4.32 g,-2.58 ± 0.64%; P < 0.01). Overall, loss of site-specific BMD was greater in the CONTROL group (P < 0.05). Only the CONTROL group experienced reductions in proximal tibia (-8.00 ± 1.10%; P < 0.01) and proximal fibula (-15.0±2.50%,P < 0.01) at week 12 compared with presurgery measures. There were no complications. Functional measures were similar between groups. RTS time was reduced in the BFR group (6.4 ± 0.3 months) compared with the CONTROL group (8.3 ± 0.5 months; P = 0.01).

CONCLUSION

After ACLR, BFR may decrease muscle and bone loss for up to 12 weeks postoperatively and may improve time to RTS with functional outcomes comparable with those of standard rehabilitation.

Failure and Complication Rates in Common Sports and Arthroscopic Procedures: Reality Check

Expectations following sports medicine and arthroscopic procedures have been elevated because of captivating modern-day media coverage of high-profile athletic injuries, surgery, and rapid return to sports. Unfortunately, this general perception may be misleading, and orthopedic sports medicine physicians must be aware of the harsh reality of the trials and tribulations associated with the subspecialty. The purpose of this review article is to provide an updated brief overview of the complications and failure rates associated with common arthroscopic procedures including rotator cuff repair, biceps tenodesis, Bankart procedure, Latarjet procedure, anterior cruciate ligament reconstruction, anterior cruciate ligament repair, meniscal repair, tibial tubercle osteotomy, and medial patellofemoral ligament reconstruction. Highlighting the complications is the first step toward early recognition, enhancing preventative measures, and successful management.

Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness.

METHODS

PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes.

RESULTS

A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I² = 96%, P = .14) and 12 weeks (MD -0.03, I² = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I² = 56%, P < .00001) and weeks 3-6 (MD -0.38, I² = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I² = 74%, P = .002) and weeks 4-6 (MD 6.17, I² = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I² = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I² = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5.

CONCLUSIONS

Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak.

LEVEL OF EVIDENCE

Level II, systematic review of therapeutic Level I-II studies.

Multi-ligament reconstructions as a risk factor for adverse outcomes in arthroscopic surgery

PURPOSE

Multi-ligament knee injuries are a serious consequence of knee dislocation with a poorly evaluated post-operative complication profile due to low incidence. The aim of this study is to assess the risk of adverse post-operative events associated with operative management of multi-ligament knee injuries.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing surgical procedures for multi-ligament knee injuries from 2006 to 2016 using Current Procedural Terminology codes. We evaluated data on patient demographics and used a propensity score algorithm to adjust for baseline differences in these patients and developed univariate and multivariate logistic regression models to assess effects on minor and severe 30-day post-operative complications.

RESULTS

We identified 444 patients in this database who underwent multi-ligament knee reconstructions between 2006 and 2016. After propensity matching, minor and major adverse post-operative events were more frequent in patients with multi-ligament knee injuries (1.4% vs 0.2%, p < 0.001 and 2.7% vs 1.1%, p = 0.002, respectively). Patients with multi-ligament knee injuries experienced a 55-fold increase risk of need for transfusion (p < 0.001) and a fivefold increased risk of pulmonary embolism (p = 0.025), with most occurring in bicruciate reconstructions (Schenck Classification KD-III and KD-IV injuries).

CONCLUSION

The surgical management of multi-ligament knee injuries confers significant increased risk of 30-day post-operative minor or severe adverse event over arthroscopic ACL reconstruction. These patients are most at risk for post-operative blood transfusion requirement, and pulmonary embolism, with patient's undergoing surgery for bicruciate ligament injuries at particularly high risk of complication.

LEVEL OF EVIDENCE

IV.

Iatrogenic common peroneal nerve injury during harvesting of semitendinosus tendon for anterior cruciate ligament reconstruction

We present a case of iatrogenic injury to the common peroneal nerve (CPN) occurring due to harvesting of a hamstring graft, using a posterior mini-incision technique. A twitch of the foot was noted on retraction of the tendon stripper. After clinically diagnosing a CPN palsy proximal to the knee, the patient was referred to a neurosurgeon within 24 hours. An electromyography (EMG) was not obtained since it cannot accurately differentiate between partial and complete nerve injury in the first week after injury. Because the nerve might have been transacted by the tendon stripper, surgical exploration within 72 hours after injury was indicated. An intraneural haematoma was found and neurolysis was performed to decompress the nerve. Functioning of the anterior cruciate ligament was satisfactory during follow-up. Complete return of motor function of the CPN was observed at 1-year follow-up, with some remaining hypoaesthesia.

Mucormycosis osteomyelitis after anterior cruciate ligament reconstruction: treatment and outcomes of 21 reported cases

Aims

Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R).

Methods

We present a case-series of consecutive patients treated at our institution due to a severe fungal osteomyelitis after an arthroscopic ACL-R from November 2005 to March 2015. Patients were referred to our institution from different areas of our country. We evaluated the amount of bone resection required, type of final reconstructive procedure performed, and Musculoskeletal Tumor Society (MSTS) functional score.

Results

A total of 21 consecutive patients were included in the study; 19 were male with median age of 28 years (IQR 25 to 32). All ACL-R were performed with hamstrings autografts with different fixation techniques. An oncological-type debridement was needed to control persistent infection symptoms. There were no recurrences of fungal infection after median of four surgical debridements (IQR 3 to 6). Five patients underwent an extensive curettage due to the presence of large cavitary lesions and were reconstructed with hemicylindrical intercalary allografts (HIAs), preserving the epiphysis. An open surgical debridement was performed resecting the affected epiphysis in 15 patients, with a median bone loss of 11 cm (IQR 11.5 to 15.6). From these 15 cases, eight patients were reconstructed with allograft prosthesis composites (APC); six with tumour-type prosthesis (TTP) and one required a femoral TTP in combination with a tibial APC. One underwent an above-the-knee amputation. The median MSTS functional score was 20 points at a median of seven years (IQR 5 to 9) of follow-up.

Conclusion

This study suggests that mucormycosis infection after an ACL-R is a serious complication. Diagnosis is usually delayed until major bone destructive lesions are present. This may originate additional massive reconstructive surgeries with severe functional limitations for the patients.

Level of evidence: IV

Cite this article: Bone Joint Open 2020;2(1):3–8.

Tranexamic acid is effective in decreasing postoperative intraarticular bleeding in arthroscopic knee surgery

: Arthroscopic knee surgery to perform partial meniscectomy and anterior cruciate ligament (ACL) reconstruction is frequent and effective, although a possible complication is postoperative hemarthrosis. When intraarticular bleeding occurs, in addition to the associated pain, the patient usually requires joint aspiration (arthrocentesis) to avoid loss of range of motion (ROM). Sometimes this complication ends up associated with a poor result of surgery due to a loss of ROM. The aim of this narrative review of the literature is to attempt to clarify whether tranexamic acid (TXA) should be utilized in arthroscopic ACL reconstruction and arthroscopic meniscectomy and by what route (intraarticular or intravenous). A number of studies seem to favor the use of intravenous TXA in patients undergoing ACL reconstruction and arthroscopic synovectomy to diminish articular postoperative bleeding and its consequences (pain, swelling, loss of ROM, and the need for arthrocentesis). Regarding the use of intraarticular TXA, one in-vitro study has indicated that TXA in high concentrations is cytotoxic to chondrocytes. Common sense leads me to conclude that until better designed studies can confirm that intraarticular TXA is not cytotoxic to chondrocytes, its use should not be advised. Currently, for patients undergoing arthroscopic ACL reconstruction and arthroscopic meniscectomy, it seems safer to use intravenous TXA.

Ultrasound Appearances of Complications After Arthroscopic Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament tears are among the most frequent knee injuries. Surgical treatment is mandatory in active athletes to prevent meniscal tears and early joint degenerative changes. Anterior cruciate ligament arthroscopic reconstruction (ACLAR) is considered the preferred procedure, allowing a successful functional restoration and a prompt return to sports practice. Postsurgical complications are infrequent and are mainly assessed clinically and by magnetic resonance imaging. Although ultrasound can only evaluate the outer aspect of the knee, it can detect several ACLAR complications. The aim of this pictorial essay is to present the ultrasound appearances of a wide spectrum of ACLAR complications.

Magnetic resonance imaging of the quadriceps tendon autograft in anterior cruciate ligament reconstruction

BACKGROUND

Quadriceps tendon (QT) autograft is emerging as a popular technique for primary anterior cruciate ligament (ACL) reconstruction. Studies have shown that it has comparable outcomes to bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts while mitigating post-operative complications associated with these grafts.

PURPOSE

To provide a literature summary of the important pre- and post-operative magnetic resonance imaging (MRI) findings of the quadriceps tendon and pertinent postoperative complications associated with the QT harvest. Radiologists should be familiar with MR findings after autologous graft harvest of the quadriceps tendon for reconstruction of the ACL.

LEVEL OF EVIDENCE

Level IV.