The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

Aims

The purpose of this study is to determine an individual’s age-specific prevalence of total knee arthroplasty (TKA) after cruciate ligament surgery, and to identify clinical and genetic risk factors associated with undergoing TKA.

Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

Anterior cruciate ligament (ACL) ruptures are debilitating injuries, often managed via ACL reconstruction (ACLR). Reduced range of motion (ROM), particularly loss of extension (LOE), is the most significant contributor to post-operative patient dissatisfaction. LOE may preclude return to sport, increase re-rupture rates and precipitate osteoarthritis. Passive LOE rates following ACLR have been reported at 15%. However, LOE incidence during active tasks are poorly characterised. Our review sought to determine knee extension angles for active tasks following an ACL injury or ACLR. We hypothesised greater incidences of active LOE following ACL injury or ACLR, compared to uninjured contralateral limbs or controls. We systematically searched MEDLINE, Embase, Cochrane Library, Scopus, SPORTDiscus, and relevant trials databases for English articles. Included were cohort, cross-sectional, case-controlled or randomised controlled trials analysing adults with ACL injury treated surgically or otherwise, with at least 12-weeks follow-up and reporting either active knee extension angle, active LOE angles or incidence of active knee LOE during functional tasks. The protocol was registered on PROSPERO (CRD42018092295). Subsequent meta-analysis was performed. After screening, 71 eligible articles were included. Studies were heterogenous in design and quality. Included tasks were overground walking (n=44), running (n=3), hopping/jumping/cutting (n=11) single-leg landing (n=7), and stair climbing (n=6). LOE incidence varied depending on functional activities (33.95-92.74%). LOE incidence did not vary depending on ACL status (67.26% vs. 65.90% vs. 62.57% for ACL intact, ACLD and ACLR, respectively). We observed no difference in active LOE incidence according to ACL status. Importantly, the observed incidence for active LOE was reliably higher than previously reported rates for passive measures. Given the discrepancy between active and passive LOE incidence, clinicians may advisably prioritise active ROM during ACL rehabilitation

Cite this article: Bone Joint Res 2022;11(8):514–517.

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

Aims. The aim of this prospective study was to assess the long-term clinical, radiological, functional, and quality of life (QoL)-related outcome of patients treated with the synthetic Ligament Advanced Reinforcement System (LARS) device for anterior cruciate ligament (ACL) rupture. Methods. A total of 41 patients who underwent ACL reconstruction with the LARS device (mean age 39.8 years (SD 12.1 ); 32% females (n = 13)) were prospectively included between August 2001 and March 2005. MRI scans and radiographs were performed at a median follow-up of 2.0 years (interquartile range (IQR) 1.3 to 3.0; n = 40) and 12.8 years (IQR 12.1 to 13.8; n = 22). Functional and QoL-related outcome was assessed in 29 patients at a median follow-up of 12.8 years (IQR 12.0 to 14.0) and clinically reconfirmed at latest median follow-up of 16.5 years (IQR 15.5 to 17.9). International Knee Documentation Committee (IKDC) and Tegner scores were obtained pre- and postoperatively, and Lysholm score postoperatively only. At latest follow-up, range of motion, knee stability tests, 36-Item Short Form Health Survey (SF-36), and IKDC scores were ascertained. Complications and reoperations during follow-up were documented. Results. Cumulative complication rate was 66% (n = 27), with 11 developing within one year from surgery and 16 after one year (including five patients with both early and late complications). Ten graft failures (24%) and eight cases of reactive synovitis were observed (20%). All 11 patients with early complications and ten with late complications underwent reoperation (including five with another surgical procedure for early complications), amounting to a cumulative reoperation rate of 51% (n = 21). Revision ACL reconstruction was performed in one patient (2.4%). Median IKDC at latest follow-up was 89.7 (IQR 78.2 to 93.1), being significantly worse in the event of previous complications. Lachman test was positive in 56% (n = 15) of reconstructed knees. All norm-based SF-36 items were at or above median at latest follow-up, and did not differ depending on development of complications. Conclusion. Despite good functional and QoL-related results in the long term, the cumulative complication rate of 66%, including graft failures and reactive synovitis, has to be viewed with great concern. Cite this article: Bone Joint J 2022;104-B(2):242–248

Aims. Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction. This study uses standing MRI to investigate changes in contact area, contact centroid location, and tibiofemoral alignment between ACL-injured knees and healthy controls, to examine the effect of ACL reconstruction on these parameters. Methods. An upright, open MRI was used to directly measure tibiofemoral contact area, centroid location, and alignment in 18 individuals with unilateral ACL rupture within the last five years. Eight participants had been treated nonoperatively and ten had ACL reconstruction performed within one year of injury. All participants were high-functioning and had returned to sport or recreational activities. Healthy contralateral knees served as controls. Participants were imaged in a standing posture with knees fully extended. Results. Participants’ mean age was 28.4 years (SD 7.3), the mean time since injury was 2.7 years (SD 1.6), and the mean International Knee Documentation Subjective Knee Form score was 84.4 (SD 13.5). ACL injury was associated with a 10% increase (p = 0.001) in contact area, controlling for compartment, sex, posture, age, body mass, and time since injury. ACL injury was associated with a 5.2% more posteriorly translated medial centroid (p = 0.001), equivalent to a 2.6 mm posterior translation on a representative tibia with mean posteroanterior width of 49.4 mm. Relative to the femur, the tibiae of ACL ruptured knees were 2.3 mm more anteriorly translated (p = 0.003) and 2.6° less externally rotated (p = 0.010) than healthy controls. ACL reconstruction was not associated with an improvement in any measure. Conclusion. ACL rupture was associated with an increased contact area, posteriorly translated medial centroid, anterior tibial translation, and reduced tibial external rotation in full extension. These changes were present 2.7 years post-injury regardless of ACL reconstruction status. Cite this article: Bone Joint J 2021;103-B(9):1505–1513

After anterior cruciate ligament (ACL) rupture, reconstructive surgery with a hamstring tendon autograft is often performed. Despite overall good results, ACL re-rupture occurs in up to 10% of the patient population, increasing to 30% of the cases for patients aged under 20 years. This can be related to tissue remodelling in the first months to years after surgery, which compromises the graft's mechanical strength. Resident graft fibroblasts secrete matrix metalloproteinases (MMPs), which break down the collagen I extracellular matrix. After necrosis of these fibroblasts, myofibroblasts repopulate the graft, and deposit more collagen III rather than collagen I. Eventually, the cellular and matrix properties converge towards those of the native ACL, but full restoration of the ACL properties is not achieved. It is unknown how inter-patient differences in tissue remodelling capacity contribute to ACL graft rupture risk. This research measured patient-specific tissue remodelling-related properties of human hamstring tendon-derived cells in an in vitro micro-tissue platform, in order to identify potential biological predictors for graft rupture. Human hamstring tendon-derived cells were obtained from remnant autograft tissue after ACL reconstructions. These cells were seeded in collagen I gels on a micro-tissue platform to assess inter-patient cellular differences in tissue remodelling capacity. Remodelling was induced by removing the outermost micro-posts, and micro-tissue compaction over time was assessed using transmitted light microscopy. Protein expression of tendon marker tenomodulin and myofibroblast marker α-smooth muscle actin (αSMA) were measured using Western blot. Expression and activity of remodelling marker MMP2 were determined using gelatin zymography. Cells were obtained from 12 patients (aged 12–51 years). Patient-specific variations in micro-tissue compaction speed or magnitude were observed. Up to 50-fold differences in αSMA expression were found between patients, although these did not correlate with faster or stronger compaction. Surprisingly, tenomodulin was only detected in samples obtained from two patients. Total MMP2 expression varied between patients, but no large differences in active fractions were found. No correlation of patient age with any of the remodelling-related factors was detected. Remodelling-related biological differences between patient tendon-derived cells could be assessed with the presented micro-tissue platform, and did not correlate with age. This demonstrates the need to compare this biological variation in vitro - especially cells with extreme properties - to clinical outcome. Sample size is currently increased, and patient outcome will be determined. Combined with results obtained from the in vitro platform, this could lead to a predictive tool to identify patients at risk for graft rupture

Anterior cruciate ligament (ACL) rupture with associated meniscal pathology commonly occurs in a young, active population. Preserving a greater proportion of the meniscus may improve long-term outcomes by maintaining shock absorption and knee stability. However, meniscal repair procedures involve longer healing and rehabilitation than meniscal debridement, which could affect return to work and activity. The purpose of this study was to examine the functional outcomes and quality of life scores through two years in patients undergoing ACL reconstruction (ACL-R) who had meniscal repair, meniscal debridement, or no meniscal damage at the time of reconstruction. Data for 1814 skeletally mature patients with isolated primary ACL-R was prospectively collected at a single centre from January 2010 to December 2015. Functional testing of operative to non-operative limb performance was completed at one- and two-years following surgery and included single-leg balance, single-leg hop for distance, timed six-meter hop, triple-hop for distance, and triple cross-over hop for distance. ACL-Quality-of-life questionnaires (ACL-QoL) were completed pre-operatively and at 1- and 2-years post-operatively. Descriptive statistics were completed for patient demographics and intra-operative pathology. Unpaired t-tests using 95% confidence intervals were conducted to compare groups. The patient cohort was 45% female, with a mean age of 31 years (SD 11, range 14–66). Meniscal injury was detected in 1229/1814 knees (67.8%). There were 729 debridements and 538 repairs performed. Graft choice was hamstring autograft in 85.8% of cases, bone-patellar-tendon-bone autograft in 2.5%, allograft in 10.1% and other graft types in 1.5%. Pre-operative ACL-QoL scores were 29 and 28.5 for knees without and with meniscal damage, respectively (p>0.05). Of 1814 patients, 1269 (69.9%) completed the ACL-QoL at the two-year appointment, and 1225 (67.5%) completed the functional testing. At two years post-operative, patients with no meniscal damage at surgery demonstrated superior limb symmetry performance on triple-hop for distance compared to patients with meniscal damage (98.4% vs 97.1%, p < 0 .05, CI 0.1–2.5%). No other functional testing parameters showed statistical significance. There was no difference in functional outcome between patients undergoing an isolated meniscal repair versus debridement at one- or two-years. ACL-QoL scores were statistically significantly higher at one- and two-years post-operative for patients without meniscal damage (1-year: 73 vs 70.2, p < 0 .05, CI 0.51–5.1, 2-years: 79.2 vs 76.1, p < 0 .05, CI 0.79–5.4). ACL-QoL scores were minimally higher for isolated meniscal debridement compared to isolated meniscal repair at both time points (1-year: 71.4 vs 68, p < 0 .05, CI 0.4–6.4, 2-years: 78.3 vs 74, p < 0 .05, CI 1.3–7.3). Functional outcomes do not differ at one or two years post-operatively for patients undergoing meniscal repair versus debridement concomitant with ACL-R. Quality of life scores were statistically significantly higher for the patients with no meniscal pathology at both one- and two-years post-operative. ACL-QoL scores were also statistically significantly different for the meniscal repair and debridement groups however these differences are unlikely to be clinically significant. Extended follow-up is needed to determine if the differences detected in ACL-QoL scores are sustained over time, as well as the long-term role of meniscal injury on functional outcomes

Objectives

The aim of this study was to investigate the biomechanical effect of the anterolateral ligament (ALL), anterior cruciate ligament (ACL), or both ALL and ACL on kinematics under dynamic loading conditions using dynamic simulation subject-specific knee models.

Objectives

Re-rupture is common after primary flexor tendon repair. Characterization of the biological changes in the ruptured tendon stumps would be helpful, not only to understand the biological responses to the failed tendon repair, but also to investigate if the tendon stumps could be used as a recycling biomaterial for tendon regeneration in the secondary grafting surgery.

The June 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited