We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis

Disruption of the extensor mechanism in total knee arthroplasty may occur by tubercle avulsion, patellar or quadriceps tendon rupture, or patella fracture, and whether occurring intra-operatively or post-operatively can be difficult to manage and is associated with a significant rate of failure and associated complications. This surgery is frequently performed in compromised tissues, and repairs must frequently be protected with cerclage wiring and/or augmentation with local tendon (semi-tendinosis, gracilis) which may also be used to treat soft-tissue loss in the face of chronic disruption. Quadriceps rupture may be treated with conservative therapy if the patient retains active extension. Component loosening or loss of active extension of 20° or greater are clear indications for surgical treatment of patellar fracture. Acute patellar tendon disruption may be treated by primary repair. Chronic extensor failure is often complicated by tissue loss and retraction can be treated with medial gastrocnemius flaps, achilles tendon allografts, and complete extensor mechanism allografts. Attention to fixing the graft in full extension is mandatory to prevent severe extensor lag as the graft stretches out over time

While injury to the posterolateral corner is accepted as a relatively common occurrence associated with rupture of the anterior cruciate ligament, posteromedial meniscocapsular injury has not previously been recognised as such. In a prospective assessment of 183 consecutive reconstructions of the anterior cruciate ligament this injury was observed in 17 cases, giving it an incidence of 9.3%. Clinically, it was associated with a mild anteromedial rotatory subluxation and it is important not to confuse this with posterolateral rotatory subluxation. In no case was this injury identified by MRI. The possible long-term clinical relevance is discussed

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period

Between 1993 and 1994, 891 patients underwent primary anterior cruciate ligament (ACL) reconstruction. A total of 48 patients had undergone bilateral ACL reconstruction and 42 were available for review. These patients were matched to a unilateral ACL reconstruction control group for gender, age, sport of primary injury, meniscal status and graft type. At 15-year follow-up a telephone interview with patients in both groups was performed. The incidence of further ACL injury was identified through structured questions and the two groups were compared for the variables of graft rupture or further ACL injury, family history of ACL injury, International Knee Documentation Committee (IKDC) subjective score and activity level.

There were 28 male and 14 female patients with a mean age of 25 years (13 to 42) at the time of first ACL injury. Subsequent further ACL injury was identified in ten patients (24%) in the bilateral ACL reconstruction study group and in nine patients (21%) in the unilateral ACL reconstruction control group (p = 0.794). The mean time from bilateral ACL reconstruction to further ACL injury was 54 months (6 to 103). There was no significant difference between the bilateral ACL reconstruction study group and the matched unilateral ACL reconstruction control group in incidence of further ACL injury (p = 0.794), family history of ACL injury (p = 0.595), IKDC activity level (p = 0.514), or IKDC subjective score (p = 0.824).

After bilateral ACL reconstruction the incidence of graft rupture and subjective outcomes were equivalent to that after unilateral ACL reconstructions.

Cite this article: Bone Joint J 2013;95-B:798–802.

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.

Aims. Little is known about the risk factors that predispose to a rupture of the posterior cruciate ligament (PCL). Identifying risk factors is the first step in trying to prevent a rupture of the PCL from occurring. The morphology of the knee in patients who rupture their PCL may differ from that of control patients. The purpose of this study was to identify any variations in bone morphology that are related to a PCL. Patients and Methods. We compared the anteroposterior (AP), lateral, and Rosenberg view radiographs of 94 patients with a ruptured PCL to a control group of 168 patients matched by age, sex, and body mass index (BMI), but with an intact PCL after a knee injury. Statistical shape modelling software was used to assess the shape of the knee and determine any difference in anatomical landmarks. Results. We found shape variants on the AP and Rosenberg view radiographs to be significantly different between patients who tore their PCL and those with an intact PCL after a knee injury. Overall, patients who ruptured their PCL have smaller intercondylar notches and smaller tibial eminences than control patients. Conclusion. This study shows that differences in the shape of the knee are associated with the presence of a PCL rupture after injury. A smaller and more sharply angled intercondylar notch and a more flattened tibial eminence are related to PCL rupture. This suggests that the morphology of the knee is a risk factor for sustaining a PCL rupture. Cite this article: Bone Joint J 2019;101-B:1058–1062

Abstract. Introduction. The study aims were to demonstrate rates, level, and time taken to RTP in elite sports after ACL reconstruction (ACL-R) and compare football and rugby. Methods. A retrospective review of a consecutive series of ACL-R between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 years post primary autograft ACL-R. The outcomes measured were return to play (RTP), (defined as participation in a professional match or in national/ international level amateur competition), time to RTP after surgery, and RTP level (Tegner score). Results. Three hundred and ninety four elite athletes with 420 ACL-Rs (235 in footballers, 125 in rugby players and 60 in other sports) were included. 95.7% of all athletes returned to competition at a mean of 10.3 months after ACL-R with 90.1% at the same / higher level. There was no difference in RTP rates between rugby and football. Rugby players RTP faster than footballers (9.6 vs 10.6 months, (p=0.027). Overall re-rupture rate within 2 years was 6.4% but not significantly different between football (8.1%) and rugby (7.2%). Footballers were more likely to rupture their ACL during jumping / landing manoeuvres and to receive a PT graft than rugby players. There were no significant differences between football and rugby regarding patient characteristics, intraoperative findings and re-operation rates. Conclusion. Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers

Abstract. Introduction. Previous research has shown that, notwithstanding ligament healing, properly selected MCL reconstruction can restore normal knee stability after MCL rupture. The hypothesis of this work was that it is possible to restore knee stability (particularly valgus and AMRI) with simplified and/or less-invasive MCL reconstruction methods. Methods. Nine unpaired human knees were cleaned of skin and fat, then digitization screws and optical trackers were attached to the femur and tibia. A Polaris stereo camera measured knee kinematics across 0. o. -100. o. flexion when the knee was unloaded then with 90N anterior-posterior force, 9Nm varus-valgus moment, 5Nm internal-external rotation, and external+anterior (AMRI) loading. The test was conducted for the following knee conditions: intact, injured: transected superficial and deep MCL (sMCL and dMCL), and five reconstructions: (long sMCL, long sMCL+dMCL, dMCL, short sMCL+dMCL, short sMCL), all based on the medial epicondyle isometric point and using 8mm tape as a graft, with long sMCL 60mm below the joint line (anatomical), short sMCL 30mm, dMCL 10mm (anatomical). Results. No significant changes were found in anterior or posterior translation, or varus at any stage. MCL deficiency caused increased valgus, external rotation and AMRI instabilities. All reconstructions restored valgus stability. The isolated long sMCL allowed residual external rotation and AMRI instability, while the short sMCL did stabilise AMRI. Both 2-strand reconstructions (dMCL+sMCL) restored stability. Conclusion. All tested techniques, except long sMCL, restored valgus and AMRI stability of the knee. The single femoral tunnel is satisfactory for both the dMCL and sMCL grafts

Aims. The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery. Patients and Methods. From a consecutive series of 200 patients who underwent primary reconstruction following rupture of the ACL, we identified 36 who sustained a further rupture, 29 of whom underwent revision surgery. Patients were reviewed prospectively at one, two, seven, 15 and about 20 years after their original surgery. Primary outcome measures were the number of further ruptures, the posterior tibial slope (PTS), and functional and radiological outcomes. These were compared with a gender and age matched cohort of patients who underwent primary ACL reconstruction only. Results. At a mean follow-up of 18.3 years (14.3 to 20.2), 29 patients had undergone revision surgery and within this revision group 11 had sustained more than three ruptures of the ACL (3 to 6). The mean age at the time of revision reconstruction was 26.4 years (14 to 54). The mean PTS was significantly higher in those patients who suffered a further injury to the ACL (11°) compared with the control group (9°) (p < 0.001). The mean PTS in those patients who sustained more than three ruptures was 12°. Conclusion. Patients who suffer recurrent injuries to the ACL after reconstruction have poorer functional and radiological outcomes than those who suffer a single injury. The causes of further injury are likely to be multifactorial but an increased PTS appears to have a significant association with recurrent ACL injuries. Cite this article: Bone Joint J 2017;99-B:337–43

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. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

Aim. This study looks for correlation between pre-operative MRI and intra-operative surgical findings regarding the site of medial patellofemoral ligament (MPFL) rupture in first time patella dislocaters with the aim of confirming the reliability of this modality of imaging. Methods. A retrospective analysis of all patients who were referred for MRI following patella dislocation was performed. The surgical and MRI findings of those who subsequently underwent MPFL repair were compared to look for any correlation. Results. 41 patients were first time patella dislocators and 38 had MPFL rupture diagnosed on MRI. Of these 19 progressed to surgical intervention and 17 had adequate data available from the notes to permit comparison. All of the MPFLs ruptured at the patella insertion. In 76.5% (13/17) of patients the site of MPFL rupture was correctly identified on MRI scan. Of those that were discordant, 3/4 had the site of rupture identified as the femoral insertion on MRI and on 1/4 had an MRI suggestive of rupture at both the femoral and patella insertions. Conclusion. MPFL rupture is common in first time dislocations occurring in 93% of this cohort on MRI. There was a predominance for patella insertion rupture in our study which contrasts with the majority of the published literature. By correlating surgical and radiological findings we can conclude that while MRI can accurately diagnose MPFL rupture at the patella insertion it is less accurate in identifying rupture at the femoral insertion

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

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.

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

Aims

Multiligament knee injuries (MLKI) are devastating injuries that can result in significant morbidity and time away from sport. There remains considerable variation in strategies employed for investigation, indications for operative intervention, outcome reporting, and rehabilitation following these injuries. At present no study has yet provided a comprehensive overview evaluating the extent, range, and overall summary of the published literature pertaining to MLKI. Our aim is to perform a methodologically rigorous scoping review, mapping the literature evaluating the diagnosis and management of MLKI.

Aims

The purpose of this study was to assess mid-term survivorship following primary total knee arthroplasty (TKA) with Optetrak Logic components and identify the most common revision indications at a single institution.

Aims

Patient dissatisfaction following primary total knee arthroplasty (TKA) with manual jig-based instruments has been reported to be as high as 30%. Robotic-assisted total knee arthroplasty (RA-TKA) has been increasingly used in an effort to improve patient outcomes, however there is a paucity of literature examining patient satisfaction after RA-TKA. This study aims to identify the incidence of patients who were not satisfied following RA-TKA and to determine factors associated with higher levels of dissatisfaction.

Aims

The aim of this study was to compare a bicruciate-retaining (BCR) total knee arthroplasty (TKA) with a posterior cruciate-retaining (CR) TKA design in terms of kinematics, measured using fluoroscopy and stability as micromotion using radiostereometric analysis (RSA).