Chronic ACL-deficient Knees Research Articles

Arthroscopic Evaluation of Association of Meniscus Injuries in Patients with Anterior Cruciate Ligament Injuries

Background: The knee joint's stability relies significantly on the integrity of the meniscus and the anterior cruciate ligament (ACL). Chronic ACL tears can compromise knee stability, making the meniscus a crucial stabilizer. Understanding the prevalence and patterns of meniscus injuries associated with chronic ACL tears is essential for effective management. Objective: This study aimed to assess the arthroscopic evaluation of association of meniscus injuries in patients with anterior cruciate ligament injuries. Method: A retrospective analysis was conducted on thirty-three patients diagnosed with ACL injuries at MuMCH between January 2021 and December 2023. Patients aged 18-50 with ACL injuries, with or without meniscus damage, were included. Clinical evaluations, knee MRI scans, and diagnostic knee arthroscopies were performed. The study evaluated meniscus injuries associated with chronic ACL injuries and assessed outcomes using the modified Lysholm score. Results: The study revealed a predominant occurrence of meniscus injuries (70%) among participants, with a majority falling within the 38-47 years age bracket (45.45%) and a male majority (60%). Sports and accidental injuries accounted for 40% each, while road traffic accidents contributed 20%. Lateral meniscus tears were the most prevalent (30.30%), followed by combined medial and lateral meniscus tears (33.33%). Posterior horn tears were predominant, particularly in the medial meniscus. Conclusion: The study highlights a high incidence of meniscus injuries associated with chronic ACL tears, with medial meniscus injuries prevailing over lateral tears. Posterior horn tears were predominant, emphasizing the medial meniscus's significant role in knee stability. These findings underscore the importance of early detection and appropriate management of meniscus injuries in chronic ACL-deficient knees to prevent degenerative changes and optimize patient outcomes.

Outcomes of Slope-Reducing Proximal Tibial Osteotomy Combined With a Third Anterior Cruciate Ligament Reconstruction Procedure With a Focus on Return to Impact Sports

Background: An increased posterior tibial slope (PTS) is a proven risk factor for both native anterior cruciate ligament (ACL) and ACL graft insufficiency. Anterior closing wedge high tibial osteotomy (ACW-HTO) for PTS correction is a validated procedure in revision ACL reconstruction (ACLR). Purpose/Hypothesis: The aim of this study was to evaluate the effect of combined ACW-HTO and at least a second revision ACLR procedure on knee stability, function, and sports performance in a large series of patients. The hypothesis was that patients would return to impact sports after ACW-HTO combined with a second or third revision ACLR procedure. Study Design: Case series; Level of evidence, 4. Methods: A total of 64 patients who underwent a second (or more) revision ACLR procedure and ACW-HTO between June 1, 2015, and June 1, 2019, and had a PTS >12° were included. The mean age was 29.60 ± 6.31 years, and the mean preoperative PTS was 13.79°± 1.50°. The cases were analyzed at a mean follow-up of 2.96 ± 0.83 years (range, 2-5 years). At the last follow-up, the rate of patients returning to impact sports (based on the University of California, Los Angeles [UCLA], activity scale), ACL graft status (per magnetic resonance imaging), International Knee Documentation Committee (IKDC) scores, Lysholm scores, and laxity measurements using a knee arthrometer were recorded. Results: The total number of patients participating in impact sports and high-impact sports was as follows: 43 and 30, respectively, before the injury; 0 and 0, respectively, preoperatively; and 31 and 12, respectively, postoperatively. At the last follow-up, the UCLA score was ≥8 in 48.44% of the patients, and only 16 patients returned to their preinjury level of activity. At a minimum of 2 years of follow-up, there was clinical improvement in the IKDC score from 37.98 ± 12.48 preoperatively to 69.06 ± 12.30 postoperatively (P < .0001), in the Lysholm score from 51.94 ± 14.03 preoperatively to 74.45 ± 11.44 postoperatively (P < .001), and in the UCLA score. However, this clinical improvement did not equate to preinjury values for all outcome scores (P < .001). The preinjury IKDC and Lysholm scores were 76.98 ± 11.71 and 89.26 ± 8.91, respectively. The mean change in anterior knee laxity using a knee arthrometer at 134 and 250 N was −4.03 ± 0.18 mm and −3.63 ± 0.16, respectively. There were 3 cases of a rerupture with a severe pivot shift on the clinical examination. None of these patients underwent revision per the patient's preference. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Conclusion: In the setting of chronic ACL-deficient knees, PTS reduction (ACW-HTO) with revision ACLR restored knee stability and improved function with an acceptable rate of specific complications. Increased knee recurvatum was observed in one-third of the patients, but all were asymptomatic. Also, approximately half of the patients were able to return to impact sports.

Association of Meniscus Injuries in Patients With Anterior Cruciate Ligament Injuries.

Introduction: In today's orthopaedic practice, meniscus and anterior cruciate ligament (ACL) injuries are prevalent. It is more common in sports injuries and automobile accidents. In patients with ACL tears, meniscus problems are also common. Several studies have linked meniscus injuries to the development of osteoarthritis in early stages. Early onset of osteoarthritis has been observed in ACL-repaired patients with meniscus tears. As a result, meniscus tears should be detected and corrected as soon as possible to avoid degenerative changes in the knee joint. The goal of the study was to see if there was a link between meniscus injuries and ACL injuries in our rural community.Methods: This retrospective study was conducted on 48 patients at the R.L. Jalappa Hospital & Research Centre from January 2012 to December 2019. Patients between the ages of 18-65 diagnosed with ACL tear with/without meniscus damage in their knees were included in the study. Patients with posterior cruciate ligament (PCL) tear, medial collateral ligament (MCL) or lateral collateral ligament (LCL) injury, previously operated index knees, and patients with more than grade 3 knee osteoarthritis (Kellgren and Lawrence classification) were excluded. Clinical assessment of patients with knee injuries, MRI and diagnostic arthroscopy of the knee joint details were collected. After obtaining the data, we estimated the incidence of meniscus injuries associated with chronic ACL injuries. We also calculated the percentage of side/laterality injury (medial meniscus or lateral meniscus) and part of meniscus injury (anterior horn, body, and posterior horn) in chronic ACL-deficient knees. Patient characteristics such as age and gender were correlated with functional knee assessment using a modified Lysholm score. P-value and chi-square tests were used to assess the data. P-value of less than 0.5 was considered significant.Results: Average age of the participants was 32.31 years. There were 42 men and six women in the group. Isolated medial meniscus, lateral meniscus, and combined medial and lateral meniscus had average ages of 31.83, 31.16, and 40.28 years, respectively. ACL injuries on the right side were seen in 23 patients the left side was seen in 25 patients. In comparison to the right side, the isolated medial meniscus injury on the left side was more severe. In case of a combination of medial and lateral meniscus tears, the right side suffered more damage than the left. Eleven patients had an isolated ACL tear without a meniscus injury, while the other 37 had a meniscus injury and an ACL tear. Excellent scores were observed in 11 cases, satisfactory scores in 26, and unsatisfactory in 11 cases. Age group was categorized into three groups, less than 30, 30-45, and more than 45 years. Excellent, satisfactory, and unsatisfactory scores were observed in seven, eleven, and seven patients on the left side and excellent, satisfactory, and unsatisfactory scores in four, fifteen, and four patients on the right side, respectively. P-value was not statistically significant when comparing outcomes by age, gender, or side.Conclusion: Meniscus injuries occurred 77% of the time when there was a persistent ACL injury. In comparison to a lateral meniscus injury, the incidence of medial meniscus injury associated with chronic ACL tear was higher. In comparison to the anterior horn and body of the medial meniscus, the majority of medial meniscus tears were found in the posterior horn.

Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years: A Systematic Review and Meta-analysis.

Background:There is no consensus regarding the best treatment approach for middle-aged patients with anterior cruciate ligament (ACL) injuries. Chronic ACL-deficient knees are often associated with instability as well as secondary meniscal and cartilage lesions. ACL reconstruction (ACLR) has achieved satisfactory outcomes in younger patients; however, the effectiveness and safety of ACLR in middle-aged patients remain uncertain.Purpose:To compare the patient-reported functional scores, arthrometric outcomes, and complications of primary ACLR between older (≥50 years) and younger (<50 years) patients.Study Design:Systematic review; Level of evidence, 3.Methods:We conducted a systematic review of cohort studies that compared the clinical outcomes of ACLR between patients aged ≥50 years and those aged <50 years. The Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases were searched for relevant studies. The Methodological Index for Non-randomized Studies (MINORS) criteria was used to assess the risk of bias and conducted a random-effects meta-analysis to combine the data, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the overall quality of the body of retrieved evidence. The primary outcome was knee functional outcomes, and secondary outcomes were arthrometric outcomes of ACLR and complications.Results:This study included 4 retrospective cohort studies with a total of 287 participants (129 in the older group and 158 in the younger group). All included studies reported significant improvements in clinical outcomes in both groups after ACLR. No significant differences were noted in the improvement of International Knee Documentation Committee (IKDC) scores (mean difference [MD], 0.20 [95% CI, −2.65 to 3.05]; P = .89) and Lysholm scores (MD, −1.98 [95% CI, −6.93 to 2.98]; P = .43) between the 2 groups. No significant differences were observed in anteroposterior stability or risk of complications between the groups.Conclusion:ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years).

Motor imagery in high-functioning individuals with chronic anterior cruciate ligament deficiency: A cross-sectional study

BackgroundThere is increasing evidence that motor imagery performance (MIP) is impaired in conditions that have a component of movement dysfunction. However, MIP has not been investigated in people with chronic anterior cruciate ligament (ACL) deficiency who experience limited disability and function at high levels. HypothesisThis study had three objectives: (1) to assess implicit MIP in individuals with a chronic ACL deficient (ACLD) knee compared with healthy controls (i.e., intact anterior cruciate ligament); (2) to determine if the location of ACL deficiency affects MIP (dominant versus non-dominant leg); and (3) to determine if impairment in MIP is specific to the side (injured versus non-injured) of ACL deficiency. MethodsForty-five participants with chronic ACLD knee and 44 healthy controls completed a left/right judgement task of pictured knees using the “Recognise” app to evaluate implicit MIP. Accuracy and reaction time of judgements were compared between groups. Additionally, within the chronic ACLD knee group, we made comparisons between the dominant ACLD knee and non-dominant ACLD knee subgroups and between the injured knee and the non-injured knee of the ACLD group. ResultsThere were no differences in implicit MIP between the ACLD knee and the control group, the non-injured knee versus injured knee of the ACLD knee group, or the dominant ACLD knee versus non-dominant ACLD knee subgroups. ConclusionImplicit MIP is not disrupted in high functioning individuals with chronic ACLD knee.

Side-to-Side Differences in Varus Thrust and Knee Abduction Moment in High-Functioning Individuals With Chronic Anterior Cruciate Ligament Deficiency

Background: There is evidence that frontal plane knee joint motion plays a crucial role in the pathogenesis of knee osteoarthritis, yet investigation of individuals with chronic anterior cruciate ligament–deficient (ACLD) knees remains sparse. Purpose: To investigate (1) if individuals with chronic ACLD knees demonstrate higher biomechanical measures of medial knee load as compared with their anterior cruciate ligament–intact (ACLI) knees, (2) if differences in static knee alignment of the ACLD knee will demonstrate a difference in the magnitude of biomechanical measures of medial knee load when compared with the ACLI knee, and (3) the side-to-side concordance of varus thrust among individuals with chronic ACLD knees. Study Design: Descriptive laboratory study. Methods: Participants were sourced from a metropolitan orthopaedic surgeon group. Those who met the inclusion criteria and agreed to participate underwent a 3-dimensional gait analysis assessment to measure knee adduction moment (KAM), knee flexion moment (KFM), KAM peaks, KAM impulse, and varus thrust. Frontal plane knee static alignment was measured with a digital inclinometer fixed to medical calipers. The participants were divided according to their static knee alignment (neutral, varus, and valgus) for subgroup analysis. Peak knee angular velocity and frontal plane knee angle were used to establish if a participant was walking with a knee thrust. An individual was deemed to have knee thrust during gait if the largest frontal plane knee movement coincided with the peak knee angular velocity that occurred within the first 30% of stance phase. Results: Forty-five participants were recruited. The mean (SD) time from injury was 34.5 (55.6) months. ACLD knees did not demonstrate higher mean KAM and KFM (P > .5) or early-stance peak KAM (P = .3-.8) and KAM impulse (P = .3-.9) as compared with ACLI knees as a whole group or when the varus, neutral, and valgus alignment subgroups were investigated separately. Twenty-three percent (n = 9) of the participants had a varus thrust at the ACLD or ACLI knee, 44% (n = 4) had a varus thrust at the ACLD knee, and 22% (n = 2) had varus thrust at both knees. Conclusion: There were no side-to-side differences in mean KAM and KFM and early-stance peak KAM and KAM impulse among high-functioning individuals with chronic unilateral ACLD knees. There was a low prevalence of varus thrust among high-functioning individuals with chronic unilateral ACLD knees.

Correlation of Meniscal Tear with Timing of Anterior Cruciate Ligament Reconstruction in Patients without Initially Concurrent Meniscal Tear.

The incidence of meniscal tear was reported to increase with the delay of anterior cruciate ligament reconstruction (ACLR). The tear may occur concurrently with the ACL injury or after the ACL injury. Few studies had focused on the patients whose meniscus is intact during ACL injury. We determined the correlation between timing of surgery and incidence of meniscal tears in ACL-deficient knees with initially intact meniscus. We retrospectively reviewed 387 patients who had undergone primary ACLR. Time of initial ACL injury, magnetic resonance imaging (MRI) examination, and surgery was recorded. The MRI was reviewed by experienced radiologic and orthopaedic doctors. Intraoperative arthroscopic images were also obtained and reviewed. The type of tear noted during surgery was classified according to the modification of International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine classification of meniscal tears. Patients were divided into early (surgery within 12 months from injury) and late surgery group (surgery at more than 12 months from injury). There were 216 patients with intact medial meniscus and 257 patients with intact lateral meniscus on the postinjury MRI study. The incidence of medial meniscus tear (MMT) was significantly higher than lateral meniscus tear (LMT) during the ACLR (33.8 vs. 19.8%, p < 0.001). The incidence of MMT is higher in late group than in early group (53.7 vs. 29.1%, p = 0.004, odds ratio= 2.815). The incidence of LMT is mildly higher in late group but without statistics significance (23.8 vs. 18.6%, p = 0.364). In both MMT and LMT, the most common injury pattern observed was a longitudinal tear. The incidence of each type is not different between early and late group. For patients without concurrent meniscal injuries with the ACL tear, the incidence of MMT significantly increased if ACLR was performed more than 12 months after injury. The medial meniscus was more prone to injury than the lateral meniscus in chronic ACL-deficient knee. ACLR should be performed earlier to reduce the risk of meniscal tears for patients without initially concurrent meniscal tear.

Arthroscopic and 3D CT Scan Evaluation of Femoral Footprint of the Anterior Cruciate Ligament in Chronic ACL Deficient Knees.

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/-2.5 mm on CT scan and 22.02+/-2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/-1.52 mm from the proximal margin the lateral femoral condyle. The "bifurcate ridge"(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation.

Association of ACL Laxity Tests with Arthroscopic Findings in Chronic ACL and PCL Deficient Knees.

An anterior cruciate ligament (ACL) injury may be diagnosed by clinical examination and radiological investigation using magnetic resonance imaging or by arthroscopy. 1,2 Based on our experience, the ACL tear in concomitant chronic ACL and posterior cruciate ligament (PCL) deficient knees may produce knee laxity, which is more difficult to assess on clinical examination, which in turn may affect the management algorithm of the patient. Our hypothesis is that, in a concomitant chronic ACL and PCL injury, posterior capsular contracture and abnormal reattachment of torn ACL will result in less clinical and subjective laxity, preoperatively. The aim of this study is to review a cohort of patients who had undergone PCL reconstructive surgery and compare the preoperative clinical assessments with and without anesthesia with arthroscopic finding of ACL. This is to assess the accuracy and reliability of clinical ACL laxity tests in detecting ACL tear in chronic ACL and PCL injury.

Kinematics and arthrokinematics in the chronic ACL-deficient knee are altered even in the absence of instability symptoms.

To analyze the in vivo kinematics and arthrokinematics of chronic ACL-deficient (ACL-D) and unaffected contralateral knees during level walking and downhill running using dynamic biplane radiography. It was hypothesized that ACL-D knees would demonstrate increased anterior translation and internal rotation, and that ACL-deficiency would alter the tibiofemoral contact paths in comparison to the unaffected contralateral side. Eight participants with unilateral chronic ACL-D without instability symptoms were recruited. The contralateral unaffected knee was considered as control. Kellgren-Lawrence (K-L) grades were determined from ACL-D and unaffected knees. Dynamic knee motion was determined from footstrike through the early-stance phase (20-25% of gait cycle) using a validated volumetric model-based tracking process that matched subject-specific CT bone models to dynamic biplane radiographs. Participants performed level walking at 1.2m/s and downhill running at 2.5m/s while biplane radiographs were collected at 100 and 150 images per second, respectively. Tibiofemoral kinematics and arthrokinematics (the path of the closest contact point between articulating subchondral bone surfaces) were determined and compared between ACL-D and unaffected knees. A two-way repeated measures analysis of variance was used to identify differences between ACL-D and unaffected knees at 5% increments of the gait cycle. Anterior-posterior translations were significantly larger in ACL-D than unaffected knees during level walking (all p < 0.001) and downhill running (all p ≤ 0.022). Internal rotation showed no significant difference between ACL-D and unaffected knees during level walking and downhill running. Closest contact points on the femur in ACL-D knees were consistently more anterior in the lateral compartment during downhill running (significant from 10 to 20% of the gait cycle, all p ≤ 0.044), but not during level walking. No differences in medial compartment contact paths were identified. Half of the participants had asymmetric K-L grades, with all having worse knee OA in the involved knee. Only 2 relatively young individuals had not progressed beyond stage 1 in either knee. The results suggest that anterior translation and knee joint contact paths are altered in ACL-D knees even in the absence of instability symptoms. The clinical relevance is that ACL-D patients who do not report symptoms of instability likely still demonstrate altered knee kinematics and arthrokinematics compared to their uninvolved limb. Case-control study, Level III.

Mri Evaluation of Anterior Cruciate Ligament Tears with Arthroscopic Correlation

Anterior Cruciate Ligament Injury Is The Most Commonly Injured Of The Major Knee Ligaments. Injuries Occur Frequently In Both Athletes And Nonathletes. In United States The Prevalence Of ACL Injury Is About 1 In 3000, And Approximately 2,50,000 Injuries Occur Every Year. Prompt Assessment Of Full Extent Of Ligamentous Damage Is Essential For Appropriate Management. Because Of Its Intraarticular Location, The ACL Has Poor Healing Potential. The Ruptured ACL Does Not Form A Bridging Scar After Complete Disruption. The Prognosis For A Partially Torn ACL May Be Favorable, If The Synovial Envelope Remains Intact. Without Treatment Complete ACL Injury Can Result In Progressively Increasing Symptomatic Knee Instability And Osteoarthritis. Meniscus Injury Occurs In Association With 50% Of Acute ACL Tears, And It Increases To 90% In Chronic ACL Deficient Knees. The Incidence Of Articular Cartilage Lesions Increases From 30% In Acute ACL Injuries To Approximately 70% Of Knees With Chronic ACL Instability. The Fundamental Rationale For Diagnosing And Treating ACL Injury Is To Prevent Future Meniscal Tears And Associated Joint Damage. For Treating ACL Injury The Orthopaedician Or Arthroscopist Needs The Answer To Following Questions: 1. Whether ACL Is Normal Or Abnormal? If ACL Is Normal, Invasive Arthroscopy Can Be Avoided In Patients With Suspected ACL Injury. 2. If Abnormal, Whether The Tear Is Complete Or Partial? If Partial Conservative Management Or Repair Can Be Done. However In Complete Tears Reconstruction Needs To Be Done In Most Of Cases. 3. What Is The Status Of Associated Structures Such As PCL, Menisci, MCL, LCL, Posterolateral, Posteromedial Plateau In ACL Injured Patients? Because An Injury To Above Structures Along With Complete Tear Of ACL Needs Early Reconstruction Of ACL. ACL Injury Can Be Diagnosed In Majority Of Patients By History And Clinical Examination. The Clinical Diagnosis Is Fraught With Difficulty In Acute Cases And In Large Patients. Also Partial Tears Are Difficult To Diagnose And The Associated Injuries Could Not Be Completely Evaluated By Clinical Examination. Arthroscopy And Arthrotomy Are The Criterion Standards For Definitive Diagnosis But Are Invasive And Costly. It Can Get Unnecessary If ACL Turns Out To Be Normal. Spiral CT Arthrography Is More Invasive Than Conventional MR Imaging. It Uses Ionizing Radiation And Is Subject To The Potential Complications Inherent In Intraarticular Injection Of Iodinated Contrast Material. The Continuing Need For A Better Non Invasive Imaging Modality For ACL Injury Led To The Use Of MRI As A Diagnostic And Pre- Operative Evaluation Modality. MRI Is A Recently Devised Modality For Evaluation Of ACL And Knee Joint. Imaging Is Done In Sagittal, Axial And Coronal Planes Using T1, T2 And STIR Sequences Using Quadrature Knee Coil. The Following Study Involves Detailed Evaluation ACL Injury And Its Associated Injuries Using MRI And Comparing With Arthroscopic Results. MR Primary And Secondary Signs Of ACL Tear Are Also Analysed And Their Usefulness Assessed In Comparison With Arthroscopic Findings.

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation, (c) distal graft tension is manually applied to distal graft sutures by the surgeon to prevent tibiofemoral subluxation, (d) the medial meniscus is repaired while graft tension is applied, and (e) the graft is then fixed to the tibia using an interference screw or another device.

Anterior Cruciate Ligament Reconstruction using Bone Patellar Tendon Bone autograft in ACL deficient Knee

Background &amp; Objectives: Injury to Anterior Cruciate Ligament (ACL) reconstruction has increased because of increased interest in sports. There are various grafts used for reconstruction of ACL, for example, Bone Patellar Tendon Bone, Hamstring etc. The study was conducted to evaluate the results of Bone Patellar Tendon Bone graft used for reconstruction of Anterior Cruciate Ligament.Materials &amp; Methods: 40 patients with chronic ACL deficient knee presenting to Neuro Hospital from July 2011 to June 2013 were included in the study. The patients with intraarticular fracture of knee, severe OA knee, local active or suspected infection and systemic disease that might influence the study results were excluded from the study. Bone patellar tendon bone graft was harvested from ipsilateral knee in all the cases. The patient was followed till 2 year with specified programme of rehabilitation. The pain was assessed using VAS and the function of the knee was assessed using Modified WOMAC knee index.Results: The long term satisfactory results in terms of functional stability, symptom relief and return to preinjury level of activity was seen in 32 cases (80%). Two knees got infected out of which one required arthroscopic debridement. Mean visual analogue scale was 8 and modified WOMAC knee score was 3 at 2 year follow up.Conclusion: Bone patellar tendon bone graft is useful in high demand patients and cost effective option with high patient satisfaction rate for reconstruction of ACL.JCMS Nepal. 2015;11(3):12-15.

Three-dimensional kinematic and kinetic gait deviations in individuals with chronic anterior cruciate ligament deficient knees: a systematic review

Background: Altered joint motion that occurs in people with an anterior cruciate ligament deficient (ACLD) knee has been proposed to play a role in the initiation of knee osteoarthritis (OA), although the exact mechanism behind this is poorly understood. There is evidence that frontal plane knee motion plays a crucial role in the pathogenesis of knee OA. However, limited information exists with regards to frontal and transverse plane knee kinematics and kinetics. Purpose: We aimed to identify all relevant articles and synthesize the findings of the literature on 3D gait deviations emphasising on the frontal and transverse plane in individuals with chronic ACLD knee; those who have had the injury for 6 months or longer compared to their uninjured knee or a control group. Methods: As per the PRISMA guidelines, we searched five electronic databases from inception to 14th October 2013, with key words related to ACL, biomechanics and gait, limited to human studies only. Two independent reviewers assessed study eligibility based on predetermined inclusion/exclusion criteria and methodological quality was evaluated using the STROBE statement checklist. Results: Of the 1075 identified citations, 16 studies met the inclusion criteria. The selected studies have a small sample size (range = 20–72) and a higher number of male participants compared to women (average = 69.3% men). The participants with ACLD knee had an average age of 30.4± 8.95 years and time from injury that ranged from 6 months to more than 7.5 years. Comparing the two groups (ACLD vs. healthy controls) most studies found no kinetic or kinematic differences. However, individual studies identified the following differences during the stance phase of gait with the ACLD group exhibiting: a) greater knee abduction angle at heel strike (1 out of 3 studies); b) greater tibial external rotation (2 out of 4 studies); c) greater average knee flexion angle (6 out of 11 studies); lower knee adduction moment (1 out of 3 studies) and e) greater knee extensor moment at heel strike (1 out of 7 studies) and terminal stance (1 out of 7 studies), and lower knee flexor moment at midstance (1 out of 7 studies). When comparing the two knees of the ACLD group, one study investigated the internal-external rotation kneemoment with no significant difference. Conclusion(s):There is limited and inconsistent evidence of altered knee kinematic and kinetic in the in individualswith chronicACLD;. Themost consistentfindingwas greater knee flexion during the stance phase. Implications: There is a need for more prospective studies that evaluate the gait characteristics of the chronic ACLD knee population in all planes; especially in the frontal and transverse. If consistently occurring gait deviations can be identified, it will provide insight in the initiation of knee osteoarthritis in individuals with chronic ACLD.

Does delay in Acl reconstruction increases incidence of associated injuries?

Background and objective: Anterior cruciate ligament (ACL) rupture is the most common among young population involved in sports activates. In previous literature it is evident that delay in reconstruction results in increased incidence of meniscal injury and degenerative changes due to knee instability. The aim of this study is to find out incidence of meniscal injury and cartilage damage in ACL deficient knee and weather the incidence is more in chronic ACL deficient knee. Methods: All cases of ACL reconstruction done in our institution during 2011 to 2015 were included in study. Patients above 50 years were excluded. The case records reviewed and data collected. The time period between primary injury and surgery noted along with findings in diagnostic arthroscopy. The cases were divided as per the times when surgery was done after primary injury in to two groups as early reconstruction group (Group A) and late reconstruction group (Group B). The associated injuries of meniscus and cartilage damage were noted in both groups. Results: After considering inclusion and exclusion criteria 113 patient were included in study. 65 patients were in Group A and 48 patients in Group B. 36 patients (74%) in Group B and 23 patients (25%) in Group had meniscal injury. It was observed that Group B had high incidence of medial meniscal injury compared to Group A. four patients in Group B had chondral damage compared to one patient in Group A. Conclusion: Incidence of medial meniscus injury and both meniscus injury was found to be more in late reconstruction group. Chondral damage also is more in late reconstruction group. Delay in ACL reconstruction results in early onset of degenerative changes and meniscal injury. We recommend early reconstruction of ACL preferably within three months. Keywords: Ligament, Meniscus, Chondral defect, Hamstring graft.

Increased meniscal loading after anterior cruciate ligament transection in vivo: a longitudinal study in sheep.

Meniscal injury has been well documented as a frequent consequence of both acute and chronic ACL deficiency. The purpose of this study was to evaluate the effect of ACL deficiency on meniscal loads in vivo and determine how these loads would change over time after ACL injury. The in vivo kinematics of the stifle joint of five sheep were measured during normal gait, as well as 4 and 20 weeks after ACL transection. A unique robotic testing platform was then programmed to reproduce all the previously recorded kinematics and the loads carried by medial and lateral menisci during gait were estimated. The results demonstrated a significant increase in both medial and lateral meniscal loads 20 weeks following ACL transection, mainly during mid-stance phase of gait (p = 0.007 and p = 0.003, respectively), with interesting inter-subject variability. A moderate correlation (R(2) ≥ 0.5) between in situ meniscal loads and anterior tibial translations was also detected over time after injury, increased translations post injury generally corresponded to larger meniscal loads. The dramatic increase in meniscal loads long term post ACL transection probably explains the meniscal changes or injuries reported clinically in many chronic ACL-deficient knees.

Patterns of Meniscal Damage Associated with Acute ACL Rupture

Patterns of Meniscal Damage Associated with Acute ACL Rupture

High Tibial Osteotomy, Over-the-Top Revision ACL Reconstruction plus Extra-Articular Tenodesis for ACL-Deficient Varus Knees in Middle Aged Patients

Lateral closing wedge HTO in addition to hamstrings ACL revision (Over-the-Top plus extra-articular tenodesis) showed 82% satisfactory results (normal aligned and stable knee) in the treatment of chronic ACL-deficient varus knees.

Treatment of unstable chronic anterior cruciate ligament-deficient knee with osteoarthritis

Untreated ruptures of anterior cruciate ligament (ACL) lead to progressive meniscus tear and development of knee osteoarthritis over decades. The present study was designed to explore the early results of ACL reconstruction for the patients with unstable ACL-deficient knee with osteoarthritis. Twelve patients with a mean age of 46 years (range: 35 - 54) underwent ACL reconstruction for ACL-deficient knee with osteoarthritis. All had chronic anterior instability and one or more episodes of knee instability. There was no previous diagnosis of ACL ruptures and no prior ligament surgery on involved knee. The preoperative duration of symptoms was 1 to 5 years. ACL reconstruction with arthroscopic single-bundle four-strand hamstring tendon autograft was performed for all patients. The laxity of knee was determined with Lachman and pivot tests. The patient subjective evaluation of function was examined with the modified Lysholm scoring scale pre- and post-operatively. Obvious articular cartilage degeneration and cartilage space stenosis in medial compartment were found in 9 patients and complex medial meniscus tear in 10. During the follow-up period of 9 - 36 months, there was no graft failure or loss of ROM (range of motion) for any of these knees. The symptoms of instability were relieved in all patients. The post-operative knee stability improved markedly. The modified Lysholm scores improved from a median pre-operative score of 62.0 points to an average of 89.5 at the last follow-up. ACL reconstruction with hamstring tendon may significantly relieve symptoms and improve knee functions in the patients of chronic anterior cruciate ligament-deficient knee with osteoarthritis, especially in those with primary symptoms of instability.

Image-matching technique can detect rotational and AP instabilities in chronic ACL-deficient knees

The purpose of this study was to quantify rotational and antero-posterior instabilities using biplanar image-matching technique. Biplanar radiographs of both chronic ACL-deficient knees and contralateral uninjured knees were taken in the pivot shift test and in the "giving way position" and lateral radiographs in stress arthrometer at 30° and 90°. Three-dimensional knee models were constructed using computed tomography. Using biplanar image-matching technique, the external rotational angle and the translation of the center of the both condyles of the femur were analyzed. The external rotation angle of geometric center axis in the pivot shift test was 16.9° ± 5.6° and 10.9° ± 7.3° (P = 0.004), and in the "giving way position" was 16.1° ± 5.7° and 10.7° ± 6.6° (P = 0.004) in ACL-deficient knees and intact knees, respectively. In the pivot shift test, the medial and the lateral femoral condylar centers of ACL-deficient knees were translated 1.2 ± 5.1 mm anteriorly and 3.9 ± 3.4 mm posteriorly, respectively, and in the "giving way position," 2.0 ± 3.7 mm anteriorly and 2.9 ± 2.6 mm posteriorly, respectively. In stress arthrometer at 30°, the medial and the lateral femoral condylar center translated 7.1 ± 6.0 and 6.6 ± 4.8 mm posteriorly (n.s.), respectively, and at 90° translated 2.7 ± 3.4 and 2.6 ± 3.5 mm posteriorly (n.s.), respectively. Rotational instability was evaluable in the pivot shift test and in the "giving way position." Translation of both condylar centers was similar in stress arthrometry. The image-matching technique is able to quantify dynamic rotational and antero-posterior instabilities with static parameters in ACL-deficient knees.