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Multipartite (or bipartite) patella is a developmental anomaly that occurs in 2%–6% of individuals. In 50%, the variant is bilateral. Multipartite patella is usually an asymptomatic condition. Quadriceps tendon rupture is also a rare entity occurring mostly in men aged >40 years and usually results from an acute eccentric quadriceps contracture. The authors present a case of a patient with bilateral multipartite patellae that sustained bilateral multipartite avulsions as well as an associated unilateral quadriceps tendon rupture. This constellation of injuries has never been reported in the literature. The patient was treated with excision of the multipartite patella fragments and quadriceps tendon repair on the side with the extensor mechanism disruption. He was treated non-operatively for the contralateral lower extremity multipartite patella avulsion. This report, along with a thorough review of the literature, serves to demonstrate the clinical and radiographic characteristics of this unusual injury.

While Achilles tendon injuries are common amongst the general population, there are very few cases in which simultaneous bilateral injuries occur. Medial malleolar fractures at the time of Achilles tendon rupture have been cited in the literature and are commonly missed. The following case outlines the presentation, treatment, and outcome of a United States Army Soldier with simultaneous bilateral Achilles tendon ruptures in addition to a unilateral right medial malleolar fracture. This patient was able to completely return to duty within 1 year after being treated with ORIF of the medial malleolus, bilateral end-to-end repair of the AT, and accelerated rehabilitation beginning at 2 weeks on the left and 6 weeks on the right.

Although anterior cruciate ligament reconstruction (ACLR) is a generally successful procedure, failure is still relatively common. An increased posterior tibial slope (PTS) has been shown to increase the anterior position of the tibia relative to the femur at rest and under load in biomechanical studies. Increased PTS has also been shown to increase forces on the native and reconstructed ACL. Clinical studies have demonstrated elevated PTS in patients with failed ACLR and multiple failed ACLR, compared with control subjects. Anterior closing-wedge osteotomies have been shown to decrease PTS and may be indicated in patients who have failed ACLR with a PTS of ≥12°. Available clinical data suggest that the procedure is safe and effective, although evidence is limited to case series. This article presents the relevant biomechanics, clinical observational data on the effects of increased PTS, and an algorithm for evaluating and treating patients with a steep PTS.

Background: Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels. Study Design: Case series; Level of evidence, 2. Methods: Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated. Results: Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group ( P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure. Conclusion: Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.

The bone-tendon-bone (BTB) autograft is widely used for anterior cruciate ligament (ACL) reconstruction. However, the primary disadvantages of this technique include postoperative kneeling pain, the risk of perioperative patellar fracture, and graft-tunnel mismatch. Therefore, a single bone plug technique for ACL reconstructions was developed to mitigate the disadvantages of the BTB technique. To differentiate this graft, we have coined the term BTA, for bone-tendon-autograft. The middle third of the patellar tendon is used with a typical width of 10 to 11 mm. A standard tibial tubercle bone plug is harvested. The length of the patellar tendon and graft construct is then measured. If the tendon is >45 mm and the construct at least 70 mm, then we proceed with the BTA technique. At the inferior pole of the patella, electrocautery is used to harvest the tendon from the patella. The advantages of this technique include faster graft harvest and preparation. Obviating the patellar bone plug harvest should eliminate the risk of perioperative patellar fracture and theoretically will mitigate donor site morbidity and kneeling pain, 2 of the most commonly cited complications of the use of BTB autografts for ACL reconstruction. In conclusion, the BTA technique is a reliable technique for ACL reconstruction.

Objective The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions. Design A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected. Results Overall, 52 total patients who underwent OCA with either fresh precut OCA cores ( n = 26) and hemi-condylar OCA ( n = 26) were pair matched at a mean follow-up of 34.0 months (range 12 months to 99 months). The mean ages were 31.5 ± 10.7 for fresh precut cores and 30.9 ± 9.8 for hemi-condylar ( P = 0.673). Males accounted for 36.4% of the overall cohort, and the mean lesion size for fresh precut OCA core was 19.6 mm2 compared to 21.2 mm2 for whole condyle ( P = 0.178). There was no significant difference in patient-reported outcomes including Visual Analogue Scale, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and Tegner ( P > 0.5 for each), or in MOCART score (69.2 vs. 68.3, P = 0.93). Conclusions This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

Anterior cruciate ligament reconstruction failure remains a commonly seen outcome despite advances in technique and graft options. Recent studies have shown that the declination of the tibial plateau slope in the sagittal plane affects the in situ stress on the anterior cruciate ligament. The native posterior tibial slope has been described to range from 7° to 10°. However, several authors have suggested that a posterior tibial slope >12° should be considered pathologic. Given the recent evidence, our institution has begun performing a tibial tubercle–sparing anterior closing wedge proximal tibial osteotomy with cross screw fixation to decrease sagittal plane tibial slope., Technique Video Video 1 This video details a tibial tubercle anterior wedge osteotomy to correct a pathologic posterior tibial slope with cross-screw fixation. The patient should be positioned supine on a radiolucent flat top table. The C-arm should be placed on the contralateral side of the operative extremity. Radiolucent triangles are helpful for positioning. The incision is typically 6 to 8 cm beginning at the tibial tubercle and proceeds distally. The osteotomy start point is just distal to the tibial tubercle aiming toward the proximal tibiofibular joint on the lateral radiograph. Breakaway pins and a parallel guide are used to guide the trajectory of the proximal and distal pins. The use of fluoroscopy is recommended to ensure the pins are coplanar on the lateral view. The distal pins are then inserted in a similar fashion to the proximal pins based on preoperative measurements of the necessary osteotomy size. The tips of the distal pins should intersect the proximal pins. The posterior cortex should not be violated. The breakaway pins are then broken off and the pins are used as a cutting guide for the osteotomy. After the bone wedge is removed, the knee should be extended to close the osteotomy gap. K-wires are then used to guide the trajectory of the 4.5mm cannulated crossing screws for fixation. A 3.2-mm drill is used to drill bicortically, followed by a 4.5-mm tap to facilitate screw passage. An anterior trajectory of the screws is recommended.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous fixation. Given the disadvantages of BTB, an alternative is a bone-tendon autograft (BTA) procedure that has been developed at our institution. BTA is a patellar tendon autograft with the single bone plug taken from the tibia. Purpose/Hypothesis: The purpose of this study was to evaluate the short-term outcomes of BTA ACLR. We hypothesized that this procedure will provide noninferior failure rates and clinical outcomes when compared with a BTB autograft, as well as a lower incidence of anterior knee pain, pain with kneeling, and patellar fracture. Methods: A consecutive series of 52 patients treated with BTA ACLR were retrospectively identified and compared with 50 age-matched patients who underwent BTB ACLR. The primary outcome was ACL graft failure, while secondary outcomes included subjective instability, anterior knee pain, kneeling pain, and functional outcome scores (Single Assessment Numeric Evaluation, Lysholm, and International Knee Documentation Committee subjective knee form). Results: At a mean follow-up of 29.3 months after surgery, there were 2 reruptures in the BTA cohort (4.0%) and 2 in the BTB cohort (4.0%). In the BTA group, 18% of patients reported anterior knee pain versus 36% of the BTB group ( P = .04). A total of 22% of patients noted pain or pressure with kneeling in the BTA cohort, as opposed to 48% in the BTB cohort ( P = .006). There were no differences in functional scores. In the BTA group, 94.2% of patients reported that their knees subjectively felt stable, as compared with 86% in the BTB group ( P = .18). Conclusion: This study demonstrated that the BTA ACLR leads to similarly low rates of ACL graft failure requiring revision surgery, with significantly decreased anterior knee pain and kneeling pain when compared with a BTB. Additionally, the potential complications of graft-tunnel mismatch and patellar fracture are eliminated with the BTA ACLR technique.