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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.

Medial patellofemoral ligament reconstruction (MPFLR) is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable return to play following MPFL reconstruction. A retrospective review of patients who underwent MPFL reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the MPFL-Return to Sport after Injury (MPFL-RSI) score, which is a modification of the ACL-RSI score. A MPFL-RSI score > 56 is considered a passing score for being psychologically ready to return to play. Additionally, reasons for not returning to play including Visual Analog Scale for pain (VAS), Kujala score, satisfaction, and recurrent instability (including dislocations and subluxations) were evaluated. The study included a total of 35 patients who were unable to return to play out of a total cohort of 131 patients who underwent MPFL reconstruction as treatment for patellar instability. Overall, 60% were female with a mean age of 24.5, and a mean follow-up of 38 months. Nine patients (25.7%) passed the MPFL-RSI benchmark of 56 with a mean overall score of 44.2 ± 21.8. The most common primary reasons for not returning to play were 14 were afraid of re-injury, 9 cited other lifestyle factors, 5 did not return due to continued knee pain, 5 were not confident in their ability to perform, and 2 did not return due to a feeling of instability. The mean VAS score was 1.9 ± 2.3, the mean Kujala score was 82.5 ± 14.6, and the mean satisfaction was 76.9%. Three patients (8.7%) reported experiencing a patellar subluxation event post-operatively. No patient sustained a post-operative patellar dislocation. Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury. IV.

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.

Negative pressure wound therapy is an effective tool for the treatment of open wounds. Occasionally these wounds are associated with injuries or procedures that require treatment with an external fixator. This article shows how a simple, inexpensive, and commercially available product can be used to prevent loss of suction around external fixator pins within the negative pressure wound treatment area.