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

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

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

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

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.

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.

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

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. 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

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

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).

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).

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

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

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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.

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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.

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

Objective. To compare the clinical outcomes of bone-patellar tendon-bone (BTB) allografts sterilised through a novel sterilisation system with aseptically processed BTB allografts for Anterior Cruciate Ligament (ACL) reconstruction. The following hypotheses were also tested: (1) the cumulative score of the IKDC is not significantly different in the sterilised treatment group than in the aseptic control group, (2) the proportion of normal laxity in patients, as measured by the KT 2000 arthrometer, is not significantly different in the sterilised group than in the aseptic control group. Methods. A total of 76 patients undergoing ACL reconstruction were randomised into one of two intervention groups, BioCleanse. ¯. -sterilised or Aseptic BTB allografts, at 6 independent investigation sites. Post-op examiners and patients were blinded to graft type. Patients were evaluated at 6 months (44 of the 76), 12 months (20 of the 76), and 24 months (27 of the 76) with KT-2000, IKDC scores, and Flexion and Extension Range of Motion (ROM) analysis. Inclusion criteria included an acute, isolated, unilateral ACL tear and exclusion criteria included prior ACL injury, multiligament reconstruction, and signs of degenerative joint disease. Results. Significant improvement (p<.0001) in IKDC scores was noted in both groups over time. Similarly, a significant improvement (p<.0001) was observed in KT-2000 results over the 24-month period for both groups. There was no difference between graft types at any time point regarding IKDC or KT-2000 scores. There was also no significant difference in active extension ROM between the two groups. Active flexion ROM significantly improved from pre-op to 24 month follow-up (p<.0001) with no difference between groups at any time point. Conclusions. Results indicate that the sterilisation process, BioCleanse. ¯. , does not appear to have an effect on the biomechanics or healing ability of the BTB allograft. BioCleanse. ¯. may provide surgeons with allografts similar to aseptically processed allograft tissue with the benefit of eliminating donor-to-recipient disease transmission