Introduction. Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Methodology. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained. Results. Twenty-eight players (77.8%) and 29 coaches (13.2%) completed the questionnaire. Seventeen (60.7%) players and 15 (51.7%) coaches reported female athletes were at greater risk for sustaining ACL injuries. Over 90% of respondents identified netball as high-risk, whilst 89% of players and 76% of coaches reported these injuries to be preventable. Two (7.1%) players and 6 (20.7%) coaches utilised ACL injury prevention programs with lack of time and engagement from coaches and players identified. Majority of respondents indicated that their club has neither promoted, advocated nor demonstrated exercises for ACL injury prevention. Over 90% of respondents would utilise such programs if it minimised players risk with appropriate training and information. Conclusion. Study highlights limited knowledge of female athletes’ increased susceptibility of ACL injuries with lack of communication and education of ACL injury prevention programs between sporting associations, coaches and players. Results demonstrate willingness of players and coaches to implement ACL injury prevention programs in Welsh netball

Background: Anterior cruciate ligament (ACL) injury and re-injury rates are high and continue to rise in adolescents. After surgical reconstruction, less than 50% of patients return to their pre-injury level of physical activity. Clearance for return-to-play and rehabilitation progression typically requires assessment of performance during functional tests. Pain may impact this performance. However, the patient's level of pain is often overlooked during these assessments. Purpose: To investigate the level of pain during functional tests in adolescents with ACL injury. Fifty-nine adolescents with ACL injury (ACLi; female n=43; 15 ± 1 yrs; 167.6 ± 8.4 cm; 67.8 ± 19.9 kg) and sixty-nine uninjured (CON; female n=38; 14 ± 2 yrs; 165.0 ± 10.8 cm; 54.2 ± 11.5 kg) performed a series of functional tests. These tests included: maximum voluntary isometric contraction (MVIC) and isokinetic knee flexion-extension strength tests, single-limb hop tests, double-limb squats, countermovement jumps (CMJ), lunges, drop-vertical jumps (DVJ), and side-cuts. Pain was reported on a 5-point Likert scale, with 1 indicating no pain and 5 indicating extreme pain for the injured limb of the ACLi group and non-dominant limb for the CON group, after completion of each test. Chi-Square test was used to compare groups for the level of pain in each test. Analysis of the level of pain within and between groups was performed using descriptive statistics. The distribution of the level of pain was different between groups for all functional tests (p≤0.008), except for ankle plantar flexion and hip abduction MVICs (Table 1). The percentage of participants reporting pain was higher in the ACLi group in all tests compared to the CON group (Figure 1). Participants most often reported pain during the strength tests involving the knee joint, followed by the hop tests and dynamic tasks, respectively. More specifically, the knee extension MVIC was the test most frequently reported as painful (70% of the ACLi group), followed by the isokinetic knee flexion-extension test, with 65% of ACLi group. In addition, among all hop tests, pain was most often reported during the timed 6m hop (53% of ACLi), and, among all dynamic tasks, during the side-cut (40% of ACLi) test (Figure 1). Furthermore, the tests that led to the higher levels of pain (severe or extreme) were the cross-hop (9.8% of ACLi), CMJ (7.1% of ACLi), and the isokinetic knee flexion-extension test (11.5% of ACLi) (Table 1). Adolescents with and without ACL injury reported different levels of pain for all functional tasks, except for ankle and hip MVICs. The isokinetic knee flexion-extension test resulted in greater rates of severe or extreme pain and was also the test most frequently reported as painful. Functional tests that frequently cause pain or severe level of pain (e.g., timed 6m and cross hops, side-cut, knee flexion/extension MVICs and isokinetic tests) might not be the first test choices to assess function in patients after ACL injury/reconstruction. Reported pain during functional tests should be considered by clinicians and rehabilitation team members when evaluating a patient's readiness to return-to-play. For any figures or tables, please contact the authors directly

Limb symmetry on a battery of functional tests is becoming more common as a clinical rehabilitation tool serving as a proxy assessment for readiness to return to sport following anterior cruciate ligament reconstruction (ACLR). The predictive capability of each included test for determining the likelihood of a second ACL injury is not well known. This study combines 14 established functional tests into a comprehensive return-to-sport assessment (RTSA). Study purpose: to determine if any of the functional tests were independently related to a second ACL injury occurring after the patient was cleared for return to sport. The RTSA was administered to 226 individuals after primary, unilateral ACLR who were followed for at least 24 months (51% female; mean ± SD age, 18.9 ± 4.0 years at RTSA, 9.4 ± 2.4 months post-surgery). The RTSA included 14 tests that involved calculation of Limb Symmetry Indices (LSI): leg press [LP], eccentric hamstring strength [HS], hip adductor strength [HA], Y Balance Test (anterior [YANT], posteromedial [YPM], posterolateral [YPL]), single hop [SH], triple hop [TH], crossover hop [CH], 6 meter timed hop [TiH], lateral hop [LH], medial hop [MH], vertical jump [VJ], single leg squat [SLS]. LSI averaged values of three trials for each leg for LP, HS, HA, SH, TH, CH, TiH, LH, MH, VJ, and SLS. The lowest bilateral difference across three trials was used for YANT, YPM, and YPL. Logistic regression using backward elimination was used to predict the odds of a second non-contact ACL injury using the RTSA, sex, age, and months post-surgery at RTSA as the independent variables. Twenty-five (11%) patients returned to have a subsequent ACL surgery. Twenty of the 25 experienced a second non-contact ACL injury (70% female; 10 ipsilateral, 10 contralateral). Of the 14 female athletes, there were eight contralateral and six ipsilateral tears. In males, there were two contralateral and four ipsilateral tears. The mean time from surgery to injury was 20.5 ± 9.8 months. Age (OR; 95%CI: 0.75; 0.58, 0.92), LP (0.97; 0.93, 0.99), YANT (1.21; 1.02, 1.43), and TiH (1.10; 1.01, 1.20) were found to be significantly associated with the odds of re-injury. Age, YANT, and the LSI of LP and TiH have a statistically significant impact on the odds of a second ACL injury after ACL reconstruction. YANT has an OR of 1.21, indicating that a 1cm increase in asymmetry will increase the likelihood of re-injury by 21%, holding all else constant. A 1% increase in the TiH LSI results in a 10% increase in the odds of re-injury. The risk of re-injury decreases as age increases. The OR for LP symmetry was near 1.0 and therefore may not have a clinically relevant effect on re-injury risk. Although LSI is a straightforward, quantitative measure, clinicians should not solely rely on it as a proxy for recovery of knee function. Many tests are available for clinical assessments, but this study found only a few of the tests to have significant associations with a subsequent ACL injury following return to play after ACL reconstruction

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

A quick, portable and reliable tool for predicting ACL injury could be an invaluable instrument for athletes, coaches, and clinicians. The gold standard, Vicon motion analysis, despite having a high sensitivity and risk specificity, is not practical for coaches or clinicians to use on a routine basis for assessing athletes. The present study validated the Kinect device to the currently used method of chart review in predicting athletes at high risk. A total of 114 participants were recruited from both the men and women McGill Varsity Sports Program. 69 males and 45 female athletes were evaluated to assess the specificity and sensitivity of the Kinect device in predicting athletes at high risk of injury. Each athlete performed three-drop vertical jumps off of a 31cm box and the data was recorded and risk score was generated. Generation of this data is done by our uniquely programmed software that measures landing angles at different time frames and compares live results to previously known data of injured athletes. A chart review was then performed by a clinician, blinded to these risk scores, to risk stratify the same athletes as high or low risk of ACL injury based on their medical charts. Data reviewed incorporated pre-season physical exams along with documented known risk factors for ACL injury, including previous knee injuries, family history of ACL injury, gender, sport, and BMI. Positive risk factors were assigned one point while negative risk factors assigned zero points. The Kinect device, powered by our software, identified 40 athletes as having a high-risk score (> 55%), and subsequently, five (4.39%) sustained an ACL injury by the end of their respective sport seasons. Two male and two female basketball players along with one male soccer player sustained non-contact ACL injuries. Given that all five of the injured athletes were in the cohort of 40 identified as high risk by the Kinect, this yielded a sensitivity of 100% for the device. As for the specificity, the Kinect computed 35 false positives, yielding a specificity of 68% for the duration of the study. The medical chart review identified 36 athletes as high risk and 60 as being low risk of ACL injury. Four of the athletes that sustained an ACL injury were in the group of 36 identified as high risk by the clinician. However, one of the five participants who sustained an ACL injury was not captured by the medical chart assessment, yielding a sensitivity of 80% and a specificity of 65% for the clinician. When it comes to injury prediction, it is preferred to have a high sensitivity even if the specificity is slightly lower as this ensures that all athletes who are at risk will be captured. Our data demonstrated that the chart analysis provided one false negative and led to missing one high-risk athlete who ended up sustaining an ACL injury. Based on the comparison of sensitivity and specificity, the Kinect system provides a slightly better predictive analysis for predicting ACL injury compared to chart review

Anterior cruciate ligament (ACL) injuries are frequent among athletes and a leading cause of time away from competition. Stability of the knee involves the ACL for limiting anterior tibial translation and the ALL (anterolateral ligament) to restrain internal rotation of the tibia. Present indications for treatment with a combined ACL-ALL reconstruction remain unclear and mostly subjective. We mathematically modeled the tibial plateau geometry to try and identify patients at risk of ACL injury, and develop an objective trigger point for the decision to proceed with additional surgery to optimize rotational stability in these higher risk patients. We hypothesized that an increased convexity and steepness of the posterior aspect of the lateral plateau would subject knees to higher rotational torques leading to potentially a higher risk of ACL injury. The study design was a case-control study involving ACL reconstruction cases (n=68) and matched controls (n=68) between 2008–2015 at our institution. We used a two-dimensional approach, evaluating sagittal MRI images of the knee to model the posterior convexity of the lateral tibial plateau. Points were selected along the articular surface, and a least-squares regression was used to curve-fit a power function (y = a xn). In the equation, larger coefficient a and n represented steeper slopes. The cases and controls were compared using a Mann-Whitney-U test, and the statistical significance was set at α < 0.05. A subgroup analysis for females and males was also performed for the curve-fit coefficients. We observed a significant difference in the tibial surface geometry between our ACL reconstruction cases and matched controls (Figure 1). The modeled power equation for our ACL cases had larger coefficients compared to controls for all groups. For all pooled subjects, coefficient a (ACL recon cases = 0.90 vs controls = 0.68, p < 0.0001) and coefficient n (ACL recon cases = 0.34 vs controls = 0.30, p = 0.07) (Table 1). For the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for predicting injury, using a cut off coefficient of a = 0.78. The odds ratio was 12.6 [5.5 – 29]. The posterolateral cartilaginous slope of the tibial plateau was mathematically modeled in patients with ACL injury. Patients with ACL injury demonstrated abnormally steep and fast slopes compared to controls that may play predispose to ACL injury by increasing anterior translation forces and internal rotation torques sustained by their knee joint. A steeper slope may also explain high-grade pivot shifts on physical exam that are thought to be a relative indication for adding an associated ALL reconstruction. Our findings are promising for adding more objectivity to surgical decision-making, especially with identifying high-risk patients that may be candidates for combined ACL-ALL reconstructions. For any figures or tables, please contact the authors directly

A method is proposed to assess risk parameters of anterior cruciate ligament (ACL) injury using human pose estimation (HPE) and a single stereo depth camera. Detectron2 is used to identify key points of a subject performing a single leg jump test. This allows dynamic pivot of the knee to be assessed during landing using four risk parameters: knee valgus, knee translation in the coronal plane, pelvic tilt, and head-ankle alignment (body sway).

Results show the model has an accuracy of 7° in angular measurements and 38 mm in linear measurements. Compared to previous studies, which only consider front-on analysis, this method has partially reduced accuracy in linear measurements and half the accuracy in angular measurements. Despite this, coupling information from multiple risk parameters reduces the accuracy required on any one parameter and the use of a single depth camera enables reliable analysis at a subject orientation of ±45° relative to the camera.

These factors create a novel solution, proposing the ability for broad evaluation of ACL risk parameters in environments outside a testing laboratory, which has not been done before.

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

Several studies have highlighted the relationship between anterior cruciate (ACL) injury and knee geometry particularly tibial slope (TS). However, clinical data are inconsistent, whether the lateral or medial or slopes have a different influence on ACL injury. Our goal was to assess whether the medial, lateral slopes are associated with ACL injury and whether meniscus geometry is associated with ACL injury. In addition, we sought to determine if lateral meniscal height could serve as a simple surrogate measurement for ACL injury risk. A case-controlled study compared 68 patients with an ACL injury and 68 matched nested controls. Radiological analysis of MRI measured the anterior-posterior distance of the medial and lateral plateaus, the tibial slope of both plateaus and meniscus geometry. Groups were compared using a Mann-Whitney test and α < 0 .05. The lateral tibial plateau slope was significantly higher in the ACL injured group (6.92 degrees ±5.8) versus the control group 2.68 ±5.26 (p 0.0001). In addition, the lateral meniscal slope was significantly steeper with (ACL injuries: −1 ±4.7 versus −4.73 ±4.4 (p 0.0001) in the control group. The ACL Injured group had a significantly lower lateral meniscal height 0.76 cm ±0.09, compared to the control group that has 0.88 cm ±0.12 (p 0.0001). The Lateral meniscal height had a sensitivity of 76.47% and specificity 75% for predicting ACL injury using a cut off of. Patients with ACL-injury had significantly higher lateral tibial plateau slope. Lateral meniscus height was found to be an easy measurement to make on MRI with a high specificity for predicting ACL injury. Lateral tibial slope and meniscal Geometry can be used to identify patients with high risk of an ACL injury, that might benefit from further surgery to optimize rotational stability in high-risk patients

Abstract. Background. Anterior cruciate ligament (ACL) injuries with coinciding posterolateral tibial plateau (PLTP) depression fractures are rare. According to the most up to date literature, addressing the PLTP is crucial in preventing failure of the ACL. However, the surgical management of these injuries pose a great challenge to orthopaedic surgeons, given the anatomical location of the depressed PTP fragment. We report a case of a 17-year-old patient presenting to our department with this injury and describe a novel fixation method, that has not been described in the literature. Surgical Technique. A standard 2-portal arthroscopy is used to visualise the fractures. The PLTP is addressed first. With the combined use of arthroscopy and fluoroscopy, a guide pin is triangulated from the anteromedial aspect of the tibia, towards the depressed plateau fragment. Once the guide pin is approximately 1cm from the centre of the fragment, it is over-drilled with a cannulated drill, and simultaneously bluntly punched up to its original anatomical location. Bone graft is then used to fill the void, supported by two subchondral screws. Both fluoroscopy and arthroscopy are used to confirm adequacy of fixation. Finally, the tibial spine avulsion fracture is repaired arthroscopically using the standard suture bridging technique. Conclusion. We describe a novel, one-stage, minimally invasive approach that addresses both the ACL injury and PLTP fracture. We highlight the advantages of utilising this approach and functional outcomes

Abstract. Ramp lesions are meniscocapsular or meniscosynovial tears associated with chronic ACL injury and are postulated to occur because of disruption of meniscotibial ligament. Various techniques have been described in literature for their diagnosis and repair. Each of the described techniques have had some concerns. The authors, hereby, describe a novel technique for RAMP repair. Our Technique. Patient is positioned supine with the knee at 90 degrees with a side support. Standard arthroscopic portals are established. Ramp lesions are visualised through a trans-notch approach and probed simultaneously using an 18-guage needle posteromedialy. Once the diagnosis has been confirmed a posteromedial (PM) portal is established. The edges of the tear are freshened from the PM portal using a shaver or rasp. Knee Scorpion device (Arthrex) is then introduced through the PM which is loaded with No. 0 Fibrewire (Arthrex) in its lower jaw. The Scorpion device is deployed on the capsular side first, avoiding injury to the posterior structures and the suture loop is retrieved. Scorpion is loaded again with the other strand and is passed through the meniscal edge. A sliding knot is used. Ramp lesion is re-probed after tying a sliding knot for requirement of another suture. This technique provides us with an improved visualisation and diagnosis, better quality of debridement and complete closure of the ramp lesion using a simple suture device. In our experience this is a safe, successful and easily reproducible technique

Abstract. Background. The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. We aim to compare the short-term outcome of ACL-R using augmented hamstring tendon autografts (internally braced with neoligament) and non-augmented hamstring autografts. Methods. This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes. Results. There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82mm versus 8.44mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width. Conclusion. Augmented ACL-R may achieve superior graft diameters, lower failure rates and better patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further

The bone-patellar tendon-bone (BTB) autograft has a lower rate of graft failure but a higher rate of contralateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction. Subsequent contralateral injury may be a marker of success of the BTB graft, but it is unclear whether the type of graft influences the rate of return to sport. This study aimed to compare the rates of return to weekly sport and return to preinjury activity levels between the BTB and hamstring tendon autografts following primary ACL reconstruction. Prospective data on primary ACL reconstructions recorded in the New Zealand ACL Registry between April 2014-November 2019 were analyzed. The primary outcome was return to weekly sport, defined as a Marx activity score of 8, at 2-year follow-up. The secondary outcome was return to preinjury activity level, defined as a post-operative Marx activity score that was equal or greater to the patient's preinjury Marx score. Return to sport was compared between the BTB and hamstring tendon autografts via multivariate binary logistic regression with adjustment for patient demographics. 4259 patients were analyzed, of which 50.3% were playing weekly sport (n = 2144) and 28.4% had returned to their preinjury activity level (n = 1211) at 2-year follow-up. A higher rate of return to weekly sport was observed with the BTB autograft compared to the hamstring tendon autograft (58.7% versus 47.9%, adjusted odds ratio = 1.23, p = 0.009). Furthermore, the BTB autograft had a higher rate of return to preinjury activity levels (31.5% versus 27.5%, adjusted odds ratio = 1.21, p = 0.025). The BTB autograft is associated with a higher return to sport and may explain the higher rate of contralateral ACL injury following primary ACL reconstruction

Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries. A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway. 570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury. The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres

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

Anterior Cruciate Ligament injuries are a common cause of downgrade in Service personnel. The Multidisciplinary Injury Assessment Clinic (MIAC) is a service which patients can be referred to for expert musculoskeletal injury management. MIAC has a Fast Track (FT) referral system in place for imaging, and can subsequently refer isolated ACL injuries to a private provider for reconstruction. We examined this pathway in the South West region which has an overall population at risk of 19775. Over 4 years 173 knee injuries were referred to MIAC, of which 32 were ACL injuries. Of the 29 patients referred for MRI, the median time to imaging was 8 days with FT (n=13, range 2–14) and. 15 days via the NHS (n=16, range 5–64). The majority of injuries were found to involve multiple pathologies (n=19), excluding them from FT surgery. Time to NHS clinic from point of referral took a median time of 54 days, and onward delay to surgery was 47 days. None of the referrals to the private provider for reconstruction were accepted (n=3). We have identified aspects of current referral and treatment pathways that are inefficient and discuss a current solution utilising Military surgeons

Abstract. Background. The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft augmentation with suture tape (internal brace) are techniques purported to reduce the risk of rupture and hasten recovery. Our aim was to assess the short-term outcome of ACL-R using fibre tape augmented and non-augmented hamstring tendon grafts. Methods. This was a retrospective comparative study looking at augmented and non-augmented ACL-R. All procedures were performed by a single surgeon in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes. Results. There were 72 patients in the augmented and 132 patients in the control group. Confounding factors were comparable in both groups. The mean graft diameter in the augmented group was 8.81mm versus 8.01mm in the non-augmented. Six strand graft was achievable in 71% of the augmented group compared to 62.5% in the non-augmented group. Two graft failures reported in the non-augmented group and none in the augmented group. The average 14-month postoperative KOOS in the augmented group was 90.5 compared to an average 30-month score of 82.5 in the non-augmented group, which is statistically significant. Conclusion. Augmented ACL-R demonstrate statistically significant better patient-reported outcomes compared to the nonaugmented group. Graft failure rates may also be lower in augmented ACL-R

Previous studies have identified the anterolateral complex (ALC) as having an important role in controlling anterolateral rotatory laxity following anterior cruciate ligament injury and subsequent reconstruction. In particular, injury to the iliotibial band (ITB) and its component deep (dITB) and capsulo-osseous (coITB) layers, have been shown to significantly correlate with different grades of the pivot-shift test in patients with acute ACL injuries. However, the kinematic properties of the capsulo-osseous layer of the ITB, throughout knee range of motion, are not fully understood. The purpose of this study was to quantify the kinematic behaviour of the capsulo-osseous layer of the ITB through various degrees of knee flexion. Ten fresh-frozen cadaveric knee specimens were dissected to expose the capsulo-osseous layer of the iliotibial band. Radiopaque beads were embedded, at standardized increments (12.5%, 25%, 50% and 75% of total length from proximal to distal), into the tissue and fluoroscopic images were taken from 0o to 105o of knee flexion in 15° increments. The positions of the beads were identified in each image and the length, width, and area changes of the capsulo-osseous layer were calculated. Comparisons of the total length of the anterior and posterior borders of the coITB through knee ROM were conducted using a two-way (8 knee angles by 2 borders) repeated measures analysis of variance (rm-ANOVA), whereas the effect of knee angle on isometry and total area changes was assessed using one-way rm-ANOVAs (α=0.05). There was a significant increase in the length of the anterior capsulo-osseous layer at flexion angles greater than 15o and on the posterior border at angles greater than 75 o with changes occurring primarily at 12.5 % of the total length. In addition, at all flexion angles the length changes were significantly larger in the anterior border compared to the posterior border. Meanwhile, non-homogenous decreases in width and area were found with increasing flexion angle. The distance between the capsulo-osseous layer insertion on the distal femur and proximal tibia significantly increased from 60o-105o, maximal changes occurred at 105o (9.64 [4.12] %, p = 0.003). The primary finding of this study was that the coITB behaved in a non-isometric fashion, with significant increases in length occurring at flexion angles greater than 15o. Moreover, these changes in length were non-homogenous across the different regions of the coITB that were investigated, with the greatest changes occurring in the proximal segments (0–25%). The data presented here suggest that coITB in flexion angles from 0o to 105o behaves in a non-isometric fashion, with the majority of its length change occurring in its proximal segment. Further quantification of the pathway that the coITB takes with respect to osseous landmarks may result in improvements in ALC procedures as an augmentation to ACL reconstruction, thereby potentially improving rotational stability and clinical outcomes

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

Introduction. This biomechanics investigation evaluated commercially available studded and bladed football boots to determine whether boot type influences potential non-contact ACL injury when football players sidestep cut. Methods. Fifteen professional outfield male football players, without history of lower limb injury, with at least two consecutive injury-free seasons participated. Each undertook three trials of a straight line run and sidestep cuts at 30° and 60° with approach velocity 5.5ms. -1. - 6.0ms. -1. on a FIFA (Fédération Internationale de Football Association) approved artificial football surface. Four pairs of standardised football boots (two bladed and two studded) were investigated. Using 3D inverse dynamics analyses based on an eight camera gait analysis system (120Hz) synchronised with a force platform (960Hz), peak absolute knee internal tibial rotational moments (M. z. ), valgus moments (M. y. ) and anterior joint forces (F. x. ) were determined throughout the stance phase. Values were compared with cadaveric critical limits for ACL injury. A univariate repeated measures ANOVA quantified differences between the variables as a function of cutting angle and boot type. Results. Comparisons between the investigated boots revealed M. z. , M. y. and F. x. were similar for each manoeuvre. Straight line running using studded and bladed boots was associated with M. z. , M. y. and F. x. insufficient for cadaveric injury. Sidestep cutting using studded and bladed boots resulted in M. z. and M. y. significantly greater than during straight line running (p < 0.001), M. z. and F. x. exceeding critical limits and M. y. values which did not. Conclusion. The boot type did not significantly alter potential non-contact ACL injury based on cadaveric critical limits. Sidestep cutting using studded and bladed football boots resulted in M. z. and F. x. sufficient for non-contact ACL injury. Sidestep cutting, when compared to straight line running, may influence potential non-contact ACL injury more than the boot type used by altering knee joint loading to a greater extent