Difference In Anterior Tibial Translation Research Articles

Quantification of anterior translation of tibia over femur using Lachmeter in anterior cruciate ligament reconstruction with hamstring tendon autograft

Background: The anterior cruciate ligament (ACL) is an important restraint on anterior tibial translation of the knee. Arthroscopic ACL reconstruction using hamstring tendon autograft is the most widely accepted surgical procedure for ACL insufficiency. This study is assessing the effect of ACL reconstruction by hamstring tendon autograft on the anteroposterior stability of the knee joint by measuring the side-to-side difference of anterior tibial translation using the Lachmeter. We are also assessing the functional outcome of the same surgery using international knee documentation committee (IKDC) score. Methods: The study included 30 patients who were admitted for ACL reconstruction with hamstring tendon autograft. The side-to-side difference of anterior tibial translation was assessed by using Lachmeter preoperatively and postoperatively at the end of the 1st, 3rd, and 6th months. The IKDC score was assessed preoperatively and postoperatively at the end of 6th month. Results: The mean Lachmeter value of respondents in the current study was 4.31±0.56 mm during the preoperative period. Lachmeter values were 2.79±0.42 mm, 2.09±0.42 mm, and 1.29±0.39 mm, respectively, at the end of the first, third, and sixth months postoperatively. Mean preoperative and postoperative 6th month IKDC scores were 55.83±7.7 and 89.20±5.3 respectively. Conclusions: There is significant serial improvement in the side-to-side difference of anterior tibial translation in the 6 months of post operative period following ACL reconstruction using hamstring tendon autograft. The improved IKDC score from preoperative to postoperative level is also indicating a positive functional outcome.

Systematic Review of Clinical Outcomes After Proximal Tibia Anterior Closing-Wedge Osteotomy With ACL Reconstruction.

While increased posterior tibial slope (PTS) is an important risk factor for failure after anterior cruciate ligament (ACL) reconstruction, controversy exists regarding indications and outcomes of proximal tibia anterior closing-wedge osteotomy (ACWO) with concomitant ACL reconstruction in patients with ACL tears. To assess clinical outcomes after combined ACL reconstruction and proximal tibia ACWO. Systematic review; Level of evidence, 4. In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we performed a systematic review of the existing literature on ACWO and ACL reconstruction using PubMed (MEDLINE), Cochrane Library, Scopus, and Embase. The search phrases included "anterior closing wedge osteotomy,""anterior closing wedge tibial osteotomy,""anterior closing wedge proximal tibial osteotomy,""anterior cruciate ligament," and "revision anterior cruciate ligament." Non-English publications and single-patient case reports were excluded. Extracted data included study details, patient demographics, patient-reported outcomes (PROs), clinical outcomes, radiographic outcomes, complications, and return-to-sport (RTS) rates. A total of 6 studies with 110 patients (110 knees) were included. Two-stage ACWO and ACL reconstruction was reported in 2 studies of 78 patients (71%), while a single-stage technique was reported in 4 studies of 32 patients (29%). ACWO was performed in the setting of primary ACL tear in 23 patients (21%) and in recurrent ACL tear in 87 patients (79%). Patients demonstrated postoperative improvements in Lysholm, pivot-shift test, and side-to-side difference in anterior tibial translation. After ACWO, all studies reported mean postoperative PTS of <10° (range, 4.4°-9.2°). Of patients with available RTS data (n = 43), the same-level RTS rate ranged from 65% to 100%. A two-stage procedure reported in 1 study had a lower RTS rate (n = 13 of 20 [65%]) than that of 2 studies with single-stage procedure (n = 4 of 5 [80%] and n = 18 of 18 [100%]). The overall complication rate was 0.9% to 1.3%, and there were no reported ACL retears. The current evidence, which is constrained by the quantity and quality of studies, showed that ACWO with single- or two-stage ACL reconstruction in patients with ACL insufficiency and increased PTS was associated with significant improvements in PROs and high RTS rates.

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

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

Posterior Displacement of Meniscal Ramp Lesion Is Observed on Flexed Knee Magnetic Resonance Imaging of Anterior Cruciate Ligament-Deficient Knees

To confirm whether posterior displacement of the detached meniscocapsular structure in ramp lesions could be observed on magnetic resonance imaging (MRI) in the flexed knee position and to clarify whether this displacement on MRI is related to greater anterior knee laxity. This retrospective comparative trial study included 50 patients with anterior cruciate ligament injuries in whom attendant ramp lesions were observed on preoperative MRI. All patients underwent 3-T MRI at 120° of knee flexion preoperatively. The gap distance of the ramp lesion on sagittal slices was measured, and a distance greater than 1 mm was classified as gap positive. Additionally, joint effusion in the posteromedial recess was quantitatively evaluated by measuring the surface area of joint fluid. Prior to surgery, the side-to-side difference in anterior tibial translation (ATT) on stress radiographs at 20° of knee flexion was measured to evaluate anterior knee laxity. During anterior cruciate ligament reconstruction, the length of the ramp lesion was measured by a scale from the posteromedial portal. Of the 50 knees, 29 had ramp lesion gaps greater than 1 mm on MRI at knee flexion. The gap-positive group had a significantly greater side-to-side difference in ATT (9.6 ± 3.6 mm vs 5.0 ± 2.7 mm, P < .001) and significantly larger ramp lesion length (15.7 ± 4.9 mm vs 11.7 ± 3.9 mm, P= .002) than the gap-negative group. The gap-positive group also had a significantly greater amount of joint effusion than the gap-negative group (P < .001). Posterior displacement of the detached meniscocapsular structure in ramp lesions can be observed on MRI at knee flexion and is related to greater anterior knee laxity, lesion size, and joint effusion. Level III, retrospective comparative trial.

3D assessment of graft malposition after ACL reconstruction: Comparison of native and 11o'clock ligament orientations

BackgroundFemoral tunnel malposition makes up the majority of technical failures for ACL reconstructive surgery. The goal of this study was to develop adolescent knee models that accurately predict anterior tibial translation when undergoing a Lachman and pivot shift test with the ACL in the 11o’clock femoral malposition (Level of Evidence: IV). MethodsFEBio was used to build 22 subject-specific tibiofemoral joint finite element representations. To simulate the two clinical tests, the models were subject to loading and boundary conditions established in the literature. Clinical, historical control data were used to validate the predicted anterior tibial translations. ResultsA 95% confidence interval showed that with the ACL in the 11o’clock malposition, the simulated Lachman and pivot shift tests produced anterior tibial translations that were not statistically different from the in vivo data. The 11o’clock finite element knee models resulted in greater anterior displacement than those with the native (approximately 10o’clock) ACL position. The difference in anterior tibial translation between the native and 11o’clock ACL orientations was statistically significant. ConclusionClinically, by understanding the impact that ACL orientation has in anterior tibial displacement biomechanics, surgical interventions can be improved to prevent technical errors from occurring. The integration of this methodology into surgical practice not only allows for anatomical visualization prior to surgery, but also creates the opportunity to optimize graft placement, thus improving post-surgical outcomes.

Comparison of Onlay Anchor Fixation Versus Transosseous Fixation for Lateral Extra-articular Tenodesis During Revision ACL Reconstruction.

There is evidence on the clinical effectiveness of the Lemaire technique for lateral extra-articular tenodesis (LET) in patients undergoing revision anterior cruciate ligament reconstruction (ACLR), but the best fixation technique is unknown. To compare the clinical outcomes of 2 fixation techniques after revision ACLR: (1) onlay anchor fixation, which would avoid tunnel conflict and physis injury, and (2) transosseous tightening and interference screw fixation. Pain at the area of LET fixation was also assessed. Cohort study; Level of evidence, 3. This was a retrospective 2-center study of patients with first-time revision ACLR and either LET with anchor fixation (aLET) with a 2.4-mm suture anchor or LET with transosseous fixation (tLET). Outcomes at minimum 12-month follow-up were assessed with the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain at the LET fixation area, Tegner score, and anterior tibial translation (ATT). A subgroup analysis within the aLET group investigated passing the graft over or under the lateral collateral ligament (LCL). In total, 52 patients were included (26 patients in each group); the mean ± SD follow-up was 13.7 ± 3.4 months. No statistically significant differences were detected between the groups with respect to patient-reported outcome scores, clinical examination, or instrumented testing (side-to-side difference in ATT at 30° of flexion; aLET, 1.5 ± 2.5 mm; tLET, 1.6 ± 1.7 mm). Clinical failure was detected in 1 patient with aLET and none with tLET. Subgroup analysis revealed a small, nonsignificant flexion deficit in knees in which the iliotibial band strand was passed under (n = 42) or over (n = 10) the LCL. No clinically relevant tenderness was detected at the area of LET fixation in any group (aLET, 0.6 ± 1.3; tLET, 0.9 ± 1.7; over the LCL, 0.2 ± 0.6; under the LCL, 0.9 ± 1.6). Onlay anchor fixation and transosseous fixation of the LET were equivalent with respect to outcome scores and instrumented ATT testing. Clinically, there were minor differences in passage of the LET graft over or under the LCL.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BackgroundAnterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.MethodsThe study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.DiscussionThis will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.Trial registrationAustralia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021

Good clinical scores, no evidence of excessive anterior tibial translation, a high return to sport rate and a low re-injury rate is observed following anterior cruciate ligament reconstruction using autologous hamstrings augmented with suture tape.

Augmented anterior cruciate ligament reconstruction (ACLR) techniques have been proposed to reduce the high reported re-injury rates and low rates of return to sport (RTS). This study reports clinical outcomes, RTS and re-injury rates in patients undergoing ACLR using autologous hamstrings augmented with suture tape. A total of 53 patients were prospectively recruited, undergoing ACLR using hamstrings with suture tape augmentation, combined with a structured rehabilitation programme. Outcomes were collected to 24months, including patient-reported outcome measures (PROMs), KT-1000 measurements, peak isokinetic knee strength and a four hop test battery. Limb Symmetry Indices (LSIs) were calculated for performance measures, whilst RTS rates, re-tears and re-operations were presented. There were no significant side-to-side differences in anterior tibial translation between the operated and non-operated knees at 6months (p = 0.433), with no increase (p = 0.841) in side-to-side anterior tibial translation from 6 to 24months. At 24months, 98.0% of patients demonstrated normal (< 3mm) or near normal (3-5mm) side-to-side differences. LSIs for peak knee extensor torque (p < 0.0001) and the single (p = 0.001), triple (p = 0.001) and triple crossover (p < 0.0001) hop tests for distance significantly improved. All PROMs significantly improved (p < 0.0001), with 70.2% and 85.7% of patients actively participating in pivoting sports at 12 and 24months, respectively. Three patients underwent secondary procedures for meniscal symptoms. One patient suffered an ACL re-tear (17months), with no further ipsilateral or contralateral injuries. ACLR with suture tape augmentation demonstrated no evidence of excessive anterior tibial translation, high-scoring PROMs, sound performance scores, a high rate of RTS and low re-injury rate.

Remnant Preservation of the Primary Vertical Graft in Revision Anterior Cruciate Ligament Reconstruction.

The remnant preservation of a primary vertical graft in revision anterior cruciate ligament reconstruction (ACLR) can benefit anteroposterior stability. However, studies that address this concept are rare. To evaluate clinical outcomes of remnant preservation of primary vertical graft in revision ACLR. Cohort study; Level of evidence, 3. A total of 74 patients with revision ACLR were included in this retrospective study. Remnant preservation revision ACLR was performed only in patients with primary vertical grafts. The patients were divided into 2 groups according to whether the primary remnant vertical graft was preserved (remnant group; n = 48) or absent or sacrificed (no-remnant group; n = 26). The remnant group was further divided according to the degree of remnant tissue: sufficiently preserved subgroup (graft coverage, ≥50%; n = 25) and insufficiently preserved subgroup (graft coverage, <50%; n = 23). Clinical outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective form, Lysholm score, Tegner activity scale, manual laxity tests, and side-to-side difference in anterior tibial translation on Telos stress radiographs. The mean time to final follow-up was 40.7 ± 16.8 months. The remnant group showed more improved results in the postoperative Lachman test and Telos side-to-side difference than did the no-remnant group (P = .017 and .016, respectively). The post hoc test revealed that the side-to-side difference in laxity in the sufficiently preserved subgroup significantly outperformed that in the no-remnant group (P = .001), although no significant difference existed between the insufficiently preserved and no-remnant subgroups (P = .850). The postoperative IKDC subjective form, Lysholm score, and Tegner activity scale did not show significant differences between the 2 groups (P = .480, .277, and .883, respectively). The remnant preservation of the primary vertical graft in revision ACLR may result in better anteroposterior stability. However, subjective outcomes in the remnant group did not exceed that of the no-remnant group. The subgroup analysis revealed that only sufficiently preserved remnants demonstrated better anteroposterior stability.

Lateral meniscal status, chronicity of anterior cruciate ligament (ACL) deficiency, and initial graft tension were associated with abnormal knee laxity after anatomical ACL reconstruction

PurposeGraft failure or recurrence of instability without obvious trauma remains one of the problems following anterior cruciate ligament (ACL) reconstruction. This retrospective study aimed to identify risk factors for abnormal knee laxity after anatomical ACL reconstruction. MethodsA total of 291 patients who underwent primary anatomical ACL reconstruction were included in this study. Sex, age, body mass index (BMI), time to surgery, medial meniscal status, lateral meniscal status, graft materials, initial graft tension protocol, preoperative and postoperative pivot shift test and side-to-side differences in anterior tibial translation using the arthrometer were reviewed. Abnormal knee laxity was defined as constituting one or both of the following criteria: (i) a side-to-side difference of ≥3 mm by arthrometer; and (ii) a positive pivot shift test, being “glide,” “clunk”, or “gross”. ResultsAbnormal knee laxity occurred in 30 patients (10.3%) at a median follow-up of 25 months. Results of univariate analysis indicated that a higher likelihood of abnormal knee laxity was associated with female sex, greater BMI, longer time to surgery, higher initial graft tension protocol, and lateral meniscus resection. Multivariate logistic regression analysis showed that abnormal knee laxity was significantly associated with time to surgery [1-month increase; odds ratio (OR), 1.01], higher initial graft tension protocol (vs. lower tension; OR, 3.5), and lateral meniscus resection (vs. intact and repaired lateral meniscus; OR, 12.8). ConclusionHigher initial graft tension protocol, chronicity of ACL deficiency, and lateral meniscus resection were risk factors for abnormal knee laxity after anatomical ACL reconstruction. Level of evidenceLevel III retrospective prognostic study.

Graft failure and revision rate after ACL repair with dynamic intraligamentary stabilization. One-year results of a prospective case series of 155 patients

PurposeThe aim of this study was to assess graft failure, revision rate, and functional outcomes after treatment of acute ACL rupture with dynamic intraligamentary stabilization (DIS) Ligamys device one year post surgery. Additionally, differences in functional outcome between patients with and without anteroposterior laxity were assessed. It was hypothesized that the failure rate of DIS was non-inferior to that of previously reported ACL reconstruction (10%).MethodsIn this prospectively designed multicenter study, including patients with an acute ACL rupture, DIS was performed within 21 days after rupture. Primary outcome was failure of the graft at 1 year post surgery, defined as 1) re-rupture of the graft, 2) revision of DIS, or 3) a > 3 mm side-to-side difference in anterior tibial translation compared to the non-operated knee (∆ATT), measured by the KT1000 device. Additional analysis was performed using a 5 mm threshold. The subjective International Knee Documentation Committee Score (IKDC) and Numerical Rating Scales (NRS) for pain and confidence were used to evaluate functional outcome.ResultsA total of 155 patients were included with a mean age at surgery of 27.8 years (SD 9.4). The mean interval from rupture to DIS was 16.4 days (SD 5.2). At a median follow-up of 13 months (IQR 12–18) the failure rate of the graft was 30.2% (95%CI:22.0–39.4); 11 patients (7%) required secondary reconstructive surgery and of the 105 patients who attended ATT measurement, 24 patients (23%) had an ∆ATT > 3 mm. Secondary analysis, based on a 5 mm threshold, revealed a failure rate of 22.4% (95%CI: 15.2; 31.1). A total of 39 patients (25%) reported at least one complication, comprising mainly arthrofibrosis, traumatic re-rupture and pain. In these patients, removal of the monoblock was performed in 21 cases (13.5%). At follow-up no significant differences in functional outcomes between patients with ∆ATT > 3 mm and stable ATT were observed.ConclusionThis prospective multicenter study found a high failure rate at one year follow-up of 30% (7% revision surgery and 23% > 3 mm side-to-side difference in anterior tibial translation) in patients treated by primary repair of the ACL with DIS, and did therefore not demonstrate non-inferiority to ACL reconstruction. For patients who did not require secondary reconstructive surgery, this study found good functional outcomes, also in case of persistent anteroposterior knee laxity (∆ATT > 3 mm).Level of evidenceLevel IV.

Isometric Knee Muscle Strength and Patient-Reported Measures Five Years after Anterior Cruciate Ligament Reconstruction: Comparison of Single versus Dual Autograft Hamstring Tendon Harvesting.

There is some controversy regarding the use of one or two hamstring tendons for anterior cruciate ligament reconstruction (ACLR). In this study, two cohorts of 22 male patients underwent an ACLR with hamstring tendon autografts. One cohort was reconstructed through an all-inside technique with the semitendinosus tendon (ST group) and the other with the semitendinosus and gracilis tendons (ST-G group). Anterior tibial translation (ATT), Lysholm, and IKDC scores were assessed preoperatively and five years postoperation. Additionally, isometric knee muscle strength was manually measured in both groups and in another cohort of 22 uninjured control male subjects five years after the operation. There were no significant differences in ATT and Lysholm scores between the operated groups. The IKDC score was lower in the ST-G group than in the ST group—9.57 (CI 14.89–4.25) (p < 0.001). No significant differences between injured and uninjured knees were detected in hamstring to quadriceps ratio strength and quadriceps limb symmetry index of the two operated groups, but the hamstring limb symmetry index was significantly lower in the ST-G group than in the ST and control groups. This study shows that using an ST-G autograft for ACLR yielded less flexor strength and worse results in some patient-reported outcome measures (PROM) than using an ST autograft five years after the operation. The observed results let us suggest that the use of one autograft hamstring tendon for ACLR is clinically preferable to the use of two hamstring tendons.

Comparable Instrumented Knee Joint Laxity and Patient-Reported Outcomes After ACL Repair With Dynamic Intraligamentary Stabilization or ACL Reconstruction: 5-Year Results of a Randomized Controlled Trial

Background: Technical innovation has led to the renaissance of anterior cruciate ligament (ACL) repair in the past decade. Purpose/Hypothesis: The present study aimed to compare instrumented knee joint laxity and patient-reported outcomes (PROs) after ACL repair with those after primary ACL reconstruction for acute isolated ACL tears. It was hypothesized that ACL repair would lead to comparable knee joint stability and PROs at 5 years postoperatively in comparison with ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair using dynamic intraligamentary stabilization (DIS) or primary ACL reconstruction with a semitendinosus tendon autograft. The primary outcome was the side-to-side difference in anterior tibial translation (ΔATT) assessed by Rolimeter testing at 5 years postoperatively. Follow-up examinations were performed at 1, 2, and 5 years. PROs were assessed using the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score, and the Lysholm score. Furthermore, the rates of recurrent instability, other complications, and revision surgery were recorded. A power analysis was performed a priori, and the Friedman test, Mann-Whitney U test, and Bonferroni correction were applied for statistical comparisons with significance set at P < .05. Results: The mean age at inclusion was 28.3 ± 11.5 years in the ACL repair group and 27.1 ± 11.5 years in the ACL reconstruction group. At 5 years postoperatively, a total of 64 patients (ACL repair: n = 34 of 43 [79%]; ACL reconstruction: n = 30 of 42 [71%]) were available for follow-up. At 5 years, ΔATT was 1.7 ± 1.6 mm in the ACL repair group and 1.4 ± 1.3 mm in the ACL reconstruction group (P = .334). Preinjury PROs were restored as soon as 1 year after surgery and plateaued until 2 and 5 years postoperatively in both groups. At the 5-year follow-up, the mean Lysholm score was 97.0 ± 5.4 versus 94.5 ± 5.5 (P = .322), respectively, and the mean IKDC subjective score was 94.1 ± 9.9 versus 89.9 ± 7.8 (P = .047), respectively, in the ACL repair group versus ACL reconstruction group. At 5 years postoperatively, 12 patients in the ACL repair group (35%; age <25 years: n = 10/12; Tegner score ≥7: n = 10/12) had recurrent instability, of whom 10 underwent single-stage revision ACL reconstruction. In the ACL reconstruction group, there were 6 patients with recurrent instability (20%; age <25 years: n = 6/6; Tegner score ≥7: n = 5/6); however, in 5 patients, staged revision was required. Differences between both groups regarding recurrent instability (P = .09) or ACL revision surgery (P = .118) were not statistically significant. Recurrent instability was associated with age <25 years and Tegner score >7 in both groups. Conclusion: At 5 years after ACL repair with DIS, instrumented knee joint laxity and PROs were comparable with those after ACL reconstruction. Although no significant difference was found between repair and reconstruction, a critical appraisal of the rates of recurrent instability (35% vs 20%, respectively) and revision surgery (38% vs 27%, respectively) is needed. Young age and a high preinjury activity level were the main risk factors for recurrent instability in both groups. However, single-stage revision ACL reconstruction was possible in each case in the ACL repair group. Although ACL reconstruction remains the gold standard in the treatment of ACL tears, the present study supports the use of ACL repair with DIS as a feasible option to treat acute ACL tears in patients aged ≥25 years with low to moderate activity levels (Tegner score <7). Registration: DRKS00015466 (German Clinical Trials Register).

Single versus double hamstring tendon graft in anterior cruciate ligament reconstruction in the paediatric patient: a single-blind randomised controlled trial study protocol

IntroductionThere is currently no clear indication in the literature regarding a single or double hamstring tendon (single bundle) autograft for anterior cruciate ligament (ACL) reconstruction in the paediatric patient. The...

Arthroscopic Anterior Cruciate Ligament Repair Versus Autograft Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of Comparative Studies.

PurposeTo compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) repair and autograft ACL reconstruction for ACL ruptures.MethodsPubMed, EMBASE, Scopus, Web of Science and The Cochrane Library were searched for relevant studies from 1 January 1990 to 21 March 2022. Two evaluators independently screened the literature, extracted data and assessed the methodological quality of the enrolled studies. Meta-analysis was conducted using RevMan 5.4 software.ResultsTen studies with mean follow-up periods from 12 to 36 months were included. For 638 patients with ACL ruptures, arthroscopic ACL repair showed statistically comparable outcomes of failure (p = 0.18), complications (p = 0.29), reoperation other than revision (p = 0.78), Lysholm score (p = 0.78), Tegner score (p = 0.70), and satisfaction (p = 0.45) when compared with autograft ACL reconstruction. A significantly higher rate of hardware removal (p = 0.0008) but greater International Knee Documentation Committee (IKDC) score (p = 0.009) were found in the ACL repair group. The heterogeneity of the side-to-side difference of anterior tibial translation (ΔATT) was high (I2 = 80%). After the sensitivity analysis, the I2 decreased dramatically (I2 = 32%), and the knees with ACL repair showed significantly greater ΔATT (P = 0.04).ConclusionFor proximal ACL ruptures, arthroscopic ACL repair showed similar clinical outcomes, and even better functional performance when compared to autograft ACL reconstruction. ACL repair has a higher rate of hardware removal, and might be related to greater asymptomatic knee laxity. More high-quality prospective trials are needed to confirm our findings.

Dynamic Ultrasound Assessment of the Anterior Tibial Translation for Anterior Cruciate Ligament Tears Diagnostic.

The aim of our study was to investigate the accuracy of dynamic ultrasound assessment of the anterior tibial translation, in diagnosing anterior cruciate ligament tears, and to assess its test–retest reliability. Twenty-three patients (32 ± 8.42 years; 69.56% males) with a history of knee trauma and knee instability participated in the study. Knee ultrasound was performed by an experienced orthopedic surgeon. The anterior tibial translation was measured in both knees and differences between the injured and uninjured knee were calculated. Side-to-side differences > 1 mm were considered a positive diagnosis of an ACL tear. The anterior tibial translation values were 3.34 ± 1.48 mm in injured knees and 0.86 ± 0.78 mm in uninjured knees. Side-to-side differences > 1 mm were found in 22 cases (95.65%). The diagnosis accuracy was 91.30% (95%CI: 71.96–98.92%) and sensitivity 95.45% (95%CI: 77.15–99.88%). The intraclass correlation coefficient showed an excellent test–retest reliability (ICC3,1 = 0.97 for the side-to-side difference in anterior tibial translation). The study highlights the accuracy and reliability of the dynamic ultrasound assessment of the anterior tibial translation in the diagnosis of unilateral anterior cruciate ligament tears. Ultrasound assessment is an accessible imaging tool that can provide valuable information and should be used together with physical examination in suspected cases of ACL injuries.

Reliability and Validity of an MRI-Based Knee Sagittal Alignment Measure in a Pediatric Cohort.

Magnetic resonance imaging (MRI) sagittal alignment is a measure that has been described and validated in the adult population as a means of distinguishing normal knees from those with anterior cruciate ligament (ACL) injury, but this measure has not been formally assessed among pediatric patients. The purpose of this study was to (1) assess the reliability of this MRI-based measure in a pediatric cohort, and (2) validate its ability to distinguish between ACL and non-ACL-injured knees in this population. A consecutive series of knee MRI examinations performed at our center were reviewed to identify studies of pediatric patients (1) with ACL injury, and (2) without significant pathology. Patient age, sex, physeal status (open, closing, or closed), knee laterality, and magnet strength (1.5 or 3-Tesla) were collected. The sagittal alignment was measured in both medial and lateral tibiofemoral compartments using a previously described method. Mean anterior tibial translation was then calculated for each study. Inter-rater and intrarater reliability testing was performed on a subset of randomly-selected patients from each cohort by three raters by calculating intraclass correlation coefficients. Sagittal alignment measurements of all patients were then completed by a single author after reliability was confirmed. The medial and lateral compartment translation and mean anterior tibial translation measurements of normal and ACL-injured knees were compared. Inclusion criteria were met by 131 studies: 86 from uninjured knees (normal cohort) and 45 knees with ACL injury (ACL cohort). Studies were performed at a mean age of 13.4 with a near equivalent sex distribution. Inter-rater and intrarater reliability were good to excellent for all measures for patients in both normal and ACL cohorts. Normal and ACL-injured knees demonstrated a significant difference in anterior tibial translation in all measured regions. The mean anterior tibia translation for ACL-injured knees was 2.01 mm (95% confidence interval: 1.03-2.98) versus -0.44 mm (95% confidence interval: -0.89-0.014). This study identified good to excellent inter-rater and intrarater reliability of knee sagittal alignment measurements among pediatric patients. It also demonstrated a significant difference in medial compartment, lateral compartment, and mean tibial translation in patients with and without ACL injury, validating previous findings demonstrated in adult cohorts. These findings may be useful in assisting providers in the confirmation of suspected ACL injury and insufficiency and guide operative management in cases of clinical uncertainty. Level III-retrospective comparative study.

Ideal Combination of Anatomic Tibial and Femoral Tunnel Positions for Single-Bundle ACL Reconstruction.

Background:Anatomic anterior cruciate ligament reconstruction (ACLR) is preferred over nonanatomic ACLR. However, there is no consensus on which point the tunnels should be positioned among the broad anatomic footprints.Purpose/Hypothesis:To identify the ideal combination of tibial and femoral tunnel positions according to the femoral and tibial footprints of the anteromedial (AM) and posterolateral (PL) anterior cruciate ligament bundles. It was hypothesized that patients with anteromedially positioned tunnels would have better clinical scores, knee joint stability, and graft signal intensity on follow-up magnetic resonance imaging (MRI) than those with posterolaterally positioned tunnels.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 119 patients who underwent isolated single-bundle ACLR with a hamstring autograft from July 2013 to September 2018 were retrospectively investigated. Included were patients with clinical scores and knee joint stability test results at 2-year follow-up and postoperative 3-dimensional computed tomography and 1-year postoperative MRI findings. The cohort was divided into 4 groups, named according to the bundle positions in the tibial and femoral tunnels: AM-AM (n = 33), AM-PL (n = 26), PL-AM (n = 29), and PL-PL (n = 31).Results:There were no statistically significant differences among the 4 groups in preoperative demographic data or postoperative clinical scores (Lysholm, Tegner, and International Knee Documentation Committee subjective scores); knee joint stability (anterior drawer, Lachman, and pivot-shift tests and Telos stress radiographic measurement of the side-to-side difference in anterior tibial translation); graft signal intensity on follow-up MRI; or graft failure.Conclusion:No significant differences in clinical scores, knee joint stability, or graft signal intensity on follow-up MRI were identified between the patients with anteromedially and posterolaterally positioned tunnels.

Anterior cruciate ligament (ACL) repair using cortical or anchor fixation with suture tape augmentation vs ACL reconstruction: A comparative biomechanical analysis

BackgroundThe purpose was to compare knee kinematics in a cadaveric model of anterior cruciate ligament (ACL) repair using an adjustable-loop femoral cortical suspensory (AL-CSF) or independent bundle suture anchor fixation (IB-SAF) with suture tape augmentation to a bone-patellar tendon-bone (BPTB) ACL reconstruction. MethodsTwenty-seven cadaveric knees were randomly assigned to one of three surgical techniques: (1) ACL repair using the AL-CSF technique with suture tape augmentation, (2) ACL repair using the IB-SAF technique with suture tape augmentation, (3) ACL reconstruction using a BPTB autograft. Each specimen underwent three conditions according to the state of the ACL (native, proximal transection, repair/reconstruction) with each condition tested at four different angles of knee flexion (0°, 30°, 60°, 90°). Anterior tibial translation (ATT) and internal tibial rotation (ITR) were evaluated using 3-dimensional motion tracking software. ResultsACL transection resulted in a significant increase in ATT and ITR when compared to the native state (P < 0.001, respectively). ACL repair with the AL-CSF or IB-SAF technique as well as BPTB reconstruction restored native ATT and ITR at all tested angles of knee flexion, while showing significantly less ATT at 0°, 30°, 60°, and 90° as well as significantly less ITR at 30°, 60°, and 90° of knee flexion when compared to the ACL-deficient state. There were no significant differences in ATT and ITR between the three techniques utilized. ConclusionACL repair using the AL-CSF or IB-SAF technique with suture tape augmentation as well as BPTB ACL reconstruction each restored native anteroposterior and rotational laxity, without significant differences in knee kinematics between the three techniques utilized. Level of EvidenceControlled Laboratory Study.

Clinical Outcomes and Postoperative Complications After All-Epiphyseal Double-Bundle ACL Reconstruction for Skeletally Immature Patients.

Background:The treatment strategy for pediatric anterior cruciate ligament (ACL) tears, especially in patients with open physes, remains controversial.Purpose:To assess clinical outcomes and postoperative complications after all-epiphyseal double-bundle ACL (DB-ACL) reconstruction for patients with open physes.Study Design:Cohort study; Level of evidence, 3.Methods:Included were 102 patients aged ≤15 years who underwent ACL reconstruction at a single institution and had a minimum of 2 years of follow-up. Of these patients, 18 had undergone all-epiphyseal DB-ACL reconstruction (mean age, 12.4 ± 1.2 year) and 84 had undergone conventional DB-ACL reconstruction (mean age, 14.1 ± 0.9 year). The outcomes of the all-epiphyseal group were compared with those of the conventional group. Objective clinical outcomes included KT-1000 arthrometer measurements of side-to-side difference in anterior tibial translation, Lachman test grade, and pivot-shift test grade. Radiographic angular deformity (defined as >3° of the side-to-side difference in femorotibial angle) and incidence of second ACL injury were also compared.Results:The postoperative side-to-side difference in laxity significantly improved from 6.1 ± 2.4 to 0.6 ± 0.9 mm in the all-epiphyseal group (P = .001), and postoperative laxity was similar to that of the conventional group (0.4 ± 0.8 mm; P = .518). A Lachman grade 1 positive result was observed in 20% of the all-epiphyseal group and 3% of the conventional group (P = .042), and a pivot-shift grade 1 positive result was observed in 22% of the all-epiphyseal group and 4% of the conventional group (P = .074). A total of 4 patients (26.7%) in the all-epiphyseal group and 4 (6.1%) in the conventional group demonstrated angular deformity (P = .035). The incidence of postoperative ipsilateral ACL tear was 16.7% in the all-epiphyseal group and 23.8% in the conventional group (P = .757). The incidence of contralateral ACL tear was 11.1% in the all-epiphyseal group and 14.3% in the conventional group (P ≥ .999).Conclusion:All-epiphyseal DB-ACL reconstruction for skeletally immature patients achieved satisfactory clinical outcomes compared with conventional DB-ACL reconstruction. The incidence of ipsilateral graft rupture was relatively high in both groups. The all-epiphyseal group had a significantly higher incidence of angular deformity.