Complete Anterior Cruciate Ligament Tears Research Articles

Lateral Posterior Tibial Slope in Male and Female Athletes Sustaining Contact Versus Noncontact Anterior Cruciate Ligament Tears: A Prospective Study

Background: Lateral posterior tibial slope (PTS) has been identified as a risk factor for primary anterior cruciate ligament (ACL) tears. Purpose/Hypothesis: The purpose was to prospectively determine if there was a difference in lateral PTS between male and female athletes sustaining contact ACL tears as compared with a group of sex-, age-, and activity-matched athletes who sustained noncontact ACL tears. It was hypothesized that there would be no difference in degree of lateral PTS between contact and noncontact mechanisms among patients sustaining primary ACL tears in sports. Study Design: Cohort study; Level of evidence, 3. Methods: Data from patients who underwent primary ACL reconstruction without posterior cruciate ligament injury between 2016 and 2018 by a single surgeon were prospectively analyzed. Measurements of lateral PTS were performed on magnetic resonance imaging. Mean values of lateral PTS were compared between the ACL tear groups. Additionally, a group of patients with intact knee ligaments were matched to patients with ACL tears to serve as controls. Results: A total of 245 patients had complete primary ACL tears during the inclusion period. Of these, 56 (23%) reported a contact mechanism of injury at the time of ACL tear, and 56 patients who sustained noncontact ACL tears were matched to the contact ACL tear group. There were no significant differences in sex (P≥ .999), age (P = .990), or body mass index (P = .450) between the patient groups. The mean lateral PTS was 9.1°± 2.9° for the ACL contact and 9.9°± 3.0° for the ACL noncontact group (P = .180). There was a significant difference in mean lateral PTS between the ACL tear groups (noncontact and contact: 9.5°± 3.0°) and matched control group (5.6°± 1.9°, P = .0001). Conclusion: The lateral PTS was significantly increased among patients with contact and noncontact ACL tears as compared with controls. However, there were no differences in lateral PTS between patients who sustained contact and noncontact ACL tears. Lateral PTS measured on magnetic resonance imaging does not appear to be predictive of the mechanism of injury type among patients who sustain a contact or noncontact primary ACL tear.

Higher aggrecan 1-F21 epitope concentrations in synovial fluid early after knee injury are associated with worse cartilage quality 20 years later

Purpose: To investigate if synovial fluid biomarkers of cartilage turnover acutely or years after an anterior cruciate ligament (ACL) injury are associated with subsequent knee cartilage status 20 years after injury. Methods: We studied a cohort of 32 patients who had coped with an ACL injury without ACL reconstruction and presented without radiographic diagnosis of osteoarthritis 16 years post injury. All had a delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) 20 years after a complete ACL tear. 25 out of 32 had one or more available synovial fluid samples aspirated without lavage either acutely after injury, or during 1-5 (median 4) follow up visits between 0.6 and 7 years after injury, and were included in this study (Table 1).Tabled 1Table 1 Characteristic of the 25 study subjects grouped by synovial fluid (SF) availability.Acute SF sampleChronic SF sample *n (% males)19 (63)22 (50)Age at injury, mean years (SD)25.2 (6.5)24.7 (6.3)BMI 20 years post-injury, mean (SD)25.3 (4.0)25.6 (3.6)Time between injury and sampling, median (range)4 (<1 to 13) days3.1 (0.6 to 7.1) yearsYears between injury and dGEMRIC, median (range)20.2 (18.8 to 23.1)20.2 (18.4 to 23.1)* 1-5 per individual, using the mean biomarker concentration or time for each individual. Open table in a new tab We quantified synovial fluid concentrations of two aggrecan epitopes (the 1-F21 epitope residing in or close to the keratan sulfate rich region, and the ARGS neoepitope generated by aggrecanase cleavage in the interglobular domain), cartilage oligomeric matrix protein (COMP), matrix metalloproteinase-3 (MMP-3) and tissue inhibitor of metalloproteinase-1 (TIMP-1) by immunoassays, and sulfated glycosaminoglycan (sGAG) content by Alcian blue precipitation. We created the ratio MMP-3/TIMP-1 to investigate differences in using these biomarkers alone or as a ratio between the enzyme and its inhibitor. We also investigated the ratios aggrecan/COMP, since the ratio 1-F21 aggrecan/COMP was reported to be more elevated in subjects with more progressive cartilage destruction in rheumatoid arthritis than 1-F21 aggrecan alone. Linear regression analysis was used to investigate associations between acute or chronic biomarker concentrations and cartilage quality at 20 years post injury. We included adjustments for age, sex, BMI at 20 years, and time between injury and knee puncture. For subjects with more than one chronic visit, we used the mean values for biomarkers and time in the regression models. Biomarker concentrations were log 10 transformed to achieve linear relationships with dGEMRIC values. To be able to compare effect sizes between biomarkers, we report standardized effects from the linear regression analysis. Results: With negative standardized effects close to 1, higher synovial fluid 1-F21 aggrecan concentrations or higher ratio 1-F21 aggrecan to COMP early after ACL injury were associated with shorter T1Gd values (inferior cartilage quality) 20 years later (Figure 1A). There was no similar association between acute ARGS aggrecan or sGAG content and T1Gd (Figure 1A), nor was chronic 1-F21 aggrecan concentrations associated with T1Gd values (Figure 1B). High similarity in the standardized effect sizes between aggrecan or sGAG concentrations alone and as ratios with COMP (Figures 1A and 1B), indicate that there was no added value in making such ratios compared to using the biomarker concentrations alone. Neither MMP-3 concentrations, nor the ratio MMP-3/TIMP-1 were predictive of subsequent cartilage quality in these subjects, which is consistent with previous findings of no apparent role of MMP-3 in pathological turnover of aggrecan. Conclusions: Acute (but not chronic) turnover of aggrecan generating increased synovial fluid concentrations of the 1-F21 epitope of aggrecan was associated with worse cartilage quality assessed by dGEMRIC 20 years later. Measuring specific aggrecan fragments carrying different epitopes appears to be important when investigating aggrecan as a predictive biomarker of cartilage quality.

Deep Learning for Detection of Complete Anterior Cruciate Ligament Tear.

Deep learning for MRI detection of sports injuries poses unique challenges. To address these difficulties, this study examines the feasibility and incremental benefit of several customized network architectures in evaluation of complete anterior cruciate ligament (ACL) tears. Two hundred sixty patients, ages 18-40, were identified in a retrospective review of knee MRIs obtained from September 2013 to March 2016. Half of the cases demonstrated a complete ACL tear (624 slices), the other half a normal ACL (3520 slices). Two hundred cases were used for training and validation, and the remaining 60 cases as an independent test set. For each exam with an ACL tear, coronal proton density non-fat suppressed sequence was manually annotated to delineate: (1) a bounding-box around the cruciate ligaments; (2) slices containing the tear. Multiple convolutional neural network (CNN) architectures were implemented including variations in input field-of-view and dimensionality. For single-slice CNN architectures, validation accuracy of a dynamic patch-based sampling algorithm (0.765) outperformed both cropped slice (0.720) and full slice (0.680) strategies. Using the dynamic patch-based sampling algorithm as a baseline, a five-slice CNN input (0.915) outperformed both three-slice (0.865) and single-slice (0.765) inputs. The final highest performing five-slice dynamic patch-based sampling algorithm resulted in independent test set AUC, sensitivity, specificity, PPV, and NPV of 0.971, 0.967, 1.00, 0.938, and 1.00. A customized 3D deep learning architecture based on dynamic patch-based sampling demonstrates high performance in detection of complete ACL tears with over 96% test set accuracy. A cropped field-of-view and 3D inputs are critical for high algorithm performance.

LONG-TERM FOLLOW-UP OF SKELETALLY IMMATURE PATIENTS WITH THE PHYSEAL-SPARING COMBINED EXTRA-/INTRA-ARTICULAR ILIOTIBIAL BAND ACL RECONSTRUCTION: KINEMATIC AND KINETIC RESULTS

Background: Anterior cruciate ligament (ACL) tears are among the most devastating orthopaedic injuries affecting young athletes, especially when they occur in children and adolescents. Growing interest in physeal-sparing techniques has prompted various investigations into the combined extra-articular/intra-articular modified-Macintosh ACL reconstruction with Iliotibial band autograph (ACLR-ITB), which is often used for younger skeletally immature patients with complete ACL ruptures. However, several aspects of the long-term function of knees undergoing this technique remain under-investigated. Therefore, the purpose of the current study was to determine two critical parameters of knee function—the vertical ground reaction force (VGRF) and vertical jump height - at various time intervals following the ACLR-ITB: 1-2 years, 2-5 years, 5-10 years, and &gt;10 years post-surgically. Methods: The current investigation was conducted at a single pediatric tertiary care center using a cross-sectional, laboratory-controlled study design. Inclusion criteria were skeletally immature patients with ACL tears who underwent an ACLR-ITB procedure. Exclusion criteria were major knee injuries (requiring rehabilitation &gt; 3 months) or subsequent surgery on the ipsilateral knee and/or any surgery on the contralateral knee. During data collection, 29 reflective markers were applied to participants who performed drop vertical jumps (DVJ) three consecutive times and vertical single-limb hops (one time, each limb). A three dimensional (3D) motion analysis system with force plates was used. Kinematic and kinetic data were collected at 240 Hz and 1080 Hz respectively, and synchronized in time. The sequence of which limb was tested first in the vertical single-limb hop test was randomized. The instance of initial contact was identified and the landing phase was defined as the first 500 ms after initial contact. Major outcome variables included VGRF and vertical jump height. The VGRF were normalized by mass (kg), and mean peak values of the landing phase were used for analysis. Vertical jump height was calculated through following equation: ½ g(t/2)2, where g=9.81 m/s2 and t=time in seconds in the air. Descriptive statistics were used to analyze basic demographic characteristics. Paired t-tests were employed to compare VGRF and vertical jump height between the two limbs by four groups (1-2 years, 2-5 years, 5-10 years, and &gt;10 years) separately. Additionally, equivalence analysis using two one-sided paired t-tests was applied to further support comparison of the two limbs. Any difference in the outcome measures (VGRF and vertical jump height) at the 26 patient-level was further tested to examine equivalency between the two limbs using a margin of equivalence of 4 (a difference less than 4 was not considered clinically important). The a priori statistical significance was set as p=0.05. Results: The study population consisted of 40 subjects (1-2 years: N=9; 2-5 years: N=13; 5-10 years: N=10; &gt;10 years: N=8), with demographic information presented at Table 1. Based on available data (26 of 40, 19 males and 7 females, 1-2 years: N=6, 2-5 years: N=9, 5-10 years: N=7, &gt;10 years: N=4), paired t-tests showed no statistically significant differences in VGRF and vertical jump height between ACLR-ITB and non-ACLR limbs in DVJ (Table 2) and vertical single-limb hop (Table 3) in any of the follow-up time groups. The equivalence analysis identified that the main outcome measures for the ACLR-ITB limb were equivalent to those of the non-reconstructed limb at the 26 patient-level (DVJ: p=0.016, VSH: p&lt;0.001, JH: p=0.01; Note: p&lt;0.05 confirms equivalency that the measures for the two limbs are close enough so that reconstructed limb cannot be considered superior or inferior to the native limb). Conclusion/Significance: Based on VGRF and vertical jump height in DVJ and vertical single-limb hop maneuvers through kinematic and kinetic analyses, ACLR-ITB knee demonstrated equivalent or superior function to the contralateral uninjured limbs at 1-2 years, 2-5 years, 5-10 years, and &gt;10 years following reconstruction. These data contribute broader scientific support for the ACLR-ITB procedure offering lasting functional benefits for skeletally immature athletes with complete ACL tears. [Table: see text][Table: see text][Table: see text]

Outcome analysis of arthroscopic single bundle anterior cruciate ligament reconstruction through an accessory antero medial portal technique

Introduction: Anterior Cruciate Ligament (ACL) injuries are quite common among young sportspersons and those leading an active life, thereby stressing on the need to provide a rehabilitation that provides full functionality and can cut-back the duration of hospital stay in order to enable these persons to contribute actively to the society. As far as the incidence of ACL injuries in general population is concerned, it is one of the most common ligament injuries in sports traumatology.Materials and Methods: This is a comparative prospective study comprising of two groups each having 30 patients with complete ACL tear. In one group Accessory Antero medial portal technique was used and in the other group antero medial portal technique was used. The follow period was 1 year. Patients were assessed clinically and by lysholm knee score.Result: On the basis of this study it was found that patients in short term there is no significant difference between two techniques. However, in mid-term (6 months and 12 months) functional results are better in AAM as compared to AM. Femoral tunnel angles are smaller in AAM as compared to AM.Conclusion: For single bundle ACL reconstruction Accessory antero medial portal technique is a better procedure.

Defining a prognostic criterion of orthopaedic complications development in patients with an injury of anterior cruciate ligament of knee joint

IntroductionPrognostic indices of orthopaedic implications development were investigated among patients with anterior cruciate ligament (ACL) injuries on the basis of stabilography research during the functional period of rehabilitation.MethodsThe study included 52 randomly selected individuals with a complete ACL tear qualified for surgical reconstruction. The patients’ age was 18–59 (average: 37.8 ± 2.0) years. All participants underwent rehabilitation treatment in the Institute of Traumatology and Orthopaedics, National Academy of Medical Sciences of Ukraine, and had surgeries in the Institute’s clinics. The crural part of the graft was fixed with the assistance of either the RigidFix system or the Cross-Pin system, and the Biointrafix or Biosure Sync system was applied for the tibial part.Results and conclusionsOn the basis of the performed analysis of indices that characterize the functional condition of the injured limb of patients with an injury of ACL of knee joint at the functional stage of rehabilitation treatment, it is possible to identify a high and medium level of loading asymmetry in the lower extremities, decrease of electrobiological activity and muscle resistance ability during bending, stretching, adduction, and abduction, as the main prognostic criterion of orthopaedic complications development.

A threshold value of 3.5 mm of passive anterior tibial subluxation on MRI is highly specific for complete ACL tears

To identify and quantify passive anterior tibial subluxation on MRI using a standardized measurement protocol and determine the diagnostic threshold of subluxation for complete anterior cruciate ligament tears. A retrospective case-control study was performed. Patients who underwent surgery for a complete isolated ACL tear between 2009 and 2015 were matched for age and gender to controls with an intact ligament on knee MRI. All subjects underwent 1.5T closed field MR imaging with the same protocol. Measurements were performed on axial sequences to evaluate translation of the medial and lateral condyles compared to the tibial plateau. Each compartment was measured between the vertical tangent to the posterior femoral condyles and the most posterior part of the tibial plateau. The main criterion was global passive subluxation measurements on MRI, corresponding to mean medial and lateral compartment subluxation. The reproducibility and diagnostic value of passive subluxation were calculated. Sixty (30/30) subjects were included, mean age 27.1 ± 1.7years, 20 women and 40 men. Patients had a significantly higher global passive subluxation than controls (3.3 ± 0.6mm vs 0.6 ± 0.2mm, respectively p < 0.00001). Reproducibility was excellent and the diagnostic value of passive subluxation for a complete ACL tear was fair. A passive subluxation threshold of 3.5mm had a sensitivity of 55.2%, a specificity of 100% and 77.6% of well-classified subjects. The calculated cutoff value for global passive subluxation to identify patients with a complete ACL tear was 3.5mm, with excellent specificity and a high positive likelihood ratio. Suboptimal clinical results following ACL reconstruction could be partially due to failure to restore an anatomical femorotibial relationship. III.

Uncovered Medial Meniscus Sign on Knee MRI: Evidence of Lost Brake Stop Mechanism of the Posterior Horn Medial Meniscus.

The objective of our study was to evaluate the association between anterior tibial translation and injuries on the posterior horn medial meniscus (PHMM) and the integrity of the brake stop mechanism of the PHMM in the anterior cruciate ligament (ACL)-deficient knee. This retrospective study included 85 consecutive patients with an arthroscopically confirmed complete ACL tear. Anterior tibial translation was quantitatively measured using sagittal MRI at the midpoint of the lateral femoral condyle. The "uncovered medial meniscus" sign was considered positive if a vertical line tangent to the posteriormost margin of the medial tibial plateau intersected the PHMM at the midpoint of the medial femoral condyle on sagittal MRI. Concomitant injuries on the structures of the posteromedial and posterolateral corners of the knee, including PHMM tear and meniscal ramp lesion, were recorded. Stratified subgroup analysis and multivariable regression analysis were performed to identify factors associated with anterior tibial translation. The uncovered medial meniscus sign was positive in 21.2% (18/85) of patients and was significantly associated with anterior tibial translation. In the stratified subgroup analysis and multivariable regression analysis, positive uncovered medial meniscus sign consistently showed a significant association with anterior tibial translation and generated an additional 2.8 mm of anterior tibial translation. Other injuries, including PHMM tear and meniscal ramp lesion, were not associated with anterior tibial translation. The uncovered medial meniscus sign showed a statistically significant correlation with anterior tibial translation and could be a useful marker for the lost brake stop mechanism of PHMM in the ACL-deficient knee.

Magnetic Resonance Imaging-Based Prevalence of Anterolateral Ligament Abnormalities and Associated Injuries in Knees with Acute Anterior Cruciate Ligament Injury.

The purpose of this study was to determine and compare the prevalence of anterolateral ligament abnormality and associated injuries among patients with complete and partial anterior cruciate ligament tears. In addition, the prevalence of associated injuries with anterolateral ligament abnormality was further analyzed. Of the 158 patients diagnosed with acute anterior cruciate ligament tear, 82 patients were diagnosed with acute complete anterior cruciate ligament confirmed by magnetic resonance imaging (MRI) and arthroscopic procedures (Group C), and 74 patients were diagnosed with acute partial anterior cruciate ligament tears confirmed by MRI (Group P). The status of the anterolateral ligament, collateral ligaments, menisci, and osseous lesions was assessed. There was a significantly higher prevalence of anterolateral ligament abnormalities in Group C than Group P (36.6 vs. 4.1%, p < 0.001). Medial collateral ligament, lateral collateral ligament, Segond fracture, osseous lesion at the fibular head, lateral tibial plateau, lateral femoral condyle, and medial tibial plateau were significantly associated with anterolateral ligament abnormality. Furthermore, severity of osseous lesion at the lateral tibial plateau, lateral femoral condyle, and medial tibial plateau was significantly associated (with linear correlation) with anterolateral ligament abnormality. The prevalence of anterolateral ligament abnormality was significantly higher in patients with complete anterior cruciate ligament tear (36.6%) than those with partial anterior cruciate ligament tear (4.1%), but with noticeable prevalence of anterolateral ligament abnormality in the partial anterior cruciate ligament tear group. Associated lesions significant to anterolateral ligament abnormality were tears in both collateral ligaments, lateral-sided osseous lesions, and osseous lesion of the medial tibial plateau.

Knee Examination under Anesthesia: Development of a Predictive Score for Partial Anterior Cruciate Ligament Tears.

PurposeTo determine the accuracy of knee examination under anesthesia (EUA) and develop a prognostic score for partial anterior cruciate ligament (ACL) tears.Materials and MethodsA total of 229 patients with an ACL injury were included. Knee EUA was performed using the Lachman test, pivot shift test and arthrometric maximum manual side-to-side difference (AMMD) test. The arthroscopic examination is the gold standard for the diagnosis of partial and complete ACL tears, which was compared with EUA findings. Multivariate logistic regression was estimated, and the significant variables were used to develop a predictive score.ResultsThe relative risk for a complete tear with Lachman 2+ was 8.55 (range, 3.5 to 20.7) and 53.04 (range, 6.7 to 417) with Lachman 3+, compared to Lachman 1+. Negative pivot shift was reported in 23 cases in the partial tear group (76.7%) and in 22 in the complete tear group (11.1%). The AMMD was 3.5 mm in the partial tear group and 5.4 mm in the complete tear group (p<0.05). A prognostic score of less than five suggested the presence of a partial ACL tear. The score showed 81.1% sensitivity and 68.7% specificity.ConclusionsPartial ACL tears can be differentiated from complete tears with Lachman test, pivot shift test, and AMMD test.

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

ObjectiveTo assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.DesignProspective diagnostic study.SettingsOrthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.ParticipantsConsecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).InterventionsNot applicable.Main outcome measuresHistory elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.ResultsForty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Trends in Management and Complications of Anterior Cruciate Ligament Injuries in Pediatric Patients: A Survey of the PRiSM Society.

Anterior cruciate ligament (ACL) injuries have been recognized and treated with increasing frequency in children and adolescents. ACL reconstruction (ACLR) in skeletally immature patients has unique considerations and there is a large practice variation in the management of these injuries. The purpose of this study was to survey the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their experience with the management and complications of pediatric ACL injuries. A 15-question survey was distributed to 71 orthopaedic members of the Pediatric Research in Sports Medicine study group. Regarding treatment of an 8-year-old child with a complete ACL tear, 53% of respondents recommended iliotibial band reconstruction, 33% recommended all-epiphyseal reconstruction, and only 3% would treat nonoperatively in a brace. In adolescent patients with 2 years of growth remaining, 47% of respondents recommended a physeal "respecting" technique, 31% recommended a physeal-sparing technique, and 19% would perform an adult-style ACLR. There were 29 new cases of growth arrest reported. This study demonstrates that there have been major changes in the trends in pediatric ACLR over the past 15 years, and the most treatment variability is found among adolescent patients with about 2 years of growth remaining. The study also demonstrates that while the overall incidence of growth disturbance after ACLR remains low, new cases of growth disturbance continue to be identified. Level V-survey of expert opinion and experience.

Anterior cruciate ligament reconstruction surgery timing with respect to meniscal-chondral damage

Background: Anterior cruciate ligament (ACL) tear is one of the most common types of knee injuries. Delay in diagnosis and treatment of ACL injuries can lead to further damage of the meniscus and cartilage. In this study, we tried to show the distribution of injuries over time and types. Methods: This retrospective study was performed on 336 patients with the diagnosis of primary ACL tear without other ligament injuries. The data including site and grade of the meniscal tear and cartilage damage, based on the International Cartilage Repair Society Classification, the time between diagnosis and surgical procedure, and the treatment method were collected. In this study, we divided patients into four groups according to injury to surgery time. Groups were 3 months, 3–6 months, 6–12 months, and over 12 months to surgery. Results: The results showed that a rate of cartilage damage had no significant correlation with a time interval between injury and surgery (P = 0.54). Furthermore, no significant correlation was found between the site of cartilage damage and the interval time after injury to surgery. The results indicated that the meniscal tear increases in case of a delay to perform surgery (P = 0.004). However, no significant relation was found between the site and pattern of meniscal injury and time. Moreover, patients with a complete ACL tear had a significantly higher rate of meniscus injury compared to those with a partial ACL tear (0.048). Conclusion: The findings of this study show that there is no significant relationship between the time of surgery and the risk of chondral damage after the ACL tear over time. ACL-ruptured patients should undergo the ACL reconstruction surgery up to 3 months from knee trauma to prevent further meniscal injuries.

Functional outcome following open reconstruction of anterior cruciate ligament using bone patellar tendon bone graft and interference screws

Background: Various surgical methods have been described for the anterior cruciate ligament (ACL)tear with its own merits and demerits. Though arthroscopic reconstruction is the commonly done surgery, open reconstruction is still a good alternative in hospitals where scopy instruments/facilities are not available. This studies aim was to analyse the functional outcome following open ACL reconstruction using Bone- patellar tendon -bone graft (BPTB) Materials and methods: This is a prospective study of 30 patients aged between 18 to 50years with complete ACL tear with or without meniscal injury. Patients were treated by open reconstruction using bone- patellar tendon- bone graft and interference screws. Appropriate post-operative care was given. ACL rehabilitation protocol was followed for all patients. The functional evaluation of the patients was done at 1year follow up. We used IKDC-2000, Lysholm & Gillquist scoring system for the evaluation of the results. Results: 90% of patients had normal or near normal knee, 10% of the patients had abnormal knee as per IKDC 2000 scoring system. excellent-good results were seen in 83% of the cases, while 14% had intermediate grade. The complications observed were anterior knee pain (26%), mildnumbness over donor site (13%), patella fracture (n=1). Conclusion: Open ACL reconstruction is still a good alternative to arthroscopic reconstruction in hospitals where scopy instruments/facilities are not available.

Accuracy of the Lever Sign Test in the Diagnosis of Anterior Cruciate Ligament Injuries.

Background:The lever sign test is a new physical examination tool to diagnose anterior cruciate ligament (ACL) tears. Preliminary results suggest almost 100% sensitivity and specificity to diagnose acute and chronic complete ACL tears and clinically significant partial tears as compared with magnetic resonance imaging (MRI).Purpose:To assess the sensitivity and specificity of the lever sign test for the diagnosis of acute ACL injuries, as compared to MRI. We also aimed to determine the accuracy of the lever sign test compared with 3 other tests (anterior drawer, Lachman, and pivot shift) when performed by providers of various training levels, and with the patient awake or under anesthesia.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:We evaluated patients with a chief concern of acute (≤4 weeks) knee pain seen between October 2014 and January 2015, with a thorough history, physical examination, and standard radiographs. MRI was the reference standard; patients without an MRI evaluation were excluded. The 4 physical examination maneuvers were performed on each symptomatic knee during the initial clinic visit (for nonsurgical patients) or under anesthesia in the operating room (for surgical patients) by a randomly assigned undergraduate student, medical student, orthopaedic resident, or orthopaedic fellow. The senior author trained all staff to perform the lever sign test. Statistical analyses were performed.Results:Of 102 patients, 54 were surgical (28 female, 26 male), and 48 were nonsurgical (16 female, 32 male); the mean patient age was 23 years (range, 15-66 years). The overall accuracy of the lever sign test was 77% (63% sensitivity, 90% specificity); the accuracy was similar between patients under anesthesia and awake (77% vs 76%, respectively). There were no significant differences when comparing the sensitivity and specificity of the lever sign test with patients under anesthesia and awake (sensitivity: under anesthesia, 86%, and awake, 68% [P = .40]; specificity: under anesthesia, 85%, and awake, 96% [P = .17]). Furthermore, the accuracy of the lever sign test was similar when performed on female versus male patients (75% vs 79%, respectively) or when performed by undergraduate students and medical students compared with orthopaedic residents and fellows (84% vs 88%, respectively).Conclusion:Our study results challenge the exceptional sensitivity and specificity values (both 100%) of the lever sign test, as reported by the original author of the test.

Surgical Treatment of Segond Fractures in Acute Anterior Cruciate Ligament Reconstruction.

Background:The Segond fracture is an avulsion-type fracture located on the anterolateral aspect of the tibia associated with a ligament recently termed the anterolateral ligament. This injury has been described as pathognomonic for an anterior cruciate ligament (ACL) tear and is associated with a higher grade pivot shift.Purpose:To present and report 2-year clinical outcomes of a surgical technique for acute ACL reconstruction with fixation of a concomitant Segond fracture.Study Design:Case series; Level of evidence, 4.Methods:A retrospective chart review was performed of patients who underwent acute reconstruction for a complete ACL tear with concomitant Segond fracture fixation between January 2010 and December 2014; surgery was performed by a single surgeon. Patients underwent direct Segond fracture repair by either suture alone, suture anchor, or cannulated screw fixation based on the size of the lesion, followed by a 2-incision hamstring autograft intra-articular reconstruction. Pre- and postoperative KT-1000 arthrometer assessment, Lachman test, and pivot-shift test were performed, and patients were administered validated subjective outcome surveys.Results:Twelve patients met inclusion criteria for this review. The measured pre- and postoperative objective and subjective scores were significantly improved in all patients. Side-to-side anterior laxity was significantly improved in all patients based on Lachman and KT-1000 arthrometer testing. A significant pivot shift demonstrated preoperatively (3+, n = 11 [92%]; 2+, n = 1 [8%]) was corrected after fixation, except in 1 patient (8%), who maintained a 1+ pivot shift. Lysholm, Tegner, and International Knee Documentation Committee subjective and objective scores were significantly improved. At a minimum 2-year follow-up, no patients reported rerupture, and only 1 patient (8%) underwent a subsequent procedure (a meniscectomy). No major or minor complications were reported, and all patients returned to their previous activity levels at a mean of 6 months postoperatively.Conclusion:Direct repair of the Segond fracture and plication of the anterolateral capsule in patients with an ACL rupture and a high-grade pivot shift demonstrate good clinical outcomes, restoration of rotational stability, and maintenance of knee range of motion at 2 years postoperatively, with no major complications.

Assessment of knee joint range of motion and the level of pain in patients after arthroscopic ACL reconstruction in the selected physiotherapy model

Abstract Introduction: In the majority of cases, anterior cruciate ligament (ACL) injuries require specialist surgical and physiotherapeutic treatment. The fact that the patient regains a full range of flexion and extension in the knee joint as well as the reduction or elimination of pain is a significant determinant of successful physiotherapy. Material and methods: The study included 72 randomly selected individuals with a complete ACL tear who were qualified for its surgical reconstruction. The research group included 37 patients aged 18-60 (mean age 37±10.3 years). All the participants from this group underwent physiotherapy based on recognised schemes of rehabilitation and performed for 4 weeks before the reconstruction surgery. The control group included 35 patients aged 18-60 (mean age 34±10.0 years) who did not undergo any presurgical physiotherapy programme. Results: Both in the research group and in the control group, subsequent measurements revealed a statistically significant improvement in the range of flexion and extension (p&lt;0.05). Statistical analysis revealed a significantly better extension 1 week and 6 weeks after the ACL reconstruction (p&lt;0.05) in the research group. Statistically significant differences in the level of pain in patients from both groups were noted in subsequent measurements (p&lt;0.05). Also, a statistically significant difference concerning pain assessment 12 weeks after the reconstruction was noted in the research group (p&lt;0.05). Conclusions: A quicker recovery of the range of extension in the operated knee joint and lower intensity of pain in the final measurement noted in the research group may indicate a certain therapeutic value of presurgical physiotherapy.

Accuracy of Magnetic Resonance Imaging in Diagnosis of Internal Derangement of the Knee

The current study aims to assess the sensitivity and specifi city of magnetic resonance imaging by reference to arthroscopy in the preoperative diagnosis of knee pathologies. In this retrospective study, pre-operative knee magnetic resonance imaging reports of 70 patients were reviewed by a blinded musculoskeletal radiologist and compared with the respective arthroscopic fi ndings recorded in the operative notes. Pre-operative magnetic resonance imaging demonstrated a sensitivity level of 92.7% and 61.3% and specifi city level of 33.3% and 53.9% in detecting pathologies of the medial and lateral menisci, respectively. With respect to the cases of complete anterior cruciate ligament tear, sensitivity was 76.7% with 92.5% specifi city. On the other hand, magnetic resonance imaging demonstrated 100% sensitivity and 90.7% specifi city in the diagnosis of posterior cruciate ligament partial tear. Relatively better sensitivity in detecting cruciate ligaments pathology and better specifi city in detecting menisci pathology was reported using magnetic resonance imaging. Almost 25% of complete anterior cruciate ligament injuries may remain undetected in preoperative magnetic resonance imaging reports, while they represent the most prevalent knee injury. Magnetic resonance imaging should be used with caution in knee pathology and arthroscopy continues to be the gold standard.

Projecting Lifetime Risk of Symptomatic Knee Osteoarthritis and Total Knee Replacement in Individuals Sustaining a Complete Anterior Cruciate Ligament Tear in Early Adulthood

To estimate the lifetime risk of knee osteoarthritis (OA) and total knee replacement (TKR) in persons sustaining anterior cruciate ligament (ACL) tear by age 25 years. We used the Osteoarthritis Policy Model to project the cumulative incidence of symptomatic knee OA requiring TKR in varying situations: no prevalent or incident injury; isolated ACL tear, surgically treated; isolated ACL tear, nonoperatively treated; or a prevalent history or surgically treated ACL and meniscal tear (MT). We estimated MT prevalence and incidence and increased risk of knee OA associated with ACL injury and MT from published literature. We conducted a range of sensitivity analyses to examine the impact of uncertainty in input parameters. Estimated lifetime risk of symptomatic knee OA was 34% for the cohort with ACL injury and MT, compared to 14% for the no-injury cohort. ACL injury without MT was associated with a lifetime risk of knee OA between 16% and 17%, depending on ACL treatment modality. Estimated lifetime risk of TKR ranged from 6% in the no-injury cohort to 22% for the ACL injury and MT cohort. Subjects in the ACL injury and MT cohort developed OA approximately 1.5 years earlier (55.7 versus 57.1) and underwent TKR approximately 2 years earlier (66 versus 68) than the cohort without knee injuries. Sustaining ACL injury early in adulthood leads to greater lifetime risk and earlier onset of knee OA and TKR; concomitant MTs compound this risk. These data provide insight into the impact of sustainable injury prevention interventions in young adults.

Cyclops lesions detected by MRI are frequent findings after ACL surgical reconstruction but do not impact clinical outcome over 2years.

To assess the impact of cyclops lesions with MRI in patients treated for anterior cruciate ligament (ACL) tears on clinical outcome. In 113 patients (age 29.8 ± 10.5y; 55 females; BMI 24.8 ± 3.7kg/m2) with complete ACL tear, 3T-MRI scans were obtained before, 6-months, 1-year (n = 75) and 2-years (n = 33) after ACL reconstruction. Presence and volume of cyclops lesions were assessed. Clinical outcomes were measured using the Knee injury and Osteoarthritis Outcome Score (KOOS) and differences between time points (∆KOOS) were calculated. Changes of KOOS subscales were compared between patients with and without cyclops lesion. KOOS was also correlated with lesion volume. Cyclops lesions were found in 25% (28/113), 27% (20/75) and 33% (11/33) of patients after 6-months, 1- and 2-years, respectively. The lesion volume did not change significantly (P > 0.05) between time points, measuring 0.65 ± 0.59, 0.81 ± 0.70 and 0.72.9 ± 0.96cm3, respectively. Clinical outcomes based on KOOS subscales were not significantly different in patients with cyclops lesions compared to those without cyclops lesions (each comparison P > 0.05), and no significant associations of clinical outcomes with lesion volume were found (P > 0.05). Neither presence nor size of cyclops lesions within the first 2-years after ACL surgery were associated with inferior clinical outcome. • Cyclops lesions had a prevalence of 25% in patients after ACL reconstruction. • Subjects with cyclops lesions did not have an inferior clinical outcome. • Cyclops lesions developed within the first 6months after surgery. • The size of cyclops lesions did not significantly change over a period of 2years.