Publications by authors named "Nicholas N DePhillipo"

79 Publications

Femur Length is Correlated with Isometric Quadriceps Strength in Post-Operative Patients.

Int J Sports Phys Ther 2022 2;17(4):628-635. Epub 2022 Jun 2.

Twin City Orthopedics.

Background: Few existing studies have examined the relationship between lower extremity bone length and quadriceps strength.

Purpose/hypothesis: To evaluate the relationship between lower extremity, tibia and femur lengths, and isometric quadriceps strength in patients undergoing knee surgery. The null hypothesis was that there would be no correlation between lower extremity length and isometric quadriceps strength.

Study Design: Cross-sectional study.

Methods: Patients with full-length weightbearing radiographs that underwent isometric quadriceps strength testing after knee surgery were included. Using full-length weightbearing radiographs, limb length was measured from the ASIS to the medial malleolus; femur length was measured from the center of the femoral head to the joint line; tibia length was measured from the center of the plateau to the center of the plafond. Isometric quadriceps strength was measured using an isokinetic dynamometer. Pearson's correlation coefficient was used to report the correlation between radiographic limb length measurements. A Bonferroni correction was utilized to reduce the probability of a Type 1 error.

Results: Forty patients (26 males, 14 females) with an average age of 25.8 years were included. The average limb, femur, and tibia lengths were not significantly different between operative and non-operative limbs (p>0.05). At an average of 5.8±2.5 months postoperatively, the peak torque (156.6 vs. 225.1 Nm), average peak torque (151.6 vs. 216.7 Nm), and peak torque to bodyweight (2.01 vs 2.89 Nm/Kg) were significantly greater in the non-surgical limb (p<0.01). Among ligament reconstructions there was a significant negative correlation between both limb length and strength deficit (r= -0.47, p=0.03) and femur length and strength deficit (r= -0.51, p=0.02). The average strength deficit was 29.6% among the entire study population; the average strength deficit was 37.7% among knee ligament reconstructions. For the non-surgical limb, femur length was significantly correlated with peak torque (r = 0.43, = 0.048).

Conclusion: Femur length was significantly correlated with the isometric quadriceps peak torque for non-surgical limbs. Additionally, femur length and limb length were found to be negatively correlated with quadriceps strength deficit among ligament reconstruction patients. A combination of morphological features and objective performance metrics should be considered when developing individualized rehabilitation and strength programs.
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http://dx.doi.org/10.26603/001c.35704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159727PMC
June 2022

Posterior Tibial Slope in Patients With Torn ACL Reconstruction Grafts Compared With Primary Tear or Native ACL: A Systematic Review and Meta-analysis.

Orthop J Sports Med 2022 Apr 7;10(4):23259671221079380. Epub 2022 Apr 7.

Twin Cities Orthopedics, Edina, Minnesota, USA.

Background: Increased posterior tibial slope (PTS) is a risk factor for anterior cruciate ligament (ACL) rupture and failure of ACL reconstruction (ACLR) grafts.

Purpose: The purpose was to conduct a systematic review of literature on PTS measurements and to conduct a meta-analysis of comparable PTS measurements based on a patient's ACL status. It was hypothesized that patients with torn ACLR grafts would have significantly larger medial and lateral PTS compared with patients with native ACLs or those who underwent primary ACLR.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that reported medial and/or lateral PTS measurements, those that reported PTS measurements based on ACL status (ie, intact ACL, primary ACL tear, failed ipsilateral ACLR, or revision ACLR), and those that reported their specific PTS measurement technique. Average PTS measurements, measurement location (medial or lateral tibial plateau) and technique, imaging modality used, and ACL status were extracted from each study. Data were pooled using DerSimonian and Laird random-effects models, and results were compared using the Altman interaction test.

Results: The literature search identified 1705 studies, of which 82 (N = 12,971 patients) were included. There were 4028 patients in the intact ACL group (31%), 7405 in the primary ACLR group (57%), and 1538 in the failed ACLR group (12%). Measurements were obtained from lateral radiographs in 31 studies (38%), from magnetic resonance imaging in 47 studies (57%), and from computed tomography in 4 studies (5%). The failed ACLR group had a significantly larger lateral PTS (9.55°; 95% CI, 8.47°-10.63°) than either the primary ACL tear (7.13°; 95% CI, 6.58°-7.67°) or intact ACL (5.57°; 95% CI, 5.03°-6.11°) groups ( < .001 for both). The failed ACLR group also had a significantly larger medial PTS (9.05°; 95% CI, 7.80°-10.30°) than the primary (6.24°; 95% CI, 5.71°-6.78°) or intact ACL (6.28°; 95% CI, 5.21°-7.35°) groups ( < .001 for both).

Conclusion: Both lateral and medial PTS measurements were greater in patients who had failed previous ACLR than those with a primary ACL tear or an intact native ACL. The lateral PTS of patients with primary ACL tears was greater than those with an intact native ACL.
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http://dx.doi.org/10.1177/23259671221079380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9003651PMC
April 2022

Improved Accuracy of Coronal Alignment Can Be Attained Using 3D Printed PSI for Knee Osteotomies: A Systemic Review of Level III and IV Studies.

Arthroscopy 2022 Mar 2. Epub 2022 Mar 2.

Eglin Air Force Base, Eglin, Florida, U.S.A.. Electronic address:

Purpose: To evaluate the accuracy and precision of postoperative coronal plane alignment using 3D-printed patient-specific instrumentation (PSI) in the setting of proximal tibial or distal femoral osteotomies.

Methods: A systematic review evaluating the accuracy of 3D-printed PSI for coronal plane alignment correcting knee osteotomies was performed. The primary outcomes were accuracy of coronal plane limb alignment correction and number of correction outliers. Secondary variables were duration of surgery, number of intraoperative fluoroscopic images, complications, cost, and clinical outcomes (as applicable).

Results: Ninety-three studies were identified, and 14 were included in the final analysis. Overall, mean postoperative deviation from target correction ranged from 0.3° to 1° for all studies using hip-knee angle measurements and 2.3% to 4.9% for all studies using weight-bearing line measurements. The incidence of correction outliers was assessed in 8 total studies and ranged from 0 to 25% (total n = 10 knees) of patients corrected with 3D-printed PSI. Osteotomies performed with 3D-printed cutting guides or wedges demonstrated significantly shorter operative times (P < .05) and fewer intraoperative fluoroscopic images (P < .05) than control groups in four case control studies.

Conclusion: Patients undergoing distal femoral osteotomy or proximal tibial osteotomy procedures with 3D-printed patient-specific cutting guides and wedges had highly accurate coronal plane alignment with a low rate of outliers. Patients treated with 3D printed PSI also demonstrated significantly shorter operative times and decreased intraoperative fluoroscopy when compared to conventional techniques.

Level Of Evidence: Level IV, systematic review of Level III-IV studies.
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http://dx.doi.org/10.1016/j.arthro.2022.02.023DOI Listing
March 2022

Acute Intervention With Selective Interleukin-1 Inhibitor Therapy May Reduce the Progression of Posttraumatic Osteoarthritis of the Knee: A Systematic Review of Current Evidence.

Arthroscopy 2022 08 19;38(8):2543-2556. Epub 2022 Feb 19.

Eglin Air Force Base, Eglin, Florida, U.S.A.. Electronic address:

Purpose: To evaluate the efficacy of selective interleukin (IL)-1 inhibitor therapy in the reduction of posttraumatic osteoarthritis (PTOA) progression following knee ligament or meniscal injury.

Methods: A systematic review was conducted evaluating the disease-modifying efficacy of selective IL-1 inhibition in the setting of knee PTOA.

Results: The literature search identified 364 articles and 11 studies were included (n = 10 preclinical, n = 1 clinical). Drug delivery in preclinical studies was administered using IL-1Ra-encoded helper-dependent adenovirus particles (n = 3), synovial cells transfected with an IL-1Ra-encoded retroviral vector (n = 3), or varying chemical compositions of nonviral microcapsule gene carriers (n = 4). Intervention with selective IL-1 inhibitor therapy within 2 weeks of injury provided the greatest protective benefits in reducing the progression of PTOA regardless of drug delivery methodology in preclinical models. The majority of studies reported significantly better cartilage integrity and reduction in lesion size in animals treated with gene therapy with the greatest effects seen in those treated within 5 to 7 days of injury.

Conclusions: Early intervention with selective IL-1 inhibitor therapy were effective in reducing proinflammatory IL-1β levels in the acute and subacute phases following traumatic knee injury in preclinical animal model studies, while significantly reducing cartilage damage, lesion size, and PTOA progression at short-term follow-up. However, it was found that the effect of these therapies diminished over time.

Clinical Relevance: Acute, intra-articular injection of selective IL-1 inhibitors may reduce PTOA progression, supporting the need for additional basic and clinical investigation.
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http://dx.doi.org/10.1016/j.arthro.2022.02.009DOI Listing
August 2022

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial.

Am J Sports Med 2022 03 2;50(4):968-976. Epub 2022 Feb 2.

Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark.

Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear.

Purpose/hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney test was used to compare postoperative patient-reported outcome measures between groups.

Results: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group ( = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) ( = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] ( = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) ( = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) ( = .184).

Conclusion: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.
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http://dx.doi.org/10.1177/03635465211069373DOI Listing
March 2022

Editorial Commentary: Rotator Cable Compromise May Not Always Result in Poor Shoulder Function.

Arthroscopy 2021 08;37(8):2452-2454

Oslo Sports Trauma Research Institute.

Compromise of the rotator cable has been linked with poor shoulder function in patients with rotator cuff tears. Yet, some patients remain asymptomatic with relatively good function despite rotator cuff tear pathology. Dynamic changes in co-contraction of opposing muscle groups throughout full range of motion have a significant effect on the stability of the shoulder joint. Advancements in biomechanical shoulder models have allowed investigators to diverge from historically static methods to more physiologic dynamic tests, which may provide stronger and more meaningful evidence when applied clinically. Nevertheless, with limitations seen in cadaveric models, the findings observed in live patients under fluoroscopic evaluation with known rotator cuff tear patterns remain a gold standard and practical way to approach the pathologic biomechanical environment of the rotator cuff tear compromised shoulder. The functional status of the glenohumeral joint and the integrity of various aspects of the rotator cuff remain a key part of clinical decision-making in approaches of rotator cuff repair (decompression and debridement, partial repair, margin convergence, augmentations, releases, double-row repairs), tendon transfers, superior capsular reconstructions, resurfacing options, and even considerations of arthroplasty.
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http://dx.doi.org/10.1016/j.arthro.2021.04.029DOI Listing
August 2021

High incidence of acute self-reported sleep disturbances in patients following arthroscopic-assisted knee surgery.

J ISAKOS 2021 09 16;6(5):259-264. Epub 2021 Jul 16.

Twin Cities Orthopedics, Edina-Crosstown, Edina, Minnesota, USA.

Objectives: To evaluate the self-reported incidence of sleep disturbances, defined as ≤7 hours of sleep per 24-hour period, in patients undergoing arthroscopic-assisted knee surgery.

Methods: Patients who underwent arthroscopic knee surgery over the course of a 4-month period were prospectively included. Patients were excluded if a history of insomnia or other sleep altering medical history was reported. Self-reported sleep metrics included average number of hours of sleep per night, average number of awakenings during sleep per night, perceived quality of sleep, average pain level during sleep and number of hours of physical activity/therapy per week. Data were collected at weeks 1, 3, and 6 postoperatively. Joint circumference was measured on postoperative day 1 and served as an indicator of a knee effusion. Paired -tests were used to compare preoperative to postoperative hours of sleep. Simple and multiple linear regression were used to evaluate relationships between surgical variables and postoperative sleep metrics.

Results: There were 123 patients who underwent arthroscopic knee surgery during the prospective enrolment period; 83 patients were included in the final analysis. The overall incidence of preoperative sleep disturbances was 20% (n=17). The overall incidence of self-reported postoperative sleep disturbances was 99%, 96% and 90% at weeks 1, 3 and 6, respectively. The average number of hours slept was significantly reduced at 1, 3 and 6 weeks postoperatively compared with the preinjury state (p<0.001). Knee joint circumference had a significantly negative correlation with average number of hours of sleep in the first 6 weeks postoperatively (=-0.704; p=0.001). Surgical variables including severity of surgery, weekly postoperative pain level and weekly hours of postoperative physical therapy were not significant independent predictors of acute postoperative sleep disturbances (p>0.05).

Conclusion: Sleep disturbances were commonly reported in patients following arthroscopic knee surgery without correction of sleep metrics by 6 weeks postoperatively. The majority of sleep disturbances in this cohort correlated with an increased knee effusion. A multidisciplinary team approach is recommended to counsel patients regarding the potential for and problems with acute sleep disturbances following arthroscopic knee surgery. : 3.
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http://dx.doi.org/10.1136/jisakos-2020-000594DOI Listing
September 2021

An Acute Osteochondral Defect Secondary to Fabella Impaction: A Case Report.

JBJS Case Connect 2020 Oct-Dec;10(4):e2000513

1The Steadman Clinic, Vail, Colorado 2Steadman Philippon Research Institute, Vail, Colorado.

Case: A healthy 37-year-old man sustained a knee injury after performing a deep flexion maneuver while skiing and noted immediate knee pain and swelling. Because of persistent inability to fully extend his knee and persistent posterolateral knee pain, he was evaluated and noted to have an acute osteochondral defect of the posterolateral femoral condyle directly adjacent to his fabella. After a trial of nonoperative interventions, he elected to undergo an arthroscopic-assisted open excision of the fabella and a chondroplasty of the posterolateral femoral condyle defect.

Conclusion: A traumatic osteochondral defect secondary to a lateral fabella impaction is a rare pathology but must be evaluated in patients performing deep flexion maneuvers who have persistent knee pain and mechanical symptoms. When there is a focal defect with increased edema of both the fabella and posterolateral femoral condyle, an arthroscopic chondroplasty and fabella excision is a valid treatment to return the patient back to desired activities.
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http://dx.doi.org/10.2106/JBJS.CC.20.00513DOI Listing
April 2022

Mobile Phone GPS Data and Prevalence of COVID-19 Infections: Quantifying Parameters of Social Distancing in the U.S.

Arch Bone Jt Surg 2021 Mar;9(2):217-223

Adjunct Faculty University of Minnesota, Twin Cities Orthopedics, Edina, MN, USA.

Background: To evaluate the association between social distancing quantified by mobile phone data and the current prevalence of COVID-19 infections in the U.S. per capita.

Methods: Data were accessed on April 4, 2020, from Centers for Disease Control and Prevention, Google COVID-19 Community Mobility Report, and the United States Census Bureau to report prevalence of COVID-19 infections, mobility data, and population per state, respectively. Mobility data points were defined as daily length of visit or time spent in a single location based on mobile phone users shared locations from February 7 - March 29, 2020. Multivariable linear regression was used to evaluate relationships between normalized per capita infection prevalence and six parameters of social distancing.

Results: Mobility data indicated the following percent changes compared to median values of baseline activity: -50% in transit stations, -45% in retail/recreation, -36% in workplaces, -23% in grocery/pharmacy, -19% in parks, and +12% in residential living areas. Multivariable linear regression revealed significant correlation between prevalence of infection per capita and parameters of social distancing (= 0.604, ). Time at home was not an independent predictor for prevalence of infection per capita (beta= 0.016; 95% CI, -0.003 to 0.036; ).

Conclusion: Based on mobility reports from mobile phone GPS data and six characteristics of social distancing, significant associations were identified between geographic activity and prevalence of COVID-19 infections in the U.S. per capita. Mobile phone data utilizing 'location history' may be warranted to monitor the effectiveness of social distancing parameters on reducing prevalence of COVID-19 in the U.S.
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http://dx.doi.org/10.22038/abjs.2020.48515.2404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121034PMC
March 2021

Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Arthroscopy 2021 08 20;37(8):2677-2703. Epub 2021 Apr 20.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes.

Methods: PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data.

Results: A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction.

Conclusions: Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR.

Level Of Evidence: IV, systematic review and meta-analysis.
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http://dx.doi.org/10.1016/j.arthro.2021.03.058DOI Listing
August 2021

Preventative and Disease-Modifying Investigations for Osteoarthritis Management Are Significantly Under-represented in the Clinical Trial Pipeline: A 2020 Review.

Arthroscopy 2021 08 31;37(8):2627-2639. Epub 2021 Mar 31.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A. Electronic address:

Purpose: To conduct a review of active United States-based clinical trials investigating preventative, symptom resolution, and disease-modifying therapies for osteoarthritis (OA).

Methods: We conducted a review of currently active clinical trials for OA using data obtained from the ClinicalTrials.gov database as of August 2020. The inclusion criteria were active studies registered in the United States that involved the prevention, symptom resolution, or disease modification of OA. Descriptive statistics were recorded and summarized.

Results: A total of 3,859 clinical trials were identified, and 310 were included in the final analysis. Of the currently active trials, 89% (n = 275) targeted symptom resolution in patients with existing OA, 6% (n = 19) targeted OA disease-modifying therapeutics, and 5% (n = 16) targeted the prevention of OA in high-risk patients (P < .001). Primary interventions included medical devices (44%, n = 137), pharmaceutical drugs (14%, n = 42), surgical procedures (14%, n = 42), cellular biologics (13%, n = 41), and behavioral therapies (13%, n = 41). There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs (30% vs 14%) (P = .015). Most trials targeted the knee joint (63%, P = .042), with 38% of all trials evaluating joint arthroplasty. There were no significant differences between private sector and government funding sources (43% and 49%, respectively) (P = .288), yet there was a significantly lower rate of funding from industry (8%) (P = .026).

Conclusions: There was a significantly higher number of clinical trials investigating symptomatic resolution therapy (89%) for existing OA in comparison to preventative (5%) and disease-modifying (6%) therapies. The most common interventions involved medical devices and joint replacement surgery, with the knee joint accounting for more than 60% of the current clinical trials for OA. There was a significantly higher number of disease-modifying therapeutics for cellular biologics than pharmaceutical drugs. Funding of clinical trials was split between the private sector and government, with a low rate of reported funding from industry partners.

Clinical Relevance: Identifying existing needs in the current market may help increase rates of research funding or optimize current funding pathways, in this study, specifically for targeting unaddressed focus areas in OA research. Our systematic review highlights the potential need for additional research and development regarding OA preventative and disease-modifying therapies.
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http://dx.doi.org/10.1016/j.arthro.2021.03.050DOI Listing
August 2021

The future of meniscus science: international expert consensus.

J Exp Orthop 2021 Mar 31;8(1):24. Epub 2021 Mar 31.

Centre Hospitalier de Versailles, Versailles, France.

Purpose: The purpose of this study was to evaluate the main focus areas for research and development for furthering the state of meniscus science in 2021.

Methods: An electronic survey including 10 questions was sent in a blind fashion to the faculty members of the 5 International Conference on Meniscus Science and Surgery. These faculty served as an expert consensus on the future of research and development areas of meniscus science. Survey responses were analyzed using descriptive statistics and ranking weighted averages were calculated to score survey questions.

Results: Of the 82 faculty, 76 (93%) from 18 different countries completed the survey (84% male, 16% female). The highest ranked future research and development focus areas were meniscus repair, biologics, osteotomy procedures, addressing meniscus extrusion, and the development of new therapies for the prevention of posttraumatic osteoarthritis. Currently, the most 'valuable' type of biologic reported for meniscus treatment was platelet-rich plasma. The main reported global research limitation was a lack of long-term clinical outcomes data. The most promising emerging medical technologies for improving meniscus science were 3-D printing, personalized medicine, and artificial implants.

Conclusions: This survey suggests that the future of meniscus science should be focused on meniscal preservation techniques through meniscus repair, addressing meniscal extrusion, and the use of orthobiologics. The lack of long-term clinical outcomes was the main reported research limitation globally for meniscus treatment. Future product development utilizing emerging medical technologies suggest the use of 3-D printing for meniscal transplants/scaffolds, personalized treatment, and bioengineering for artificial implants.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1186/s40634-021-00345-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012449PMC
March 2021

Risk Factors for Ramp Lesions of the Medial Meniscus: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 11 10;49(13):3749-3757. Epub 2021 Feb 10.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Background: Failure to appropriately identify and repair medial meniscal ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR) may result in increased anterior tibial translation and internal rotation, increasing the risk for graft failure. Knowledge of the risk factors leading to the development of ramp lesions may enhance clinicians' vigilance in specific ACL-deficient populations and subsequently repair of these lesions at the time of ACLR.

Purpose: To perform a systematic review and meta-analysis of factors tested for associations with ramp lesions and to determine which were significantly associated with the presence of ramp lesions.

Study Design: Systematic review and meta-analysis; Level of evidence, 4.

Methods: PubMed, OVID/Medline, and Cochrane databases were queried in April 2020. Data pertaining to study characteristics and reported risk factors for ramp lesions were recorded. DerSimonian-Laird binary random-effects models were constructed to quantitatively evaluate the association between risk factors and ramp lesions by generating effect estimates in the form of odds ratios (ORs) with 95% CIs. Qualitative analysis was performed to describe risk factors that were variably reported.

Results: The review included 12 studies with 8410 patients. The overall pooled prevalence of ramp lesions was 21.9% (range, 9.0%-41.7%). A total of 45 risk factors were identified, of which 8 were explored quantitatively. There was strong evidence to support that posteromedial tibial edema on magnetic resonance imaging (MRI) (OR, 2.12; 95% CI, 1.27-3.56; = .004), age <30 years (OR, 2.02; 95% CI, 1.23-3.22; = .002), and complete ACL tears (OR, 3.0; 95% CI, 1.41-6.20; = .004) were risk factors for ramp lesions. There was moderate evidence to support that male sex (OR, 1.58; 95% CI, 1.36-1.83; < .001) and concomitant lateral meniscal tears (OR, 1.54; 95% CI, 1.11-2.13; = .009) were risk factors for ramp lesions. Chronic ACL injury (≥24 months) demonstrated minimal evidence as a risk factor (OR, 1.41; 95% CI, 1.14-1.74; = .001). No significant associations were determined between contact injury or revision ACLR and the presence of ramp lesions.

Conclusion: Significant associations between male sex, age <30 years, posteromedial tibial edema on MRI, concomitant lateral meniscal tears, complete ACL tears, injury chronicity, and the presence of ramp lesions were found. Contact injury and revision ACLR were not significantly associated with the presence of ramp lesions.
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http://dx.doi.org/10.1177/0363546520986817DOI Listing
November 2021

Increased posterior tibial slope results in increased incidence of posterior lateral meniscal root tears in ACL reconstruction patients.

Knee Surg Sports Traumatol Arthrosc 2021 Nov 1;29(11):3883-3891. Epub 2021 Feb 1.

Twin Cities Orthopedics, 4010 West 65th Street, Edina, MN, 55435, USA.

Purpose: While the association with acute anterior cruciate ligament (ACL) tears has been established, other risk factors and associated pathologies which occur with a concomitant lateral meniscal posterior root tear (LMPRT) are not well defined. The purpose of this study was to compare the risk factors and concomitant pathologies between patients with LMPRT and patients without LMPRTs in the setting of a primary ACL tear.

Methods: Patients with a LMPRT identified at the time of primary ACL reconstruction by a single surgeon were identified. These patients were matched by age and sex to patients undergoing primary ACL reconstruction who were not found to have lateral meniscus root tears (control group) in a 1:1 ratio. Lateral posterior tibial slope (PTS), medial PTS, lateral femoral condyle height and depth, lateral tibial plateau depth, and lateral tibial plateau subluxation were measured on MRI. Anteroposterior full-limb alignment radiographs were used to measure the medial proximal tibia angle (MPTA), the mechanical lateral distal femoral angle (mLDFA), and the mechanical weightbearing axis for the injured extremity.

Results: One-hundred three patients were included in both the LMPRT group and the matched control group. Patients with a LMPRT had a significantly steeper lateral PTS (9.1° vs. 7.0°, p = 0.001), a steeper medial PTS (7.0° vs. 6.0°, p = 0.03), and a greater lateral-to-medial slope asymmetry (2.0° vs. 1.0°, p = 0.001). There were no differences in lateral femoral condyle depth or height, lateral tibial plateau depth, lateral tibial plateau subluxation, MPTA, mLDFA, or mechanical weightbearing axis between groups. There was a significantly increased incidence of medial meniscus ramp lesions in patients with lateral meniscus posterior root tears compared with controls (34.0% vs. 15.5%, odds ratio: 2.8, p = 0.002). There were no associations with concomitant ligament injuries, medial meniscus root tears, or non-ramp tears based on case/control grouping.

Conclusion: In conclusion, LMPRTs in the setting of primary ACL injuries were associated with significantly increased lateral and medial PTSs, and increased asymmetry between lateral and medial PTSs. In addition, clinicians should be aware of the increased incidence of concurrent medial meniscal ramp lesions in patients with LMPRTs. Knowledge of these associations helps guide clinical decision-making and counselling of patients in the setting of ACL tears with concomitant LMPRTs.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06456-4DOI Listing
November 2021

Chondral Lesions of the Knee: An Evidence-Based Approach.

J Bone Joint Surg Am 2021 04;103(7):629-645

Twin Cities Orthopedics, Minneapolis, Minnesota.

: Management of chondral lesions of the knee is challenging and requires assessment of several factors including the size and location of the lesion, limb alignment and rotation, and the physical and mental health of the individual patient.

: There are a multitude of options to address chondral pathologies of the knee that allow individualized treatment for the specific needs and demands of the patient.

: Osteochondral autograft transfer remains a durable and predictable graft option in smaller lesions (<2 cm2) in the young and active patient population.

: Both mid-term and long-term results for large chondral lesions (≥3 cm2) of the knee have demonstrated favorable results with the use of osteochondral allograft or matrix-associated chondrocyte implantation.

: Treatment options for small lesions (<2 cm2) include osteochondral autograft transfer and marrow stimulation and/or microfracture with biologic adjunct, while larger lesions (≥2 cm2) are typically treated with osteochondral allograft transplantation, particulated juvenile articular cartilage, or matrix-associated chondrocyte implantation.

: Emerging technologies, such as allograft scaffolds and cryopreserved allograft, are being explored for different graft sources to address complex knee chondral pathology; however, further study is needed.
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http://dx.doi.org/10.2106/JBJS.20.01161DOI Listing
April 2021

Stress Radiographs for Ligamentous Knee Injuries.

Arthroscopy 2021 01;37(1):15-16

Norwegian School of Sports Sciences, Oslo Sports Trauma Research Center, Oslo, Norway; University of Oslo, Ulleval Hospital, Oslo, Norway.

Stress radiographs can provide an objective, quantifiable assessment of ligamentous knee injury. Commonly utilized techniques include varus, valgus, and posterior stress radiographs and can be used to augment findings on physical examination and magnetic resonance imaging. Both in vitro and in vivo studies have demonstrated reliability and validity of stress radiographs for diagnosing isolated and multiple ligament knee injuries. Varus stress radiographs are clinician applied at 20° flexion to detect injuries to the fibular collateral ligament and posterolateral corner. Valgus stress radiographs are clinician applied at 20° flexion to detect injuries to the medial collateral ligament or posteromedial corner. To evaluate the posterior cruciate ligament, posterior kneeling stress radiographs are obtained with the patient kneeling at 90° flexion on a firm platform. Bilateral radiographs are obtained and the side-to-side difference is compared to established criteria for injury severity. Stress radiographs support accurate diagnosis of complex knee injuries and also provide an objective measure of knee stability following ligament reconstruction. These imaging techniques can be performed in an ambulatory clinic setting with minimal additional equipment, and are thereby cost-effective, efficient, and support clinical decision-making in the treatment of complex knee injuries.
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http://dx.doi.org/10.1016/j.arthro.2020.11.001DOI Listing
January 2021

True Mechanical Alignment is Found Only on Full-Limb and not on Standard Anteroposterior Radiographs.

Arthrosc Sports Med Rehabil 2020 Dec 15;2(6):e753-e759. Epub 2020 Dec 15.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A.

Purpose: The purpose of this study was to compare alignment measured on standard anteroposterior (AP) radiographs versus full-length weight-bearing radiographs.

Methods: Patients were prospectively enrolled from June 2019 to August 2019 from a single orthopedic surgeon's practice if they were ≥ 18 years of age, obtained both AP and full-length alignment radiographs and were capable of full weight-bearing with appropriate positioning. Patients were excluded if they were < 18 years of age, had previous knee arthroplasty, previous knee or hip osteotomy, were unable to bear full weight on both limbs, and if the patient's body habitus precluded appropriate visualization of necessary landmarks on the radiographs. Tibiofemoral angles were measured on AP radiographs using 2 techniques (AP angles 1 and 2). Linear regression and paired tests were used to compare measurements. The minimal clinically important difference was defined as < 2°.

Results: There were 120 patients (62 males, 58 females) with an average age of 45 ± 17 years who were enrolled. There were positive correlations between average alignment on full-length weight-bearing and AP radiographs for AP angle 1 ( = 0.72) and AP angle 2 ( = 0.76) measurement techniques ( < .001). There was a significant difference in mean alignment between full-length weight-bearing and AP measurements (AP angle 1: 2.5° difference; AP angle 2: 4.4° difference; < .001). Frequency distributions for the minimal clinically important difference between true mechanical alignment and AP views demonstrated that 46.7% of patients had ≥ 2° difference for AP angle 1, and 78.3% of patients had ≥ 2° difference for AP angle 2.

Conclusion: The average absolute difference in alignment measured between standard AP radiograph and full-length weight-bearing radiograph views was significant, with 46.7% to 78.3% of patients having a greater than 2° absolute difference between these 2 views. In cases where precise objective alignment measurement is necessary, full-length weight-bearing radiographs are recommended over standard AP radiographs for presurgical planning so as to reduce potential error in over- or underestimation of the true mechanical alignment.

Study Design: Prospective case-comparison; Level of evidence, 1.
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http://dx.doi.org/10.1016/j.asmr.2020.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754530PMC
December 2020

Fibular Collateral Ligament Reconstruction Graft Options: Clinical and Radiographic Outcomes of Autograft Versus Allograft.

Arthroscopy 2021 03 27;37(3):944-950. Epub 2020 Oct 27.

Twin Cities Orthopaedics, Minneapolis, Minnesota, U.S.A.. Electronic address:

Purpose: To compare varus knee stability and clinical outcomes between patients who underwent fibular collateral ligament reconstruction (FCLR) or lateral collateral ligament (LCL) reconstruction with autografts versus allografts when undergoing concomitant anterior cruciate ligament reconstruction (ACLR).

Methods: All patients who underwent primary ACLR and concomitant FCLR from 2010 to 2017 performed by a single surgeon (R.F.L.) were retrospectively identified. Clinical characteristics and graft choices for FCLR were collected. Patients with a minimum 2-year follow-up for clinical outcome scores and 6-month stress radiographs were included. Patients with any other ligamentous procedure or revision ACLR were excluded.

Results: We identified 69 primary ACLR with concomitant FCLR patients who met the inclusion criteria. Fifty patients underwent FCLR with semitendinosus autografts, and 19 with allografts. There were no significant side-to-side differences (SSDs) in lateral compartment gapping on varus stress x-rays between the 2 cohorts (allograft, 0.49 mm; autograft, 0.15 mm, P = .22), and no FCLR failures. There were no significant differences between autograft and allograft groups at minimum 2-year outcomes for 12-Item Short Form mental or physical composite score (SF12 MCS, P = .134; SF12 PCS, P = .642), WOMAC total (P = .158), pain (P = .116), stiffness (P = .061), or activity (P = .252); International Knee Documentation Committee (IKDC) (P = .337), Tegner (P = .601), Lysholm (P = .622), or patient satisfaction (P = .218). There were no significant differences in clinical knee stability between groups at an average follow-up of 3.6 years (P = 1.0).

Conclusion: There were no differences in varus stress laxity 6 months postoperatively or clinical outcome scores at ≥2 years postoperatively between patients having FCL reconstructions with either autograft or allograft. This study demonstrates that both hamstring autografts and allografts for FCL reconstructions offer reliable and similar radiographic and clinical results at short-term follow-up.

Level Of Evidence: III, retrospective comparative trial.
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http://dx.doi.org/10.1016/j.arthro.2020.10.034DOI Listing
March 2021

Low-Energy Multiligament Knee Injuries Are Associated With Higher Postoperative Activity Scores Compared With High-Energy Multiligament Knee Injuries: A Systematic Review and Meta-analysis of the Literature.

Am J Sports Med 2021 07 30;49(8):2248-2254. Epub 2020 Oct 30.

Twin Cities Orthopedics, Edina, Minnesota, USA.

Background: Multiligament knee injuries (MLKIs) can result from high-energy injury mechanisms such as motor vehicle accidents or low-energy injury mechanisms such as activities of daily living or sports.

Purpose/hypothesis: The purpose was to conduct a systematic review on postoperative patient-reported outcomes after MLKIs and to conduct a meta-analysis of comparable outcome variables based upon high- versus low-energy injury mechanisms. It was hypothesized that MLKIs with low-energy injury mechanisms would demonstrate significantly improved subjective clinical outcome scores compared with high-energy injuries.

Study Design: Meta-analysis and systematic review.

Methods: A systematic review was performed with the inclusion criteria of postoperative MLKI outcomes based upon high-versus low-energy mechanisms of injury with a minimum 2-year follow-up. Outcome scores included were the Lysholm knee scoring scale, Tegner activity scale, and the International Knee Documentation Committee (IKDC) score. High-energy mechanisms included motor vehicle accidents or falls from a height >5 feet; low-energy mechanisms included sports-related injuries, activities of daily living, or falls from <5 feet. A meta-analysis was performed comparing the outcome scores of high- versus low-energy mechanisms of MLKIs.

Results: Overall, 1214 studies were identified, 15 of which were included in the systematic review and meta-analysis. Thirteen studies included surgical reconstructions of all injured ligaments. A total of 641 patients with 275 high-energy and 366 low-energy injuries were grouped for comparison in the meta-analysis. No significant differences in Lysholm scale (78.6 vs 78.0) or IKDC scores (69.0 vs 68.4) were found between high- and low-energy groups at a minimum of 2 years (range, 2-10 years) postoperatively ( > .05). The low-energy injury group demonstrated significantly higher Tegner activity scale scores (5.0 vs 3.9; = .03). There was no significant difference in failure rates between groups (3.5% vs 2.0%; = .23).

Conclusion: We found in this systematic review and meta-analysis that patients with low-energy mechanisms of MLKI surgery had improved postoperative Tegner activity scores compared with those patients with high-energy mechanisms after MLKI surgery. However, there were no differences in Lysholm score, IKDC score, or failure rates between high- and low-energy MLKI patients at an average of 5.3 years postoperatively.
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http://dx.doi.org/10.1177/0363546520962088DOI Listing
July 2021

Posterior Tibial Slope Measurements Using the Anatomic Axis Are Significantly Increased Compared With Those That Use the Mechanical Axis.

Arthroscopy 2021 01 17;37(1):243-249. Epub 2020 Sep 17.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A.. Electronic address:

Purpose: To compare posterior tibial slope (PTS) measurements from standard lateral knee radiographs with measurements from full-length lateral tibia radiographs.

Methods: We performed a multicenter, prospective study. Lateral knee and full-length lateral tibia radiographs were obtained for each patient, and PTS was measured. Slope measurements were obtained by measuring the angle between an average of the medial and lateral tibial plateaus and a representative tibial diaphysis line. The proximal anatomic axis was measured on lateral knee radiographs, and both the mechanical axis and anatomic axis were measured on full-length lateral tibia radiographs. The mechanical axis was defined as the center of the plateau to the center of the plafond, and the anatomic axis was defined as the center of the tibial diaphysis. The minimal clinically significant difference was defined a priori as 2° of PTS or greater.

Results: A total of 140 patients met the inclusion criteria. The average PTS using the proximal anatomic axis was 11.6° ± 3.2° on lateral knee radiographs; the PTS measured on full-length lateral tibia radiographs was 9.5° ± 3.4° using the mechanical axis and 11.8° ± 3.1° using the anatomic axis. There was a significant difference between the measurements with the mechanical axis and both anatomic axis measurements (P < .01) but no significant difference between the 2 anatomic axis measurement techniques (P = .574). In total, 55% of patients (n = 77) had a 2° or greater difference between the proximal anatomic axis and mechanical axis PTS measurement techniques.

Conclusions: There was no significant difference between PTS measurements that used the proximal anatomic axis from lateral knee radiographs and those that used the anatomic axis from full-length lateral tibia radiographs. Thus, lateral knee radiographs are adequate to accurately obtain tibial slope measurements. However, there was a significant difference between PTS measurements that used the anatomic axis and those that used the mechanical axis of the tibia.

Clinical Relevance: It is recommended that future studies report tibial slope based upon measurements that utilize the anatomic axis in order to ensure that subsequent conclusions are comparable, independent of the radiographic view.
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http://dx.doi.org/10.1016/j.arthro.2020.09.006DOI Listing
January 2021

Beighton Score, Tibial Slope, Tibial Subluxation, Quadriceps Circumference Difference, and Family History Are Risk Factors for Anterior Cruciate Ligament Graft Failure: A Retrospective Comparison of Primary and Revision Anterior Cruciate Ligament Reconstructions.

Arthroscopy 2021 01 7;37(1):195-205. Epub 2020 Sep 7.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A.. Electronic address:

Purpose: To assess patient history, physical examination findings, magnetic resonance imaging (MRI) and 3-dimensional computed tomographic (3D CT) measurements of those with anterior cruciate ligament (ACL) graft failure compared with primary ACL tear patients to better discern risk factors for ACL graft failure.

Methods: We performed a retrospective review comparing patients who underwent revision ACL reconstruction (ACLR) with a primary ACLR group with minimum 1-year follow-up. Preoperative history, examination, and imaging data were collected and compared. Measurements were made on MRI, plain radiographs, and 3D CT. Inclusion criteria were patients who underwent primary ACLR by a single surgeon at a single center with minimum 1-year follow-up or ACL graft failure with revision ACLR performed by the same surgeon.

Results: A total of 109 primary ACLR patients, mean age 33.7 years (range 15 to 71), enrolled between July 2016 and July 2018 and 90 revision ACLR patients, mean age 32.9 years (range 16 to 65), were included. The revision ACLR group had increased Beighton score (4 versus 0; P < .001) and greater side-to-side differences in quadricep circumference (2 versus 0 cm; P < .001) compared with the primary ACLR group. A family history of ACL tear was significantly more likely in the revision group (47.8% versus 16.5%; P < .001). The revision group exhibited significantly increased lateral posterior tibial slope (7.9° versus 6.2°), anterolateral tibial subluxation (7.1 versus 4.9 mm), and anteromedial tibia subluxation (2.7 versus 0.5 mm; all P < .005). In the revision group, femoral tunnel malposition occurred in 66.7% in the deep-shallow position and 33.3% in the high-low position. The rate of tibial tunnel malposition was 9.7% from medial to lateral and 54.2% from anterior to posterior. Fifty-six patients (77.8%) had tunnel malposition in ≥2 positions. Allograft tissue was used for the index ACLR in 28% in the revision group compared with 14.7% in the primary group.

Conclusion: Beighton score, quadriceps circumference side-to-side difference, family history of ACL tear, lateral posterior tibial slope, anterolateral tibial subluxation, and anteromedial tibia subluxation were all significantly different between primary and revision ACLR groups. In addition, there was a high rate of tunnel malposition in the revision ACLR group.
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http://dx.doi.org/10.1016/j.arthro.2020.08.031DOI Listing
January 2021

Peripheral Stabilization Suture to Address Meniscal Extrusion in a Revision Meniscal Root Repair: Surgical Technique and Rehabilitation Protocol.

Arthrosc Tech 2020 Aug 7;9(8):e1211-e1218. Epub 2020 Aug 7.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A.

Meniscal root tears are an increasingly recognized condition. These tears can cause the meniscus to become extruded outside the joint, which can diminish the biomechanical functionality of the meniscus. Anatomic repair of the meniscal root has previously been described, but this surgical procedure may not adequately address severe extrusion of the meniscal tissue. Additionally, when a primary anatomic repair fails, meniscal extrusion can increase, which can possibly accelerate joint degeneration if untreated. Therefore, the purpose of this Technical Note is to describe our surgical technique for revision medial meniscal root repair with a peripheral stabilization suture to address medial meniscal root tears with severe meniscal extrusion.
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http://dx.doi.org/10.1016/j.eats.2020.04.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451443PMC
August 2020

Treatment for Symptomatic Genu Recurvatum: A Systematic Review.

Orthop J Sports Med 2020 Aug 12;8(8):2325967120944113. Epub 2020 Aug 12.

Twin Cities Orthopedics, Edina, Minnesota, USA.

Background: Symptomatic genu recurvatum is a challenging condition to treat. Both osseous and soft tissue treatment options have been reported to address symptomatic genu recurvatum.

Purpose/hypothesis: The purpose of this article was to review the current literature on surgical treatment options for symptomatic genu recurvatum and to describe the associated clinical outcomes. We hypothesized that anterior opening-wedge proximal tibial osteotomy (PTO) would be the most common surgical technique described in the literature and that this intervention would allow for successful long-term management of symptomatic genu recurvatum.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the inclusion criterion of surgical treatment options for symptomatic genu recurvatum. Recurvatum secondary to polio, cerebrovascular accident, or cerebral palsy was excluded from this review.

Results: A total of 311 studies were identified, of which 6 studies with a total of 80 patients met the inclusion criteria. Causes of genu recurvatum included physeal arrest; soft tissue laxity; and complications related to fractures, such as prolonged immobilization and malalignment. Mean follow-up times ranged from 1 to 14.5 years postoperatively. There were 5 studies that described anterior opening-wedge PTO, 2 of which used the Ilizarov distraction technique. All 3 studies that used PTO without the Ilizarov technique reported correction of recurvatum and increased posterior tibial slope; 2 of these studies also included subjective outcomes scores, reporting good or excellent outcomes in 70% (21/30) of patients. Of the studies that used the Ilizarov technique, both reported correction of recurvatum and increased posterior slope from preoperative to postoperative assessments. Both of these studies reported good or excellent subjective outcomes postoperatively in 89.5% (17/19) of patients. Additionally, 1 study successfully corrected recurvatum by performing a retensioning of the posterior capsule to address knee hyperextension, although follow-up was limited to 1 year postoperatively.

Conclusion: Anterior opening-wedge PTO, with or without postoperative external fixation with progressive distraction, was found to be a reliable surgical treatment for symptomatic genu recurvatum. After surgical management with PTO, patients can expect to achieve correction of knee hyperextension, restoration of a more posterior tibial slope, and increased subjective outcome scores.
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http://dx.doi.org/10.1177/2325967120944113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425269PMC
August 2020

Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis in Skeletally Immature Patients: Surgical Technique.

Arthrosc Tech 2020 Jul 9;9(7):e897-e903. Epub 2020 Jun 9.

Twin Cities Orthopedics, Edina, Minnesota, U.S.A.

Pediatric anterior cruciate ligament (ACL) reconstructions have a relatively high risk for re-rupture, and a low proportion of these patients report a successful return to sport. With an increasing emphasis on youth participation in pivoting sports, the incidence of these injuries has increased in recent years. A reappreciation of lateral extra-articular stabilizing procedures in high-risk adult populations who undergo ACL reconstruction has demonstrated potential improved outcomes for vulnerable ACL reconstructions. However, the open status of the pediatric physes makes the use of these procedures more challenging. Therefore, the purpose of this Technical Note is to describe the current authors' surgical technique for a combined ACL reconstruction with a lateral extra-articular tenodesis for these high-risk patients with open physes.
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http://dx.doi.org/10.1016/j.eats.2020.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372307PMC
July 2020

High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2020 07;48(9):2185-2194

Twin Cities Orthopedics, Edina, Minnesota, USA.

Background: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known.

Purpose: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR.

Study Design: Cohort study; Level of evidence, 3.

Methods: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present.

Results: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR ( < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = -0.156; = .023), WOMAC total (PCC = 0.159; = .02), Lysholm (PCC = -0.203; = .003), and Tegner scores (PCC = -0.151; = .032).

Conclusion: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.
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http://dx.doi.org/10.1177/0363546520932912DOI Listing
July 2020

Medial Meniscus Root Repair in Patients With Open Physes.

Arthrosc Tech 2020 Jun 15;9(6):e723-e728. Epub 2020 Jun 15.

Twin Cities Orthopedics, Edina, MN, U.S.A.

Meniscal root tears have become increasingly recognized in the past decade. Lateral meniscus root tears typically occur in active, younger patients who sustain acute anterior cruciate ligament tears. Conversely, medial meniscus root tears typically occur in isolation and affect middle-aged patients. However, recent reports have described the incidence of meniscal root tears occurring in pediatric populations who are skeletally immature. The purpose of this technical note is to describe the authors' surgical technique for medial meniscal root repair for patients with open physes.
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http://dx.doi.org/10.1016/j.eats.2020.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301213PMC
June 2020

Clinical Characteristics and Outcomes After Primary ACL Reconstruction and Meniscus Ramp Repair.

Orthop J Sports Med 2020 Apr 24;8(4):2325967120912427. Epub 2020 Apr 24.

Twin Cities Orthopedics, Edina, Minnesota, USA.

Background: Satisfactory outcomes have been reported after all-inside meniscus ramp repair with combined anterior cruciate ligament reconstruction (ACLR). However, clinical outcomes after ACLR with inside-out meniscus ramp repair are limited.

Purpose/hypothesis: The purpose of this study was to evaluate patient-reported outcomes for patients who underwent ACLR and medial meniscus ramp repair compared with those who underwent isolated ACLR; patients in the 2 groups were matched for age, sex, and sport/activity. The null hypothesis was that there would be no significant differences in clinical outcomes between groups at a minimum of 2 years postoperatively.

Study Design: Cohort study; Level of evidence 3.

Methods: Patients who underwent primary ACLR with bone-patellar tendon-bone (BPTB) autograft by a single surgeon were retrospectively identified. A subgroup of patients with combined ACLR and meniscus ramp repair with a minimum 2-year postoperative follow-up were matched to a cohort who underwent isolated ACLR. Subjective patient-reported questionnaires, knee stability, and return to level of activity/sport were collected.

Results: There were 851 patients who underwent primary ACLR; of these, 158 (18.6%) had medial meniscus ramp lesions confirmed at arthroscopy. The most common clinical characteristics in patients with ramp lesions were chronic injuries (68.4%), contact mechanism (88%), concomitant lateral meniscus tears (63.2%), and concomitant lateral meniscus posterior root tears (22.2%). Further, 50 patients who underwent combined ACLR and meniscus ramp repair with minimum 2-year follow-up were matched to patients who underwent isolated ACLR. Both groups reported significant improvements in subjective outcomes from preoperative to postoperative assessments ( < .001). No significant differences were found in postoperative outcomes for combined ACLR with ramp repair versus isolated ACLR ( > .05). Patients with meniscus ramp repair had increased preoperative knee laxity demonstrated by grade 3 Lachman (44% vs 6%) and pivot-shift (38% vs 12%) test results compared with patients who underwent isolated ACLR ( ≤ .005 for both).

Conclusion: This study demonstrates similar clinical outcomes, knee stability on postoperative physical examination, and return-to-sport rates for patients who underwent combined ACLR with BPTB autograft and inside-out meniscus ramp repair versus a matched cohort who underwent isolated ACLR. Clinicians should have a high index of suspicion for the presence of ramp lesions in patients with ACL tears who have a contact mechanism of injury, grade 3 Lachman test result, and concomitant lateral meniscal abnormality.
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http://dx.doi.org/10.1177/2325967120912427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218952PMC
April 2020

The identification and treatment of snapping posterior tendons of the knee improves patient clinical outcomes.

Knee Surg Sports Traumatol Arthrosc 2021 Mar 7;29(3):908-913. Epub 2020 May 7.

Twin Cities Orthopedics, 4060 West 65th Street, Edina, MN, 55435, USA.

Purpose: To assess the most common presenting symptoms, clinical outcomes, and patient satisfaction following treatment of either snapping medial pes anserinus hamstrings or snapping lateral biceps femoris tendons.

Methods: Consecutive patients with a minimum 2-year follow-up after isolated medial hamstring release for a diagnosis of medial snapping pes anserinus tendons or patients treated with primary biceps repair for lateral snapping biceps femoris tendons were evaluated. Clinical outcome scores of the following domains were collected: SF12, WOMAC score, Lysholm Knee Survey, and a simple numeric patient satisfaction score (0-10). Statistical analysis was performed with paired t-tests between preoperative and postoperative scores.

Results: At an average follow-up of 4.6 years (range 2.0-8.6 years) with two patients lost to follow-up, six consecutive patients (three male, three female) with seven knees were diagnosed with medial snapping pes anserinus tendons and treated with semitendinosus and gracilis tenotomies. Seven knees in seven patients (three male, four female) were diagnosed with lateral snapping biceps femoris tendons and were treated with an isolated biceps femoris repair. Nine of 13 patients were able to return to full desired activities/pre-operative level of sporting activities (4/6 medial, 5/7 lateral. Lysholm and SF-12 scores improved from preoperative to post-operative status for patients with snapping biceps femoris. Only patients undergoing primary biceps repair showed improvement across all WOMAC domains. Patients with medial hamstring tenotomy demonstrated improvement in Lysholm scores. Median postoperative satisfaction for both pathologies was 7 out of 10.

Conclusion: Medial hamstring release for snapping pes anserinus and isolated biceps repair for lateral snapping biceps femoris yields improvement in patient satisfaction and clinical outcomes at mid-term follow-up.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-020-06046-wDOI Listing
March 2021

Editorial Commentary: Comparing Medial and Lateral Meniscal Root Tears Is Like Comparing Apples and Oranges.

Arthroscopy 2020 04;36(4):1142-1144

Edina, Minnesota.

The importance of treating meniscal root tears has been increasingly recognized, and surgeons have to make conscious decisions routinely regarding repair for select patients. The clinical and patient demographic differences between medial and lateral meniscal root tears are important and ultimately leave us wondering whether outcome differences are due to unique anatomic factors or the patient population sustaining these injuries.
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http://dx.doi.org/10.1016/j.arthro.2020.01.016DOI Listing
April 2020
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