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.

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

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

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

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Aims

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

Aims

To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes.

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.

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There is little evidence examining the relationship between anatomical landmarks, radiological placement of the tunnels and long-term clinical outcomes following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate the reproducibility of intra-operative landmarks for placement of the tunnels in single-bundle reconstruction of the ACL using four-strand hamstring tendon autografts.

Isolated reconstruction of the ACL was performed in 200 patients, who were followed prospectively for seven years with use of the International Knee Documentation Committee forms and radiographs. Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel was a mean of 86% (sd 5) along Blumensaat’s line and the tibial tunnel was 48% (sd 5) along the tibial plateau. Taking 0% as the medial and 100% as the lateral extent, the tibial tunnel was 46% (sd 3) across the tibial plateau and the mean inclination of the graft in the coronal plane was 19° (sd 5.5).

The use of intra-operative landmarks resulted in reproducible placement of the tunnels and an excellent clinical outcome seven years after operation. Vertical inclination was associated with increased rotational instability and degenerative radiological changes, while rupture of the graft was associated with posterior placement of the tibial tunnel. If the osseous tunnels are correctly placed, single-bundle reconstruction of the ACL adequately controls both anteroposterior and rotational instability.

We examined the association of graft type with the risk of early revision of primary anterior cruciate ligament reconstruction (ACLR) in a community-based sample. A retrospective analysis of a cohort of 9817 ACLRs recorded in an ACLR Registry was performed. Patients were included if they underwent primary ACLR with bone–patellar tendon–bone autograft, hamstring tendon autograft or allograft tissue. Aseptic failure was the main endpoint of the study. After adjusting for age, gender, ethnicity, and body mass index, allografts had a 3.02 times (95% confidence interval (CI) 1.93 to 4.72) higher risk of aseptic revision than bone–patellar tendon–bone autografts (p < 0.001). Hamstring tendon autografts had a 1.82 times (95% CI 1.10 to 3.00) higher risk of revision compared with bone–patellar tendon–bone autografts (p = 0.019). For each year increase in age, the risk of revision decreased by 7% (95% CI 5 to 9). In gender-specific analyses a 2.26 times (95% CI 1.15 to 4.44) increased risk of hamstring tendon autograft revision in females was observed compared with bone–patellar tendon–bone autograft. We conclude that allograft tissue, hamstring tendon autografts, and younger age may all increase the risk of early revision surgery after ACLR.

Cite this article: Bone Joint J 2013;95-B:623–8.

We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 (sd 14) of a possible 100 points. Regular participation in moderate to strenuous activities was possible for only seven patients pre-operatively; this increased to 23 patients post-operatively. The mean Lysholm score improved from 64 (sd 15) to 90 (sd 14) at ten years (p = 0.001).

At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament.

This procedure for symptomatic patients with posterior cruciate ligament laxity who have failed conservative management offers good results.

The aim of this review is to address controversies in the management of dislocations of the acromioclavicular joint. Current evidence suggests that operative rather than non-operative treatment of Rockwood grade III dislocations results in better cosmetic and radiological results, similar functional outcomes and longer time off work. Early surgery results in better functional and radiological outcomes with a reduced risk of infection and loss of reduction compared with delayed surgery.

Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Although non-controlled studies report promising results for arthroscopic coracoclavicular fixation, there are no comparative studies with open techniques to draw conclusions about the best surgical approach. Non-rigid coracoclavicular fixation with tendon graft or synthetic materials, or rigid acromioclavicular fixation with a hook plate, is preferable to fixation with coracoclavicular screws owing to significant risks of loosening and breakage.

The evidence, although limited, also suggests that anatomical ligament reconstruction with autograft or certain synthetic grafts may have better outcomes than non-anatomical transfer of the coracoacromial ligament. It has been suggested that this is due to better restoration horizontal and vertical stability of the joint.

Despite the large number of recently published studies, there remains a lack of high-quality evidence, making it difficult to draw firm conclusions regarding these controversial issues.

Cite this article: Bone Joint J 2013;95-B:1595–1602.