Concomitant Ligament Injury Research Articles

Does Knee Flexion Influence the Relationship between the Femoral Tunnel and the Lateral Anatomic Structures During ACL Reconstruction?

In ACL reconstruction, the relationship of the femoral tunnel outlet to the anatomy of the lateral knee is clinically important, but whether that relationship is influenced by knee flexion using a transportal technique is unclear. The purposes of this study were to (1) to describe the relationship between the outlet of the femoral tunnel and the lateral anatomic structures of the femur, including the lateral epicondyle, lateral collateral ligament, popliteus tendon, and lateral head of the gastrocnemius, as a function of knee flexion angle when the tunnel was created; and (2) to determine the knee flexion range of angles that best limits the risk of damage to these structures as the femoral tunnel is created during anatomic single-bundle ACL reconstruction using the transportal technique. Between January 2017 and June 2018, 113 patients underwent ACL reconstruction, of which 62 (55%) who had a primary single-bundle ACL reconstruction with transportal technique using autogenous quadruple hamstring graft were included. Patients who were treated with grafts other than autogenous quadruple hamstring tendon, and had concomitant ligamentous injury, revisional ACL reconstruction, previous operative history of the affected knee, osseous deformity and osteoarthritis were excluded. Included patients were divided into three groups according to their knee flexion angles as the femoral tunnel was created. The femoral tunnel was created with rigid straight reamer with the knee flexed as much as possible in figure-of-four position and the flexion angle was measured with a sterile 12-inch goniometer intraoperatively for all patients. Fourteen patients (23%) had the femoral tunnel created with the knee in < 120° of flexion, 23 (37%) had the tunnel created in 120° to 129° of flexion, and 25 (40%) had the tunnel created in ≥ 130° of flexion. The femoral tunnel's outlet and the lateral anatomic structures of the femur, including the femoral origins of the lateral epicondyle, lateral collateral ligament, popliteus tendon, and lateral head of the gastrocnemius, were identified on a three-dimensional model that was reconstructed using CT images taken on postoperative day 1. The shortest distances from the femoral tunnel's outlet to these lateral anatomic structures were measured by two observers and interobserver reliability was high (intraclass correlation coefficient > 0.75). The distances were compared among the groups, and a correlation analysis of the measured distances regarding the knee flexion angle during creation of the femoral tunnel was performed. The safe distance was set as 12 mm between the centers of the femoral tunnel's outlet and the lateral structures considering the footprint of the lateral structures, diameter of the femoral tunnel, and femoral tunnel widening. Any anatomic structures that were closer to the femoral tunnel than the safe distance were noted, and the cutoff point of knee flexion for injury to the lateral anatomic structures was determined with a receiver operating characteristic curve. As knee flexion angle increased, the distance from the femoral tunnel to the lateral head of the gastrocnemius increased (r = 0.657, p < 0.001), and the distance to the lateral epicondyle decreased (r = -0.627, p < 0.001), as did the distance of the tunnel to the lateral collateral ligament (r = -0.443, p < 0.001) and the popliteus tendon (r = -0.653, p < 0.001). The cutoff point of the knee flexion angle associated with structural injury was 131° (sensitivity, 70%; specificity, 73%) for the lateral collateral ligament and 121° (sensitivity, 86%; specificity, 67%) for the lateral head of the gastrocnemius. As knee flexion increased, the femoral tunnel's outlet tended to move more anteriorly and distally. Consequently, the safe distance to the lateral head of the gastrocnemius increased and the distances to the lateral epicondyle, lateral collateral ligament, and popliteus tendon decreased with increased knee flexion. To avoid possible damage to the lateral anatomic structures and obtain stable fixation in ACL reconstruction using the transportal technique, we recommend creating a femoral tunnel within 121° and 131° of knee flexion. Level III, therapeutic study.

Midterm Outcomes following Acute Repair of Grade III Distal MCL Avulsions in Multiligamentous Knee Injuries.

There is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4-9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

Primary Repair of the Medial Collateral Ligament with a Double Row Suture Technique and Suture Tape Augmentation for Acute Tibial-Sided Injuries

The management of medial collateral ligament (MCL) injuries has evolved during the past 30 years. Most heal reliably with conservative management. The treatment of MCL sprains with concomitant other ligamentous injuries continues to be controversial. Surgical management of chronic laxity of the medial structures can be quite difficult, and therefore anatomic repair of the medial support structures in the acute setting is preferred when indicated. Complete avulsion of the superficial and deep MCL from the tibia with disruption of the meniscal coronary ligament have a poor prognosis with non-operative treatment and may be optimally managed with acute surgical repair for improved valgus stability. A recent review demonstrated that there is a role for primary MCL repair for select patients. This technique addresses complete avulsions from the tibia, using multiple anchors for anatomic reattachment of the deep and superficial MCL, SutureBridge construct to enhance footprint compression, and suture tape to augment the MCL repair. Advantages of this technique include utilization of suture tape augmentation to allow for early range of motion, maintenance of the native MCL to preserve proprioception, and repair in the acute setting for faster recovery.

“RELATIVE” RISK OF ACL RE-INJURY

Background Several studies have examined ACL injury history among relatives of patients undergoing ACL reconstruction, but they have primarily analyzed adult populations with variable results. Additionally, few studies have examined concomitant injuries or post-operative outcomes among pediatric patients with a family history of ACL tear. Therefore, the purpose of this study was to identify the proportion of pediatric ACL patients with a first degree relative who had suffered an ACL tear while also examining concomitant meniscal or ligamentous injuries and subsequent complication rates. Methods 1009 patients who underwent ACL reconstruction at an urban tertiary care children’s hospital between January 2009 and May 2016 were contacted via email and/or telephone and asked to complete a follow-up survey. Data collected included subsequent complications – including graft rupture, contralateral ACL injury, and meniscus tears – along with information regarding any relatives who had suffered an ACL tear. Patient medical records were reviewed to determine the age of the patient at the time of surgery as well as concomitant meniscus and ligamentous injuries at the time of injury. Results 425 patients who underwent primary ACL reconstruction completed the survey. The mean age at surgery was 15.0? 2.4 years with a mean follow-up time of 4.6? 2.1 years. Patients were stratified into three groups by the number of first degree relatives (parent or sibling) who had an ACL tear history: no relatives, one relative, or more than one relative. 101 respondents (23.8%) reported at least one first degree relative who had previously torn an ACL. 15 (3.5%) had more than one first degree relative with an ACL tear. There were no differences in the age at time of surgery or the number of concomitant meniscus and ligamentous injuries suffered across the three stratified groups. While children with zero or one affected first degree relative had similar rates of graft failure (11.4% and 9.3%, respectively), those with two or more affected first-degree relatives had a significantly higher graft failure rate (40.0%, p=0.003). There were no differences in the number of post-operative contralateral ACL tears (p=0.438) or meniscus tears (p=0.477) across the groups. When these complications were analyzed together as one outcome, patients with more than one affected first-degree relative suffered more combined graft ruptures, contralateral ACL tears, and meniscal tears (53.3%) than patients with zero (21.9%) or only one affected first degree relative (22.1%, p=0.02). This group of patients also suffered more total complications that required surgical intervention (66.7%) than patients with zero (21.0%) or only one affected first degree family member (22.1%, p&lt;0.001). Conclusion/Significance Patients undergoing primary ACL reconstruction who have a strong family history of ACL tear appear more likely to suffer a post-operative graft rupture and suffer a complication requiring surgery.

Long-term Results After Repair of Isolated Meniscal Tears Among Patients Aged 18 Years and Younger: An 18-Year Follow-up Study

Background: Meniscal repair is desirable over resection to prevent postmeniscectomy arthritis, especially among young and active patients. However, long-term data are currently lacking following isolated meniscal repair, particularly in the pediatric population. Purpose/Hypothesis: To report long-term follow-up of isolated meniscal tears treated by meniscal repair in a pediatric and adolescent population and to compare those results with previous midterm follow-up data reported. The authors hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Forty-four patients aged ≤18 years undergoing repair of an isolated meniscal tear (without concomitant anterior cruciate ligament injury) between 1990 and 2005 were included. At the time of final follow-up, recurrent tear, reoperations, and International Knee Documentation Committee (IKDC) and Tegner scores were determined. With logistic regression, the overall failure among tear types was calculated. Wilcoxon rank sum analysis were performed to calculate the differences in clinical outcome for different time points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At a mean follow-up of 17.6 years (range, 13.1-25.9 years), 32 patients with 33 isolated meniscal repairs (29 male, 3 female) with a mean age of 16.1 years (range, 9.9-18.7 years) at surgery were included in this study. At early follow-up, the overall failure rate was 14 of 33 (42%); complex tears (80%) and bucket-handle tears (47%) had higher overall failure rates when compared with simple tears (18.2%), although only complex tears had a significantly higher failure rate. However, no further failures occurred since midterm follow-up with any tear type. At final follow-up, the mean IKDC score was 92.3, which was significantly increased when compared with preoperative (65.3, P < .0001) and midterm (90.2, P = .01) scores. The mean Tegner score (6.5) was significantly lower than both preoperative (8.3, P < .0001) and midterm (8.4, P < .0001) scores. There was no difference in Tegner or IKDC score for patients with successful versus failed repair. Conclusion: In conclusion, while there was a high early failure rate, this study demonstrated overall good to excellent long-term clinical outcomes after isolated meniscal repair in an adolescent population, even for those requiring reoperation. Early failure and reoperation rates were variable, depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears as compared with other tear types.

Effect of Activity at Time of Injury and Concomitant Ligament Injuries on Patient-Reported Outcome After Posterior Cruciate Ligament Reconstruction.

Background:The outcomes after posterior cruciate ligament reconstruction (PCLR) have been shown to be inferior to those of anterior cruciate ligament reconstruction. There is a lack of knowledge regarding prognostic factors of PCLR outcomes.Purpose:To explore the effect of injury mechanism and concomitant ligament injuries on patient-reported outcomes at 2-year follow-up after PCLR.Study Design:Cohort study; Level of evidence, 2.Methods:A total of 373 patients who underwent primary PCLR and who were registered in the Norwegian Knee Ligament Registry were included. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used as the patient-reported outcome measure. At 2-year follow-up, 252 patients (68%) had completed the KOOS. Multiple regression analysis was used to evaluate the effects of injury activity and multiligament injuries on the KOOS outcomes.Results:In the adjusted and unadjusted regression analyses, patients injured during sports reported significantly better outcome at 2-year follow-up after PCLR than patients injured during other activities (P < .001) according to all KOOS subscales. Adjusted analysis was as follows for the KOOS subscales: Symptoms (regression coefficient [β], 7.0; 95% CI, 1.9-12.2), Pain (β, 13.4; 95% CI, 8.0-18.9), Activities of Daily Living (β, 12.6; 95% CI, 7.1-18.1), Sport/Recreation (β, 15.3; 95% CI, 8.0-22.5), and Quality of Life (β, 13.5; 95% CI, 7.1-20.0). In the unadjusted analysis, patients with isolated PCL injuries reported higher scores in the Sport/Recreation subscale (β, –7.9; 95% CI, –15.5 to –0.3). The difference was not significant in the adjusted analysis. No other significant differences in KOOS outcomes were found between isolated and multiligament injuries.Conclusion:Patients injured in sports reported better outcomes at 2 years after PCLR as compared with patients injured in other activities. Multiligament injuries involving the PCL do not seem to predict a worse outcome than for isolated PCL injuries.

Static patellofemoral alignment in anterior cruciate ligament deficient knees; a retrospective analysis with magnetic resonance imaging

Static patellofemoral alignment in anterior cruciate ligament deficient knees; a retrospective analysis with magnetic resonance imaging

Risk Factors for Concomitant Collateral Ligament Injuries in Children and Adolescents With Anterior Cruciate Ligament Tears.

Background:Risk factors for concomitant ligament injuries (CLIs) of the lateral collateral ligament (LCL) and medial collateral ligament (MCL) in children and adolescents with anterior cruciate ligament (ACL) tears are unknown.Purpose:To determine whether body mass index (BMI), sex, age, and injury mechanism are associated with CLIs in children and adolescents with ACL tears and whether CLIs are associated with meniscal and chondral injuries and a delay to surgery.Study Design:Cohort study; Level of evidence, 3.Methods:We reviewed the records of patients aged ≤18 years with ACL tears from 2009 through 2013 for sex, age, height, weight, CLI, injury mechanism, intra-articular injury, and time to surgery. Patients were assigned to groups according to the presence of a CLI (CLI group) compared with the presence of an isolated ACL tear (ACL group). BMI was categorized as underweight, normal weight, or overweight/obese. The older group was defined as age ≥14 years for girls and ≥16 years for boys. Logistic regression, Mann-Whitney U tests, and chi-square tests were performed (alpha = 0.05).Results:We included 509 patients (267 girls) with a mean age of 15 years (range, 6-18 years) at the time of injury. There were 396 patients (78%) in the ACL group and 113 patients (22%) in the CLI group (90 with MCL, 11 with LCL, and 12 with both MCL and LCL injuries). Groups had similar proportions of overweight/obese patients (P = .619) and girls (P = .104). Older age (odds ratio [OR], 2.0 [95% CI, 1.3-3.3]) and contact injuries (OR, 2.2 [95% CI, 1.4-3.4]) were associated with CLIs. The CLI group had a higher proportion of chondral injuries (P = .001) but not meniscal injuries (P = .295) and presented to surgery earlier than the ACL group (P = .002).Conclusion:Older age and contact injuries were associated with CLIs in children and adolescents with ACL tears, whereas BMI category and sex were not. CLIs were associated with a higher proportion of chondral injuries but not meniscal injuries and were not associated with a delay to surgery.

Bicompartmental locked bucket-handle tears of menisci concealing the concomitant anterior cruciate ligament injury for 2 years – case report

Bicompartmental locked bucket-handle tears of menisci concealing the concomitant anterior cruciate ligament injury for 2 years – case report

Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry

PurposeTo determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction.MethodsPatients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively.ResultsA total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41–0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3–23.9], p = 0.005).ConclusionNon-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction.Level of evidenceCohort study, Level III.

Using only MRI is moderately reliable in the prediction of meniscal tear reparability.

The purpose of this study was to evaluate the role of surgeons' experience with meniscal repairs and meniscectomy decisions, and to determine the factors affecting the disagreement between meniscal repairs and meniscectomy decisions. In total, 223 patients with meniscal tears, 106 meniscal repairs, and 117 meniscectomies were included. Six orthopedic surgeons (3: > 5years; 3: < 5years' arthroscopy experience) were blinded, and they independently reviewed all preoperative MR images for over a month. Their reviews were compared with arthroscopic interventions performed by a surgeon with > 10years' arthroscopy experience. Reparability-associated factors were also evaluated using multivariate logistic regression. The first and second evaluation results did not differ significantly between groups (n.s.). There was good agreement between MRI predictions and arthroscopic interventions for both groups (< 5years' experience: k = 0.248, agreement 62.3%; > 5years' experience: k = 0.351, agreement 67.3%). Sex, side, and distance of tear from the meniscocapsular junction were not significantly different between agreements and disagreements. Disagreement regarding meniscectomy was significantly higher than those regarding meniscus repair (p = 0.002). Concomitant anterior cruciate ligament (ACL) injury, osteochondral lesions, and medial meniscal tear increased the likelihood of meniscal repair (p = 0.0063, p = 0.0010, and p = 0.0369, respectively). An increased risk of disagreement between MRI and surgical procedure was found in the presence of bucket-handle, horizontal or complex tear, chronic tear, high sports activity and expectation level. Surgeon's experience level may influence the prediction of meniscus reparability. Concomitant ACL injury, osteochondral lesions, and presence of medial meniscal tear increase the likelihood of meniscal repair. Tear type, tear chronicity, patient's activity and expectation level may influence the surgeon's operative decision in addition to MRI. III.

Proximal fixation anterior to the lateral femoral epicondyle optimizes isometry in anterolateral ligament reconstruction.

Concomitant anterolateral ligament (ALL) injury is often observed in patients with an anterior cruciate ligament injury leading some to recommend concurrent ALL reconstruction. In ligament reconstruction, it is imperative to restore desirable ligament length changes to prevent stress on the graft. The purpose of this investigation is to identify the optimal femoral and tibial locations for fixation in ALL reconstruction. 3D computerized tomography (CT) knee models were obtained from six fresh-frozen, unpaired, cadaveric human knees at 0°, 10°, 20°, 30°, 40°, 90°, 110°, and 125°of knee flexion. Planar grids were projected onto the lateral knee. Isometry between each tibial and femoral grid point was calculated at each angle of flexion by the length change in reference to the length at 0° of knee flexion. The mean normalized length change over the range of motion was calculated for each combination of points at all angles of flexion were calculated. Fixation of the ALL to the lateral femoral epicondyle or 5mm anterior to the epicondyle with tibial fixation on the posteroinferior aspect of the tibial condyle (14-21mm posterior to Gerdy's tubercle and 13-20mm below the joint line) provided the lowest average length change for all possible ALL tibial insertion points. Minimal length change for all femoral fixation locations occurred from 20° to 40° of flexion, which identifies the angle of flexion where graft tensioning should occur intraoperatively. With the use of 3D reconstructed models of knee-CT scans, we observed that there was no ALL fixation point that was truly isometric throughout range of motion. Fixation of the anterolateral ligament on the lateral femoral epicondyle or anterior to the lateral femoral epicondyle and on the inferoposterior aspect of the tibial condyle restores isometry. Additionally, minimal length change was observed between 20° and 40° of flexion, which is the most appropriate range of knee flexion to tension the graft. Reproducing isometry reduces stress on the graft, which minimizes the risk of graft failure.

Evaluation of Concomitant Ligamentous Injuries of Knee Joint in Patients with Ipsilateral Femoral Shaft Fractures

Evaluation of Concomitant Ligamentous Injuries of Knee Joint in Patients with Ipsilateral Femoral Shaft Fractures

Double-Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years’ Follow-up: Outcomes Were Comparable to Anterior Cruciate Ligament Reconstructions

Background: Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions. Purpose: To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group. Results: One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores (P < .001) and patient satisfaction (P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064). Conclusion: Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years’ follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group.

To investigate the risk factors for residual pivot shift test after anterior cruciate ligament (ACL) reconstruction based on a multicenter prospective cohort study. This study included patients who were registered in the Multicenter Arthroscopic Knee Surgery Study, a prospective longitudinal multicenter cohort study, and who underwent primary ACL reconstruction using autologous hamstring tendon graft between 2013 and 2016. The exclusion criteria included prior injuries or surgeries in the contralateral knee, prior ligamentous injuries in the involved knee, grade 2 or 3 concomitant ligament injuries, and inflammatory or other forms of osteoarthritis. Data from the preoperative period and at 1-year follow-up were used for further analysis, and patients with incomplete data, re-injury and loss to follow-up were also excluded. Logistic regression analysis was conducted with age, gender, Lachman test, pivot shift test, KT measurement, hyperextension, single-bundle vs. double-bundle, meniscus injury sites, and meniscus treatments as the independent variables, and postoperative pivot shift test was used as the dependent variable. Three hundred and sixty-eight patients were included in the study. Hyperextension knee (P = 0.025) and a preoperative pivot shift test under anesthesia (P = 0.040) were identified as risk factors for a postoperative pivot shift via logistic regression analysis. There were no statistically significant differences in the other variables. The results from a multicenter cohort study indicated that knee hyperextension and greater preoperative pivot shift under anesthesia were risk factors for residual pivot shift at 1year after ACL reconstruction. In cases with a preoperative high-grade pivot shift and knee hyperextension, additional anterolateral structure augmentation might be considered in order to eliminate pivot shift and eventually obtain better outcomes after ACL reconstruction. II.

Research progress on hyperextension tibial plateau fractures

To summarize the progress in the treatment of hyperextension tibial plateau fractures. Related literature concerning hyperextension tibial plateau fractures was reviewed and analyzed in terms of injury mechanisms, clinical patterns, and treatment outcomes. Hyperextension tibial plateau fractures is a specific type of hyperextension knee injuries, which is happened with the knee in over-extended position (<0°) and characterized by fracture and concomitant ligament injury. It can be classified into 4 patterns: marginal avulsion fractures, unicondylar anteromedial fractures, anterolateral fractures, and bicondylar fractures. The failure of structures occurs according to the diagonal injury mechanism characterized by anterior compression fractures and posterior tension ruptures. It is noted as a rule that a smaller anterior fragment is more likely to accompany by a posterior ligament rupture. Unicondylar anteromedial fracture pattern is caused by hyperextension varus mechanism and usually accompanied by posterolateral corner rupture. Bicondylar hyperextension injury is characterized by posterior metaphyseal cortical tension rupture, anterior articular depression, and reversed posterior slope. Currently there is no consensus on the treatment of hyperextension tibial plateau fractures. Further basic and clinical studies are needed.

Segond Fractures Are Not a Risk Factor for Anterior Cruciate Ligament Reconstruction Failure

Background: Segond fractures may be identified when an anterior cruciate ligament (ACL) tear is diagnosed and likely represent an avulsion of the anterolateral ligament. It is currently unclear whether these fractures can be ignored at the time of ACL reconstruction or if they should be addressed surgically. Purpose: To compare the incidence of Segond fractures in patients undergoing primary ACL reconstruction compared with those undergoing revision ACL reconstruction in an attempt to determine if the presence of a Segond fracture predisposes to ACL reconstruction failure. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review of all patients undergoing primary or revision ACL reconstruction between 2007 and 2014 was performed. Demographic data (age, sex, body mass index), injury variables (acuity, mechanism of injury), and radiographic features (concomitant ligamentous injuries, growth plate status) were documented. Each Segond fracture was analyzed for its specific location, size, displacement, and healing using both radiographs and magnetic resonance imaging. Statistical analysis was performed using a P value of <.05. Results: A total of 552 patients underwent primary ACL reconstruction, and 47 patients underwent revision ACL reconstruction who met inclusion criteria. The incidence of Segond fractures was 6% in the primary reconstruction group. The fracture fragment averaged 6.6 mm in height and 2.3 mm in width and was displaced a mean of 5.0 mm. The fracture fragment bed was localized at the tibial attachment site of the anterolateral ligament a mean 20.6 mm posterior to the Gerdy tubercle in nearly all patients. After ACL reconstruction, the Segond fracture healed in 90% of patients. The incidence of Segond fractures was 3 times as common in male patients (P = .02); otherwise, its presence was not associated with any other demographic data, injury variables, or radiographic features (P > .05). No patients undergoing revision surgery had a Segond fracture, and no patient with a Segond fracture had graft failure. Conclusion: Patients with a Segond fracture are at no higher risk to require revision ACL reconstruction compared with patients without a Segond fracture. This may be attributable to its high union rate. At the time of primary ACL reconstruction, if a Segond fracture is identified, it can be ignored (not repaired or reconstructed), and this approach does not appear to predispose to early ACL graft failure.

Factors affecting knee laxity following anterior cruciate ligament reconstruction using a hamstring tendon

BackgroundThe aim of the present study was to investigate the correlation between the pre-operative and intraoperative factors that predict postoperative knee laxity following anterior cruciate ligament (ACL) reconstruction using a hamstring tendon. MethodsThe subjects included 108 patients (male, n=49; female, n=59) with ACL-deficient knees who had undergone double-bundle reconstruction. The median time between injury and surgery (TBIS) was 27.5weeks (range one to 504). The patients were divided into two groups according to the side-to-side difference (SSD) in anterior translation on a stress radiograph one year after undergoing the operation (Group A: SSD of <3mm and Group B: SSD of ≥3mm) and were compared regarding such factors as age at surgery, sex, body mass index, pivot shift test, TBIS, pre-operative laxity, concomitant ligament, meniscus, and articular cartilage injury. A logistic regression analysis was performed to identify the factors associated with knee laxity. ResultsThe postoperative SSD values after one year were correlated with the TBIS (r=0.28; P<0.01). Eighty-one and 27 knees were classified into Groups A and B, respectively, based on the SSD at one year after surgery. The TBIS in Group B (60.2weeks) was significantly longer than that in Group A (16.6weeks; P<0.01). A logistic regression analysis showed that there was a significant association between the TBIS and postoperative knee laxity (P<0.01; odds ratio 1.013; 95% CI 1.002–1.023). ConclusionIncreased knee laxity was associated with the time between injury and surgery.

Segond Fracture: A Risk Factor for Anterior Cruciate Ligament Reconstruction Failure?

Objectives:Segond fractures may be identified when an anterior cruciate ligament (ACL) tear is diagnosed and likely represent an avulsion of the anterolateral ligament. It is currently unclear whether these fractures can be ignored at the time of ACL reconstruction or if they should be addressed surgically. The purpose of this study was to compare the incidence of Segond fractures in patients undergoing a primary ACL reconstruction compared to those undergoing a revision ACL reconstruction in an attempt to determine if the presence of a Segond fracture predisposes to ACL reconstruction failure.Methods:A retrospective review of all patients undergoing a primary or revision ACL reconstruction between January 2007 and June 2014 was performed. Demographic data (age, gender, and BMI), injury variables (acuity, mechanism of injury), and radiographic features (concomitant ligamentous injuries, growth plate status) were documented. Each Segond fracture was analyzed for its specific location, size, displacement, and healing using both radiographic images and MRI. Statistical analysis was performed using a p value of <0.05.Results:The incidence of Segond fractures was 6%. The fracture fragment averaged 6.6 mm in height, 2.3 mm in width, and was displaced 5.0 mm. The fracture fragment bed was localized at the tibial attachment site of the anterolateral ligament 21 mm posterior to Gerdy’s tubercle in nearly all cases. Post-ACL reconstruction, the Segond fracture healed in 90% of cases. The incidence of a Segond fracture was twice as common in male patients (p=0.02), otherwise its presence was not associated with any other demographic data, injury variables, or radiographic features (p>0.05) (Table 1). No patients undergoing a revision surgery had a Segond fracture and no patient with a Segond fracture had a graft failure.Table 1Segond Fracture (N = 31)No Segond Fracture (N=568)p-valueAge (years)15.6 ± 1.716.0 ± 1.3p = 0.25Gender (% male)74.2%53.2% p = 0.02 Growth plate status (% closed)26.2 ± 5.825.7 ± 5.4p = 0.63Mechanism of injury (% non-contact)83.9%82.6%p = 0.94Mechanism of injury (% non-contact)48.4%44.7%p = 0.95Multi-ligament knee injury (%)19.4%12.3%p = 0.25Graft Failure0%8.3%p = 0.09Table 1: Patient demographic, injury variable, and graft failure rates in patients with Segond fractures compared to those with no Segond fracture.Data is presented with means and standard deviations or a percentage. P-values in bold represent a value less than 0.05.Conclusion:Segond fractures are relatively uncommon in adolescent patients undergoing ACL surgery (6%). This injury occurs from an avulsion of the lateral joint capsule or the anterolateral ligament (ALL). Patients with a Segond fracture are at no higher risk to require a revision ACL reconstruction compared to patients without a Segond fracture. This may be attributable to its high union rate. At the time of primary ACL reconstruction, if a Segond fracture is identified, it can be ignored (not repaired or reconstructed) and this approach does not appear to predispose to ACL graft failure.

Comparison of Clinical Outcomes Following Anatomic Single vs. Double-Bundle ACL Reconstruction: A Randomized Clinical Trial

Objectives:The shortcomings of anterior cruciate ligament reconstruction (ACL), including failure to restore normal structure and function of the knee, limited return to pre-injury level of sports participation and failure to prevent the development of post-traumatic knee osteoarthritis (OA) have recently been recognized. Anatomic methods to reconstruct the ACL, including anatomic single-bundle (SB) and double-bundle (DB) reconstruction, have been proposed to improve clinical outcomes after ACL reconstruction. We performed a double-blinded randomized clinical trial to compare clinical outcomes of anatomic SB to anatomic DB ACL reconstruction. We hypothesized that anatomic DB ACL reconstruction with a quadriceps tendon autograft with bone block would result in reduced knee laxity, better range of motion, patient-reported outcomes (PROs), return to sports and reduced risk of re-injury compared to anatomic SB ACL reconstruction.Methods:Individuals between 14 and 50 years of age participating in at least 100 hours of Level 1 or 2 sports activities that presented within 12 months of injury to both bundles of the ACL with or without injury to the medial or lateral meniscus were eligible to participate in this study. Individuals with prior injury or surgery of the ipsilateral or contralateral knee or greater than a grade 1 concomitant knee ligament injury were excluded. If the ACL insertion sites were between 14 and 18mm, as measured with an arthroscopic ruler at the time of arthroscopy, the subject was randomized to undergo SB or DB ACL reconstruction with a 10 mm quadriceps tendon autograft harvested with a patellar bone block. A single, anatomically placed femoral tunnel was used for all cases. For DB ACL reconstruction, the graft was split into to two arms and passed through two anatomically placed tibial tunnels. Subjects were followed at 3, 6, 12 and 24 months after randomization, with the primary endpoints occurring at 24 months. Outcome measures included the KT-1000 (side to side difference) and pivot shift tests, range of motion (ROM), IKDC Subjective Knee Form (IKDC-SKF) and return to pre-injury level of sports participation.Results:Fifty-seven subjects were randomized (29 DB) and two-year follow-up was attained from 51 (89.5%). There were no differences between groups in terms of age, proportion of males, body mass index (BMI), participation in competitive or recreational sports or concomitant meniscus procedures. At 24-month follow-up there were no between groups differences for the pivot shift and KT-1000 tests, ROM and IKDC-SKF scores (Table 1). Twenty-three (85.2%) DB’s and 24 (87.5%) SB’s reported returning to pre-injury level of sports 2 years after surgery (p=0.81). Three subjects (2 SB’s, 5.9% of total) suffered a graft rupture and 5 individuals (4 SB’s, 9.8% of total) had a subsequent meniscus injury.Conclusion:With the available sample size, we were unable to demonstrate significant differences in clinical outcome between anatomic SB and DB ACL reconstruction when performed with a quadriceps tendon autograft with a bone block in individuals with ACL insertion sites that ranged from 14 to 18 mm. Furthermore, both anatomic SB and DB ACL reconstruction lead to clinical outcomes that are comparable or superior to those reported for non-anatomical ACL reconstruction with minimal recurrent instability.Table 1Clinical Outcomes at 24 MonthsDouble Bundle (n=27)Single Bundle (n=24)p value6Normal Pivot Shift (n, %)25, 92.6%23, 95.8%0.48KT Arthrometer1 (30 lb) (mean ± SD)0.5 ± 1.30.6 ± 1.60.80KT Arthrometer1 (max manual) (mean ± SD)0.7 ± 1.20.8 ± 1.50.79Passive Extension of Involved Knee2 (mean ± SD)3.9 ± 3.03.8 ± 2.80.90Passive Extension Difference3 (mean ± SD)2.1 ± 1.91.7 ± 2.60.53Active Flexion of Involved Knee4 (mean ± SD)140.7 ± 5.7140.2 ± 6.30.76Active Flexion Difference5 (mean ± SD)0.3 ± 4.2-1.1 ± 9.00.47IKDC Subjective Knee Score (mean ± SD)89.4 ± 10.390.2 ± 11.10.791 Values are involved minus non-involved side to side difference in millimeters2Values are in degrees. Positive values indicate hyperextension 3 Non-involved minus involved knee difference in passive knee extension. Values are in degrees. Positive values indicate a loss of extension of the involved knee 4 Values are in degrees 5 Non-involved minus involved knee difference in active knee flexion. Values are in degrees. Positive values indicate a loss of flexion of the involved knee. 6 Independent t-tests were used for continuous variables and Fisher Exact Tests were used for nominal variables. p values were not adjusted for multiple comparisons.