Multiligament Injuries Research Articles

Modern Treatment Principles for Multiligament Knee Injuries.

Multiligament knee injuries are complex injuries that must be addressed with a comprehensive diagnostic workup and treatment plan. Multiligament injuries are commonly observed with concomitant meniscal, chondral, and neurovascular injuries, requiring a thorough clinical assessment and radiographic evaluation. Due to the higher failure rates associated with knee ligament repair following multiligament knee injury, the current literature favors single-stage anatomic knee reconstructions. Recent studies have also optimized graft sequencing and reconstruction tunnel orientation to prevent graft elongation and reduce the risk of tunnel convergence. In addition, anatomic-based ligament reconstruction techniques and the usage of suture anchors now allow for early postoperative knee motion without the risk of stretching out the graft. Rehabilitation following multiligament knee reconstruction should begin on postoperative day one and typically requires 9-12 months. The purpose of this article is to review the latest principles of the surgically relevant anatomy, biomechanics, evaluation, treatment, rehabilitation, and outcomes of multiligament knee injuries.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background:Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises.Purpose:To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises.Results:Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise.Conclusion:MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

Comparison of three surgical techniques of posterolateral knee reconstruction: A cadaver study

BackgroundInjuries to the posterolateral corner (PLC) of the knee are often overlooked but, require reconstruction in order to restore stability in varus and external rotation. Among the many anatomic and non-anatomic PLC reconstruction techniques available, the modified Larson (mLR), LaPrade (LPR) and Versailles reconstruction (VR) procedures are widely used. HypothesisThe hypothesis was that anatomic PLC reconstruction (VR and LPR procedures) provides better restoration and control of external rotation. Patients and methodsFifteen fresh-frozen cadaveric knees were tested to compare the 3 procedures. Varus laxity on stress radiographs in full knee extension and external rotatory laxity on dial test at 30° flexion were quantified at 3 phases: intact knee, PLC sectioned and PLC reconstructed. ResultsMean varus laxity did not differ significantly between techniques in intact knees (p=.14), after PLC sectioning (p=.14) or after PLC reconstruction (p=.17). After PLC reconstruction, varus laxity was restored, with no statistical difference between mLR, VR and LPR compared to intact test values (respectively, -1.0, -1.3 and -1.5; p=.98). In all 3 groups, mean external rotation laxity on dial test at 30° flexion did not significantly differ between intact knees (p=.32) and after PLC sectioning (p=.15). After PLC reconstruction, the mLR technique was significantly less effective in restoring rotational stability than the VR and LPR techniques (p=.025). DiscussionThe VR technique provided similar outcomes to LPR for restoring stability in varus and external rotation. The 2 “anatomic” reconstruction procedures (VR and LPR) were significantly more effective than the modified Larson technique for external rotation control, confirming the study hypothesis. Consequently, it remains preferable to use anatomic techniques in multiligament injuries involving the PLC. Level of evidenceIV, cadaver study.

German S2e-Guideline "Knee Dislocation".

Knee dislocation is a devastating form of multiligament injury of the knee. Due to its high complexity, there is a large number of different diagnostic and treatment strategies. With the aim of providing evidence-based treatment recommendations, the S2e guideline on knee dislocation is aimed at all professional groups involved in diagnostics and therapy (orthopaedic and trauma surgeons, physiotherapists, outpatient/inpatient surgeons, sports physicians, etc.) as well as those affected (patients with knee dislocation) and service providers (health insurance companies, pension insurance companies). In addition to the presentation of conceptual differences between the injury entities, this includes the special features of diagnostic testing, options for conservative and surgical therapy as well as aspects of follow-up treatment - against the background of the interdisciplinary treatment approach to a severe knee injury.

Outcomes Following Bone-patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction In Patients <30 Years: Allograft Vs. Autograft

PURPOSE: The purpose of this study was to investigate differences in failure rates and functional outcomes between patients <30 years of age that underwent allo- or autograft Bone-Patellar Tendon-Bone (BPTB) ACLR. METHODS: All patients aged 16-30 years who underwent a BPTB allo- or autograft ACLR with bioabsorbable interference screws by a single surgeon (1995-2019) were included. Exclusion criteria were follow-up <2 years, osteochondral drilling, revision ACLR, and multi-ligamentous injuries. The allograft was always <5 years than patient age and not terminally irradiated. Meniscal repairs were completed as necessary. All patients completed a decelerated, conservative rehab program with required bracing for 3 months and return to pivoting sports >6 months. An independent physical exam including knee ROM and stability testing, (manual max KT-1000, Lachman, pivot shift) was performed. Patients completed Lysholm, IKDC, Tegner and pain Visual Analogue Score (VAS) to assess clinical outcomes. Failure was defined as positive Lachman or pivot shift test or MRI evidence of re-tear. RESULTS: 13 patients with BPTB allograft (5 male/8 female; 24.3 ± 4.0 years) and 35 patients with BPTB autograft (28 males/7 females; 22.3 ± 4.2 years) ACLR were included (p = 0.136). Average follow-up was 11.7 ± 3.9 years in the allograft group and 13.9 ± 5.9 years in the autograft group (p = 0.685). There were no significant differences in functional outcomes between groups (Lysholm: p = 0.226; IKDC: p = 0.107; Tegner: p = 0.610). There was no significant difference in laxity between groups (KT-1000 30 lbs: p = 0.131; manual maximum: p = 0.416; side to-side difference 30 lbs: p = 0.310; side-to-side difference manual max: p = 0.472). All patients returned to preoperative sports (Tegner score ≥ 5). Overall failure rate was 1.8% (1/48) with 1 failure in the autograft group (p = 0.548). CONCLUSION: In this cohort of young patients, no difference in failure rate was seen between allograft and autograft. At a mean of >10-year follow-up, laxity and all patient reported outcomes were not different between the groups. Careful selection of an allograft for use in ACLR and a decelerated rehabilitation program can be a good alternative in young patients >30 years to return to preoperative sports with no evidence of increased failure rates in this cohort.

Primary Repair of Medial Collateral Ligament Tears With Suture Augmentation

Background: The medial collateral ligament (MCL) is considered to have superior healing and has classically been treated nonoperatively in low-grade MCL injuries. The MCL injury in the setting of concomitant anterior cruciate ligament (ACL) injury is usually treated with a delay of surgery to allow for nonoperative MCL treatment. Recent studies have shown that even with grade II MCL injury there may be residual laxity which may affect place greater strain on an ACL graft in the multi-ligamentous setting and can be corrected for with early primary repair of the MCL which also allows for early definitive treatment of concurrent ipsilateral ligamentous injuries. Indications: All patients are potential candidates given sufficient tissue quality for repair; however, this procedure is preferably performed acutely to avoid scarring, quadriceps strength loss, and allow for early intervention to any concurrent ipsilateral ligamentous knee injury. This technique may be performed on both proximal and distal MCL injuries with the same anchor positioning in either case. Technique Description: The torn superficial and deep MCL are sutured using a Bunnell-type pattern. The superficial proximal MCL is then fixed to its anatomic footprint using a suture anchor preloaded with an internal suture tape augmentation. A second small incision is made over the tibial insertion of the MCL and a passing suture is channeled from the distal to proximal incision under a skin bridge to retrieve the suture tape. The suture tape is then deployed with appropriate tensioning to the anatomic distal insertion point of the superficial MCL using a second suture anchor. Results: There is currently no published data regarding patient outcomes after MCL primary repair with suture augmentation. Our preliminary unpublished data with 49 patients treated with this technique and a variety of concomitant ligamentous injury with average follow-up of 1.7 years showed no MCL repair failures. Four patients experienced more than 10° of flexion range of motion loss, and 3 had residual valgus laxity of grade 1 at 0° and 30° of flexion. Conclusion: Primary MCL repair provides a minimally invasive treatment option for medial laxity, while the suture augmentation allows for early range of motion. Furthermore, this approach avoids delayed definitive surgical intervention of concomitant ligamentous injuries in the setting of combined multi-ligamentous injuries.

Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries.

Background: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population.Methods: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed.Result: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions.Conclusion: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.

Clinical, functional, and patient-reported outcome of traumatic knee dislocations: a retrospective cohort study of 75 patients with 6.5-year follow-up.

At present, limited knowledge regarding clinical, functional, and patient-reported outcomes at mid- and long-terms after surgical treatment of traumatic knee dislocations is available. This study aimed to investigate the mid-term recovery regarding clinical, functional, and patient-reported outcomes in patients following knee dislocation with associated multi-ligament injuries. The study design was a cross-sectional cohort study. Data were collected by retrospective chart review, clinical examination, and interview of patients. All patients treated surgically following a knee dislocation between January 2000 and December 2011 were included. The surgical technique was up to the decision of the individual surgeon. The main outcome was the Lysholm knee score. Secondary outcomes consist of clinical knee examination, functional performance test, pain, and patient-reported outcome across several domains in function, sport, pain, and quality of life. Seventy-five patients (66.3%) accepted the invitation to participate. The mean age at the time of knee dislocation was 33.5years, with a range of 16-65years of age. The mean follow-up time was 78months (R: 17-147). 75% of patient a Schenck's type 1 lesion and 23% a type 3. The median Lysholm knee score was 83 (R: 18-100). The mean KOOS for the five subscales were pain 84.5 (95% CI 80.5-88.5), symptoms 75.1 (95% CI 70.7-79.4), ADL 87.0 (95% CI 83.1-90.9), sport 59.9 (95% CI 53.3-66.4), and QOL 71.3 (95% CI 67.0-75.6). The mean Tegner activity level was 5.1 (95% CI 4.5-5.7). The median single assessment numeric evaluation (SANE) was 93 (R: 0-100). The pain intensity score for pain (VAS) during activity was reported with a mean of 2.7 (95% CI 2.1-3.3). The objective IKDC examination showed 76% of patients grouped by Grade A (normal knee function) or Grade B (nearly normal). With a mean follow-up of 6.5years, combined repair and reconstruction surgery following a knee dislocation shows good to excellent patient-reported outcome and more than 75% of patients experiencing normal knee functioned evaluated by the IKDC score.

Medial Collateral Ligament and Posterior Oblique Ligament Reconstruction for Valgus Instability After Total Knee Arthroplasty

Medial collateral ligament (MCL) injuries are typically managed non-operatively, with high rates of clinical success. However, patients who present with medial knee laxity with valgus stress testing of a fully extended knee, anteromedial rotatory instability, associated tibial plateau fracture, or multiligament injury or those who continue to be symptomatic after non-operative treatment may benefit from surgical intervention. Patients with a history of total knee arthroplasty who suffer MCL and posterior oblique ligament (POL) injuries represent a challenging patient population and often require surgical attention. In this Technical Note, we describe the preoperative assessment, decision making, and surgical technique for anatomic reconstruction of the superficial MCL and POL with an Achilles allograft in young, active patients with medial-sided knee injuries after total knee arthroplasty.

Paper 02: ACL Reconstruction in Cutting and Pivoting Athletes: Soft Tissue Quadriceps Tendon Autograft vs. Bone-Patellar Tendon-Bone Autograft

Objectives:ACL reconstruction is one of the most common knee procedures performed annually in the United States. Athletes participating in cutting and pivoting sports are at high risk for ACL injury. In the general population, most graft choices including allograft, bone-patellar tendon-bone (BTB) autograft, hamstring autograft and quadriceps autograft have all been shown to excellent results following reconstruction. However, in the high-level cutting and pivoting athlete, the optimal graft for reconstruction remains controversial. Most consider BTB autograft to be the gold standard for such athletes. However, BTB autografts have drawbacks including anterior knee pain, difficulty kneeling and possible patellar fracture and patellar tendon rupture. Quadriceps autograft has increased in popularity since it offers a thicker graft with more favorable tensile properties compared to BTB and hamstring autografts. The quadriceps autograft has nearly twice the cross sectional area, higher load to failure and greater stiffness than the BTB autograft. Studies have shown equivalent outcomes when directly comparing BTB autograft vs. soft tissue quadriceps autograft in the general population. No studies have directly compared these two grafts in athletes participating in cutting and pivoting sports. We hypothesized that the quadriceps autograft would lead to similar patient outcomes, re-tear rates, return to sport and complications as BTB autografts in the cutting and pivoting athlete.Methods:A retrospective review of cutting and pivoting athletes with ACL tears treated with BTB autograft or soft tissue quadriceps autograft with at least 2 years of follow up was performed. Only athletes participating in cutting and pivoting sports were included in the study. Four sports were considered to be cutting and pivoting including soccer, football, lacrosse and basketball. The decision on which graft to use was based on the athlete’s choice after discussing the pros and cons of each graft. Exclusion criteria included those athletes with recurrent ACL tears, multiligamentous injuries, previous meniscal surgery and those requiring osteotomies. International Knee Documentation Committee Subjective Knee Evaluation (IKDC) and Lysholm knee scoring scale were used to evaluate patient reported outcomes. Through chart review, ability to return to sport, time to return to sport and complications were identified. The postoperative rehabilitation protocol for both grafts was identical.Results:There were 32 athletes in the soft tissue quadriceps autograft group and 36 in the BTB autograft group. The average age was 18.6 years for the quad group and 19.7 years for the BTB autograft group (p=0.63). Females made up 62.5% of the quadriceps group and 44.4% of the BTB group (p=0.14). The quad group was made up of 56.3% high school and 43.7% college athletes compared to 61.1% high school and 38.9% college athletes in the BTB autograft group (p=0.53). Soccer was the most common sport with 16 in the quad group and 14 in the BTB group. The rest of the quad group included 8 football players, 4 lacrosse and 4 basketball players. The remaining BTB group consisted of 12 football players, 8 lacrosse and 2 basketball players. Meniscal surgery was performed in combination with the ACL reconstruction in 17 (53.1%) of the quad group and 22 (61.1%) of the BTB autograft group (p=0.37). Average graft size was 9.5mm for the quad autograft group and 10 for the BTB autograft group. The 2-year IKDC score was 93.6 for the quad group and 95.1 for the BTB group (p=0.45). The 2 year Lysholm scores were 95.7 and 96.1 for the quad and BTB groups respectively. Return to play at the same or higher level was 90.6% in the quad group and 86.1% in the BTB autograft group (p=0.82). Time to return was also similar between the groups with 7.1 months for the quad group and 7.6 months for the BTB autograft group. There was 1 re-tear which required revision in the BTB group and no re-tears in the quad group (p=0.34). Arthrofibrosis requiring MUA and lysis of adhesions occurred in 2 quad autografts and 4 BTB autografts (p=0.49). One contralateral ACL rupture occurred in the quad autograft group and 4 in the BTB autograft group (p=0.21).Conclusions:The optimal ACL graft in high level athletes participating in cutting and pivoting sports remains in question. In our comparison of quadriceps autograft compared to BTB autograft in this athletic population, no difference in patient reported outcomes, return to sport or re-tear rates was identified. Based on these findings, quadriceps autograft is as effective as BTB autografts in cutting and pivoting athletes and should be part of the graft choice discussion with the athlete.

Artelon as a Bio-Scaffold to Augment Collateral Ligament Repair after Knee Dislocation.

Introduction:Knee dislocations (KD) have high rates of multi-ligamentous injury (MLI). Collateral ligaments rupture in 50-60% of KDs. Traditionally, collateral ligaments have undergone primary repair, though microscopic healing is not optimal. Artelon is a degradable, polyurethane urea bio-scaffold thought to decrease mechanical forces and promote healing, motion, and strength. Currently, little evidence exists regarding its indications or outcomes.Material and methods:Thirty-two patients with KD and MLI undergoing collateral ligament repair at a level-I trauma centre between 2015-2020 were included. Patients age <18, with ipsilateral fractures or inadequate follow-up were excluded. The Artelon (AG) and primary ligamentous repair group (PR) each included 16 patients. Injury and perioperative variables were evaluated using SPSS® .Results:Thirty-two KDs were included in 32 patients, with 60% anterior. There were no significant differences between the two cohorts demographically or with regards to the type or severity of injury sustained. Meniscal pathology was addressed in 14 patients in both groups. Thirty-eight percent of all patients lacked >15° of knee flexion. Only one gross failure occurred, in the AG. No differences were noted in infection or re-operation. Lysholm Knee Scale and Tegner Activity Scale were not significantly different, although Tegner scores in both cohorts decreased from pre-injury scores.Conclusions:In summary, Artelon appears to be safe without increasing risk for hypersensitivity or infection when used for collateral ligament augmentation. Additionally, Artelon appeared to be non-inferior and statistically equivalent to primary repair in this setting and may have promise with use in certain types of knee dislocations.

Observation on the Effect of MRI Image Scanning on Knee Pain in Football Injury.

To study the effect of football injury on knee pain based on MRI image scanning, in this paper, a total of 31 knee injuries of 29 male professional football players from December 2012 to April 2015 were used as the experimental group. The players were 23.6 ± 3.5 years old and received professional football training time 15.3 ± 3.6 years; 31 outpatients of the same age group with acute knee joint acute injury were randomly selected as the control group; both groups were imaged with a 1.5 TMR scanner and knee joint standard array coil imaging, and 2 senior radiation surgeons evaluate knee cartilage, meniscus, ligaments, tendons, bone marrow, infrapatellar fat pad, and joint effusions. Pearson's chi-squared test and nonparametric test for two independent samples were used for statistical testing of the evaluation results. The experimental results showed that there were significant differences in the incidence of articular cartilage, lateral collateral ligament, tendon or ligament injury, multiligament or tendon injury, and bone marrow edema between the two groups (P < 0.05). There was no significant difference in the incidence of medial collateral ligament injury, infrapatellar fat pad edema, and joint effusion. MRI shows that knee injuries in male professional football players often involve ligaments or tendons, mostly multiligament or tendon injuries. The lesions of articular cartilage and meniscus are more common and serious, and bone marrow edema is also more common in football injuries. MRI has high diagnostic accuracy for various clinical knee injuries, and it belongs to a noninvasive examination method. It can not only reflect the pathological changes and changes of the knee joints of patients but also provide information for the formulation of clinical programs and the judgment of prognosis, for timely, accurate, and comprehensive imaging reference.

Knee dislocations and multi-ligament knee injuries: A review

Acute knee dislocations are a relatively rare type of injury that can lead to serious neurovascular compromise and ligament instability. These injuries can be potentially limb threatening if not properly identified and managed. The following review discusses the relevant anatomy of the knee joint and different classification systems of dislocations in order to highlight the complications that could occur. Timely evaluation and management, including reduction, is paramount to ensure stability and determine the need for additional imaging or urgent consultation. Knee dislocations are also associated with the unique presentation of a multi-ligament injury. This text provides an overview of multi-ligament knee injuries and the various surgical modalities currently being used. Finally, considerations are given on the role of the osteopathic approach in restoring function of the knee in the context of a dislocation.

Negative Predictive Value of Mri-Detected Medial Meniscus Tears is Reduced in Young Athletes with Chronic ACL Injury

Background:A delay in anterior cruciate ligament reconstruction (ACLR) is associated with an increase in the prevalence in medial meniscus tears identified at the time of surgery. However, the specific effect of time on the predictive value of magnetic resonance imaging (MRI) for detecting meniscus injury in the young athletic population with ACL tears is unclear.Purpose:To investigate the effect of time from MRI to ACLR on the predictive value of MRI to detect meniscus tears in adolescent and young adult athletes.Methods:A retrospective review was performed of patients aged 13-25 years who underwent primary ACLR at an academic institution from January 2017 to June 2020. Multi-ligament injuries were excluded. Primary data recorded included time from MRI to surgery and descriptions of medial and lateral meniscus tears on both MRI and operative reports. Time from MRI to surgery was divided into four intervals: 0 to 6 weeks, 6 weeks to 3 months, 3 months to 6 months, and beyond 6 months. Multivariable analysis was used to determine the positive (PPV) and negative predictive value (NPV) of MRI in detecting meniscus tears as compared to arthroscopic findings at each of the 4 time intervals.Results:432 patients (54% female) were included with a mean age of 18 ± 3.4 years. The mean time from injury to MRI was 78 ± 187 days; the mean time from MRI to surgery was 71 ± 98 days. 252 patients had pre-operative MRIs without meniscus tears; 33 (13.1%) of those had a medial meniscus tear identified at the time of surgery (Table 1). New medial meniscus tears (100% vertical tears) were identified in 7/18 (38.9%) patients with surgery 6 months from MRI. There was a statistically significant decrease in the NPV of MRI to identify medial meniscus tears in patients who underwent ACLR greater than 6 months after imaging (odds ratio 0.16 [0.05–0.53], P < 0.005). Age, gender, body mass index, mechanism of injury, primary sport, and ethnicity did not affect the predictive value of MRI. Sensitivity and specificity of MRI to predict a medial meniscus tear in the entire cohort was 79% and 80%, respectively.Conclusion:Surgeons should counsel patients preoperatively about increased possibility of undiagnosed medial meniscus tears being found at the time of ACLR if greater than 6 months have passed from MRI to surgery.Table 1.Breakdown of Medial Meniscus Tears by Time from MRI until Surgery

Reconstruction of the ligamentous-tendinous complex of the knee joint, ensuring its varus stability

А new technique for anatomical reconstruction of the ligamenttendon complex of the knee joint, which restores its varus stability, in patients with multiligament injury is substantiated. The technical feasibility, safety, and effectiveness of the proposed technique were evaluated in an anatomical experiment. The study was performed on eight lower extremities of four unfixed corpses. After simulating the varus instability of the knee joint, the plasty of the ligamenttendon complex providing the varus stability of the knee joint was performed according to the proposed technique. The essence of the proposed technique is the simultaneous restoration of the peroneal collateral ligament, popliteal tendon, and poplitealperoneal ligament using a single autograft of a semitendinosus muscle. After simulating the surgical procedure on anatomical specimens, the varus stability of the knee joint was evaluated based on the results of functional radiography. The safety of the experimental procedure was evaluated based on the results of the applied morphometric study of the distance from the reconstructed elements of the posterolateral corner of the knee joint to the popliteal artery and the common peroneal nerve in the 90-degree flexion position in the knee joint. Accordingly, the formed bone tunnels for a single autograft were located at a safe distance from the elements of the neurovascular bundle of the popliteal fossa. The technical possibility of reconstruction of the collateral peroneal ligament, popliteal tendon, and poplitealperoneal ligament according to the proposed technique. After simulating the reconstruction of elements of the posterolateral corner of the knee joint, varus stability was objectified by a series of functional X-ray studies of the anatomical specimens. The results indicate the technical feasibility, effectiveness, and relative safety of the proposed method of reconstruction of the ligamenttendon complex of the posterolateral corner of the knee joint providing the varus stability of the knee joint in patients with multiligament injury.

Is Peroneus longus autograft a better alternative to the Hamstring autograft for anterior cruciate ligament reconstruction? – A randomised control study

Purpose The anterior cruciate ligament in the knee is commonly prone to injuries. Reconstruction of this ligament with hamstring tendon has been time-tested but peroneus longus autograft is also gaining popularity. However, very limited literature is available comparing the two grafts. This study aims to compare the functional outcome and donor site morbidity between hamstrings and peroneus longus autograft in anterior cruciate ligament reconstruction. Methods A prospective randomised study was conducted on 45 patients, who underwent anterior cruciate ligament reconstruction. Patients were assigned into Hamstring group and the Peroneus longus group. Functional outcome was assessed using Lysholm score and Modified Cincinnati scores for the knee joint and American Orthopedics Foot and Ankle Scoring for ankle joint. Donor site morbidity was assessed by measuring flexion and extension strength of the knee and plantar flexion and eversion strength of the ankle by handheld dynamometer preoperatively and postoperatively at 6 months and 1 year follow up. Results Functional outcome of the knee showed significant improvement in peroneus longus group (p-value 0.002) compared to hamstring group. Even though there was minimal reduction in functional outcome of the ankle at 6 months follow-up in peroneus longus group, it improved at one year follow-up. While assessing the donor site morbidity at the knee joint, knee flexion strength showed improvement in the group (p-value 0.02) but reduced in the hamstring group where the hamstring tendon was harvested. Knee extension strength in the hamstring group scored marginally better than the peroneus longus group, which was not statistically significant (p-value 0.5). Conclusion Autologous peroneus longus tendon can be used as a graft of choice in anterior cruciate ligament reconstruction which showed promising results without compromising on the ankle function. Its usage as an alternative source of the graft may be more useful in multi-ligament injuries of the knee joint.

Determining the Roles of the Anterior Cruciate Ligament, Posterolateral Corner, and Medial Collateral Ligament in Knee Hyperextension Using the Heel-Height Test.

Background:Anterior cruciate ligament (ACL) tears are often associated with other ligamentous injuries. The side-to-side difference in heel height can represent a valuable diagnostic tool in the setting of multiligamentous injuries.Purpose:To assess in a cadaveric model how sequential sectioning of the static stabilizing structures of the knee (ACL, fibular collateral ligament [FCL], popliteus tendon [PLT], popliteofibular ligament [PFL], and medial collateral ligament [MCL]) influences heel-height measurements when comparing groups undergoing initial transection of the ACL versus FCL and to assess posterior tibial slope after sequential sectioning.Study Design:Controlled laboratory study.Methods:A total of 16 fresh cadaveric knees were carefully dissected to expose the ACL, FCL, PLT, PFL, and MCL. Each knee was randomized to either the ACL-first or FCL-first group based on the initial structure sectioned. The sectioning order was as follows: (1) ACL or FCL, (2) FCL or ACL, (3) PLT, (4) PFL, and (5) MCL. Heel height was measured with a standardized superiorly directed 12-N·m force applied to the knee while stabilizing the femur; heel height was also measured with a clinician-applied force. The measurements were compared between and within groups for each sectioned state. The correlation between tibial slope and heel-height measurements was analyzed.Results:There were no significant differences in heel-height measurements between the ACL-first and FCL-first groups (P = .863). Combined ACL-FCL injuries led to a 2.85 ± 0.83–cm increase in heel height compared to the intact state. Significant increases in heel height occurred after all sectioned states, except the PFL sectioned state. Combined ACL–posterolateral corner (PLC) injuries resulted in a 3.72 ± 1.02–cm increase in heel height, and additional sectioning of the MCL resulted in a 4.73 ± 1.35–cm increase compared to the intact state. Tibial slope was not correlated with increases in heel height after each sectioning (P = .154).Conclusion:Combined ACL-FCL, ACL-PLC, and ACL-PLC-MCL injuries resulted in increasing mean heel-height measurements (2.85, 3.72, and 4.73 cm, respectively) compared to the intact state. Tibial slope was not found to influence increases in heel height.Clinical Relevance:The side-to-side difference in heel height may be a clinically relevant examination tool for diagnosing multiligament knee injuries.

Meniscal Tear at Knee: Repair or Resect? An Early Experience from a University Hospital in Nepal

Background The meniscus plays an important role in maintaining healthy articular cartilage. Meniscus tear, one of the common intra-articular knee lesions, is treated by either debridement or repair.&#x0D; Objective This study aims at identifying the early outcome of meniscus tears treated by debridement or repair. This study also elaborates on the spectrum of meniscal injuries presented in a tertiary care hospital in Nepal.&#x0D; Method A retrospective descriptive cross-sectional study was conducted at Orthopedic Department of Dhulikhel Hospital from February 2018 until January 2020 among patients who underwent knee arthroscopies for meniscal tears treated either by debridement or repair. Patients having intra articular fractures, osteochondral injuries and multi-ligament injuries were excluded. The meniscal tears were classified according to location and type of tear. Those patients who had at least one-year of follow up were evaluated with Lysholm score for functional outcome. Data were compiled and analyzed with Microsoft Excel 2011.&#x0D; Result One hundred and ten cases of meniscal tears were managed over the study period. Ninety-three cases could be traced for outcome evaluation, which included 50 cases of meniscal debridement and 43 cases of meniscal repair. The mean Lysholm score of the patients who received debridement was 81.5 (SD 10.4) and those who received meniscal repair was 84.9 (SD 9.1) (p=0.105). The population distribution was found to be similar in both the groups according to age and sex distribution and associated ligamentous injuries.&#x0D; Conclusion Good functional outcome was seen for meniscal tears managed with debridement or repair in at least one year follow up and could not establish one modality of management better than the other.

Intra-femoral tunnel graft lengths less than 20mm do not predispose to early graft failure, inferior outcomes or poor function. A prospective clinico-radiological comparative study.

Increasing demands on skills with mounting pressures from expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions requires precise knowledge of technical details by surgeons. One such element is the minimum length of graft in femoral tunnel to allow for adequate tendon-to-bone healing and early return to activities and sports. This has, however, remained an unanswered question. To study and compare clinico-radiological outcomes of ACL reconstructions in patients with < 20mm of intra-femoral tunnel graft length with those measuring ≥ 20mm. All eligible patients undergoing arthroscopic ACL reconstruction were sequentially divided into two groups based on the intra-femoral tunnel graft lengths (A: < 20mm, n = 27; and B: ≥ 20mm, n = 25). Exclusions were made for those > 45years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively evaluated in clinics by physical examination and functional scoring (Lysholm and modified Cincinnati scores) at 3, 6 and 12-month intervals. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using magnetic resonance imaging (MRI) at 3 and 12months. No significant differences were noted in mean Lysholm and modified Cincinnati scores between the two groups at the end of 1year. There were also no significant differences in graft maturation over time and SNQR at 3 and 12months in the region of interest (ROI). Intra-femoral tunnel graft length of less than 20mm does not compromise early clinical and functional outcomes of ACL reconstructions.

Forecasting neuromuscular recovery after anterior cruciate ligament injury: Athlete recovery profiles with generalized additive modeling.

A retrospective analysis of longitudinally collected athlete monitoring data was conducted to generate a model of neuromuscular recovery after anterior cruciate ligament (ACL) injury and reconstruction (ACLR). Neuromuscular testing data including countermovement jump (CMJ) force-time asymmetries and knee extensor strength (maximum voluntary contractionext ) asymmetries (between-limb asymmetry index-AI) were obtained from athletes with ACLR using semitendinosus (ST) autograft (n = 29; AI measurements: n = 494), bone patellar tendon bone autograft (n = 5; AI measurements: n = 88) and noninjured controls (n = 178; AI measurements: n = 3188). Explosive strength measured as the rate of torque development was also calculated. CMJ force-time asymmetries were measured over discrete movement phases (eccentric deceleration phase, concentric phase). Separate additive mixed effects models (additive mixed effects model [AMM]) were fit for each AI with a main effect for the surgical technique and a smooth term for the time since surgery (days). The models explained between 43% and 91% of the deviance in neuromuscular recovery after ACLR. The mean time course was generated from the AMM. Comparative neuromuscular recovery profiles of an athlete with an accelerated progression and an athlete with a delayed progression after a serious multiligament injury were generated.Clinical Significance: This paper provides a new perspective on the utility of longitudinal athlete monitoring including routine testing to develop models of neuromuscular recovery after ACLR that can be used to characterize individual progression throughout rehabilitation.