The relevance of knee arthroscopy photographs in medicolegal proceedings

PURPOSE

Whether photographs included in the operative report of knee arthroscopies can make the surgeon liable in the event of a legal investigation remains unknown. The main objective of this study was to establish inter-observer reliability in determining the presence or absence of lesions of the cartilage, meniscus and anterior cruciate ligament (ACL). Secondary objective was to assess the inter-observer reliability in classifying lesions.

METHOD

A retrospective observational study was conducted in a continuous serie of 60 patients who underwent knee arthroscopy from the same operator. The photographs of each patient's operative report were presented separately to three experts, blinded to each other. Each expert had to decide on the presence or absence of injuries to the following structures: meniscal, cartilage and ACL and then, classify it. Primary and secondary endpoints were evaluated using the Fleiss' kappa index.

RESULTS

Inter-observer reliability for lesion detection was between 0.4 and 0.61 for all structures with three exceptions: for cartilage, it was low (0.15) at the lateral tibial plateau and poor (-0.01) at the external condyle. On the contrary, the concordance was almost perfect (0.8) for the ACL. For classifying cartilaginous and meniscal lesions, inter-observer reliability was poor (from 0.03 to 0.14), except for at the lateral meniscus (0.65).

CONCLUSION

Inter-observer reliability of arthroscopic knee diagnoses is poor when photographs alone are used. In the event of a legal investigation following knee arthroscopy, the photographs included in the operative report should not be used alone to hold the surgeon liable.

Functional and MRI results after a 7.5 year follow-up of 35 single-stage ACL and PCL reconstructions using gracilis and semitendinosus tendon grafts and LARS artificial ligaments

PURPOSE

The aim of this study was to evaluate the long-term functional and MRI results of 35 patients who underwent bicruciate ligament reconstruction combining an ACL autograft using the gracilis and semitendinosus tendons and double-bundle PCL reconstruction using the LARS artificial ligament.

METHODS

The outcomes were measured using the Lysholm score, the Tegner activity level scale and the International Knee Documentation Committee form (IKDC 2000). KT-1000 was used to assess the clinical anterior knee laxity. Radiographs and Magnetic Resonance Imaging (MRI) was used to evaluate osteoarthritis, the continuity and integrity of ACL autograft and LARS.

RESULTS

This retrospective study examined 35 patients who underwent single-stage bicruciate ligament reconstruction between May 2005 and January 2017 with a follow-up period ranging from 3 to 15 years (a mean of 7.5 years). The mean Lysholm score was 74, mean IKDC 2000 was 71. There was a statistically significant difference with a higher Lysholm score (78.9) in early versus delayed surgical intervention (p = 0.023). Using the Kellgren Lawrence osteoarthritis classification system, radiographic findings showed stage II or III in 83% of the sample population. The MRI results revealed a rupture rate of 22% of the anterior autografted ligament and 28% of the posterior LARS artificial ligament. However, there were no long-term artificial ligament-induced complications. There was no correlation between artificial ligament rupture and poor functional results (Lysholm < 65).

CONCLUSION

The results of this study with a mean follow-up of 7.5 years show satisfactory functional scores considering the initial trauma. It seems reasonable to propose early surgical treatment with double reconstruction of the cruciate ligaments within the first 21 days of the trauma. Post-traumatic osteoarthritis is inevitable in multi-ligament knee injuries despite anatomical reconstruction. The use of a LARS artificial ligament appears to be a valid alternative for PCL reconstruction in the context of multi-ligament injury and in the absence of sufficient autologous transplants.

Surgical treatment for fracture of the medial end of the clavicle associated with ipsilateral acromioclavicular dislocation

The combination of an acromioclavicular joint dislocation and an ipsilateral medial end clavicle fracture is extremely rare. We report an acromioclavicular joint dislocation type IV associated with ipsilateral medial end clavicle fracture. The clavicular fracture was surgically treated with a locking plate and a non-operative treatment was conducted for the acromioclavicular joint dislocation. The results were clinically excellent for this 48-year-old, right-handed and sportive male patient at 3 months follow-up, with pain free full of range of motions and return to sports activities obtained.

Posterior tibial slope (PTS) ≥ 10 degrees is a risk factor for further anterior cruciate ligament (ACL) injury; BMI is not

PURPOSE

This case-control study aimed to assess the influence of BMI and PTS on subsequent ACL injury affecting either ACL graft or the native ACL of the contralateral knee after primary ACL reconstruction.

METHODS

A retrospective case-control study was performed using a cohort of patients who underwent arthroscopic ACL reconstruction between 2010 and 2020 using the same surgical procedure: Hamstring tendon autograft. The study group (group I) included all the patients (n = 94) during this period who sustained a subsequent ACL injury. The control group (group II) consisted of 94 patients randomly selected (matched Group I in terms of sex, age, and ACL graft) who did not sustain any further ACL injury. PTS was measured by two blinded surgeons on lateral knee view radiographs of the operated knee after primary ACL. BMI in kg/m2 was measured during the preoperative anesthesia consultation. Exclusion criteria were: non-true or rotated lateral knee radiographs of the operated knee post-ACLR, associated knee ligament injury requiring surgical management, iterative knee surgeries, open growth plate, and related fracture.

RESULTS

The mean posterior tibial slope in group I was 7.5° ± 2.9, and 7.2° ± 2.0 in group II. A PTS angle cutoff was set at 10 degrees. The rate of patients showing a PTS ≥ 10° was significantly higher in group I compared to group II (p < 0.01). Patients with PTS ≥ 10° were 5.7 times more likely to sustain a subsequent ACL injury, (OR: 5.7 95% CI[1.858-17.486]). The Average BMI in group I was 24.5 ± 3.7 kg.m-2 compared to group II which was 23.3 ± 3.0 kg.m-2. There were no significant differences in any of the four BMI categories between both groups (p value 0.289). A series of BMI cut-offs were also analyzed at 23 to30 kg/m2, and there was no significant difference between both groups.

CONCLUSIONS

A posterior tibial slope equal to or above 10 degrees measured on lateral knee radiographs was associated with 5.7 times higher risk of ACL graft rupture or contralateral native ACL injury; however, BMI was not.

A Retrospective Comparison of the Efficacy of Embolization with Imipenem/Cilastatin and Microspheres in the Management of Chronic Shoulder Pain

PURPOSE

To compare the efficacy of embolization with imipenem/cilastatin and microspheres in chronic shoulder pain.

METHODS

This retrospective study included 29 patients who underwent embolization for chronic shoulder pain between June 2017 and March 2022 with calibrated MSs from 100 to 250 µm or IMP/CS. The main objective was the clinical success evaluated by the Minimum Clinically Important Difference (MCID) at 3 months after the procedure, validated if the patient responded yes to 2 questions: (1) Is the pain less severe than before the procedure? (2) Are you satisfied with the procedure? The decrease in visual analogue pain scale scores and the safety of the procedure were evaluated.

RESULTS

Embolization was achieved in all patients. In the MS group, 4/15 patients (26.7%) experienced clinical success at 3 months according to MCID versus 10/14 patients (71.4%) in the IMP/CS group (p = 0.02). The mean VAS decreases were respectively  - 28.6% ± 34.6 in the MS group and  - 36.8% ± 27.8 in the IMP/CS group at 1 month (p = 0.50), - 29.9% ± 29.0 and - 39.6% ± 23.0 at 3 months (p = 0.33) and - 30.6% ± 32.8 and - 46.6% ± 28.4 at 6 months after the procedure (p = 0.26). Eleven patients (73.3%) in the MS group and 3 patients (21.4%) in the IMP/CS group had complications (p = 0.01). Among them, 2/15 patients (13.3%) had transient skin ischaemia in the MS group.

CONCLUSION

Embolization with IMP/CS may be more effective and safer than MSs in the management of chronic shoulder pain.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction in Pediatric Patients: Surgical Technique

Anterior cruciate ligament (ACL) rupture is a common affliction in the athletic population. In pediatric patients, the immature skeleton with active growth plates is an issue that makes ACL reconstruction surgery technically challenging. The rerupture rate after ACL reconstruction is higher in the pediatric population than in the adult population. The addition of anterolateral ligament (ALL) reconstruction has been shown to be an effective way to reduce the rate of graft rupture and to control rotatory instability (pivot shift). Therefore, it appears necessary to combine ACL and ALL reconstruction in the pediatric population. We describe the surgical steps for combined ACL and ALL reconstruction adapted for young patients with active growth plates.

"One millimetre equals one degree": a simple way to achieve in 92% of cases the desired correction after opening proximal tibial osteotomy for genu varum

INTRODUCTION

When performing a high tibial osteotomy (HTO) for genu varum deformity, it is not always easy to obtain the correct amount of overcorrection. The aims of this study were to review the results of a simple and reproducible method of correction that we have called "1 mm equals 1°". We have applied this technique to the medial opening wedge osteotomy. Our hypothesis was that one degree of correction corresponded with one degree of opening.

METHODS

97 proximal medial opening wedge osteotomies were measured intraoperatively with a navigation system and at 3 months with long-leg X-rays. The hip-knee-ankle (HKA) angle preoperatively was on average 173.8 ± 2.3° (170°-177°). In most cases, an opening of 4° greater than the initial varus was performed using our formula that one degree varus was equal to 1 mm of opening. In other words, when the varus was 6°, an opening of 10 mm was performed. The void left by the opening wedge was filled with a calcium triphosphate wedge and the construct fixed and held with a locking plate.

RESULTS

Aiming for a knee axis of 184 ± 2°, which corresponds to 2°-6° of overcorrection, we obtained the following results: HKA intraoperatively measured angle with navigation was on average 183.5 ± 0.9° (182°-184°) and HKA radiologically postoperatively angle was 182.5° ± 1.6° (179°-189°). We therefore achieved the desired overcorrection of 2°-6° in 92% of cases based on our postoperative radiographs and in 100% cases based on intraoperative measurements with computer navigation.

CONCLUSION

The method of "1 mm equals 1°" is a simple, reliable, and reproducible method to achieve in 92% of cases the desired overcorrection (i.e., 184 ± 2°) with valgising proximal medial opening wedge osteotomy in genu varum.

Safety and Efficacy of Embolization with Microspheres in Chronic Refractory Inflammatory Shoulder Pain: A Pilot Monocentric Study on 15 Patients

Purpose: Musculoskeletal (MSK) embolization is emerging in tendinopathy treatment. The objective of this study was to assess the efficacy and safety of MSK embolization with microspheres in the treatment of chronic shoulder pain. Patients and methods: This retrospective monocentric study included patients with chronic shoulder pain resistant to 6 months or more of conventional therapies who were treated with MSK embolization between 2017 and 2021. Embolization was performed using calibrated 100–250 µm microspheres. Clinical success was defined as pain reduction, i.e., a decrease in the visual analogue scale (VAS) pain score of ≥50% at 3 months after MSK embolization as compared to baseline. Adverse events were collected. Results: Fifteen patients (11 women, 4 men) were included, with a median age of 50.3 years (IQR: 46.7–54.5). The median duration of symptoms was 26.6 months (20.6–39.8). The median VAS pain scores were 7.0 (7.0–8.0) at baseline, 6.0 (3.5–7.0) at 1 month, 5.0 (4.5–6.5) and 5.0 (3.0–7.4) at 3 months and 6 months (p = 0.002). Three patients (20%) reported clinical success at 3 months. Three patients experienced minor complications after embolization (paresthesia, n = 2; transient osteo-medullary edema, n = 1) and two patients had moderate complications (transient skin ischemia). Conclusion: MSK embolization with microspheres for treatment of refractory chronic shoulder pain showed moderate results in terms of clinical success and safety.

Comparison of knee extensor strength after anterior cruciate ligament reconstruction using either quadriceps tendon or hamstring tendon autografts

PURPOSE

The aim was to assess the consequences of quadriceps tendon (QT) harvest on knee extensor strength after anterior cruciate ligament reconstruction (ACL-R) compared to hamstring tendon (HT) autograft. Secondary objectives were to evaluate flexor strength recovery and search for correlation between strength status and functional outcome.

METHODS

This a retrospective cohort of 44 patients who underwent ACL-R using either QT (25) or HT (19). Median age was 31.1 years. We assessed thigh muscle strength thanks to concentric iso kinetic evaluation (peak torque) at 60°.s^-1, 180°.s^-1, 240°.s^-1 and eccentric at 30°.s^-1, 7 months on average after surgery. Muscle strength values were compared to the uninjured leg in order to calculate a percentage of deficit as well as unilateral hamstring/quadriceps (H/Q) ratios. KOOS score was obtained at a mean follow-up of 18 months.

RESULTS

Extensor strength deficit (concentric 60°.s^-1) was one average 33.1% in the QT group and 28.2% in the HT group (p = 0.42). Difference of flexor strength deficit (concentric 60°.s^-1) was close to be significant with 5% and 12% of deficit in the QT and HT group, respectively (p = 0.1), and statistically significant for high angular velocity (14% versus 3% at 240°.s^-1, p = 0.04). H/Q ratios were comparable in both groups ranging from 0.62 to 0.78. Quadriceps muscle strength deficit was negatively correlated with the KOOS score (Pearson coefficient = -0.4; p = 0.005).

CONCLUSION

QT autograft harvest does not yield significant quadriceps muscle weakness after ACL-R, which appear to be a pejorative factor for functional outcome.

LEVEL OF EVIDENCE

IV, Retrospective study.

Saphenous nerve injury after anterior cruciate ligament reconstruction: Reduced numbness area after ligamentoplasty using quadriceps tendon compared with hamstring tendon

PURPOSE

Injury to the infra-patellar branches of the saphenous nerve (IPBSN) is the main neurological complication of anterior cruciate ligament (ACL) reconstruction procedures. Surgical technique using quadriceps tendon (QT) autograft allows a less invasive tibial approach potentially protecting the IPBSN. The aim of this study was to compare the numbness surface of the cutaneous area supplied by the IPBSN after ACL reconstruction using either hamstring tendon (HT) or QT autografts.

METHODS

This was a retrospective comparative cohort study including 51 patients who underwent ACL reconstruction (27 QT and 24 HT) between January 2017 and April 2018. A sensory clinical evaluation was performed on each patient: length of the tibial scar, eventual numbness surface area and the type of sensory disorder were reported. To be considered as an IPBSN lesion, the numbness area had to spread at least one-centimeter away from the scar.

RESULTS

The average follow-up was 15 months. In the HT group, the numbness area surface measured 21.2 ± 19 cm² (0-77) and the scar length was on average 31.3 ± 5.6 mm. In the QT group, the numbness area was reduced to 5 ± 10 cm² (P = .0007) as well as the scar length (13.3 ± 2.8 mm, P < .0001). We counted five (17.8%) and 19 (76%) real IPBSN lesions in the QT and HT groups, respectively (P = .0002). Hypoesthesia was the main sensory disorder observed (87.5%).

CONCLUSION

Numbness area of the cutaneous surface supplied by the IPBSN after ACL reconstruction is reduced using QT autograft compared with HT autograft.

Short- and long-term results of common peroneal nerve injuries treated by neurolysis, direct suture or nerve graft

INTRODUCTION

Damage to the common peroneal nerve is the most frequent nerve injury in lower limb traumas. Our objective was to assess the motor and sensory recovery levels and the functional outcomes after remedial surgery for common peroneal nerve trauma, through either neurolysis, direct suture or nerve graft.

METHODS

This is a transversal, observational study of a monocentric cohort of 20 patients who underwent surgery between January 2004 and June 2016, which included 16 men and 4 women whose median age was 35 ± 11 years. We assessed the level of sensory and motor nerve recovery and the Kitaoka score. Nine patients benefited from neurolysis, 5 had direct sutures, and 6 received a nerve graft.

RESULTS

With 48 months' average follow-up, 7 out of 9 patients underwent neurolysis and 4 out of 5 with direct sutures had good motor recovery (≥ M4), but none for the grafts. Sensory recovery (≥ S3) was satisfactory in 7 out of 9 cases in the neurolysis group, 3 out of 5 in the direct suture group, and 3 out of 6 in the nerve graft group. The average Kitaoka score was 83.7 ± 11.5 for the neurolysis group, 86.8 ± 16 for the direct suture group, and 73 ± 14 for the graft group.

CONCLUSION

Surgical treatment by neurolysis and direct suture yields good results with a motor recovery ratio nearing 80%. When a nerve graft becomes necessary, recovery is poor and resorting to palliative techniques in the shorter run is a strategy which should be evaluated.