Concomitant Meniscal Injury Research Articles

Concomitant cartilage and meniscal injuries in patients with ACL injuries sustained during basketball versus soccer: a matched-pair analysis

Concomitant cartilage and meniscal injuries in patients with ACL injuries sustained during basketball versus soccer: a matched-pair analysis

Role of Physiotherapy in Preventing Failure of Primary Anterior Cruciate Ligament Reconstruction: 首次前十字韌帶重建手術後物理治療所扮演的角色

Background/PurposeAnterior cruciate ligament (ACL) reconstruction is routinely performed in sports medicine. We aimed to determine if there is any protective effect of postoperative physiotherapy in preventing graft rupture after primary ACL reconstruction (ACLR). MethodsA retrospective case–control study was carried out, with demographic data, concomitant meniscal injury, and intraoperative fixation methods matched. The number of sessions of physiotherapy attended by the rupture group and nonrupture group were compared using binary logistic regression. ResultsNo significant relationship between the frequency of postoperative physiotherapy and occurrence of graft rupture after primary ACLR was identified. ConclusionFurther research is needed to verify the effect of physiotherapy in the prevention of graft rupture after primary ACLR.

Clinical Outcomes of Medial Meniscus Posterior Root Tears

Objectives:Medial meniscus posterior root tears (MMPRTs) present a unique challenge for both patients and surgeons as these tears have shown to be biomechanically equivalent to complete meniscectomy. However, little is known about the natural history of these lesions. Therefore, the purpose of this study is to describe the clinical course of MMPRTs with respect to subsequent operative and non-operative treatments, and associated comorbidities.Methods:Over 2600 MRIs were identified by searching radiologist reads for the terms “root” or “root tear” from 2005-2013. Presence or absence of MMPRTs and other associated boney, meniscal, or ligamentous injuries were identified and recorded. Of these MRIs, 102 MRIs from 102 patients who had unrepaired MMPRTs with minimum 2-year follow-up and no prior ligamentous surgery were followed. These MRIs were evaluated to confirm the presence of a meniscal root tear and the presence or absence of associated meniscal or ligamentous injuries, as well as meniscal extrusion, subchondral edema, or insufficiency fractures. Chart review was performed to obtain the treatment summary after diagnosis. Radiographs from before and after the diagnosis of MMPRT were reviewed and Kellgren-Lawrence scores were determined. Finally, the association between concomitant boney, ligamentous, or meniscal injuries, patient factors, and rate of arthroplasty, as well as final Kellgren-Lawrence scores were evaluated. Chi-square analysis was used for categorical variables, and Wilcoxon Rank-Sums was used for continuous variables. Kaplan-Meier analysis was used to evaluate the effect of meniscal extrusion on the time-dependant rate of arthroplasty.Results:104 patients (43 M:61F) were diagnosed with MMPRTs at a mean age of 54±13. These patients were followed for a mean of 66±26 months. 75 (74%) patients had associated meniscal extrusion, 64 (62%) had associated subchondral edema, and 14 (13%) had associated insufficiency fractures at the time of diagnosis. After initial diagnosis, 59 (58%) underwent subsequent surgical treatment. This included 52 (51%) patients undergoing arthroscopic partial meniscectomy, and 29 (28%) patients undergoing total knee arthroplasty at a mean 38±32 (range 3-107) months after MRI. Kellgren-Lawrence grades worsened from 1.3±0.7 before diagnosis to 2.2±1.0 after (p<0.001), with a mean 44±32 months between radiographs. There was a higher rate of radiographic arthritis (K-L grade 2+) after diagnosis (73%) than before diagnosis (36%) (p<0.001). The presence of meniscal extrusion on MRI was associated with the presence of arthritis on post-diagnosis radiographs (p=0.03). Meniscal extrusion, subchondral edema, and insufficiency fractures were not associated with increased rates of surgical treatment, or time to arthroplasty.Conclusion:Little information is available to guide patients and physicians on the clinical outcomes for MMPRTs. These injuries are associated with a relatively high rate of arthroplasty and worsening arthritis, especially with concomitant meniscal extrusion. More information is needed to determine the efficacy of meniscal root repair in preventing these unfavorable outcomes.

Injury patterns in patients presenting with a recurrent anterior cruciate ligament tear following primary reconstruction.

An anterior cruciate ligament (ACL) graft rupture or a primary ACL injury in the contralateral knee is one of the greatest concerns of patients following primary anterior cruciate ligament reconstruction (ACLR). Our study describes the epidemiology and presence of concomitant meniscal injuries of patients with a graft rupture following primary ACLR or a primary rupture of the contralateral ACL following primary ACLR of the ipsilateral knee. We reviewed the medical records of 42 patients who underwent a second ACLR. ACLR was performed using the ipsilateral semitendinosus and gracilis autograft. Variables extracted included the presence of concomitant MM and LM injuries intra-operatively, the patients' level of intensity of sport (light, moderate, strenuous), duration of rehabilitation and mechanism of injury (contact, non-contact). Twenty-four (57.1%) patients had graft rupture of a previously reconstructed ACL of which 20 (83.3%) were male and 18 (42.9%) patients had a primary ACL tear of the contralateral knee following ACLR of the ipsilateral knee of which 18 (100%) were male. Patient who sustained a graft rupture were younger (29.5 vs. 31.9 years), had a higher body mass index (BMI) (26.42 vs. 25.10 kg/m(2)) and had a longer time before re-injury (6.18 vs. 4.94 years). Concomitant meniscal injury rates were comparable in both groups and the medial meniscus was injured more often. This study describes the demographics of 2(nd) ACL injuries in the Asian population. Additional studies that investigate the differences in knee anatomy of Asians and Caucasians and their impact on ACL injuries should be performed.

Arthroscopic ACL Reconstruction with Bone Patellar Bone Graft using Anteromedial Technique

There are approximately 200,000 anterior cruciate ligament (ACL) injuries per year in the United States and more than half will be treated with ACL reconstruction. The diagnosis is made by physical exam supplemented by radiographs and MRI scan. Successful ACL reconstruction returns most athletes to pre-injury activity; however, outcome depends on appropriate preoperative evaluation, surgical timing, surgical technique, and an effective postoperative physical therapy program. Specifically, graft choice, graft positioning, and fixation technique have been shown to play important roles in patient outcome. Surgeons must also be aware of concomitant meniscal tears and cartilage injury that may need to be addressed at the time of ACL reconstruction. In this case, we perform an anatomic ACL reconstruction with bone-patellar tendon-bone (BTB) autograft using an anteromedial drilling technique and flexible reamers for a young college athlete. The anteromedial approach offers the advantage of reliably reproducing the native anatomy of the ACL on the femur footprint by drilling the femoral tunnel independently of the tibial tunnel. Furthermore, using a flexible reamer instead of a straight rigid reamer allows for a longer femoral tunnel and lower risk of posterior wall blowout or fracture.

Degenerative Changes in the Knee 2 Years After Anterior Cruciate Ligament Rupture and Related Risk Factors

Background: Anterior cruciate ligament (ACL) rupture is a well-known risk factor for development of knee osteoarthritis. Early identification of those patients at risk and early identification of the process of ACL rupture leading to osteoarthritis may aid in preventing the onset or progression of osteoarthritis. Purpose: To identify early degenerative changes as assessed on magnetic resonance imaging (MRI) after 2-year follow-up in patients with a recent ACL rupture and to evaluate which determinants are related to these changes. Study Design: Cohort study; Level of evidence, 2. Methods: Included in this study were 154 adults aged between 18 and 45 years with acute ACL rupture diagnosed by physical examination and MRI, without previous knee trauma or surgery, and without osteoarthritic changes on radiographs. A total of 143 patients completed the 2-year follow-up, and the results in this study apply to these 143 patients. All patients were treated according to the Dutch guideline on ACL injury. Of the 143 patients, 50 patients were treated nonoperatively during the 2-year follow-up period. Main outcome was early degenerative changes assessed on MRI defined as progression of cartilage defects and osteophytes in tibiofemoral and patellofemoral compartments. Patient characteristics, activity level, functional instability, treatment type, and trauma-related variables were evaluated as determinants. Results: The median time between MRI at baseline and MRI at 2-year follow-up was 25.9 months (interquartile range, 24.7-26.9 months). Progression of cartilage defects in the medial and lateral tibiofemoral compartments was present in 12% and 27% of patients, and progression of osteophytes in tibiofemoral and patellofemoral compartments was present in 10% and 8% of patients, respectively. The following determinants were positively significantly associated with early degenerative changes: male sex (odds ratio [OR], 4.43; 95% CI, 1.43-13.66; P = .010), cartilage defect in the medial tibiofemoral compartment at baseline (OR, 3.66; 95% CI, 1.04-12.95; P = .044), presence of bone marrow lesions in the medial tibiofemoral compartment 1 year after trauma (OR, 5.19; 95% CI, 1.56-17.25; P = .007), joint effusion 1 year after trauma (OR, 4.19; 95% CI, 1.05-16.72; P = .042), and presence of meniscal tears (OR, 6.37; 95% CI, 1.94-20.88; P = .002). When the patients were categorized into 3 treatment groups (nonoperative, reconstruction <6 months after ACL rupture, and reconstruction ≥6 months after ACL rupture), there was no significant relationship between the treatment options and the development of early degenerative changes. Conclusion: Two years after ACL rupture, early degenerative changes were assessed on MRI. Concomitant medial cartilage defect and meniscal injury, male sex, persistent bone marrow lesions in the medial tibiofemoral compartment, and joint effusion are risk factors for degenerative changes.

Effect of Osteochondral and Meniscal Injury on Patient Reported Outcomes at Return to Sport Following Anterior Cruciate Ligament Reconstruction in Young Athletes

Objectives:Concomitant pathology at the time of ACL injury has the potential to affect outcomes after ACL reconstruction (ACLR). The effect of concomitant meniscal and osteochondral injury on patient reported outcomes (PRO) has been investigated inclusive of a wide range of ages, but has yet to be specifically reported in young, active patients at the time of return to sport (RTS). The purpose of this study was to determine if the presence of concomitant meniscal (MEN) or osteochondral (OC) pathology affected PRO at the time of RTS following ACLR in young athletes. The hypothesis tested was that concomitant pathology at the time of injury would result in poorer PRO at the time of RTS.Methods:One hundred and one (67 female) young (range 10-25 years old), active level I/II athletes were included in this study. All subjects underwent ACLR, rehabilitation, and were released to RTS. Meniscal pathology was confirmed intra-operatively and OC injury was confirmed with pre-operative MRI. All participants completed the International Knee Documentation Committee (IKDC) questionnaire and the KOOS (Knee Injury and Osteoarthritis Outcome Score) scale, at the time of RTS. One-way ANOVA was used to assess differences in PRO between patients with and without concomitant injury. Chi-square analyses were used to determine if patients with concomitant pathology were more likely to present with PRO less than age-matched normative data on the IKDC.Results:Concomitant OC injury was present in 59/101 patients, MEN pathology was present in 52/101 patients and both OC/MEN injury was present in 33/101 patients at the time of ACLR. One-way ANOVA determined that patients with OC injury had lower IKDC (p=0.001), KOOS pain (p=0.0-14), and KOOS Sport (p=0.002) scores than patients with no OC pathology. Patients with MEN pathology presented with lower KOOS Sport scores (p=0.03). Patients with combined OC/MEN injury had lower IKDC (p=0.009), KOOS ADL (p=0.024) and KOOS Sport (p<0.001) scores. Chi square analysis demonstrated that patients with an OC injury were nearly 3 times (OR=2.9; 95% CI, 1.1-7.8) more likely to present with an IKDC score below previously reported age-matched (18-24 years/old) general population norms (female=85.7, male=89.1) and also 3 times (OR=3.2; 95% CI, 1.4-7.6) more likely to score below age-matched norms of patients with no prior history of knee injury (female=93.4, male=95.5). Patients with combined OC/MEN pathology were nearly 4 times (OR=3.9; 95%CI, 1.3-11.4) more likely to present with an IKDC score below healthy age-matched norms. MEN pathology did not increase the likelihood of presenting with IKDC scores lower than population.Conclusion:The presence of OC and combined OC/MEN injury in young, active patients at time of ACLR may predict poorer patient reported function at the time of return to sport. The presence of OC injury should be addressed more closely in the post-operative management after ACLR.

Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children.

Pediatric avulsion fractures of the anterior tibial spine are injuries similar to anterior cruciate ligament injuries in adults. Sparse data exists on the association between anterior tibial spine fractures (ATSFs) and injury to the meniscus or cartilage of the knee joint in children. This research presents a retrospective review of clinical records, imaging, and operative reports to characterize the incidence of concomitant injury in cases of ATSFs in children. The purpose of this study was to better delineate the incidence of associated injuries in fractures of the anterior tibial spine in the pediatric population. We identified 58 patients who sustained an ATSF and met inclusion criteria for this study between 1996 and 2011. The subjects were separated by the Myers and McKeever classification into type I, II, and III fractures, and each of these were subclassified by associated injury pattern. 59% of children with an ATSF had an associated soft tissue or other bony injury diagnosed by magnetic resonance imaging or arthroscopy. The most prevalent associated injuries were meniscal entrapment, meniscal tears, and chondral injury. We found no meniscal or chondral injury associated with type I fractures. Twenty-nine percent of type II injuries demonstrated meniscal entrapment, 33% showing meniscal tears. Seven percent demonstrated chondral injury. Forty-eight percent of type III fractures had entrapment, whereas 12% showed meniscal tears. Eight percent had a chondral injury. A majority (59%) of displaced ATSF had either concomitant meniscal, ligamentous, or chondral injury. This finding suggests that magnetic resonance imaging evaluation is an important aspect of the evaluation of these injuries, particularly in type II and type III patterns. To date, this study reports the largest number of patients to evaluate the specific question of concomitant injuries in ATSFs in the pediatric population. Level IV.

A research for accuracy of infrared computer navigation in arthroscopic anterior cruciate ligament reconstruction bone tunnel positioning of assisted

Objective To explore the accuracy and feasibility of infrared computer navigation for femur, tibia tunnel posi-tioning in arthroscopic anterior cruciate ligament (ACL) reconstruction. Methods Data of patients who had undergone ACL reconstruction using infrared computer navigation from January 2012 to June 2013 were retrospectively analyzed. There were 26 males and 9 females, with an average age of 26.8 years old. 35 patients were with concomitant meniscal injury 21 cases, and 3 cases with medial collateral ligament injury. All patients were treated with gracilis and semitendinosus knit stitch as grafts, and bone ends were made with hydroxyapatite extrusion screws, door-shaped nails and porous plate. Results The mean follow-up time was 16 months. The rate of postoperative femoral tunnel site measurements was 63.8%±6.6%, and tibial tunnel site measurements was 45.7%±4.2%. 1 patient appeared heterotopic ossification in tibia tracker pinhole 3 months after surgery, and the joint activities was normal. Lachman test: there were 1 case with II degree, 30 with III degree, and 4 with IV degree before operation, and 33 with I degree, 1 with II degree, 1 with III degree after operation. The KT-1000 test was from 6.47±0.75 mm preoperatively to 1.01±1.14 mm postoperatively. Preoperative knee laxity differences was more than 5 mm in 32 cases, 3-5 mm in 3, and after operation they were 0-3 mm in 31, 3-5 mm in 2, and less that 0 mm in 2 cases. Lysholm score and Tegner scores were from preoperative 52.74± 10.91 points and 4.64±1.34 points to postoperative 93.97±4.13 and 6.56±0.81 points. ROM was from 85.6°±11.2° to 118.3°±5.7°; 33 cases were without flexion and extension limited; two cases had knee flexion, extension limitation less than 10°. After straight leg raising training and proprioception functional training for 6 months, the knee ROM returned to normal. Conclusion Infrared computer assisted navigation system for arthroscopic ACL reconstruction is to navigate through the use of anatomical landmarks and kinematic data, kinematic data by detecting and recording the knee, selected a secure tunnel site, viable surgical method, you can make femur, tibia tunnel position more accurately, good curative effect evaluation. Key words: Anterior cruciate ligament reconstruction; Knee joint; Arthroscopy; Surgery, computer-assisted

Factors Predictive of Concomitant Injuries Among Children and Adolescents Undergoing Anterior Cruciate Ligament Surgery

Background: The timing of treatment for pediatric anterior cruciate ligament (ACL) injuries remains controversial. The risks of delaying reconstruction and the differences between age groups are poorly defined. Purpose: To investigate factors that contribute to the prevalence and severity of concomitant chondral and meniscal injuries among patients aged 14 to 19 years versus those aged ≤14 years at the time of ACL reconstruction. The hypothesis was that concomitant injuries would be more prevalent in older versus younger subjects. Also, a delay in surgery would be predictive of the presence and severity of concomitant knee injuries requiring additional operative procedures. Study Methods: Cohort study; Level of evidence, 3. Methods: All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. The location, severity, and treatment of all concomitant knee injuries were recorded. Chi-square tests were used to compare the prevalence of chondral and meniscal injuries in the older (age, 14-19 years; n = 165) versus younger (age, ≤14 years; n = 66) cohorts. A multivariable logistic regression analysis was used to identify factors related to the presence of a concomitant injury that required additional treatment. Kaplan-Meier analyses were used to explore the relation between time to surgery and meniscal injury severity. Results: There was a significant relationship between time to surgery and the development of an irreparable meniscal injury (P < .05 for all) in both the younger and older groups. Time to surgery correlated with severity of chondral injury in the younger cohort (P = .0343) but not in the older cohort (P = .8877). In the younger cohort, only a delay in surgery >3 months (odds ratio [OR] = 4.8; 95% CI, 1.7-14.4; P = .0027) was significantly predictive of the presence of an injury that required additional operative procedures. In the older patients, a return to activity before surgery (OR = 3.8; 95% CI, 1.52-11.9; P = .0034) and obesity (OR = 2.5; 95% CI, 1.1-7.4; P = .0381) were significantly predictive of an injury that required additional operative procedures. Conclusion: Compared with younger subjects, the prevalence of concomitant knee injuries as well as the need for additional operative procedures was greater among older subjects. A delay to surgery correlated with increased severity of injury among both older and younger populations. A delay in surgery >3 months was the strongest predictor of the development of a concomitant injury in the younger cohort. A return to activity and obesity were significantly related to the presence of a concomitant knee injury in the older cohort.

Delay to Reconstruction of the Adolescent Anterior Cruciate Ligament: The Socioeconomic Impact on Treatment.

Background:A delay in pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is associated with an increase in the number of concomitant meniscal and chondral injuries. Factors that contribute to this delay have not been well described.Hypothesis:Socioeconomic and demographic factors are related to ACL surgery timing.Study Methods:Cohort study; Level of evidence, 3.Methods:All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. Variables included concomitant knee injuries (cartilage or meniscus injuries requiring additional operative treatment) and chronologic, demographic, and socioeconomic factors. Multivariable Cox proportional-hazards analyses were used to identify factors related to ACL surgery timing.Results:The mean age of the 272 subjects was 15.2 ± 2.12 years. Time to surgery was significantly different among subjects who required multiple additional surgical procedures at time of ACL reconstruction (median, 3.3 months) compared with subjects with 1 (median, 2.0 months) or no additional injuries (median, 1.6 months). Subjects underwent ACL reconstruction significantly sooner if they were older at the time of injury (hazard ratio [HR], 1.2 per 1 year; 95% CI, 1.1-1.2; P < .0001) or were covered by a commercial insurance plan (HR, 2.0; 95% CI, 1.6-2.6; P < .0001). Median time to ACL surgery was 1.5 months (95% CI, 1.3-1.7) for subjects with commercial insurance plans compared with 3.0 months (95% CI, 2.3-3.3) for subjects with noncommercial insurance coverage.Conclusion:The risk of delayed ACL surgery was significantly higher among pediatric and adolescent subjects who were less affluent, who were covered by a noncommercial insurance plan, and who were younger. This study also confirms previous studies that have reported an association between a delay in ACL surgery and the presence of additional knee injuries requiring operative treatment, accentuating the importance of timely care.Clinical Relevance:Access to care is a current area of research interest and health policy formation. Information in this arena drives 2 important aspects of health: most immediately, care provided to patients, and over a broader scope, the policy that directs health care. The orthopaedic surgeon should be aware of the association between socioeconomic and demographic factors and ACL surgery timing to optimize outcomes.

Anterior Cruciate Ligament Injuries in a Pediatric Population: Delay to Reconstruction and Concomitant Pathology

Anterior Cruciate Ligament Injuries in a Pediatric Population: Delay to Reconstruction and Concomitant Pathology

Preoperative Patient and Injury Factors of Successful Rehabilitation After Anterior Cruciate Ligament Reconstruction With Single-Bundle Techniques

The aim of this systematic review was to determine which patient determinants and injury factors, before anterior cruciate ligament reconstruction by arthroscopic single-bundle techniques, affect postoperative rehabilitation. A search of PubMed, Embase, and the Cochrane Database of Clinical Trials was performed up to February 2013. After application of our inclusion criteria, a final selection was made based on studies' methodologic score assessed with the Newcastle-Ottawa Scale. Meta-analysis was planned for each prognostic factor when data were considered clinically and statistically homogeneous. Meta-analysis showed that male patients have better functional outcomes. Qualitative synthesis from 18 high-quality studies showed that patients operated on before 30 years of age reach higher activity levels. Patients with high baseline body mass index have lower activity levels after surgery. Smoking results in more symptoms and lower activity levels and subjective scores. Reconstruction before 3 months results in higher activity levels. Preoperatively, a less than 20% quadriceps strength difference, 50° of tibial external rotation or less, absence of flexion deficits, low knee influence on the patient's activity level, and less anterior knee pain result in higher functional scores. Preoperative anterior laxity difference does not predict functional scores. The prognostic value of preoperative activity and competition level for postoperative functional outcome is controversial. Patients with concomitant meniscal injuries have worse functional outcomes. The prognostic value of concomitant chondral pathology for postoperative functional outcome is controversial. Collateral ligament injury could predict functional scores or activity level. Male gender, patient age younger than 30 years, reconstruction before 3 months, and high baseline activity level contribute to better functional outcomes. Smoking, high body mass index, quadriceps strength, and range-of-motion deficits affect rehabilitation negatively. Preoperative anterior laxity does not influence rehabilitation. The role of preoperative prognostic injury factors remains unclear because of limited evidence. Level III, systematic review of Level II and III studies.

Anterior Cruciate Ligament Reconstruction: Contemporary Revision Options

Rupture of the ACL is a common sports injury often managed with ligament reconstruction. Despite relatively high success rates, ACL graft failures do occur, providing frustration for the patient and presenting a challenge for the surgeon. Fortunately our understanding of ACL anatomy, biomechanics and reconstruction has increased dramatically in recent years. The challenge with revision ACL reconstruction begins with determining the reason for failure. Poor surgical technique with improper tunnel placement has been identified in a high proportion of failed reconstructions. Unlike primary reconstructions, additional variables including bone loss, retained hardware and concomitant meniscal, chondral and/or ligamentous injury are often present and must be addressed at the time of revision. This chapter provides an algorithm for the evaluation of patients with a failed ACL graft and guideline to revision ligament reconstruction.

Factors affecting the outcome of osteochondral autografting (mosaicplasty) in articular cartilage defects of the knee joint: retrospective analysis of 152 cases

The purpose of this retrospective study was to evaluate the results and prognostic factors affecting the outcome of osteochondral autografting (mosaicplasty) in articular cartilage defects of the knee joint. One hundred fifty-two patients who underwent mosaicplasty for femoral condylar cartilage defects (modified Outerbridge classification: Grade III and IV) of the knee joint between 1998 and 2007 in our institution were included. There were 126 male and 26 female patients with a mean age of 24.8±4.6years. The average size of the lesion was 2.7±0.7cm(2). Of these patients, 33 had concomitant meniscal and/or cruciate ligament injuries which were treated simultaneously. All patients were followed up with a mean of 18.2±4.2months (range 12-24months) using Lysholm knee score. We analyzed the relationship between the outcome variable (Lysholm knee score at the final follow-up) and the predictor variables (age, gender, lesion size, lesion grade, localization, accompanying intra-articular injuries and duration of follow-up). The mean preoperative Lysholm knee score was 55.2±3.6 points and increased to 88.2±2.5 points at the final follow-up. There was a significant increase in Lysholm score during follow-up period (p=0.0001). The results were excellent in 2 cases (1.3%), good in 144 cases (94.7%) and fair in 6 cases (3.9%). No patients had infection, systemic complication and revision surgery. Backward regression analysis showed that age, lesion size, localization and associated intraarticular injuries are the only predictors of the final Lysholm knee score in best fit model (R (2)=0.442, p=0.0001). The linear regression equation was (Lysholm score at final follow-up)=93.4-[0.2 (age of patient)+0.8 (lesion size)+0.9 (localization)+2.8 (presence of associated intraarticular injuries)]. Mosaicplasty is an effective technique for the treatment of articular cartilage defects of the knee joint which restores the joint function in a short period of follow-up. Furthermore, age, lesion size, localization, and concomitant surgical interventions are major factors affecting the final outcome. The final knee score deteriorates as the age of the patient and size of the lesion increases. Furthermore, concomitant surgical interventions and lesions located on the medial femoral condyle have a negative effect on the final knee score.

The Swedish National Anterior Cruciate Ligament Register

Background: The Swedish National Anterior Cruciate Ligament Register provides an opportunity for quality surveillance and research. Purpose: The primary objective was to recognize factors associated with a poorer outcome at an early stage. Study Design: Case series; Level of evidence, 4. Methods: Registrations are made using a web-based protocol with 2 parts: a patient-based section with self-reported outcome scores and a surgeon-based section, where factors such as cause of injury, previous surgery, time between injury and reconstruction, graft selection, fixation technique, and concomitant injuries are reported. The self-reported outcome scores are registered preoperatively and at 1, 2, and 5 years. Results: Approximately 90% of all anterior cruciate ligament (ACL) reconstructions performed annually in Sweden are reported in the register. Registrations during the period 2005-2010 were included (n = 17,794). After excluding multiligament reconstructions and reoperations, the male:female ratio was 57.5:42.5 for both primary (n = 15,387) and revision (n = 964) surgery. The cause of injury was soccer in approximately half the male patients and in one third of the female patients. All subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) were significantly improved 1, 2, and 5 years postoperatively in patients undergoing primary reconstructions. In terms of the KOOS, revisions did significantly less well than primary reconstructions on all follow-up occasions, and smokers fared significantly less well than nonsmokers both preoperatively and at 2 years. Patients who had concomitant meniscal or chondral injuries at reconstruction did significantly less well preoperatively and at 1 year in terms of most KOOS subscales compared with patients with no such injuries. At 5 years, a significant difference was only found in terms of the sport/recreation subscale. Double-bundle reconstructions revealed no significant differences in terms of all the KOOS subscales at 2 years compared with single-bundle reconstructions (114 double-bundle vs 5109 single-bundle). During a 5-year period, 9.1% (contralateral, 5.0%; revision, 4.1%) of the patients underwent a contralateral ACL reconstruction or revision reconstruction of the index knee. The corresponding figure for 15- to 18-year-old female soccer players was 22.0%. Conclusion: Primary ACL reconstruction significantly improves all the subscales of the KOOS. Young female soccer players run a major risk of reinjuring their ACL or injuring the contralateral ACL; revision ACL reconstructions do less well than primary reconstructions, and smokers do less well than nonsmokers.

Longitudinal assessment of femoral knee cartilage quality using contrast enhanced MRI (dGEMRIC) in patients with anterior cruciate ligament injury – comparison with asymptomatic volunteers

In this observational longitudinal study we estimate knee joint cartilage glycosaminoglycan (GAG) content, in patients with an acute anterior cruciate ligament (ACL) injury, with or without a concomitant meniscus injury. 29 knees (19 men/10 women) were prospectively examined by repeat delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), approximately 3 weeks and 2.3±1.3 (range 4.5) years after the injury. We estimated the GAG content (T1Gd) in the central weight-bearing parts of the medial and lateral femoral cartilage and compared results with a reference cohort (n=24) with normal knees and no history of injury examined by dGEMRIC at one occasion previously. The healthy reference group had longer T1Gd values compared with the ACL-injured patients at follow-up both medially: 428±38 vs 363±61ms (P<0.0001) and laterally: 445±41 vs 396±48ms (P=0.0002). At follow-up T1Gd was lower in meniscectomized patients compared to those without a meniscectomy, both medially (-84ms, P=0.002) and laterally (-38ms, P=0.05). In the injured group, the medial femoral cartilage showed similar T1Gd at the two dGEMRIC investigations: 357±50 vs 363±61ms (P=0.57), whereas the lateral femoral cartilage T1Gd increased: 374±48 vs 396±48ms (P=0.04). The general decrease in cartilage T1Gd in ACL-injured patients compared with references provide evidence for structural matrix GAG changes that seem more pronounced if a concomitant meniscal injury is present. The fact that post-traumatic OA commonly develops in ACL-injured patients, in particularly those with meniscectomy, suggests that shorter T1Gd may be an early biomarker for OA.

Fifteen-Year Outcome of Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft for “Isolated” Anterior Cruciate Ligament Tear

Background: Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries. Purpose: To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft. Study Design: Case series; Level of evidence, 4. Methods: Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment. Results: Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle <17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age <18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C). Conclusion: Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization.

Hamstring Allograft Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Reconstruction of the anterior cruciate ligament (ACL) remains the most appropriate treatment for adolescent patients who are ACL deficient. This article reviews the indications for adolescent ACL reconstruction, potential risks, and the technique for allograft HISTORICAL PERSPECTIVE In the last 20 years, there has been an increase in the literature pertaining to the management of a skeletally immature patient with anterior cruciate ligament (ACL) injuries. With increasing involvement of children in sports, an increase in ACL injuries in this population has been reported.' In a survey of members of the Herodicus Society and the ACL Study Group, Kocher et al2 reported that the members studied a mean of 5.8 pediatric patients with ACL injuries annually. In addition, 78% of those surveyed stated that they had performed an ACL reconstruction on a skeletally immature patient within the previous year. Historically, ACL reconstruction in skeletally immature patients has been discouraged because of the theoretical risks of damage to the physes and the risk of growth disturbance. However, the case series data available in the literature have not supported a significant pattern of leg length discrepancy or angular deformity caused by ACL reconstruction in adolescent patients.310 Controversy still exists between nonoperative management and surgical reconstruction of these patients based on the potential risks of both treatment options. Nonsurgical treatment risks an unstable knee and further damages the meniscal structures and articular cartilage. Anterior cruciate ligament injuries in adolescents behave similarly to those injuries in adults; chondral and meniscal injuries are common. Operative reconstruction risks potential damage to the growth plate. Previous research has shown that 21% to 100% of pediatric patients with ACL injuries will have a concomitant meniscal injury.1'4'5'1014 In addition, there is a risk of exacerbating initial injury or new meniscal damage if the knee remains chronically unstable.5'15'16 Growth plate arrest after ACL reconstruction, although a concern, has only been infrequently reported.2'17'18 Furthermore, the treatment of physeal arrest is soft tissue interposition, and for this reason, hamstring tendon grafts have

The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury?

To map by magnetic resonance imaging (MRI) and quantitative MRI (qMRI) concomitant fractures and meniscal injuries, and location and volume of traumatic bone marrow lesions (BMLs) in the acutely anterior cruciate ligament (ACL) injured knee. To relate BML location and volume to cortical depression fractures, meniscal injuries and patient characteristics. One hundred and twenty-one subjects (26% women, mean age 26 years) with an ACL rupture to a previously un-injured knee were studied using a 1.5T MR imager within 3 weeks from trauma. Meniscal injuries and fractures were classified by type, size and location. BML location and volume were quantified using a multi-spectral image data set analyzed by computer software, edited by an expert radiologist. Fractures were found in 73 (60%) knees. In 67 (92%) of these knees at least one cortical depression fracture was found. Uni-compartmental meniscal tears were found in 44 (36%) subjects and bi-compartmental in 24 (20%). One hundred and nineteen (98%) knees had at least one BML, all but four (97%) located in the lateral compartment. Knees with a cortical depression fracture had larger BML volumes (P<0.001) than knees without a cortical depression fracture, but no associations were found between meniscal tears and BML volume or fractures. Older age at injury was associated with smaller BML volumes (P<0.01). A majority of the ACL injured knees had a cortical depression fracture, which was associated with larger BML volumes. This indicates strong compressive forces to the articular surface and cartilage at the time of injury, which may constitute an additional risk factor for later knee osteoarthritis development.