Pivot-shift Test Results Research Articles

Effect of Preoperative Anterolateral Ligament Injury on Outcomes After Isolated Acute ACL Reconstruction With Hamstring Graft: A Prospective Study With Minimum 5-Year Follow-up

Background: The potential influence of a preoperative anterolateral ligament (ALL) lesion seen on magnetic resonance imaging (MRI) on the mid- and long-term surgical outcomes of anterior cruciate ligament (ACL) reconstruction is still controversial. Purpose: To evaluate the clinical outcomes and failure rate of isolated ACL reconstruction at a minimum 5-year follow-up in patients with and without ALL injury diagnosed preoperatively using MRI. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort of patients with acute ACL injury was divided into 2 groups based on the presence (ALL injury group) or absence (control group) of ALL injury on preoperative MRI. This is a longer-term follow-up study of a previously published study that had a minimum 2-year follow-up. Both groups underwent anatomic isolated reconstruction of the ACL. The Lysholm and subjective International Knee Documentation Committee scores, KT-1000 arthrometer and pivot-shift tests, reconstruction failure rate, incidence of contralateral ACL injury, presence of associated meniscal injury, and presence of knee hyperextension were evaluated. The evaluation at the 5-year follow-up was also compared with the same patient’s evaluation at 2 years of follow-up. Results: A total of 156 patients were evaluated. No significant differences were found between the groups in the preoperative evaluation. In the postoperative evaluation, patients in the ALL injury group had a higher reconstruction failure rate (14.3% vs 4.6% for the control group; P = .049) and worse clinical outcomes according to the Lysholm scores (85.0 ± 10.3 vs 92.3 ± 6.6; P < .00001). Although the pivot-shift test results were similar, anteroposterior translation using the KT-1000 arthrometer revealed worse results for the ALL injury group (2.8 ± 1.4 mm vs 1.9 ± 1.3 mm; P = .00018). Patients in the ALL injury group also had an increase in KT-1000 arthrometer values from 2 to 5 years (2.4 ± 1.6 vs 2.8 ± 1.4; P = .038). Patients in the control group had no differences in outcomes from 2 to 5 years of follow-up. Conclusion: Combined ACL and ALL injuries were associated with significantly less favorable outcomes than were isolated ACL injuries at a minimum follow-up of 5 years after isolated ACL reconstruction with hamstring autograft. Patients with concomitant ALL injury showed a higher failure rate and worse functional scores. Also, knee stability tended to slightly worsen from 2 to 5 years in cases of associated ALL injury.

Male Sex, Revision Surgery, Low Volume of Anterior Cruciate Ligament Remnant, and Significant Instability Are Risk Factors for Posterior Root Tear of the Lateral Meniscus in Patients Undergoing Anterior Cruciate Ligament Reconstruction

PurposeThis multicenter study aimed to determine the incidence of lateral meniscus posterior root tears (LMPRTs) in patients undergoing ACL reconstruction and identify associated risk factors. MethodsWe conducted a retrospective, multicenter study using data from the Francophone Arthroscopic Society's registry. The study included all the patients in the registry who underwent ACL reconstruction surgery between June 2020 and June 2023, we excluded incomplete data. We compared delay from injury to surgery between LMPRTs group and No LMPRTs group. Variables investigated as potential risk factors for LMPRTs included age, sex, nature of surgery (primary or revision), pivot shift test result, side-to-side laxity under anesthesia, presence of ACL remnant, occurrence of medial meniscal tear, and presence of collateral ligament injury. Risk factors were analyzed using a logistic regression model. ResultsAmong the 5359 patients analyzed, LMPRTs occurred in 7.0% (n=375) of cases during ACL reconstruction. Mean age at surgery was 29.3 +/- 10.3 years old [11-77]. Concerning delay to surgery, the mean time was 8.4 +/- 23.1 weeks [0.0-347.2] in the No LMPRTs group and 6.5 +/- 10.2 weeks [0.2-61.6] in the LMPRTs group (p = 0.109). Univariate analysis revealed that male sex (p < 0.001), revision surgery (p < 0.001), medial meniscal injury (p = 0.007), ACL remnant (0% vs > 70%, <10% vs > 70%, 10 to 30% vs > 70%, 30 to 50% vs > 70%, 50 to 70% vs > 70%; p < 0.001) and higher pivot shift grade (p = 0.011) were significantly associated with a presence of LMPRTs. Age, side-to-side laxity, and collateral ligament injury were not found to be significant risk factor In multivariate analysis : male sex, revision surgery, pivot shift test result and a low volume of ACL remnant remained significant. Side to side laxity was also a significant factor in multivariate analysis. ConclusionThis study identified male sex, revision surgery, low volume of ACL remnant, side to side laxity and higher grade of pivot shift as significant risk factors for LMPRTs during ACL reconstruction.

A Lateral Extra-articular Procedure Reduces the Failure Rate of Revision Anterior Cruciate Ligament Reconstruction Surgery Without Increasing Complications: A Systematic Review and Meta-analysis

Background: Lateral extra-articular procedures are becoming increasingly popular in association with anterior cruciate ligament (ACL) reconstruction, especially in patients with persistent rotatory instability and in a high-risk population. However, few studies have investigated the outcomes of the lateral extra-articular procedure as an associated procedure in an ACL revision (R-ACLR) setting and its benefit with respect to isolated intra-articular reconstruction. Hypothesis: Lateral extra-articular procedures reduce the failure rate of revision ACL reconstruction (R-ACLR). Purpose: To compare subjective outcomes, knee stability, and failure and complication rates between patients who underwent ACL revision with and without an associated lateral extra-articular procedure. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: A systematic search of the PubMed, Cochrane, and OVID databases was performed on September 2022 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies were trials directly comparing patients who had isolated ACL revision with patients who had ACL revision associated with lateral extra-articular procedures at a minimum follow-up of 2 years. A meta-analysis was performed, and bias and the quality of the evidence were rated according to the Newcastle-Ottawa Scale. The meta-analysis was conducted according to the PRISMA guidelines. Results: Eight studies were included: a total of 334 patients were treated with isolated revision (isolated (R-ACLR)) and 342 treated with combined revision and a lateral extra-articular procedure (combined (R-ACLR)). For the failure rate, the meta-analysis showed a significantly decreased relative risk reduction of 54% (P = .004) in patients with combined (R-ACLR) with respect to isolated R-ACL, whereas no difference in complication rate was observed. The combined (R-ACLR) group demonstrated a decreased risk ratio of 50% (P = .002) for having a positive pivot-shift test result and a relative risk reduction of 68% (P = .003) for having a grade 2-3 pivot shift when compared with the isolated (R-ACLR) group. Finally, no significant differences were observed among the lateral extra-articular procedures. Conclusion: The addition of a lateral extra-articular procedure to revision ACL significantly reduced the failure rate and postoperative pivot shift without increasing the complication rate. Anterolateral ligament reconstruction and a lateral extra-articular procedure with iliotibial band were effective in improving the outcomes of revision ACL reconstruction. Further high-level studies could help to clarify which subgroup of patients could particularly benefit from an anterolateral procedure in the context of ACL revision.

Distribution of bone tunnel positions and treatment efficacy of bone landmark positioning method for anatomical reconstruction of the anterior cruciate ligament: a case control study

BackgroundThis study aimed to investigate the distribution of femoral tunnel and explore the influences of bone tunnel positions on knee functions. The bone landmark positioning method was used to position the femoral tunnel during the anatomical reconstruction surgery in patients with anterior cruciate ligament (ACL) rupture.MethodsData of patients who underwent anatomical reconstruction of the ACL between January 2015 and July 2018, were retrospectively analyzed. The distribution of the femoral tunnel was recorded on 3-D CT after surgery. The tunnel positions were classified into good and poor position groups based on whether the position was in the normal range (24–37% on the x-axis and 28–43% on the y-axis). The Lysholm and IKDC scores, KT-1000 side-to-side difference, pivot shift test and Lachman test results of the knee joints were recorded, and then the differences in knee joint functions between the two groups were analyzed.Results84 eligible patients (84 knees) were finally included in this study. Twenty-two and 62 of the patients were categorized in the good and poor position groups, respectively, and the rate of good position was 26.2%. The distribution of bone tunnel was as follows: (x-axis) deep position in 10 patients (12%), normal position in 58 patients (69%), and shallow position in 16 patients (19%); (y-axis) high position in 54 patients (64%), normal position in 26 patients (31%), and low position in 4 patients (5%). 1 year later, the Lysholm and IKDC scores were significantly better in the good position group (P < 0.05), the KT-1000 side to side difference, the pivot shift test and Lachman test results were better in the good position group (P < 0.05).ConclusionsThe bone tunnels were found to be distributed in and beyond the normal range using the bone landmark method to position the femoral tunnel in the single-bundle anatomical reconstruction of ACL, while the rate of good bone tunnel position was low. The knee joint function scores and stability were lower in patients with poor position of the femoral tunnel.

Untreated Injuries to the Anterolateral Capsular Structures Do Not Affect Outcomes and Kinematics after Anatomic Anterior Cruciate Ligament Reconstruction.

Injuries to the anterolateral complex (ALC) may contribute to increased rotatory knee laxity. However, it has not been evaluated whether such injuries affect in vivo kinematics when treated in situ. The purpose of this study was to determine the grade of ALC injury and its effect on kinematic and clinical outcomes of ACL-injured patients 24 months after anatomic ACL reconstruction. It was hypothesized that injury to the ALC would be significantly related to patient-reported outcomes (PROs) and in vivo knee kinematics during downhill running. Thirty-five subjects (mean age: 22.8 ± 8.5 years) participating in a randomized clinical trial to compare single- and double-bundle ACL reconstruction were included in the study. Subjects were divided into two groups based on the presence or absence of injury to the ALC, as determined on MRI scans performed within 6 weeks of injury. None of the patients underwent treatment for these ALC injuries. At 24 months, PROs, including the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS) and in vivo knee kinematics during downhill running, were obtained. Pivot-shift test results, PROs and in vivo knee kinematics were compared between groups with and without ALC injury using the Pearson's Chi Squared test and Mann-Whitney U test with significance set at p < 0.05. The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (49%) study participants. No significant differences were detected in PROs and in vivo kinematics between subjects with and without ALC injury (n.s.). The findings of this study demonstrate that MRI evidence of an ALC injury does not significantly affect in vivo knee kinematics and PROs even in individuals with a high-grade ALC injury. Injuries to the ALC as observed on MRI might not be a useful indication for an anterolateral procedure.

Tibial graft fixation in anterior cruciate ligament reconstruction: multiple tibial tunnel technique (collateral tunnel technique).

This study aimed to compare the outcomes of patients with an anterior cruciate ligament (ACL) rupture who underwent tibial fixation using the multiple tibial tunnel fixation (MTTF) and standard tibial fixation methods. This retrospective study was conducted between January 1, 2020, and August 1, 2021. MTTT was applied to 43 patients diagnosed with ACL rupture. Of the 43 patients who met the study criteria, 38 were classified as Group 1. In the clinic where the study was conducted, 40 of 57 patients who underwent standard ACL reconstruction by opening a single tibial tunnel were assigned to Group 2. The Endobutton technique was used for fixation of the graft to the femur in both groups. Bioabsorbable and postfix screws were used for the tibial fixation of the patients in Group 2. For patients in Group 1, a bioabsorbable screw, a postfix screw, and an additional MTTT fixation were performed for tibial fixation. Lachman, anterior drawer, Pivot-Shift test results, Lysholm and IKDC knee evaluation scores of the patients in both groups were compared. In this study, there was no significant difference between the groups for the anterior drawer, Lachman, and Pivot-Shift test results at the final control (p > 0.05). There was a significant difference between the two groups for the Lysholm and IKDC scores at the final controls (p < 0.05). There was a significant difference in the Lysholm and IKDC scores between the groups (p < 0.05). In conclusion, ACL reconstruction was performed using the MTTF technique in this study. Due to the additional fixation, it was observed that the patients had a more successful knee function after the surgery.

Low-Profile Modifications of the Losee Pivot Shift Test for Assessment of an ACL-Deficient Knee in the Awake Patient

Background: Pivot shift test results have demonstrated widely inconsistent sensitivities when used on awake clinic patients. We believe the painful valgus force applied during traditional pivot shift techniques is the primary culprit and can be circumvented with our novel examination technique. Indications: The reason for publishing this examination technique is to maximize the sensitivity and accuracy of the pivot shift examination in the awake patient. Technique Description: Four major modifications of Ronald Losee’s original valgus-based examination technique are introduced. These are the 4 general modifications: minimizing the sagittal plane arc of motion, avoiding applying valgus force to the knee, application of gentle anteriorly directed force to the lateral tibia, and performing the examination on the patient’s noninjured knee first. We also provide detailed description of the hand placement during the Albright-Losee pivot shift test. (1) Once the patient is relaxed, the examiner’s hands are placed as follows: (1) the ulnar side of the examiner’s thumb is applied to the posterior aspect of the fibular head. The fingers are placed above the patella on the distal femur as shown in the video. (2) With the examiner’s hands in the correct position, the knee is flexed to 20° to 30°. One-to-3 pounds of anterior translatory force is then applied by the side of the thumb to the fibular head while the knee is taken slowly toward extension. Pathological anterior tibial translation can be expected to begin in a 20° to 30° range short of the patient’s complete knee extension. The examiner must be conscious not to provide any valgus or additional internal or external rotation of the leg. Results: This examination is useful for reproducing the subluxation phenomenon in anterior cruciate ligament (ACL)-deficient knees. Our work has shown that these modifications yield an accuracy of 95.51% and a sensitivity of 94.7% in 353 knees examined by 71 clinicians. Discussion/Conclusion: The Albright-Losee pivot shift test is an easy to perform, highly sensitive, and highly specific test. In our recently submitted American Journal of Sports Medicine manuscript, the Albright-Losee pivot shift test suggested to be of greater value than Lachman test. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anterolateral ligament MRI of the knee in ACL injuries: MRI abnormalities association with instability.

To evaluate anterolateral ligament abnormalities (ALL) at MRI scans and correlate with data from clinical instability tests (Lachman and pivot shift) performed under anesthesia in patients with acute anterior cruciate ligament (ACL) tears. Furthermore, perform multivariate analysis with other variables to isolate the ALL contribution to instability from other abnormalities. Retrospective analysis of MRI and instability tests of 95 patients with ACL tears. The ALL was classified as no abnormality, abnormality without discontinuity, and discontinuity. Injuries in other knee ligament structures and menisci were also assessed. Results of instability tests (pivot shift and Lachman) with the patient anesthetized for arthroscopic ACL reconstruction were obtained from the patient database. Statistical analysis was performed using the IBM SPSS 22. ALL abnormalities and iliotibial band (ITB), lateral (LCL), and medial (MCL) collateral ligament injuries showed a statistically significant correlation with the pivot shift test. The ALL MRI abnormalities were associated with the high-grade pivot shift results (p < 0.0005), with an odds ratio of 55.9 for high degrees of pivot shift in patients with abnormal ALL. The logistic model for all variables analyzed with the results of the pivot shift test demonstrated that the ALL was the only variable with a statistically significant correlation in the model (p < 0.0005). MRI ALL abnormalities in patients with ACL injuries have a significant association with pivot shift test results in patients under anesthesia. The logistic model for high - grade pivot shift test results demonstrated that ALL abnormalities were the only variable with significant correlation. • Evaluating the anterolateral ligament with MRI in acute anterior cruciate ligament injuries is useful to predict higher grades of pivot shift test in the moment of the arthroscopic reconstruction. • An abnormal anterolateral ligament presented an odds ratio of 55 for high degrees of pivot shift. • ALL MRI abnormalities association with knee instability is independent from other internal knee injuries.

Outcomes of Combined Lateral Meniscus Posterior Root Repair and Anterior Cruciate Ligament Reconstruction.

Background:Lateral meniscus posterior root tears (LMPRTs) almost always occur in association with anterior cruciate ligament (ACL) tears. Their repair is advocated to restore the stabilizing and load-sharing functions of the meniscus.Purpose:To study the functional outcomes of combined arthroscopic repair of LMPRTs and ACL reconstruction (ACLR).Study Design:Case series; Level of evidence, 4.Methods:The authors evaluated patients who underwent simultaneous arthroscopic ACLR and LMPRT repair. All patients had chronic injuries, with a mean time since ACL rupture of 7.9 months. Patient characteristics, Lachman and pivot-shift test results, type of LMPRT, associated injuries, and surgery details were documented. Pre- and postoperative functional status was assessed using the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. An independent single-tunnel transtibial repair using 2 SutureTapes was performed for Forkel type 1 and 3 tear root avulsions, while side-to-side suture repair was performed for type 2 radial/oblique tears. The Wilcoxon signed rank test and minimal clinically important difference (MCID) of the IKDC score were used for statistical analysis.Results:Included were 25 patients with a mean age of 29.6 ± 6.5 years. Of these, 22 patients (88%; 95% CI, 73.1%-100%) had a high-grade (grade 2 or 3) preoperative pivot shift. Diagnosis of the LMPRT on magnetic resonance imaging (MRI) scans was possible only in 5 patients (20%). At final evaluation, performed at 37.4 ± 7.1 months postoperatively, all functional scores had improved significantly from preoperatively: IKDC score, from 47.6 ± 9.5 to 81.8 ± 11.5; KOOS, from 45.5 ± 10.9 to 86.5 ± 10.3, and Lysholm score, from 49.0 ± 11.5 to 88.8 ± 7.6 (P < .001 for all). Twenty-four patients (96%) achieved the MCID for the IKDC score. All knees had a negative pivot shift at final analysis, and no patient underwent revision ACLR or LMPRT repair.Conclusion:LMPRT repair combined with ACLR led to good short-term clinical outcomes in this study. An LMPRT may frequently go undetected on preoperative MRI scans, but a high-grade pivot shift is present in a large majority of these patients.

Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

Background:The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques.Purpose:To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique.Study Design:Systematic review; Level of evidence, 3.Methods:Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament.Results:Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman (P = .0005) and pivot-shift test (P = .0001) results, lower KT-1000 arthrometer maximum manual displacement (P = .00001), higher Lysholm score (P = .001), a higher incidence of IKDC grade A/B (P = .05), and better visual analog scale score for satisfaction (P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length (P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique.Conclusion:In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.

Effect of Tibial Tunnel Placement Using the Lateral Meniscus as a Landmark on Clinical Outcomes of Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: It remains unclear if use of the lateral meniscus anterior horn (LMAH) as a landmark will produce consistent tunnel positions in the anteroposterior (AP) distance across the tibial plateau. Purpose: To evaluate the AP location of anterior cruciate ligament (ACL) reconstruction tibial tunnels utilizing the LMAH as an intra-articular landmark and to examine how tunnel placement affects knee stability and clinical outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was conducted of 98 patients who underwent primary ACL reconstruction with quadrupled hamstring tendon autografts between March 2013 and June 2017. Patients with unilateral ACL injuries and a minimum follow-up of 2 years were included in the study. All guide pins for the tibial tunnel were placed using the posterior border of the LMAH as an intra-articular landmark. Guide pins were evaluated with the Bernard-Hertel grid in the femur and the Stäubli-Rauschning method in the tibia. Patients were divided by the radiographic location of the articular entry point of the guide pin with relation to the anterior 40% of the tibial plateau. Outcomes were evaluated by the Marx Activity Scale and International Knee Documentation Committee (IKDC) form. Anterior knee laxity was evaluated using a KT-1000 arthrometer and graded with the objective portion of the IKDC form. Rotational stability was evaluated using the pivot-shift test. Results: A total of 60 patients were available for follow-up at a mean 28.6 months. The overall percentage of AP placement of the tibial tunnel was 39.3% ± 3.8% (mean ± SD; range, 31%-47%). Side-to-side difference of anterior knee laxity was significantly lower in the anterior group than the posterior group (1.2 ± 1.1 mm vs 2.5 ± 1.3 mm; P < .001; r = 0.51). The percentage of AP placement of the tibial tunnel demonstrated a positive medium correlation with side-to-side difference of anterior knee laxity as measured by a KT-1000 arthrometer (r = 0.430; P < .001). The anterior group reported significantly better distribution of IKDC grading as compared with the posterior group (26 grade A and 6 grade B vs 15 grade A and 13 grade B; P = .043; V = 0.297). The pivot-shift test results and outcome scores showed no significant differences between the groups. Conclusion: Using the posterior border of the LMAH as an intraoperative landmark yields a wide range of tibial tunnel locations along the tibial plateau, with anterior placement of the tibial tunnel leading toward improved anterior knee stability.

An older age, a longer duration between injury and surgery, and positive pivot shift test results increase the prevalence of articular cartilage injury during ACL reconstruction in all three compartments of the knee in patients with ACL injuries.

To investigate factors that influence the prevalence of articular cartilage injury in patients with anterior cruciate ligament (ACL) injury. This multicentre study included patients with ACL injury. Logistic regression analysis was conducted to identify factors that influence the prevalence of cartilage injury during ACL reconstruction. A total of 811 patients were enrolled. The factors that significantly influenced the prevalence of cartilage injury were age (odds ratio [OR], 1.04; P = 0.000), a positive pivot shift test result (OR, 1.43; P = 0.021), medial meniscal injury (OR, 2.55; P = 0.000), and delayed surgery (≥ 12months) (OR, 2.52; P = 0.028) in the medial compartment of the knee; age (OR, 1.05; P = 0.000), subjective grades of apprehension during the pivot shift test (OR, 1.46; P = 0.010), lateral meniscal injury (OR, 1.98; P = 0.003), femoro-tibial angle (FTA) (OR, 0.92; P = 0.006), and delayed surgery (≥ 12months) (OR, 2.63; P = 0.001) in the lateral compartment; and age (OR, 1.06; P = 0.000), body mass index (OR, 1.07; P = 0.028), a positive pivot shift test result (OR, 1.60; P = 0.018), FTA (OR, 0.90; P = 0.006), and delayed surgery (≥ 12months) (OR, 3.17; P = 0.008) in the patellofemoral compartment. An older age, a longer duration between injury and surgery, and a positive pivot shift test result were positively associated with the prevalence of cartilage injury in three compartments in patients with ACL injuries. Early ACL reconstruction is recommended to prevent cartilage injury. Level III.

Outcomes After Isolated Acute Anterior Cruciate Ligament Reconstruction Are Inferior in Patients With an Associated Anterolateral Ligament Injury

Background: Isolated reconstruction of the anterior cruciate ligament (ACL) does not reestablish the normal knee biomechanics in cases of associated injuries to the anterolateral structures. Studies evaluating the potential clinical effect of anterolateral ligament (ALL) injury on the treatment of ACL injuries are necessary to validate the findings of biomechanical studies. Purpose: To evaluate the clinical outcomes and failure rate of ACL reconstruction in patients with and without ALL injury diagnosed using magnetic resonance imaging. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort of patients with acute ACL injury was divided into 2 groups based on the presence (ALL group) or absence (no-ALL group) of ALL injury on preoperative magnetic resonance imaging scans. Both groups underwent anatomic reconstruction of the ACL with autologous hamstring tendon grafts. The Lysholm and subjective IKDC scores (International Knee Documentation Committee), KT-1000 arthrometer and pivot-shift test results, reconstruction failure rate, incidence of contralateral ACL injury, presence of associated meniscal injury, and presence of knee hyperextension were evaluated. Results: A total of 182 patients were evaluated. Postoperative mean ± SD follow-up was 33.6 ± 7.1 and 36.1 ± 8.1 months for the ALL and no-ALL groups, respectively. No significant differences were found between the groups in terms of age, sex, knee hyperextension, duration of injury before reconstruction, follow-up time, or associated meniscal injuries. In the preoperative evaluation, the pivot-shift grade was similar, and the ALL group had worse KT-1000 arthrometer values (7.9 ± 1.2 mm vs 7.2 ± 1.1 mm; P < .001). In the postoperative evaluation, patients in the no-ALL group had a lower reconstruction failure rate (10.2% vs 1.4%; P = .029) and better clinical outcomes according to the IKDC subjective (85.5 ± 10.7 vs 89.1 ± 6.6; P = .035) and Lysholm scores (85.9 ± 10.1 vs 92.0 ± 6.3; P < .001). There was no postoperative difference in the KT-1000 or pivot-shift results. Conclusion: Combined ACL and ALL injuries were associated with significantly less favorable outcomes than were isolated ACL injuries at a minimum follow-up of 2 years after ACL reconstruction. Patients with concomitant ALL injury showed a higher rerupture rate and worse functional scores.

No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction.

The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement. During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1week and MRI 1.5years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B). Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups. No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements. II.

Superior Postoperative Stability and Functional Outcomes With Anteromedial Versus Transtibial Technique of Single-Bundle Autologous Hamstring Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Prospective Randomized Controlled Trials

The aim of this meta-analysis was to compare the postoperative stability and functional outcomes of anteromedial (AM)- and transtibial (TT)-based single-bundle hamstring anterior cruciate ligament (ACL) reconstruction techniques. A meta-analysis comparing the outcomes of single-bundle hamstring ACL reconstruction using the AM and TT techniques was performed. Prospective randomized controlled trials identified from searches of PubMed, Cochrane, and Embase were included in this review. The outcome measures analyzed included postoperative Lachman test and pivot-shift test results, side-to-side difference, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity score. A total of 7 randomized controlled trials (654 patients) were included in this review. The AM technique, compared with the TT technique, resulted in superior postoperative stability based on the negative Lachman test rate (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.01 to 1.24; P= .03; 95% prediction interval [PI], 0.32 to 3.46), negative pivot-shift test rate (RR, 1.16; 95% CI, 1.06 to 1.28; P= .002; 95% PI, 0.40 to 2.88), and side-to-side difference (weighted mean difference [WMD], -0.32 mm; 95% CI, -0.48 to -0.16; P < .0001; 95% PI, -0.55 to -0.09). Likewise, the AM technique contributed to superior postoperative functional outcomes based on the proportion of IKDC grade A findings (RR, 1.16; 95% CI, 1.02 to 1.32; P= .03; 95% PI, 0.40 to 2.83) and the Lysholm score (WMD, 0.82; 95% CI, 0.23 to 1.41; P= .007; 95% PI, -0.22 to 1.86). However, the AM and TT techniques had comparable subjective IKDC scores (WMD, 0.98; 95% CI, -0.91 to 2.88; P= .31; 95% PI, -3.18 to 5.14) and Tegner activity scores (WMD, 0.32; 95% CI, -0.23 to 0.86; P= .25; 95% PI, -3.84 to 4.48). The AM method of single-bundle hamstring ACL reconstruction results in superior postoperative stability and functional outcomes compared with the TT method. Level I, systematic review of Level I studies.

The long-term outcomes of different grafts in anterior cruciate ligament reconstruction: a network meta-analysis.

ObjectivesTo compare the long-term prognosis of patients with different types of grafts used in anterior cruciate ligament reconstruction (ACLR).MethodsPubMed, Ovid (MEDLINE and Embase) and the Cochrane library were searched up to Feb 2020. Eligible studies about different grafts in ACLR were searched for identifying the evidence comparing the long-term (mean or median follow-up time or the general description of the follow-up time≥2 years) knee outcomes of different grafts for ACLR. The final included articles and evaluation criteria were confirmed by the authors and senior clinicians to ensure the validity of the included articles. Lysholm score, the results of pivot shift test, Lachman test and International Knee Documentation Committee (IKDC) evaluation were selected as prognostic indicators. A Bayesian network meta-analysis was conducted.ResultsA total of 30 articles were included in our network meta-analysis. Finally, we found that artificial graft or augmentation can provide the not bad Lysholm score but the worse result of IKDC evaluation for patients with ACLR compared with other types of grafts. Double-bundle hamstring autograft can provide a good Lysholm score as well as lower positive rate of pivot shift test and Lachman test. Patellar tendon autograft can provide the better result of IKDC evaluation. The patients with allogeneic tendon graft may get the higher positive rate of pivot shift test and Lachman test. Patients with single-bundle hamstring autograft may get the ordinary result of IKDC evaluation and Lysholm score.ConclusionsDouble-bundle hamstring autograft may be a better choice because of more items of good prognosis for the patients with ACLR. Patellar tendon autograft is a right choice which only shows the disadvantage on the Lysholm score. The prognosis of patients with single-bundle hamstring autograft is ordinary. The effect of artificial graft or augmentation needs more evidence to prove. Allogeneic tendon graft is not a better choice when compared with other grafts referred in our network meta-analysis.Translational potential statementIn this study, we made a comprehensive comparison of the grafts commonly used in anterior cruciate ligament reconstruction. The evidence presented in this study provides a reference for clinicians to select a suitable anterior cruciate ligament graft.

The mechanical characteristics and early-stage clinical effects of double bundle anterior cruciate ligament reconstruction with femoral direct fiber insertion

Objective To investigate the finite element analysis and early-stage clinical effects of double bundle anterior cruciate ligament (ACL) reconstruction with femoral direct fiber insertion. Methods From June 2016 to June 2017, a total of 26 cases of ACL reconstruction were analyzed retrospectively, including 15 males and 11 females, mean age 30.5±4.6 years. All the patients underwent ACL reconstruction by the same operator. The early-stage clinical effects were evaluated by the finite element analysis, pivot shift test, Lachman test, preoperative and postoperative IKDC score, Lyshlom score, KT-2000, 3D-CT and MRI. Results The finite element analysis confirmed theoretically that the double bundle ACL reconstruction with femoral direct fiber insertion could restore the stability and biomechanics of knee effectively. The results of pivot shift test were negative, and the Lachman test were negative except one first-stage positive after operation. 3D-CT showed that the bone tunnel was located in the direct fiber area. MRI showed clearly the ACL of double bundle after operation. Lysholm score increased from 56.5±3.6 pre-operation to 61.9±3.2 at three months after operation, and up to 88.5±2.0 two years after operation with statistically significant difference (F=824.72, P<0.001). IKDC score increased from 48.3±2.8 before operation to 58.0±2.0 at three months after operation, and to 92.5±2.6 at two years after operation with statistically significant difference (F=2 256.66, P<0.001). KT-2000 side-side difference decreased from 5.6±0.7 mm to 1.6±0.5 mm at three months after operation, and to 1.5±0.6 mm at two years after operation with statistically significant difference (F=389.14, P<0.001). Conclusion The double bundle ACL reconstruction with femoral direct fiber insertion can effectively restore the stability and the biomechanical environment of knee joint with satisfied early-stage clinical effects. Key words: Anterior cruciate ligament; Reconstructive surgical procedures; Finite element analysis

Clinical Characteristics and Outcomes After Primary ACL Reconstruction and Meniscus Ramp Repair

Background:Satisfactory outcomes have been reported after all-inside meniscus ramp repair with combined anterior cruciate ligament reconstruction (ACLR). However, clinical outcomes after ACLR with inside-out meniscus ramp repair are limited.Purpose/Hypothesis:The purpose of this study was to evaluate patient-reported outcomes for patients who underwent ACLR and medial meniscus ramp repair compared with those who underwent isolated ACLR; patients in the 2 groups were matched for age, sex, and sport/activity. The null hypothesis was that there would be no significant differences in clinical outcomes between groups at a minimum of 2 years postoperatively.Study Design:Cohort study; Level of evidence 3.Methods:Patients who underwent primary ACLR with bone–patellar tendon–bone (BPTB) autograft by a single surgeon were retrospectively identified. A subgroup of patients with combined ACLR and meniscus ramp repair with a minimum 2-year postoperative follow-up were matched to a cohort who underwent isolated ACLR. Subjective patient-reported questionnaires, knee stability, and return to level of activity/sport were collected.Results:There were 851 patients who underwent primary ACLR; of these, 158 (18.6%) had medial meniscus ramp lesions confirmed at arthroscopy. The most common clinical characteristics in patients with ramp lesions were chronic injuries (68.4%), contact mechanism (88%), concomitant lateral meniscus tears (63.2%), and concomitant lateral meniscus posterior root tears (22.2%). Further, 50 patients who underwent combined ACLR and meniscus ramp repair with minimum 2-year follow-up were matched to patients who underwent isolated ACLR. Both groups reported significant improvements in subjective outcomes from preoperative to postoperative assessments (P < .001). No significant differences were found in postoperative outcomes for combined ACLR with ramp repair versus isolated ACLR (P > .05). Patients with meniscus ramp repair had increased preoperative knee laxity demonstrated by grade 3 Lachman (44% vs 6%) and pivot-shift (38% vs 12%) test results compared with patients who underwent isolated ACLR (P ≤ .005 for both).Conclusion:This study demonstrates similar clinical outcomes, knee stability on postoperative physical examination, and return-to-sport rates for patients who underwent combined ACLR with BPTB autograft and inside-out meniscus ramp repair versus a matched cohort who underwent isolated ACLR. Clinicians should have a high index of suspicion for the presence of ramp lesions in patients with ACL tears who have a contact mechanism of injury, grade 3 Lachman test result, and concomitant lateral meniscal abnormality.

Delayed or neglected meniscus tear repair and meniscectomy in addition to ACL reconstruction have similar clinical outcome.

To compare the clinical outcomes of meniscus repair and meniscus resection with concurrent anterior cruciate ligament (ACL) reconstruction in patients with ACL rupture and neglected or delayed medial meniscus tears. Thirty patients with ACL ruptures and unstable vertical longitudinal medial meniscus tears were included. Patients were divided into two groups. Group I included 15 patients who underwent meniscal repair and Group II included 15 patients who underwent meniscectomy. The knee range of motion, McMurray test, Lachman test, pivot shift test, Lysholm Knee Scoring Scale, International Knee Documentation Committee (IKDC) Questionnaire, Hospital for Special Surgery (HSS) Knee score, and Tegner activity (TA) scale were used to assess all patients. The median follow-up time was 3.6 (0.5-6.5) years. Median age was 28 (16-36) years. Fourteen patients (93.3%) in Group I and six patients (40%) in Group II returned to their preinjury sport activity level (P = .007). Median maximum knee flexion was 132° (121°-140°) in Group I and 134° (121°-139°) in Group II (n.s.). All patients had full knee extension and negative McMurray test results. Lachman and pivot shift test results were similar between groups. The median IKDC Questionnaire score was 99 (86-100) in Group I and 93 (70-100) in Group II (P = .016). The difference in Lysholm Knee Scoring Scale, HSS knee, and TA scale score between groups were not significant. Clinical outcomes of patients that underwent meniscus repair were better than those that underwent meniscus resection with concurrent ACL reconstruction. The technically complicated and costly meniscus repair may achieve better clinical outcomes than meniscectomy when treating a neglected or delayed meniscal tear with a concurrent ACL tear. III.

Oval femoral tunnel technique is superior to the conventional round femoral tunnel technique using the hamstring tendon in anatomical anterior cruciate ligament reconstruction.

This study was conducted to compare the efficacy between the oval femoral tunnel technique and the conventional round femoral tunnel technique in ACL reconstruction using an autologous hamstring tendon on the basis of the postoperative clinical outcomes and ACL graft tendon maturity. The hypothesis was that ACL reconstruction performed using the oval femoral tunnel technique was better than that performed using the round femoral tunnel technique in clinical functions and graft maturity. One hundred and eight patients who underwent anatomical single-bundle ACL reconstruction were included in this study and the follow-up period was at least 2years. Thirty-nine patients admitted between February and August in 2016 were included in the oval femoral tunnel group and 69 patients admitted between September 2016 and March 2017 were included in the round femoral tunnel group. The Lachman test result, pivot-shift test result, Lysholm score, IKDC score, and VAS score were used for the clinical evaluation. An objective assessment of anteroposterior stability was performed using a KT1000 arthrometer. Postoperative MRI was conducted to compare the ACL graft maturity differences between the oval femoral tunnel group and round femoral tunnel group, where the signal/noise quotient (SNQ) was calculated. In addition, second-look arthroscopy was conducted to compare the graft status and synovial coverage at 24months postoperatively. All the patients presented with significant improvement in all clinical scores from the preoperative period to the 24-month follow-up. During the postoperative follow-up period, no statistically significant differences were found between the two groups in terms of the VAS score, knee ROM, Lachman test results, and graft status determined in the second-look arthroscopic evaluation. The Lysholm score was 97.1 ± 3.9 and 94.8 ± 5.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the 24-month follow-up (p = 0.031). The IKDC subjective score was 92.0 ± 2.6 and 89.0 ± 3.6 in the oval femoral tunnel group and round femoral tunnel group, respectively, at the end of the follow-up period (p < 0.001). Significantly more patients with 1-degree positive pivot-shift test results were observed in the round femoral tunnel group (10/65) than in the oval femoral tunnel group (1/37) at the end of the follow-up period (p = 0.048). The mean SNQ of the oval femoral tunnel group was 2.7 ± 0.9, which was significantly lower than that of the round femoral tunnel group (3.6 ± 1.1) at the 24-month postoperative follow-up (p < 0.001). Based on the clinical evaluations, MRI findings and second-look arthroscopy results of the two groups, the oval femoral tunnel technique yielded significantly better knee function and knee laxity restoration and more mature ACL grafts than the round femoral tunnel technique, whereas no significant differences were found at the second-look arthroscopy. III.