Objective International Knee Documentation Committee Score Research Articles

Leukocytes Do Not Influence the Safety and Efficacy of Platelet-Rich Plasma Injections for the Treatment of Knee Osteoarthritis: A Double-Blind Randomized Controlled Trial

Background: Platelet-rich plasma (PRP) is increasingly used for the injection treatment of knee osteoarthritis (OA). However, the role of leukocytes contained in PRP is controversial, with some preclinical studies suggesting detrimental effects and others emphasizing their contribution in secreting bioactive molecules. Purpose: To compare the safety and effectiveness of leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) for the treatment of knee OA. Hypothesis: That leukocytes could influence results both in terms of adverse events and clinical outcomes. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This double-blind randomized controlled trial included 132 patients with Kellgren-Lawrence grade 1-3 knee OA who were randomized to a 3-injection cycle of either LR-PRP or LP-PRP. Patients were prospectively assessed at baseline and at 2, 6, and 12 months with subjective evaluations comprising the International Knee Documentation Committee (IKDC) subjective score, the KOOS (Knee injury and Osteoarthritis Outcome Score), the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), the visual analog scale for pain, the EuroQol–visual analog scale, the EuroQol–5 dimensions, and the Tegner activity scale. Objective evaluations consisted of the IKDC objective score, active/passive range of motion, and circumference of the index and contralateral knees. Patient judgment of the treatment was recorded as well as adverse reactions and failures. Results: An overall improvement in subjective and objective outcomes was documented, with no differences between the 2 groups, except for the improvement in the IKDC subjective score at 2 months, which was greater for the LR-PRP group compared with the LP-PRP group (14.8 ± 14.8 vs 8.6 ± 13.3, respectively; P = .046), as well as for active (P = .021) and passive (P = .040) ROM of the index knee at 6 months, showing statistically significant higher values in the LP-PRP group; and for quadriceps circumference of the index (P = .042) and contralateral (P = .045) knees at 12 months, which were significantly greater in the LR-PRP group. The IKDC subjective score improved from 42.5 ± 17.6 at baseline to 55.6 ± 21.4 at 12 months for the LR-PRP group (P < .0005) and from 45.7 ± 16.4 to 55.3 ± 20.4 for the LP-PRP group (P = .001). No differences in terms of patient treatment judgment were observed at all follow-up time points. No severe adverse events related to the treatment were reported, but some mild adverse events related to the treatment were observed: 16 in the LR-PRP group and 17 in the LP-PRP group. Treatment failed in 5 patients in the LR-PRP group and 2 in the LP-PRP group. Conclusion: This double-blind randomized controlled trial demonstrated that leukocytes did not affect the safety and efficacy of intra-articular PRP injections for the treatment of patients with knee OA. Both LR-PRP and LP-PRP demonstrated comparable clinical outcomes at all follow-up time points, without showing differences in subjective and objective outcomes or in adverse events and treatment failures. Registration: NCT04187183 (ClinicalTrials.gov).

Cell-free biomimetic osteochondral scaffold for the treatment of knee articular surface lesions: Clinical outcomes differ based on patient and lesion characteristics.

A cell-free biomimetic osteochondral scaffold was developed to treat cartilage knee lesions, with positive clinical results documented in small case series. However, clear evidence on patient and lesion characteristics that might affect the outcome is still lacking. The aim of this study isto analyse a large cohort of patients treated with this scaffold to investigate factors that could influence the clinical outcome. Two hundred and three patients (mean age 30.7 ± 10.9 years) treated with this scaffold were prospectively evaluated at baseline, 6-, 12-and 24-month follow-up. The clinical outcome was analysed using the International Knee Documentation Committee (IKDC) score, and the activity level was assessed with the Tegner score. The influence of patient and lesion characteristics on clinical outcomes was analysed. Mild and severe adverse reactions were found in 39.0% and 1.5% of patients, respectively. The failure rate was 2.0%, increasing to 12.3% when including also clinical failures. The IKDC subjective score increased from 43.3 ± 15.9 to 61.0 ± 16.2 at 6 months, 68.3 ± 18.5 at 12 monthsand 73.8 ± 18.3 at 24 months (p < 0.0005). The Tegner improved from 2.5 ± 1.7 to 4.2 ± 1.7 at 24 months (p < 0.0005), without reaching the pre-injury level (6.0 ± 2.2) (p < 0.0005). The IKDC objective score changed from 68.5% normal and nearly normal knees before the treatment to 90.1% at 24 months. At 24 months, age showed a correlation with the IKDC subjective score (ρ = -0.247; p < 0.0005), women had a lower score (p < 0.0005), as well as patients with patellar lesions (p = 0.002). Previous surgery correlated with lower results (p = 0.003), while better results were found in osteochondritis dissecans (OCD) compared to degenerative lesions (p = 0.001). This cell-free biomimetic scaffold is a safe and effective treatment for cartilage knee lesions, offering positive clinical results at 2 years with a low failure rate. Better outcomes were observed in younger patients, in lesions of the femoral condylesand in OCD, while joints affected by patellar lesions, patients who underwent previous knee surgery, and women may expect lower results. III, Cohort study.

Effect of different degrees of primary varus knee on short-term effectiveness of anterior cruciate ligament reconstruction

To investigate whether different degrees of primary varus knee affect joint function and stability in patients undergoing anterior cruciate ligament (ACL) reconstruction. A clinical data of 160 patients with primary varus knee, who were admitted between January 2020 and December 2021 and met the selection criteria, was retrospectively analyzed. All patients underwent primary ACL reconstruction using autologous single-bundle hamstring tendon. Patients were divided into three groups based on the hip-knee-ankle angle (HKA): group A (64 patients with HKA 0°-3°), group B (55 patients with HKA 3°-6°), and group C (41 patients with HKA 6°-9°). Except for the significant difference in HKA among the three groups ( P<0.05), baseline data such as age, gender, affected side, body mass index, interval between injury and operation, Kellgren-Lawrence grading, posterior tibial slope, proportion of combined meniscal injuries, Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) objective score, anterior drawer test, Lachman test, pivot shift test, and the results of KT1000 (side-to-side difference, SSD) showed no significant difference ( P>0.05). At last follow-up, joint stability was assessed through the anterior drawer test, Lachman test, pivot shift test, and SSD; joint function was evaluated using the Tegner score, Lysholm score, and IKDC objective score. All incisions in the three groups healed by first intention after operation. All patients were followed up 24-31 months, with an average of 26 months; there was no significant difference in the follow-up time among the three groups ( Z=0.675, P=0.714). At last follow-up, the knee stability and functional assessment indicators in each group significantly improved when compared to preoperative ones ( P<0.05); there was no significant difference among the three groups ( P>0.05) in terms of the anterior drawer test, Lachman test, pivot shift test, IKDC objective scores, and the changes of the Lysholm scores and Tegner scores. The Kellgren-Lawrence grading and HKA at last follow-up were consistent with preoperative results in the three groups. Varying degrees of primary varus knee do not affect early knee joint stability and functional recovery after ACL reconstruction, and there is no significant difference in effectiveness between different degrees of varus knee.

Clinical outcomes of primary anterior cruciate ligament reconstruction using six-strand hamstring autograft

Objectives: Quadrupled and five-strand hamstring tendon (HT) autografts are commonly used in anterior cruciate ligament reconstruction (ACLR), but there is significant variability in graft diameter. The six-strand HT autograft has been introduced to increase graft diameter in patients with undersized HT grafts and may achieve better clinical outcomes. None of the studies has reported clinical outcomes following this technique in Indian patients. We investigated clinical outcomes in patients who underwent primary ACLR using a six-strand HT autograft technique with a minimum six-month follow-up. Materials and Methods: Fifty-five patients who underwent primary ACLR using six-strand HT autografts with interference screw fixation were included in the study. These patients were followed up at three and six months for the evaluation of clinical outcomes. Subjective evaluations included the TegnerLysholm score, anterior cruciate ligament-quality-of-life (ACL-QOL) score, and International Knee Documentation Committee (IKDC) subjective score. Laxity assessments of the knees were performed using the Lachman test and the pivot-shift test. Functional evaluation of the patients was performed with an overall IKDC objective score. Results: The mean IKDC subjective score was significantly improved at three-month (63.42 ± 5.38) and six-month (82.82 ± 7.49) follow-up after surgery (P &lt; 0.05) when compared with pre-operative scores (50.55 ± 1.84). A similar finding was also noted with the Tegner-Lysholm score and ACL-QOL score in our study. All patients have achieved normal to near-normal functional outcomes at six months in our study without any major complications. The most commonly found complication was paresthesia (21.80%) in the present study. Conclusion: In the primary ACLR, six-strand hamstring autograft achieves similar clinical outcomes and complications as reported with four-strand or five-strand HT autografts. However, the percentages of patients who achieved normal to near-normal outcomes were higher in the present study (100%) as compared to earlier reported data using four-strand or five-strand HT autografts (~85%). The six-strand graft technique is a useful means of increasing graft diameter when faced with an undersized hamstring graft.

Do Age and Timing Influence the Outcomes of Single-stage Reconstruction of Multiple Ligament Knee Injuries? 5-10 Years Follow Up.

Multiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single-stage reconstruction of MLKIs. The patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF-36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann-Whitney U test or χ2 test. A total of 102 MLKI patients managed by single-stage multi-ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2-10.7 years). At the last follow-up, no significant difference was found in knee ROM, functional scores, and patient-reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%-80.4% of patients, and grade B in 11.8%-23.5% patients. The single-stage reconstruction of MLKIs can obtain comparative long-term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.

Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis.

To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR. CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate. Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54years (391 patients) and follow-up ranged from 12 to 60months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI -1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups. Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized. Level III.

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis.

Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R. A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective. In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value=0.465). Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft. Level 1; Randomized Comparative Study.

Clinical and Radiologic Outcomes after Meniscal Root Repair: A Case Series.

This study aimed to describe the demographics, clinical outcomes, and radiologic outcomes of patients who underwent meniscal root repair at a single, large academic institution. Patients who underwent meniscal root repair between January 2011 and April 2015 were identified. Patient demographics, injury characteristics, and intraoperative findings of medial femoral condyle chondromalacia and other concomitant pathology were retrospectively recorded. Enrolled patients returned to clinic for prospectively collected International Knee Documentation Committee (IKDC) subjective and objective forms, knee radiographs, and magnetic resonance imaging (MRI). A total of 25 root injuries (23 patients) were included in the final analysis. Majority of root injuries were medial menisci (68%) and repaired using transosseous pull-out technique (80%). Most patients (65%) were male, relatively young (median age = 37 years), overweight (median body mass index [BMI] = 26 kg/m2), and reported a traumatic event associated with their injury (60%). Also, 36% (9/25) of root repairs were performed concomitantly with an anterior cruciate ligament (ACL) reconstruction; 100% (8/8) lateral meniscal root injuries were associated with a concomitant ACL injury compared with 6% (1/17) of medial root injuries. Overall, 53% (9/17) of medial meniscal root repairs were performed in the setting of high-grade (Outerbridge's grade III/IV) chondral pathology of the ipsilateral femoral condyle. Median follow-up was 16 months. The Kellgren-Lawrence radiographic scale progressed in two knees that underwent meniscal root repair based on comparison of preoperative to follow-up radiographs. MRI showed 88% (22/25) of meniscal roots had completely healed, 6% (1/17) of the medial root repairs showed evidence of extrusion, and 44% (11/25) of repairs were associated with progressive chondromalacia. All patients had normal or near normal IKDC objective scores at time of follow-up. Surgeons should have a high suspicion for concomitant ACL injuries in the setting of lateral meniscal root tears, and be wary of concomitant high-grade chondral damage in the setting of medial meniscal root tears. Most meniscal root repairs appeared completely healed with low rates of medial meniscal extrusion on MRI at short-term follow-up, despite a high rate of chondromalacia progression. Present study is a large case series with prospective follow-up and reflects level of evidence IV.

Bone plug fixation in anterior cruciate ligament reconstruction: A clinical and radiological assessment of graft-tunnel integration

BackgroundThe decision regarding graft choice and fixation in anterior cruciate ligament (ACL) reconstruction remains controversial. Free cylindrical bone plugs have been used successfully as graft fixation method. However, some concerns continue to exist regarding how well these plugs integrate with the bony walls of the tunnel. The aim of this study was to assess osteo-integration of free cylindrical bone plugs and to evaluate its effect on the clinical outcomes of the procedure. MethodsFrom January 2015 to December 2017, 30 patients (21–40 years old) with torn ACL were operated on and followed up for 24 months after surgery. All patients were assessed clinically (International Knee Documentation Committee score (IKDC) and Tegner–Lysholm knee scoring system), instrumentally (KT 1000 and Rolimeter), and radiologically (X-ray, computed tomography and magnetic resonance imaging). Young active patients with torn ACL were included while those with previous ligamentous injury and/or surgery were excluded. ResultsAll bone grafts showed solid bone healing after 6 months of surgery; incorporation was ‘good to excellent’ (tibial side: 66.6%; femoral side: 86.6%). There was no correlation between age or time interval and graft incorporation. Positive correlation was shown between tibial and femoral graft incorporation within the same patient. Only one patient was abnormal in our final objective IKDC scores (graded C). The mean side-to-side difference with KT 1000 and Rolimeter was 1.9 and 1.8, respectively. ConclusionFree cylindrical bone plugs could be used safely for hamstring tendon graft fixation; it enhances graft tunnel integration within the first 6 months and yields comparable clinical outcomes whilst avoiding the potential hazards of foreign hardware implants.

Outcomes of Repair and Reconstruction of the Acute Posterolateral Corner Injuries of the Knee Combined with Cruciate Ligaments Injuries.

This study aimed to report objective and subjective knee stability scores for patients who underwent acute repair of avulsed posterolateral corner (PLC) structures or acute reconstruction of midsubstance tears combined with delayed reconstruction of cruciate ligaments. A total of 48 sport and vehicle accident traumatic patients were enrolled in a three-year follow-up study. The patients were investigated by clinical exams, subjective and objective International Knee Documentation Committee (IKDC) score, Tegner score, Lysholm score, and stress imaging. All scores were compared between the reconstruction and repair groups. Subjective IKDC scores were obtained at 83.3±9.6 and 88.3±4.39 for the reconstruction and repair groups, respectively. Only two patients in the reconstruction group had abnormal objective IKDC scores. Based on the Tegner score, 15 out of 18 patients in the repair group and 20 out of 24 patients in the reconstruction group regained their pre-injury functional level. Mean Lysholm scores for the reconstruction and repair groups were estimated at 83.4±8.2 and 88.2±4.1, respectively. Mean lateral joint opening differences between two knees in the reconstruction and repair groups were -0.2±0.1mm and 0.5±0.1mm, respectively. There were no statistically significant differences between groups outcomes. We had no failure of treatment at the final follow-up. Acute intervention within 3 weeks after PLC injuries combined with delayed cruciate ligaments reconstructions showed favorable outcomes. Both repair and reconstruction are effective when deciding based on the type of injury (i.e., avulsion and midsubstance tear).

Failure rate analysis and clinical outcomes of two different femoral tunnel positions using anteromedial portal technique in anterior cruciate ligament reconstruction

AimTo analyze two different femoral tunnel positions and to evaluate their correlation with clinical, functional outcomes and surgical revision rate in patients who underwent primary arthroscopic anterior cruciate ligament (ACL) reconstruction with anteromedial (AM) portal technique. MethodsFrom January 2015 to October 2018, we recruited 244 patients that underwent primary single-bundle ACL reconstruction, using four strand-semitendinosus graft and AM portal technique for femoral tunnel placement. Patients were divided into two groups based on the different femoral tunnel positions: 117 patients of group A had ACL footprint center femoral tunnel position compared with 127 patients of group B, with femoral tunnel placement close to the AM bundle footprint. Preoperatively and at last follow up, all patients were assessed subjectively by Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores, while Lachman, Pivot-shift, and KT-1000 tests were performed to evaluate knee joint stability. ResultsGroup B patients showed significantly better results in Lysholm, objective, and subjective IKDC scores compared with patients of group A (P < 0.001). A significantly higher surgical failure rate was found in group A than in group B (10.26% vs. 2.3%; P < 0.001). A higher anterior knee laxity was recorded in patients of group A than in patients of group B (1.9 ± 1.1 vs. 1.3 ± 1 mm; P < 0.001); a reduction in mean anterior tibial translation from preoperative to final follow up was found in group B compared with group A (3.5 ± 1.2 vs. 2.7 ± 1.1 mm; P < 0.001). No significant differences in the Tegner scale were found between the two groups. ConclusionACL reconstruction performed using the AM portal technique showed better and more satisfactory clinical and functional outcomes associated with a lower failure rate when the femoral tunnel had been placed more eccentrically in the footprint, in the AM bundle center position.

Clinical outcomes of single-bundle versus double-bundle ACL reconstruction in adolescent elite athletes: A retrospective comparative study.

The aim of the study was to evaluate the single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstruction in terms of graft survival, complications, and patient reported functional outcomes in adolescent athletes. In this retrospective study, 89 elite adolescent athletes who underwent either SB or DB ACL reconstruction were included. All patients were then divided into two groups: group 1 including 51 patients with SB ACL reconstruction (31 male, 20 female; mean age = 15.4 ± 1.03 years) and group 2 including 38 patients with DB ACL (30 male, 8 female; mean age = 15.7 ± 1.3 years). Clinical data were obtained, comprising skeletal maturity, sports type, ACL reconstruction technique, Lachman scores, KT-1000™ arthrometer measurement, additional meniscal procedures as well as International Knee Documentation Committee (IKDC) score, Cincinnati score, and graft size. The mean follow-up period was 53.1 ± 8.6 months in group 1 and 46.4± 9.1 months in group 2 (P = 0.61). The type of ACL reconstruction technique (SB or DB), gender, skeletal maturity, sports type, additional meniscal procedures and Lachman scores were not associated with the re-rupture of the ACL (P > 0.05). Moreover, ACL reconstruction technique did not effect the rate of re-rupture of an ACL. There were 21 re-ruptures (23.5%) and 11 (12.3%) contralateral ACL ruptures in total. Among 21 reruptures, 12 of them were in the DB group while nine of them in the SB group (P > 0.05). The groups did not differ with respect to age, the injured side, the time from injury to surgery, the postoperative follow-up time, or the preoperative physical examination results KT-1000 device (SSD), Cincinnati score, IKDC objective and subjective score,Lachman test and pivot-shift test). There are no differences in the re-rupture of an ACL, patient reported outcomes, and complications in adolescent elite players, when either an SB or DB technique is performed. Level III, Therapeuthic Study.

Anterior Cruciate Ligament Reconstruction versus Nonoperative Treatment: Better Function and Less Secondary Meniscectomies But No Difference in Knee Osteoarthritis-A Meta-Analysis.

The impact of anterior cruciate ligament (ACL) reconstruction on knee osteoarthritis (OA) is still unclear. The aim of the current meta-analysis was to compare surgical treatment versus nonoperative management of ACL tears to assess the impact of these approaches on knee OA development at a 5 and 10 years of follow-up. A meta-analysis was performed after a systematic literature search (May 2021) was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Both randomized and nonrandomized comparative studies with more than 5 years of follow-up were selected. Influence of the treatment was assessed in terms of knee OA development, subjective and objective clinical results, activity level, and risk of further surgeries. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. Twelve studies matched the inclusion criteria, for a total of 1,004 patients. Level of evidence was rated low to very low. No difference was documented in terms of knee OA development, Tegner score, subjective International Knee Documentation Committee (IKDC), and Lysholm scores. A significant difference favoring the surgical treatment in comparison with a nonsurgical approach was observed in terms of objective IKDC score (P = 0.03) and risk of secondary meniscectomy (P < 0.0001). The level of evidence was considered very low for subjective IKDC, low for knee OA development, objective IKDC, number of secondary meniscectomies, and Lysholm score, and moderate for post-op Tegner score. The meta-analysis did not support an advantage of ACL reconstruction in terms of OA prevention in comparison with a nonoperative treatment. Moreover, no differences were reported for subjective results and activity level at 5 and 10 years of follow-up. On the contrary, patients who underwent surgical treatment of their ACL tear presented important clinical findings in terms of better objective knee function and a lower rate of secondary meniscectomies when compared with conservatively managed patents.Protocol Registration: CRD420191156483 (PROSPERO).

Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee.

The existence and anatomy of the anterolateral ligament (ALL) of the knee are a somewhat controversial topic in orthopaedic surgery. The fixation of the avulsion fracture of the ALL (Segond fracture), associated with periarticular knee fractures, is rarely given much consideration while the major fracture fragments are reconstructed. This study aims to confirm the existence of ALL and evaluate the clinical outcomes of surgical management for avulsion fractures, involving its insertion, when associated with periarticular knee fractures. Twenty-three patients (16 males and 7 females) with avulsion fractures of the ALL associated with periarticular knee fractures were fixed with a spider plate, cannulated screw, or suture anchor. Eight patients were diagnosed with distal femoral fracture, 10 with tibial plateau fracture, and 5 with tibial eminence avulsion fracture. All patients underwent X-rays at follow-up. Clinical and functional outcomes were assessed with the pivot-shift test, objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale. The ALL was found and identified as a distinct ligamentous structure in all patients. Prior to Segond repair, patients had significantly more instability, as determined by pivot-shift test, than seen postoperatively (p < 0.0001). At final follow-up, the mean subjective IKDC score was 83.2 ± 10.3. Fourteen patients were graded A, 6 were graded B, and 3 was graded C on the IKDC objective score. The mean Lysholm score was 85.4 ± 12.2. The mean Tegner score was 7.5 ± 1.2. This study confirmed that the ALL is a distinct structure in the anterolateral portion of the knee. The fixation of the avulsion fracture of the ALL associated with periarticular knee fractures can be an effective procedure without specific complications. Long-term and comparative follow-up studies are necessary to confirm the effects.

Two-year postoperative MRI appearances of anterior cruciate ligament hamstrings autografts are not correlated with functional outcomes, anterior laxity, or patient age.

AimsMRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation.MethodsA consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing.ResultsTwo-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score.ConclusionThe two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed.Cite this article: Bone Jt Open 2021;2(8):569–575.

Subjective assessment reported by patients shows differences between single-bundle and double-bundle anterior cruciate ligament reconstruction, systematic review and meta-analysis

To determine the functional recovery, active reincorporation, and anteroposterior and rotational stability of patients undergoing anterior cruciate ligament (ACL) reconstruction using arthroscopy techniques with simple-bundle (SB) or double-bundle (DB). The following databases were searched: PubMed, Embase (Elsevier platform), the Cochrane Central Register of Controlled Trials (Wiley platform), Web of Science, and CINAHL. Level I and II studies involving anterior cruciate ligament arthroscopy were included in the search. Records were screened by title and abstract and assessed the risk of bias of selected studies. Meta-analyses using RevMan 5.3 software were conducted on the following outcomes: knee functionality, objective measurements of knee stability, rotational knee stability and knee anterior stability, sports reincorporation, and subjective assessments. Twenty-four studies of patients undergoing ACL reconstruction were included in the qualitative and quantitative synthesis (1707 patients) for Lysholm score, Subjective International Knee Documentation Committee (IKDC) score, Tegner score, KT-1000/2000, Lachman test, Objective IKDC score, and Pivot-Shift test. A return to pre-injury level showed a significant decrease in the Lysholm score (mean difference, − 0.99; 95% CI − 1.71 to − 0.40; P = 0.007) and Tegner score (mean difference, − 0.07; 95% CI, − 0.13 to − 0.01; P = 0.02) at DB reconstruction, similar to the knee functionality outcome of the subjective IKDC score (mean difference − 1.42; 95% CI − 2.46 to − 0.38; P = 0.007). There is no clear or significant difference in clinical stability and knee function or in sports incorporation with the true difference occurring in the subjective assessment.

Cell-Free Biomimetic Osteochondral Scaffold for the Treatment of Knee Lesions: Clinical and Imaging Results at 10-Year Follow-up

Background: Cell-free devices have been introduced to restore osteochondral defects, avoiding the limitations of cell-based procedures. Among these, an osteochondral scaffold made of type I collagen and hydroxyapatite has been investigated with promising results up to medium-term follow-up. However, the clinical and imaging results over time still need to be documented. Purpose: To evaluate the clinical outcome and tissue maturation at long-term follow-up after the implantation of the osteochondral scaffold. Study Design: Case series; Level of evidence, 4. Methods: A total of 24 patients (7 women, 17 men; age, 36 ± 9.5 years) underwent surgical implantation of the osteochondral scaffold and were prospectively evaluated before surgery, at 2-, 5-, and 10-year follow-up. The mean defect size was 2.9 ± 1.4 cm2. Patients were evaluated using the International Knee Documentation Committee (IKDC) subjective and objective scores, and the activity level was documented with the Tegner score. Magnetic resonance imaging (MRI) evaluation involved the use of the magnetic resonance observation of cartilage repair tissue score combined with 5 more variables focused on the bone layer. Results: A statistically significant improvement of all clinical scores was documented from the baseline to the final evaluation. The IKDC subjective score improved from the preoperative level to 2 years (41 ± 13.2 and 77.1 ± 14.6, respectively) (P < .0005), with stable results up to 10 years (77.4 ± 19.4). The IKDC objective score changed from 52% of normal and nearly normal knees before the treatment to 84% at 10 years (P < .0005). Tegner sports activity at the final evaluation (3.8 ± 1.7) was higher compared with the preoperative level (1.6 ± 1.1; P < .05), but it remained significantly lower compared with the preinjury level (5.5 ± 2.6; P < .05). Treatment failed in 1 patient. Persisting graft alterations were observed on MRI scans, although without correlating with the clinical outcome. Conclusion: The regenerative potential of this scaffold is limited, as demonstrated by the signal alterations persisting over time on MRI scans. On the other hand, the clinical improvement was significant and stable over time both in terms of subjective and objective outcomes, including activity level, with overall good results.

Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression.

Background:Anterior cruciate ligament (ACL) reconstruction can be performed with different techniques for independent and transtibial (TT) drilling of femoral tunnels, but there is still no consensus on which approach leads to the best outcome.Purpose:To assess whether the independent or TT drilling approach for ACL reconstruction leads to the best functional outcomes.Study Design:Systematic review; Level of evidence, 2.Methods:A systematic literature search was conducted on July 1, 2020, using the PubMed, Web of Science, Cochrane Library, and Scopus databases. The influence of different femoral drilling techniques was analyzed through a meta-analysis in terms of patient-reported outcome measure scores, risk of complications, range of motion limitations, graft failure, and differential laxity. Subanalyses were performed to compare the different independent drilling techniques considered. Linear metaregression was performed to evaluate if the year of study publication influenced the results. The risk of bias and quality of evidence were assessed following the Cochrane guidelines.Results:A total of 22 randomized controlled trials including 1658 patients were included in the meta-analysis. Both International Knee Documentation Committee (IKDC) subjective score and Lysholm score were higher with the independent drilling approach (mean difference [MD], 1.24 [P = .02] and 0.55 [P = .005], respectively). No difference was documented in terms of the risk of reinjury, but independent drilling led to reduced KT-1000 arthrometer–assessed anterior tibial translation (MD, 0.23; P = .01) and a higher probability of a negative postoperative pivot-shift test finding (risk ratio, 1.13; P = .04). There were no significant differences in IKDC objective or Tegner scores. A P value of .07 was found for the association between the year of the study and IKDC objective scores.Conclusion:Independent femoral tunnel drilling provided better results than the TT approach, although the difference was not clinically significant. No difference was observed in the risk of reinjury. Increasingly better results were seen among surgical procedures performed in more recent years. Among the independent drilling options, the anteromedial portal technique seemed to provide the most favorable outcomes. The lack of clinically significant differences and the promising outcomes reported with new modified TT techniques suggest the importance of correct placement, rather than the tunnel drilling approach, to optimize the results of ACL reconstruction.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial

BackgroundFor active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking.MethodsThis study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up.DiscussionOver the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores.Trial registrationRegistered at Netherlands Trial Register (NL9072) on 25th of November 2020.

One-Stage Anatomical Revision Anterior Cruciate Ligament Reconstruction: Results According to Tunnel Overlaps

To present clinical results according to tunnel overlap in 1-stage anatomical revision anterior cruciate ligament reconstruction (ACLR). All patients who underwent revision ACLR performed by a single surgeon (J.H.A.) from 2012 to 2017 and were followed up for >24 months were retrospectively evaluated. The exclusion criteria were concomitant ligament injury, including medial collateral ligament injury, modified Outerbridge grade ≥3 cartilage lesion, and severe meniscus defects. Tunnel overlap was measured on 3-dimensionally reconstructed computed tomography images. Patients in the nonoverlapped femoral tunnel group (group NO, n= 52) were treated with new tunnel drilling that completely avoided previous tunnels, and those in the overlapped femoral tunnel group (group O, n= 41) were treated with a new tunnel that overlapped with previous tunnels. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) and Lysholm scores. Knee joint stability was measured using the Lachman and pivot shift tests. Patients with femoral tunnel widening of ≥14 mm underwent 2-stage ACLR. The mean follow-up duration of 93 patients was 46.9 months (range, 24-97 months). All preoperative subjective and objective IKDC (P<0.001) and Telos stress test scores (P= .016) were significantly improved at the last follow-up. Forty-one patients had overlapping femoral tunnels, whereas 87 had overlapping tibial tunnels. At the last follow-up, subjective IKDC and Lysholm scores (73.6 ± 15.3 vs 74.9 ± 12.1, P= .799 and 80.0 ± 19.2 vs 81.44 ± 13.5, P= .505, respectively) and objective pivot shift (IKDC grade) in the Lachman test (P= .183 and P= .450, respectively) did not differ significantly between groups NO and O, respectively. One-stage anatomical revision ACLR significantly improved the clinical results. Most tibial tunnels (94%) and approximately one-half (44%) of the femoral tunnels overlapped. The overlapped femoral tunnel group did not show inferior outcomes or stability. Level III, cohort study.