Chronic Anterior Cruciate Ligament Injuries Research Articles

Diagnostic accuracy of lever sign test in acute and chronic ACL injuries

IntroductionThe anterior cruciate ligament (ACL) is a commonly affected knee ligament prone to frequent injuries. Henceforth, we aimed to determine the diagnostic accuracy of lever sign test in Acute and chronic ACL injuries. MethodAt the institution's initial outpatient visit, 150 consecutive patients (92 males and 58 females) were evaluated. Total 108 patients had injury in their right leg, whereas 42 had injury in their left leg. Based on time since injury, the patients were divided into Acute and chronic groups. Clinical examinations (lachman's test and lelli's test) of all patients were confirmed with arthroscopic findings and compared between the two groups. ResultsIn the acute ACL injury, the lever test had a kappa value 0.704. The accuracy and sensitivity of the Lachman, anterior drawer, pivot shift, and lever tests were calculated. We found that the lever test had the highest accuracy and sensitivity (85.48 %, 91.18 %) than the rest. In the chronic ACL injury, the kappa value for the results of the Lachman test evaluation was 0.723. The chronic ACL injuries accuracy and sensitivity values for the Lachman (86.36 %, 91.67 %), anterior drawer (76.14 %, 81.25 %), pivot shift (55.68 %, 58.49 %), and lever tests were determined. ConclusionThe lever sign test is more accurate and reliable in the acute ACL injuries, while the Lachman test is more accurate and reliable in the chronic ACL injuries.

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.

Combined ACL and Anterolateral Ligament Reconstruction Using an Adjustable-Loop Fixation Device: Surgical Technique

Background: There are several techniques for the combined reconstruction of the anterior cruciate ligament (ACL) and the anterolateral ligament (ALL), but none have shown superiority. This study aims to present a surgical technique that theoretically reduces some of the risks reported in these procedures. Indications: The main indications for the ALL reconstruction include chronic ACL injuries, revision ACL reconstruction, acute ACL injuries in patients with high-grade pivot-shift (grades 2 or 3), patients involved in pivoting sports, and generalized ligament hyperlaxity or knee hyperextension. Technique Description: Hamstring tendon autografts are used for the ACL and ALL reconstruction; a common femoral ACL and ALL tunnel is made outside-in, making a short socket. A continuous looped hamstring tendon autograft attached to one button is used. The ACL is fixed with an adjustable-loop button. Through small incisions, the tibial fixation of both grafts is performed with bioabsorbable screws. Results: We present a 19-year-old professional soccer player with an acute ACL tear, with no associated meniscal or chondral lesions. Owing to his young age and high-risk sports practice, a combined ACL and ALL reconstruction was performed. The combined ACL and ALL reconstruction with a single femoral tunnel using the hamstrings tendons graft is a well-established procedure for ACL augmentation, reducing failure rates for certain risk groups, with excellent outcomes reported. The use of an adjustable-loop button on the femur is a viable option for this kind of reconstruction with postoperative stability comparable to the interference screw, classically used for this kind of reconstruction. Discussion/Conclusion: This technique has some advantages, such as the use of a short outside-in femoral socket, thus theoretically improving healing. In addition, this lowers the risk of lateral collateral ligament injury, and since the ileotibial band graft is not used, the risk of injuring the lateral inferior genicular vessels and the peroneal nerve is theoretically reduced. Besides, using an adjustable-loop cortical button in the femur can theoretically reduce potential complications such as screw migration, soft-tissue impingement, femoral-site pain, and implant removal. Finally, the reconstruction is done with small incisions, improving the aesthetic result and postoperative pain. Considering all the aforementioned factors, this technique theoretically offers some benefits. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Femoropatellar alterations in knees with chronic anterior cruciate ligament injuries: a radiographic analysis

Background: The objective of this study was to correlate the occurrence of patellofemoral malalignment in a chronic anterior cruciate ligament (ACL) deficient knee using common radiological parameters. Methods: A case-control study was conducted on 35 adult patients with previously diagnosed unilateral chronic ACL injury. The injured knee was considered as the case, while the contralateral normal knee served as the control. Radiological parameters including the Caton-Deschamps patellar height index, Merchant patellar congruence angle, and Laurin lateral patellar tilt angle were measured on X-rays obtained from both normal and ACL injured knees. A comparative analysis was performed between the two groups. Results: The Caton-Deschamps patellar height index had a mean value of 0.95±0.05 in the ACL-deficient knee. The Merchant patellar congruence angle showed mean values of 12.66±0.84 degrees in the ACL injured knee, while the Laurin lateral patellar tilt angle was 8.06±1.41 degrees in knees with ACL failure. These results indicate lower patellar height, greater lateral displacement of the patella, and increased lateral patellar tilt in knees with chronic ACL tears, thereby affecting the patellofemoral joint. Conclusions: Chronic ACL tears are associated with patellofemoral malalignment, characterized by decreased patellar height, increased lateral displacement of the patella, and greater lateral patellar tilt, thus impacting the patellofemoral joint.

The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury.

The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. III.

Chronic ACL-injured patients show increased medial and global anterior tibial subluxation measured on 1-year postoperative MR images after primary single-bundle ACL reconstruction

BackgroundThe association between chronic anterior cruciate ligament (ACL) injury and inferior postoperative outcomes following ACL reconstruction (ACLR) has been highlighted in the literature. However, the inclusion of postoperative radiological assessments in previous studies has been limited. The aim of this study is to investigate whether chronic ACL injury is associated with an inferior tibiofemoral position measured on magnetic resonance (MR) images after primary ACLR.MethodsA total of 62 patients that underwent primary ACLR were included in this study based on the time from injury to surgery, namely the acute ACL-injured group (within 6 weeks) and the chronic ACL-injured group (more than 1 year) and were matched 1:1 according to sex, age (± 2 years), and time from surgery to follow-up (± 3 months). Patient demographics, surgical records and follow-up data were retrieved and analyzed. The altered tibiofemoral position was measured quantitatively on preoperative and at least 1-year postoperative MR images and compared between the two groups, including the lateral, medial and global anterior tibial subluxation (LATS, MATS and GATS) and internal rotational tibial subluxation (IRTS).ResultsNo significant differences in preoperative LATS, MATS, GATS or IRTS were identified between the acute and chronic ACL-injured groups. The chronic ACL-injured patients showed significantly increased postoperative MATS (p = 0.001) and GATS (p = 0.012), while no significant difference was identified in postoperative LATS or IRTS. Multivariate linear regression analyses showed that chronic ACL injury resulted in an estimated increase of 2.0 mm in postoperative MATS (p = 0.012) and 1.9 mm in postoperative GATS (p = 0.040). A significant improvement in postoperative LATS was observed in the acute ACL-injured group (p = 0.044) compared to preoperative LATS, while no improvements in these MRI measurements were observed in the chronic ACL-injured group.ConclusionChronic ACL-injured patients showed increased MATS and GATS measured on 1-year postoperative MR images after primary single-bundle ACL reconstruction, while no difference was identified in rotational tibiofemoral position. The acute ACL-injured group demonstrated a significant improvement in postoperative LATS, whereas no improvements were observed in the chronic ACL-injured group.Level of evidence Level III.

Poster 126: Chronic ACL Injury Patients Have Lower Levels of Pro-Inflammatory Biomarkers in their Synovial Fluid and Worse ACLOAS Score at the Time of Surgery Than Those with Acute ACL Injury: A Cohort Study

Objectives: The relationship between structural abnormalities and inflammatory changes in the synovial fluid following ACL injury has not been well defined. The purpose of this study is to compare MRI findings and concentration of inflammatory biomarkers in the synovial fluid (SF) of acute and chronic anterior cruciate ligament (ACL) injury patients. Methods: Patients undergoing surgery for ACL injury from October 2011 to December 2021 were included in a database of patients who had SF samples collected at the time of surgery. From this cohort, 82 patients with acute ACL injury and 28 patients with chronic ACL injury were identified. All patients underwent a preoperative MRI examination of the knee and SF was aspirated from the operative knee prior to the surgical incision and concentrations of inflammatory biomarkers were quantified. MRI examinations were reviewed by a fellowship-trained musculoskeletal radiologist to assess radiographic features of acute and chronic knee injury using the validated ACLOAS system. Nonparametric tests were used to compare demographic factors, MRI findings, clinical symptoms, and SF inflammatory biomarkers between acute versus chronic ACL injury patients. A generalized linear model was used to assess the relationship of each SF biomarker with the ACLOAs subscores. Results: For acute ACL injury patients, mean time from injury to MRI and injury to surgery was 14 ± 35 days and 49 ± 38 days, respectively. The mean time from injury to MRI and injury to surgery was 3.2 ± 3.7 years and 3.4 ± 3.8 years, respectively, for those with chronic ACL injury. There were no significant demographic differences between groups; age (acute: 31.62 ± 8.02 years, chronic: 33.70 ± 10.60 years, p=0.130), sex (acute: 51.2% males, chronic: 57.1%, p=0.588), or body mass index (acute: 5.5 ± 4.4 kg/mm2, chronic: 25.3 ± 3.6 kg/mm2, p=0.931). Acute ACL injury patients had higher bone marrow edema severity scores (p&lt;0.001), Hoffa’s synovitis score (p=0.002), and effusion severity scores (p&lt;0.001). Chronic ACL injury patients had higher cartilage degeneration severity scores (p&lt;0.001), prevalence of meniscus tears (p=0.003), and meniscus tear severity scores (p&lt;0.001). Acute ACL injury patients had significantly higher synovial fluid levels of IL-6 (p=0.032), VEGF (p=0.002), TIMP1 (p&lt;0.001), IL1-RA (p=0.003), and MMP3 (p&lt;0.001) than chronic ACL injury patients. The generalized linear model revealed that after adjusting for age, sex, BMI, and time from injury to surgery, increased VEGF (p=0.003) and MMP3 (p=0.012) were associated with higher effusion score. MMP-3 was associated with a higher bone marrow edema score (p=0.034), and RANTES was associated with both a higher meniscus severity score (p=0.027) and increased cartilage lesions in the chronic ACL injury cohort. Conclusions: The findings from this study suggest that despite having more severe cartilage degeneration and a higher prevalence of meniscus pathology, chronic ACL injury patients had lower levels of synovial fluid inflammatory biomarkers at time of surgery compared to acute ACL injury patients. Additionally, we found that in chronic injuries, RANTES was associated with worse ACLOAS cartilage scores.

Paper 25: The Impact of Posterior Tibial Slope on Meniscal Injury in Acute ACL Ruptures: A Large, Retrospective Registry Study

Objectives: Increased posterior tibial slope has previously been associated with an elevated risk of anterior cruciate ligament (ACL) rupture. Recent studies have suggested there may be a relationship between posterior slope and meniscal tears in ACL ruptures, however, these studies have either included chronic ACL injuries, revision ACL reconstructions or an overall low number of study participants. The goal of this study is to leverage a large ACL registry to assess the impact of posterior tibial slope on meniscal tears in acute ACL ruptures. Methods: A large, single-institution knee registry was consulted to identify all patients between the age of 18 and 45 who underwent primary ACL reconstruction between Jan 2019 and July 2022 for acute, noncontact ACL rupture, defined as undergoing surgery within 90 days of injury. Patients with pre-existing meniscal pathology, chronic ACL reconstructions, revisions, multi-ligament knee injuries and nonoperatively managed ACL injuries were excluded. Preoperative MRIs were used to measure lateral and medial posterior tibial slope for all patients. Meniscal injury seen in-situ during arthroscopy was recorded based on operative reports. Demographics data, including age, sex, and body mass index, was also recorded. Independent cohorts were created based on the presence or absence of any meniscal injury. Two-tailed student’s t tests were used to compare average medial and lateral posterior tibial slopes between these groups. Separate analyses were also performed to assess the impact of posterior slope on medial and lateral meniscus tears independently. Multiple logistic regression was carried out to determine risk factors for meniscal injury in this population. Results: 1059 patients ultimately met inclusion criteria. The average age was 29.5 and there were 532 (50%) women. There were 253 (24%) patients with isolated lateral meniscus tears, 152 (14%) patients with isolated medial meniscus tears and 93 (9%) patients with both medial and lateral tears. The average lateral and medial posterior tibial slopes were 5.54 (-4.2 to 13.4) and 5.67 (0 to 15.7), respectively. Increased lateral tibial slope was associated with a statistically significant increase in rate of any meniscal tear (p=.0022). Lateral slope was also associated with a higher rate of lateral meniscal tears, specifically (p=.0009). Multiple logistic regression identified elevated BMI and male sex as independent risk factors for meniscal injury in this population. Conclusions: Increased lateral posterior tibial slope is associated with a higher rate of meniscus injury in acute ACL ruptures and should be considered when devising treatment algorithms for patients in this population. [Table: see text][Table: see text][Table: see text][Table: see text]

Poster 121: Association Between MRI Findings in ACL Injury and Subacute Synovial Fluid Inflammatory Biomarker Levels at the Time Of Surgery

Objectives: To Investigate the association between MRI findings following anterior cruciate ligament (ACL) injury and synovial fluid biomarker profile at the time of surgery Methods: Patients undergoing surgery for ACL injury from October 2011 to December 2021 were included in a database of subjects who had synovial fluid samples collected at the time of surgery. From this cohort, 82 subjects with acute ACL injury were retrospectively selected who met the following inclusion criteria: no history of prior knee trauma to suggest chronic ACL injury, history of acute non- contact knee injury, MRI examination of the knee performed within 3 weeks of knee injury, subsequent knee surgery performed between 4 and 12 weeks of knee injury, and no additional ligament tear requiring surgical treatment. All subjects underwent a preoperative MRI examination of the knee using multi-planar, multi-contrast fast spin-echo sequences. Synovial fluid was aspirated from the operative knee prior to surgical incision. Concentrations of inflammatory biomarkers including regulation on activation normal T cell expressed and secreted (RANTES), interleukin 6 (IL-6), vascular endothelial growth factor (VEGF), tissue inhibitor matrix metalloproteinase 1 (TIMP1), interleukin 1 receptor agonist (IL1-RA) and matrix metalloproteinase 3 (MMP-3) were measured. The MRI examinations of all subjects were reviewed by a fellowship trained musculoskeletal radiologist to assess the presence and severity of various MRI features of acute and chronic knee injury using the validated Anterior Cruciate Ligament Osteoarthritis Score (ACLOAS) system. Nonparametric Wilcoxon tests and Fisher’s exact test were used to compare demographic factors, MRI findings, clinical symptoms, and synovial fluid inflammatory biomarkers between clusters. K-means cluster analysis was used to identify 2 distinct clusters of subjects with acute ACL injury based on biomarkers concentrations in synovial fluid. Results: The mean age of the cohort was 31.6 ± 8 years, average body mass index (BMI) was 25.5 ± 4.4 kg/m2. There 42.7% (n=35) of the cohort was female and 85.4% (n=70) were non-smokers. Two distinct clusters were identified: cluster 1 included 45 subjects and was marked by older subjects (33.2 ± 9.1 years, p=.038) with lower levels of all inflammatory synovial fluid biomarkers. Cluster 2 included 37 subjects and was marked by younger patients (29.7 ± 6.1 years, p=.038) with a more pro-inflammatory synovial fluid biomarker profile, higher ACLOAS Hoffa’s synovitis score (p=.001), and a higher incidence of subchondral bone fractures (54%, p=.002). There were no differences between clusters in time from injury to surgery (p=), BMI (p=.141), or ACLOAS meniscus (p=.086), cartilage (p=.730), or effusion scores (p=.202) Conclusions: Given the variable outcomes seen following ACL reconstruction (ACLR) surgery, a better understanding of the pathophysiology following ACL injury is needed. This study found distinct cluster of patients who exhibited a higher inflammatory reaction at the time of surgery as well as more severe findings on preoperative MRI. These findings could be used to identified clinical parameters associated with more inflammation at the time of surgery and their effect on clinical outcomes of ACLR.

Translation and Validation of a Simplified Chinese Version of the Anterior Cruciate Ligament–Quality of Life Questionnaire

Background: The Anterior Cruciate Ligament–Quality of Life (ACL-QOL) questionnaire is a widely used and effective scale for quality of life in patients with chronic anterior cruciate ligament (ACL) injury. Purpose: To translate and adapt the ACL-QOL questionnaire for Chinese patients and evaluate its reliability, validity, and responsiveness in this population. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Translation and adaptation were conducted in accordance with the guidelines of the A merican Academy of Orthopaedic Surgeons Outcome Committee. Included were 121 patients who were diagnosed with a chronic ACL injury and underwent ACL reconstruction between January 2020 and June 2021. Preoperatively, patients completed the simplified Chinese version of the ACL-QOL (ACL-QOL-C), the Knee injury and Osteoarthritis Outcome Score, and the 12-Item Short Form Health Survey. The ACL-QOL-C was also completed at 12- and 24-week follow-ups. Psychometric evaluations were then performed and included score distribution, internal consistency, test-retest reliability, construct validity, and responsiveness. Results: The Cronbach alpha ranged from .905 to .975, indicating excellent internal consistency, and the intraclass correlation coefficient ranged from 0.864 to 0.985, indicating excellent test-retest reliability. The consistency between the above results and our a priori hypotheses was more than 70% (35/42), indicating good construct validity. The standard error of measurement and effect size of the total score and each item of the ACL-QOL-C were &gt;0.8 at the final follow-up, indicating good responsiveness. Conclusion: The English version of the ACL-QOL has been successfully translated into Chinese, and it has been shown to be applicable for the assessment of the quality of life in Chinese patients with chronic ACL injury.

Association Between Anterior Tibial Subluxation of Lateral Compartment and High-Grade Knee Laxity in Patients With Anterior Cruciate Ligament Deficiency

Background: High-grade knee laxity and excessive anterior tibial subluxation (ATS) are correlated with poor clinical outcomes in patients with anterior cruciate ligament (ACL) deficiency and share similar risk factors; however, the association between excessive ATS and high-grade knee laxity remains unclear. Purpose: To identify the association between excessive ATS and high-grade knee laxity in patients with ACL deficiency and determine the possibility that ATS can predict high-grade knee laxity. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 226 patients who underwent ACL reconstruction between May 2018 and March 2022 were analyzed in the present study; the high-grade group consisted of 113 patients who had a grade 3 result on the preoperative anterior drawer test, Lachman test, or pivot-shift test while under anesthesia, and the low-grade group consisted of 113 matched patients. The ATS values for medial and lateral compartments (ATSMC and ATSLC) were measured on magnetic resonance imaging while patients relaxed the quadriceps in the supine position under no anesthesia. The optimal cutoff values of ATSMC and ATSLC for high-grade knee laxity were determined using receiver operating characteristic curves. Univariate and multivariate logistic regression analyses with stratification were performed to identify the association between excessive ATS and high-grade knee laxity. Results: Compared with the low-grade group, the high-grade group had a longer time from injury to surgery; higher rates of medial meniscus posterior horn tear (MMPHT), lateral meniscus posterior horn tear (LMPHT), and anterolateral ligament (ALL) abnormality; and larger lateral tibial slope, ATSMC, and ATSLC. The optimal cutoff value was 2.6 mm (sensitivity, 52.2%; specificity, 76.1%) for ATSMC and 4.5 mm (sensitivity, 67.3%; specificity, 64.6%) for ATSLC in predicting high-grade knee laxity. After adjustment for covariates, ATSLC ≥4.5 mm (odds ratio [OR], 2.94; 95% CI, 1.56-5.55; P = .001), MMPHT (OR, 2.62; 95% CI, 1.35-5.08; P = .004), LMPHT (OR, 2.39; 95% CI, 1.20-4.78; P = .014), and ALL abnormality (OR, 2.09; 95% CI, 1.13-3.89; P = .019) were associated with high-grade knee laxity. The association between excessive ATSLC and high-grade knee laxity was validated in patients with acute ACL injury as well as those with chronic ACL injury. Conclusion: Excessive ATSLC was associated with high-grade knee laxity in patients who had ACL deficiency, with a predictive cutoff value of 4.5 mm. This study may help surgeons estimate the degree of knee instability more accurately before anesthesia and may facilitate preliminary surgical decision-making, such as appropriate graft choices and consideration of extra-articular augmentation.

Peroneous Longus Tendon Versus Hamstring Tendon Autograft On Anterior Cruciate Ligament Reconstruction: A Meta-Analysis and Systematic Review

Introduction: Anterior Cruciate Ligament (ACL) injury is one of the most common knee injuries. ACL reconstruction is the current gold standard to restore functional of the knee. Graft selection is important for satisfactory outcomes. Currently, most used autograft are hamstring tendon (HT) and bone patellar tendon bone (BPTB) grafts. This study aims to thoroughly evaluate and review an alternative autograft for ACL reconstruction, which is peroneus longus tendon (PLT). Method: Systematic review and meta-analysis was conducted using PRISMA guidelines. Literature was searched through PubMed, Google Scholar, Science Direct and Cochrane Library using Boolean operators. This study included original articles reporting on (1) clinical studies of ACL reconstruction (single-bundle or double-bundle) using PLT autograft (anterior-half, posterior half, or full-thickness); and (2) studies directly comparing outcomes of PLT versus HT. All procedures were primary ligament reconstructions performed for symptomatic acute or chronic ACL injury, with or without meniscal injury. The outcomes assessed included clinical and functional outcome, namely IKDC score, AOFAS scale and FADI. Results: From 247 studies obtained, after full-text review, 4 studies met all eligibility criteria. A total of 259 patients were included in this study. No significant differences was found in IKDC score (p = 0.99) and FADI score (p = 0.11) but significant differences was found in the mean of AOFAS score in favor of HT autograft (p = 0.03). Conclusion: PLT autograft is a suitable alternative graft choice from the others for the knee of patients undergoing ACL reconstruction.

Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries.

Background: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population.Methods: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed.Result: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions.Conclusion: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.

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 Tibial Subluxation of Lateral Compartment Is Associated With High-Grade Rotatory Instability for Acute But Not Chronic Anterior Cruciate Ligament Injuries: An Magnetic Resonance Imaging Case-Control Study

To investigate whether anterior tibial subluxation obtained from magnetic resonance imaging (MRI) could be a predictor of high-grade rotatory instability for anterior cruciate ligament (ACL) injuries, including acute and chronic cases. From September 2016 to August 2018, we retrospectively investigated 163 patients with ACL injuries who subsequently underwent primary ACL reconstruction. Among them, 30 patients with high-grade rotatory instability (grade II/III pivot shift) were included in the high-grade group, and their age and sex were matched 1:2 to low-grade cases (<grade II pivot shift). On preoperative MRI, we measured anterior tibial subluxation, posterior tibial slope, as well as the time from injury to surgery. Meniscal lesions were documented from arthroscopy. Multivariable logistic regression was used to determine predictors of high-grade rotatory instability. Furthermore, subgroup comparisons between 2 groups were divided into acute (≤3 months) and chronic (>3 months) phases. The high-grade group had a larger anterior tibial subluxation of lateral compartment (8.1 mm vs 5.9 mm; P=.004) than the low-grade group, whereas no significant difference was found in anterior tibial subluxation of medial compartment (P > .05). Moreover, high-grade anterior tibial subluxation of lateral compartment (≥6 mm) was found to be an independent predictor (odds ratio, 12.992; P= .011) associated with concomitant meniscal tears after ACL injuries. Anterior tibial subluxation of lateral compartment demonstrated statistical significance between the two groups when comparing subgroups within 3 months but not beyond 3 months. In ACL-injured patients, high-grade anterior tibial subluxation of lateral compartment (≥6 mm) could be a unique predictor of high-grade knee rotatory instability for acute but not chronic injuries. Prolonged time from injury to surgery and lateral meniscus tears were risk factors for high-grade rotatory laxity in chronic patients. Level III, retrospective prognostic trial.

Is Lever Test Superior to Lachman, Pivot Shift, Drawer Tests in Diagnosing Anterior Cruciate Ligament Injuries?

Introduction: The physical examination in anterior cruciate ligament (ACL) injuries is extremely important, and the Lever test is commonly utilized on ACL evaluation. However, the number and scope of studies on the Lever test is limited. In this prospective cross-sectional study, we aimed to evaluate the effectiveness of the diagnostic values of Lachman, Pivot Shift, Lever, and Anterior Drawer tests in terms of quadriceps atrophy and case phase in ACL injuries.Methods: In this prospective study, diagnostic values of Lachman, Pivot Shift, Lever, and Anterior Drawer tests were examined on 189 patients with positive MRI results as the gold standard.Results: Lever test positivity was significantly more frequent in the group with quadriceps atrophy preoperative and after sedation (p<0.05). Anterior Drawer test positivity was significantly more frequent in the group with positive quadriceps atrophy preoperatively, after sedation and after spinal anesthesia (p<0.05). Lever and Anterior Drawer tests were positively correlated with quadriceps atrophy preop and after sedation (p<0.05). Lever test before surgery, after sedation and after spinal anesthesia in the chronic patient group was more positive than in the acute and subacute groups (p<0.05). Lever test was positively correlated with phase preoperatively, after sedation and after spinal anesthesia (p<0.01).Conclusion: The presence or absence of quadriceps atrophy in patients with acute, sub-acute, or chronic ACL injury has a significant effect on the predictive value of the Lever test. We think that univariate analyzes may give incorrect results when demonstrating predictive value, and it would be more correct to perform multivariate analyzes.

Return to sport rate following sports trauma-related delayed bucket-handle meniscus repair with concomitant ACL reconstruction.

Return to sports rate of chronic meniscus repair concurrent with Anterior Cruciate Ligament (ACL) reconstruction remains unclear, especially there is no well-defined return to sports criteria for evaluation. The purpose of this retrospective study was to determine the success rate of chronic locked bucket-handle meniscal tear (BHMT) repair with concomitant ACL reconstruction. This study includes 51 chronic ACL injury patients with a locked meniscal tear of at least 6 weeks who underwent surgery. All cases were treated with arthroscopic BHMT repair and ACL reconstruction between 2017 and 2020. Patient demograph-ics, chronicity, pre-operative, and intraoperative surgical variables which associated with return to sports were defined. BHMT was repaired with an all-in-side meniscus repair and/or combined repair procedure first, then an anatomic outside-in ACL reconstruction using a suspension device for femoral fixation was performed. Patients underwent same rehabilitation program with the goal of return-ing to sport at approximately 4-8 months. A modified return-to-sport criterion was performed in this study. Fifty-one patients with an average age of 27.4 (range 18-48) years were included in the study. The average time elapsed from the occurrence of locked knee symptoms to surgery was 10.5±4.4 weeks. The mean follow-up time was 25.3±4.5 months. Sig-nificant improvement was observed in all patient-reported outcomes from baseline to the final follow-up. The mean modified Lysholm knee score increased from 45.5 points to 91.5 at the final follow-up (p<0.001). The 43 out of 51 patients (84.3%) were return to their recreational activities (amateur sports). The mean time to return to sport was 5.9±0.8 (5-8) months. Majority of the patients who underwent ACL reconstruction with BHMT repair return to their pre-operative activity levels in 8 months. All neglected BHMTs with concomitant chronic ACL rupture should be repaired in a single-stage surgery if the half plane-concave shape of the menisci has been preserved regardless of the delay in time to surgery.

Quantitative assessment of postural balance in patients with chronic anterior cruciate ligament injury- A controlled study

PurposeEvaluation of single and double limb support postural balance in patients with Anterior cruciate ligament (ACL)injury and comparison of the postural strategy adopted after ACL injury/deficiency(ACLD) with that of an age-matched healthy individual. MethodsThe study group that included 33 subjects confirming inclusion criteria had undergone postural balance assessment using the HUMAC Balance system. The parameters of the center of pressure excursion were recorded on a force plate and compared with age, BMI matched 66 healthy volunteers of control group. The center of pressure excursions was monitored using dependable variables such as sway path length(cm), the average velocity of sway(cm/sec), and the mean COP stability score(%). The mobility component was recorded as the percentage (%) of time spent on each target. ResultA decrease in postural balance in the injury group was evidenced by a statistically significant decrease of stability score(p = 0.015), increase in path length(p = 0.002) and decrease on time on target mean score (p= <0.001),. Although, the stability score path length and average sway velocity scores in the sound limb of the ACLD group showed impaired balance, the differences were not statistically significant (p = 0.180, p = 0.561, and p = 0.639 respectively) when compared with the dominant limb of the control group. ConclusionHUMAC balance system is an effective and simplified measure for quantifying postural balance. Although overall postural stability in ACL injury is impaired, static postural balance is maintained by the compensatory of strategy of sound limb. However, the quantitative parameters of postural stability for the sound limb, despite of a lower mean value, did not show statistically significant differences from the dominant limb of the controlled group.

Both medial and lateral bucket-handle meniscus tears associated with chronic ACL injury: A rare presentation of triple-PCL sign

BackgroundSeveral types of meniscal tear could be presented in both acute and chronic anterior cruciate ligament injury. The incidence of bucket-handle meniscus tears can be up to 30% of the overall meniscus tears cases. The case of both compartment (medial and lateral) bucket-handle meniscus is rarely occurred.CaseA case of both medial and lateral bucket-handle meniscus tears was reported in a male of 21 years old. The patient also had a chronic anterior cruciate ligament injury. The magnetic resonance imaging also showed a rare presentation of the triple-PCL sign with the sagittal view. Arthroscopic surgery with a meniscus repair and anterior cruciate ligament reconstruction was performed on the patient.ConclusionsSeveral specific imaging signs including triple-PCL sign could be presented in a rare case of both medial and lateral bucket-handle meniscus tears. Recognition of this sign is important to have accurate preoperative diagnosis and proper treatment plan.

Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears.

To analyse possible associations between the preoperative pivot shift (PS) test and both patient and injury characteristics in anterior cruciate ligament (ACL)-injured knees, considering previously neglected meniscal injuries such as ramp and root tears. The hypothesis was that a preoperative grade III PS was associated with the amount of intra-articular soft-tissue damage and chronicity of the injury. The cohort involved 376 patients who underwent primary ACL reconstruction (239 males/137 females; median age 26). Patients were examined under anesthesia before surgery, using the PS test. During arthroscopy, intra-articular soft-tissue damage of the injured knee was classified as: (1) partial ACL tear; (2) complete isolated ACL tear; (3) complete ACL tear with one meniscus tear; and (4) complete ACL and bimeniscal tears. Chi-square and Mann-Whitney U tests were used to evaluate whether sex, age, body mass index, sport at injury, mechanism of injury, time from injury and intra-articular damage (structural damage of ACL and menisci) were associated with a grade III PS. Intra-articular damage was further analyzed for two sub-cohorts: acute (time from injury ≤ 6months) and chronic injuries (> 6months). A grade III PS test was observed in 26% of patients. A significant association with PS grading was shown for age, time from injury and intra-articular soft-tissue damage (p < 0.05). Further analyses showed that grade III PS was associated with intra-articular damage in chronic injuries only (p < 0.01). In complete ACL and bimeniscal tears, grade III PS was more frequent in chronic (53%) than in acute knee injuries (26%; p < 0.01). Patients with chronic complete ACL and bimeniscal tears had a grade III PS 3.3 [1.3-8.2] times more often than patients in the acute sub-cohort. In ACL-injured patients, a preoperative grade III PS was mainly associated with a higher amount of intra-articular soft-tissue damage and chronicity of the injury. Patients with complete chronic ACL injuries and bimeniscal tears were more likely to have a preoperative grade III PS than their acute counterparts. This suggests that grade III PS may be an early sign of knee decompensation of dynamic rotational knee laxity in chronic ACL-injured knees with bimeniscal lesions. Level III.