Isolated Anterior Cruciate Ligament Tears Research Articles

Nonoperative Treatment as an Option for Isolated Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis.

An anterior cruciate ligament (ACL) tear is a risk factor for early osteoarthritis (OA) onset. Generally, ACL reconstruction (ACLR) is associated with better outcomes. However, there is a lack of evidence regarding the effect of operative versus nonoperative treatment for preventing premature knee OA in isolated ACL tears while achieving good functional outcomes. The purpose of the study was to compare the outcomes of ACLR to primarily nonoperative management of isolated ACL tears. It was hypothesized that the outcomes between treatment types would be similar. Systematic review; Level of evidence, 3. This systematic review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (registration No. CRD42021285901) and was conducted according to the Cochrane Handbook guidelines. We systematically searched for randomized and nonrandomized studies that compared ACLR with nonoperative treatments in isolated ACL tears in 3 databases until October 25, 2021. The risk of bias and quality of evidence of the included studies was assessed in accordance with the Cochrane guidelines. The primary outcome was radiologic signs of OA, and the secondary outcomes were functional parameters. Using the common effects model, we calculated pooled mean differences (MDs) and odds ratios (ORs) with 95% CIs. Five studies-2 randomized controlled trials (RCTs) and 3 retrospective non-RCTs-were included. There was a moderate risk of bias in 2 studies and a serious risk of bias in 1 study. The quality of evidence was rated low because of the higher risk of bias and inconsistency. Nonoperatively treated knees showed a trend toward lower odds of developing radiological signs of OA (OR, 1.84 [95% CI, 0.90 to 3.75]); however, surgically reconstructed knees had significantly better stability (MD, -2.44 [95% CI, -3.21 to -1.66 ]) and a trend toward better but clinically not meaningful Lysholm scores (MD, 2.88 [95% CI, -1.09 to 6.85]). The qualitative synthesis showed that surgical reconstruction was protective against subsequent injuries but not superior when returning to previous activity levels or various functional tests. Findings indicated that there is no certain evidence that ACLR for an isolated ACL tear is superior to nonoperative treatment. Clinicians should consider nonoperative treatments with a well-designed rehabilitative program as a primary option. However, these findings must be interpreted with caution because of low study quality and high risk of bias.

An early care void: The injury experience and perceptions of treatment among knee-injured individuals and healthcare professionals – A qualitative interview study

ObjectivesTo better comprehend the initial injury experience and care requirements of knee-injured individuals, as well as healthcare professionals' interactions with early care. DesignQualitative interviews. SettingPublic healthcare in Denmark. ParticipantsTen individuals (6 women) with major knee injuries (6 anterior cruciate ligament (ACL) and meniscal tears, 2 isolated ACL tears, 1 isolated meniscal tear, 1 patella dislocation), aged 16–33 years (median 19 years), 1–26 months post-injury (median 3 months). Thirteen HCPs (5 physiotherapists, 5 orthopedic surgeons, 3 general practitioners). Main outcome measureSemi-structured individual and focus group interviews, transcribed verbatim and with latent thematic analysis. ResultsThe three main themes were: 1) Emotional struggles in solitude – knee-injured individuals dealing with emotions alone due to limited HCP resources for emotional support. 2) Blurry beginning – knee-injured individuals finding initial care frustrating, a sentiment shared by HCPs. 3) A journey with no map – knee-injured individuals holding varied outcome expectations, while HCPs hesitate to discuss long-term knee health. ConclusionEarly care for knee-injured individuals is filled with worries and unmet emotional and information support needs. HCPs need more support and training to deliver timely and appropriate care.

Knee stiffness post anterior cruciate ligament reconstruction- factors to worry about

Background: Knee stability is affected by integrity of anterior cruciate ligament (ACL). Knee stiffness is a worrying postoperative complication, preventing patients from returning back to pre-injury sport level. In this study, we analyzed incidence of knee stiffness post ACL reconstruction and possible associated risk factors. Methods: This is retrospective study, was held in Royal Medical Services/Jordan–Queen Alia Military hospital/Arthroscopic and Sport injuries division. We analyzed 250 patients’ data using computerized patients record system (CPRS) called Hakeem complaining of knee stiffness post ACL reconstruction between July 2022 and July 2023, whom ACL reconstructive surgeries were performed between March and September 2022. Results: Incidence of knee stiffness post ACL reconstruction is about 1.5% (4 out of 250). All of those 4 patients were males,3 of them had limited flexion (75%), while 1 of them had limited extension (25%). All of the 3 patients having extension contracture had an associated medial meniscus tear, repaired at time of ACL reconstruction, while flexion contracture patient had an isolated ACL tear. Conclusions: Incidence of knee stiffness post ACL reconstruction is about 1.5%. 75% of patients were associated with medial meniscus tear, who underwent meniscus repair and hinged knee brace was applied. We conclude that ACL patients having an associated meniscus tear managed by meniscus repair and hinge knee brace are at higher risk to develop knee stiffness. Therefore, we recommend limiting the usage of knee brace for ACL reconstruction with meniscus repair only.

Poster 305: Hybrid Transtibial Technique for Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction: A Retrospective, Matched Comparison Study to Anteromedial Portal and Transtibial Approaches

Objectives: Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial portal (AMP) technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more angulated tunnel. A hybrid transtibial technique (HTT) using medial portal guidance of a flexible transtibial guide wire may combine the strengths of both the AM and TT approaches while mitigating the technical challenges of both techniques. The purpose of our study was to evaluate the clinical efficacy of ACLR using a HTT technique for femoral tunnel drilling in comparison to matched cohorts of AMP and TT drilling approaches in terms of failure/revision requirements and patient-reported outcomes. Methods: A database consisting of all patients with isolated ACL tear and primary reconstruction at a single center between 2005 and 2020 was retrospectively reviewed. Inclusion criteria were patients age ³ 13 years at the time of index ACL reconstruction (ACLR), isolated ACL tear with/without concomitant meniscal/chondral pathology and had minimum 2 year ³ postoperative follow-up. Patients with open physes, prior surgical intervention on the ipsilateral knee, chondral pathology treated with high tibial osteotomy/distal femoral osteotomy, treated for other concurrent ligamentous pathology were excluded. Patients treated with the AMP, TT, and HTT approach meeting inclusion criteria were matched based on age ± 3 years, same sex, and body mass index (BMI) ± 3 Kg/m2. Demographical data (Table 1), surgical data, plain radiographic femoral tunnel angle measurements on anteroposterior and lateral films, postoperative complications and reoperation/revision rates, and patient reported outcome (PRO) scores were collected and reported for each of the three cohorts. Results: A total of 495 patients were included; 170 patients underwent ACLR using the HTT approach, 162 using AMP approach, and 163 using the TT approach. The most common graft of choice for HTT technique was bone patellar tendon bone (BPTB) (162/170 [95.3%]) and for AMP (131/162 [80.9%] and TT (158/163 [96.9%]) technique was hamstring (Table 2). The median (IQR) femoral tunnel angle on sagittal plane showed significant differences between HTT 40° (34°, 46°) and TT 32° (27°, 38°) cohorts ( P- value < 0.0001) (Table 3). On coronal plane the median (IQR) femoral tunnel angles showed significant differences between HTT 47° (42°, 52°) and for both AMP 44° (33°, 54°) and TT 55° (47°, 60°) cohorts ( P- value: 0.001 and <0.001 respectively. Recurrent ACL injury in the ipsilateral knee was experienced in 3/170 (1.8%) HTT patients, 6/162 (3.7%) AMP patients, and 6/163 (3.7%) TT patients at minimum 2-year clinical follow-up (Table 4). When patients were surveyed via phone or email questionnaires, 6/170 (7.4%) HTT, 11/163 AMP (20%), and 18/162 (24.3%) TT patients responded to having further ACLR procedures. The Knee injury and Osteoarthritis Outcome Score (KOOS) pain score and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) function and total scores were found to be statistically significant between HTT and TT technique patients. All other PRO scores showed comparable scores between HTT patients when compared with AMP and TT patients. Conclusions: Patients that underwent ACLR with HTT approach had lower failure/revision rates and comparable or better PRO scores at medium-term follow-up when compared to AMP and TT approach. [Table: see text][Table: see text][Table: see text][Table: see text]

Synovial Fluid Proteomics From Serial Aspirations of ACL-Injured Knees Identifies Candidate Biomarkers

Background: Anterior cruciate ligament (ACL) tears often result in knee effusion and an increased risk for developing knee osteoarthritis (OA) in the long run. The molecular profile of these effusions could be informative regarding initial steps in the development of posttraumatic OA after an ACL tear. Hypothesis: The proteomics of knee synovial fluid changes over time after ACL injury. Study Design: Descriptive laboratory study. Methods: Synovial fluid was collected from patients with an acute traumatic ACL tear presenting to the office for evaluation (18.31 ± 19.07 days from injury) (aspiration 1) and again at the time of surgery (35.41 ± 58.15 days after aspiration 1 (aspiration 2). High-resolution liquid chromatography mass spectrometry was used to assess the quantitative protein profile of synovial fluid, and differences in protein profile between the 2 aspirations were determined computationally. Results: A total of 58 synovial fluid samples collected from 29 patients (12 male, 17 female; 12 isolated ACL tear, 17 combined ACL and meniscal tear) with a mean age and body mass index of 27.01 ± 12.78 years and 26.30 ± 4.93, respectively, underwent unbiased proteomics analysis. The levels of 130 proteins in the synovial fluid changed over time (87 high, 43 low). Proteins of interest that were significantly higher in aspiration 2 included CRIP1, S100A11, PLS3, POSTN, and VIM, which represent catabolic/inflammatory activities in the joint. Proteins with a known role in chondroprotection and joint homeostasis such as CHI3L2 (YKL-39), TNFAIP6/TSG6, DEFA1, SPP1, and CILP were lower in aspiration 2. Conclusion: Synovial fluid from knees with ACL tears exhibits an increased burden of inflammatory (catabolic) proteins relevant to OA with reduced levels of chondroprotective (anabolic) proteins. Clinical Relevance: This study identified a set of novel proteins that provide new biological insights into the aftermath of ACL tears. Elevated inflammation and decreased chondroprotection could represent initial disruption of homeostasis, potentially initiating the development of OA. Longitudinal follow-up and mechanistic studies are necessary to assess the functional role of these proteins in the joint. Ultimately, these investigations could lead to better approaches to predict and possibly improve patient outcomes.

Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries

BackgroundNumerous individual, temporal, injury- and surgery-specific factors impact the functional capacity during rehabilitation, return to sports (RTS), and re-injury prevention after an anterior cruciate ligament (ACL) reconstruction.PurposeThis multicentre cohort study evaluated the isolated and interactive contributions of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries as to inertial sensor-assessed motor function after ACL reconstructions in multiple linear mixed model regressions.MethodsAnonymized data were retrieved from a nationwide German registry. In this cohort study, patients with an acute unilateral ACL rupture, with or without concomitant ipsilateral knee injuries, and having passed an arthroscopically assisted anatomic reconstruction were included. Potential predictors were age [years], gender/sex, time since reconstruction [days], time between injury and reconstruction [days], concomitant intra-articular injuries (isolated ACL tear, meniscal tear, lateral ligament, unhappy triad), graft type (hamstrings, patellar, or quadriceps tendon autograft), and pain during each measurement (visual analogue scale 0–10 cm). Repeated inertial motion unit-assessments of a comprehensive battery of classic functional RTS test were performed in the course of the rehabilitation and return to sports: Joint position sense/kinesthesia (Angle reproduction error [degrees]), Dynamic Balance Composite score [cm] of the Y-Balance test), drop jumps (Knee displacement [cm]), Vertical hop (Hopping height [mm]), Speedy jumps (Duration [seconds]), Side hops (Number of hops [n]), single leg hop for distance (hopping distance [cm]). Repeated measures multiple linear mixed models investigated the impact and nesting interaction of the potential predictors on the functional outcomes.ResultsData from 1441 persons (mean age 29.4, SD 11.8 years; 592 female, 849 male) were included. Most had an isolated ACL rupture: n = 938 (65.1%). Minor shares showed lateral ligament involvement: n = 70 (4.9%), meniscal tear: n = 414 (28.7%), or even unhappy triad: n = 15 (1%). Several predictors such as time between injury and reconstruction, time since reconstruction (estimates for ndays ranged from + .05 (i.e., an increase of the hopping distance of 0.05 cm per day since reconstruction occurs) for single leg hop for distance to + 0.17 for vertical hopping height; p < 0.001), age, gender, pain, graft type (patellar tendon graft: estimates between + 0.21 for Y-balance and + 0.48 for vertical hop performance; p < 0.001), and concomitant injuries contribute to the individual courses of functional abilities of the reconstructed side after ACL reconstruction. The unimpaired side was mostly influenced by sex, age, the time between injury and reconstruction (estimates between − 0.0033 (side hops) and + 0.10 (vertical hopping height), p < 0.001)), and time since reconstruction.ConclusionsTime since reconstruction, time between injury and reconstruction, age, gender, pain, graft type, and concomitant injuries are not independent but nested interrelating predictors of functional outcomes after anterior cruciate ligament reconstruction. It might not be enough to assess them isolated; the knowledge on their interactive contribution to motor function is helpful for the management of the reconstruction (earlier reconstructions should be preferred) deficit-oriented function-based rehabilitation (time- and function based rehabilitation instead of solely a time- or function based approach) and individualized return to sports strategies.

Morphometric MRI Evaluation of Three Autografts Used in Anterior Cruciate Ligament Reconstruction in Athletes

The purpose of the present study was to quantify the morphometric characteristics of three tendon autografts (hamstring tendons (HT), quadriceps tendon (QT), and patellar tendon (PT)) used in anterior cruciate ligament (ACL) reconstruction. For this purpose, knee magnetic resonance imaging (MRI) was obtained in 100 consecutive patients (50 males and 50 females) with an acute, isolated ACL tear without any other knee pathology were used. The level of the physical activity of the participants was determined using the Tegner scale. Measurements of the tendons' dimensions (PT and QT tendon length, perimeter, cross-sectional area (CSA), and maximum mediolateral and anteroposterior dimensions) were performed perpendicular to their long axes. Higher values were recorded as regards the mean perimeter and CSA of the QT in comparison with the PT and the HT (perimeter QT: 96.52 ± 30.43 mm vs. PT: 63.87 ± 8.45 mm, HT: 28.01 ± 3.73 mm, F = 404.629, p < 0.001; CSA QT: 231.88 ± 92.82 mm2 vs. PT: 108.35 ± 28.98 mm2, HT: 26.42 ± 7.15 mm2, F = 342.415, p < 0.001). The length of the PT was shorter in comparison with the QT (53.1 ± 7.8 vs. 71.7 ± 8.6 mm, respectively, t = -11.243, p < 0.001). The three tendons showed significant differences in relation to sex, tendon type, and position as regards the perimeter, CSA, and the mediolateral dimensions but not for the maximum anteroposterior dimension.

Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes

Background: There is growing evidence that anterolateral procedures can reduce the risk of rerupture in high-risk recreational athletes undergoing primary anterior cruciate ligament (ACL) reconstruction (ACLR). However, this effectiveness has never been evaluated in elite athletes. Purpose: The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis (LET) in reducing revision rates in primary ACLR in elite athletes. Additionally, this study evaluated whether LET had a greater effect when combined with ACLR utilizing a hamstring or patellar tendon graft. Study Design: Cohort study; Level of evidence, 3. Methods: A consecutive cohort of elite athletes with an isolated ACL tear undergoing autograft patellar or hamstring tendon reconstruction with or without Lemaire LET were analyzed between 2005 and 2018. A minimum 2-year follow-up was required. The association between the use of LET and ACL graft failure as defined by revision ACLR was evaluated with univariate and multivariate logistic regression models. Results: A total of 455 elite athletes (83% men and overall age 22.5 ± 4.7 years) underwent primary ACLR with (n = 117) or without (n = 338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure, including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACLR reduced the risk of graft failure by 2.8 times, with 16.5 athletes needing LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (relative risk = 0.325; P = .029) as compared with ACLR alone after controlling for sex and age at ACLR. Including graft type in the model did not significantly change the risk profile, and although a patellar tendon graft had a slightly lower risk of failure, this was not statistically significant (P = .466). Conclusion: The addition of LET reduced the risk of undergoing revision by 2.8 times in elite athletes undergoing primary ACLR. This risk reduction did not differ significantly between the patellar tendon and hamstring tendon autografts. With these results, status as an elite athlete should be included in the indications for a LET, as they are at increased risk for ACL graft failure.

Prone Lachman with Ultrasound: A Literature Review and Description of the Technique.

Magnetic resonance imaging is the current gold standard imaging modality for diagnosing anterior cruciate ligament (ACL) tears. However, ultrasound has grown in popularity for detecting ACL injuries because of its low cost, portability, and dynamic assessment capabilities. Recent studies demonstrate high sensitivity and specificity for diagnosing isolated ACL tears via ultrasound, but tremendous heterogeneity remains for optimal technique including patient positioning, transducer placement, and dynamic versus static ultrasound usage. As ultrasound becomes ubiquitous in clinics, training rooms, and on the sidelines, identifying objective and sensitive measurements to appropriately screen athletes for significant knee injuries is imperative. This article aims to review the current role of diagnostic ultrasound in ACL injuries and propose a standardized version of the Prone Lachman with Ultrasound test, which is an objective, reliable, and easily reproducible technique to evaluate ACL competency. Developing a standardized protocol will expand the use of point-of-care ultrasound, which may reduce cost and improve efficiency in care.

Single Bundle Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

Anterior cruciate ligament (ACL) tear is considered as one of the most common sport-related musculoskeletal injuries. Double bundle (DB) and single bundle (SB) surgical techniques has been widely adopted for ACL reconstruction. This systematic review aimed to provide updated evidence by comparing the short-term, mid-term, and long-term knee stability and functional outcomes of DB and SB reconstruction techniques. We searched Medline, Web of Science, and CENTRAL. We have selected randomized controlled trials (RCTs) that compared DB and SB ACL reconstruction techniques for primary isolated ACL tear. We have assessed the following outcomes: pivot shift test, Lachman test, KT-1000/2000 knee ligament arthrometer, Lysholm knee function score, Tegner activity score, and graft failure. We have used the standardized mean difference (SMD) was to summarize the continuous outcomes while risk ratio (RR) was used to summarize the dichotomous outcomes. A total of 34 RCTs that enrolled 2,992 participants deemed eligible. Overall, DB showed significantly better outcomes in terms of pivot shift test (RR = 0.61, 95% confidence interval (CI) 0.49-0.75), Lachman test (RR = 0.77, 95% CI 0.62 to 0.95), and KT 1000/2000 arthrometer (SMD = -0.21, 95% CI -0.34 to -0.08). No discernible difference was found between DB and SB techniques in the overall Lysholm score (SMD = 0.12, 95% CI -0.03 to 0.27), Tegner score (SMD = 0.03, 95% CI -0.17 to 0.24), or graft failure rate (RR = 0.78, 95% CI 0.33 to 1.85). Our review suggests that DB ACL reconstruction technique shows significantly better knee stability and functional outcomes than SB at short-term follow-up. However, both techniques exhibit similar outcomes at mid-term and long-term follow-up. The online version contains supplementary material available at 10.1007/s43465-022-00718-0.

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).

Proteomic Profile Analysis of Synovial Fluid in Patients With Anterior Cruciate Ligament Tears

Background: Anterior cruciate ligament (ACL) tears are associated with posttraumatic osteoarthritis, but the early biological changes that initiate joint degeneration after this injury are not well characterized. ACL tears typically result in effusion in the knee, which may provide insight into the initial response of the joint to injuries. Hypothesis: Patient- and injury-specific factors are associated with the proteomics of synovial fluid in knees with ACL tears. Study Design: Descriptive laboratory study. Methods: Synovial fluid was collected from 105 patients (38 male, 67 female) with an acute traumatic ACL tear. Patient- and injury-specific factors such as age, sex, body mass index, time from injury, presence/absence of concomitant meniscal tears, and location of concomitant bone bruises (if present) were recorded. The protein concentration of synovial fluid was measured, followed by benchmarking of samples for multi-affinity high-abundance protein depletion. An isotropically labeled high-resolution nano-liquid chromatography with tandem mass spectrometry–based proteomic approach was used to determine the synovial fluid protein profile. Data were processed, quality controlled, and analyzed computationally for each patient and injury factor. Results: The proteomics of synovial fluid from ACL tears was associated with patient sex, injury pattern, and location of bone bruises but not with patient age, body mass index, or time from injury. Knees with an isolated ACL tear had higher glutathione peroxidase 1 (GPX1) and plastin 3 levels than knees with an ACL tear and meniscal tear. A bone bruise on the lateral femoral condyle was associated with elevated leptin and glucose-6-phosphate dehydrogenase (G6PD) levels. A bone bruise on the lateral tibial plateau was associated with decreased GPX1 levels. Male patients had higher matrix metalloproteinase 9 and lower G6PD levels than female patients. Conclusion: Patient sex, injury pattern, and bone bruise location were important determinants of the proteomic profile of effusion resulting from ACL tears. Clinical Relevance: Longitudinal follow-ups to see if and how proteomic differences relate to clinical outcomes and mechanistic studies to assess the role that specific proteins play in the joint are warranted. Ultimately, these investigations could lead to better approaches to predict clinical outcomes and identify possible interventions to optimize outcomes in these patients.

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...

Comparison of functional outcome after early and delayed anterior cruciate ligament reconstruction: A systematic review

This study aims to find the optimal timing for Anterior Cruciate Ligament (ACL) reconstruction by comparing the outcome of early versus delayed ACL reconstruction, meniscus, and chondral damage. A systematic literature search was performed from February to March 2021 from 4 databases. Inclusion criteria were English language Randomized Control Trial (RCT) and observational studies published in 2000-2020, 20-50 years old patients with an isolated ACL tear with/without meniscal injury underwent ACL reconstruction. Early ACL reconstruction was estimated at less than six weeks post-injury, and delayed ACL reconstruction was estimated at more than six weeks. Tegner and Lysholm were the functional outcomes to compare early and delayed ACL reconstruction with a meniscus tear and chondral damage. The search yielded 3094 studies. After removing duplicates, titles and abstracts were screened, leaving 154 potential studies. The studies were selected, and eight studies were eligible. No statistically significant difference between early and delayed ACL reconstruction in Lysholm and Tegner score (p&gt;0,05) was found. Both scores were similar regarding whether the patient performs early/delayed ACL reconstruction. Therefore, early ACL reconstruction could be an optimal timing for the patient who will undergo ACL reconstruction.

Association of Meniscus Injuries in Patients With Anterior Cruciate Ligament Injuries.

Introduction: In today's orthopaedic practice, meniscus and anterior cruciate ligament (ACL) injuries are prevalent. It is more common in sports injuries and automobile accidents. In patients with ACL tears, meniscus problems are also common. Several studies have linked meniscus injuries to the development of osteoarthritis in early stages. Early onset of osteoarthritis has been observed in ACL-repaired patients with meniscus tears. As a result, meniscus tears should be detected and corrected as soon as possible to avoid degenerative changes in the knee joint. The goal of the study was to see if there was a link between meniscus injuries and ACL injuries in our rural community.Methods: This retrospective study was conducted on 48 patients at the R.L. Jalappa Hospital & Research Centre from January 2012 to December 2019. Patients between the ages of 18-65 diagnosed with ACL tear with/without meniscus damage in their knees were included in the study. Patients with posterior cruciate ligament (PCL) tear, medial collateral ligament (MCL) or lateral collateral ligament (LCL) injury, previously operated index knees, and patients with more than grade 3 knee osteoarthritis (Kellgren and Lawrence classification) were excluded. Clinical assessment of patients with knee injuries, MRI and diagnostic arthroscopy of the knee joint details were collected. After obtaining the data, we estimated the incidence of meniscus injuries associated with chronic ACL injuries. We also calculated the percentage of side/laterality injury (medial meniscus or lateral meniscus) and part of meniscus injury (anterior horn, body, and posterior horn) in chronic ACL-deficient knees. Patient characteristics such as age and gender were correlated with functional knee assessment using a modified Lysholm score. P-value and chi-square tests were used to assess the data. P-value of less than 0.5 was considered significant.Results: Average age of the participants was 32.31 years. There were 42 men and six women in the group. Isolated medial meniscus, lateral meniscus, and combined medial and lateral meniscus had average ages of 31.83, 31.16, and 40.28 years, respectively. ACL injuries on the right side were seen in 23 patients the left side was seen in 25 patients. In comparison to the right side, the isolated medial meniscus injury on the left side was more severe. In case of a combination of medial and lateral meniscus tears, the right side suffered more damage than the left. Eleven patients had an isolated ACL tear without a meniscus injury, while the other 37 had a meniscus injury and an ACL tear. Excellent scores were observed in 11 cases, satisfactory scores in 26, and unsatisfactory in 11 cases. Age group was categorized into three groups, less than 30, 30-45, and more than 45 years. Excellent, satisfactory, and unsatisfactory scores were observed in seven, eleven, and seven patients on the left side and excellent, satisfactory, and unsatisfactory scores in four, fifteen, and four patients on the right side, respectively. P-value was not statistically significant when comparing outcomes by age, gender, or side.Conclusion: Meniscus injuries occurred 77% of the time when there was a persistent ACL injury. In comparison to a lateral meniscus injury, the incidence of medial meniscus injury associated with chronic ACL tear was higher. In comparison to the anterior horn and body of the medial meniscus, the majority of medial meniscus tears were found in the posterior horn.

Objective laxity and subjective outcomes are more influenced by meniscal treatment than anterior cruciate ligament reconstruction technique at minimum2 years of follow-up

ObjectiveThe purposes of this study were: (1) to compare three different surgical techniques for anterior cruciate ligament (ACL) reconstruction at a minimum 2 years of follow-up in terms of objective laxity and patient-reported outcomes; (2) to inspect the role of meniscal tears and treatment alongside with ACL reconstruction. Methods59 patients were randomly assigned to one of the three reconstruction groups according to the ACL reconstruction technique: Double Bundle, Single Bundle, Single Bundle with Lateral Plasty. Autologous hamstring tendons were used in all the ACL reconstruction techniques. Objective laxity tests and KOOS were collected before surgery as a baseline and at a minimum of 2 years of follow-up and compared through a Repeated measure ANOVA. Secondary analysis to evaluate the effect of meniscal treatment on laxity reduction and scores improvement was also conducted using ANOVA. Three laxity evaluations were performed: anterior/posterior displacement at 30° of knee flexion (AP 30), anterior/posterior displacement at 90° of knee flexion (AP 90), and pivot-shift test. ResultsObjective laxity and KOOS showed statistically significant improvement at follow-up in all three groups (p < 0.0001) without differences among the techniques. A higher AP 30 (mean difference 2.4 mm, p = 0.0333, ES = 0.66) was found at baseline for the patients with irreparable medial meniscal tear compared to the patients with isolated ACL tear; a statistically significant difference in pain score at two-year follow-up was found between patients who underwent lateral meniscectomy and patients with either meniscal repair (mean difference 6.9 ± 12.5) or isolated ACL tear (mean difference 6.8 ± 16.1); patients with reparable meniscal tear had a statistically significant pain score improvement compared to the patients who underwent medial and lateral meniscectomy (mean difference of 9.5 ± 14.53 and 23.4 ± 19.2 respectively). ConclusionComparable objective laxity and subjective outcomes were found among the three ACL reconstruction techniques at a minimum of 2 years of follow-up. The presence of irreparable medial meniscal tear increased pre-operative laxity (AP 30, mean difference 2.4 ± 3.6 mm). Patients with meniscal repair presented higher pain relief between baseline and follow-up compared with patients undergoing medial or lateral meniscectomy (mean difference of 9.5 ± 14.53 and 23.4 ± 19.2, respectively).

Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group

Background: Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. Purposes: To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. Results: The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). Conclusion: Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.

Do Clinical Outcomes and Failure Rates Differ in Patients With Combined ACL and Grade 2 MCL Tears Versus Isolated ACL Tears?: A Prospective Study With 14-Year Follow-up.

Background:A combined injury to the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) is a common injury pattern encountered during clinical practice. Recent systematic reviews have found no consensus on the optimal method of managing this combined ligament injury pattern, and no long-term studies with modern techniques are available in the literature.Purpose:To compare 2 groups of patients who underwent isolated ACL reconstruction in terms of failures and clinical scores at long-term follow-up. In the first group were patients with isolated ACL tears (ACL group), while the second was composed of patients with combined ACL and MCL grade 2 tears (ACL + MCL group).Study Design:Cohort study; Level of evidence, 3.Methods:A total of 57 patients (37 in the ACL group and 20 in the ACL + MCL group) underwent isolated ACL reconstruction with a double-bundle technique between January and December 2005. Patients were contacted for scores on the International Knee Documentation Committee subjective form, Western Ontario and McMaster Universities Osteoarthritis Index, and Tegner activity scale as well as data regarding ipsilateral or contralateral revision ACL surgery. A 2-way analysis of variance for repeated measures was used to statistically assess the differences between the groups.Results:Overall, 49 patients (86%) completed the survey and were therefore included in the study. The minimum follow-up was 14.6 years (range, 14.1-15.2 years). There was a significant reduction in both groups of all the outcome scores between the intermediate and final-follow-up. The number of failures was 3 of 31 (9.7%) in the ACL group and 1 of 18 (5.5%) in the ACL + MCL group; this difference was not significant. Moreover, there were no clinical differences between the groups in terms of graft failures, contralateral lesions, and clinical scores.Conclusion:At 14-year follow-up, no clinical difference or increased failure rate was observed between the study groups, suggesting that isolated ACL reconstruction could represent an appropriate treatment for a combined ACL and MCL grade 2 lesion.

Pattern of anterior cruciate ligament injuries in armed forces

Background: Anterior cruciate ligament (ACL) injuries are the commonly seen and potentially devastating injuries in sportsperson and high-demand professionals like military personals. The return to the preinjury status even after the successful ACL reconstruction surgery is not assured. The aim of this study was to assess the pattern and profile of ACL injuries seen in military personnel. Materials and Methods: Five hundred and twenty-four patients who were operated at our center with ACL reconstruction and were meeting the inclusion criteria were included in this study. Patients were evaluated with detailed history and clinical and radiological examination. Results: Five hundred and twenty-four patients were evaluated at a mean of 7.86 months. The mean age was 29.64 years (range: 20–46 years). Five hundred and twenty patients were male and four were female. The mode of injury was sporting activity in 244 (46.6%), military training-related activity in 180 (34.3%), and other activities in 100 (19.1%). Football and basketball were the most common sporting activities in which ACL injuries were sustained, while landing injuries during 9-feet ditch activity (n = 109) were the single most common activity in which ACL injuries were sustained. An isolated ACL tear in 235 patients was the most common type of injury seen, while the meniscus injuries (medial and lateral meniscus) in 149 (28.4%) and 115 (21.9%) patients, respectively, were the most commonly seen associated injuries. Conclusions: ACL injuries are a common occurrence in armed forces. Injury during sports and landing injuries in 9-feet ditch are the common modes by which patients sustained ACL injuries.

Kinematic Analysis of Lateral Meniscal Oblique Radial Tears in the Anterior Cruciate Ligament–Deficient Knee

Background: Lateral meniscal oblique radial tears (LMORT) occur frequently in conjunction with anterior cruciate ligament (ACL) disruption and are anatomically distinct from meniscus root tears. Hypothesis/Purpose: The purpose of this study was to characterize the effects of LMORT types 3 (LMORT3) and 4 (LMORT4) lesions on joint stability and meniscal extrusion in ACL-deficient knees. Our hypothesis was that both lesions would promote significant increases in anterior translation and meniscal extrusion, with the LMORT4 lesion having a greater effect. Study Design: Controlled laboratory study. Methods: Two matched pairs of cadaveric knees (n = 4) were used to optimize the testing sequence. Additional cadaveric knees with LMORT3 (n = 8) and LMORT4 (n = 8) lesions created after ACL transection underwent robotic kinematic testing for anterior drawer and pivot-shift simulations with associated ultrasound-measured meniscal extrusion at clinically relevant knee flexion angles. Results: Optimization testing showed no differences on the effect of LMORT4 lesions for anterior translation and lateral meniscal extrusion with ACL-intact versus ACL-deficient knees. ACL deficiency and LMORT3 and LMORT4 lesions with ACL deficiency were associated with significantly greater anterior translation compared with ACL-intact state for both anterior drawer and pivot-shift testing at all flexion angles (P < .001). ACL deficiency with either LMORT3 or LMORT4 lesion was associated with significantly greater anterior translation than was ACL deficiency only (P < .005) for anterior drawer testing at 90° of flexion. Meniscal extrusion was greater with LMORT3 and LMORT4 lesions compared with ACL deficiency only (P < .05) for anterior drawer at 60° of flexion and for pivot shift at 15° of flexion. The LMORT4 lesion demonstrated increased anterior translation for anterior drawer (P = .003) at 60° of flexion (12%) as well as for pivot shift at 15° of flexion (7%) and 30° of flexion (13%) (P < .005) compared with ACL deficiency only. Conclusion: In this cadaveric model, the addition of an LMORT3 or LMORT4 lesion increased anterior laxity for both the anterior drawer and the pivot shift when compared with an isolated ACL tear. Lateral meniscal extrusion was also exacerbated by these LMORT lesions. Clinical Relevance: LMORT lesions, distinct from meniscus root tears, occur frequently in conjunction with ACL tears. This study characterized the biomechanical consequences of LMORT3 and LMORT4 lesions on joint stability and meniscal function, highlighting the importance of diagnosing and treating LMORT lesions at the time of ACL reconstruction.