Isolated ACL Tears Research Articles

Role of placental membrane in ACL graft healing – A series of 18 patients

IntroductionACL injuries are common and the standard treatment remains to be ACL reconstruction. Controversy still remains around graft ligamentisation and various methods have been experimented to augment this process. In this series we discuss the outcome of using dehydrated umbilical cord derived membrane in ACL reconstruction. Material and methodA prospective Level IV analysis of outcome in 30 consecutive patients of complete isolated ACL tear presenting to us between May 2022 to September 2022 was done. There was no age or sex restriction. Revision cases were excluded from this series. ACL reconstruction was done using standard all inside technique using the ipsilateral semitendinosus graft which was wrapped with dehydrated umbilical cord derived membrane (5*3 cm2) after soaking in normal saline (Cord Thick - Life Cell; LifeCell international private limited, Chennai, Tamil Nadu, India) and secured with Monocryl 3-0 sutures in a continuous manner. Results18 patients completed the one year follow up and were analysed for final results. Eleven of the patients followed up were females and seven males, with an average age of 30.3 years.The average VAS score at 6 weeks was 2.2. The mean KOOS score at the follow up visits were 72.3, 82.3, 90.7, 95.8. The mean SANE score reported at 6 weeks, 3 months, 6 months and 1 year were 68.8, 80, 87.5, 95.1.The follow up MRI's confirmed good ligamentisation of the graft even as early as 6 weeks with minimal fluid in the tunnel. ConclusionThe use of dehydrated umbilical cord derived membrane augmentation to potentiate graft integration in ACL reconstruction seems promising and helps improve patient outcomes.

A High-Grade Lachman’s Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation

Background: Medial meniscus ramp tears are present in 22.9–40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman’s exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman’s exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman’s exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

Poster 297: Deep medial collateral ligament reconstruction of the knee restores rotational stability throughout full range of motion while contemporary MCL reconstruction only does in extension

Objectives: The past decade has taught the importance of identifying and treating the concomitant injuries that frequently occur at the time of ACL rupture. Failure to do so can result in increased stresses on the ACL graft and subsequently increased risk of failure. While the focus has largely been on the menisci and the anterolateral soft tissues, recent studies have highlighted high frequency at which injuries to the medial structures occur in previously presumed isolated ACL tears and the increased risk of poor outcomes when they are not addressed. Injuries to the medial ligament complex result in valgus and anteromedial rotatory instability (AMRI). Historic MCL reconstruction techniques have focused on the superficial MCL in an effort to restore valgus stability while frequently ignoring the importance of the deep MCL in controlling tibial external rotation. The recent recognition of the importance of the medial ligament complex has led to multiple studies revisiting medial sided anatomy and questioning contemporary MCL reconstruction techniques. The objective of this study is to assess and compare the ability of a contemporary medial collateral ligament (MCL) reconstruction and a deep MCL (dMCL) reconstruction to restore rotational and valgus stability to the knee. Methods: Six pairs fresh-frozen cadaveric knee specimens were included and with intact soft tissue, the distal femur and tibia were potted in PVC pipes to facilitate biomechanical testing using a customized multi-axial knee activity simulator. Four states were tested: 1) intact 2) after sectioning of the sMCL and dMCL, 3) contemporary MCL reconstruction as described by LaPrade et al, and 4) dMCL reconstruction. In each state, the knees were tested under four loading conditions at varying flexion angles (0°, 20°, 40°, 60° and 90°): 8 Nm valgus torque, 5 Nm tibial external rotation torque, 90N anterior drawer, and combined 90 N anterior drawer plus 5 Nm tibial external rotation torque. Results: Transection of the sMCL and dMCL resulted in increased laxity with the application of the valgus torque, external rotation torque, and combined anterior drawer plus external rotation at all flexion angles. dMCL reconstruction restored external rotation stability to intact levels (all p<0.05) throughout all degrees of flexion (Figure 1), yet dMCL reconstruction did not restore valgus stability at any flexion angle (Figure 2). Contemporary MCL reconstruction restored valgus and external rotation stability at 0° and 20° and valgus stability at 40° (p<0.01). In response to a combined anterior drawer plus tibial external rotation, the dMCL restored stability back to the intact level at 20° and improved stability between 40° and 90° flexion (Figures 3 and 4). In contrast, the contemporary MCL reconstruction did not restore stability at any degree of flexion (p>0.05). Conclusions: Deep MCL reconstruction restored rotational stability to the knee throughout range of motion but did not restore valgus stability. The contemporary MCL reconstruction restore stability only near full extension.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction.

To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage. A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles. A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01). The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients. Level III.

Deficits in Dynamic Balance and Hop Performance Following ACL Reconstruction Are Not Dependent on Meniscal Injury History.

Athletes often exhibit persistent deficits in dynamic balance and hop performance in their involved limb following ACL reconstruction. However, it is unclear how meniscal injury history affects inter-limb asymmetry. The purpose of this study was to compare inter-limb asymmetry in dynamic balance and hop performance in athletes with and without a history of concomitant meniscal injury. Cross-sectional study. Dynamic balance and hop test data were analyzed for 34 adolescent athletes who had undergone ACL reconstruction; 19 athletes had sustained an isolated ACL tear, while 15 had sustained an ACL tear along with a meniscus injury. Athletes who had sustained a meniscus injury were sub-divided into those who underwent a meniscal repair (n = 9) versus a partial meniscectomy (n = 6). Dynamic balance was assessed using the Y-Balance Test, while hop performance was assessed using the single and triple hop tests. Data were recorded at the time of return-to-sport testing (5-11 months post-surgery). For each variable, mixed-model analysis of variance, with a between-subjects factor of group (isolated ACL tear, meniscal repair, partial meniscectomy) and a within-subjects factor of limb (involved, uninvolved), was conducted. The groups exhibited similar degrees of inter-limb asymmetry in dynamic balance and hop test performance, as there was not a group-by-limb interaction effect for the Y-Balance Test distances (p ≥ 0.43) or hop test distances (p ≥ 0.96). However, there was a main effect of limb for the anterior and posteromedial Y-Balance Test distances and the single and triple hop test distances (p ≤ 0.004). For each variable, performance was worse for the involved limb, compared to the uninvolved limb. It appears that deficits in dynamic balance and hop performance among adolescent athletes who have undergone ACL reconstruction are not dependent on meniscal injury/surgery history. 3.

Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique

BackgroundAnterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year. MethodsA total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes. ResultsThe two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time. ConclusionThe AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.

FUNCTIONAL OUTCOME OF ARTHROSCOPIC ACL RECONSTRUCTION WITH HAMSTRING GRAFT

Background: The most common joint to be injured in our body is knee joint, and the commonest ligament to be injured is anterior cruciate ligament in the knee.Etiology includes road trafc accidents and sport injuries. The ACL, along with other ligaments, the capsule are the stabilizers of the knee and prevents anterior translation, and limits valgus and rotational stress. The articular cartilage injuries in acute ACL tears constitutes from 16 – 46%, and in chronic tears, the incidence increases further2. For prevention of further worsening of the existing lesions and also to prevent formation of new lesions, stablity of the knee should be achieved.The present study is to assess the functional outcome of arthroscopic anterior cruciate ligament reconstruction using hamstring tendon (gracilis and semitendinosus) autograft in patients with ACL tears. Methods: Study design: Hospital Based Observational study. Study period: September 2019 to August 2021. Sample size: 30 30 consecutive patients who underwent arthroscopic ACL reconstructions with hamstring graft were taken for this study. Results: Out of these, 27 patients were male and 3 were female. Right side affected in 18 patients and left side in 12 patients. The most common mechanism of the injury was sports activity in 17 patients, RTA injuries in 10 patients and other job related injuries in 3 patients. Isolated ACL tears in thirteen patients in our study and rest had associated injuries to menisci in same knee.Better postoperative functional scores are seen with patients with isolated ACL injuries compared to those patients with associated injuries of the knee like meniscal tears. Observations include anterior drawer test was negative in 83.33% of patients at 3 months, 86.67% of patients at 6 months and at 1 year 96.15% of patients had a negative anterior drawer test. Full range of motion attained in 86.67% of patients at 3 months, 93.33% of patients at 6 months and at 1 year 96.15% of patients.Pivot shift test was negative postoperatively for all the patients at any follow-up. Postoperatively at 3 months 25 (83.33%) patients had 5/5 quadriceps power (MRC grading) 92.3% of them had 5/5 power at latest follow up. Complications include Supercial infection and Deep infection in our study. Conclusion: Anterior cruciate ligament tears are most common at a mean age of 28 years with preponderance to male gender. The most common mechanism of the injury was sports activity. Isolated ACL injury is more common than along with associated meniscal injuries.Anatomic single bundle reconstruction with quadrupled hamstring graft gives good functional results.Hamstring graft xation with endobutton and interference screw gives better functional outcome.

Anterior cruciate ligament injuries in the prepubescent and adolescent. Modern trends and researches

The article represents a literature review of research on diagnostics and treatment of ACL tears and intercondylar eminence fractures in children and adolescence published between 2015 and 2020. We scrolled the following databases: Google scholar, Pubmed, and eLilbrary. Today knee injury with isolated ACL tears in young patients is growing more frequent due to their enhanced participation in extreme sports and other organized leisure activities where the risk of injury perceives. The injury with isolated ACL tears represents 1/4 of all knee injuries. Apart from extreme activities there is another risk factor that causes ACL tears late surgical involvement. Partial ACL tears and surgical techniques of skeletal immature patients (extraphyseal and all-ephyseal) were analysed in this study too. This work also includes the subject of re-fixation of fresh ACL rupture. Perspectives of return to sports of young athletes were also analysed. The most common predictive factor of returning to sports is a patients age. Young children return to their usual physical activities more promptly. Questions of proprioceptive impact on bio-mechanics and graft re-innervation also raised. The problem of ACL tears in children and adolescent patient are relevant. It needs more researches and improvements of surgery techniques.

Is in-vivo 80 N tensioned quadrupled hamstring graft better than conventional unmeasured pull for arthroscopic ACL reconstruction

PurposeTo find clinical outcome of in-vivo standard 80 N tensioning of quadrupled hamstring graft during arthroscopic single bundle ACL reconstruction in comparison to traditional graft tensioning. MethodsSixty cases of isolated ACL tears were included in this study. All cases underwent Arthroscopic ACL reconstruction with Tibial attachment sparing quadrupled hamstring graft. Cases were divided into group I and group II (30 cases each). Graft Tensioning in group 1 was conventional one-handed unmeasured pull and in group II it was measured tension of 80 N with tensionometer during graft fixation. Pre-operative and post-operative (12 months) Anterior tibial translation (ATT) was measured with KT-1000 arthrometer. Clinical outcome was measured using Lysholm knee scoring system at 6weeks, 3months, 6months, 12 months and compared statistically among both groups. ResultsThe mean pre-op ATT of 10.6 ± 2.04 mm (group I) & 10.83 ± 2 mm (group II) improved to 3.63 ± 1.16 mm (group I) & 3.63 ± 0.92 (group II) respectively at one year without significant difference (p value 1). The mean pre-op Lysholm score was 46.73 ± 6.77 (group I) and 45.97 ± 8.68 (group II). The mean Lysholm score at 6 weeks was 91.5 ± 2.78 (group I) and 93.43 ± 3.02 (group II) with significant difference (p value 0.014). At 3 months it was 95.4 ± 2.99 (group I) and 97.07 ± 2.07 (group II) with significant difference (p value 0.025). At 6 months it was 95.53 ± 2.46 (group I) and 97.5 ± 1.2 (group II) with significant difference (p value 0.0002). At 1 year it was 95.73 ± 2.22 (group I) and 97.8 ± 0.979 (group II) with significance (p value 0.0001). ConclusionThe clinical score of ACL reconstruction is better when in-vivo 80 N tension is applied using tensionometer during graft fixation in comparison to conventional manual tensioning but there is no difference in ATT.

Repair vs. Reconstruction for Acute Isolated ACL Tears- 2-Year Results of a Prospective Randomized Study

Aims and Objectives:Recently, due to the development of new techniques, ACL repair has returned back into focus of experimental and clinical research. Newer studies highlight the fact that ACL repair can lead to satisfying functional results and healing rates. Aim of the present study was to compare the functional results after ACL repair in comparison to primary ACL reconstruction for acute isolated ACL tears. It was hypothesized, that functional results and knee joint stability after ACL repair are comparable to those after ACLR.Materials and Methods:A prospective randomized study (Level of evidence 1) including a total of 85 patients with acute ACL tears was performed. Patients were randomized to undergo either ACL repair or primary ACL reconstruction with a semitendinosus autograft. The preinjury activity level and function were recorded. Follow-up examinations were performed at six weeks, six, twelve and 24 months postoperatively. At each follow up, the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score and the Lysholm score were acquired. Furthermore, anterior tibial translation (ATT) was evaluated by Rolimeter testing. The rate of recurrent instability and other complications were recorded.Results:79 patients could be re-evaluated (follow-up rate 93%). No significant differences between ACL repair and ACLR were found for the Tegner, IKDC and Lysholm score at any time of the follow-up. ATT was increased in the ACL repair group (& ATT 1.9 vs. 0.9). This difference was statistically significant (p=0.0086). Seven patients (17%) of the ACL repair group presented with recurrent instability and underwent single-stage revision reconstruction with hamstring autografts. Another three patients showed increased laxity with insufficient healing after ACL repair but did not require revision. In the ACLR group, five patients (13%) sustained a re-tear after return to their previous activity level. However, in three cases, a two-staged revision was required. Recurrent instability was associated with young age and higher Tegner scores in both groups.Conclusion:Functional results after ACL repair for acute tears are comparable to those after ACLR. However, the rate of ACL insufficiency seems to be slightly increased after ACL repair. In the revision situation, single-stage revision was possible in all cases following primary repair, whereas after primary reconstruction, a two-staged revision had to be performed in three of five cases. The current study supports the use of ACL repair as an option to treat acute ACL tears.

Transportal single bundle ACL reconstruction with quadruple hamstring graft using suspensory femoral and hybrid tibial fixation: A prospective study

Objectives: The aim of the study was to evaluate the functional outcome of transportal single bundle ACL reconstruction with Quadruple Hamstring Graft using suspensory femoral and hybrid tibial fixation for restoration of joint stability, patient satisfaction and for any complications. Design: Prospective Study Design. Methods: Patients admitted to the department of Orthopaedics, Bhagat Phool Singh Government medical college, Khanpur Kalan, Sonipat and fulfilling the inclusion criteria of age group 20-45 years without pre-existing arthritis and clinical and radiological evidence of anterior cruciate ligament tear were included in the study who were followed upto six months. Preoperatively Lysholm score and IKDC score was evaluated of each patient and post operatively Lysholm score and IKDC score were calculated at 2 weeks, 8 weeks, 12 weeks and 24 weeks. Results and conclusion: All patients were taken for single bundle ACL reconstruction using suspensory femoral and hybrid tibial fixation. The Lysholm and Knee Scoring Scale consists of eight parameters for evaluation. The individual parameters were allotted specific scores depending on the patient’s functional ability. The maximum possible knee score was 100. Based on the outcome scores they were divided into Excellent, Good, Fair and Poor. The Subjective IKDC scale was evaluated by summing the scores for the individual items and then transforming the score to a scale that ranges from 0 to 100. The patients were followed up in OPD and their functional outcomes were measured by Lysholm scoring and IKDC scoring at 2 weeks, 8 weeks, 12 weeks, 24 weeks. There were 20 (83.3%) male patients and 4 (16.7%) female patients. The right side was more commonly injured (54.2%) than the left side (45.8%). The most common mode of injury in our study was Road Traffic Accidents (58.3%) followed by sports (20.8%). Most of the patients (41.7%) presented 4 to 6 months after injury. The most common symptom at presentation was knee pain (37.5%) followed by instability (29.2%). Both knee pain and instability were present in 16.7% of patients. There was associated meniscal injury in 75.0% of patients. The most commonly injured was medial meniscus (50%) followed by injury to both medial and lateral menisci (16.7%). Isolated ACL tear was present in 25% of the patients. In our study, 83.3% had excellent functional outcome while 16.7% patients had good outcome on the basis of Lysholm Scoring. In our study the mean pre-operative IKDC score was 55.60 whereas the post-operative score after 24 weeks was 86.13. There was significant improvement in post-operative IKDC score when compared with preoperative score. In young active adults, anatomic single bundle reconstruction with quadrupled hamstring graft gives good functional results. Endobutton on the femoral side and Bioabsorbable interference screw and suture disc on the tibial end is a good mechanical and strong suspensory type of fixation device for ACL reconstruction. This technique offers an excellent knee function, knee stability and restoration of preoperative functional status with minimal complication. The patients undergoing hybrid method of fixation return to preinjury level of activity early.

Functional outcomes of quadrupled semitendinosus vs. four strand semitendinosus / Gracilis graft for arthroscopic ACL reconstruction

Introduction: Anterior cruciate ligament is a commonly disrupted ligament causing anterior instability of knee. Arthroscopic ACL reconstruction is the treatment of choice. Many graft options are available most common being the four-strand hamstring autograft. Four strand hamstring graft can be made either by doubling both Semitendinosus and Gracilis tendon (STG) or by quadrupling Semitendinosus tendon (ST4). Aim: To compare functional outcomes following ACL reconstruction with STG graft vs ST4 graft using femoral adjustable loop button and tibial bio-screw fixation.Material and Methods: This was a prospective cohort study in which 68 patients with isolated ACL tear with knee instability were enrolled during 2017-2018. Patients with multi-ligamentous injury, associated meniscal tears, chondral lesions, juxta-articular fractures and previous surgery on same knee were excluded. Patients were randomly allocated into two groups in which Group one patient underwent Arthroscopic ACL reconstruction by autologous four strand STG graft and Group two patients using quadrupled ST4 graft. Functional evaluation was done using Lysholm scoring system preoperatively and postoperatively at 1 year. Knee flexion strength was measured post-operatively at 1 year as maximum standing knee flexion angle. The side to side ratio of knee flexion angle was used for comparison. Appropriate statistical analysis of the data was done. Results: 68 patients were enrolled for the study in which, 38 patients underwent Arthroscopic ACL reconstruction by Autologous four strand STG graft and 30 patients using quadrupled ST4 graft. Out of 68 patients 52(76.47%) were male and 16 (23.53%) were female. 50 (73.5%) patients had right sided involvement and 18 (26.4%) had left side involvement. Mean age of patients was 29 years ranging from 19-45 years. Mean follow-up duration was 20 months (14-32 months). Average duration since injury was 6.22 ± 4.68 months (2-24 months). Mean Pre-operative Lysholm score in STG and ST4 groups were 69.78 ± 8.46 and 68.6 ± 10.41 respectively. Mean post-operative Lysholm scores at 1 year in STG and ST groups were 91.5 ± 6.13 and 92.96 ± 6.00 respectively. Lysholm score was reported as excellent in 49 patients (72%), good in 12 patients (17.6%) and fair in 7 patients (10.2%) with none of the patients reporting poor outcome. Mean maximum standing knee flexion angle ratio of operated knee compared to non -operated knee at 1 year was 90.51±6.37% and 94.45 ±2.89% in STG and ST4 groups respectively. There were no major complications reported with the procedure. Conclusion: Quadrupled Semitendinosus graft is a viable alternative to Semitendinosus/Gracilis graft for ACL reconstruction. Preserving Gracilis tendon results in better knee flexion. Hence Gracilis tendon harvest must be avoided whenever possible.

Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years

ObjectiveThe aim of this retrospective study was to compare the clinical outcomes of anatomic single bundle ACL reconstruction using either a free quadriceps tendon autograft or a quadrupled hamstring autograft with a minimum follow-up of 24 months. MethodsConsecutive patients undergoing ACL reconstruction using either a free quadriceps tendon autograft or hamstring tendon autograft from January 2013 to December 2014 were included. ACL reconstruction was done in all patients due to isolated ACL tears. Patients with associated cartilage lesions > Outerbridge III, meniscal lesions in need of meniscectomy or repair as well as patients with prior knee surgery on the affected or contralateral knee were excluded. The primary outcome evaluation was the side-to-side difference in instrumented Lachman testing. Secondary outcome evaluation consisted in the Lysholm, modified Cincinnati and SF-36 scores. Side-to-side difference in range of motion and thigh diameter was also documented. ResultsAfter applying the inclusion/exclusion criteria, a total of 82 patients were identified and 72 (87.8%) presented to the hospital for follow-up. There were 39 patients with quadriceps graft (30.64 ± 8.71, range: 18–53 years) and 33 patients with hamstrings (28.60 ± 6.74, range: 18–46 years). No statistically significant difference between groups was detected with regard to KT-1000 measurements (p = 0.326). No significant difference was found between the mean postoperative Lysholm (p = 0.299), the modified Cincinnati (p = 0.665) and the general SF-36 scores between groups (p = 0.588). Less side-to-side thigh diameter difference was noted in the quadriceps graft group (p = 0.026). ConclusionIn conclusion, similar clinical results, in terms of stability and subjective measures, can be obtained after ACL reconstruction both with a free quadriceps and a 4-strand hamstring tendons autograft. Level of evidenceLevel III, Therapeutic Study.

Radiological evaluation of tunnel position in single bundle anterior cruciate ligament reconstruction in the Indian population and their clinical correlation

BackgroundProper positioning of osseous tunnels during single bundle arthroscopic ACL reconstruction, which gives reproducibly good clinical outcome, is a matter of concern. Little evidence is there correlating tunnel position in arthroscopic ACL reconstruction with their clinical outcome in Indian population. Our aim in this study was to examine if the radiological tunnel-positions were significantly associated to the clinical outcomes. MethodsACL reconstruction was performed in 147 young patients with an isolated ACL tear. They were followed up prospectively for the next two years. Clinical assessment of each patient was done using the International Knee Documentation Committee (IKDC) evaluation form before surgery and at two years later the surgery. At the same time, the radiological assessment was done on standard digital radiographs. ResultsConsidering the anterior and posterior-most points on the Blumensaat's line as 0% and 100% respectively the average position of the femoral tunnel was at 84.8%. Similarly, the tibial tunnel was at 46.8% along the tibial plateau. On the coronal plane the average position of the tibial tunnel was at 45.6% point along the tibial plateau (measured from the medial-most point towards laterally). The mean position of the femoral tunnel in the coronal plane was at 43.2% along the broadest part of the distal femur (measured from the lateral extent). The average inclination angle of the graft measured 19.6° (along the coronal plane). ConclusionIdeal clinical outcome was significantly associated with the placement of the femoral tunnel along the sagittal plane. Placement of the femoral tunnel should not be beyond the 85% mark along the Blumensaat's line from the anterior-most point. No correlation was established between clinical results and any of the remaining radiological parameters described above.

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

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

Is development of osteoarthritis more common in patients who did not have surgical repair after complete isolated ACL tear?

EVIDENCE-BASED ANSWER No. Development of osteoarthritis over 10 to 16 years is similar in patients treated nonoperatively after a complete ACL tear compared with patients who have undergone ACL reconstruction (33% vs 24%-35%) (SOR: B, metaanalysis of RCTs and observational studies, 1 small RCT).

Investigating the Precision and Accuracy of Subjective Patient and Surgeon Expectations Following Anterior Cruciate Ligament Reconstruction

The purpose of this investigation was to compare patient’s expectations and surgeon’s expectation using validated outcome assessment tools as expectation questionnaires. Advances in orthopaedic surgery have redefined patient’s perception of the successful outcome, particularly for patients undergoing elective arthroscopic procedures such as anterior cruciate ligament reconstruction (ACLR). Recent literature suggests that patient satisfaction following orthopaedic surgery is related to their outcome as well as their pre-operative expectation. Unfortunately for providers, patients undergoing ACLR may have unrealistic expectations. These expectations may contribute to worse outcomes and reduced patient satisfaction. The purpose of this investigation was to compare patient’s expectations and surgeon’s expectation using validated outcome assessment tools as expectation questionnaires. Actual patient outcomes were also tracked to determine accuracy of the expectations. 122 consecutive patients agreed to participate and were enrolled in this prospective, IRB approved study. All patients undergoing primary ACLR for isolated ACL tear were eligible to participate in this study. Patients were instructed to complete IKDC and Lysholm knee questionnaires before surgery and at 3, 6, 12, and 24 months after surgery. In addition, before surgery, patients completed a second set of IKDC and Lysholm knee questionnaires pertaining to how they expect their knee to feel in 18 months, or after complete healing of their surgery. Immediately post-operative, surgeons completed a set of IKDC and Lysholm questionnaires representing how they expected the patient to fare upon complete recovery of the patient (taking into account psychosocial and surgical variables). Pre-operatively the patient average Lysholm score was 56.5; scores at 3, 6, 12 and 24 months post-operatively were 76.4, 85.2, 87.9, and 89.3 respectively. The average IKDC score pre-operatively was 44.8%; scores at 3, 6, 12 and 24 months post-operatively were 61.9%, 75.0%, 84.6% and 84.3% respectively. The average patient’s expectations were higher than average surgeon’s expectations according to both Lysholm and IKDC scores (Lysholm 95.3, 92.4; IKDC 92.4%, 89.6%, respectively). The differences were statistically significant between the patient’s expected Lysholm score and the physician’s expected Lysholm score (p=.006). At almost every post-operative period, the Lysholm and IKDC scores when compared to the surgeon’s expectation’s scores were statistically significantly different except when compared to the 12-month and 24-month Lysholm scores (p=0.110, p=0.560, respectively). The patient 24-month follow-up scores for the Lysholm and the IKDC were still below the patient’s pre-operative expectations (p=0.004, 0.026, respectively). In this study, we found that when using validated outcome measures to determine expectations, patients have slightly higher expectations than surgeons with regard to ultimate function and pain after ACLR. Significant difference between expectations and 24-month outcome scores were observed for the patient, suggesting that patients are less satisfied with their results then they expected. The surgeon’s expectations on Lysholm was not significantly different from the 24-month outcome, but the surgeon’s IKDC was, suggesting surgeons had a better sense of what the patient outcome would be. This study is the first to assess the differences in expectations of patients versus surgeons prior to ACLR. Further data collection will determine if any correlation of expectation to ultimate outcome is observed.

Return to Play After Multi-Ligament Knee Injuries in National Football League (NFL) Athletes

Objectives:Return to play (RTP) of NFL athletes following isolated ACL tears has been reported in the literature. However, there have been no studies reporting on RTP of NFL athletes following multi-ligament knee injuries. The authors hypothesize that NFL athletes with multi-ligament knee injuries will have lower RTP rates and longer time to RTP compared to athletes with isolated ACL tears, as reported in the literature. We also hypothesize that athletes with ACL and MCL injuries will have higher RTP rates and shorter time to RTP compared to athletes with an ACL tear and a PCL and/or LCL tear(s).Methods:NFL injury surveillance data was reviewed for all multi-ligament knee injuries between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited due to reasons unrelated to the injury such as suspension, unrelated injury, or personal matters. Extracted data included injury, RTP, time to return to play (months), number of games played, percent of possible games played, and performance.Results:51 NFL athletes were found to have multi-ligament knee injuries between 2000 and 2016 that met inclusion and exclusion criteria. 47.1% (24/51) of athletes had ACL and MCL tears. 52.9% (27/51) of athletes had ACL and PCL and/or LCL tears. Of the players with ACL and PCL/LCL tears, there were 8 frank knee dislocations. The overall return to play rate following multi-ligament knee injuries was 62.7%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, while the athletes with ACL and PCL/LCL tears had an RTP rate of 55.6% (p=.26). Athletes with frank knee dislocations had a 50% RTP rate. Mean time to RTP for all 51 athletes was 11.9 ± 3.52 months. The mean time to RTP for athletes with ACL/MCL injuries was 10.4±1.6 months compared with 13.7±4.3 for those with combined ACL and PCL/LCL injuries, and for frank dislocations was 20 ±6.1 (p<.001). Athletes with ACL/MCL injuries were more likely to return to prior performance levels 46% vs 18% compared to those with ACL and PCL/LCL injuries (p < .001).Conclusion:This study is the first to provide important prognostic information for NFL players sustaining multi-ligament knee injuries. The RTP rate for athletes with multi-ligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a higher likelihood of returning to prior performance than athletes with combined ACL and PCL/LCL tears.

Effect of Hamstring Harvest in the Setting of ACL and MCL Concurrent Injury

Objectives:Hamstrings autograft is commonly used to reconstruct an isolated ACL tear, however, there is evidence to suggest that the tendons harvested may contribute to medial knee stability. We tested the hypothesis that the gracilis (G) and semitendinosus (St) tendons significantly contribute to sagittal, coronal and/or rotational knee stability in the setting of an ACL reconstruction with concurrent partial MCL injury.Methods:Twelve human cadaveric knees were subject to a static anteriorly-directed force and moments in varus, valgus, internal and external rotation at the tibia while the femur was held stationary in order to quantify laxity at 0, 30, 60, and 90 degrees of flexion. Testing was performed on each leg in following ligament conditions: (1) ACL-intact/MCL-intact, (2) ACL-deficient/MCL-intact, (3) ACL-deficient/ MCL-partial injury, and (4) ACL-reconstruction, MCL-partial injury (chart 1). To quantify the effect of muscle loads the quadriceps, semimembranosus, biceps femoris, sartorius (Sr), St and G muscles were sutured and physiologically loaded. Quadriceps were loaded to 200 N and semimembranosus and biceps femoris were loaded to 40 N and held constant for all test conditions. The G and St were attached to a 40N load which was removed during test conditions in order to simulate hamstring graft harvest. Similarly, a Sr load of 20N was added and removed to determine its role in contributing to knee stability. For each ligament condition, the response to loading was determined with either (A) St/G muscles loaded and Sr unloaded; (B) St/G loaded, Sr loaded; (C) St/G unloaded, Sr unloaded; and (D) St/G unloaded, Sr loaded (chart 1). Three-dimensional positional data of the tibia relative to the femur was recorded to determine displacement and rotation across the knee.Results:ACL reconstruction restored anterior stability regardless of whether or not G/St and/or Sr loads were applied. A partial tear of the MCL significantly increased external rotation when the G/St were unloaded and approached significance (p<0.06) when the G/St load was applied. When an internal rotation load was applied all conditions tested were significantly less stable than intact. No differences were demonstrated during varus loading. When specimens were loaded with a valgus moment there was no significant increase in motion after ACL transection. However, when a partial MCL tear was added to the ACL injury there was a significant increase in valgus rotation regardless of whether or not the G/St and Sr muscles forces were applied. ACL reconstruction only restored valgus stability when the G/St muscles were loaded, Figure 1. However, there was no difference in valgus stability when comparing testing conditions 4A (G/St loaded) and 4D (G/St unloaded, Sr loaded, Figure 1).Conclusion:Absence of load on the G and St, as would be the case when harvested for hamstrings autograft, did not lead to increased anterior translation of the tibia in ACL reconstructed knees with partial MCL injury. Although the absence of an applied G and St muscle force did lead to increased valgus rotation after ACL reconstruction, there was no difference between the G/St loaded state compared to the G/St unloaded state once a Sr load was applied. This may have clinical implications for surgeons with regard to post-operative bracing and ACL reconstruction graft recommendations. Figure 1:Valgus rotation with application of 10N-m valgus stress

Long-term rate of graft failure after ACL reconstruction: a geographic population cohort analysis

Graft failure following anterior cruciate ligament reconstruction (ACLR) is a devastating injury among patients returning to activity. The goals of this study were to define the long-term rate of graft failure after ACLR in the general population and evaluate factors associated with graft failure. This long-term observational study included a population-based incidence cohort of patients who underwent primary ACLR after diagnosis with new-onset, isolated ACL tears between 1990 and 2010. For all patients, a chart review was performed to collect information related to the initial injury, treatment, and outcomes. Patients were retrospectively followed to determine the incidence of graft failure following ACLR. The study cohort consisted of 1355 patients with new-onset, isolated ACL tears treated with ACLR. At a mean follow-up of 10.0years (±6.4years) following ACLR, a total of 72patients (5.3%) sustained ipsilateral graft failure. The graft survival following ACLR was 99.7% at 1year, 96% at 5years, 94% at 10years, 93% at 15years, 92% at 20years and 91% at 25years. Among patients 22years or younger (n=571), the rate of graft failure was significantly higher compared to patients older than 22years (6.3 vs. 4.6%, p=0.04). The rate of graft failure decreased significantly over the 21-year observation period of this study (p<0.0001). Among all patients receiving primary ACLR, graft failure remains an uncommon but functionally devastating outcome with an estimated graft survival rate of 91% at 25years following surgery. Patients aged 22 or younger had a significantly higher rate of graft failure than older patients. The rate of graft failure decreased over the 21-year span of this study. Retrospective case series, Level IV.