Background: Distal tibial deformities are not assessed using the proximal anatomical axis (PAA) to determine the posterior tibial slope (PTS). Therefore, it seems advantageous to measure PTS on full-length lateral tibial radiographs using the mechanical axis (MA). Purposes: To (1) compare the PTS measurements using the MA and the PAA and (2) determine whether using the PAA fails to detect a certain number of significantly elevated PTS values compared with using the MA. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Full-length lateral tibial radiographs of 218 consecutive cases were reviewed. Radiographs were checked for malrotation. Therefore, the distance between the posterior tibial condyles was measured in millimeters. Patients with a difference of ≥7 mm between the posterior tibial condyles were excluded, leaving 196 cases for the final statistical analysis. The PTS was measured using the MA and the PAA. Differences between these 2 techniques were analyzed. The sensitivity and specificity of the PAA as a screening method for pathological PTS were calculated, with the MA as the standard for comparison. Four subgroups were formed, all with PAA <12° and different lower limits for the MA: group 1, MA ≥10°; group 2, MA ≥10.5°; group 3, MA ≥11°; and group 4, MA ≥11.5°. Results: Radiographs with ≥7 mm between the posterior tibial condyles showed an increased inconsistency between the PTS measurement with the MA and the PAA. In the group with a distance of <7 mm between the posterior tibial condyles (n = 196), the mean PTS measured with the MA was 9.4°± 3.8° (range, 0.4° to 21.9°), and the mean PTS was 10.5°± 3.5° (range, 1.7° to 20.9°) according to the PAA. The mean difference in PTS between the PAA and the MA was 1.1°± 1.2° (range, –2.4° to 4.1°; P < .001). Group 1 had a sensitivity of 73% and specificity of 98%; group 2, sensitivity of 84% and specificity of 97%; group 3, sensitivity of 87% and specificity of 93%; and group 4, sensitivity of 95% and specificity of 89%. Conclusion: Measuring the PTS using the MA was advantageous, as the measurement with the PAA did not correctly identify all cases with sagittal alignment changes. The proportion of patients with pathologically increased PTS not identified with the proximal anatomical measurement, reflected by the sensitivity, depended on the threshold value defined for the MA. Lateral radiographs, showing an increased distance between the posterior tibial condyles, indicated malrotation of the tibia leading to measurement inaccuracy.

Background: Previous biomechanical studies have identified capsular closure, labral repair or reconstruction, and osteochondroplasty as important surgical interventions to improve hip stability. Purpose: To investigate the outcome metrics used to quantify hip stability and assess and measure the relative contributions of the labrum, capsule, and bone to hip stability through a quantitative analysis. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed and Embase databases were searched using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies evaluated cadaveric hip biomechanics related to capsular, labral, and bony management during hip arthroscopy. Studies were assessed for distraction force and distance, fluid measures, and contact forces used to quantify the suction seal. Exclusion criteria included open surgery, arthroplasty, reorientation osteotomy, or traumatic dislocation. Results: A total of 33 biomechanical studies comprising 322 hips that evaluated 1 or more of the following were included: distraction force or distance (24 studies), fluid measures (10 studies), and contact forces (6 studies). Compared with a capsulotomy or capsulectomy, capsular repair or reconstruction demonstrated greater resistance to distraction (standardized mean difference [SMD], 1.13; 95% CI, 0.46-1.80; P = .0009). Compared with a labral tear, a labral repair or reconstruction demonstrated less resistance to distraction (SMD, -0.67; 95% CI, -1.25 to -0.09; P = .02). Compared with a labral debridement, repair or reconstruction demonstrated greater resistance to distraction (SMD, 1.74; 95% CI, 1.23 to 2.26; P < .00001). No quantitative analysis was feasible from studies evaluating the effect of osseous resection due to the heterogeneity in methodology and outcome metrics assessed. Conclusion: Most biomechanical evidence supports capsulotomy repair or reconstruction to improve hip distractive stability at the end of hip arthroscopic surgery. While the repair of a torn labrum does not improve distractive resistance, it is superior to labral debridement in most biomechanical studies.

BACKGROUND:Injuries to the medial collateral ligament (MCL), specifically the deep MCL (dMCL) and superficial MCL (sMCL), are both reported to be factors in anteromedial rotatory instability (AMRI); however, a partial sMCL (psMCL) injury is often present, the effect of which on AMRI is unknown. PURPOSE:To investigate the effect of a dMCL injury with or without a psMCL injury on knee joint laxity. STUDY DESIGN:Controlled laboratory study. METHODS:Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. The anterior cruciate ligament (ACL) was cut first and last in protocols 1 and 2, respectively. The dMCL was cut completely, followed by an intermediary psMCL injury state before the sMCL was completely sectioned. Tibiofemoral kinematics were measured at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 4 N·m of external tibial rotation, 4 N·m of internal tibial rotation, and combined 89 N of anterior tibial translation and 4 N·m of external tibial rotation for both anteromedial rotation (AMR) and anteromedial translation. The differences between subsequent states, as well as differences with respect to the intact state, were analyzed. RESULTS:In an ACL-intact or -deficient joint, a combined dMCL and psMCL injury increased external tibial rotation and VR compared with the intact state at all angles. A significant increase in AMR was seen in the ACL-intact knee after this combined injury. Cutting the dMCL alone showed lower mean increases in AMR compared with the psMCL injury, which were significant only when the ACL was intact in knee flexion. Moreover, cutting the dMCL had no effect on VR. The ACL was the most important structure in controlling anteromedial translation, followed by the psMCL or dMCL depending on the knee flexion angle. CONCLUSION:A dMCL injury alone may produce a small increase in AMRI but not in VR. A combined dMCL and psMCL injury caused an increase in AMRI and VR. CLINICAL RELEVANCE:In clinical practice, if an increase in AMRI at 30° and 90° of knee flexion is seen together with some increase in VR, a combined dMCL and psMCL injury should be suspected.

Background: New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)–injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. Purpose: To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL–deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. Results: Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR ( P < .05). All reconstructions restored VR to the intact state except at 90° of knee flexion ( P < .05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position ( P < .05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT ( P < .05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion ( P < .05). Conclusion: In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. Clinical Relevance: In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs.

PurposeTo provide an update on the incidence and extent of graft extrusion following meniscus allograft transplantation (MAT) and to systematically review the literature to identify if the type of root fixation or additional surgical techniques may reduce the risk of developing graft extrusion.MethodsA systematic search, in accordance with the PRISMA guidelines, was conducted using the MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Patients undergoing medial meniscal allograft transplantation (MMAT) or Lateral MAT (LMAT) were included. The primary outcome measure was meniscal extrusion measured on post-operative MRI taken > 6 weeks after the MAT. The following extrusion outcomes were investigated; Absolute extrusion (AE), Relative percentage extrusion (RPE), Proportion of major extrusion (PME). Additional surgical techniques that reduced the risk of developing graft extrusion in the included comparative studies were identified.ResultsFor MMAT, the pooled mean extrusion outcomes were; AE 3.2 mm vs 3.36 mm and RPE 44.43% vs 33.18% for soft tissue versus (vs) bony fixation, respectively. The pooled mean PME for soft tissue fixation MMAT was 51.62%. For LMAT, the pooled mean extrusion outcomes were; AE: 3.72 mm vs 2.78 mm , RPE: 31.89% vs 29.47% and PME: 64.37% vs 35.80% for soft tissue vs bony fixation, respectively. Additional capsulodesis was identified as a technique to reduce LMAT extrusion.ConclusionThis study highlights that graft extrusion is a common finding following MMAT and LMAT, independent of the root fixation technique. However, MAT extrusion with bony fixation was, depending on the outcome measurement, lower or equal to soft tissue fixation.

PurposeThe purpose of this pilot cross-sectional study was to compare the operating room (OR) efficiency and intraoperative staff task load when performing individualised versus off-the-shelf (OTS) total knee arthroplasty (TKA).MethodsA consecutive series of 28 patients randomised (1:1) to receive either OTS TKA or individualised TKA were included. The OR staff workload was assessed with the NASA Task Load Index (TLX), a subjective grading system assessing mental demand, physical demand, temporal demand, performance, effort and frustration on a scale from 0 (very low) to 20 (very high). The time for patient preparation, surgical time, closure and total OR time was recorded to assess OR efficiency. Effect sizes of differences between OTS and individualised TKA were expressed as mean differences (MDs) with 95% confidence intervals (CIs).ResultsPatients in both cohorts were similar in age (OTS vs. individualised TKA (median [IQR]), 67 [63-76] vs. 71 [68-79]; p = 0.207) and body mass index (BMI) (29 [24-33] vs. 29 [26-31]; p = 0.807), and there were no significant differences in other preoperative characteristics. The OR staff perceived individualised TKA as less demanding than OTS TKA: Individualised TKA was rated significantly better across the six domains of the NASA TLX: mental demand by 5.6 points, physical demand by 6.3 points, temporal demand by 5.3 points, performance by 3.6 points, effort by 5.9 points and frustration by 5.8 points. Individualised TKA resulted in statistically significantly shorter mean total OR time (MD, 10 min; p = 0.018).ConclusionThe staff in the OR found that individualised TKA is less mentally, physically and temporally demanding than OTS TKA. The average total time spent in the OR during individualised TKA is 10 min less than during OTS TKA.Clinical Trial RegistrationThis study constitutes a part of a larger registered randomised controlled trial comparing patient satisfaction following OTS versus individualised TKA (NCT04460989).Level of EvidenceLevel III.

Purpose: The purpose of this study was to compare postoperative patellar tilt at 4 months follow-up in a consecutive series of randomised patients that received individualised or off-the-shelf (OTS) primary total knee arthroplasty (TKA). The hypothesis was that patellar tilt would be lower and less variable in patients who received individualised TKA compared to patients who received OTS TKA. Methods: A consecutive series of 385 patients randomised (1:1) to receive either OTS TKA or individualised TKA were analysed. Pre- and postoperative radiographs at 4 months were obtained of weight-bearing long leg, anterior-posterior and lateral knee views and a skyline view at 30 degrees of flexion. Postoperative patellar tilt was measured between the anterior femoral line and patellar resection surface (beta) and the anterior femoral line and mediolateral patellar axis (sigma). Postoperative patellar tilt (absolute value) was compared between the individualised and OTS TKA groups based on preoperative phenotypes of their femoral mechanical angle, tibial mechanical angle and hip-knee-ankle angle. Variability in postoperative patellar tilt was compared using the 95% confidence intervals (CIs). Results: Comparisons of baseline patient characteristics revealed no difference between the individualised and OTS TKA groups. Comparison of absolute postoperative patellar tilt revealed significant differences between individualised and OTS TKA (|beta|, 1.0 degrees +/- 1.0 degrees and 2.5 degrees +/- 2.2 degrees, respectively, p < 0.001; |sigma|, 1.7 degrees +/- 1.6 degrees and 2.8 degrees +/- 2.3 degrees, respectively, p < 0.001). The 95% CI of postoperative patellar tilt (|beta|) was narrower in patients that received individualised compared to OTS TKA (0.0 degrees to 3.8 degrees and 0.1 degrees to 8.3 degrees, respectively), irrespective of their preoperative phenotype. Conclusion: Patients who underwent individualised TKA had lower and less variable postoperative patellar tilt than those with OTS TKA, irrespective of preoperative phenotype. Individualised TKA allows the decoupling of the tibiofemoral and patellofemoral joints, replicating anatomical trochlear orientation and improving patellar tilt, which could facilitate better clinical outcomes.

Background:To evaluate the technique of transtibial pull-out repair with tibial interference screw fixation for medial meniscus posterior root (MMPR) tear by reporting on short-term outcomes and complications. Methods:All MMPR repairs performed between January 2019 and August 2021 (n = 70) were retrospectively screened regarding demographic data and surgical parameters. The patients were questioned for performed revision surgery, symptoms and complications. The Numeric Rating Scale (NRS) for pain, Lysholm Knee Score and International Knee Documentation Committee Subjective Knee Form (IKDC) questionnaires were used to evaluate clinical outcome. In cases of revision surgery for re-tear the mode of failure was intraoperatively classified (patients with re-tear were excluded from the clinical follow-up examination). The influence of demographic and treatment parameters (surgical and rehabilitation) on the incidence and mode of re-tear and clinical scores was evaluated. Results:After 2.3 ± 0.7 years, 62 patients (88.6 %) were available for follow-up. There were no direct intra- or postoperative complications. No revision was performed due to symptoms related to the tibial fixation material. The mean surgery time was 33.5 ± 10.8 min. The overall re-tear rate was 17.7 % (11 patients) of whom 10 were treated surgically and one conservatively. Primary mode of failure was suture cut-out from the meniscus (70 %). The NRS, Lysholm Knee Score and subjective IKDC were obtained in 38 patients and improved from 6.8 ± 2.4, 40.1 ± 23.9 and 32.8 ± 16.3 to 2.2 ± 2.2, 80.5 ± 16.3 and 63.0 ± 13.9, respectively (all p < 0.001). No influence was observed from demographic and treatment parameters on re-tear rates or clinical Scores. Conclusions:Tibial interference screw fixation is a fast and promising technique for MMPR transtibial pull-out repair. In the presented technique, utilizing non-absorbable locking sutures alongside tibial interfenrence screw fixation, the primary mode of failure was suture cut-out from the meniscus.

BACKGROUND:Injuries to the deep medial collateral ligament (dMCL) and partial superficial MCL (psMCL) can cause anteromedial rotatory instability; however, the contribution of each these injuries in restraining anteromedial rotatory instability and the effect on the anterior cruciate ligament (ACL) load remain unknown. PURPOSE:To investigate the contributions of the different MCL structures in restraining tibiofemoral motion and to evaluate the load through the ACL after MCL injury, especially after combined dMCL/psMCL injury. STUDY DESIGN:Controlled laboratory study. METHODS:Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. Tibiofemoral kinematic parameters were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8-N·m valgus rotation, 4-N·m external tibial rotation (ER), 4-N·m internal tibial rotation, and a combined 89-N anterior tibial translation and 4-N·m ER for both anteromedial rotation (AMR) and anteromedial translation (AMT). The kinematic parameters of the 3 different MCL injuries (dMCL; dMCL/psMCL; dMCL/superficial MCL (sMCL)) were recorded and reapplied either in an ACL-deficient joint (load sharing) or before and after cutting the ACL (ACL load). The loads were calculated by applying the principle of superposition. RESULTS:The dMCL had the largest effect on reducing the force/torque during ER, AMR, and AMT in extension and the psMCL injury at 30° to 90° of knee flexion (P < .05). In a comparison of the load through the ACL when the MCL was intact, the ACL load increased by 46% and 127% after dMCL injury and combined dMCL/psMCL injury, respectively, at 30° of knee flexion during ER. In valgus rotation, a significant increase in ACL load was seen only at 90° of knee flexion. CONCLUSION:The psMCL injury made the largest contribution to the reduction of net force/torque during AMR/AMT at 30° to 90° of flexion. Concomitant dMCL/psMCL injury increased the ACL load, mainly during ER. CLINICAL RELEVANCE:If a surgical procedure is being considered to treat anteromedial rotatory instability, then the procedure should focus on restoring sMCL function, as injury to this structure causes a major loss of the knee joint's capacity to restrain AMR/AMT.

To determine the prevalence of an “increased posterior tibial slope (PTS)” (PTS ≥ 12°) in a population with one, two or ≥ three anterior cruciate ligament (ACL) graft insufficiencies. Furthermore, to investigate whether the prevalence of an increased PTS and the absolute PTS increases with an increasing number of ACL graft insufficiencies, as well as to determine the survival time of the first ACL graft. Patients diagnosed with an ACL graft insufficiency between January 2021 and March 2022 were included. The PTS was measured using the proximal anatomical tibial axis on long lateral knee radiographs. Patients were divided into 3 groups depending on the number of ACL graft insufficiencies: group A (1 graft insufficiency), group B (2 graft insufficiencies) and group C (≥ 3 graft insufficiencies). The prevalence of increased PTS and absolute PTS between groups was compared alongside the survival of the first ACL graft between patients with or without increased PTS. Two-hundred and six patients (147 males/59 females) met the inclusion criteria. 73 patients showed an increased PTS [prevalence 35

BACKGROUND:The posterior tibial slope has been identified as an anatomic risk factor for anterior cruciate ligament insufficiency and reruptures after anterior cruciate ligament reconstruction. Anterior tibial closing wedge osteotomy for correction of sagittal plane deformities has the potential to cause an unintended change in coronal plane alignment.PURPOSE:To evaluate the effects of anterior tibial closing wedge osteotomies for correction of posterior tibial slope on coronal plane alignment using an infratuberosity surgical approach and to identify predictive factors for a change in medial proximal tibial angle (MPTA).STUDY DESIGN:Case series; Level of evidence, 4.METHODS:This study reports on retrospectively obtained data from radiographic measurements of 38 anterior tibial closing wedge osteotomies. All patients underwent revision anterior cruciate ligament reconstruction and had undergone ≥1 previous anterior cruciate ligament reconstruction. In all patients, an infratuberosity approach was used with angular stable plate fixation. Pre- and postoperative radiographs were examined retrospectively to detect changes in the sagittal and coronal plane alignment (posterior tibial slope and MPTA). A multivariate regression analysis was used to identify predictors for a change in MPTA.RESULTS:The study group consisted of 14 women and 24 men whose mean ± SD age at the index procedure was 31.6 ± 8.7 years (range, 17-51 years). Posterior tibial slope decreased significantly (by 7.2° ± 2.3°; P < .001) from 14.6° ± 2.0° preoperatively to 7.4° ± 2.1° postoperatively. MPTA decreased significantly by 1.3° ± 1.5° (P = .005) from pre- to postoperative measurement. Mean wedge height was 9.3 ± 1.1 mm. A lower preoperative MPTA (coefficient = 0.32; P = .017; 95% CI, 0.06-0.59) and larger wedge height (coefficient = 0.48; P = .029; 95% CI, 0.05-0.9) were significant predictive factors for a decrease in MPTA.CONCLUSION:Anterior tibial closing wedge osteotomy for posterior tibial slope reduction resulted in a slight but significant decrease of the MPTA in the coronal plane. These changes were dependent on the preoperative MPTA and the wedge height.

In patients with ACL graft failure and increased tibial slope, anterior closing wedge high tibial osteotomy provides a safe and reliable technique to control ACL graft re-tear and offer good functional outcome on the midterm.Data: Background: Increased tibial slope is correlated with increased tibial translation and higher failure rates of ACL reconstruction.Cadaveric studies have shown that slope-reducing high tibial osteotomy (SR HTO) decreases ACL-graft forces and anterior tibial translation under axial load.However, the effect of SR HTO on ACL revision outcomes has not been comprehensively analyzed on the midterm.Purpose: To evaluate the midterm functional outcomes after slopereducing osteotomy associated with revision ACL reconstruction.Study design: prospective cohort study; level of evidence, 2. Methods: 41 consecutive patients with ACL reconstruction failure and increased tibial slope (18AE2.7 degrees) were included.Tibial slope was calculated from full length standing lateral views using the tibial mechanical axis as a reference.Age 25AE5.9years, sex ratio 1.4, BMI 24.6AE4.4Kg/m2.Revision was staged in two procedures in all cases: first surgery for SR HTO and tunnels bone grafting; second for reimplantation of ACL graft.The amount of slope reduction was measured with a target of slope at 6 to 8 degrees.The SR HTO was performed by an anterior approach with a tibial tubercle osteotomy for access.It was guided by a 3D printed patient-specific cutting jig to avoid alteration of coronal plane alignment and it was fixed with staples.Patients were followed for 3AE1.4 years.Adverse events occurred in 9.7%: secondary displacement (2/41), deep infection (1/41), delayed union (1/41).At the time of follow-up: ACL-RSI 48.8AE22.6,IKDC 60.1AE14.9,no recurrence in ACL graft failure.We onserved no iatrogenic coronal plane alterations and no tibial slope over/under correction on postoperative EOS long standing AP and lateral x-rays.Secondary knee hyperextension was not reported.Return to sport was observed in 70.7% (29/ 41) with half of these patients (15/29) involved in level I sports according to the classification by Hefti et al.Conclusion: In patients with ACL graft failure and increased tibial slope, anterior closing wedge high tibial osteotomy provides a safe and reliable technique to control ACL graft re-tear and offer good functional outcome on the midterm.

Background: In cases of complex arthroscopic knee surgery in the lateral compartment, such as performing lateral meniscus repair or transplantation, a tight lateral compartment can jeopardize the best possible care and could lead to iatrogenic cartilage injury. This technique shows a way to increase arthroscopic working space in a tight lateral compartment by performing an osteotomy of the femoral insertion of the lateral collateral ligament (LCL), utilizing a novel adjustable loop refixation technique. Indication: The femoral LCL insertion osteotomy can be performed if increased visualization and working space of the lateral compartment are needed during the complex arthroscopic knee surgery. Technique Description: After identification of the LCL femoral insertion, a 2-mm drill is passed through the LCL insertion to prepare for an anatomic reduction. The osteotomy is performed by taking a small bone plug together with the complete LCL insertion. Increased visualization and working space in the lateral compartment are obtained without damaging the intrinsic LCL structure. For reinsertion, the bone plug and proximal LCL is whipstitched with a high-strength suture and fixated to an adjustable loop Ultrabutton. The adjustable loop is shuttled through a predrilled 4.5-mm femoral tunnel and flipped on the medial side. The adjustable button is tensioned in 30° of flexion until the bone plug is anatomically reduced. Results: We present 1 patient who underwent a femoral LCL osteotomy during arthroscopic lateral meniscus allograft transplantation. The osteotomy healed without any issues, and there was no residual LCL laxity; which was confirmed with varus stress radiographs. Discussion/Conclusion: A femoral LCL insertion osteotomy can release a tight lateral compartment without damaging the intrinsic LCL structure. The adjustable loop fixation avoids the use of more traditional screw and washer fixation techniques, which tend to be more prominent and have the potential to back out. An osteotomy is more invasive than the “pie-crusting” technique of the medial collateral ligament for a tight medial compartment. However, it is required due to the poor intrinsic healing capacity of the LCL. Care should be taken to anatomically reduce the bone plug to avoid iatrogenic creation of LCL laxity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Objective: The purpose of this review is to improve the awareness of lateral meniscal hypermobility by describing its relevant anatomy, biomechanics, pathophysiology, imaging and arthroscopic findings as well as the treatment options. Background: The lateral meniscus is less stable than the medial meniscus. Its important posterior stabilizers are the popliteomeniscal fascicles, the posterior capsule, the meniscofemoral ligaments and the posterior meniscotibial ligament, which are divided by a bare area, the popliteal hiatus. Atraumatic insufficiency or rupture of one of these key structures may impact the mobility of the lateral meniscus and can lead to an unstable, hypermobile lateral meniscus. Lateral meniscus hypermobility can cause lateral knee pain and mechanical symptoms as locking. Ruptures of the popliteomeniscal fascicles are frequently associated with anterior cruciate ligament and posterolateral corner injuries. Their repair may be important to fully restore knee stability. Methods: This is a narrative overview of the literature synthesizing current knowledge about the hypermobile lateral meniscus. Anatomy, biomechanics, diagnosis and treatment of this entity was of particular interest for this review. Literature was retrieved from PubMed database, hand searches and cross-reference checking. Conclusions: Diagnosing lateral meniscus hypermobility is challenging since the magnetic resonance imaging are often unspecific and may show no structural alterations of the meniscus and its attachments. The only hint can be the patient's history and clinical symptoms (e.g., locking). Ultimately, the diagnosis is confirmed during knee arthroscopy, when the lateral meniscus can be mobilized over 50% of the lateral tibial plateau or lateral femoral condyle while anterior probing or by using the aspiration function during arthroscopy. Treatment includes stabilizing the posterior lateral meniscus by repairing the injured structures. Therefore, a systematic arthroscopic evaluation of the lateral compartment is important to fully recognize the problem. Repair can be achieved arthroscopically with various suturing techniques used for meniscal repair with satisfactory results and low recurrence rates.

CASE:A 70-year-old female patient underwent total hip arthroplasty (HA) using a stem cemented line-to-line without centralizer. Postoperatively, she complained of load-dependent thigh pain. Conventional radiographs identified cortical overload because of a distal cement mantle discontinuity at the level of the stem's tip, confirmed by single-photon emission computed tomography/computed tomography scan (SPECT/CT). After cement-in-cement revision using a stem with centralizer, pain ceased rapidly. The cortical overload disappeared, as confirmed on a following SPECT/CT performed for low back pain. CONCLUSION:In HA, the stem's tip may cause overload on the bone's cortex if the cement mantle is incomplete. Implanting a stem with centralizer avoids or cures this.

The aim of this study was to determine whether posterior tibial slope (PTS), meniscal slope (MS), and bone bruise pattern (BBP), as observed on magnetic resonance imaging (MRI), differed between patients with or without medial meniscus ramp lesions at the time of anterior cruciate ligament reconstruction (ACLR). The hypothesis was that patients with a ramp lesion had a higher PTS and MS, with a different BBP than patients without a ramp lesion. Fifty-six patients undergoing ACLR were selected from an in-house registry and separated into 2 groups: (1) the RAMP group included patients with a primary ACLR and a medial meniscus ramp lesion diagnosed intraoperatively; (2) the CONTROL group included patients with a primary ACLR without ramp lesion after arthroscopic exploration of the posteromedial knee area. The two groups were matched for age, sex and type of concomitant meniscal lesions. The medial/lateral-PTS/MS and BBP were subjected to blinded evaluation on the preoperative MRI of the reconstructed knee. Twenty eight patients (21 males; 7 females) were included in each group. No significant difference could be observed between groups in terms of demographical characteristics, PTS, and MS. A posteromedial tibial plateau (PMTP) bone bruise was more often observed in the RAMP group (n = 23/28) compared to the CONTROL group (n = 12/28) (p < 0.01). The RAMP group was 6.1 (95%CI [1.8; 20.8]) times more likely to present a PMTP bone bruise. The likelihood of having a bone bruise in both the medial and lateral compartments was 4.5 (95%CI [1.2; 16.5]) times higher in the RAMP group. However, a BBP only involving the lateral tibiofemoral compartment was more likely to be observed in the CONTROL group (n = 10/28) compared to the RAMP group (n = 3/28, p < 0.05 – odds ratio 4.6 (95%CI [1.1; 19.2]). Ramp lesions were 6.1 and 4.5 times more likely to be observed in the presence of a posteromedial tibia plateau bone bruise or a combined bone bruise respectively in both the medial and lateral tibiofemoral compartment in patients undergoing ACLR. The tibial and meniscal slopes did not differ between patients with or without ramp lesions undergoing ACLR. Level III

The aim of this study was to assess the correlation between posterior tibial slope and meniscal slope over postoperative anterior tibial translation during the first 18 months after primary anterior cruciate ligament (ACL) reconstruction. The main hypothesis was that PTS and MS would be positively correlated with post-operative ATT-SSD after ACL reconstruction. Patients (28 males and 15 females) with confirmed ACL tears were selected from an in-house registry and included if they were over 16 years old, had primary ACL-reconstruction and healthy contralateral knee. Patients meeting one of the following criteria were excluded: previous knee surgeries, intraarticular fractures, associated ligamentous lesions, previous or concomitant meniscectomy or extraarticular procedures. Lateral posterior tibial slope, medial posterior tibial slope, lateral meniscal slope and medial meniscal slope were measured using preoperative MRIs. The side-to-side-difference in anterior tibial translation was evaluated 9–18 months postoperatively. Forty-three patients were included, (28 males/15 females; mean age 25 ± 8 years). Mean postoperative anterior tibial translation was 1.0 ± 1.1 mm at a mean time of 12 ± 1 months. Mean slope values were: lateral posterior tibial slope 4.7° ± 2.2°, medial posterior tibial slope 4.0° ± 2.8°, lateral meniscal slope 3.0° ± 2.2° and medial meniscal slope 2.0° ± 2.8°. The anterior tibial translation was significantly correlated with lateral meniscal slope (r = 0.63; p < 0.01). For each 1° increase in lateral meniscal slope, a 0.3 mm 95% CI [0.2, 0.4] (p < 0.01) increase in anterior tibial translation was observed. A lateral meniscal slope greater or equal to 4.0° was estimated as optimal threshold for increased risk of abnormal side-to-side difference in postoperative anterior tibial translation (≥ 1.2 mm). The lateral meniscal slope was positively correlated to side-to-side difference in anterior tibial translation after primary ACL reconstruction. A lateral meniscal slope greater or equal to 4.0° was detected as threshold for an increased risk of abnormal side-to-side difference in postoperative anterior tibial translation in patients who underwent primary ACL reconstruction. This confirms that soft tissue slopes have an impact on the outcomes after reconstructive surgery. Level of evidence III.

La contracture en flexion des doigts longs n’a pas seulement une répercussion sur la fonction des doigts longs, elle diminue la fonction de toute la main. Les patients sont incapables de porter des gants, de mettre leur main dans des espaces étroits et sont souvent embêtés par des accrochages involontaires d’objets. Nous avons revu les résultats d’une technique chirurgicale proposée par Guy Raimbeau, qui consiste en la résection de la phalange moyenne (P2) suivi d’une arthrodèse de la phalange distale (P3) à la phalange proximale (P1) dans le traitement des contractures invétérées des doigts longs. Dix patients furent retenus pour cette étude. Chaque patient ayant subi cette intervention chirurgicale les 7 années précédent l’étude a été invité pour un interview ainsi qu’un examen clinique et contrôle radiographique. La fonction postopératoire de la main a été évaluée utilisant les questionnaires PRWE et Quick Dash, l’échelle visuelle analogique, intolérance au froid et satisfaction personnelle. Les patients ont été examinés sur le plan clinique par rapport à leurs mobilités de l’articulation métacarpo-phalangienne (MCP), force de poigne (Jamar) et force pollicidigale, test de Weber pour la sensibilité pulpaire ainsi qu’une radiographie. Nos résultats démontrent que l’intégrité pulpaire et sa capacité discriminatoire (Weber) sont préservée. Les mobilités des MCP sont préservées. Les mêmes résultats sont retrouvés pour la force de poigne (Jamar) ainsi que la force de pince. Nous avons retrouvé une différence significative entre le score PRWHE préopératoire et celui en postopératoire contrairement au Quick Dash. En comparant la situation préopératoire, 87,5 % des patients s’estimaient satisfait, ou très satisfait concernant le résultat de cette intervention chirurgicale. L’intolérance au froid a été documentée dans 37,5 % des patients. Seul un patient était toutefois déçu par le résultat esthétique, tous les autres étaient satisfaits. Mitz V et al. ont démontré la valeur de la préservation de la pulpe pour les doigts longs en crochet. Ces déformations sont souvent traitées en réséquant tout le rayon ou par amputation. Les bénéfices de cette procédure sont la préservation de la pulpe et sa sensibilité, ainsi qu’un résultat esthétique après la régression du volume de la peau palmaire comprimée. Par ailleurs, des névromes douloureux, complication possible aux amputations digitales sont évités. Cette intervention donne un résultat fiable pour des contractions irréparables des doigts longs sur le versant ulnaire.