Anterior Cruciate Ligament Lesions Research Articles

Underutilization of coper/non-coper screening in anterior cruciate ligament injuries management in Italy: an online survey

IntroductionTotal and sub-total lesions of the anterior cruciate ligament (ACL) are one of the most frequent and performance-limiting injuries to the knee joint within the active population. Early surgical management, often regarded as the primary management strategy, has recently been shown to have similar outcomes when compared with an initial rehabilitative approach followed by surgical ACL reconstruction if higher levels of functionality are needed. The primary objective of the study was to investigate the physiotherapists and orthopedic surgeons’ “coper/non-coper” screening application in the clinical management of the patient after ACL injury. Second, the authors aimed to investigate the cooperation between physiotherapists and orthopedic surgeons when dealing with patients with ACL injuries.MethodsAn online survey consisting of 12 questions on the clinical practice of the surveyed physiotherapists (n = 803) and orthopedic surgeons (n = 201), and the relation between these healthcare professionals, was distributed. The answers were stratified depending on clinical experience in dealing with ACL injuries.ResultsBoth physiotherapists and orthopedic surgeons showed a low degree of confidence and application of the “coper/non-coper” screening when managing ACL lesions. The sub-population of ACL experts reported a good level of interprofessional interaction. Nevertheless, an updated level of knowledge regarding the recent evidence on the non-surgical management of ACL lesions is still lacking.ConclusionsThe study findings indicate the need to improve the collaboration between Italian physiotherapists and orthopedic surgeons as well as their knowledge of the non-surgical approaches to ACL lesions.

Changes in the Elongation Pattern of the Medial Collateral Ligament During a Single-Leg Squat After Anterior Cruciate Ligament Reconstruction.

An anterior cruciate ligament (ACL) tear impairs knee biomechanics in daily activities and potentially breaks the synergy among other knee ligaments. Previous studies have demonstrated that the biomechanics of collateral ligaments is influenced by ACL deficiency. To investigate changes in the elongation patterns of the medial collateral ligament (MCL), lateral collateral ligament (LCL), and posterior cruciate ligament (PCL) during the execution of a single-leg squat before and after ACL reconstruction. Descriptive laboratory study. A total of 16 patients (mean age, 24.9 ± 8.5 years) with ACL deficiency were enrolled in the study. Magnetic resonance imaging scans of the affected knees were used to produce 3-dimensional models of the tibia and femur and identify insertion sites of the MCL, LCL, and PCL. Motion capture of a single-leg squat was performed through a biplanar radiographic system. Data were acquired before ACL reconstruction and at a minimum of 18 months (mean, 22.9 ± 4.1 months) postoperatively. The centroids of the ligaments' insertions were used to calculate the length of the investigated structures during the squat task. Absolute length (L), absolute length increase from the orthostatic resting position (ΔL), and relative length increase (ΔL%) were computed for each ligament, and preoperative and postoperative data were compared using the paired Student t test. The intraclass correlation coefficient was used to determine the reliability of the ligament insertion's identification and kinematics between 2 independent observers. Significant differences were found for the MCL in absolute length increase (P = .047; Cohen d = 0.60) and relative length increase (P = .043; Cohen d = 0.61) from rest between preoperatively and postoperatively (ΔL pre = 1.0 mm; ΔL post = -1.1 mm; difference = 2.1 mm) at 0° to 30° of knee flexion during the descending phase of the single-leg squat. No differences were seen in the elongation patterns of the LCL or PCL from before to after ACL reconstruction. The MCL was significantly longer between 0° and 30° in ACL-deficient knees compared with ACL-reconstructed knees during the descending phase of a single-leg squat. No differences were identified for the LCL or PCL. Early ACL reconstruction could have a protective effect on the MCL in combined ACL and MCL lesions.

Younger age, longer delay to surgery and meniscal tears are associated with a smaller ACL remnant: An analysis from the registry of the Francophone Arthroscopic Society

AbstractPurposeThis study aimed to evaluate which preoperative patient, injury or clinical factors were associated with the anterior cruciate ligament (ACL) remnant volume in patients undergoing ACL surgery. It was hypothesized that the main factors determining an insufficient ACL remnant volume at the time of surgery were younger age and longer time to surgery.MethodsA retrospective analysis from the Francophone Arthroscopic Society's registry was conducted, including 1565 patients with an ACL lesion underdoing a primary ACL surgery (reconstruction or repair) between June 2020 and June 2023. Patients were excluded in case of revision surgery and incomplete data. Preoperative factors—including patient demographics, delay to surgery, preoperative laxity and the presence of meniscal tears or cartilage lesions—were analysed to determine their influence on ACL remnant volume (estimated by the surgeon as the percentage of residual volume). Univariate, multivariate and receiver operating characteristic curve analyses were performed to explore these relationships.ResultsMultivariate analyses demonstrated that younger age (<20 years and 20–30 years compared to ≥40, p = 0.02), higher time from injury to surgery (≥12 months compared to <3 months, p = 0.01) and the presence of a medial (p = 0.01) or a lateral meniscal tear (p = 0.02) were significant predictors of an ACL remnant volume ≤ 50%.ConclusionsYounger age (under 30 years of age), a time from injury to surgery above 12 months and the presence of medial and lateral meniscal tears are associated with higher odds of observing a smaller ACL remnant volume at the time of the ACL surgery. These factors should be considered when planning ACL remnant preservation techniques.Level of evidenceLevel III.

Magnetic Resonance Imaging Features and Functional Score in Patients Requiring Total Knee Arthroplasty.

Introduction Knee osteoarthritis (KOA) is a progressive degenerative disease, with an increasing prevalence among the population. The degenerative changes in KOA affect the cartilage, menisci, synovial tissue, and subchondral bone. The treatment for patients in advanced stages of the disease is total knee arthroplasty (TKA). The purpose of this descriptive study is to identify the MRI features in the case of patients with KOA who did not obtain an improvement in symptoms and joint function after the non-surgical treatmentsand who applied for surgical treatment, i.e. TKA. Also, we aimed to identify the correlations between the MRI changes and the functional score of the patients, as well as the inter-variable correlations. Materials and methods The study was conducted in the Department of Orthopedics and Traumatology at the University Emergency Hospital of Bucharest between January 1, 2023, and January 31, 2024. It included 50 patients who required TKA. This study is a prospective, observational, and descriptive analysis focusing on patients scheduled for TKA. Results The patients in the study group who required TKA had a Knee Society Score (KSS) ranging from 35 to 70and a KSS function score between 24 and 60. Among them, 98% had tricompartmental lesions of the articular cartilage, and 100% presented with osteophytes, even when they were not identifiable radiologically. Additionally, 58% of the patients had changes in the infrapatellar fat pad, 66% presented with joint effusion without any traumatic history, and 86% of the patients had partial or complete lesions of the anterior cruciate ligament. Conclusion TheMRI pattern of the patient who requires TKA consists of the presence of articular cartilage lesions in more than two compartments with exposure of the subchondral bone and diameter greater than 1 cm, meniscus lesions (>grade 2), meniscus extrusion (>grade 1), the presence of bone marrow lesions (BMLs) in the medial or lateral compartment of the femur or tibia, hyperintense signal of the infrapatellar fat pad, anterior cruciate ligament (ACL) lesions (>grade 2), and the presence of osteophytes together with the presence of effusion in the suprapatellar bursa. BMLs and changes in the infrapatellar fat pad may lead to the opening of new research perspectives explaining the complex changes in KOA in relation to the inflammatory process and gene expression.

Commitment of human mesenchymal stromal cells towards ACL fibroblast differentiation upon rAAV-mediated FGF-2 and TGF-β overexpression using pNaSS-grafted PCL films.

Despite various clinical options, human anterior cruciate ligament (ACL) lesions do not fully heal. Biomaterial-guided gene therapy using recombinant adeno-associated virus (rAAV) vectors may improve the intrinsic mechanisms of ACL repair. Here, we examined whether poly(sodium styrene sulfonate)-grafted poly(ε-caprolactone) (pNaSS-grafted PCL) films can deliver rAAV vectors coding for the reparative basic fibroblast growth factor (FGF-2) and transforming growth factor beta (TGF-β) in human mesenchymal stromal cells (hMSCs) as a source of implantable cells in ACL lesions. Efficient and sustained rAAV-mediated reporter (red fluorescent protein) and therapeutic (FGF-2andTGF-β) gene overexpression was achieved in the cells for at least 21 days in particular with pNaSS-grafted PCL films relative to all other conditions (up to 5.2-fold difference). Expression of FGF-2 and TGF-β mediated by rAAV using PCL films increased the levels of cell proliferation, the DNA contents, and the deposition of proteoglycans and of type-I and -III collagen (up to 2.9-fold difference) over time in the cells with higher levels of transcription factor expression (Mohawk, Scleraxis) (up to 1.9-fold difference), without activation of inflammatorytumor necrosis alpha especially when using pNaSS-grafted PCL films compared with the controls. Overall, the effects mediated by TGF-β were higher than those promoted by FGF-2, possibly due to higher levels of gene expression achieved upon rAAV gene transfer. This study shows the potential of using functionalized PCL films to apply rAAV vectors for ACL repair.

Kinematics but not kinetics alterations to single-leg drop jump movements following a subject-tailored fatiguing protocol suggest an increased risk of ACL injury.

Neuromuscular fatigue causes a transient reduction of muscle force, and alters the mechanisms of motor control. Whether these alterations increase the risk of anterior cruciate ligament (ACL) injury is still debated. Here we compare the biomechanics of single-leg drop jumps before and after the execution of a fatiguing exercise, evaluating whether this exercise causes biomechanical alterations typically associated with an increased risk of ACL lesion. The intensity of the fatiguing protocol was tailored to the aerobic capacity of each participant, minimizing potential differential effects due to inter-individual variability in fitness. Twenty-four healthy male volunteers performed single leg drop jumps, before and after a single-set fatiguing session on a cycle ergometer until exhaustion (cadence: 65-70 revolutions per minute). For each participant, the intensity of the fatiguing exercise was set to 110% of the power achieved at their anaerobic threshold, previously identified by means of a cardiopulmonary exercise test. Joint angles and moments, as well as ground reaction forces (GRF) before and after the fatiguing exercise were compared for both the dominant and the non-dominant leg. Following the fatiguing exercise, the hip joint was more extended (landing: Δ=-2.17°, p = 0.005; propulsion: Δ=-1.83°, p = 0.032) and more abducted (landing: Δ=-0.72°, p = 0.01; propulsion: Δ=-1.12°, p = 0.009). Similarly, the knee joint was more extended at landing (non-dominant leg: Δ=-2.67°, p < 0.001; dominant: Δ=-1.4°, p = 0.023), and more abducted at propulsion (both legs: Δ=-0.99°, p < 0.001) and stabilization (both legs: Δ=-1.71°, p < 0.001) hence increasing knee valgus. Fatigue also caused a significant reduction of vertical GRF upon landing (Δ=-0.21 N/kg, p = 0.003), but not during propulsion. Fatigue did not affect joint moments significantly. The increased hip and knee extension, as well as the increased knee abduction we observed after the execution of the fatiguing exercise have been previously identified as risk factors for ACL injury. These results therefore suggest an increased risk of ACL injury after the execution of the participant-tailored fatiguing protocol proposed here. However, the reduced vertical GRF upon landing and the preservation of joint moments are intriguing, as they may suggest the adoption of protective strategies in the fatigued condition to be evaluated in future studied.

Externally validated treatment algorithm acceptably predicts nonoperative treatment success in patients with anterior cruciate ligament rupture.

This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture. Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression modeland then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness-of-fit were assessed and externally validated by discrimination and calibration measures. In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift testand the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58-0.81) and 0.68 (95% CI: 0.58-0.78). This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further. Level II.

Dynamic radiostereometry can objectively quantify the kinematic laxity patterns and rotation instability of the knee during a pivot-shift test.

The pivot-shift test is used to clinically assess knee instability in patients with anterior cruciate ligament (ACL) lesions; however, it has low interobserver reliability. Dynamic radiostereometry (dRSA) is a highly precise and noninvasive method for the objective evaluation of joint kinematics. The purpose of this study was to quantify precise knee kinematics during a pivot-shift test using dRSA imaging. Eight human donor legs, including hemipelvises, were evaluated. Arthroscopic intervention was performed inducing ligament lesions in the ACL, and anterolateral ligament (ALL) section was performed as a capsular incision. The pivot-shift test was recorded with dRSA on knees with intact ligaments, ACL-deficient and ACL + ALL-deficient knees. A pivot-shift pattern was identifiable after ligament lesion, as a change in tibial posterior drawer velocity from 7.8 mm/s (95% CI: 3.7; 11.9) in ligament intact knees to 30.4 mm/s (95% CI 23.0; 38.8) after ACL lesionto 35.1 mm/s (95% CI 23.4; 46.7) after combined ACL-ALL lesion. The anterior-posterior drawer excursion increased from 2.8 mm (95% CI 2.1; 3.4) in ligament intact kneesto 7.2 mm (95% CI 5.5; 8.9) after ACL lesionto 7.6 mm (95% CI 5.5; 9.8) after combined lesion. A statistically significant increase in tibial external rotation towards the end of the pivot-shift motion was observed when progressing from intact to ACL + ALL-deficient knees (p < 0.023). This experimental study demonstrates the feasibility of dRSA to objectively quantify the kinematic laxity patterns of the knee during the pivot-shift test. The dynamic parameters obtained through dRSA revealed the kinematic changes from ACL to combined ACL-ALL ligament lesion. Not applicable.

Italian research on anterior cruciate ligament: a bibliometric analysis.

This study analysed thetrend of publications on anterior cruciate ligament(ACL) in Italy. It was hypothesised that publications on this topic have quickly increased in recent years due to increased knowledge of both clinical and radiological pathology. PubMed and Scopus were accessed on 29/11/2023. This retrieved 838 articles from PubMed and 1050 from Scopus. We analysed the top 10 authors, and journals in publication numbers, citation numbers, and citations per year. We have also looked at the top 10 institutions publishing on anterior cruciate ligament from Scopus as PubMed does not give this information in the output. Data mining was performed using the Orange software, Mac version 3.32.0 ( https://orangedatamining.com/ ) from the titles of all articles. A word cloud analysis of titles, authors, journals and universities was performed. The peak of citations was in 2017 with 1529, whilst the peak of publications was in 2019 with 59 articles published. Analysing the number of publications and citations for the journal, the most impacted journal is Knee Surgery, Sports Traumatology, Arthroscopy with 5472 citations and 183 articles, followed by The American Journal of Sports Medicine, with 2722 citations and 56 articles and Arthroscopy with 1990 citations and 62 articles. Considering also international collaborations, the most cited author is Della Villa F. in 2020 with 43.67 citationsper year.The Italian author with the major number of publications is Zaffagnini S. with 39 articles, whilst the author with the higher number of citations is Aglietti P. with 1612 citations. ACL reconstruction has gained growing interest amongst the scientific community. Publications and citations presented a rising trend, the majority of the highly cited papers were contributed by few centres, and clinical trials were the most cited study designs. The long-term outcomes of ACL lesions have attracted interest. The authors hypothesised that shortly there will be an increase in articles analysing the results of ACL revisions, the use of lateral extra-articular tenodesis, and meniscus transplants. Cross-Sectional Study.

Magnetic resonance imaging combined with histological evaluation of repair process using the microfracture technique in an association of osteocartilaginous and meniscal surgically induced lesions of the knee. In vivo experiment on a rabbit model.

The present research study aimed to assess magnetic resonance imaging (MRI) changes and histological findings in the therapeutic effects of microfractures in the treatment of complex animal knee lesions resulting from osteochondral and meniscal defects resulting from non-total meniscectomies. The anterior cruciate ligament lesions are also proven to facilitate the development of osteoarthritis in the knee and worsen the prognosis. Surgery was performed on the right knee joint of 22 male rabbits in order to partially remove the anterior horn of the internal meniscus and to induce an osteochondral defect at the level of the internal femoral condyle. The induced lesion complex was aimed to simulate a clinical situation that occurs frequently in orthopedic practice when young adults undergo partial meniscectomy and at the time of surgery, an osteochondral defect is diagnosed. Rabbits were separated into two study groups: the control (C1) group and the microfractures (MF2) group. After the induced cartilage defect and partial meniscectomy, both groups were followed-up for six months using detailed MRI. Also, anatomical specimens were histologically analyzed to show modifications and signs of healing process, along with complications, in the study group. The results showed that the microfracture group had better results concerning articular surface defect healing in comparison to the control group. Our results suggest that microfractures do improve results concerning surface contact healing and serial MRI studies can be useful in observing the remodeling process in dynamics.

Reliability and validity of the Lever Sign Test in suspected ligament and/or meniscus injuries of the knee: a comparison between an orthopaedist and a physical therapist

The purpose of this study was to investigate the intertester reliability and validity of the Lever Sign Test. Intertester reliability has received little attention in previous studies. In order to make comparisons with other studies, the intertester reliability and validity of the Lachman and Anterior Drawer Tests were also calculated. Patients between 18 and 50 years of age with suspected ligament and/or meniscus injuries were included. Exclusion criteria were suspected malignant, systemic, or central neurologic disease, acute cartilage injury, suspected fracture, or knowledge of the participant's knee findings. Testing was randomized and blinded by an experienced orthopaedic surgeon and a physical therapist. Cohen's kappa was calculated for intertester reliability. Sensitivity and specificity, positive and negative predictive value, and positive and negative likelihood ratio were calculated. MRI findings were used as the gold standard. Thirty-six patients were enrolled in the study, 27 male (75%) and 9 female (25%). The prevalence of anterior cruciate ligament lesions was 44.4%. Cohen's kappa (κ) was κ=0.6 (CI 95% [0.29, 0.91]) for the Lever Sign Test, κ=0.64 (CI 95% [0.35, 0.93]) for the Lachman test, and κ=0.63 (CI 95% [0.3, 0.95]) for the Anterior Drawer Test. The sensitivity of the Lever Sign Test was 0.53 and 0.40 for the orthopaedic surgeon and physical therapist, respectively, specificity was 0.89 and 0.79, the positive predictive value was 0.80 and 0.60, the negative predictive value was 0.70 and 0.62, the positive likelihood ratio was 4.80 and 1.90, respectively, and the negative likelihood ratio was 0.76 and 0.53. The estimated intertester reliability of the Lever Sign Test was good. The Lever Sign Test is suitable as a complement to the Lachman Test, which is considered the most valid test in the literature. The weaknesses and ambiguities of the operating mechanism of the Lever Sign Test should not be ignored and should be further explored.

OBJECTIVELY MEASURED KNEE INSTABILITY DURING PIVOT-SHIFT TEST: AN EXPERIMENTAL DYNAMIC RSA STUDY

The Pivot-shift test is a clinical test for knee instability for patinets with Anterior cruciate ligament (ACL), however the test has low inter-observer reliability. Dynamic radiostereometry (dRSA) imaging is a highly precise method for objective evaluation of joint kinematics. The purpose of the study was to quantify precise knee kinematics during Pivot-shift test by use of the non-invasive dynamic RSA imaging.Eight human donor legs with hemipelvis were evaluated. Ligament lesion intervention of the ACL was performed during arthroscopy and anterolateral ligament (ALL) section was performed as a capsular incision. Pivot-shift test examination was recorded with dRSA on ligament intact knees, ACL-deficient knees and ACL+ALL-deficient knees.A Pivot-shift pattern was identifyable after ligament lesion as a change in tibial posterior drawer velocity from 7.8 mm/s in ligament intact knees, to 30.4 mm/s after ACL lesion, to 35.1 mm/s after combined ACL-ALL lesion. The anterior-posterior drawer excursion increased from 2.8 mm in ligament intact knees, to 7.2 mm after ACL lesion, to 7.6 mm after combined lesion. Furthermore a change in tibial rotation was found, with increasing external rotation at the end of the pivot-shift motion going from intact to ACL+ALL-deficient kneesThis experimental study demonstrates the feasibility of RSA to objectively quantify the kinematic instability patterns of the knee during the Pivot-shift test. The dynamic parameters found through RSA displayed the kinematic changes from ACL to combined ACL-ALL ligament lesion.

PATIENTS WITH KNEE OSTEOARTHRITIS CAN BE DIVIDED INTO SUBGROUPS BASED ON TIBIOFEMORAL JOINT KINEMATIC CLUSTERING OF GAIT: AN EXPLORATORY AND DYNAMIC RADIOSTEREOMETRIC STUDY

In an attempt to alleviate symptoms of the disease, patients with knee osteoarthrosis (KOA) frequently alter their gait patterns. Understanding the underlying pathomechanics and identifying KOA phenotypes is essential for improving treatments. We aimed to investigate altered kinematics in patients with KOA to identify subgroups.Sixty-six patients with symptomatic KOA scheduled for total knee arthroplasty and 12 age-matched healthy volunteers with asymptomatic knees were included. We used k-means to separate the patients based on dynamic radiostereometric assessed knee kinematics. Ligament lesions, KOA score, and clinical outcome were assessed by magnetic resonance imaging, radiographs, and patient reported outcome measures, respectively.We identified four clusters that were supported by clinical characteristics. Compared with the healthy group; The flexion group (n=20): revealed increased flexion, greater adduction, and joint narrowing and consisted primarily of patients with medial KOA. The abduction group (n=17): revealed greater abduction, joint narrowing and included primarily patients with lateral KOA. The anterior draw group (n=10): revealed greater anterior draw, external tibial rotation, lateral tibial shift, adduction, and joint narrowing. This group was composed of patients with medial KOA, some degree of anterior cruciate ligament lesion and the greatest KOA score. The external rotation group (n=19): revealed greater external tibial rotation, lateral tibial shift, adduction, and joint narrowing while no anterior draw was observed. This group included primarily patients with medial collateral and posterior cruciate ligament lesions.Patients with KOA can, based on their gait patterns, be classified into four subgroups, which relate to their clinical characteristics. The findings add to our understanding of associations between disease pathology characteristics in the knee and the pathomechanics in patients with KOA. A next step is to investigate if patients in the pathomechanic clusters have different outcomes following total knee arthroplasty.

Anterior Cruciate Ligament Reconstruction Using a 4-Strand Semitendinosus Tendon Graft or a Doubled Semitendinosus and Gracilis Tendon Graft: A 4.5-Year Prospective, Randomized, Double-Blind, Parallel-Group Study

Background: Hamstring tendon grafts are the most common choice for anterior cruciate ligament (ACL) reconstruction (ACLR). Previous studies have provided evidence that offers conflicting opinions concerning the most favorable graft choice. Purpose: To identify whether the use of a quadrupled semitendinosus tendon (ST) or doubled semitendinosus tendon and gracilis tendon (ST/G) graft provides comparable anterior tibial translation (ATT) with similar functional results and similar donor site morbidity. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a prospective, patient- and surgeon-blinded, randomized trial set in a busy orthopaedic and traumatology department at a university hospital. Between 2015 and 2017, a total of 162 patients with ACL lesions were randomized to undergo ACLR with either a quadrupled ST or doubled ST/G graft. The primary endpoint was ATT assessed with the KT-1000 arthrometer. Clinical outcomes were assessed using the patient-reported outcome measures (PROMs) of the visual analog scale (VAS), International Knee Documentation Committee (IKDC) subjective evaluation form, Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, and Lysholm knee scoring scale. Results: Preoperative demographic data, ATT, and PROM scores showed no significant differences. At 4.5 years, no significant differences were found between the ST and ST/G groups with respect to PROM scores and KT-1000 arthrometer, Lachman test, and pivot-shift test findings. Differences in functional results between groups were significant (muscle strength). Subgroup analysis revealed significantly increased ATT in female patients undergoing ACLR with a quadrupled ST graft during the 4.5-year observation period, as assessed by the KT-1000 arthrometer, as well as inferior KOOS, IKDC, Lysholm, and VAS scores. Conclusion: This study showed a significant increase in ATT as well as inferior results on PROMs during a 4.5-year observation period in female patients undergoing ACLR with a quadrupled ST graft. In male patients, the study provided evidence of the noninferiority of ACLR with an ST graft, with no influence on donor site morbidity. Trial Registration: clinicaltrials.gov: NCT03626883

Advanced Gene Therapy Strategies for the Repair of ACL Injuries.

The anterior cruciate ligament (ACL), the principal ligament for stabilization of the knee, is highly predisposed to injury in the human population. As a result of its poor intrinsic healing capacities, surgical intervention is generally necessary to repair ACL lesions, yet the outcomes are never fully satisfactory in terms of long-lasting, complete, and safe repair. Gene therapy, based on the transfer of therapeutic genetic sequences via a gene vector, is a potent tool to durably and adeptly enhance the processes of ACL repair and has been reported for its workability in various experimental models relevant to ACL injuries in vitro, in situ, and in vivo. As critical hurdles to the effective and safe translation of gene therapy for clinical applications still remain, including physiological barriers and host immune responses, biomaterial-guided gene therapy inspired by drug delivery systems has been further developed to protect and improve the classical procedures of gene transfer in the future treatment of ACL injuries in patients, as critically presented here.

Smart Brace for Static and Dynamic Knee Laxity Measurement.

Every year in Europe more than 500 thousand injuries that involve the anterior cruciate ligament (ACL) are diagnosed. The ACL is one of the main restraints within the human knee, focused on stabilizing the joint and controlling the relative movement between the tibia and femur under mechanical stress (i.e., laxity). Ligament laxity measurement is clinically valuable for diagnosing ACL injury and comparing possible outcomes of surgical procedures. In general, knee laxity assessment is manually performed and provides information to clinicians which is mainly subjective. Only recently quantitative assessment of knee laxity through instrumental approaches has been introduced and become a fundamental asset in clinical practice. However, the current solutions provide only partial information about either static or dynamic laxity. To support a multiparametric approach using a single device, an innovative smart knee brace for knee laxity evaluation was developed. Equipped with stretchable strain sensors and inertial measurement units (IMUs), the wearable system was designed to provide quantitative information concerning the drawer, Lachman, and pivot shift tests. We specifically characterized IMUs by using a reference sensor. Applying the Bland–Altman method, the limit of agreement was found to be less than 0.06 m/s2 for the accelerometer, 0.06 rad/s for the gyroscope and 0.08 μT for the magnetometer. By using an appropriate characterizing setup, the average gauge factor of the three strain sensors was 2.169. Finally, we realized a pilot study to compare the outcomes with a marker-based optoelectronic stereophotogrammetric system to verify the validity of the designed system. The preliminary findings for the capability of the system to discriminate possible ACL lesions are encouraging; in fact, the smart brace could be an effective support for an objective and quantitative diagnosis of ACL tear by supporting the simultaneous assessment of both rotational and translational laxity. To obtain reliable information about the real effectiveness of the system, further clinical validation is necessary.

Meniscal Tear Management Associated with ACL Reconstruction

Meniscal lesions often occur in association with anterior cruciate ligament (ACL) tears at the moment of the injury or, secondarily, as a consequence of knee instability. Both ACL and meniscus lesions are associated with a higher risk of osteoarthritis. Adequate treatment of these lesions reduces the rate of degenerative changes in the affected knee. Meniscal tears should be addressed concomitantly with ACL reconstruction and the treatment must be oriented towards preserving the meniscal tissue anytime this is possible. Several options for approaching a meniscus tear are available. The meniscal suture should always be considered, and, if possible, meniscectomy should be the last choice. “Masterly neglect” is a valuable option in selected cases.

High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings.

Anterior cruciate ligament (ACL) ruptures are considered high burden injuries in sports with high pivotal activity, especially for professional footballers. A lack of evidence exists about long-term follow up of professional elite athletes who underwent ACL reconstruction. The purpose of the study is to analyze the return to play and the career of professional footballers who underwent ACL reconstruction with hamstrings, to evaluate re-rupture and reoperation at either indexed and contralateral knee, and to assess the long-term clinical subjective outcomes and satisfaction. Twenty-eight professional footballers that underwent 33 ACL reconstructions were retrospectively included in the study. All surgical interventions were performed using hamstring tendons graft and an over the top technique. Inclusion criteria were: inability to compete due to joint instability caused by total or subtotal ACL lesion, patients contracted to a professional football team at time of surgery. Exclusion criteria were: multi-ligament reconstruction or concomitant meniscal allograft transplantation. Patients were contacted by phone and a brief questionnaire about surgery was administered. Subsequently, a Lysholm knee scoring scale was obtained. After that, an online research was performed on publicly available websites in order to retrieve information of the patients included after surgery. In all cases, ACL Reconstruction was performed with hamstring tendons using a non-anatomic Double-Bundle technique in 16 cases (49%), an Over-The-Top Single-Bundle technique in 9 cases (27%), and an Over-The-Top Single-Bundle plus Lateral Plasty technique in 8 cases (24%); moreover, a meniscal lesion was present in 20 cases (61%). Three (9%) of the 33 ACL reconstruction failed (2/16 Double-Bundle, 1/9 Single- Bundle, 0/8 Single-Bundle + Lateral Plasty; p = n.s.), with two of them within 12months from surgery. Other procedures, mainly arthroscopic meniscectomies, were performed in 10 cases (30%). The first official match was played after an average of 8.0 ± 3.6 (4.6-18.2) months in 31 cases (94%). Patients were evaluated after 12.6 ± 3.3years (6.7-17.5) from the indexed ACL reconstruction. The average Lysholm score was 94.2 ± 8.3. In our small case-series, professional soccer players were able to return to play at a competitive level with a hamstrings over the top technique. Patients with long careers had a high percentage of reoperation on the contralateral knee. IV.

Ultrasound Imaging of the Anterior Cruciate Ligament: A Pictorial Essay and Narrative Review.

Ultrasound has been extensively applied to the diagnosis of and guided interventions for knee disorders. However, although it is commonly affected during sports injuries, the anterior cruciate ligament (ACL) is not usually incorporated in the majority of ultrasound scanning protocols. In the past, because of its oblique trajectory and deeper location, the ACL was considered to be a challenging structure for ultrasound imaging. Owing to advances in ultrasound technology and knowledge of knee sono-anatomy, an increasing number of studies are investigating the clinical value of ultrasound in the diagnosis and management of ACL injuries. In this regard, the present review aims to elaborate on the sono-anatomy of the ACL, to summarize the evidence for ultrasound imaging for ACL lesions and to investigate whether it is useful in the pre-operative preparation and post-operative follow-up of ACL reconstruction.

Efficiency of platelet-rich plasma therapy for healing sports injuries in young athletes.

In recent years, platelet-rich plasma (PRP) therapy has been a subject of controversy in orthopedics field. Our objective was to assess the efficiency of PRP therapy for patients who have suffered grade 2 meniscal lesions and grade 2 anterior cruciate ligament (ACL) lesions, graded by magnetic resonance imaging (MRI). A retrospective observational study was conducted, which included 72 young recreational athletes who had been diagnosed with grade 2 meniscal injury, graded using MRI, that benefited from PRP therapy as an enhancement of the primary treatment, after cast immobilization. The Lysholm score, the pain intensity and the resuming of the physical activity before the PRP treatment and one month after were analyzed. Our study revealed that patients had an improved subjective perception of pain after PRP therapy and an improvement of the Lysholm score. Concurrently, 83.3% of patients could return to sports and daily physical activity. It can be concluded that PRP therapy is a safe, easy to manage treatment, efficient for pain relief and in resuming of sports activities for young recreational athletes who have sustained partial meniscal or ACL tears. In terms of pain relief, it appears that the PRP therapy could be more efficient for young patients with ACL injuries.