The tibial tubercle osteotomy (TTO) is a versatile surgical approach for patellofemoral joint conditions, with nonunion, fracture, and recurrent instability as common indications for revision. This case series describes the management and outcomes of revision TTOs performed for these complications. A retrospective review of 20 patients undergoing revision TTO was conducted. Patients were included if they underwent revision for nonunion, delayed union, or fracture after primary TTO. Data collected included patient demographics, primary and revision TTO details, concurrent procedures, biological adjuncts, fixation methods, and clinical outcomes. Outcomes measured were union rates, time to healing, and subsequent revision. The mean age of the cohort was 26.8 +/- 11.7 years, with a mean follow-up of 2.6 +/- 2.7 years. Indications for revision were nonunion (70%), fracture (15%), and recurrent instability (15%). Biological augmentation, including bone marrow aspirate concentrate (BMAC), was used in 80% of revisions. Following revision TTO, 65% achieved union at a mean time of 14.6 +/- 5.0 weeks, 15% had delayed union (mean time to union 11.9 +/- 6.7 weeks), and 15% required a second revision for nonunion, achieving union at a mean time of 15.2 +/- 12.7 weeks. Patients with delayed union were older (38 +/- 12 years, p = 0.049) and had higher rates of vitamin D deficiency. Revision TTO is effective in addressing nonunion, delayed union, and fractures, with a majority achieving union after revision or re-revision. Strategies such as robust fixation, biological augmentation (e.g., BMAC), and management of comorbidities, including vitamin D deficiency, play a critical role in optimizing outcomes. Further research is needed to standardize protocols and improve union rates in high-risk populations. What are the new findings: This 20-patient case series focuses specifically on revision TTO, reporting granular management and outcomes-65% union after revision, union after all re-revisions, 80% use of biologic augmentation, and an observed association of delayed union with older age and vitamin D deficiency. This adds actionable details on biologic use and fixation escalation and spotlights potentially modifiable risk factors in the revision setting.
Total knee arthroplasty (TKA) is the treatment of choice for knee osteoarthritis. When it is associated with moderate and severe valgus deformities, surgical correction has proven to be more complex. However, there are scarcely any long-term studies assessing this treatment. The aim of this study was to analyze the long-term evolution of a cohort of patients with moderate or severe valgus deformities versus a control group with mild deformities. A total of 1,223 primary TKAs with a mean follow-up of 20.3 years were retrospectively reviewed. A total of 141 TKAs with moderate or severe valgus deformities (hip-knee-ankle [HKA] angle equal to or greater than 190 degrees) were compared with a control group of 1,083 TKAs with mild deformities (HKA between 170 and 190 degrees). Patients were evaluated preoperatively and postoperatively at 1, 3, 5, 8, and 13 years after surgery. The minimum follow-up done was 13 years. In addition, any complications, reinterventions, replacements, and deaths were registered until the end of the follow-up. Preoperatively, the moderate-severe valgus deformities group showed significantly worse Knee Score results than the control group ( p < 0.001), while the range of motion was better in the moderate-severe valgus deformities group ( p < 0.001). The postoperative outcomes were not statistically different in either group. There were no differences in the complications until the 8th year; however, from this year on and especially from 13 years after surgery, complications increased significantly ( p < 0.001) in the moderate-severe valgus deformities group. A long-term observation of a group of TKAs with preoperative moderate or severe valgus deformities, compared with a group with mild deformities, shows that complications increase significantly 13 years after surgery.
Abstract To determine whether medial tibial plateau fracture-dislocations with posterolateral central depression demonstrate radiographic features consistent with an anterior cruciate ligament (ACL)-type anterolateral rotatory injury pattern, characterized by anterior tibial translation and internal rotation. Retrospective radiologic evaluation of adult patients who underwent surgery for medial plateau fracture-dislocation with associated posterolateral central depression. Only patients with both preoperative computed tomography (CT) and magnetic resonance imaging (MRI) were included. Imaging was assessed for features associated with anterolateral tibiofemoral rotational injuries, including pivot-shift edema, anterior subluxation of the lateral compartment, tibial eminence fractures, meniscal pathology (root and intrasubstance tears), and Segond fractures. Two independent dual fellowship–trained sports traumatology orthopaedic surgeons reviewed all imaging. Categorical variables were reported as proportions and continuous variables as means with standard deviations. Institutional research ethics board approval was obtained. Eighteen patients met inclusion criteria. The mean age was 37 (± 11) years, and 72% were male. Pivot-shift femoral edema, anterior subluxation of the lateral compartment on MRI, tibial eminence fracture at the ACL footprint, and posterolateral central tibial depression were present in all cases (18/18, 100%). Lateral meniscal root pathology was also universal, with lateral meniscus incarceration into the posterolateral depression observed in eight patients (44%). A Segond fracture was identified in nine patients (50%). Medial tibial plateau fracture-dislocations with posterolateral central depression demonstrate a consistent pattern of osseous and soft-tissue injury associated with anterolateral rotation. These findings suggest that transverse plane assessment may complement traditional fracture-based evaluation and help identify associated soft-tissue injuries that may be important to tibiofemoral stability.
Abstract Multiligamentous knee injuries (MLKIs) in pediatric patients generally occur due to high-energy mechanisms, exhibiting unique injury patterns when compared with adults. Further understanding of the injury patterns, functional outcomes, and postsurgical complications in pediatric patients sustaining MLKIs is warranted. This study aimed to systematically review the literature to evaluate causes and outcomes of MLKIs in pediatric patients. Studies published in PubMed, Embase, and the Cochrane Library reporting on MLKIs in the pediatric population from inception to January 2026 were identified. Inclusion criteria included studies written in English reporting on pediatric patients (≤ 18 years) undergoing management of MLKIs, with reported lesion etiology, surgical technique, postoperative complications, reoperations, and any patient-reported outcomes. Four studies comprising 142 patients with a weighted mean follow-up of 41.2 months (range 9.5–204) were identified. The weighted mean patient age and body mass index (BMI) were 16.2 years (range 6–18) and 24.9 kg/m2 (range 17.9–41.6), respectively, with 69.7% (n = 99/142) of patients being male. The most common injury mechanism was sports-related (70.6%, n = 96/136). The posterolateral corner (PLC) was the most commonly injured structure in 71.1% (n = 101/142) of patients, followed by injuries to the posterior cruciate ligament (PCL; 66.2%, n = 94/142) and anterior cruciate ligament (ACL; 57.7%, n = 82/142). Surgical reconstruction was performed in 96.0% (n = 97/101) of PLC-involved injuries, 98.9% (n = 93/94) of PCL injuries, 98.8% (n = 81/82) of ACL injuries, and 48.4% (n = 15/31) of medial collateral ligament (MCL) injuries. Repair was performed in 4.0% (n = 4/101) of PLC injuries, 1.1% of PCL injuries (n = 1/94), 1.2% (n = 1/82) of ACL injuries, and 38.7% (n = 12/31) of MCL injuries. Complications were reported in 36% (n = 19/53) of patients, most commonly stiffness (11.3%, n = 6/53) and reconstruction failure (5.7%, n = 3/53). Revision procedures were reported in 7.5% (n = 4/53) of patients. MLKIs in pediatric patients are most commonly reported following sport-related mechanisms, with the PLC and PCL most frequently involved. Surgical reconstruction is more frequently reported when compared with repair procedures, with complications and revision surgery reported in 36% and 7.5% of patients, respectively.
Abstract This study aimed to develop and internally evaluate a multidimensional nomogram incorporating intraoperative cartilage damage and perioperative synovial fluid biomarkers to estimate the probability of poor functional recovery at 3 months after total knee arthroplasty (TKA). A retrospective cohort of 360 patients undergoing primary unilateral TKA was included in this study. Interleukin-6 (IL-6), tumor necrosis factor-α, cartilage oligomeric matrix protein (COMP), and total BDNF were measured in perioperative synovial fluid specimens collected after induction of anesthesia and before skin incision and were assessed together with intraoperative Outerbridge cartilage damage grade and routinely available demographic and clinical variables. The primary outcome was functional recovery at 3 months, defined by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscale. Least absolute shrinkage and selection operator regression was used for predictor selection, and a nomogram was developed using multivariable logistic regression. Model performance was evaluated using area under the curve (AUC), calibration, and decision curve analysis (DCA). Six predictors were retained in the final model: age, body mass index, preoperative WOMAC function score, Outerbridge grade, log(IL-6), and log(COMP). The nomogram showed promising discrimination in the held-out internal test set (AUC = 0.861, 95% CI: 0.782–0.934) and acceptable calibration (Hosmer–Lemeshow test, p = 0.45). Bootstrap optimism correction yielded a bias-corrected AUC of 0.842. DCA suggested potential net benefit across the evaluated threshold probabilities. The nomogram integrates clinical characteristics, intraoperative cartilage damage, and perioperative synovial fluid biomarkers to estimate the probability of poor functional recovery at 3 months after TKA. It should be regarded as a development-stage perioperative prediction model that requires prospective external validation before any clinical application.
