Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results. 12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1). The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively. There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability. This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results

Recurrent patellar instability is a common problem and there are multiple demographic and pathoanatomic risk factors that predispose patients to dislocating their patella. The most common of these is trochlear dysplasia. In cases of severe trochlear dysplasia associated with patellar instability, a sulcus deepening trochleoplasty combined with a medial patellofemoral ligament reconstruction (MPFLR) may be indicated. Unaddressed trochlear pathology has been associated with failure and poor post-operative outcomes after stabilization. The purpose of this study is to report the clinical outcome of patients having undergone a trochleoplasty and MPFLR for recurrent lateral patellofemoral instability in the setting of high-grade trochlear dysplasia at a mean of 2 years follow-up. A prospectively collected database was used to identify 46 patients (14 bilateral) who underwent a combined primary MPFLR and trochleoplasty for recurrent patellar instability with high-grade trochlear dysplasia between August 2013 and July 2021. A single surgeon performed a thin flap trochleoplasty using a lateral para-patellar approach with lateral retinaculum lengthening in all 60 cases. A tibial tubercle osteotomy (TTO) was performed concomitantly in seven knees (11.7%) and the MPFLR was performed with a gracilis tendon autograft in 22%, an allograft tendon in 27% and a quadriceps tendon autograft in 57% of cases. Patients were assessed post-operatively at three weeks and three, six, 12 and 24 months. The primary outcome was the Banff Patellar Instability Instrument 2.0 (BPII 2.0) and secondary outcomes were incidence of recurrent instability, complications and reoperations. The mean age was 22.2 years (range, 13 to 45), 76.7% of patients were female, the mean BMI was 25.03 and the prevalence of a positive Beighton score (>4/9) was 40%. The mean follow-up was 24.3 (range, 6 to 67.7) months and only one patient was lost to follow-up before one year post-operatively. The BPII 2.0 improved significantly from a mean of 27.3 pre-operatively to 61.1 at six months (p < 0 .01) and further slight improvement to a mean of 62.1 at 12 months and 65.6 at 24 months post-operatively. Only one patient (1.6%) experienced a single event of subluxation without frank dislocation at nine months. There were three reoperations (5%): one for removal of the TTO screws and prominent chondral nail, one for second-look arthroscopy for persistent J-sign and one for mechanical symptoms associated with overgrowth of a lateral condyle cartilage repair with a bioscaffold. There were no other complications. In this patient cohort, combined MPFLR and trochleoplasty for recurrent patellar instability with severe trochlear dysplasia led to significant improvement of patient reported outcome scores and no recurrence of patellar dislocation at a mean of 2 years. Furthermore, in this series the procedure demonstrated a low rate (5%) of complications and reoperations

Complications involving the knee extensor mechanism occur in 1% to 12% of patients following total knee arthroplasty (TKA), and have negative effects on patient outcomes. While multiple reconstruction options have been described for complete disruption of the extensor mechanism, the results in patients with a prior TKA are inferior to those in patients without a TKA, and frequently have required the use of allograft tendon grafts which can attenuate and stretch over time. However, encouraging results have been reported by Browne and Hanssen in treatment of patellar tendon disruption with the use of a synthetic mesh (knitted monofilament polypropylene). In this technique, a synthetic graft is created by folding a 10 × 14 inch sheet of mesh and securing it with non-absorbable sutures. A burr is then used to create a trough in the anterior aspect of the tibia to accept the mesh graft. The graft is inserted into the trough and secured with cement. After the cement cures, a transfixion screw with a washer is placed. A portal is subsequently created in the soft tissues lateral patellar tendon remnants to allow delivery of the graft from deep to superficial. The patella and quadriceps tendon are mobilised, and the graft is secured with sutures to the lateral retinaculum, vastus lateralis, and quadriceps tendon. The vastus medialis is then mobilised and brought in a pants-over-vest manner over the mesh graft, and secured with additional sutures. Finally, the distal arthrotomy is closed tightly to completely cover the mesh graft with host tissue. In their series, Browne and Hanssen noted that 9 of 13 patients achieved an extensor lag of <10 degrees with preserved knee flexion and significant improvements in the mean Knee Society scores for pain and function. A similar modified method has been used at our institution for chronic quadriceps tendon disruptions as well. The reconstructions have shown less of a tendency to late attenuation, stretch and recurrent extensor lag beyond two years compared to our experience with tendon allograft reconstructions and remains our procedure of choice at our institution for the majority of these challenging problems

Introduction. A deficient abductor mechanism leads to significant morbidity and few studies have been published describing methods for reconstruction or repair. This study reports the reconstruction of hip abductor deficiency using human allograft. Methods. All patients were identified as having deficient abductor mechanisms following total hip arthroplasty through radiographic assessment, MRI, clinical examination and intra-operative exploration. All patients underwent hip abductor reconstruction using a variety of human allografts including proximal humeral, tensor fascia lata, quadriceps and patellar tendon. The type of allograft reconstruction used was customized to each patient, all being attached to proximal femur, allograft bone adjacent to host bone, with cerclage wires. If a mid-substance muscle rupture was identified an allograft tendon to host tendon reconstruction was performed. Results. Allograft reconstruction was performed in 15 patients over 18 months. One patient had an abductor deficiency after a primary total hip. All patients had an abductor lurch gait and positive Trendelenburg test preoperatively. Manual muscle strength testing showed significant weakness with a mean MRC grade of 3+/5. Peri-trochanteric pain was cited as a significant complaint in > 80 % of patients. Proximal humeral allografts, with rotator cuff, were used in 8 patients, 5 had tensor fascia lata and the remainder had patella with attached tendon allograft. The majority of patients had a reduction in pain and 8/15 (53%) increased their abductor strength by almost a full grade. A reduced lurch was observed in 10 (66%) patients and one patient re-dislocated after a failed revision for instability. Conclusion. To our knowledge, this is the largest reported series of allograft reconstruction for a deficient abductor mechanism following hip arthroplasty. A viable solution is demonstrated, with promising early results for a difficult problem, utilizing a straightforward technique with low morbidity

Introduction. Chronic ruptures of the quadriceps tendon after total knee arthroplasty (TKA) are rare but are a devastating complication. The objective of this study was to validate the use of fresh frozen total fresh quadriceps tendon allografts for quadriceps tendon reconstruction. The hypothesis of this work was that the graft was functional in more than 67% of cases, a higher percentage than the results of conventional treatments. Material – methods. We designed a continuous monocentric retrospective study of all patients operated on between 2009 and 2017 for a chronic rupture of the quadriceps tendon after TKA by quadriceps allograft reconstruction. The usual demographic and perioperative data and the rehabilitation protocols followed were collected. Initial and final radiographs were analyzed to measure patellar height variation. The main criterion was the possibility of achieving an active extension of the knee with a quadriceps contraction force greater than or equal to 3/5 or the possibility of lifting the heel off the ground in a sitting position. Results. 29 patients with 33 allografts were included; 3 iterative allografts were performed on ruptures of the initial transplant and 1 patient was grafted on both sides in one step. There were 21 women and 8 men with a mean age of 73 years, and a mean body mass index of 33 kg/m. 2. Ruptures occurred in 22 cases after chronic periprosthetic infection. Walking was allowed immediately in 29 cases, but free mobilization was delayed in 29 cases. Complications affected 22 cases, but the majority of complications were not related to allograft use (including infectious failures and periprosthetic fractures). After a mean follow-up of 52 months, 28 allografts were still in place, and 22 allografts were considered functional. The active quadriceps extension force was rated on average at 3.5/5. The average pre/post-operative patellar height differential was +2 mm. Discussion. This continuous series of 33 allografts is in line with recent publications on the subject. It confirms their negative impact on the functional outcome of the TKA. The complication rate is high but the specific complication rate is not prohibitive. Two thirds of transplants are functional in the long term. Early rehabilitation procedures can be used in these difficult patients with encouraging results. The management of chronic ruptures of the quadriceps tendon after TKA by quadriceps allograft must be part of the current therapeutic options

Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL deficient knee in skeletally immature patients is controversial. To determine the outcome of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years after surgery. Between 2007–2008, 16 prepubescent skeletally immature patients underwent anatomic transphyseal ACL reconstruction using soft tissue grafts. All patients were tanner stage 1 and 2 and all had open growth plates. Outcomes were assessed at a minimum of 2 years after surgery and included: limb alignment, limb length, instrumented testing with KT-1000 and International Knee Documentation Committee (IKDC) score. Mean age at the time of surgery was 12 years (8–14). Graft choices included: living-related donor hamstring tendon allograft (n=14), hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). Mean IKDC subjective score was 96 (84–100). Sixty-two percent of patients had <3mm side-to-side difference on instrumented KT-1000 testing and 88% had a negative pivot shift. At 2 years after surgery, all patients had returned to strenuous activities and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest. We present a large series of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years following surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients