Multiligament Injuries Research Articles

Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis.

For elite professional soccer players and alpine skiers, injuries associated with anterior cruciate ligament (ACL) rupture, such as meniscal, cartilage, or collateral ligament lesions, could result in a delayed return to sport compared with isolated ACL injury. The purpose of the study was to provide a detailed description of associated injuries at the time of primary ACL reconstruction in elite soccer players and alpine skiers. It was hypothesized that soccer players and skiers would present different typical injury patterns due to different injury mechanisms. Cohort study; Level of evidence, 3. Surgical reports and arthroscopic images of elite professional soccer players and alpine skiers who underwent primary ACL reconstruction at a single institution between January 2010 and June 2022 were analyzed retrospectively. The presence and location of multiligamentous injury, meniscal tears, and chondral lesions were compared between the athlete groups. A propensity score matching analysis with 1:1 ratio was performed between skiers and soccer players to limit the effect of selection bias. Included were ACL reconstruction data representative of 37 soccer players and 44 alpine skiers. Meniscal pathology was found in 32 (86%) soccer players and 30 (68%) skiers. Chondral injuries were reported in 11 (30%) soccer players and 15 (34%) skiers. Results of the propensity score matching analysis in 15 pairs of soccer players and skiers indicated that soccer players had a significantly higher rate of medial meniscal injuries (73% vs 27%; P = .03) and lateral posterior root tears (33% vs 0%; P = .04) compared with skiers. A higher prevalence of combined chondral and meniscal injuries versus isolated ACL injuries was observed in both groups of athletes. Professional soccer players were characterized by higher prevalence of medial meniscal tears and lateral posterior root lesions compared with professional alpine skiers.

Outcome of Single-stage Multi-ligament Reconstruction: A Retrospective Observational Study

Introduction: Multi-ligament injuries of the knee can cause significant functional impairment. It is uncommon, and treatment is still controversial. The main controversies are around staged versus single-stage surgery. There is scanty literature on the functional outcome of the single-stage multi-ligament reconstruction. Moreover, less is known about the outcomes following single-stage multi-ligament reconstruction in the context of Nepal. We have been practicing single-stage reconstruction for multi-ligament injuries for the last few years at our center. This study was conducted to evaluate the functional outcome after single-stage multi-ligament reconstruction in our setup. Methods: The records of 75 patients who underwent single-stage multi-ligament reconstruction were retrospectively reviewed. All the patients were interviewed by telephone and face-to-face using set questionnaires. The KOOS QoL, Lysholm, and IKDC scores were used to evaluate outcomes. The data analysis was done using SPSS 20. Student’s t-test and Chisquared test were used to calculate the p-value for parametric and nonparametric variables. p-value of less than 0.05 was considered to be significant. Results: The mean age of patients who underwent multi-ligament reconstruction was 36.63 years. Among 75 patients, 51 were males, and 24 were females. 50 (66.7%) had RTA, 20 (26.7%) had fall injuries, 3 (4%) had a sports injury, and 2 (2.7%) had other injuries. The mean KOOS QoL, Lysholm, and IKDC scores were 71.19, 85.85, and 75.92, respectively. Conclusion: This study found that more than 77% of patients undergoing single-stage multi-ligament reconstruction have good to excellent outcomes. KeyWords: KOOS QOL score, Lysholm score, IKDC score, RTA.

Poster 314: Hamstring Autograft Diameter Effect on Surgical Outcome in a Prospective ACL Reconstruction Patient Cohort

Objectives: The purpose was to investigate the effect of hamstring autograft diameter on risk of graft failure and subsequent either knee surgery following ACLR in a prospective cohort. Background: Optimization of graft selection and incorporation in anterior cruciate ligament (ACL) reconstruction (ACLR) is an evolving science. Recent studies suggest hamstring tendon autograft diameter may influence outcomes in primary ACLR, with a larger diameter acting as a protective factor against ACL graft rupture. Further evidence using a prospective patient database is valuable in corroborating the association between ACL autograft diameter and patient outcomes. Methods: Prospective data was collected for a cohort of patients undergoing primary ACLR from February 2015 to February 2018. Exclusion criteria included non-hamstring graft selection, allograft augmentation, skeletally immature patients, revision ACLR, prior contralateral ACLR, and multiligament injuries. Cases from 10 fellowship-trained surgeons within a single institution were included. Recorded tunnel size was utilized as a surrogate for autograft diameter. The contribution of age, sex, BMI and operating surgeon on autograft diameter was studied via mixed effect modeling. The effect of hamstring tendon autograft diameter on risk of subsequent surgery was measured using multivariable linear regression modeling that controlled for patient and surgery characteristics including age, sex, BMI, Marx activity score, and graft diameter. Two-year outcomes were collected for incidence of subsequent surgery to either knee, including ipsilateral revision ACLR and contralateral primary ACLR. Results: Of the patients undergoing ACLR with hamstring autograft who met inclusion criteria, there was 90.5% follow up for subsequent surgery outcomes at minimum of 2 years, resulting in 381 patients. Female sex and lower BMI was associated with smaller autograft diameter and operating surgeon had a significant effect on autograft diameter. 59 patients (15.5%) had subsequent ipsilateral surgery and 27 patients (7.09%) had revision ACLR within 2 years. 29 patients (7.61%) had contralateral subsequent knee surgery and 20 patients (5.25%) had primary contralateral ACLR within 2 years. After controlling for age, sex, BMI, and baseline Marx activity score, hamstring autograft diameter was not associated with risk of all ipsilateral subsequent knee surgery (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.56 - 1.36, p = 0.536). Baseline Marx score greater than or equal to 12 was associated with risk of all ipsilateral subsequent knee surgery with OR 2.55 (CI 1.41 – 4.59, p = 0.002). After controlling for age, sex and BMI, hamstring autograft diameter was not associated with risk of revision ACLR (OR 0.71, CI 0.38 - 1.33, p = 0.286). Age was associated with risk of ipsilateral revision ACLR with OR 0.16 (CI 0.05 – 0.51, p = 0.002). After controlling for age, sex and BMI, hamstring autograft diameter was not associated with risk of all contralateral subsequent knee surgery (OR 0.89, CI 0.50 - 1.59, p = 0.703) including contralateral ACLR (OR 0.78, CI 0.39 - 1.59, p = 0.501). Age was found to be a significant prognostic variable of contralateral ACLR with OR 0.30 (CI 0.10 – 0.93, p = 0.037). No variables within the model were associated with risk of all contralateral subsequent surgery events. Conclusions: Hamstring autograft diameter greater than 8mm was not associated with risk of revision ACLR or other subsequent surgery in the ipsilateral or contralateral knee in a multivariable logistic regression analysis of a prospective patient cohort. Lower age was associated with risk of ipsilateral revision ACLR and contralateral ACLR. Baseline Marx activity score greater than or equal to 12 was associated with risk of all subsequent ipsilateral knee surgery. [Table: see text][Table: see text][Table: see text][Table: see text]

Allograft Anterior Cruciate Ligament Reconstruction in Adolescent Patients May Result in Acceptable Graft Failure Rate in Nonpivoting Sports Athletes.

Studies have demonstrated that pediatric patients have an increased risk of failure with allograft anterior cruciate ligament reconstruction (ACLR); however, there is no study investigating whether allograft ACLR may be safe in older adolescent patients who are not returning to competitive pivoting sports (ie, low risk). The purpose of this study was to assess outcomes for low-risk older adolescents selected for allograft ACLR. We performed a retrospective chart review of patients younger than 18 years who received a bone-patellar-tendon-bone allograft or autograft ACLR by a single orthopaedic surgeon from 2012 to 2020. Patients were offered allograft ACLR if they did not intend to return to pivoting sports for 1 year. The autograft cohort was matched 1:1 based on age, sex, and follow-up. Patients were excluded for skeletal immaturity, multiligamentous injury, prior ipsilateral ACLR, or concomitant realignment procedure. Patients were contacted to obtain patient-reported outcomes at ≥2 years follow-up, including single assessment numerical evaluation, surgery satisfaction, pain scores, Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Parametric and nonparametric tests were used as appropriate. Of the 68 allografts, 40 (59%) met inclusion and 28 (70%) were contacted. Among the 456 autografts, 40 (8.7%) were matched and 26 (65%) were contacted. Two allograft patients (2/40; 5%) failed at a median (interquartile range) follow-up of 36 (12, 60) months. There were 0/40 failures in the autograft cohort and 13/456 (2.9%) among the overall autografts; neither were significantly different from the allograft failure rate (both P > 0.05). Two (5.0%) patients in the autograft cohort required manipulation under anesthesia and arthroscopic lysis of adhesions. There were no significant differences between cohorts for single assessment numerical evaluation, Lysholm, Tegner, pain, and satisfaction scores (all P > 0.05). Although ACL allograft failure rates remain nearly two times higher than autograft failure rates in older adolescents, our study suggests that careful patient selection can potentially bring this failure rate down to an acceptable level. Level III; retrospective matched cohort study.

Open Repair of Posterior Cruciate Ligament Femoral Peel-Off Lesion in Multiligamentous Knee Injuries Results in Good Outcomes

To identify posterior cruciate ligament (PCL) peel-off lesions, to separate these lesions from more common midsubstance tears, and to evaluate patient outcomes after primary open repair. Patients with acute femoral-side "peel off"-type lesions associated with multiligamentous injuries who underwent PCL repair were identified. Patients with chronic PCL injuries, midsubstance PCL tears, or PCL tibial avulsions were excluded from the study. A total of 11 patients were included in this study. All patients underwent open repair using a suture pullout technique. The mean follow-up period was 18 months. The mean Lysholm score at 12 months was 87. Mean knee range of motion (flexion) achieved at 12 months was 121°. No patient had grade 3 laxity on posterior stress testing at final follow-up. Our study showed good outcomes after primary repair of femoral PCL peel-off lesions. Level IV, therapeutic case series.

Ankle Instability Update.

Sprains are the most frequent injuries of the ankle, especially in sports. Up to 85% of cases affect the lateral ligament complex. Multi-ligament injuries with associated lesions of the external complex, deltoid, syndesmosis, and sinus tarsi ligaments are also common. Most ankle sprains respond to conservative treatment. However, up to 20 to 30% of patients can develop chronic ankle pain and instability.New concepts have been recently developed, based on arthroscopic advances, such as microinstability and rotatory ankle instability. These entities could be precursors of mechanical ankle instability and at the origin of frequently associated ankle injuries, such as peroneus tendon lesions, impingement syndromes, or osteochondral lesions.Imaging methods, especially magnetic resonance (MR) imaging and MR arthrography, are key in precisely diagnosing ligament lesions and associated injuries, facilitating an adequate therapeutic approach.

Outcome of Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction Using the Posterior Trans-Septal Approach.

Posterior Cruciate Ligament (PCL) reconstruction is a complex surgical procedure and often challenging. The newer posterior trans-septal portal technique is thought to make tibial tunnel preparation easier with better visualization of the tibial attachment site. It is also thought to lower the risk of neurovascular injuries. The aim of this study was to evaluate the functional and clinical outcomes of patients who underwent arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal at our institute. This was a retrospective study with prospectively collected data between 2016 and 2020. Data collected were age, gender, types of graft used, range of movement, posterior drawer test grade, KOOS score, Lysholm knee scoring scale, and post-operative complications. All patients underwent pre- and post-operative PCL rehabilitation. A total of 36 patients (26 males and 10 females) were identified from our database. The mean age was 35.2years. Mean time from injury to surgery was 20months. Mean follow-up was 41.2months (range, 13-72months). Twenty cases involved multi-ligament injuries and another 16 patients had isolated PCL injury. Post-operative mean posterior drawer test grade improved from 2.7 to 0.7 (p < 0.001). Knee range of movement was 116.3 degrees pre-operatively and 115.6 degrees postoperatively (p = 0.814). Lysholm knee scoring scale improved from 50.9 to 91.0 (p < 0.001). KOOS score improved from 65.1 to 77.2 (p = 0.196). One patient required manipulation under anesthesia for stiffness. No patients needed any additional surgical procedures. All PCLs were clinically intact at the final follow-up. Greater visualization of the PCL tibial attachment minimizes the 'killer turn' giving a huge advantage to this technique. Arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal technique is a safe, reliable and reproducible procedure. From our study, it shows that post-operative clinical and functional outcomes improved significantly.

Deltoid ligament injury and repair.

The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament.The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.

The lateralization pattern has an influence on the severity of ankle sprains

Study design: Descriptive study. Background: Many risk factors contributing to ankle sprains have been studied in medical literature with coordination and balance being two of the major endogenous factors described. These are influenced by lateralization – a developmental and adaptive ability determined by the asymmetrical construction of the human brain, with cross-laterality referring to mixed limb dominance. Objectives: To determine whether cross lateralization is a risk factor for the severity of ligamentous injuries in ankle sprains since no data is yet available on such correlation. Methods: Two hundred forty-four patients with acute ankle sprains (136 men and 108 women) were prospectively evaluated between April 2006 and March 2009. The mean age was 30 (ranging from 18 to 76). Clinical and ultrasonographic examinations were performed on the study subjects. Laterality was then assessed by the Coren questionnaire and the AOFAS score was calculated. Patients with syndesmotic injuries and fractures were excluded from the study. Those qualified were divided into straight and crossed groups, according to their laterality type. Results: One hundred forty-four patients displayed straight lateralization, while cross-laterality was found in 100 subjects. Patients in the crossed group experienced more multi-ligamentous injuries than those in the straight group (p = 0.02). Following trauma, a higher AOFAS score was attributed to subjects that displayed a straight lateralization pattern, in comparison to subjects presenting with crossed laterality (p = 0.04). Conclusion: Crossed lateralization is associated with higher severity of ligament injuries in ankle sprains and may be considered a risk factor for calcaneofibular ligament injuries.

Characteristics of multi-ligament knee injuries accompanied with patellar tendon disruption.

Patella tendon rupture with multi-ligament injury is a rare injury. We observed patients with patella tendon rupture (or patella inferior pole fracture) with multi-ligament injury. This study intends to inspect the mechanism of the injury and classify them. This is a case series involving patients from two hospitals. Twelve patients who had patella tendon rupture (PTR) with multi-ligament injury were studied. The incidence of multi-ligament injury in patella tendon rupture patients found to be 13% in retrospective search. Two types of injury were observed. First type is relatively low energy injury involving ACL and patella tendon which does not involve rupture of PCL. Second type is high energy injury involving PCL and patella tendon. Treatment differed among the patients, due to severity of trauma. Two-staged operation was the basis of treatment. Patella tendon was repaired in first stage. Reconstruction of ligaments was done in second stage. The patients who had infection or stiffness did not have a second surgery. Patella tendon rupture with multi-ligament injury can be classified into low energy rotational injury and high energy dashboard injury. Two-staged surgery is the basis of treatment.

WHAT IS THE MINIMUM LENGTH OF AN ANTERIOR CRUCIATE LIGAMENT AUTOGRAFT REQUIRED WITHIN THE FEMORAL TUNNEL TO ALLOW SATISFACTORY GRAFT FIXATION? OR IS THERE SUCH A THING?

Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. A common belief of having ≥20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof.We examined clinico-radiological outcomes in patients with intra-femoral tunnel graft lengths &lt;20 and ≥20mm. Primary outcomes were knee scores at 1-year. Secondarily, graft revascularization was compared using magnetic resonance imaging (MRI). We hypothesized that outcomes would be independent of intra-femoral tunnel graft lengths.This prospective, single-surgeon, cohort study was conducted at a tertiary care teaching centre between 2015–2018 after obtaining ethical clearances and consents. Eligible arthroscopic ACL reconstruction patients were sequentially divided into 2 groups based on the intra-femoral tunnel graft lengths (A: &lt; 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those &gt; 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively examined and scored (Lysholm and modified Cincinnati scores) at 3, 6 and 12 months. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using MRI. Statistical significance was set at p&lt;0.05.Age and sex-matched patients of both groups were followed to 1 year (1 dropout in each). Mean femoral and tibial tunnel diameters (P =0.225 and 0.595) were comparable. Groups A (&lt;20mm) and B (≥20mm) had 27 and 25 patients respectively. At 3 months, 2 group A patients and 1 group B patient had grade 1 Lachman (increased at 12 months to 4 and 3 patients respectively). Pivot shift was negative in all patients. Lysholm scores at 3 and 6 months were comparable (P3= 0.195 and P6= 0.133). At 1 year both groups showed comparable Cincinnati scores. Mean ROM was satisfactory (≥130 degrees) in all but 2 patients of each group (125–130 degrees). MRI scans at 3 months and 1 year observed anatomical tunnels in all without any complications. Femoral tunnel signals in both groups showed a fall from 3–12 months indicating onset of maturation of graft at femoral tunnel.Our hypothesis, clinical and radiological outcomes would be independent of intra-tunnel graft lengths on the femoral aspect, did therefore prove correct. Intra-femoral tunnel graft lengths of &lt;20 mm did not compromise early clinical and functional outcomes of ACL reconstructions. There seems to be no minimum length of graft within the tunnel below which suboptimal results should be expected.

Patients With Anterior Cruciate Ligament Rupture and Ipsilateral Segond Fractures Have High Rates of Concurrent Knee Pathology

The purpose of this study was to determine the rates of concomitant knee pathology in patients with ACL injuries and Segond fractures. A retrospective study is undertaken with patients identified via query of CPT codes for ACL reconstruction from 2014 to 2020. All patients with preoperative radiographs were reviewed for the presence of Segond fractures. Operative reports were analyzed for the presence of concurrent pathology, including meniscus, cartilage, and other ligamentous injuries at the time of arthroscopic ACL reconstruction. A total of 1,058 patients were included in the study. Segond fractures were identified in 50 (4.7%) patients. Ipsilateral concomitant knee pathology was identified in 84% of Segond patients. Thirty-eight (76%) patients had meniscal pathology with a total 49 meniscal injuries, of which 43 were treated operatively. Multiligamentous injuries were present in 16 patients (32%), with 8 patients undergoing further ligament repair/reconstruction at the time of surgery. Chondral injuries were identified in 13 patients (26%). A high prevalence of concomitant meniscal, chondral, and ligamentous injuries was found in patients with Segond fractures. These additional injuries may require further operative management and may place patients at increased risk for future instability or degenerative changes. Patients with Segond fractures should be counseled preoperatively on the nature of their injuries and risk of associated pathologies. Level IV, prognostic case series.

Relationship of incidence of anterior cruciate ligament injuries and body-built Index somatotype in Indian population

Background: Incidence of ACL injuries and physical parameters like age, sex, height, weight and BMI has been studied intensely as a risk factor. Each of them poses as a different risk factor for occurrence of ACL injuries. But body-built index-somatotype considers relative proportions of fatness, muscle mass and skeletal architecture in terms of endomorphy, mesomorphy and ectomorphy in a single individual which neutralises variables like age, sex, BMI. Methods: 100 patients were included in the study, excluding those with multiligament injuries, associated fractures around knee, mucoid degeneration of ACL and road traffic accident cases. Parameters such as skin fold thickness, circumference and epicondylar, condylar width was taken into consideration. Body built index was calculated in terms of endomorphy, mesomorphy and ectomorphy using the heath-carter anthropometric somatotype manual. Results: We found that amongst all those have ACL injury, endomorphy was higher grade (5.49), followed by mesomorphy (4.75). Lesser grades of ectomorphs i.e., slender people were having ACL injuries. Though there was low margin of grading between the two, endomorphy was higher in ACL injured people followed by mesomorphy. Conclusions: Endomorphs and mesomorphs have higher tendancy of ACL injury. Ectomorphs have lesser incidence of ACL injury.

Outcomes of single-stage reconstruction with ipsilateral peroneus longus and hamstring graft in multiligament knee injuries: A case series

Abstract Background: The diagnosis and management of patients presenting with more than one ligament injury in the knee have been a controversial topic for several decades and it is difficult to draw any firm conclusions. No single approach has proven optimal for the treatment of multiligament knee injuries (MLKI) and there is no consensus between most specialists. This case series seeks to describe and clarify management's current state and future. Objective: The purpose of this study was to determine the outcome of single staged MLKI reconstruction. Materials and Methods: It is a hospital-based case series conducted on 10 patients. Patients who were surgically treated for MLKI between 2017 and 2020 were included in this study. In our study, we included patients with grade 3 or grade 4 cruciate ligament injury with grade 3 or 4 collaterals injury for arthroscopic reconstruction. Data were collected pre- and postoperatively and their Lysholm and International knee documentation committee (IKDC) scores were used to evaluate the outcomes. Results: A male predominance was noted in the present study. Road traffic accidents were the most common mode of injury (70%). Anterior cruciate ligament and medial collateral ligament combination constituted the most common injury pattern (70%). Overall, there was a statistically significant difference in outcomes postsurgery with regards to pre-operative and postoperative Lysholm and IKDC scores in our patients with a P-value of less than 0.0001, substantiating the need for surgical management of MLKI. With a mean postoperative Lysholm score of 89 and a mean postoperative IKDC score of 85, this study showed functionally good results in the patients treated in a single sitting. At the end of 1 year, none of the patients showed positive results for anterior drawer and valgus or varus stress tests. None of the patients showed extensor lag at the last follow-up. Conclusion: A wide variety of management approaches have been described for MLKI. Proper evaluation and full diagnosis are key in multiligament injury of the knee. Failure to treat all injured structures can lead to changes in knee kinematics, poorer outcomes, and increased risk for graft failure. Single-stage early surgical treatment with proper rehabilitation yields good functional and clinical outcomes with early return to work and sports activity.

Management of Multiligament Knee Injury

Multiligament knee injuries are defined as injuries to at least two of the four major ligaments in the knee: anterior cruciate ligament, posterior cruciate ligament, lateral collateral ligament (and posterolateral corner) and medial collateral ligament (and posteromedial corner). Multiple ligament knee injuries that results from high energy trauma, may have nerve and vascular injuries, therefore neurovascular examination with clear documentation of capillary refill time, distal pulses, function of all lower limb compartments and common peroneal and tibial nerve function should be performed. Before definitive treatment performed, we have to classified the multiligament injury according to the energy of the injury and the anatomic injured structures. MRI still recommended to know about the ligaments injury. The goal and our priority treatment is to obtain functional stability of the knee without the loss of motion or stiffnes that can lead to longterm pain, weakness, and the subsequent osteoarthritis.

Extent of posterolateral tibial plateau impaction fracture correlates with anterolateral complex injury and has an impact on functional outcome after ACL reconstruction

PurposeThe impact of posterolateral tibial plateau impaction fractures (TPIF) on posttraumatic knee stability in the setting of primary anterior cruciate ligament (ACL) tear is unknown. The main objective was to determine whether increased bone loss of the posterolateral tibial plateau is associated with residual rotational instability and impaired functional outcome after ACL reconstruction.MethodsA cohort was identified in a prospective enrolled study of patients suffering acute ACL injury who underwent preoperative standard radiographic diagnostics and clinical evaluation. Patients were included when scheduled for isolated single-bundle hamstring autograft ACL reconstruction. Exclusion criteria were concurrent anterolateral complex (ALC) reconstruction (anterolateral tenodesis), previous surgery or symptoms in the affected knee, partial ACL tear, multi-ligament injury with an indication for additional surgical intervention, and extensive cartilage wear. On MRI, bony (TPIF, tibial plateau, and femoral condyle morphology) and ligament status (ALC, concomitant collateral ligament, and meniscus injuries) were assessed by a musculoskeletal radiologist. Clinical evaluation consisted of KT-1000, pivot-shift, and Lachman testing, as well as Tegner activity and IKDC scores.ResultsFifty-eight patients were included with a minimum follow-up of 12 months. TPIF was identified in 85% of ACL injuries (n = 49). The ALC was found to be injured in 31 of 58 (53.4%) cases. Pearson analysis showed a positive correlation between TPIF and the degree of concomitant ALC injury (p < 0.001). Multiple regression analysis revealed an increased association of high-grade TPIF with increased lateral tibial convexity (p = 0.010). The high-grade TPIF group showed worse postoperative Tegner scores 12 months postoperatively (p = 0.035).ConclusionHigher degrees of TPIFs are suggestive of a combined ACL/ALC injury. Moreover, patients with increased posterolateral tibial plateau bone loss showed lower Tegner activity scores 12 months after ACL reconstruction.Level of evidenceIII.

A COMPARATIVE STUDY BETWEEN SUSPENSORY AND APERATURE FIXATION METHOD IN ARTHROSCOPIC SINGLE BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Purpose: To compare the functional outcome of suspensory and aperture fixation method in arthoscopic single bundle anterior cruciate ligament. Method: 30 patient (mean age grp ,35yr)underwent arthroscopic ACL repair with 15 got suspensory and another 15 got aperture fixation in random selection. Similar implant were use to nullify the error.We taken patient with MRI finding of isolated ACL (23)and ACL with medial meniscus tear(7) in our study. No multiligamentous injury were taken.The functional outcome measure with lachman test,Lysholm score ,IKDC score.Post op rehabilitation of early mobilization was done. Inclusion Criteria: Patient given their consent , Age 20-60 years ,Confirmed Complete ACL Tear in MRI Exclusion Criteria: Patients refusing for consent,Patient not ambulatory ,Multiligament knee injury ,Chronic ACL insufficiency with osteoarthritis ,Contradiction to Arthroscopy Result: Patient were followed up in 3week,6week,3month,6month and 1 year.Lysholm score of suspensory were 65.3%, 81.6%,84.5%, 85.1%,97.2%.Aperture fixation scores were 63.7%,76.8%,80.6%,82.13%,95.9%. The IKDC score is 57%, 62.1%,65%,66.6%,77.7% in suspensory fixation and 58.6%,61.6%,63.8%,65.4%,75.1% in aperture fixation. Conclusion: Lysholm score ad IKDC score show no much difference between these two after 3 week,6 week,3 months,6 months of post operation.But after 1 year somehow suspensory had a better result than aperture fixation method.

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.