Difference In Anterior Translation Research Articles

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature.

Background Anterior cruciate ligament reconstruction (ACLR) is a common operative procedure and many options regarding the type of the selected graft and fixation technique have been described to date. Although many studies have addressed the issue of the optimal femoral fixation device during ACLR with a hamstring tendon (HT) autograft, no clear evidence to indicate one technique over another has been found. Objective The purpose of this study was to compare the long-term postoperative outcomes and complication rates between transfemoral Cross-pin (CP) and Endobutton-Cortical Button (CB) fixation techniques in patients undergoing ACLR with an HT autograft. Methods One hundred and seven consecutive patients underwent ACLR by using a quadruple HT autograft that was stabilized with either a CP (CP Group: 52 patients) or a CB (CB Group: 55 patients) fixation technique. The Lachman test (LT), the Pivot-shift test (PST), the side-to-side difference in anterior translation of the tibia, the International Knee Documentation Committee (IKDC), and the Lysholm knee scoring systems were evaluated before surgery and during long-term follow up. Thefemoral and tibial tunnel diameter was measured in the anteroposterior (AP) and lateral radiographsafter surgery and at the final follow-up. Areview of the literature was also carried out to identify any differences between both techniques. Results Study groups were comparable in terms of patient demographics. The mean follow-up was 10.4 ± 1.3 and 10.6 ± 1.3 years in the CP and CB Groups, respectively (p = 0.47). In the CP Group, improvements after surgery in LT and PST from grade 2 (n=34) or 3 (n=18) to grade 0 (n = 41) or 1 (n = 11) and from grade 2 (n=36) or 3 (n = 16) to grade 0 (n = 44) or 1 (n = 8), respectively, were observed. In the CB Group, similar improvements in LT and PST scores from grade 2 (n = 40) or 3 (n = 15) to grade 0 (n = 46) or 1 (n = 9) and from grade 2 (n = 41) or 3 (n = 14) to grade 0 (n = 47) or 1 (n = 8), respectively, were observed. However, no differences between the groups (p = 0.53 for LT and p = 0.90 for PST) were noted. The mean Lysholm scores were 89.7 ± 6.8 and 90.2 ± 7.2 in the CP and CB groups, respectively (p = 0.59). Side-to-side difference improved from 9.1 ± 2.8 to 1.7 ± 1.5 mm and from 8.6 ± 2.5 to 1.6 ± 1.4 mm in the CP and CB groups, respectively (p = 0.89 between groups). According to IKDC grades, 92.1% and 91.4% of knees in the CP and CB groups, respectively were reported to be Grade A (Normal) or B (Nearly Normal) with a p = 0.7. Femoral and tibial tunnel widening was found in the last follow-up in both groups. However, there was no difference in the degree of tunnel widening among the two techniques.With respect to LT, PST, anterior drawer test, and IKDC score, none of the 15 published comparative studies demonstrated any significant differences between the two techniques and only one study detected a difference regarding the Lysholm score in favor of CP fixation. Conclusion In the long term, both CB and CP femoral stabilization techniques were shown to be associated with similar functional outcomes and low complication rates. Further large multicenter random clinical trials are still required to identify the most effective method of femoral fixation for HT autograft during ACLR surgery.

The Effect of Concavity Restoration on Glenohumeral Stability in a Glenoid Bone Loss Model: Comparing the Distal Tibial Allograft Reconstruction and the Latarjet Procedure

Objectives: Glenoid bone loss occurs in more than 80% of patients with recurrent glenohumeral instability. The Latarjet procedure has become the gold standard for restoration of bone loss despite a high (15-30%) complication rate.1–3 Distal tibial allograft (DTA) reconstruction has recently gained interest due to its ability to restore width and concavity to the glenoid while providing a cartilage surface.4 The purpose of this study is to evaluate the restoration of glenohumeral anterior stability and glenoid concavity after DTA reconstruction when compared to the Latarjet procedure in a glenoid bone loss model. Methods: Five human cadaveric specimens (mean age: 62.2, range 57-69; 80% male) underwent preoperative computed tomography (CT) scans to assess native glenoid concavity as determined by the glenoid depth and bony shoulder stability ratio (BSSR). Stability testing was performed using a cadaveric shoulder simulator that allows 6 DoF at the glenohumeral joint. The specimens were placed with the scapula at 30° upward rotation and humerus at 60° glenohumeral abduction with a constant compressive force created by loading the supraspinatus, infraspinatus, teres minor, and subscapularis muscles (2lbs, 3lbs, 1lb and 4lbs respectively). A Kuka robot applied a 40N anterior force through the pectoralis tendon with the humerus in neutral as well as 60 degrees of external rotation. A motion capture system recorded humeral head translations for each condition. To create the Latarjet and DTA conditions, the coracoid was first harvested and the thickness was measured. A distal tibial allograft was then contoured to an identical size. A glenoid defect was created to match the thickness of the graft since both Latarjet and DTA aimed for a 100% glenoid restoration.. The following conditions were tested: 1. intact, 2. Bankart lesion, 3. bone loss model with DTA reconstruction, 4. Latarjet procedure without the conjoint tendon loaded, and 5. Latarjet with conjoint tendon loading (‘sling effect’). All specimens underwent post-testing CT scan to measure the BSSR of the DTA and Latarjet reconstructions. A repeated measures ANOVA was performed to determine if there was a significant difference in maximum anterior translation or BSSR between the distal tibial allograft reconstruction and Latarjet procedure (with or without the sling effect). Results: The mean preoperative glenoid depth measured 2.61±1.03mm with a BSSR of 0.40±0.16. However, postoperative measurements showed that BSSR for the DTA was greater than the Latarjet (0.46±0.11 vs 0.35±0.5). The maximum anterior translation was significantly lower after the DTA reconstruction than the Latarjet procedure without the sling effect (5.5mm vs 9.6mm, p = 0.044). However, there was no difference in anterior translation between the DTA reconstruction and Latarjet procedure with the sling effect applied (5.5mm vs 4.7mm, p = 0.36). The DTA reconstructed the glenoid with a significantly greater concavity than the Latarjet procedure (BSSR: 0.46 vs 0.35, p = 0.036). Conclusions: When addressing bone loss in glenohumeral instability, additional factors besides the restoration of glenoid width contribute to stability. The concave reconstruction produced by the distal tibial allograft decreases anterior translation compared to the flat reconstruction produced by the Latarjet, but there is no difference in translation between the DTA and Latarjet procedure when the sling effect is applied. The DTA reconstruction provides an alternative to the Latarjet procedure with equivalent biomechanical properties and less morbidity or change to the native shoulder structure.

Biomechanical Comparison of Anterior Cruciate Ligament Reconstruction Using a Single-Bundle Round or Ribbon-like Hamstring Tendon Graft

Background: Persistent instability of the knee is reported in up to 30% of patients after anterior cruciate ligament (ACL) reconstruction. Based on anatomic findings showing that ACL is a flat ribbon-like structure that twists during knee flexion, a new surgical ACL reconstruction technique using a ribbon-like graft has been developed. However the effect of this surgical technique on knee kinematics has not yet been evaluated. Purpose: To compare the anteroposterior and rotational stability of the knee after ACL reconstruction using single-bundle (SB) round and ribbon-like grafts in anterolateral-intact/deficient knees. Study Design: Controlled laboratory study. Methods: Twelve human fresh-frozen cadaveric knees were tested with a 6 degrees of freedom robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the ACL, (3) after ACL reconstruction using a SB hamstring tendon graft in a round configuration and a ribbon-like configuration, and (4) after sectioning of the anterolateral structures. One-way analysis of variance and post hoc Tukey tests were used for statistical analyses. Results: When compared with the intact knee, the ACL-deficient knee demonstrated a mean ± SD increase in anterior translation and internal rotation of 6.3 ± 2.5 mm (P < .01) and 5.8°± 2.3° (P < .01), respectively. After ACL reconstruction using a SB ribbon-like graft, the mean difference in anterior translation and internal rotation as compared with the intact knee was −0.1 ± 1.5 mm (P = .842) and 0.0°± 1.1° (P = .999). These differences from the intact knee were also not significant after ACL reconstruction using a round graft (−0.1 ± 1.3 mm, P = .999; −0.5°± 1.5°, P = .401). In the ACL-reconstructed knee using either a ribbon-like or round graft, sectioning of the anterolateral structures did not induce a significant increase of anterior translation and internal rotation of the knee. Conclusion: ACL reconstruction using a SB ribbon-like or round graft restored the kinematics of the intact knee at time zero. Secondary sectioning of the anterolateral structures in the ACL-reconstructed knee using both types of graft did not significantly affect the anterior translation and internal rotation of the knee. Clinical Relevance: This is the first biomechanical study on the new ACL reconstruction technique using a ribbon-like graft.

High reproducibility of a novel supported anterior drawer test for diagnosing ankle instability

BackgroundThe manual traditional anterior drawer test (ADT) is essential for deciding the treatment for chronic ankle instability, but it has been shown to have a comparatively low reproducibility and accuracy, especially in less experienced hands. To clarify the inter-examiner reproducibility, we compared the actual distance of anterior translation between junior and senior examiners in ADT. We also evaluated the diagnostic abilities of traditional ADT, and a novel modified ADT (supported ADT).MethodsThirty ankles were included in this study, and ankle instability was defined using stress radiography. All subjects underwent two methods of manual ADT by junior and senior examiners, and ankle instability was judged in a blinded fashion. The anterior drawer distance was calculated from the lengthening measured using a capacitance-type sensor device.ResultsThe degree of anterior translation determined by the junior examiner was significantly lower than that determined by the senior examiner when traditional ADT was performed (3.3 vs. 4.5 mm, P = 0.016), but there was no significant difference in anterior translation between the two examiners when supported ADT was performed (4.6 vs. 4.1 mm, P = 0.168). The inter-examiner reliability of supported ADT was higher than that of traditional ADT. For the junior examiner, the diagnostic accuracy of supported ADT was higher than that of traditional ADT (sensitivity, 0.40 vs. 0.80; specificity, 0.75 vs. 0.80).ConclusionSupported ADT may have the advantage of being a simple manual test of ankle instability with less error between examiners.

Functional biomechanical comparison of Latarjet vs. distal tibial osteochondral allograft for anterior glenoid defect reconstruction.

Glenoid reconstruction is indicated for recurrent glenohumeral instability with significant glenoid bone deficiency. Coracoid autograft (Latarjet) and distal tibial osteochondral allograft (DTA) reconstructions have been used to successfully restore glenohumeral stability. Relative advantages and disadvantages associated with each reconstruction technique have been described. However, direct comparisons of functional glenohumeral biomechanics associated with Latarjet vs. DTA reconstruction are lacking. This study was designed to compare these 2 glenoid reconstruction techniques with respect to joint kinematics and cartilage pressure mapping using a robotic testing system. In accordance with institutional review board policies, human cadaveric shoulders (n=8) were cyclically tested in the neutral position and 90° of external rotation with 60° and 90° of abduction under a 45-N joint-compression load to measure clinically relevanttranslations, loads, and torques. Joint contact pressure maps were obtained under a 120-N joint-compression load using pressure mapping sensors. After confirming that a 25% anterior glenoid defect resulted in glenohumeral dislocation, testing was performed to compare 3 conditions: native intact glenoid, 25% anterior glenoid defect with Latarjet reconstruction, and 25% anterior glenoid defect with DTA reconstruction. Analyses of variance and t tests were used to analyze data with statistical significance set at P< .05. Significant differences in anterior translation, inferior drawer, anterior drawer, compression loads, horizontal abduction, negative elevation (adduction), and external rotation torques during cyclical testing in 90° of external rotation with 60° and/or 90° of abduction were noted when comparing the 2 different glenoid bone reconstruction techniques to native, intact shoulders. The only significant difference between Latarjet and DTA reconstructions for measured translations, loads, and torques was a significantly higher absolute maximum compressive load for Latarjet compared to DTA at 60° of abduction. Latarjet coracoid osseous autograft and distal tibial osteochondral allograft reconstructions of large (25%) glenoid bone defects prevent failure (dislocation) and are associated with significant glenohumeral kinematic differences that largely confer less translation, load, and torque on the joint in abduction when compared to the native state. These findings suggest that these 2 surgical techniques exhibit similar glenohumeral kinematics such that each provides adequate functional stability following anterior glenoid bone reconstruction. Joint compression load and articular contact pressure distribution may favor distal tibial osteochondral allograft reconstruction for treatment of large (25%) anterior glenoid bone defects associated with shoulder instability.

Using an Arthrometer to Quantify Ankle Laxity: An Infographic Summary.

Lateral ankle sprains are a common musculoskeletal injury. The anterior talofibular ligament (ATFL) is the primary ligament involved and is assessed via an anterior drawer test. Clinically assessing joint laxity has been a subjective task. Evaluating both magnitude of translation and quality of the endfeel has presented challenges. Until recently, a reliable and valid arthrometer to test joints other than the knee has not been available. The Mobil-Aider arthrometer has undergone bench testing for validity, reliability testing in healthy persons, and most recently the testing of participants for pathology. A summary of these studies is available in the Online Supplement. The goal of this study was to determine the ability of the arthrometer to objectively identify the anterior translation of the ankle and the relationship to the clinical diagnosis. The participant was evaluated by a physician and magnitude of ankle sprain was determined. An arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each) in the prone position. Both clinicians were blinded to the data of the other. There were 30 participants, 10 per group (uninjured, 1° sprain, 2° sprain). Mann-Whitney U testing found significant differences between the control and grade 1 ankle sprain groups (P < .001), the control and grade 2 ankle sprain groups (P < .001), and the grade 1 and grade 2 ankle sprain groups (P = .004). There was ± 0.31 mm difference in anterior translation between healthy ankles, whereas there was 1.11 mm and 2.16 mm difference between ankles in grade 1 and grade 2 sprains, respectively. The anterior drawer test is the gold standard for clinical ATFL testing, but the subjective nature of this test poses challenges. Technology is available to assess ankle joint laxity and enhance the objectivity of patient assessment and throughout the recovery process. An arthrometer is a valuable tool in quantifying orthopaedic examination.

ANTEROMEDIAL OR CENTRAL ANATOMIC ACL RECONSTRUCTION? A CADAVERIC HIP-TO-TOE STUDY.

To compare anatomic anterior cruciate ligament (ACL) reconstruction between two tunnel positions in knees with isolated ligament tears. Anatomic ACL reconstruction was performed, from hip-to-toe, on 15 fresh cadaveric specimens. No associated lesions were created to enhance knee instability. The protocol was conducted in three states: (1) complete isolated ACL deficiency; (2) anatomic femoral and tibial anteromedial ACL reconstruction (AM REC); and (3) anatomic femoral and tibial central ACL reconstruction (Central REC). The reconstruction protocols were randomly assigned. The continuous mechanized pivot-shift test was recorded dynamically with a tracking system. The Central REC group showed a smaller degree of internal rotation (0.6° ± 0.3° vs. 1.8° ± 0.3°, respectively, P < 0.05) and no difference in anterior translation (4.7 mm ± 0.4 mm vs. 4.5 mm ± 0.4 mm, respectively, P > 0.05) in the pivot-shift test, compared with the AM REC group. The central anatomic ACL reconstruction resulted in greater restriction of internal rotation than the anteromedial anatomic ACL reconstruction. Experimental Study on Cadaver.

Assessing Lateral Ankle Sprains With a New Arthrometer.

Lateral ankle sprains are a common musculoskeletal injury across a variety of activities. Researchers have sought to identify a method to objectively assess joint laxity with a device that is simple to use and affordable. The purpose of this study was to assess the use of an ankle arthrometer on individuals with ankle sprains. The participant was evaluated by the physician and the degree of ankle sprain was identified. In the prone position, the arthrometer was used to perform an anterior drawer test (uninjured before injured, 3 measures each). Both clinicians were blinded to the data of the other. There were 30 participants, 10 in each group (uninjured, grade 1 sprain, grade 2 sprain). Mann-Whitney U testing found significant differences between the control and grade I ankle sprain groups (P < .001), the control and grade II ankle sprain groups (P < .001), and the grade I and grade II ankle sprain groups (P = .004). There was ±0.31-mm difference in anterior translation between healthy ankles, whereas there was 1.11- and 2.16-mm difference between ankles in grade 1 and grade 2 sprains, respectively. Despite the manual anterior drawer test being convenient, the subjectivity makes it unreliable. This study is consistent with prior literature about the difference in translation (millimeters) between the uninjured and injured ankles corresponding to the magnitude of ankle laxity. This study also contributes to the evolving evidence to support the relationship of a ratio of measures (injured/uninjured) as an objective measure of laxity. These comparisons to the individual's healthy ankle mitigate the variability of the normative values. The use of an arthrometer to assess ankle joint laxity enhances the objectivity of patient assessment throughout the recovery process. Level III.

Poster 167: Biomechanics of a Novel Dermal Augmentation Procedure for Subcritical Bone Loss

Objectives:Subcritical glenoid bone loss has been associated with high failure rates when treated with standard labral repair. While a Latarjet can provide stability, high complication rates and the risk of long term arthritis makes this procedure less then ideal when bone loss is under 20%. The purpose of the current study was to demonstrate biomechanical results of a new arthroscopic procedure using dermal allograft augmentation of subcritical bone loss when compared to a standard labral repair for subcritical bone loss.Methods:Six cadaveric specimens were prepared sequentially to simulate four clinical scenarios (Figure 1): 1) an intact shoulder; 2) a 15% bony glenoid defect; 3) 15% defect repaired using a 3-anchor labral; and 4) Dermal Allograft augmentation of the bony defect. The glenoid was potted on a ball-bearing base allowing horizontal degrees of freedom, with 50N weights applied to simulate intra-articular compression. The humerus was potted and placed in an Instron at 45 degrees of abduction, allowing anterior translation to dislocation. Translation (mm) and force (N) to dislocation were measured, using ANOVA for statistical analysis.Results:Dermal augmentation of the 15% defect resulted in a significantly higher force to dislocation (20.53+/-7.76N) when compared to the defect group (14.75+/-4.99N, p=0.002) or the labral repair (13.94+/-4.13N, p=0.007). There was no difference between the force to dislocation between the defect and labral repair groups (p=1.0). The intact shoulder translated 8.37+/-1.06mm prior to dislocation. This was significantly higher than both the defect (5.23 +/- 0.65mm, p<0.001) or the labral repair (6.55+/-0.97mm, p=0.048). The dermal augmentation resulted in no significant difference in anterior translation to dislocation (8.92 +/- 4.13mm, p=1.0).Conclusions:While labral repair is often used in patients with subcritical bone loss, clinical failure rates are high, ranging from 25-100%. Results of the current study indicate that a standard labral repair does not restore the force to dislocation when used in a 15% defect. On the contrary, it may lead to tightening of the shoulder in a non-anatomic position, resulting in the repair being “tested” at earlier range of motions. This may cause the repair to stretch during every day range of motion. Dermal augmentation of the glenoid defect can restore the normal anterior translation of the shoulder, while also increasing the force to dislocation when compared to a standard repair.

Laxity measurement of internal knee rotation after primary anterior cruciate ligament rupture versus rerupture

PurposeThe aim of the current study was to objectify the rotational laxity after primary anterior cruciate ligament (ACL) rupture and rerupture after ACL reconstruction by instrumented measurement. It was hypothesized that knees with recurrent instability feature a higher internal rotation laxity as compared to knees with a primary rupture of the native ACL.Study designCross-sectional study, Level of evidence III.MethodsIn a clinical cross-sectional study successive patients with primary ACL rupture and rerupture after ACL reconstruction were evaluated clinically and by instrumented measurement of the rotational and antero-posterior laxity with a validated instrument and the KT1000®, respectively. Clinical examination comprised IKDC 2000 forms, Lysholm Score, and Tegner Activity Scale. Power calculation and statistical analysis were performed (p value < 0.05).Results24 patients with primary ACL rupture and 23 patients with ACL rerupture were included. There was no significant side-to-side difference in anterior translation. A side-to side difference of internal rotational laxity ≥ 10° was found significantly more frequent in reruptures (53.6%) compared to primary ruptures (19.4%; p < 0.001). A highly significant relationship between the extent of the pivot-shift phenomenon and side-to-side difference of internal rotation laxity could be demonstrated (p < 0.001). IKDC 2000 subjective revealed significantly better scores in patients with primary ACL tear compared to patients with ACL rerupture (56.4 ± 7.8 vs. 50.8 ± 6.2; p = 0.01). Patients with primary ACL tears scored significantly better on the Tegner Activity Scale (p = 0.02). No significant differences were seen in the Lysholm Score (p = 0.78).ConclusionPatients with ACL rerupture feature significantly higher internal rotation laxity of the knee compared to primary ACL rupture. The extend of rotational laxity can be quantified by instrumented measurements. This can be valuable data for the indication of an anterolateral ligament reconstruction in ACL revision surgery.

Randomized comparative study of suspension femoral fixation device in graft position maintenance in anterior cruciate ligament reconstruction: EndoButton CL vs TightRope RT

BackgroundIn double-bundle anterior cruciate ligament reconstruction (ACLR), fixed-loop and adjustable-loop cortical suspensory devices are commonly used to fix the soft graft on the femoral side. However, few studies have compared in vivo elongation of the two devices. The purpose of this study was to determine whether EndoButton CL (EB) and TightRope RT (TR), the suspensory fixation devices used in ACLR, maintained their length in vivo from the time of surgery through the postoperative period in a randomized controlled trial. MethodsThis study prospectively incorporated 30 patients undergoing initial ACLR at a single center. Participants were divided into two groups using a stratified randomization method with age and sex as assignment adjustment factors. EB or TR was used for fixation of the soft graft on the femoral side. The primary endpoint was to compare the elongation distance of the suspensory device. MRIs were taken within seven days after ACLR and 3,6,12 months postoperatively and measured by a radiologist in a blinded fashion. Secondary endpoints included the side-to-side difference in anterior translation, one leg hop test (HOP index), Lachman test, lateral pivot shift test, and Lysholm score one year postoperatively. ResultsTwenty-eight patients (EB, n = 13; TR, n = 15) were followed for one year. There was no significant difference between EB and TR groups in elongation from the immediate postoperative period to 3, 6, 12 months after surgery. However, the non-inferiority of TR to EB (non-inferiority margin: 1.5 mm) was not proved by the difference in measured elongation between the two groups (TR – EB, lower 95% CI. AM: 1.80 mm; PL: 1.86 mm) at 6 months. There was no significant difference in anterior translation, HOP index, Lachman test, lateral pivot shift test, or Lysholm score. ConclusionEB and TR had similar graft retaining ability in vivo for 12 months, but the non-inferiority of TR against EB was not verified statistically.

L’amplificateur de brillance est-il nécessaire dans les reconstructions double faisceau du ligament croisé antérieur? Une étude prospective randomisée

IntroductionProperly placed tibial and femoral tunnels in anterior cruciate ligament (ACL) reconstruction are important because tunnel misplacement can cause abnormal changes in graft tension patterns, resulting in postoperative knee laxity. To overcome the inaccuracy of tunnel position in ACL reconstruction, intraoperative fluoroscopy has been proven to be a useful method in previous studies focusing on the tunnel position in single-bundle reconstruction, but few studies are available on the efficacy and necessity of intraoperative fluoroscopy for double-bundle (DB) reconstruction. The purpose of this prospective randomized case-control study was to evaluate the effect of intraoperative fluoroscopy on femoral and tibial tunnel position in anatomic DB ACL reconstruction using a postoperative tunnel position in a three-dimensional computed tomography (3D-CT). HypothesisIntraoperative fluoroscopy during ACL DB reconstruction could make an appropriate tunnel position closer to the anatomical center compared to conventional fluoroscopy-free procedure. Material and methodsSixty patients undergoing ACL DB reconstruction (30 fluoroscopy-free reconstruction group and 30 in fluoroscopy-assisted reconstruction group) were included in this prospective study, and randomly allocated into two groups. Mean values of the percentage distance of femoral and tibial tunnel center in a 3D-CT were compared between the two groups. Knee laxity (the anterior translation and pivot-shift grade) and clinical outcomes were also compared at the last follow-up. ResultsThere was a significant difference only in femoral anteromedial (AM) bundle tunnel position, but not in femoral posterolateral (PL) bundle, tibial AM, or PL bundle tunnel position between the two groups. Femoral AM bundle tunnel in the fluoroscopy-assisted reconstruction group showed significantly (p=0.005) deeper position compared to that in the fluoroscopy-free reconstruction group. There was no significant difference in anterior translation, pivot-shift grade, or clinical outcomes between the two groups. DiscussionFluoroscopy-assisted ACL DB reconstruction can make deeper placement of the femoral AM bundle than the conventional ACL DB reconstruction. Level of evidenceII, prospective randomized controlled trial.

Optimal cutoff score for patient-reported outcome measures after anterior cruciate ligament reconstruction using load-displacement curve analysis.

To assess psychological components after anterior cruciate ligament (ACL) injury, we developed a new patient-reported outcome measure, the Japanese anterior cruciate ligament injury questionnaire 25 (JACL-25), and demonstrated that the JACL-25 is valid, reliable, and sufficiently responsive to evaluate psychological factors that are associated with outcomes in individuals with ACL injuries. The purpose of this study was to identify the optimum cutoff score for the JACL-25 that indicates successful clinical outcomes, combining with the graphical data obtained using the KT-2000. We studied 30 patients who underwent primary ACL reconstruction with a patella tendon or hamstring tendon autograft. On the same day of the JACL-25 evaluation, anterior knee laxity tests were performed using the KT-2000 arthrometer. ACL stiffness was calculated on the graphs of the hysteresis, which can be used to measure side-to-side differences in anterior translation. Akaike's information criterion (AIC) was used to determine the most appropriate cutoff level for the JACL-25 score for the stiffness reduction ratio and anterior-posterior (AP) translation. The average JACL-25 score was 23.8 (standard deviation (SD) 18.4). The average side-to-side displacement difference in AP translation was 2.4 (SD 4.2) mm. The average stiffness reduction ratio was 24.4% (SD 31.8). The smallest AIC values for the cutoff level for the JACL-25 score, the stiffness reduction ratio, and side-to-side differences of the anterior translation were 9, 27%, and 1.1 mm, respectively. We determined the optimal cutoff score for the JACL-25 that identifies successful clinical outcomes.

Is intraoperative fluoroscopy necessary in anterior cruciate ligament double-bundle reconstruction? A prospective randomized controlled trial

IntroductionProperly placed tibial and femoral tunnels in anterior cruciate ligament (ACL) reconstruction are important because tunnel misplacement can cause abnormal changes in graft tension patterns, resulting in postoperative knee laxity. To overcome the inaccuracy of tunnel position in ACL reconstruction, intraoperative fluoroscopy has been proven to be a useful method in previous studies focusing on the tunnel position in single-bundle reconstruction, but few studies are available on the efficacy and necessity of intraoperative fluoroscopy for double-bundle (DB) reconstruction. The purpose of this prospective randomized case-control study was to evaluate the effect of intraoperative fluoroscopy on femoral and tibial tunnel position in anatomic DB ACL reconstruction using a postoperative tunnel position in a three-dimensional computed tomography (3D-CT). HypothesisIntraoperative fluoroscopy during ACL DB reconstruction could make an appropriate tunnel position closer to the anatomical center compared to conventional fluoroscopy-free procedure. Material and methodsSixty patients undergoing ACL DB reconstruction (30 fluoroscopy-free reconstruction group and 30 in fluoroscopy-assisted reconstruction group) were included in this prospective study, and randomly allocated into two groups. Mean values of the percentage distance of femoral and tibial tunnel center in a 3D-CT were compared between the two groups. Knee laxity (the anterior translation and pivot-shift grade) and clinical outcomes were also compared at the last follow-up. ResultsThere was a significant difference only in femoral anteromedial (AM) bundle tunnel position, but not in femoral posterolateral (PL) bundle, tibial AM, or PL bundle tunnel position between the two groups. Femoral AM bundle tunnel in the fluoroscopy-assisted reconstruction group showed significantly (p=0.005) deeper position compared to that in the fluoroscopy-free reconstruction group. There was no significant difference in anterior translation, pivot-shift grade, or clinical outcomes between the two groups. DiscussionFluoroscopy-assisted ACL DB reconstruction can make deeper placement of the femoral AM bundle than the conventional ACL DB reconstruction. Level of evidenceII, prospective randomized controlled trial.

Distal femur morphology affects rotatory knee instability in patients with anterior cruciate ligament ruptures.

Distal femur morphology has been shown to influence knee joint kinematics and may affect rotatory knee laxity. The purpose of this study was to determine the relationship between rotatory knee laxity and distal femoral morphology in patients with complete anterior cruciate ligament (ACL) rupture. It was hypothesized that increased posterior femoral condylar depth on standard lateral radiographs, quantified as the "lateral femoral condyle ratio" would correlate with increased rotatory knee laxity, measured by a quantitative pivot shift test. Consecutive patients who underwent ACL reconstruction from 2014 to 2016 were retrospectively reviewed. A standardized pivot shift test was performed preoperatively on both knees and quantified using tablet technology. Using standard lateral radiographs of the knee, the ratio of posterior condylar distance over total condylar distance was defined as the lateral femoral condyle ratio. Data sets were obtained for 57 patients. The mean anterior translation of the lateral knee compartment during a quantitative pivot shift test was found to be 4.0 ± 2.4mm and 1.3 ± 0.9mm for the injured and uninjured knees, respectively. The mean lateral femoral condyle ratio on X-ray was 63.2 ± 4.5%. There were significant correlations between the lateral femoral condyle ratio and the absolute quantitative (ρ = 0.370, p < 0.05) and side-to-side differences in anterior translation of the lateral knee compartment (ρ = 0.419, p < 0.05). The most important finding from this study is that increased posterior femoral condylar depth, quantified as a lateral femoral condyle ratio, is associated with increased rotatory knee laxity in ACL-deficient patients. This suggests that distal femur morphology may influence rotatory knee laxity. This study may assist clinicians in evaluating ACL injuries and identifying patients at greater risk for persistent increased rotatory knee laxity after ACL reconstruction. III.

Correlation of Condylar Translation During Maximal Mouth Opening with Presence of Signs of Temporomandibular Joint Disorders in an Asymptomatic Population of 18-25 Years Age Group of Northern India.

Objective(s):The objective of this study was to determine the frequency of “subluxation” and presence of clinical signs of Temporomandibular Joint Disorder (TMD) in asymptomatic individuals and its distribution according to age and sex.Materials and Methods:The material investigated comprised of 200 asymptomatic subjects with 400 joints. The subjects were divided into two groups of 18-25 years and 50-60 years of age consisting of equal number of males and females. Clinical examination involved measurement of maximal inter-incisal distance, joint sounds and deviation. For radiological examination, Temporomandibular Joint (TMJ) open mouth close mouth view option (TMJ1/2) was used on a Digital Panoramic Machine. All the radiographs were traced to assess subluxation and anterior translation of the condyle. The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows).Results:The prevalence of the signs of TMDs in the asymptomatic population was found to be very high and more predominant in females as compared to males. Furthermore, the older age group had comparatively less signs of TMDs. It was of interest that the subjects presenting with clinical signs of TMD were significantly less as compared to the subjects presenting with subluxation. The value of anterior translation was found to be more in females in the younger age group as compared to the males. Similarly, it was more in males as compared to females in older age group. But the mean anterior translation difference in females in 18-25 years and 50-60 years showed a statistically significant difference with P-value 0.017.Conclusion:Subluxation is a very common feature found in almost all the subjects in this study with a high prevalence. Hence, we may assume that the increased incidence of TMDs could be a direct result of the phenomena of subluxation. The decrease in mandibular length could be the cause of decreased mouth opening and increased subluxation.

Drilling through anteromedial portal with a femoral aiming device ensures a sufficient length and a proper graft position, and prevents posterior wall breakage during anterior cruciate ligament reconstruction.

The aim of this study was to evaluate the characteristics of the femoral tunnel (FT) which was drilled through the AM portal by using a femoral aimer device and AP stability of the knee. Thirty-eight patients, with the mean age 29.6 (range: 20-43) years, were evaluated after ACL reconstruction. The mean follow-up time was 31.9 (range: 16-57) months. The FT was drilled using a femoral aimer with different offset according to the graft size measured, through the AM portal. The semitendinous and gracilis tendon autograft was used for reconstruction. The angles of FT and the exit point on the lateral condyle were measured on AP views of the knee. AP stability of the knee was measured with the KT-2000. The mean angle of FT was 46.5° (± 8.4°), on the AP view. The mean distance between the exit point of FT and the most distal end of the femoral condyles was 46.7 (± 4.9) mm. The mean FT length was 36.1 (± 3.1) mm. The mean difference of anterior translation compared to the intact knee was 1.9 (± 1.6) mm. Except the three patients, with "one positive" pivot shift test, in the remaining 35 knees stability was equal to the healthy knee. Femoral drilling by using a femoral aimer device through AM portal provided long enough FT for safe graft fixation and appropriate coronal plan obliquity. The exit point was far proximal from the insertion site of the popliteus tendon and lateral collateral ligament. Furthermore, the AM portal technique significantly improved AP stability of the knee.

A Tomahawk Shape of the Femur Predicts Greater Rotatory Knee Laxity in Patients with Anterior Cruciate Ligament Ruptures

Aims and Objectives: Interindividual variations in knee laxity are poorly understood. Utilizing novel pivot shift arthrometers and patients in our ACL registry the magnitude of the pivot shift was found to vary between 0-14 mm of anterior translation in the lateral compartment. Increased tibial slope was found to influence the magnitude of the pivot shift, however, it is unclear if femur morphology might influence the magnitude of the pivot shift. Therefore, the purpose of this study was to determine the relationship between anterior translation of the lateral compartment during a quantitative pivot shift test and the posterior femoral offset, quantified as the “tomahawk ratio”, in patients with complete ACL rupture. It was hypothesized that the “tomahawk ratio” would correlate with increased anterior translation of the lateral compartment of the knee. Materials and Methods: Consecutive patients with no history of prior knee surgeries undergoing primary ACL reconstruction were analyzed. A standardized pivot shift test was performed preoperatively under anesthesia on both knees and quantified using tablet technology as previously described. Radiographic measurements were made using standard lateral knee radiographs. The long axis of the femur shaft was determined by a line through the center of two circles centered on the femoral shaft. The axis of the femoral condyle was determined by a line between the most posterior and most anterior points of the lateral condyle. The distance from the intersection of these lines to the posterior end of the condyle was divided by the total anteroposterior length of the condyle. This ratio was defined as “tomahawk ratio”. Pearson correlation coefficient was used to analyze correlations (p- value < 0.05). Results: Data sets were successfully obtained for 32 female and 25 male patients. The mean anterior translation of the lateral compartment during the pivot shift test was found to be 3.96 ±2.38 mm and 1.27±0.89 mm for the involved and uninvolved knees, respectively, with a mean side-to-side difference of 2.70±2.25 mm. The mean length of the lateral femoral condyle on x-ray was 68.36±5.31 mm, and the mean tomahawk ratio was 63.16±4.53%. There was a significant correlation between the tomahawk ratio and the absolute quantitative (r = 0.370 p < 0.05) and side-to-side differences in anterior translation of the lateral compartment (r =0.419 p < 0.05). Conclusion: The main finding from this study is that ACL-deficient patients with larger posterior femoral offsets quantified as the “tomahawk ratio” were found to have higher lateral translations of the knee during the pivot shift test. This suggests that variation in knee instability may be significantly affected by femoral bony morphology characterized by a larger posterior portion of the lateral condyle. This study may assist clinicians in evaluating ACL injuries and identifying patients at greater risk for increased rotational knee instability.

Primary anatomical repair of proximal acl ruptures with suture anchors: 1 year follow-up

Aims and Objectives: ACL injuries are common. Going trough the literature, numerous studies show a healing potential for the repair of acl tears, histologically comparable to mcl healing. In this study, the postoperative follow-up after acl preservation was examined up to 1 year. Materials and Methods: We performed a prospective clinical follow-up in 13 sportive patients (case series, no comparison group). Inclusion criterias were a proximal avulsion tear of the acl, patient age under 50 years and surgery within 6 weeks after trauma. In an arthroscopic procedure, the quality of the acl tissue was examined and judged if suitable for a repair. Concomitant injuries were treated at the same time. Using a suture passer, a Bunnell stitch was created with a nonabsorbable suture through the anteromedial bundel as through the posterolateral bundel. The footprint of the acl was prepared with an awl for liberation of stem cells. The bundels were reattached to the origins of the footprint with two absorbable suture anchors. No drain was used. The postoperative protocoll was as follows: partial weight bearing for 4 weeks and wearing a protective brace with a limitation for extension and flexion of 0-0-90° for 4 weeks. At week 5, the brace was unlocked and range of motion and weight bearing were gradually increased at the level of comfort. Patients were examined at 6 weeks, 3 months, 6 months and 12 months after surgery. The stability was tested with the KT 1000, the subjective outcome with the ACL-RSI and the clinical outcome using the Tegner activity score, the Lysholm score, the KOOS score and the IKDC objective form. X-rays were done after 3 and 12 months, a MRI after 6 months. Between months 4 and 6, patients returned to their previous level of sport. Results: All 13 patients have been included in the 1 year follow-up. No rerupture was seen. There have been no major complications, as minor complications we observed 2 effusions of the knee 7 days after surgery which were treated with aspiration. The patients presented the following outcomes after 1 year: the mean anterior translation difference in the KT 1000 was 0,85 mm; the median Tegner activity score was 6 (range from 5 to 9); the median Lysholm score 95,9; the median KOOS was 94,5. The IKDC was A in 9 of 13 patients, B in 3 and C in 1 patient. The ACL-RSI in the 6 week follow-up was 64,14%, indicating a high level of subjective stability and confidence. This score increased gradually to the 1 year follow-up (94,5%). X-rays showed no pathologic bone signal or tunnel widening. MRI showed appropriately positioned and continous ligaments with scar tissue and an irregular signal due to suture material. Conclusion: In this study, the results 1 year after surgery with an anatomical repair of the acl are promising. Nearly all patients returned to their previous sports level, indicating healing potential for acl injuries. If patient selection is done carefully, this technique is a supplement in the treatment algorithm of acl injuries.

Short-term effectiveness of absorbable anchor in repairing of partial anterior cruciate ligament rupture

To study the short-term effectiveness of absorbable anchor in repairing of partial anterior cruciate ligament (ACL) rupture. Between December 2013 and February 2015, 22 patients with partial ACL rupture were repaired with absorbable anchor under arthroscopy. There were 12 males and 10 females with an average age of 27.5 years (range, 20-44 years). The injury located at left knee in 8 cases and at right knee in 14 cases. The time from injury to admission ranged from 2 to 13 days (mean, 9.8 days). Sixteen partial ACL ruptures combined with meniscus injury. The effectiveness was assessed by Tegner score, Lysholm score, International Knee Documentation Committee (IKDC) score, visual analogue scale (VAS) score, and MRI, as well as knee laxity was evaluated by KT-1000. All incisions healed at stage Ⅰ without any complication. All patients were followed up 12 months. ACL rerupture did not occurred during follow-up. There was no significant difference in Tegner score, Lysholm score, and IKDC score between before injury and at 12 months after operation ( P>0.05). And the median satisfaction VAS score was 9.5 (range, 9-10). The tibial anterior translation difference was 0.5 mm (range, 0-6 mm). MRI showed that the scarring and continuity of the ligament were rated as grade 1 in all patients. Arthroscopic repairing by absorbable anchor is a feasible method for partial ACL rupture, with ideal knee function, good satisfaction, and satisfactory short-term effectiveness.