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Background: Combining an anterior cruciate ligament (ACL) reconstruction with an anterolateral ligament (ALL) reconstruction results in significant advantages including reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to preinjury levels of sport. Indications: The previously reported indications for combined ACL and ALL reconstruction are as follows: ACL reconstruction revision; high-grade pivot shift test; long-term ACL rupture; young patients; pivoting activities; concomitant medial meniscus repair, and, specifically, regarding the ALL repair, it must be an acute surgery (within 15 days from injury). Technique Description: Several modern techniques have been described to repair and reconstruct the ALL. This technical note details a number of these techniques performed by the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. Results: First, we describe a combined ACL reconstruction and double-bundle ALL reconstruction using hamstring autograft. Secondly, we describe a single-bundle ALL reconstruction using gracilis autograft. Thirdly, we describe an ALL reconstruction technique using a knotless soft anchor, which provides shallow fixation and prevents tunnel convergence. Finally, we describe a technique for ALL repair. Conclusion: Several techniques have been described to repair and reconstruct the ALL, all offering significant advantages over an isolated ACL reconstruction. 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.

Background: The arthroscopic approach to the posterior compartment of the knee is always challenging. This easy arthroscopic transseptal approach allows safe access to the posterior compartment of the knee, avoiding any potential neurovascular injury. Indications: Indications include arthroscopic posterior cruciate ligament (PCL) reconstruction, fixation of avulsion fractures of the tibial attachment of the PCL, arthroscopic posterolateral corner reconstruction, removal of loose bodies from the posterior compartment, PCL cyst removal, ramp repair, and arthroscopic arthrolysis of the posterior compartment. Technique Description: Using a posteromedial portal, a shaver is introduced with the tip in direct contact with the medial side of the septum facing anteriorly, away from the popliteal neurovascular bundle. The scope is then inserted into the posterolateral compartment to visualize the lateral side of the septum while the shaver remains in the posteromedial compartment. The septum is then released until the tip of the shaver is visible. The shaver is then removed and the scope can now be inserted from the posteromedial portal to the posterolateral compartment through the released septum. Results: The transseptal approach can be performed without any additional risk if the shaver remains centrally on the inferior aspect of the septum. Therefore, the risk of iatrogenic injury of the middle genicular artery is minimized. Likewise, with the knee flexed to 90°, there is no risk of damaging the popliteal neurovascular bundle. Having a precise knowledge of the anatomy of the posterior compartment of the knee minimizes any risks of the transseptal approach, avoiding any additional surgical time whilst facilitating the indicated operation. Conclusion: This easy arthroscopic transseptal approach allows safe access to the posterior compartment of the knee, avoiding any potential neurovascular injury.

Background: Arthrogenic muscle inhibition (AMI), a process in which quadriceps activation failure is caused by neural inhibition, is common following knee injury or surgery. No classifications exist to describe the variable presentations of AMI following knee injury. Indications: AMI can result in significant morbidity following knee injury, and it is essential to recognize and treat. It is crucial to identify patients at higher risk of postoperative complications as surgery should be delayed for specific rehabilitation programs. Understanding the pathophysiology of AMI is vital as this can guide therapeutic interventions. Technique Description: AMI following knee injury can present in a variety of ways including inhibition of the vastus medialis obliquus (VMO) muscle, extension deficits due to hamstring contracture, as well as chronic extension deficits. They also respond differently to conventional treatment modalities and often require longer and specific rehabilitation programs. Therefore, we propose a classification to define these different presentations. Results: Grade 0 is a normal VMO contraction. Grade 1a is when VMO contraction is inhibited but activation failure is reversible with simple exercises while Grade 1b requires longer and specific rehabilitation programs. Grade 2a is when VMO contraction is inhibited with an associated extension deficit due to hamstring contracture, but activation failure and loss of range of motion is reversible with simple exercises. However, Grade 2b is refractory to simple exercises, and longer and specific rehabilitation programs are required. Grade 3 is a chronic extension deficit that is irreducible without extensive posterior arthrolysis. Conclusion: In conclusion, AMI is a process in which quadriceps activation failure is caused by neural inhibition and is common following knee injury or surgery. Not taking AMI into account preoperatively can result in a very high risk of stiffness postoperatively. We propose a classification for AMI following knee injury or surgery, which describes different presentations and can be used to guide management.

Background: The anatomy of the posterolateral corner (PLC) of the knee is complex. The approach of the PLC can be a challenging and stressful surgical time. Indications: The indications are posterolateral meniscal repair, open lateral meniscus allograft transplantation, posterolateral tibial plateau fracture, and PLC reconstruction for grade III sprains. Technique Description: The skin incision is straight, realized with the knee positioned at 90° of flexion, passing slightly posterior to the lateral epicondyle, anterior to the fibular head (FH), and ending on Gerdy’s tubercle. The subcutaneous tissues are dissected posteriorly so as to expose the FH and the biceps femoris (BF) tendon. The aponeurosis of the peroneus muscles is incised vertically opposite to the anterior side of the FH. The common fibular nerve is exposed at the neck of the fibula. Metzenbaum scissors are then inserted subaponeurotically, posteriorly, and parallel to the BF tendon, superficially to the nerve. An incision is made opposite the scissor’s blades, freeing the common fibular nerve. The BF tendon is spread forward and the lateral gastrocnemius is pulled posteriorly. Metzenbaum scissors are inserted in a closed position between the lateral gastrocnemius and the posterolateral joint capsule, and then spread to create a triangular door with a proximal base. The base consists of the BF tendon, the posterior side of the lateral gastrocnemius, and the anterior side of the posterolateral joint capsule. A counter-angled Hohmann retractor can now be applied against the posterior tibial plateau to retract the lateral gastrocnemius posteriorly and medially, exposing the PLC of the knee. Results: Noble structures are easily exposed and protected. The common fibular nerve is dissected and reclined posteriorly, and the popliteus vessels are reclined posteriorly and medially, protected by the lateral gastrocnemius. Passing under the BF tendon allows a better vision of the PLC along with less constraint than passing above, as the working window is further away from the femoral insertion of the lateral gastrocnemius. Discussion/Conclusion: The present surgical approach allows a simple, safe, and reproducible exposure of the PLC of the knee.

Background: Ramp lesions are longitudinal lesions of the meniscocapsular complex of the posterior horn of the medial meniscus. These lesions are poorly recognized, difficult to diagnose, and require specific arthroscopic exploration. Ramp lesions are typically associated with anterior cruciate ligament rupture and have important biomechanical consequences as they result in increased anterior tibial translation and external rotation. Suture hook repair through the posteromedial portal is safe and provides a high healing rate. Indications: Spontaneous healing of ramp lesions is rarely observed, and repair is indicated for all lesions with the involvement of meniscotibial ligament. The choice of a posteromedial repair technique with vertical suture performed under visual control allows restoration of the continuity of meniscotibial ligament and effective healing of these lesions. Technique Description: Standardized arthroscopic exploration with systematic visualization of the posteromedial compartment using the transnotch technique is a crucial point to diagnose these lesions. The use of transillumination and a needle allows to palpate the lesion with the tip of the needle in case of doubt (hidden lesion) before performing the posteromedial portal safely. By using the transnotch vision and by introducing the instruments through the posteromedial portal, debridement with the shaver and repair with the hook of the lesion are performed under visual control. Vertical repair is performed by taking care to pass the hook through the meniscotibial ligament by perforating the deep face of the capsular portion and anterior portion of the ramp lesion. Similarly, it is recommended not to catch too much meniscal tissue on the anterior margin side to remain in the red zone and not to perforate the meniscus in the avascular zone to avoid secondary lesions caused by the “cheese wire” effect of the sutures in the white zone. Results: This technique has allowed us to reduce our percentage of secondary meniscectomy after ramp lesion repair from 25% using a standard arthroscopic exploration and meniscal repair technique through the anterior portal to 11.3% using a arthroscopic exploration and repair technique through the posteromedial portal at 4 years of follow-up. Discussion/Conclusion: Systematic use of the transnotch vision and repair through the posteromedial portal are recommended for the management of these lesions, which demonstrate serious mechanical and clinical consequences.

Background: Implant manufacturers typically offer several sizes of a humeral stem for shoulder arthroplasty so that time zero fixation can be achieved with the optimal size. Stem size can be templated preoperatively but is definitively determined intraoperatively. The purpose of this study was to determine if preoperatively acquired parameters, including patient demographics and imaging, could be used to reliably predict intraoperative humeral stem size. Methods: A cohort of 290 patients that underwent shoulder arthroplasty (116 anatomic and 174 reverse) was analyzed to create a regression formula to predict intraoperative stem size. The initial cohort was separated into train and test groups (randomly selected 80% and 20%, respectively). Patient demographics, anatomical measurements, and statistical shape model parameters determined from a preoperative shoulder arthroplasty planning software program were used for multilinear regression. The implant used for all cases was a short-stemmed metaphyseal-fit prosthesis. Results: Metaphyseal bone density, humeral statistical shape model parameters, and humeral intramedullary canal diameter were identified as highly predictive of intraoperative final humeral prosthesis size. On the train group, a coefficient of determination R2 of 0.63 was obtained for the multilinear regression equation combining these parameters. When analyzing the cohort for the prediction of stem size in the test group, 95% were within plus or minus one size of that used during surgery. Conclusion: Preoperative criteria such as humeral geometry and proximal humeral bone density can be combined in a single multilinear equation to predict intraoperative humeral stem size within one size variation. Embedding the surgeon’s decision-making process into an automated algorithm potentially allows this process to be applied across the surgical community. Predicting intraoperative decisions such as humeral stem size also has potential implications for the management of implant stocks for both manufacturers and health-care facilities.

Background: Various implant designs have been proposed to increase active range of motion (ROM) and avoid notching in patients treated by reverse total shoulder arthroplasty (RSA). The purpose of this study was to investigate the efficacy and safety of an onlay prosthesis design combining a 135° humeral neck-shaft angle with the glenoid component lateralized and inferiorized. Methods: A retrospective descriptive study was conducted of the clinical and radiological outcomes at the final follow-up (≥24 months) of all RSAs performed by the same surgeon between September 2015 and December 2016 in the study center. At the last follow-up, patients were clinically assessed for ROM, Constant score, and subjective shoulder value and radiologically for scapular notching and glenoid radiolucent lines. Patients were followed up radiographically at 1 month and clinically at between 6 and 12 months (midterm) and again at between 24 and 48 months (final follow-up). Scapular notching was graded as per the Sirveaux classification at the last follow-up on anterior-posterior radiographs. Results: Seventy-nine RSAs were included with a mean follow-up time of 31 months. The mean Constant score at the final follow-up was 42 points higher than before surgery (69 vs. 27, P