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

To investigate temporal changes in synovial lymphatic system (SLS) drainage function after Anterior cruciate ligament (ACL) injury, a non-invasive ACL rupture model was used to induce the PTOA phenotype without altering the SLS structure. We have created a non-invasive ACL rupture model in the right knee (single overload impact) of 12- week-old C57bl/6 male mice to mimic the ACL rupture-induced PTOA development. 70 kDa-TxRedDextran were injected into the right knee of the mice at 0, 1, 2, and 4 wks post modeling (n=5/group), and the fluorescence signal distribution and intensity were measured by the IVIS system at 1 and 6 hrs post-injection. After 24 hrs, the drainage lymph nodes and whole knee joint were harvested and subjected to ex vivo IVIS imaging and immunofluorescence detection respectively. Manual ACL rupture was induced by 12N overloaded force and validated by a front drawer test. Intraarticular clearance of TxRed-Dextran detected by the IVIS was significantly reduced at 1, and 2 wks at a level of 43% and 55% respectively but was not significantly different from baseline levels at 4 wks (89%). TxRed-Dextran signal in draining lymph nodes was significantly reduced at 1 week at the level of but not for 2 and 4 wks compared to baseline levels (week 1–29%, week 2–50%, week 4–94%). TxRed-Dextran particle was significantly enriched in the synovium at 1, 2 wks but was not significantly different from baseline levels at 4 wks rupture-post ACL rupture (Particle numbers: Sham Ctrl-34 ±14, week 1, 113 ± 17; week 2, 89 ± 13; week 4, 46 ± 18; mean ± SD). We observed the drainage function of SLS significantly decreased at 1 and 2 wks after the ACL rupture, and was slowly restored at 4 wks post-injury in a non-invasive ACL rupture model. Early impairment of SLS drainage function may lead to accumulation of inflammatory factors and promote PTOA progression

Abstract. Introduction. High posterior tibial slope (PTS) has been recognised as a risk factor for anterior cruciate ligament rupture and graft failure. This prospective randomised study looked at intra-operative findings of concomitant intra-articular meniscal and chondral injuries during a planned ACL reconstruction. Material and Methods. Prospective data was collected as part of a randomised trial for ACL reconstruction techniques. Intra-operative data was collected and these findings were compared with the PTS measured on plain radiograph by a single person twice through a standardised technique and intra-observer analysis was performed. Results. 49 confirmed ACL rupture patients were in the trial. The average age was 34 (23–66) years and 12 patients were female. 17 patients (34%) had PTS of 12 degrees or more. The intra-observer analysis for PTS measurements in a 2-sided paired T test, showed a mean difference of 0.03 degrees with a P value = 0.83. 23 patients had medial meniscal pathology identified, 15 (65%) had a PTS <12 degrees. 16 patients had lateral meniscus pathology and 9 (56%) had a PTS <12 degrees. Chondral damage did not appear significantly different in the two groups (<12 degrees 15% vs >12 degrees 23%). Conclusion. In this sample, a PTS >12 degrees was not associated with a higher incidence of meniscal or chondral damage after a confirmed ACL rupture

It is unclear why ACL rupture increases osteoarthritis risk, regardless of ACL reconstruction. Our aims were: 1) to establish the reliability and accuracy of a direct method of determining tibiofemoral contact in vivo with UO-MRI, 2) to assess differences in knees with ACL rupture treated nonoperatively versus operatively, and 3) to assess differences in knees with ACL rupture versus healthy knees. We recruited a convenience sample of patients with prior ACL rupture. Inclusion criteria were: 1) adult participants between 18–50 years old; 2) unilateral, isolated ACL rupture within the last five years; 3) if reconstructed, done within one year from injury; 4) intact cartilage; and 5) completed a graduated rehabilitation program culminating in return to sport or recreational activities. Participants were excluded if they had other ligament ruptures, osteoarthritis, an incompletely rehabilitated injury, were prohibited from undergoing MRI, or had a history of ACL re-rupture. Using the UO-MRI, we investigated tibiofemoral contact area, centroid location, and six degrees of freedom alignment under standing, weightbearing conditions with knees extended. We compared patients with ACL rupture treated nonoperatively versus operatively, and ACL ruptured knees versus healthy control knees. We assessed reliability using the intra-class correlation coefficient, and accuracy by comparing UO-MRI contact area with a 7Tesla MRI reference standard. We used linear mixed-effects models to test the effects of ACL rupture and ACL reconstruction on contact area. We used a paired t test for centroid location and alignment differences in ACL ruptured knees versus control knees, and the independent t test for differences between ACL reconstruction and no reconstruction. Analyses were performed using R version 3.5.1. We calculated sample size based on a previous study that showed a contact area standard deviation of 13.6mm2, therefore we needed eight or more knees per group to detect a minimum contact area change of 20mm2with 80% power and an α of 0.05. We recruited 18 participants with ACL rupture: eight treated conservatively and 10 treated with ACL reconstruction. There were no significant differences between the operative and nonoperative ACL groups in terms of age, gender, BMI, time since injury, or functional knee scores (IKDC and KOOS). The UO-MRI demonstrated excellent inter-rater, test-retest, and intra-rater reliability with ICCs for contact area and centroid location ranging from 0.83–1.00. Contact area measurement was accurate to within 5% measurement error. At a mean 2.7 years after injury, we found that ACL rupture was associated with a 10.4% larger medial and lateral compartment contact areas (P=0.001), with the medial centroid located 5.2% more posterior (P=0.001). The tibiae of ACL ruptured knees were 2.3mm more anterior (P=0.003), and 2.6° less externally rotated (P=0.010) relative to the femur, than contralateral control knees. We found no differences between ACL reconstructed and nonreconstructed knees. ACL rupture was associated with significant mechanical changes 2.7 years out from injury, which ACL reconstruction did not restore. These findings may partially explain the equivalent risk of post-traumatic osteoarthritis in patients treated operatively and nonoperatively after ACL rupture

Aims. Adenosine, lidocaine, and Mg. 2+. (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery. Methods. Male (n = 21) and female (n = 21) adult Sprague-Dawley rats were randomly divided into ALM or Saline control treatment groups. Three days after ACL rupture, animals underwent ACLR. An ALM or saline intravenous infusion was commenced prior to skin incision, and continued for one hour. An intra-articular bolus of ALM or saline was also administered prior to skin closure. Animals were monitored to 28 days, and joint function, pain, inflammatory markers, histopathology, and tissue repair markers were assessed. Results. Despite comparable knee function, ALM-treated males had reduced systemic inflammation, synovial fluid angiogenic and pro-inflammatory mediators, synovitis, and fat pad fibrotic changes, compared to controls. Within the ACL graft, ALM-treated males had increased expression of tissue repair markers, decreased inflammation, increased collagen organization, and improved graft-bone healing. In contrast to males, females had no evidence of persistent systemic inflammation. Compared to controls, ALM-treated females had improved knee extension, gait biomechanics, and elevated synovial macrophage inflammatory protein-1 alpha (MIP-1α). Within the ACL graft, ALM-treated females had decreased inflammation, increased collagen organization, and improved graft-bone healing. In articular cartilage of ALM-treated animals, matrix metalloproteinase (MMP)-13 expression was blunted in males, while in females repair markers were increased. Conclusion. At 28 days, ALM therapy reduces inflammation, augments tissue repair patterns, and improves joint function in a sex-specific manner. The study supports transition to human safety trials. Cite this article: Bone Joint Res 2024;13(6):279–293

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries. Cite this article: Bone Joint J 2023;105-B(7):723–728

Introduction: Anterior cruciate ligament (ACL) rupture leads to biomechanics disturbances of the knee joint which are reflected also in the plantar supports. Our hypothesis is that a redistribution of the sole bilateral charges will be produced to allows the feet to get a new control system to compensate ACL rupture. The aim of this research is to study the plantar support pressures disturbances in patients with ACL rupture before operation. Material and Methods: We analyzed the plantar pressure distribution in two populations: Group A: 39 males of 37 years average age (21–49 y.o), previous surgery of isolated ACL rupture, excluding patients with meniscal tear or serious cartilage damage, contralateral lesions and knee previous surgery as well. Group B (control group): 37 healthy males of 31 years average age (21–40 y.o) without any musculoskeletal disorders. We performed physical examination and walking through a pedography plate (Emed, Novel Munich, Germany). We studied global plantar support (pressure, forces and areas) of each foot and also divided each foot into six parts. Data obtained was compared between group A, patients (healthy leg and ACL rupture leg) and group B (control group). Statistical analysis was performed with a non-parametric Wilcoxon test. Results: Group A (healthy leg and ACL rupture leg) total support area of both feet were statistically superior than Group B total support area (p< 0,019 and p< 0,005 respectively). Evenly midfoot total support area was superior in Group A that in Group B, as well as midfoot force support (p< 0.089). Group A midfoot pressure was higher in ACL rupture leg than in healthy leg (p< 0.007) and it was also higher to the one obtained for group B (p< 0.046). Evenly the anterior-external region of Group A, healthy leg got the highest pressure (p< 0.076), followed by Group A, ACL rupture leg (p< 0.022) and finally Group B. Group B anterior-internal pressure was statistically superior to Group A, ACL rupture leg (p< 0.049) followed by Group A, healthy leg (p=0.022). During foot takeoff, first toe pressures were higher in Group B compared to Group A (p< 0.076). Conclusion: ACL rupture shows differences in plantar support pressures distribution of both legs (ACL rupture leg and healthy leg) compared with a control population. The injured leg seeks balance decreasing heel support and increasing the contact surfaces between floor, midfoot and forefoot

The aim of this study was to determine Anterior Cruciate Ligament (ACL) graft and contralateral ACL (CACL) survival in patients who have undergone ACL reconstruction (ACLR) with hamstring autograft following netball injuries, and determine factors associated with repeat ACL injury and return to netball. From a prospectively collected database, a consecutive series of 332 female netballers who underwent primary ACLRs using hamstring autografts were identified. Subjects were surveyed at a minimum of five years following reconstruction, including details of further ACL injuries to either knee, return to netball or other sports and psychological readiness with the ACL-RSI score. 264 participants (80%) were reviewed at the mean follow up of 9 years (60-180 months). There were 12 ACL graft ruptures (5%) and 35 contralateral ACL ruptures (13%). ACL graft survival was 97% and 97%, 96% at 2, 5 and 7 years respectively. CACL survival was 99%, 94%, and 90% at 2, 5 and 7 years respectively. The 7-year ACL graft survival was 97% in those 25 or more and 93% in those under 25 years (p=0.126). The 7-year CACL survival was 93% in those 25 or more and 85% in those under 25 years (HR 2.6, 95%CI 1.3-5.0, p=0.007). A family history of ACL injury was reported by 32% of participants. A return to netball was reported by 61% of participants. The mean ACL-RSI score was 65 in those who returned to netball and 37 in those who did not (p=0.001). ACLR with hamstring autografts is a reliable procedure for netballers with a survival rate of 96% at 7 years, allowing 63% of participants to return to netball. A successful return to sport was associated with greater psychological readiness. CACL injury occurred with more than double the frequency of ACL graft rupture and was increased by 2.6x in those <25 years

The purpose of this report was to describe a new arthroscopic finding in anterior cruciate ligament rupture: the presence of osteochondral injury beneath the posterior horn of the lateral meniscus. A single surgeon performed arthroscopic evaluation of 43 consecutive patients with ACL rupture within 12 months of injury. Nine patients (21 %) had a chondral lesion of the posterolateral tibia beneath the posterior horn of the lateral meniscus, not seen unless the meniscus was elevated with the arthroscopic probe. On four occasions a chondral loose body was identified and removed. Seven of the nine (78%) had an associated lateral meniscal tear and four (44 %) a chondral lesion of the lateral femoral condyle. MRI was not accurate in predicting the presence of a chondral lesion in those patients with a lesion that had an MRI preoperatively. We report a new arthroscopic finding in ACL rupture not previously mentioned in the literature. The clinical significance is that when chondral loose bodies are encountered of unknown origin, arthroscopic evaluation of the area beneath the posterior horn of the lateral meniscus should be involved in any systematic search for the lesion

The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament. Methods: Two groups of patients aged 18 to 50 years were recruited from operating theatre lists examined at a check and consent clinic. One of the groups had ACL deficient knees and the control group had intact ACL, later proven at arthroscopy. A total of 48 independent examinations, 26 with ACL rupture and 22 without, were undertaken by a consultant or registrar proficient in the modified version of the pivot shift test. At the start of the consultation the examiner, who was blinded to the operation that the patient was listed for and to the patient’s history, performed the modified pivot shift test only. The result of the test was reported as positive or negative for ACL rupture to the study co-ordinator before the examiner continued with the consultation. Results: Of the 26 examinations of ACL deficient knees, 22 were reported as positive and four negative for ACL rupture using the pivot shift test only. Of the 22 examinations of ACL intact knees one was reported as positive for ACL rupture and 21 as negative. This gives a specificity and sensitivity of the modified version of the pivot shift test as 95.5% (95% CI 75.1–99.8%) and 84.6% (95%CI 64.3–95.0%) respectively. Conclusion: The modified pivot shift test is an accurate test for the detection of ACL rupture. Our modified pivot shift test compares favourably with data from previous accuracy studies of previously described versions of the pivot shift test. We now plan to assess the accuracy of the modified pivot shift test when carried out by medical students and junior doctors

Purpose of the study A prospective observational study to ascertain any correlation between joint laxity and knee hyperextension to anterior cruciate ligament rupture. Methods used Joint laxity as defined by Beighton’s method and hyperextension of uninjured knee in 169 patients with symptomatic isolated anterior cruciate ligament rupture was recorded in a prospective fashion. This was correlated to the scores obtained in a selected group of age and sex matched controls. Results 72 out of 169 of the patients had hyperlaxity in their joints and 133 out of 169 had knee hyperextension. In the control group 14 out of 65 had hyperlaxity in their joints and 24 out of 65 had knee hyperextension. Statistical analysis showed that ACL injury was common in those with lax joints and with knee hyperextension with a p < 0.001. Conclusion ACL injury is common in patients with joint laxity especially in those with knee hyperextension

The management of symptomatic single bundle Anterior Cruciate Ligament (ACL) ruptures is still a surgical dilemma. Preservation of the intact fibres of the ACL bundle is considered to be a possible source of reinnervation of the ACL autograft which reflects on better proprioceptive knee control after major ligament reconstruction. Results of a prospective study of 67 patients who had a double stranded but single bundle Anterior Cruciate Ligament (ACL) reconstruction for partial ACL ruptures are presented. There were 43 males and 24 females in this study with a mean age at the time of injury of twenty-five years (14 – 40). Eight played sport professionally and thirty-four played at a competitive level. A valgus twisting force was the most common mechanism of injury. Mean injury to operation time was 7.5 weeks (2–12). All procedures were done arthroscopically without using tourniquet, but using an arthroscopy pump and irrigation fluid containing adrenaline. The semitendinosis hamstring graft was used in all reconstructions. The mean follow-up period was 3.3 years (2–5.4). There was one major complication, who developed a reflex sympathetic dystrophy following a saphenous nerve neuroma. The Quality of Life (QOL) score was assessed using the Mohtadi index. The mean pre-operative QOL score of 30 (13–50) was improved to 93 (70–100) post-operatively. Fifty patients were able to return to their previous sporting level at a mean duration of 9 months (6–12). Preservation of mechanoreceptors by performing a double stranded, single bundle ACL reconstruction in partial ACL ruptures in high demand patients yields good results and enables early return to high demand sports

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis

Anterior tibial translation was measured in both knees using the radiological Lachman test and the lateral monopodal stance tests in 281 patients with unilateral anterior cruciate ligament (ACL) rupture. Measurements of translation in the medial compartment were more useful than those in the lateral compartment. Measurement of anterior tibial translation in the medial compartment using the radiological Lachman test showed ACL rupture in 92% of cases compared with 70% for the lateral monopodal stance test. In normal and in ACL-ruptured knees the monopodal stance test showed that every 10 degrees increase in posterior inclination of the tibial plateau was associated with a 6 mm increase in anterior tibial translation; the radiological Lachman test showed a 3 mm increase for every 10 degrees increase in tibial slope

Introduction and Aims: Anterior cruciate ligament (ACL) injuries have historically been classified as non-contact or contact based on the mechanism of injury. The purpose of this study was to establish a detailed correlation between mechanism and the associated osteochondral, meniscal and other injuries to improve understanding of this common injury and its outcome. Method: A descriptive analysis of prospectively collected data on ACL injuries requiring reconstruction between 2000 and 2004 was completed. Mechanism of injury was clearly elicited and correlated with clinical, radiologic and operative findings. Magnetic resonance imaging (MRI) was performed on all patients to analyse patterns of ACL rupture and associated osteochondral, meniscal and ligament injuries. Osteochondral injuries were analysed by a musculoskeletal radiologist according to location, intensity and depth. Intra-operative documentation of intra-articular injury pattern was also performed and correlated with MRI findings. Classification into ‘active’ (non-contact) and ‘passive’ (contact) mechanisms was completed and correlated with injury pattern. Results: Seventy patients were identified with appropriate clinical, radiologic and operative data. A thorough review of the events surrounding the injury was documented. Forty-six patients described an active mechanism and 24 patients a passive mechanism of injury. Clinical examination demonstrated a similar proportion of medial collateral ligament injuries in each group. MRI within three months of injury demonstrated occult osteochondral lesions or ‘bone bruises’ in the majority of patients. Clear distinguishing patterns of femoral and tibial osteochondral injury were identified in the active and passive groups. Depth of osteochondral injury was most commonly classified as at least two-thirds the distance to the physeal scar in both groups. Intensity of the abnormal edema-like signal in the marrow of the distal femur and proximal tibia was most commonly classified as severe in both groups. Lateral meniscus injury was more common than medial, and was found in the majority of patients, more commonly in the passive group. Conclusion: Although surgical techniques continue to improve, the ACL injury mechanism and its relation to intra-articular pathology is less well defined. This study defines either ‘active’ or ‘passive’ mechanisms, with implications for likely associated osteochondral and meniscal injury. This gives valuable insight into the ACL injured knee, its management, and eventual prognosis

We assessed hyperextension of the knee and joint laxity in 169 consecutive patients who underwent an anterior cruciate ligament reconstruction between 2000 and 2002 and correlated this with a selected number of age- and gender-matched controls. In addition, the mechanism of injury in the majority of patients was documented. Joint laxity was present in 42.6% (72 of 169) of the patients and hyperextension of the knee in 78.7% (133 of 169). All patients with joint laxity had hyperextension of their knee. In the control group only 21.5% (14 of 65) had joint laxity and 37% (24 of 65) had hyperextension of the knee. Statistical analysis showed a significant correlation for these associations. We conclude that anterior cruciate ligament injury is more common in those with joint laxity and particularly so for those with hyperextension of the knee.

Aim: The accuracy of joint line tenderness (JLT) and magnetic resonance imaging (MRI) were determined in the diagnosis of meniscal tears in patients with complete rupture of the anterior cruciate ligament (ACL). Additionally, the effects of time from injury (to arthroscopy) and medial femoral condyle (MFC) lesions on diagnosis with JTL and MRI were established. Methods: A total of 133 male patients, whose first arthroscopy was performed by MU, were included. Preoperative MRI findings, the initial knee trauma causing ACL rupture, and the time from injury (TFI) were recorded. Physical examinations including JLT were performed within 1 week preceding the operation by the same observer. MRIs were performed within 6 weeks preoperatively by a 1.5 T imager. The first 6 week period after the initial trauma was defined as the acute (Grup I), 6 weeks to 12 months as the subchronic (Grup II) and 12 months or longer as the chronic period (Grup III). The sensitivity, specificity, and accuracy for JLT and MRI were calculated. Retrospective analyses were performed for TFI. Chi-square and kappa (k) tests were used for statistical analyses. Results: In all patients, mean TFI was calculated as 14.8±16.8 months (median; 8.0). Patient distribution were as follows; 29(21.8%) were Group I, 51(38.3%) Group II, and 53(39.8%) Group III. The sensitivity, specificity, and accuracy of MRI were 89.1%, 87.0%, and 87.9% for MML (p=0.0001,k=0.76), while 91.6%, 74.6%, and 82.7% for LML (p=0.0001,k=0.66), respectively. The sensitivity, specificity, and accuracy of JLT independent from TFI were 66.2%, 76.8%, and 70.7% for MML (p=0.0001,k=0.42), while 59.4%, 67.2%, and 63.2% for LML (p=0.002,k=0.27), respectively. For MML, the accuracy values of Groups I and III were; 86.2% (k=0.72) and 88.7% (k=0.76) for MRI (p=0.0001) and 55.2% (p=0.363, k=0.13) and 77.4% (p=0.0001,k=0.51) for JLT, respectively. For LML these were 75.9% (p=0.007,k=0.51,) and 90.6% (p=0.0001,k=0.81) for MRI and 48.3% (p=0.604,k=0.02) and 71.7% (p=0.002,k=0.43) for JLT, respectively. In Group III, diagnostic accuracy of JLT for MML was 80.0% (p=0.003,k=0.57) in the absence of MFC lesions and decreased to 73.9% (p=0.035,k=0.44) in their presence. In chronic MML, rate of false positive results of JLT in the presence and absence of MFC lesions was 21.7% and 10.0%, respectively (p=0.237). Conclusion: The accuracy of MRI and JLT in LML was lower than MML, especially in the acute period. In the diagnosis of acute and subchronic LML, and acute MML, use of JTL was not statistically significant. However, in determination of MML, the presence of MFC lesions particularly in the chronic period, lead to a 2-fold increase in the rate of false positive results in terms of diagnosis with JTL

We have investigated whether shape of the knee can predict the clinical outcome of patients after an anterior cruciate ligament rupture. We used statistical shape modelling to measure the shape of the knee joint of 182 prospectively followed patients on lateral and Rosenberg view radiographs of the knee after a rupture of the anterior cruciate ligament. Subsequently, we associated knee shape with the International Knee Documentation Committee subjective score at two years follow-up. The mean age of patients was 31 years (21 to 51), the majority were male (n = 121) and treated operatively (n = 135). We found two modes (shape variations) that were significantly associated with the subjective score at two years: one for the operatively treated group (p = 0.002) and one for the non-operatively treated group (p = 0.003). Operatively treated patients who had higher subjective scores had a smaller intercondylar notch and a smaller width of the intercondylar eminence. Non-operatively treated patients who scored higher on the subjective score had a more pyramidal intercondylar notch as opposed to one that was more dome-shaped. We conclude that the shape of the femoral notch and the intercondylar eminence is predictive of clinical outcome two years after a rupture of the anterior cruciate ligament.

Cite this article: Bone Joint J 2014;96-B:737–42.

We reviewed 5086 patients with a mean age of 30 years (9 to 69) undergoing primary reconstruction of the anterior cruciate ligament (ACL) in order to determine the incidence of secondary pathology with respect to the time between injury and reconstruction. There was an increasing incidence of medial meniscal tears and chondral damage, but not lateral meniscal tears, with increasing intervals before surgery. The chances of requiring medial meniscal surgery was increased by a factor of two if ACL reconstruction was delayed more than five months, and increased by a factor of six if surgery was delayed by > 12 months. The effect of delaying surgery on medial meniscal injury was also pronounced in the patients aged < 17 years, where a delay of five to 12 months doubled the odds of medial meniscal surgery (odds ratio (OR) 2.0, p = 0.001) and a delay of > 12 months quadrupled the odds (OR 4.3, p = 0.001). Increasing age was associated with a greater odds of chondral damage (OR 4.6, p = 0.001) and medial meniscal injury (OR 2.9, p = 0.001), but not lateral meniscal injury. The gender split (3251 men, 1835 women) revealed that males had a greater incidence of both lateral (34% (n = 1114) vs 20% (n = 364), p = 0.001) and medial meniscal tears (28% (n = 924) vs 25% (n = 457), p = 0.006), but not chondral damage (35% (n = 1152) vs 36% (n = 665), p = 0.565). We conclude that ideally, and particularly in younger patients, ACL reconstruction should not be delayed more than five months from injury.

Cite this article: Bone Joint J 2013;95-B:59–64.

We treated 90 patients with an isolated injury to the anterior cruciate ligament (ACL) by reconstruction using a patellar tendon autograft and interference screw fixation.

Of these, 82 (91%) were available for review at 24 months. Two grafts and two contralateral ACLs had ruptured during sport and there was one case of atraumatic graft resorption. Using the assessment of the International Knee Documentation Committee (IKDC), 86% of the remaining patients were normal or nearly normal. The median Lysholm knee score was 95/100 and 84% of patients were participating in moderate to strenuous activity. All had grade-0 or grade-1 Lachman, pivot-shift and anterior-drawer tests. Measurement with the KT1000 arthrometer gave a side-to-side difference of < 3 mm of anterior tibial displacement in 90%. Sixty-six radiographs were IKDC grade A and one was grade B. Pain on kneeling was present in 31% and graft site pain in 44%.

At 24 months after operation all patients had excellent knee stability, a high rate of return to sport and minimal radiological evidence of degenerative change. Our series therefore represents a basis for comparison of results using other techniques and after more severe injuries.

To describe our experience with computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy. It may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention such as arthroplasty.

Two patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction along with femoral osteotomy in one case and upper tibial osteotomy in the other. We used Orthopilot software to perform computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy.

Subjective evaluation at postoperatively indicated significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation by International Knee Documentation Committee showed improved score postoperatively. Both had minor complications occurred in the immediate postoperative period. The average correction angle of the osteotomy was 7 degrees (7–10).

Computer assisted ACL reconstruction and osteotomy may provide long-term symptomatic pain relief, increased activity and improved function. Only Anterior cruciate ligament reconstruction may not effectively provide pain relief to the ACL-deficient knee with degenerative medial arthrosis. The results of this study suggest that combined high tibial or femoral osteotomy and ACL reconstructions are effective in the surgical treatment of varus, ACL-deficient knees with symptomatic medial compartment arthritis. Computer aided surgery allows precise correction of the axial deformity and tunnel orientation intraoperatively.

Abstract. Introduction. The medial meniscus is crescent shaped and it is wider posteriorly than anteriorly. It covers up to 60 % of the articular surface of medial tibial condyle and helps with the loading distribution in the medial compartment. Meniscal lesions occur in association with ACL tears in 60 % of the time. The posterior aspect of the menisco-capsular junction is known as the meniscal rampzone. If not addressed during surgery, it could lead to unfavourable results. Objective. Incidence of ramp lesion following ACL injuries. Methods. Observational study of 100 patients at EL Hadara Main University Hospital who underwent anterior cruciate ligament reconstruction. MRI and arthroscopic diagnosis was done to detect Ramp lesions associated with ACL ruptures in November 2017 till November 2019. Results. Incidence was 9%. Duration of injury and increased medial meniscal slope were associated with increased incidence of ramp lesion. MRI signs were present in 79% of cases without Ramp lesion, 100% in Cases with ramp lesion. Mode of Injury and presence of locking or giving way symptoms were not associated with increased incidence. Conclusion. The ramp lesion at the posterior aspect of the meniscus is difficult to visualize from standard anterior portals and is, therefore, frequently missed and can be underestimated. Also, there are no specific MRI signs of this lesion. The overall incidence of ramp lesions in 100 cases that had undergone ACL reconstruction in our study was 9 %. It was found also that the longer the duration from injury, the more likely ramp lesion would occur. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Recent findings have identified the importance of previously undiagnosed or neglected meniscus lesions in association with anterior cruciate ligament (ACL) injuries (e.g. medial meniscus ramp lesions and posterior root tears of the lateral meniscus). There is increasing biomechanical evidence that they bear the potential to alter both anteroposterior and rotational laxity patterns in ACL injured knees. Few data exist with respect to the presence of these specific tear entities in large series of ACL injured patients. The purpose of the study was to analyze the meniscus tear pattern in a series of ACL injured knees with a special focus on ramp lesions of the medial meniscus and posterior root lesions of the lateral meniscus. The hypothesis was that a significant number of ACL injured patients would display these types of lesions. Data from 358 patients undergoing an ACL reconstruction (227 males /131 females, age: 28±10) were extracted from a center-based registry. The type of ACL tear (partial versus complete) as well as the presence of associated meniscus lesions were documented. Meniscus lesions were classified into the following categories: medial ramp lesions, lateral root lesions, medial ramp and lateral root lesion, other medial meniscus injuries, other lateral meniscus injuries, other bimeniscal injuries. Chi-square tests were used to determine whether the percentage of meniscal lesions differed between types of ACL tear, gender and age (below 21, 21–35, above 35). Significance was set at p < 0.05. Isolated ACL tears were present in 107 (30%) of the operated knees (31 partial; 327 complete). Complete ACL lesions were more likely to present an associated meniscus injury (321 out of 327, 71%) than partial tears (13 out of 31, 42%). The incidence of meniscus injuries which are associated with ACL tears is very high (70%). Previously undiagnosed or neglected meniscus injuries like medial ramp or lateral root tears could be identified in 35% of patients. As such, the hypothesis was confirmed that an important amount of ACL injured knees display this specific intraarticular soft tissue damage. A systematic evaluation of these lesions under arthroscopy should thus be performed and specific repair needs to be evaluated

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females’ greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries. Cite this article: Bone Joint J 2023;105-B(10):1033–1037

There is increasing evidence that patients with ACL reconstruction using ipsilateral graft harvest are at greater risk of rupture (12.5%) on their contralateral compared to their surgical side (7.9%). The purpose of this study is to re-evaluate patients from a previous study comparing ipsi- versus contralateral graft harvest to compare ACL rupture rate at a minimum 10 year follow-up. An attempt to contact all participants from a previously published study was made to invite them to return for a follow-up. The assessment included an International Knee Documentation Committee Knee Clinical Assessment (IKDC), isokinetic concentric knee flexion and extension strength testing, as well as the ACL-Quality of life (ACL-QOL). A chart review was conducted to identify or confirm subsequent ipsi- or contralateral knee surgeries. In patients with ipsilateral graft, 3/34 (8.8%) re-ruptured and 3/34 (8.8%) had contralateral rupture. In the contralateral group, 1/28 (3.6%) re-ruptured and 2/28 (7.1%) had contralateral rupture. The relative risk (RR) of re-rupture with ipsilateral graft was 2.47 compared to using the contralateral site (p=0.42). RR of rupture on the contralateral side when ipsilateral graft was used was 1.23 compared to the alternate approach. Current contact information was unavailable for 21 patients. Of the 47 remaining, 37 were consented (79%). No difference in the ACL-QOL between groups (ipsilateral 68.4±24.4, contralateral 80.1±16.0, p=0.17) was observed. There were no differences in knee flexion strength between groups (peak torque flexion affected leg: ipsilateral 77.8nm/kg±27.4, contralateral: 90.0 nm/kg±35.1; p=0.32; Unaffected leg: ipsilateral: 83.3 nm/kg±30.2 contralateral 81.7 nm/kg±24.4; p= 0.89). This study suggests that using the contralateral hamstring in ACL rupture is not associated with an increase in ACL rupture on either side. The risk of ACL injury was low in all limbs; therefore, a larger study would be required to definitively state that graft side had no impact

Rotational laxity increases the risk of anterior cruciate ligament (ACL) injuries and residual rotational laxity can result in inferior surgical outcomes and risk of retears. The dynamic rotatory knee stability can be assessed through manual examination, but it is limited to the surgeon's experience and it provides inaccurate measurements, highlighting the need for objective measurement of knee rotational laxity. The objective measurement of knee laxity can help to better identify patients that may benefit from conservative treatment or those that require surgical treatment with or without concomitant extra-articular procedures. We rely in Porto Knee Testing Device (PKTD®) to accurately measure sagittal and rotatory laxity of the knee, either individually or in a combined fashion. The PKTD® is safe and can be used in combination with CT or MRI, which allows to assess both the “anatomy” and the “function” in the same examination. By this way, we may have a total ACL rupture and a stable knee not requiring surgery or, on the other hand, the same injury scenario but with an unstable knee that requires surgical intervention (with or without lateral extra-articular tenodesis). In cases of partial ACL tears, it may be possible to identify some ligamentous fibers that remain functional, where the conservative treatment or augmentation techniques can provide satisfactory results. It can also identify when a posteromedial or posterolateral instability is associated. The PKTD® can also be used to follow-up the laxity results of conservative and surgical procedures and contribute to the decision-making of return to sports

To investigate changes in quadriceps and hamstrings muscle groups during sustained isokinetic knee flexion and extension. 125 paediatric participants (45 males and 80 females, mean age 14.2 years) were divided into two groups: participants with a confirmed ACL tear (ACLi, n = 64), and puberty- and activity-level matched control participants with no prior history of knee injuries (CON, n = 61). Participants completed a series of 44 repetitions of isokinetic knee flexion and extension at 90 deg/ sec using a Biodex dynamometer (Biodex Medical Systems Inc, Shirley, New York). Surface EMG sensors (Delsys Incorporated, Natick, MA) simultaneously recorded the quadriceps and hamstring activations. Muscle function was assessed as the change in quadriceps activation and extension torque were calculated using the percent difference between the mean of the first five trials, and the mean of the last five trials. ACLi participants had significantly higher percent change in quadriceps activation for both healthy and injured legs, in comparison to CON dominant leg. As such, the healthy leg of the ACLi participants is activating significantly more than their health matched controls, while also demonstrating reduced muscular endurance (less torque in later repetitions). Therefore, we conclude that the non-injured limb of the ACLi participant is not performing as a healthy limb. Since return to activity clearance following ACLi implies return to sport against age- and activity matched opponents, clearing young athletes based on the non-injured contralateral limb may put them at greater risk of reinjury

The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis

Abstract. Purpose. This study aims to compare the clinical and functional outcomes and donor site morbidity of anterior cruciate ligament reconstruction with hamstring tendon autograft and peroneus longus tendon autograft in patients with complete anterior cruciate ligament rupture. Methods. Patients who underwent ACL reconstruction from February 2018 to July 2019 were randomly allocated into two groups (hamstring and peroneus longus). Functional scores (IKDC and Lysholm scores) and pain intensity by visual analogue score were recorded preoperatively, 3, 6months, 1, and 2 years postoperatively. Donor site morbidities were assessed with thigh circumference measurements in hamstring group and ankle scoring with the American foot and ankle score in peroneus longus group. Results. Sixty patients (hamstring n = 30, peroneus n = 30) met the inclusion criteria. The functional scores (IKDC and Lysholm) did not show statistical difference among the two groups at two years follow-up (P- value>0.05). The means values for visual analogue score after two years in the hamstring and Peroneus longus group was 1±0.74 and 1.03± 1.06, respectively. In peroneus longus group, the mean foot and ankle score was 98.63±3.88 (range= 85–100). A significant difference was found in the hamstring group between operated and non-operated thigh circumferences with p- value <0.001. Conclusions. Peroneus longus tendon autograft is an easily accessible tendon for ACL reconstruction and gives comparable functional outcomes as hamstring tendon with no additional donor site morbidity in our study

BACKGROUND. Injuries of the both menisci and complete ACL tear is quite common. In the literature, functional outcome in these patients is often variable and less than satisfactory. We studied the functional outcome of this group of patients (retrospective study of prospectively followed case series). MATERIAL AND METHODS. All patients who were diagnosed with ACL injury by arthroscopy at an tertiary hospital in southern India between January2013 and june2017 were enrolled in the study. From the total of 189 consecutive patients who had ACL tears with either one meniscus or both meniscus tear, 41 patients had injuries of both menisci of the same knee with ACL tear. 6 patients were lost to follow up. All patients underwent repair/balancing of one/both meniscus and reconstruction of ACL. There were 29 males and 6 females with age ranging from 18 – 60yrs (mean 25.2) years available for final analysis. RESULTS. In 45.71% of patients (n=16) both meniscal tear was diagnosed by arthroscopic examination only. Bucket handle tear was observed in 5 knees (medial: 4 knees, lateral: 1 knee) in fresh group, and 4 knees (medial: 3 knees, lateral: 1 knees) in delayed presentation. PMMRT was noted in 6 patients and PLMRT was noted in 3 patients. All patients were evaluated using lysholm score. CONCLUSION. The incidence of both meniscal tear associated with ACL injury has significant effect on the post operative management and the overall functional outcome. The incidence of injuries of both menisci is higher in acute injuries in our series

Abstract. Introduction. MCL injuries often occur concurrently with ACL rupture – most noncontact ACL injuries occur in valgus and external rotation (ER) - and conservative MCL treatment leads to increased rate of ACL reconstruction failure. There has been little work developing effective MCL reconstructions. Methods. Cadaveric work measured MCL attachments by digitisation and radiographically, relating them to anatomical landmarks. The isometry of the superficial and deep MCL (sMCL and dMCL) and posterior oblique ligament (POL) was measured using fine sutures led to displacement transducers. Contributions to stability (restraint) were measured in a robotic testing system. Two MCL reconstructions were designed and tested: 3-strand reconstruction (sMCL+dMCL+POL), and 2-strand method (sMCL+dMCL) addressing anteromedial rotatory instability (AMRI). The resulting stability was measured in a kinematics test rig, and compared to the ‘anatomic’ sMCL+POL reconstruction of LaPrade. Results. The sMCL was isometric, centred on the medial epicondyle, and the primary restraint of valgus. The dMCL elongated rapidly in ER, and was the primary restraint of ER near knee extension. The POL slackened rapidly with flexion and only stabilised the knee near extension. With sMCL+dMCL+POL deficiency (‘grade 3’), the 2-strand AM reconstruction restored all stability measures to native, apart from internal rotation. The 3-strand reconstruction restored all stability measures to native. The LaPrade reconstruction did not control ER, lacking a dMCL graft, or valgus in flexion, being anisometric. Conclusions. This work has revealed the importance of the dMCL in stabilising AMRI as part of anatomical MCL reconstruction, with the sMCL restraining valgus

Introduction. Over the past 30 years multiple wars and embargos have reduced healthcare resources, infrastructure, and staff in Iraq. Subsequently, there are a lack of physiotherapists to provide rehabilitation after an anterior cruciate ligament reconstruction (ACLR). The implementation of home-based rehabilitation programmes may provide a potential solution to this problem. This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. Methods. A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. This was performed arthroscopically using a hamstring autograft (2 portal technique). Patients completed a home-based rehabilitation programme of appropriate simplicity for the home setting. The programme consisted of stretching, range of motion and strengthening exercises based on criterion rehabilitation progressions. A full description of the programme is provided at: . https://ngmvcharity.co.uk/. . Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. Results. The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. A peak score of 90 was observed at nine months. Post-operative TAS results showed an improvement in level of function but did not reach pre-injury levels by the final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. Conclusion. Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world

Meniscal tears commonly co-occur with ACL tears, and many studies address their side, pattern, and distribution. Few studies assess the patient's short-term functional outcome concerning tear radial and circumferential distribution based on the Cooper et al. classification. Meniscal tears require primary adequate treatment to restore knee function. Our hypothesis is to preserve the meniscal rim as much as possible to maintain the load-bearing capacity of the menisci after meniscectomy. The purpose of this study is to document the location and type of meniscal tears that accompany anterior cruciate ligament (ACL) tears and their effect on patient functional outcomes following arthroscopic ACL reconstruction and meniscectomy. This prospective cross-sectional observational study was conducted at AL-BASRA Teaching Hospital in Iraq between July 2018 and January 2020 among patients with combined ipsilateral ACL injury and meniscal tears. A total of 28 active young male patients, aged 18 to 42 years, were included. All patients were subjected to our questionnaire, full history, systemic and regional examination, laboratory investigations, imaging studies, preoperative rehabilitation, and were followed by Lysholm score 6 months postoperatively. All 28 patients were males, with a mean age of 27 ± 0.14 years. The right knee was the most commonly affected in 20/28 patients (71.4%). The medial meniscus was most commonly injured in 11 patients, 7 patients had lateral meniscal tears, and 10 patients had tears in both menisci. The most common tear pattern of the medial meniscus was a bucket handle tear (36.4%), while longitudinal tears were the most frequent in the lateral meniscus (71.4%) (P-value = 0.04). The most common radial tear location was zone E-F (5/28, 17.8%), and the most common circumferential zone affected was the middle and inner third, reported in 50% of tears. Good and excellent outcomes using the Lysholm score after 6 months were obtained in 42.9% and 17.9% of patients, respectively. Better functional scores were associated with lateral meniscal tears, bucket handle tears, tears extending to a more peripheral vascular area, and if no more than one-third of the meniscus was resected (P-value = 0.002). Less favourable outcomes were reported in smokers, posterior horn tears, and when surgery was delayed more than 1 year (P-value = 0.03). We conclude that there is a negative correlation between the amount of meniscus resected and functional outcome. Delayed ACL reconstruction increases the risk of bimeniscal tears. Bucket handle tears are the most common tears, mostly in the medial meniscus, while longitudinal tears are most common in the lateral meniscus. We recommend performing early ACL reconstruction within 12 months to reduce the risk of bimeniscal injuries

It has been suggested that an increased posterior tibial slope (PTS) and a narrow notch width index (NWI) increase the risk of anterior cruciate ligament (ACL) injury. The aim of this study was to establish why there are conflicting reports on their significance. A total of fifty patients with a ruptured ACL and 50 patients with an intact ACL were included in the study. The group with ACL rupture had a statistically significantly increased PTS (p < 0.001) and a smaller NWI (p < 0.001) than the control group. When a high PTS and/or a narrow NWI were defined as risk factors for an ACL rupture, 80% of patients had at least one risk factor present; only 24% had both factors present. In both groups the PTS was negatively correlated to the NWI (correlation coefficient = -0.28, p = 0.0052). Using a univariate model, PTS and NWI appear to be correlated to rupture of the ACL. Using a logistic regression model, the PTS (p = 0.006) and the NWI (p < 0.0001) remain significant risk factors. From these results, either a steep PTS or a narrow NWI predisposes an individual to ACL injury. Future studies should consider these factors in combination rather than in isolation

Anterior cruciate ligament (ACL) injuries are one of the most common ligament injury occurring in young and active individuals. Reconstruction of the torn ligament is the current standard of care. Of the many factors which determine the surgical outcome, fixation of the graft in the bony tunnels has significant role. This study compared the clinical and functional outcome in patients who underwent ACL reconstruction by standard anteromedial portal technique with single bundle hamstring graft anchored in the femoral tunnel using rigidfix and cortical button with adjustable loops. The tibial fixation and rehabilitation protocol were same in both groups. 107 patients underwent ACL reconstruction over a two-year period (87 males, 20 females, 44 after motor vehicle accident, 34 after sports injuries, 79 isolated ACL tear, 21 associated medial meniscus tear, 16 lateral meniscus tear and 11 both menisci). Rigid fix group had 47 patients and adjustable loop 60 patients. Clinical evaluation at end of one year showed better stability in rigid fix group regarding Lachman, anterior drawer, pivot shift tests, KT 1000 arthrometer side to side difference and hop limb symmetry index. However, the differences were not statistically significant. Functional evaluation using IKDC 2000 subjective score and Lysholm score showed better results in rigidfix group than variable loop, but was not statistically significant. However, lower scores were noted in patients with concomitant meniscal injury than in isolated acl tear patients and this was statistically significant in both groups. Rigidfix seems to give better graft fixation on femoral side than variable loop, but by the end of one year the functional outcome is comparable in isolated acl reconstructions

The knee joint has also a periarticular adipose tissue, which is known as Hoffa's fat pad (IPFP). IPFP has a dual function in the joint it reduces the concentration of Nitric Oxide, the release of glycosaminoglycans and the expression of MMP1 in the cartilage, but it also contains MSC and macrophages. Our hypothesis is that synovial fluid contains elements, not all of which are understood, which act as messengers and alter the “homeostasis” of the knee and the metabolism of all the cellular components of the joint, including the MSC of Hoffa's fat pad, thus making them another piece in the puzzle as far as OA of the knee is concerned. The IPFP of 37 patients with OA and 36 patients with ACL rupture were analyzed. Isolation, primary culture, and a functional and proteomic study of MSCs from IPFP were performed. Our results show that OA of the knee, in its more severe phases, also affects the MSC's of IPFP, which is a new actor in the OA degenerative process and which can contribute to the origin, onset and progression of the disease. A differential protein profile between OA and ACL patients were identified. Infrapatellar pad should be regarded as an adipose tissue with its own characteristics and it´s also able to produce and excrete important inflammatory mediators directly into the knee joint

Abstract. Objectives. Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study was to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment. Methods. Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery. Results. 4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p < 0.001). Conclusion. The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present

Purpose: To document healing of the anterior cruciate ligament. Introduction: Conventional wisdom holds that the anterior cruciate ligament (ACL) does not heal. In an athlete the ACL deficient knee is likely to be symptomatic and lead to functional instability. This has led to the belief that all ACL tears in the active athlete require reconstruction. Some ACL tears in recreational athletes are successfully treated conservatively with activity modification and bracing. A literature search was performed which found three articles on ACL healing. These articles felt that complete ACL tears could heal if patients were properly braced and rehabilitated. Materials and Methods: At the Carleton University Sports Medicine Clinic we retrospectively reviewed ACL tears diagnosed by the Lachman, pivot shift, and KT-1000 arthrometer testing. We then examined those whose clinical exam became stable by the same three tests. The latest follow up exam was performed by the same examiner (P.P). At the follow up exam, knee function was evaluated with the expanded IKDC form. Results: Nine patients were found to be asymptomatic and stable after an initial diagnosis of an ACL tear. In follow up the Lachman test had a good endpoint, the pivot shift was normal and the KT – 1000 manual max was less than 3mm. The IKDC results showed 3/9 were grade A, 5/9 were grade B and 1/9 was grade C. The clinical implication: ACL tears should be treated initially conservatively since in a small percentage of patients, the ACL tear can heal

An ACL reconstruction is designed to restore the normal knee function and prevent the onset and progression of degenerative changes such as osteoarthritis. However, contemporary literature provides limited consensus on whether knee degeneration can be attenuated by the reconstruction procedure. The aim of this pilot study was to identify the presence of early osteoarthritis after ACL reconstruction using MRI analysis. 19 patients who had undergone an ACL reconstruction (9 isolated ACL rupture, 8 ACL rupture and meniscectomy, 2 ACL rupture and meniscal repair) volunteered for this study. MRI's were collected preoperatively and postoperatively for analysis with a mean follow up of 23 months. The Boston-Leeds Osteoarthritis Knee Score (BLOKS) was used for the analysis of the articular cartilage by a consultant orthopaedic surgeon. Scores ranged from 0–3, with 0 being total coverage and thickness of the cartilage and 3 being no coverage. Qualitative analysis was then conducted on each patient to determine if the articular cartilage improved, degenerated, or did not change between preoperative and follow-up scans. All patients with isolated ACL rupture were found to either have no change or improved articular cartilage scores in their follow up scans compared preoperatively. In contrast, patients with a meniscal repair displayed worse cartilage scores postoperatively. Lastly, of the patients who had an associated meniscectomy, 6 had worse follow-up results, with the remaining patients showing no change or improved cartilage scores. The present results indicate that patients with an isolated ACL rupture have a reduced risk of developing OA compared to those with associated meniscal injuries. This has implications for analysing the outcome of current ACL reconstruction techniques and in predicting the likelihood of patients developing OA after ACL reconstruction. Future work will involve confirming this pattern in a larger patient sample, as well as exploring additional factors such as time to surgery delay and rehabilitation strategy

Osteoarthritis (OA) is the most common musculoskeletal disease in the EU and is characterized by cartilage degeneration, pain and restricted movement. Post-Traumatic OA (PTOA) is a specific disease subset that occurs subsequent to traumatic injury, such as ACL rupture and makes up 12% of the overall disease burden. Our current understanding PTOA is that initial injury affects multiple tissues, and many/all contribute to overall ‘joint failure.’ MRI scans show that subchondral bone marrow lesions (BMLs) are present in 80% of ACL rupture cases in the immediate aftermath of joint injury. Their presence indicates an acute consequence in subchondral bone. It has also been suggested that BMLs overlap with, or directly represent, bone microdamage. Microdamage is known to induce osteoclast-mediated remodelling in bone. Therefore, the inhibition of subchondral bone remodelling, particularly in the early phase post-injury, may be a candidate therapeutic approach for preventing PTOA. Finally, the contiguous link between subchondral bone and articular cartilage, can allow transport of small molecules across this boundary, this suggests that bone/cartilage crosstalk is likely to be a key factor in PTOA development after injury. This presentation will summarize recent advances in our understanding these phenomena in both animal and human studies

Introduction. Rupture of the anterior cruciate ligament (ACL) is a common injury and often presents with a typical injury pattern. Historic literature has shown that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation despite the history of injury strongly suggesting an ACL injury. The aims of this study were to determine: if the accuracy of diagnosis of ACL ruptures at initial presentation has improved over the last decade; grade of medical staff at initial and subsequent consultations; the mechanism of injury; and the subsequent delay in diagnosis and definitive treatment. Materials and Methods. One hundred and thirty two consecutive patients who underwent ACL reconstruction between January 2005 and January 2009 were analysed using prospective collected data. The mean age of the patients was 29 years (12-57). Sixteen patients were excluded due to chronic ACL injury (15). Results. One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (75%) of cases. The most common sporting activities associated with an ACL injury were football (35.3%), skiing (21.6%), rugby (10.3%) and other (32.8%). The vast majority of patients (68.1%) sought medical attention within 1 week from time of injury. The diagnosis of an ACL rupture was made in 33 cases (28%) at the initial medical consultation. The diagnosis was made in 13 (11%) of cases with the use of MRI and 6 (5%) cases at arthroscopy. The most common diagnoses made in cases of failed ACL rupture diagnosis were medial meniscal tear (10.3%), medial collateral ligament injury (7.8%) and none (33.6%). The mean time to diagnosis was 21 weeks (0-192) and the mean time to ACL reconstruction was 44 weeks (1-240). Conclusions. Despite a typical mechanism of injury leading to ACL rupture the rate of initial diagnosis remains poor. This often leads to an unnecessary delay in diagnosis and subsequent treatment. Possible reasons for this are discussed

Introduction: Rupture of the anterior cruciate ligament (ACL) is a common injury and often presents with a typical injury pattern. Historic literature has shown that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation despite the history of injury strongly suggesting an ACL injury. The aims of this study were to determine: if the accuracy of diagnosis of ACL ruptures at initial presentation has improved over the last decade; grade of medical staff at initial and subsequent consultations; the mechanism of injury; and the subsequent delay in diagnosis and definitive treatment. Materials and Methods: One hundred and thirty two consecutive patients who underwent ACL reconstruction between January 2005 and January 2009 were analysed using prospective collected data. The mean age of the patients was 29 years (12–57). Sixteen patients were excluded due to chronic ACL injury (15). Results: One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (75%) of cases. The most common sporting activities associated with an ACL injury were football (35.3%), skiing (21.6%), rugby (10.3%) and other (32.8%). The vast majority of patients (68.1%) sought medical attention within 1 week from time of injury. The diagnosis of an ACL rupture was made in 33 cases (28%) at the initial medical consultation. The diagnosis was made in 13 (11%) of cases with the use of MRI and 6 (5%) cases at arthroscopy. The most common diagnoses made in cases of failed ACL rupture diagnosis were medial meniscal tear (10.3%), medial collateral ligament injury (7.8%) and none (33.6%). The mean time to diagnosis was 21 weeks (0–192) and the mean time to ACL reconstruction was 44 weeks (1–240). Conclusions: Despite a typical mechanism of injury leading to ACL rupture the rate of initial diagnosis remains poor. This often leads to an unnecessary delay in diagnosis and subsequent treatment. Possible reasons for this are discussed

More than 250,000 people are suffering from Anterior Cruciate Ligament (ACL) related injuries each year in the US, with a cost of $17–25K/patient. There is an unmet clinical demand for improving grafts/scaffolds to provide biological integration in addition to mechanical support. Currently, no data is available for the utilization of fibrous scaffolds with bimodal distribution for ACL regeneration. The novelty in this study is that it proposes for the first time to investigate the collagen fibril diameter distribution in healthy and injured bovine ACL tissue, and utilization of such structure for scaffold design. Objectives are 1) developing a bovine ACL tear model and measuring the collagen fibril diameter distribution of both healthy and injured ACL tissues, and 2) fabricating scaffolds to mimic the structural properties of healthy and injured ACL tissue. Bovine ACL tissues (1–3 years old) were harvested and characterized for their fibril diameter distribution using Transmission Electron Microscopy (TEM) and biomechanical properties under tension. The electrospun polycaprolactone (PCL) scaffolds were characterized using SEM and mechanical testing. Healthy and injured ACL fibril diameter, and that of PCL scaffolds representing healthy and injured ACL are compared using unpaired student t-test. The proposed fibrous scaffold design represents a significant departure from the conventional unimodal approach, and is expected to have significant contribution to ACL regeneration. These discoveries will serve as the foundation for the development of biomimetic tissue engineering substrates aimed at promoting biological graft fixation

The purpose of this study is to investigate the incidence of patients with isolated bundle ACL tear (either isolated posterolateral or anteromedial bundle) during arthroscopy, and its correlation with physical exam. The relevant surgical technique to reconstruct the ligament is discussed. Between September 2006 and March 2009, patients with ACL injuries who received double- bundle ACL reconstruction were reviewed retrospectively. A specialist fellow performed a physical exam before and after anaesthesia. Intraop status of the ACL tear was assessed with correlation of the physical findings. Patients with isolated bundle tear would receive anatomical reconstruction of the torn bundle with preservation of the intact bundle. Double-bundle hamstrings reconstruction would be performed to those with complete tear. Medical notes of 159 patients were reviewed. There were 118 patients (74%) with complete ACL tear, 36 (23%) with isolated AM tear, and 5 (3%) with PL tear. For patients with complete ACL tear, 94% and 100% had positive Lachman, 50% and 87% had positive pivot shift, before and after anaesthesia. For patients with isolated AM tear, 100% had positive Lachman, 36% and 19% had positive pivot shift, before and after anaesthesia. For patients with isolated PL tear, 100% had positive Lachman, 20% and 80% had positive pivot shift, before and after anaesthesia. With better understanding of ACL, patients with isolated-bundle tear can preserve their intact bundle during reconstruction. However, in this study we find that physical exam correlates poorly with the arthroscopic findings. Further imaging (e.g. MRI) may be helpful to differentiate patients from isolated- bundle tear to complete tear

The purpose of this study was to investigate the mechanism of injury causing anterior cruciate ligament ruptures in snowboarders and skateboarders. Knee injuries in snowboarding and skateboarding are rare. We have seen 22 ACL ruptures with an identical injury mechanism that has not been previously described. Fifteen ACL ruptures occurred in snow-boarders and 7 in skateboarders. All were advanced or expert boarders. All injuries occurred on landing a high jump, which resulted in significant knee compression. All described a flat landing on a flexed knee with no twisting component. We postulate that anterior cruciate ligament rupture in these patients is due to explosive eccentric quadriceps contraction when landing from a jump. The injury mechanism is not boot induced as has been described in downhill skiers landing from a jump

Aim: The arthroscopic þndings after a knee injury in the general population, and the inßuence of Cause of injury, Gender and Age upon Meniscal, ACL and Combined Meniscal and ACL tears is presented. Methods: Patients (n:215) with no history of previous knee injury or surgery, no history of arthritis, and normal X-rays that underwent arthroscopy by the same surgeon. The data was analysed by an independent bio-statistitian using unconditional logistic regression analysis. Results: Patients with Sports related injuries (62.8%) were younger than patients with Non-sporting injuries (37.2%), (p< 0.001). More men than women underwent arthroscopy in both groups. Patients in sporting group had greater odds than patients in non-sporting group to have: an ACL tear, an ACL and meniscal tear (combined), a lateral meniscal tear. Women had lower odds than men to have: a meniscal tear, a combined tear. Conclusions: In the general population (a) more patients underwent arthroscopy after a sporting than after a non-sporting injury (b) men were more than women in both groups (c) the cause of injury was predictive for an ACL and combined meniscal and ACL tears as well as the meniscus involved (d) in both sporting and non-sporting injuries women had less odds to have a meniscal and a combined meniscal and ACL tear

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures. In this paper we review the management of ACL tears in skeletally immature patients. . Cite this article: Bone Joint J 2013;95-B:1562–9

Introduction. Simultaneous correction of knee varus malalignment with medial open wedge high tibial osteotomy (MOWHTO) combined with anterior cruciate ligament (ACL) surgery aims to address symptomatic unicompartmental osteoarthritis in addition to restore knee stability in order to improve outcomes. The aim of this study is to present at least 5 years results of 32 patients who underwent simultaneous knee realignment osteotomy with ACL surgery. Methods. Patients with symptomatic instability due to chronic ACL deficiency or failed previous ACL surgery together with a varus malalignment of ≥6°, previous medial meniscectomy and symptomatic medial compartment pain who were treated with MOWHTO combined with ACL surgery were enrolled. ACL surgery was performed with the anatomical single bundle all-inside technique using TightRope. ®. RT (Arthrex, Naples, FL, USA) and MOWHTO using TomoFix. ®. medial high tibia plate (DePuy Synthes, Raynham, MA, USA) in all cases. Patients were evaluated preoperatively and at 6 months, 12 months and annually postoperatively using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS) and Euroqol's Visual Analogue Score (VAS) for pain. Results. 32 patients (22 men and 10 women) with a mean age of 41.2 years and mean BMI of 28.6 kg/m. 2. , underwent the combined procedures. Tibiofemoral neutral re-alignment was achieved in all patients with HTO. Complete subjective and objective scores have been obtained in 84.4% of patients with at least 5 years of follow-up (mean 8.7 years). An improvement in total KOOS of 27.1 points (p<0.003), OKS of 15.1 (p<0.003) and VAS for pain of 24.7 points (p<0.001) were detected. No ACL reconstruction failure was noted. Complications consisted of one superficial wound infection and one delayed union. Plate removal was needed in 20 (62.5%) patients due to pes anserinus pain. Conclusions. Simultaneous restoration of coronal knee axis by applying HTO and stability by ACL reconstruction/revision were reported to offer excellent improvement in early outcomes in patients with ACL rupture and symptomatic unicompartmental osteoarthritis. The combined procedure requires careful pre-operative planning and is therefore technically challenging. However, by restoring the neutral axis and providing stability, it represents a good joint preserving alternative to arthroplasty for active middle-aged patients

Purpose of Study. To investigate the proprioceptive function of patients with an ACL rupture before and after reconstruction and correlate these findings with ligament laxity testing and clinical outcome measures. Summary of Methods and Results. Fifty patients with an ACL rupture and 50 normal controls were recruited to the study. The Biodex Balance SD System was used to assess knee proprioception. This equipment measures proprioceptive function using an electronic platform. The balance of the subject is computed using stabilometry and an Overall Stability Index (OSI) is produced. A lower score reflects better proprioception. Knee stability was assessed clinically and with the Rolimeter knee arthrometer in all subjects. Participants were evaluated using the Tegner, Lysholm, Cincinnati and IKDC scoring systems. In the ACL group, 34 patients underwent ACL reconstruction and returned for their follow-up review 3 months post-operatively. The proprioceptive function of the injured knee of the ACL group (mean OSI 0.70) was significantly poorer compared to that of their uninjured knee (mean OSI 0.46, p<0.001, 95%CI 0.14, 0.34) and to the Normal Control group (mean OSI 0.49, p=0.01, 95%CI 0.05, 0.38). There was a significant improvement in proprioception of the injured knee following ACL reconstruction (mean OSI 0.47, p=0.003, 95%CI 0.10, 0.42). A significant correlation was found between pre-operative proprioception measurements and all the pre-operative knee outcome scores, however this correlation was not found post-operatively. No correlation was found between ligament laxity testing and either proprioception measurements or knee outcome scores. Conclusion. Patients with ACL ruptures were found to have a proprioceptive deficit which improved following reconstruction, the measurements of which correlated better with clinical outcome scores than instrumented ligament laxity testing

The June 2013 Knee Roundup. 360 . looks at: iodine washout: chondrotoxic or antiseptic?; stem tip pain following revision knee replacements; metalwork removal prior to TKR; astroturf and ACL rupture; Robert Jones dressings; if thicker gloves safer; and the long leg radiograph: is it still the gold standard?

The purpose of this study was to evaluate the results of selective anatomic augmentation of partial anterior cruciate (ACL) ligament tears in 36 consecutive patients with mean 3years follow-up. Our hypothesis is that this selective augmentation of partial ACL tears could restore knee stability and function. In a consecutive series of 314 ACL reconstructions, 40 patients in which intact ACL fibers remained in the location corresponding to the anteromedial or posterolateral bundle were diagnosed perioperatively. All patients underwent selective augmentation of the torn bundle, while keeping the remaining fibers intact using autogenous hamstring graft. 38 patients (28 males, 10 females) were available with minimum 3 year follow- up. 26 cases had AM bundle tears and 12 cases had PL bundle tears respectively. Patients were assessed with International Knee Documentation Committee (IKDC) 2000 Knee Evaluation Form, Lysholm score; instrumented knee testing was performed with the arthrometer (KT 2000). Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. At 3 year follow-up, 12 (31.6%) patients were graded A, 25 (65.8%) graded B and 1 C (2.6%) at IKDC objective evaluation. Lysholm's score and mean side to side instrumental laxity improved significantly. The results of anatomic single bundle augmentation in partial ACL tears are encouraging with excellent side to side laxity

The April 2012 Knee Roundup. 360 . looks at the torn ACL, ACL reconstruction, the risk of ACL rupture, the benefit of warm-ups before exercise, glucosamine and tibiofemoral osteoarthritis, sensitisation and sporting tendinopathy, pain relief after TKR, the long-term results of the Genesis I, the gender specific recovery times after TKR, and the accuracy of the orthopaedic eyeball

Introduction: Transient posterolateral subluxation of the lateral femoral condyle has been postulated as a non-contact mechanism of ACL rupture. The consistent location of MRI bone bruises on the anterior half of the lateral femoral condyle and the posterior rim of the lateral tibial plateau in ACL injuries suggest this mechanism of injury. Previous studies utilizing radiographs have investigated and eliminated the possibility of an increase in posterior tibial slope angle as a risk factor for ACL injury. None, however, have specifically measured the slope angle of the lateral tibial plateau. This study was designed to utilize MRI images for specific measurement of the lateral tibial slope angle and investigate this as a risk factor for ACL injuries. Materials & methods: The MRI images of 30 knees with complete ACL ruptures (Group I) and those of 30 knees with an intact ACL were studied. Both groups were age-matched (range 15 to 50 years) and predominantly male. The slope angles of the medial plateau and the lateral tibial plateau were measured separately. Statistical comparison was made between the slope angles of the medial and lateral tibial plateaus within both groups, and between the lateral tibial slope angles of Group I and Group II., using a Student’s t-Test. Results: The mean slope angle of the medial plateau was 3.43 degrees in Group I and 3.67 in Group II. The mean slope angle of the lateral tibial plateau was 6.40 degrees in Group I, and 5.43 in Group II. The difference between medial and lateral slope angles was statistically significant, as well as that between the lateral tibial slopes of Group I and Group II. There was no statistical difference between the mean slope angles of the medial plateau of both groups. Conclusion: There is a significant difference in slope angles of the medial and lateral tibial plateaus, and thus the need to specify the lateral tibial slope angle in determining slope angles as a risk for ACL injuries. While there is a statistically significant difference in lateral tibial slope angles of patients with ACL tears, the actual measured difference of one degree is not clinically useful as a predictor of ACL injury risk

Aims

The aim of this study was to evaluate the association between chondral injury and interval from anterior cruciate ligament (ACL) tear to surgical reconstruction (ACLr).

Summary. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Introduction. The Medial Patello-Femoral Ligament (MPFL) is the largest component of the medial parapatellar ligamentous complex. The senior surgeon felt that there was an anecdotally high rate of MPFL injury amongst his patients undergoing Anterior Cruciate Ligament (ACL) repair, but no discussion of this in the present literature. Method. A literature search was performed; although there were both scanty radiographic and anatomical studies of the MPFL, we found no literature looking at ACL and MPFL concurrent injury rates. The Magnetic Resonance Imaging (MRI) scans of fifty consecutive ACL reconstruction patients were retrospectively reviewed. Two independent radiologists were asked to review the scans looking specifically for evidence of MPFL rupture or Injury. The degree of injury was rated as rupture or by degree of sprain as applicable. One patient was excluded due to motion artefact limiting certainty. Results. Of the remaining forty-nine patients, 35 (71%) were intact, but fourteen (29%) showed evidence of injury. Five (10%) had a low-grade sprain, six (12%) had high-grade sprain, and three (6%) had complete rupture. The radiologists also noted that there was some variation in scanning protocols, and those with fat suppressed scans had better diagnostic value; this offered an opportunity to change the scanning practice. Conclusion. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Further, we would suggest that fat suppression sequences are included as standard to improve imaging quality

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 study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes.

Cite this article: Bone Jt Open 2024;5(2):94–100.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: Can you treat type IIA supracondylar humerus fractures conservatively?; Bone bruising and anterior cruciate ligament injury in paediatrics; Participation and motor abilities after treatment with the Ponseti method; Does fellowship training help with paediatric supracondylar fractures?; Supracondylar elbow fracture management (Supra Man): a national trainee collaborative evaluation of practice; Magnetically controlled growing rods in early-onset scoliosis; Weightbearing restrictions and weight gain in children with Perthes’ disease?; Injuries and child abuse increase during the pandemic over 12,942 emergency admissions.

Aims. The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL). Patients and Methods. Between March 2011 and April 2012, 50 patients (34 men and 16 women) with an acute rupture of the ACL underwent primary repair using this device. The mean age of the patients was 30 years (18 to 50). Patients were evaluated for laxity, stability, range of movement (ROM), Tegner, Lysholm, International Knee Documentation Committee (IKDC) and visual analogue scale (VAS) scores over a follow-up period of two years. Results. At final follow-up, anteroposterior translation differed from the normal knee by a mean of 0.96 mm (-2 mm to 6 mm). Median (interquartile range) IKDC, Tegner, Lysholm and VAS scores were 98 (95 to 100), 6 (5 to 7), 100 (98 to 100) and 10 (9 to 10), respectively. Pre-injury Tegner activity levels were reached one year post-operatively. A total of nine patients (18%) required a secondary intervention; five developed instability, of whom four underwent secondary hamstring reconstructive surgery, and five required arthroscopic treatment for intra-articular impingement due to scar tissue which caused a fixed flexion deformity. In addition, 30 patients (60%) required removal of the tibial screw. Conclusion. While there was a high rate of secondary interventions, 45 patients (90%) retained their repaired ACL two years post-operatively, with good clinical scores and stability of the knee. Take home message: Dynamic intraligamentary stabilisation presents a promising treatment option for acute ACL ruptures, eliminating the need for ACL reconstruction. Cite this article: Bone Joint J 2016;98-B:793–8

This prospective longitudinal study compares the results of isolated endoscopic ACL reconstruction utilizing 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over a 15-year period with respect to re-injury, clinical outcomes and the development of osteoarthritis. 90 consecutive patients with isolated ACL rupture were reconstructed with a PT autograft and 90 patients received HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10 and 15 years. Assessment included the IKDC Knee Ligament Evaluation including radiographic evaluation, KT1000, Lysholm Knee Score, kneeling pain, and clinical outcomes. Subjects who received the PT graft had significantly worse outcomes compared to those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (p=0.03), motion loss (p=0.01), single leg hop test (p=0.002), participation in strenuous activity (p=0.05), and kneeling pain (p=0.04). There was no significant difference between the HT and PT groups in overall IKDC grade (p=0.31). ACL graft rupture occurred in 16% of HT group and 8% of the PT group (p=0.07). ACL graft rupture was associated with non-ideal tunnel position (odds ratio 5.0) and males (odds ratio 3.2). Contralateral ACL rupture occurred in significantly more PT patients (24%) than HT patients (12%) (p=0.03), and was associated with age < 18 years (odds ratio 4.1) and the patellar tendon graft (odds ratio 2.6). Radiologically detectable osteoarthritis at 15 years was associated with the PT graft (odds ratio 2.3). Significant differences have developed in the groups at 15 years after surgery which were not seen at earlier reviews. Compared to the HT Group, the PT group had significantly worse outcomes with respect to radiological osteoarthritis, extension loss and functional tests but no significant difference in laxity was identified. There was a high incidence of ACL injury after reconstruction, to both the reconstructed and the contralateral knee

Introduction. Autologous chondrocyte implantation (ACI) is contra-indicated in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our experience of ACI repair with ACL reconstruction. Methods. Patients underwent arthroscopic examination and cartilage harvesting of the knee. A second operation was undertaken approximately six weeks later to repair the ruptured ACL with hamstring graft or Bone patella-Bone (BPB) and to implant the chondrocytes via formal arthrotomy. Three groups were assessed: Group 1: Simultaneous ACL Reconstruction and ACI; Group 2: Previous ACL Reconstruction with subsequent ACI repair; Group 3: Previously proven partial or complete ACL rupture, deemed stable and not treated with reconstruction with ACI procedure subsequently. Patients then underwent a graduated rehabilitation program and were reviewed using three functional measurements: Bentley functional scale, the modified Cincinnati rating system, and pain measured on a visual analogue scale. All patients also underwent formal clinical examination at review. Results. Those who underwent simultaneous ACL Reconstruction and ACI had a 47% improvement in Bentley functional scale, 36% improvement in visual analogue score and 38% improvement in the modified Cincinnati rating system. This is in contrast to only a 15% improvement in the modified Cincinnati rating system, 30% improvement in Bentley functional scale, and 32% improvement in visual analogue score in patients who had ACI repair after previous ACL reconstruction. 68% of patients who had the procedures simultaneously rated their outcome as excellent/good and 27% felt it was a failure. In contrast 38% of patients rated their outcome as a failure if they had ACI repair without reconstruction of ACL rupture. Conclusion. Symptomatic cartilage defects and ACL deficiency may co-exist in many patients and represent a treatment challenge. Our results suggest that a combined ACL and ACI repair is a viable option in this group of patients and should reduce the anaesthetic and operative risks of a two-stage repair. Patients with complete rupture of ACL despite being deemed stable performed poorly at review and our study suggests all complete ruptures regardless of stability should be treated with a reconstruction when performing an autologous chondrocyte implantation

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

This prospective longitudinal study compared the results of isolated endoscopic ACL reconstruction utilising 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over 15-years with respect to reinjury, clinical outcomes and osteoarthritis. Ninty consecutive patients with isolated ACL rupture were reconstructed with a PT autograft and 90 patients received HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10 and 15 years. Assessment included the IKDC Knee Ligament Evaluation, radiographic evaluation, KT1000, Lysholm Knee Score, kneeling pain, and clinical outcomes. Subjects who received the PT graft had significantly worse outcomes compared to those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (p=0.03), motion loss (p=0.01), single leg hop test (p=0.002), participation in strenuous activity (p=0.05), and kneeling pain (p=0.04). There was no significant difference between the HT and PT groups in overall IKDC grade (p=0.31). ACL graft rupture occurred in 16% of HT group and 8% of the PT group (p=0.07). ACL graft rupture was associated with non-ideal tunnel position (odds ratio 5.0) and males (odds ratio 3.2). Contralateral ACL rupture occurred in significantly more PT patients (24%) than HT patients (12%) (p=0.03), and was associated with age < 18 years (odds ratio 4.1) and the patellar tendon graft (odds ratio 2.6). Radiologically detectable osteoarthritis at 15 years was associated with the PT graft (odds ratio 2.3). Significant differences have developed in the groups at 15 years after surgery which were not seen at earlier reviews. Compared to the HT Group, the PT group had significantly worse outcomes with respect to radiological osteoarthritis, extension loss and functional tests but no significant difference in laxity was identified. There was a high incidence of ACL injury after reconstruction, to both the reconstructed and the contralateral knee

Aims

To verify whether secretory leucocyte protease inhibitor (SLPI) can promote early tendon-to-bone healing after anterior cruciate ligament (ACL) reconstruction.

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

The AMMFL is an anatomical variant of the attachment of the anterior horn of the medial meniscus to the posterolateral wall of the intercondylar notch. It is distinct from the meniscofemoral ligaments of Wrisberg and Humphrey. This large series prospectively documented its incidence and any associated meniscal or chondral pathology. The study period was from September 2006 until December 2007. All patients that underwent arthroscopy of the knee for meniscal, chondral or ligamentous pathology including arthroscopic anterior cruciate ligament reconstruction were included. The procedures were performed by the two senior authors, according to their standard protocols at one of two hospitals. All the findings from the arthroscopies were prospectively recorded in a standardized datasheet. This recorded all meniscal, chondral and miscellaneous pathology including the presence or absence of an AMMFL. This data was entered into a database including all patients. The results of 401 arthroscopic procedures were recorded during the study period. Of these patients, 14 were found to have AMMFLs, resulting in an incidence of 3.49%, higher than previously reported. (. Anderson et al. describe an incidence of 0.44% from a combined retrospective and prospective review.). The associated pathology was most commonly a radial tear of the medial meniscus, found in six patients. One had a bucket handle tear of the medial meniscus. There were three lateral meniscus tears, two of which were associated with an ACL rupture. Two patients had an ACL rupture as the only other pathology at arthroscopy. One patient was found to have a ruptured AMMFL as her only pathology. This anatomical variant is more common in this Australian sample than has been described in the literature, and there seems to be a relationship between the presence of the AMMFL and a particular pattern of medial meniscus tear, suggesting an influence of this anatomical variant on meniscal pathology

Introduction. The Segond's fracture is described as a cortical avulsion of the lateral tibial plateau at the site of insertion of the middle third of the lateral capsular ligament. The Segond's fracture is usually associated with a tear of the Anterior Cruciate Ligament (ACL) and it is considered as an indirect radiological sign of complete rupture of the ACL. However there are no studies investigating the effect of a Segond's fracture on the kinematic of the knee especially on the rotatory instability and Pivot Shift (PS) phenomenon. The purpose of this study is to investigate the effect of a Segond's fracture on the kinematic of the knee with the use of navigation and the PS test. Methods. Ten whole fresh-frozen cadavers were used. A navigator (2.0 Orthopilot Navigation System, BBraun Aesculap, Tuttlingen, Germany) was used to measure maximum manual Anterior Tibial Translation (ATT) at 30°, 60° and 90° of flexion, maximum manual Internal Rotation (IR) and maximum manual External Rotation (ER) at 0°, 15°, 30°, 45° and 90° of flexion. All procedures were performed three times and the mean value taken as the final result in each case. Moreover a PS test was performed by the senior, most experienced, surgeon, and graded as mild (gliding), moderate (jerk) and severe (subluxation). Navigation measurements and PS tests were performed in each knee with ACL intact, after arthroscopic cutting of the entire ACL and after a Segond's fracure was produced by exposing the antero lateral compartment of the knee underneath the ileo-tibial tract. Statistical analysis was performed using ANOVA 1-way and MANOVA tests and value for statistical analysis was set at p<0.05. Results. Navigation procedure: Cutting the whole ACL resulted in a significant increase of ATT at 30° and 60° of flexion, with no significant effect on IR and ER. Producing the Segond's fracure resulted in a significant increase of ATT at 60° and 90° of flexion, in a significant increase of IR at 30°, 45° and 60° of flexion with no significant effect on ER. PS: The PS was clinically undetectable in all knees with ACL intact. After cutting the ACL it continued to be undetectable in two cases, mild positive in six cases and moderate in two. The addition of the Segond's fracture resulted in an increase of the PS in all cases with a moderate grade detected in three and severe in seven. Conclusions. Despite the limitations of this study, which include manual loads applied to the knee during navigation measurements and subjective evaluation of the PS, the results of this cadaver study indicate that the Segond's fracture has a significant effect on knee stability especially on rotational stability, which is functionally the most important in case of ACL tear. Therefore, in case of an acute ACL tear, when a Segond's fracture is radiologically detected and an ACL reconstruction is performed, an inspection of the lateral compartment with repair of capsule and fixation of the fracture could be advisable in order to better restore knee stability

The aim of this longitudinal study is to compare the clinical outcomes of endoscopic ACL reconstruction with either a 4-strand HT or PT autograft over a 5-year period. 90 patients with isolated ACL rupture received PT autograft and 90 received HT autograft were studied annually for 5 years. Assessment included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs. The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, Xray findings, manual ligament KT1000 instrumented testing, graft rupture or contralateral ACL rupture. There was an increasing incidence of fixed flex-ion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at 5 years was significantly higher in the PT group. Endoscopic reconstruction of the ACL utilizing either autograft can restore knee stability and is menisco protective despite a high level of sporting activity. We did find a worrying trend towards an increasing incidence of fixed flexion deformity with time in the patellar tendon group. Kneeling pain also remains a persistent problem in this subgroup

Purpose: To analyze the causes of repeat knee arthroscopy in the same knee. Materials and methods: We reviewed 923 patients that had undergone knee arthroscopy during 2005 and assessed those that had already undergone previous arthroscopy of the same knee that year or in previous years and analyzed the causes. Results: Of the 923 patients that required knee arthroscopy 169 (18.3%) had undergone previous surgery. Four (2.3%) had undergone 3 previous arthroscopies, 27 (15.9%) two and 138 (81.6%) one. In 59.8% of cases, the symptoms that led to repeat arthroscopy were non-traumatic continuous pain. The other cases required repeat arthroscopy due to new trauma, or meniscal or anterior cruciate ligament (ACL) tears. The patients with affected menisci (104) underwent partial meniscectomy, 31% had a posterior cruciate ligament (PCL) tear and 58% had menisci remains with or without osteochondral lesions. Repeat arthroscopies of ACL tears treated by ligamentoplasties (41) were due to plasty tears in 46% of cases and adhesions in 27%. In patients that underwent 3 arthroscopies, the main diagnosis was plasty tear in 45% of the total sum of 2. nd. and 3. rd. arthroscopies. Mean time between first and second arthroscopy was 28 months and between second and third arthroscopy 12 months. The relative risk of undergoing a new arthroscopy during the same year as meniscectomy was 1.12% and as ACL ligamentoplasty 0.95%. Conclusions: Not all repeat arthroscopies are caused by previous complications. The main clinical reasons for a repeat arthroscopy can be traumatic or non-traumatic, with a greater frequency of the latter. We found that the risk of repeat arthroscopy was greater during the first year in meniscal tears than in ACL tears

Aims. Wales in collaboration with the Welsh Assembly Government, has attempted to start a national ligament register. Introduction. Norway is the lead in Europe for running a successful national quality knee ligament registry. As yet there is no UK wide registry encompassing all forms of knee ligament surgery. The issue has been discussed at previous society meetings, but no consensus has been reached. Method. A pilot study covering three NHS Trusts in South Wales was run between April 2010 and September 2010. Data is gathered prospectively on non-operatively treated and surgically treated knee ligament injuries performed in the regions. This data is recorded on the WKLR form which is then sent to the WKLR centre and entered onto a secure database. Four knee surgeons agreed to take part in the study, from three NHS Health Boards. The data is recorded at the time of the operation on a tick box form akin to that used by the NJR. The prospectively gathered data is stored at the central registry office in Princess of Wales Hospital Bridgend. Results. A total of 68 forms were returned to the registry, 58 Males and 10 Females, average age 30 and 35 years respectively. Four per cent of ACL ruptures were treated non-operatively. Sixty two (96%) ACL ruptures were reconstructed; 57 primary reconstructions; 3 revisions; 2 were multi-ligament injuries. The most common mechanisms of injury in females were basketball and football. Rugby was the most common mechanism for males. Six PCL injuries were reported, half (3) were reconstructed, all using allograft Achilles tendon. Of the fifty seven primary ACL reconstructions, twenty nine (47%) ACL reconstructions were recorded with no meniscal injury, thirty (53%) of ACL reconstructions had concomitant meniscal injury, which equates to 8% requiring repair (5 medial, 1 lateral) and 25 (43%) requiring meniscectomy for non-repairable tears (15 medial, 10 Lateral). Cartilage lesions were seen in 18 reconstructions (27%). Of these 2 (3%) had synthetic mosaic plasty. Four lesions (6%) had chondroplasty and the remaining 12 (18%) treatment was not required but noted. Conclusion. The WKLR, although in its infancy, has shown that a ‘National Quality Database’ of this type is feasible and will provide the necessary quality assurance demanded by this active young group of patients. The WKLR will provide an invaluable research tool for assessing and comparing outcomes of the various techniques, graft types, and fixation devices. Failing implants can be identified early. Under performing institutions can be identified, and performance can be compared to the national average. All of these aims are focused at improving patient safety, satisfaction and outcome

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.

Introduction: recent studies showed the possibility of spontaneous ACL healing in acute lesion with proper treatment. The goal of our study was to analyze the functional outcome of partial ACL tears treated acutely with suture-repair combined with a bone marrow stimulation (BMS) technique (microperforation). We hypothesized that knee stability could be restored and good functional outcome could be obtained with a simple primary repair technique. Methods: From January 2003 to January 2006, 22 patients (14 males and 8 females – mean age: 23 years) with partial ACL rupture underwent acute primary ACL repair with our technique. Inclusion-exclusion criteria:. anterior instability (confirmed intraoperatively by an isolated ACL tear),. surgery performed within 3 weeks from injury. No grade 4 chondral defect,. no associated pathologies except for meniscal lesion. will to undergo to the same rehabilitation protocol. Parameters analyzed included the standard knee scales (IKDC, Noyes, Lysholm and Tegner), SANE Score, Knee Laxity Analysis and Deep Flexion Tests. In 6 cases, second look arthroscopy was performed. All patients underwent a post-operative MRI. Results: All these patients were available for follow up at 3/6 and final follow up (average of 18 months). Scoring systems revealed: Lysholm 93% (74–100), Tegner 7 (6–9), Noyes 80% (60–100) and Subjective (SANE) 86,22% (60–100). IKDC score demonstrated 55% group A, 36% B, 4% C and 4% D. This last patient didn’t go back to his previous activity level because of subjective apprehension. The knee was stable. Pivot shift test was negative in all the cases. Side to side difference was less or equal to 2 mm in all of our patients. Conclusion: Based on the preliminary results, primary ACL repair with BMS can lead to favourable results in acute partial ACL lesion. However, further prospective randomized studies are recommended at longer follow-up to validate these findings

In the last few years the number of women who practise sport activities has substantially increased and this has led to an increase in the incidence of ACL tear in females. The aim of this study is to assess outcome differences at a minimum 3-year follow-up after ACL reconstruction in women using either a patellar tendon (BPTB) or a quadrupled-looped hamstring (DSTG) autograft fixed with modern devices. Fifty women with a chronic, isolated ACL tear were randomised to receive a DSTG or BPTB graft for ACL reconstruction. Both groups were comparable as to age, injury-surgery, activity level, meniscal tears, surgical technique and reabilitation. All patients were prospectively evaluated by an independent observer using the IKDC form, the FKSAKP Score, the KT-1000 arthrometer and the Cybex NORM dynamometer. A radiographic study was performed to investigate tunnel widening. All but two patients were satisfied with the reconstruction. The average side-to-side difference in anterior tibial translation was 2.4 mm in the BPTB group and 2.5 mm in the DSTG group. The final result was A (normal knee) in 56% and in 60% of the BPTB and the DSTG knees, respectively. A failure (4%) was present in each group. Muscle strength deficits at 60°/s, 120°/s and 180°/s were within 10% for extensors and within 5% for flex-ors in both groups. No statistically significant differences were found in terms of subjective satisfaction, objective evaluation, knee stability and muscle strength recovery. The BPTB group showed a higher incidence of postoperative kneeling discomfort (p< 0.05) and a larger area of decreased skin sensitivity (p< 0.001). The DSTG group showed a higher incidence of femoral tunnel widening (p=0.02). Using strong and stiff fixation devices, ACL reconstruction in women is not influenced by the graft choice

Purpose: The purpose of this study was to determine psychometric properties of the Lysholm score and Tegner activity scale as patient-administered outcomes scores for anterior cruciate ligament injuries of the knee. We hypothesized that these two outcomes measures remain valid by today’s standards twenty-five years after they were originally introduced as physician-administered outcomes instruments. Methods: One thousand seven hundred eighty-three (1783) patients were included in this study. There were 749 females and 1034 males. Average age was 37 years (range, 18 to 77). Isolated ACL tears were documented in 593 patients, and 1190 patients had concurrent injuries including meniscus pathology and/or cartilage damage. Patients with multiple ligamentous injuries were excluded. All patients in this study were diagnosed with an ACL tear at arthroscopy. For responsiveness, scores were measured preoperatively and at a minimum of two years postoperatively. For test-retest, scores were measured at a minimum of two years postoperatively and again within four weeks of the original postoperative questionnaire. For criterion validity, patients completed the short form (SF-12. ®. ) of the health related quality-of-life scale and the IKDC score in addition to Lysholm and Tegner instruments. For all other analyses, preoperative Lysholm score or Tegner activity levels were used. Results: There was acceptable test-retest reliability for overall Lysholm score (ICC=0.94 [95% confidence interval=0.88 to 0.96]) and Tegner (ICC=0.82 [95% confidence interval=0.66 to 0.89]). The minimum detectable change for Lysholm was 8.9 and for Tegner was 1.4. The Lysholm score demonstrated acceptable internal consistency (Cronbach’s alpha=0.72). The Lysholm score correlated with IKDC (r=0.78) and the physical function domain of SF-12. ®. (r=0.43). The Tegner scale correlated with physical function domain of SF-12. ®. (r=0.2) and IKDC (r=0.22). Both scores had acceptable floor and ceiling effects, and all hypotheses were significant. The Lysholm score and Tegner scale both had a large overall effect size. There were no differences between isolated and combined ACL injuries. Conclusion: After 25 years of changes in treatment of ACL injuries and postoperative rehabilitation protocols, the Lysholm knee score and Tegner activity scale continue to demonstrate acceptable psychometric parameters. The Lysholm score and Tegner scale both had acceptable test-retest reliability, construct validity, criterion validity, content validity, and responsiveness when patient-administered similar to the physician-administered results when they were originally validated. Our hypothesis was affirmed

The aim of this study is to assess the accuracy of clinical examination of the knee compared to MRI and Arthroscopy in diagnosing significant internal derangement. We performed a retrospective analysis on 245 patients who underwent an MRI of the knee over a two-year period. The MRI diagnoses were compared with both clinical and arthroscopic findings. There were 169 male and 76 female patients with an average age of 33 years. A history of significant trauma was seen in 98 (40%) patients. The commonest clinical diagnosis was isolated medial meniscal tear (25%). Anterior cruciate ligament (ACL) tear was diagnosed in 8% and lateral meniscal tear in 7% of cases. No definite clinical diagnosis could be reached in 32% of patients. MRI showed no significant abnormality in 103 (42%) patients. Medial meniscal tear was noted in 47 (19%), ACL tear in 20 (8%) and lateral meniscal tear in 10 (4%) of the MRI scans. 96 patients (39%) proceeded to arthroscopy after their MRI scans. The mean time from MRI scan to arthroscopy was 181 days. The MRI and arthroscopy findings were in complete agreement in 90 (94%) patients. Of the 6 patients whose MRI findings did not correlate with arthroscopy, 4 showed meniscal tears not seen at surgery and two diagnosed ACL ruptures subsequently shown to be normal at arthroscopy. Three of the 4 meniscal tears were of the inferior surface of the posterior horn of the medial meniscus and one of the inferior surface of the lateral meniscus. The films were reviewed independently by three experienced MR radiologists all of whom confidently diagnosed a tear in each case. Clinical examination alone is not satisfactory in the diagnosis of knee injuries. MRI is a highly sensitive tool for diagnosis. Injuries that are commonly missed at arthroscopy can be diagnosed easily with MRI

Aim: To compare, in a longitudinal study, the clinical outcomes of endoscopic anterior cruciate ligament (ACL) reconstruction with either a four-strand hamstring tendon (HT) or a patellar tendon (PT) autograft over a five-year period, when a similar operative procedure is followed for both groups. Method: Ninety patients with isolated ACL ruptures who had received PT autografts and another 90 who had received HT autografts were studied annually for five years. Fifty patients were randomised as a subgroup. The assessments included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs. Results: The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, X-ray findings, manual ligament KT1000 instrumented testing, graft rupture or contra-lateral ACL rupture. There was an increasing incidence of fixed flexion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at five years was significantly higher in the PT group. The results of the randomised patients were identical to the sequential patients. Conclusions: Endoscopic reconstruction of the ACL utilizing either type of autograft restored knee stability and was protective of the meniscus despite a high level of sporting activity. We found a worrying trend towards an increasing incidence of fixed flexion deformity with time in the PT group. Pain when kneeling also remained a persistent problem in this subgroup. PT grafts appeared tighter clinically and, with the KT 1000, when assessed up to three years post operatively, compared with HT grafts. Thereafter the results were similar

Purpose of the study: The aim of this retrospective epidemiological study was to report the complete arthroscopic results concerning meniscus or cartilage injuries for procedures performed to repair the anterior cruciate ligament (ACL). The goal was to search for risk factors and improve patient care. Material and methods: Between 2000 and 2004, the same operator performed 129 consecutive ligamentoplasties to repair ACL tears. The following preoperative factors were analyzed: body weight, height, type and level of sports activity, laxity, positive pivot test, morphotype, time from accident to surgery. Meniscal lesions were identified and classified according to Trillat. The Beguin and Locker classification was used for cartilage lesions. The Panthéon-Sorbonne statistics laboratory performed the statistical analysis. Results: Meniscal lesions were found in 53.5% of knees and cartilage lesions in 24.2%. The medial meniscus was involved in 75.4% and the lateral meniscus in 20.3%, both in 4.3%. The injury could be repaired by suture or a conservative procedure for 45%. The medial compartment presented cartilage injury in 51.6% of knees, the patella in 29%, the trochlea in 19.35% and the same percentage for the lateral condyle. The degree of preoperative laxity, the time from accident to surgery and body mass index were statistically correlated with presence of a meniscal injury. Age, the degree of pre-operative laxity and body mass index were statistically correlated with presence of a cartilage injury. Discussion: Meniscal injuries are frequent in knees with ACL tears. The posterior segment of the medial ligament, which blocks anterior translation of the tibia if the ACL is absent, is predominantly involved. The amount of tibial movement below the femur and stress applied to the knee (particularly related to body mass) favor such lesions. Many lesions will heal spontaneously after surgery. Inversely others are more frequent after a longstanding tear. Cartilage injury is also frequent and occurs often on aging cartilage. The extent of tibial movements and their repetition as well as important stress are factors predictive of such injuries. Conclusion: Indications for reconstruction of the ACL in the young subject are well identified, less so in the older subject. This study confirms the usefulness of reconstructing the ACL to protect the menisci and joint cartilage. Excessive weight appears to be another important point to take into consideration for the surgical management of these patients

Anterior cruciate ligament (ACL) reconstruction is the current standard of care for ACL tears. However, the results are not consistently successful, autografts or allografts have certain disadvantages, and synthetic grafts have had poor clinical results. The aim of this study was to determine the efficacy of tissue engineering decellularized tibialis tendons by recellularization and culture in a dynamic tissue bioreactor. To determine if recellularization of decellularized tendons combined with mechanical stimulation in a bioreactor could replicate the mechanical properties of the native ACL and be successfully used for ACL reconstruction in vivo. Porcine tibialis tendons were decellularized and then recellularized with human adult bone marrow-derived stem cells. Tendons were cultured in a tissue bioreactor that provided biaxial cyclic loading for up to 7 days. To reproduce mechanical stresses similar to hose experienced by the ACL within the knee joint, the tendons were subjected to simultaneous tension and torsion in the bioreactor. Expression of tendon-specific genes, and newly synthesized collagen and glycosaminoglycan (GAG) were used to quantify the efficacy of recellularization and dynamic bioreactor culture. The mechanical strength of recellularized constructs was measured after dynamic stimulation. Finally, the tissue-engineered tendons were used to reconstruct the ACL in mini-pigs and mechanical strength was assessed after three months. Dynamic bioreactor culture significantly increased the expression of tendon-specific genes, the quantity of newly synthesized collagen and GAG, and the tensile strength of recellularized tendons. After in vivo reconstruction, the tensile strength of the tissue-engineered tendons increased significantly up to 3 months after surgery and were within 80% of the native strength of the ACL. Our translational study indicates that the recellularization and dynamic mechanical stimuli can significantly enhance matrix synthesis and mechanical strength of decellularized porcine tibialis tendons. This approach to tissue engineering can be very useful for ACL reconstruction and may overcome some of the disadvantages of autografts and allografts

Following acute ACL rupture patients are routinely referred for rehabilitation but the timing and level of functional recovery related to rehabilitation outcome are poorly defined. The primary aim of this study was to measure functional recovery following acute ACL rupture in the clinical setting using a two dimensional movement analysis system. A longitudinal research design was used; we aimed for three clinical movement analysis sessions over the course of rehabilitation. One hundred and fifteen patients were recruited. Sixty three uninjured matched controls were recorded once performing all the functional activities; walking, jogging, distance hop and run and stop. Participants were filmed in the sagittal plane using a digital camcorder to extract kinematic data. Average recovery over time was modelled using a least squares third order polynomial. The secondary aim was to define the outcome measures and treatment goals used in ACL rehabilitation by specialist knee physiotherapists. A questionnaire was distributed to 300 hospitals across the UK. From the 44 responses insight was obtained about parameters physiotherapists use to plan treatment and evaluate recovery. Repeated movement analysis showed that gait velocity took on average 85 days to recover to within the normal limits of uninjured controls. Jogging velocity took 30 days; Hop distance took 55 days for the non-injured leg and 100 days for the injured leg; Knee range during the landing phase of run and stop took 80 days to recover but demonstrated some deterioration. The questionnaire identified that specialist knee physiotherapists use 60 different outcome measures and 34 rehabilitation treatment goals, which can be sub-divided into patient reported (PR), functional activities (A) and impairments (I). The percentage usage by physiotherapists for each category of outcome measure were 55.8% (A), 62.8% (I) to 67.4% (PR) and for treatment goals 55.8% (PR), 69.8% (A) to 81.4% (I). Hopping is the most frequently evaluated functional activity but there are large differences in its utilisation. The application of functional goals and outcome measures in rehabilitation is not universal with specialist physiotherapists generally adopting an impairment approach. Repeated movement analysis in the clinical setting provided objective data on the recovery of functional activities that progressively challenge knee stability. Gait and hop distance appear to be the most useful variables for tracking performance over time but their predictive value needs to be explored further. Adaptations in the non-injured leg indicate that its use as a control needs to be done with caution. For jogging and run and stop there appears to be a threshold after which patients can perform these activities rather than a gradual recovery. Clinical movement analysis could be used to provide objective feedback on recovery levels and help guide the rehabilitation process. However, currently functional goals and milestones are not always included in the planning and evaluation of rehabilitation. Developing better rehabilitation should involve greater integration of functional activity measures into practice. This would require a shift from an impairment rehabilitation approach to focus on functional goals

Cite this article: Bone Joint J 2023;105-B(11):1133–1134.

The December 2022 Sports Roundup³⁶⁰ looks at: Anterior cruciate ligament (ACL) repair with dynamic intraligamentary stabilization or anterior ACL at five years?; Femoroacetabular impingement in mild osteoarthritis: is hip arthroscopy the answer?; Steroids in Achilles tendinopathy: A randomized trial.

Introduction and Aims: This longitudinal prospective study reports the 10-year results of anterior cruciate ligament (ACL) reconstruction in 90 patients with isolated ACL rupture. Method: Three hundred and thirty-three patients undergoing endoscopic ACL reconstruction over a 15-month period using patellar tendon autograft and interference screw fixation were evaluated prospectively. Those patients with an associated ligament injury, chondral damage, previous meniscectomy, excision > 1/3 of one meniscus, an abnormal radiograph or contra-lateral knee, or a compensable injury were excluded. This left 90 patients in the study group. Evaluation was conducted annually for five years, then at seven and 10 years after surgery and included the IKDC Standard Evaluation, Lysholm knee score, kneeling pain, KT1000 testing and weight-bearing radiographs at two, five, seven and 10 years. Results: Repeat ACL injury occurred in a total of 23 patients (26%). There were six cases of graft rupture (7%) and 18 cases of contralateral ACL injury (20%). One patient suffered both a contralateral and graft ACL rupture. Eight patients (9%) underwent surgery for meniscal or chondral symptoms during the 10-year period. Of the 84 patients with intact grafts at 10 years, 75 (89%) were reviewed. On radiological examination at 10 years, 47% displayed mild to moderate evidence of osteoarthritis. The median Lysholm knee score was 95. Ninety-six percent felt their knee was normal or nearly normal. Forty-seven percent were still participating in moderate to strenuous activity after 10 years. Eighty-seven percent reported that their knee did not affect their activity level. Ninety-seven percent had grade 0–1 on Lachman and pivot shift testing. On instrumented testing 81% had < 3mm of anterior tibial displacement. Twenty-five percent displayed loss of extension range when compared to the contralateral limb, however this was < 5 degrees in 20% of patients. Pain on kneeling was present in 56%. On overall IKDC assessment, 77% were normal or nearly normal. Conclusion: Endoscopic ACL reconstruction using the PT autograft and interference screw fixation achieves and maintains excellent subjective results and objective stability. This combined with the low incidence of patients requiring subsequent meniscal or chondral surgery enforces the meniscoprotective function of ACL reconstruction. However, early signs of osteoarthritis are developing at 10 years, as displayed by radiological examination and early loss of extension

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

Machine-learning (ML) prediction models in orthopaedic trauma hold great promise in assisting clinicians in various tasks, such as personalized risk stratification. However, an overview of current applications and critical appraisal to peer-reviewed guidelines is lacking. The objectives of this study are to 1) provide an overview of current ML prediction models in orthopaedic trauma; 2) evaluate the completeness of reporting following the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement; and 3) assess the risk of bias following the Prediction model Risk Of Bias Assessment Tool (PROBAST) tool.

Artificial intelligence and machine-learning analytics have gained extensive popularity in recent years due to their clinically relevant applications. A wide range of proof-of-concept studies have demonstrated the ability of these analyses to personalize risk prediction, detect implant specifics from imaging, and monitor and assess patient movement and recovery. Though these applications are exciting and could potentially influence practice, it is imperative to understand when these analyses are indicated and where the data are derived from, prior to investing resources and confidence into the results and conclusions. In this article, we review the current benefits and potential limitations of machine-learning for the orthopaedic surgeon with a specific emphasis on data quality.

There is increasing interest in the placement of the femoral and tibial tunnels for anterior cruciate ligament (ACL) reconstruction, with a trend towards a more anatomically accurate reconstruction. Non-anatomical reconstruction of the ACL has been suggested to be one of the major causes of osteoarthritis in the knee following ACL rupture. Knee surgeons from an international community were invited to demonstrate their method for arthroscopic ACL tunnel placement in an ACL deficient cadaveric knee. These positions were recorded with image intensification and compared with the native ACL insertion sites, which had previously been recorded with image intensification, before the ACL had been resected. Some clear trends were observed; the use of three tunnel placement techniques (anatomic ridges, ‘ruler method’ and use of image intensification) was associated with most accurate position of the femoral tunnel in the centre of the native ACL femoral insertion site. The choice of arthroscopy portals also affected tunnel placement. There is considerable variation in ACL reconstruction tunnel placement amongst experienced knee surgeons. This study provides useful information as to which tunnel placement methods are associated with the most anatomically accurate ACL reconstruction

Aims

The aim of this study was to screen the entire genome for genetic markers associated with risk for anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injury.

INTRODUCTION. In native knees the anterior cruciate ligament (ACL) plays a major role in joint stability and kinematics. Sacrificing the ACL in contemporary total knee arthroplasty (TKA) is known to cause abnormal knee motion, and reduced function. Hence, there is growing interest in the development of ACL retaining TKA implants. Accommodation of ACL insertion around the tibial eminence is a challenge with these designs. Therefore, a reproducible and practical test setup is necessary to characterize the strength of the ACL/bone construct in ACL retaining implants. Seminal work showed importance of loading the ACL along its anatomical orientation. However, prior setups designed for this purpose are complex and difficult to incorporate into a standardized test for wide adoption. The goal of this study was to develop a standardized and anatomically relevant test setup for repeatable strength assessment of ACL construct using basic force-displacement testing equipment. METHODS. Cadaver knees were positioned with the ACL oriented along the loading axis and being the only connection between femur and tibia. 15° knee flexion was selected based on highest ACL tensions reported in literature. Therefore, the fixtures were adjusted accordingly to retain 15° knee flexion when the ACL was tensioned. The test protocol included 10 cycles of preconditioning between 6N and 60N at 1mm/s, followed by continuous distraction at 1mm/s until failure (Fig. 1). Eleven cadaveric knees (4 male, 7 female; 70.9 yrs +/−13.9 yrs) were tested using this setup to characterize a baseline ACL pullout strength (peak load to failure) in native knees. RESULTS. The average ACL pullout strength was 935.6N +/−327.5N with the extremes ranging from a minimum of 346N to a maximum of 1425N. There were five failure modes observed: [1] ACL avulsion from the femur with bony attachment (one knee), [2] ACL pull-off from the femur w/o bony attachment (two knees), [3] ACL tear (three knees), [4] ACL pull-off from the tibia w/o bony attachment (one knee), [5] ACL avulsion from the tibia with bony attachment (three knees). One knee showed a combined failure mode of 2 & 4, meaning part of the ACL was pulled off the femur and part pulled off the tibia. CONCLUSION. There was a large variation in failure load between specimens. The knee with the minimum failure load had severe arthritis, osteophytes and signs of ACL deficiency. The average failure load (935.6N +/−327.5N) is in line with those published in literature for a comparable age group. This indicates that failure loads and modes obtained with more complex setups could be reproduced by using standard uniaxial load frames and simple fixtures. The failure modes in our experiment were evenly spread between mid-substance, and insertions (either femur or tibia). This test could be used as a standardized method to investigate the strength of the ACL complex following procedures such as ACL reconstruction, partial- and total knee arthroplasty. In particular, this setup provides a reliable mechanism for evaluation of the ACL-bone construct in bi-cruciate retaining (BCR) TKA, which is likely required for regulatory pathways

To evaluate the clinical outcome of arthroscopic treatment of ACL with an Achilles tendon allograft in patient with acute rupture. 22 patients, between 2003 and 2006, with acute rupture of ACL, were treated with an Achilles tendon allograft. The mean age was 26 years. Patients were evaluated before and after surgery and at the latest follow-up with Noulis-Lahmann test and Pivot shift test. We also used IKDC score, Lysholm score and one leg stance test and functional reach test. Patients were also evaluated with Cybex II + and with plain radiographies. The mean follow-up time was 3.5 years. 90% of the patients had a negative pivot shift test and 95% of the patients had a score at Noulis-Lahmann test +1. The mean value of IKDC score was 88 (62–100) and the mean time of Lysholm score was 91 (75–100). Until the latest follow-up there were no clinical sighs of inflammation or graft rejection. Radiologic evaluation revealed no sign of tunnel enlargement. We believe that the use of a fresh-frozen allograft in the treatment of acute ACL ruptures is an effective procedure for the restoration of ligamentous stability of the knee

The biomechanical function of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) remains controversial. Some studies report that the AM bundle stabilises the knee joint in anteroposterior (AP) translation and rotational movement (both internal and external) to the same extent as the PL bundle. Others conclude that the PL bundle is more important than the AM in controlling rotational movement. The objective of this randomised cohort study involving 60 patients (39 men and 21 women) with a mean age of 32.9 years (18 to 53) was to evaluate the function of the AM and the PL bundles of the ACL in both AP and rotational movements of the knee joint after single-bundle and double-bundle ACL reconstruction using a computer navigation system. In the double-bundle group the patients were also randomised to have the AM or the PL bundle tensioned first, with knee laxity measured after each stage of reconstruction. All patients had isolated complete ACL tears, and the presence of a meniscal injury was the only supplementary pathology permitted for inclusion in the trial. The KT-1000 arthrometer was used to apply a constant load to evaluate the AP translation and the rolimeter was used to apply a constant rotational force. For the single-bundle group deviation was measured before and after ACL reconstruction. In the double-bundle group deviation was measured for the ACL-deficient, AM- or PL-reconstructed first conditions and for the total reconstruction. We found that the AM bundle in the double-bundle group controlled rotation as much as the single-bundle technique, and to a greater extent than the PL bundle in the double-bundle technique. The double-bundle technique increases AP translation and rotational stability in internal rotation more than the single-bundle technique