Case: This case report describes the clinical outcomes for 2 patients who underwent a primary or revision anterior cruciate ligament (ACL) reconstruction with a combined inside-out and transtibial pullout repair for a medial meniscal ramp lesion (MMRL) and a lateral meniscus root tear (LMRT), respectively. Promising short-term outcomes were seen at the oneyear follow-up for both patients.Conclusions: Utilization of these repair techniques can successfully treat a combined MMRL and LMRT injury at the time of primary or revision ACL reconstruction.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C26).

Background: Anterior cruciate ligament (ACL) reconstructions in skeletally immature patients have an increased risk of graft failure and a decreased rate of successful return to sports. Anterior cruciate ligament reconstructions (ACLRs) combined with lateral extra-articular tenodesis (LET) procedures are reported to limit anterolateral rotary instability of the knee, decreasing tension on the ACL graft. However, the open physes found in pediatric patients present unique challenges for ACLR. This video demonstrates a technique to avoid the femoral physis and necessary precautions for performing an ACLR with LET in a skeletally immature patient. Indications: The indications for combined ACLR and LET, as opposed to ACLR alone, mainly center on the risk factors for graft failure. These include the following: posterior tibial slope >12°, revision ACLR, high-grade pivot shift on physical examination, meniscal deficiency, generalized ligamentous hyperlaxity, and—especially pertinent to this procedure—skeletally immature patients. Technique Description: Standard plain radiographs and long-leg alignment films, along with a magnetic resonance imaging (MRI) study, are necessary to assess for malalignment, bone age, and concomitant meniscal and chondral pathology. This technique describes the senior author’s preferred technique for pediatric ACLR with LET. The senior author’s preferred order of operations includes performing the autologous hamstring graft harvest and LET before performing the diagnostic arthroscopy. This is followed by the intra-articular work including the ACLR. It is also the senior author’s preference to perform physeal-sparing femoral tunnels, using fluoroscopy for tunnel placement. Results: Getgood et al reported that an ACLR with an LET in young patients with a high risk of graft failure had a significant reduction in graft rupture compared to an ACLR alone. Furthermore, Noyes et al reported a significantly lower rate of graft failure and a higher rate of return to sports in those who received LET in addition to ACLR compared with those who received ACLR alone. Discussion: An ACLR combined with an LET has been reported to reduce graft failure rates and improve clinical outcomes in high-risk patients. An ACLR with LET may also be considered in skeletally immature patients with appropriate indications and extra precautions to avoid growth arrest or deformity. 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: Valgus malalignment leads to excessive loading of the lateral compartment and has been associated with lateral compartment meniscal injuries and early-onset knee osteoarthritis. Distal femoral osteotomy (DFO) is a treatment option that allows correction of the mechanical access to offload the lateral compartment. Lateral opening-wedge distal femoral osteotomy and medial meniscal root repairs are both aimed to address the pathologic biomechanics of the tibiofemoral joint and when successful can delay or even prevent progression to end-stage osteoarthritic changes in the lateral and medial compartment, respectively. Indications: Distal femoral osteotomy is indicated for patients with normal metabolic bone health and valgus malalignment who may present with concurrent lateral meniscal injury, symptomatic lateral compartment arthritis, or a chronic medial collateral ligament tear/laxity. Technique Description: Long-leg alignment radiographs and preoperative magnetic resonance images are required to evaluate the degree of mechanical access deviation and to evaluate for soft tissue injury, as there is often concomitant lateral meniscal or cartilage pathology present. This technique demonstrates the optimal order of surgical steps for DFO with a concurrent medial meniscal root repair. The senior author’s preferred order is to first perform the open lateral approach and expose the lateral cortex for the placement of plate prior to arthroscopic work and excess fluid extravasation. Intra-articular work is then performed with a diagnostic arthroscopy followed by medial meniscal root repair. Finally, the osteotomy and subsequent internal fixation are performed. Results: The literature on opening-wedge DFO outcomes is heterogeneous, with variable rates of successful outcomes and complications. Saithna et al reported that International Knee Documentation Committee and the pain subdomain of Knee injury and Osteoarthritis Outcome Scores significantly improved postoperatively following lateral opening-wedge DFOs in patients with lateral compartment osteoarthritis. The 10-year success rate of varus-producing DFO has been reported to be 64% to 85%. Discussion: We describe a technique for correction of a valgus deformity with opening-wedge DFO and concurrent meniscal root repair. This surgical technique effectively restores the native femoral and tibial axis with appropriate load distribution and also concurrently restores the appropriate function of the medial meniscus which allows axial force dispersion via hoop stresses for the medial compartment. 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: Injuries to the fibular collateral ligament (FCL) seldom occur in isolation and may present with a concomitant injury to the biceps femoris tendon and anterior cruciate ligament (ACL). Injuries to structures of the posterolateral corner (PLC) lead to varus and rotational instability of the knee, subjecting the cruciate ligaments to increased forces that may result in graft failure. Therefore, reconstruction of these structures should be performed concurrently with the ACL. Indications: Grade III FCL injuries heal poorly without operative treatment and often result in residual varus instability of the knee that increases medial knee compartment forces, and forces on both the native ACL and the graft status post ACL reconstruction. Therefore, preservation of biomechanical stability and long-term health of the knee are reliant on addressing injuries to the PLC surgically. Technique Description: A key concept of this surgical technique is a meticulous peroneal nerve neurolysis in the setting of altered biceps femoris anatomy, and the proper order of the surgical steps for tunnel creation, graft passage, and fixation and suture anchor insertion to achieve optimal patient outcomes. The described technique involves a lateral surgical approach, peroneal neurolysis, and preparation of fibular and femoral FCL tunnels, followed by a Bone-patellar tendon-bone graft (BTB) graft harvest. Attention is then turned to intra-articular work including the diagnostic arthroscopy, femoral and tibial tunnel preparation, passage of the ACL graft, and fixation of the grafts in femoral tunnels. Last, fixation is achieved in the following order: FCL graft on fibula, ACL graft on tibia, and biceps femoris tendon to fibular head. Results: Compared with the preoperative state, Moulton et al reported significant improvements in the average Lysholm and Western Ontario scores at 2.7 years postoperatively following anatomic FCL reconstrution. Furthermore, Thompson et al reported on primary suture anchor repair of distal biceps femoris in 22 elite athletes and reported that all patients had returned to their preinjury level of sporting activity at 2-year follow-up. Discussion: Anatomic reconstructions of the FCL and ACL, such as the one described in our technique, effectively restore near native knee biomechanics and offer superior clinical outcomes compared with nonanatomic-based FCL reconstructions. 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.

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