Previous Anterior Cruciate Ligament Research Articles

Meniscal allograft transplantation: A matched-pair analysis reveals worse sport activity level but similar clinical improvement and survival in women compared to men.

The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT). A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches. Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences. While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT. Level III, comparative study.

Knee Biomechanics During Cutting Maneuvers and Secondary ACL Injury Risk: A Prospective Cohort Study of Knee Biomechanics in 756 Female Elite Handball and Soccer Players.

An athlete who returns to sport after an anterior cruciate ligament (ACL) injury has a substantially high risk of sustaining a new secondary ACL injury. Because ACL injuries most frequently occur during cutting maneuvers, such movements should be at the center of research attention. To investigate whether knee biomechanical parameters during side-step cutting maneuvers differ between female elite athletes with and without a history of ACL injury and to evaluate whether such parameters are associated with future secondary ACL injury. Cohort study; Level of evidence, 2. A total of 756 female elite handball and soccer players, of whom 76 had a history of ACL injury, performed a sport-specific cutting task while 3-dimensional kinematics and kinetics were measured. ACL injuries were registered prospectively over an 8-year follow-up period. Seven knee-specific biomechanical variables were the basis for all analyses. Two-way analyses of variance were applied to assess group differences, whereas logistic regression models served to evaluate associations between the knee-specific variables and future secondary ACL injury. When players with a previous ACL injury performed the cutting maneuver with their ipsilateral leg, they exhibited lower knee abduction angles (mean difference [MD], 1.4°-1.5°; 95% CI, 0.2°-2.9°), lower peak knee flexion moments (MD, 0.33 N·m/kg-1; 95% CI, 0.18-0.48 N·m/kg-1), lower peak knee abduction moments (MD, 0.27 N·m/kg-1; 95% CI, 0.12-0.41 N·m/kg-1), and lower peak knee internal rotation moments (MD, 0.06 N·m/kg-1; 95% CI, 0.01-0.12 N·m/kg-1) compared with injury-free players. When players performed the cut with their contralateral leg, no differences were evident (P < .05). None of the 7 knee-specific biomechanical variables was associated with future secondary ACL injury in players with an ACL injury history (P < .05). Approximately 4 years after ACL injury, female elite team-ball athletes still unloaded their ipsilateral knee during cutting maneuvers, yet contralateral knee loading was similar to that of injury-free players. Knee biomechanical characteristics were not associated with future secondary ACL injury.

Relationship between Anterior Cruciate Ligament Injury and Subtalar Pronation in Female Basketball Players: Case-Control Study.

Anterior cruciate ligament (ACL) injuries are a common issue in basketball. Several studies point to subtalar pronation as a relevant risk factor for these injuries, despite their multiarticular and multiplanar nature. This study evaluated the correlation between subtalar pronation and ACL injuries in female basketball players. A total of 30 players were recruited and divided into two groups: 15 with previous ACL injury and 15 without injury. The navicular drop test (NDT) and drop vertical jump test were applied to quantify parameters such as navicular drop, calcaneal eversion, ankle dorsiflexion, knee flexion, and dynamic valgus. The results showed significantly higher NDT values (6.93 ± 1.64 mm vs. 5.41 ± 1.96 mm, p = 0.029) and maximum calcaneal eversion angle (10.94 ± 3.22° vs. 5.30 ± 3.33°, p < 0.001) in the injured group. There were also significant differences in maximum dynamic valgus (152.73 ± 15.00° vs. 165.26 ± 5.628°, p = 0.005) and knee flexion (93.70 ± 7.47° vs. 82.92 ± 11.14°, p = 0.004) between groups. These findings suggest that subtalar pronation, assessed by NDT, and calcaneal eversion could be indicators of higher susceptibility to ACL injuries in female basketball players.

Previous anterior cruciate ligament reconstruction influences the complication rate of total knee arthroplasty: a systematic review and meta-analysis

Purpose The results of total knee arthroplasty (TKA) following anterior cruciate ligament (ACL) reconstruction are still under-investigated. The purpose of this research is to investigate the differences between TKA after ACL reconstruction and TKA for primary osteoarthritis through a review and meta-analysis of the literature. Methods Case–control and cohort studies reporting outcomes of TKA following ACL reconstruction were considered eligible for inclusion. The primary endpoint was to systematically review and meta-analyze the reported complications of TKA following ACL reconstruction. The outcomes have been compared with a group of patients who underwent TKA for primary knee osteoarthritis (OA) with any previous ACL surgery. Secondary endpoints were to assess and compare technical difficulties and results including the operative time, the use of revision components, the request for intraoperative release or additional procedures, the revision rate, and the clinical outcomes. Results Seven studies were included involving 1645 participants, 619 of whom underwent TKA in previous ACL reconstruction and 1026 TKA for primary OA with no previous ACL reconstruction. Meta-analysis showed that TKA in previous ACL reconstruction had a significantly higher complication rate (OR = 2.15, P &lt; 0.001), longer operative times (mean differences (MD): 11.19 min; P &lt; 0.001) and increased use of revision components (OR = 2.16; P &lt; 0.001) when compared to the control group without differences of infection, and revision rate. Conclusions TKA in a previous ACL reconstruction has a significantly higher complication rate, longer operative times, and a higher need for revision components and intraoperative soft tissue releases in comparison to TKA for primary OA without previous ACL reconstruction.

Identification of genetic variants associated with anterior cruciate ligament rupture and AKC standard coat color in the Labrador Retriever

Canine anterior cruciate ligament (ACL) rupture is a common complex disease. Prevalence of ACL rupture is breed dependent. In an epidemiological study, yellow coat color was associated with increased risk of ACL rupture in the Labrador Retriever. ACL rupture risk variants may be linked to coat color through genetic selection or through linkage with coat color genes. To investigate these associations, Labrador Retrievers were phenotyped as ACL rupture case or controls and for coat color and were single nucleotide polymorphism (SNP) genotyped. After filtering, ~ 697 K SNPs were analyzed using GEMMA and mvBIMBAM for multivariate association. Functional annotation clustering analysis with DAVID was performed on candidate genes. A large 8 Mb region on chromosome 5 that included ACSF3, as well as 32 additional SNPs, met genome-wide significance at P < 6.07E-7 or Log10(BF) = 3.0 for GEMMA and mvBIMBAM, respectively. On chromosome 23, SNPs were located within or near PCCB and MSL2. On chromosome 30, a SNP was located within IGDCC3. SNPs associated with coat color were also located within ADAM9, FAM109B, SULT1C4, RTDR1, BCR, and RGS7. DZIP1L was associated with ACL rupture. Several significant SNPs on chromosomes 2, 3, 7, 24, and 26 were located within uncharacterized regions or long non-coding RNA sequences. This study validates associations with the previous ACL rupture candidate genes ACSF3 and DZIP1L and identifies novel candidate genes. These variants could act as targets for treatment or as factors in disease prediction modeling. The study highlighted the importance of regulatory SNPs in the disease, as several significant SNPs were located within non-coding regions.

Anterior cruciate ligament injury occurrence, return to sport and subsequent injury in the Australian High Performance Sports System: A 5-year retrospective analysis

ObjectivesTo report anterior cruciate ligament (ACL) injury occurrence, return to sport (RTS) timeframes and ACL subsequent injuries recorded in the Australian High Performance Sports System according to athlete sex. MethodsACL injury data of injured athletes were prospectively collected by the treating sports and exercise physicians and physiotherapists within the Australian High Performance Sports System between January 1, 2015 and May 31, 2020. RTS time frames for ACL injuries and the proportion of subsequent ACL injuries were calculated. The RTS time was compared between sexes, age groups and ACL injury categories using the Mann-Whitney U test and the Kruskal-Wallis test. ResultsA total of 132 ACL injuries were reported in 108 athletes (77 female, 31 male). ACL injuries accounted for 6.4% of all reported knee injuries, with almost half (48.5%) of the ACL injuries reported to occur during training. Median RTS time was 369 days (IQR = 273–487), with RTS times reducing with increasing age (X2 (Zbrojkiewicz et al., 2018) = 11.781, p = 0.008). The presence of concurrent knee pathology did not significantly affect the RTS timeframes. ACL injuries were most frequently reported in netball, winter sports, basketball, field hockey and gymnastics. One quarter of the ACL reported (n = 34, 25.8%) were subsequent to a prior ACL injury, with the majority of these injuries occurring to the ipsilateral knee (n = 26) as opposed to contralateral knee (n = 6). ConclusionsDespite ACL injuries accounting for a small proportion of all knee injuries reported in the Australian High Performance Sports System, more than a quarter are subsequent to a previous ACL injury. Shorter RTS times were observed in older athletes; however, considerable periods of time-loss occur as a consequence of ACL injuries. Effective primary prevention, rehabilitation processes, and ongoing tertiary prevention strategies are warranted in this population.

The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury.

The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. III.

Lateral Extra-Articular Tenodesis in Skeletally Immature Patients: The Modified Ellison Technique

Background: Anterior cruciate ligament (ACL) rupture is an increasingly common injury in the young population. Unfortunately, reinjury rates in this population following ACL reconstruction (ACLR) are also very high. As such, lateral extra-articular procedures have been proposed to augment ACLR and shown to reduce reinjury rates. Most techniques use a strip of iliotibial band (ITB) fixed proximally on the distal femur in close proximity to the lateral femoral epicondyle, which in the skeletally immature patient may be closely associated with the distal femoral physis. In addition, there is also a risk of convergence with the femoral tunnel for the ACLR. The modified Ellison technique avoids both of these risks given it is a distally based tenodesis with its fixation point on the proximal tibial epiphysis. The purpose of this video is to describe a modified Ellison technique in a skeletally immature patient. Indications: Primary ACLR in skeletally immature patients at high risk of ACL graft rerupture due to their young age, a positive family history of ACL rupture in a first-degree relative, previous contra-lateral ACL rupture, generalized joint hypermobility, high-grade pivot-shift test, and participating in pivoting sports. Technique Description: The modified Ellison technique is a distally based lateral extra-articular procedure. A 1-cm strip of ITB is detached from Gerdy’s tubercle, passed beneath the lateral collateral ligament, and reattached back to from where it was removed. The fixation is within the proximal epiphysis of the tibia. Results: In a high-risk adult population, the modified Ellison technique has been shown to have a low ACL graft reinjury rate at 2 years following an ACLR. Biomechanical studies have demonstrated that a modified Ellison technique closely restores native knee kinematics following simulated anterolateral complex injury. Discussion/Conclusion: The modified Ellison technique is a safe and reproducible lateral extra-articular procedure in skeletally immature patients when performed in combination with an ACLR. Patient Consent Disclosure Statement: 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.

Effect of Anterior Tibial Closing Wedge Osteotomy on Coronal Tibial Alignment in Relation to Preoperative Medial Proximal Tibial Angle and Wedge Height.

The posterior tibial slope has been identified as an anatomic risk factor for anterior cruciate ligament insufficiency and reruptures after anterior cruciate ligament reconstruction. Anterior tibial closing wedge osteotomy for correction of sagittal plane deformities has the potential to cause an unintended change in coronal plane alignment. To evaluate the effects of anterior tibial closing wedge osteotomies for correction of posterior tibial slope on coronal plane alignment using an infratuberosity surgical approach and to identify predictive factors for a change in medial proximal tibial angle (MPTA). Case series; Level of evidence, 4. This study reports on retrospectively obtained data from radiographic measurements of 38 anterior tibial closing wedge osteotomies. All patients underwent revision anterior cruciate ligament reconstruction and had undergone ≥1 previous anterior cruciate ligament reconstruction. In all patients, an infratuberosity approach was used with angular stable plate fixation. Pre- and postoperative radiographs were examined retrospectively to detect changes in the sagittal and coronal plane alignment (posterior tibial slope and MPTA). A multivariate regression analysis was used to identify predictors for a change in MPTA. The study group consisted of 14 women and 24 men whose mean ± SD age at the index procedure was 31.6 ± 8.7 years (range, 17-51 years). Posterior tibial slope decreased significantly (by 7.2° ± 2.3°; P < .001) from 14.6° ± 2.0° preoperatively to 7.4° ± 2.1° postoperatively. MPTA decreased significantly by 1.3° ± 1.5° (P = .005) from pre- to postoperative measurement. Mean wedge height was 9.3 ± 1.1 mm. A lower preoperative MPTA (coefficient = 0.32; P = .017; 95% CI, 0.06-0.59) and larger wedge height (coefficient = 0.48; P = .029; 95% CI, 0.05-0.9) were significant predictive factors for a decrease in MPTA. Anterior tibial closing wedge osteotomy for posterior tibial slope reduction resulted in a slight but significant decrease of the MPTA in the coronal plane. These changes were dependent on the preoperative MPTA and the wedge height.

Comparison of survival rates between total knee arthroplasty after a previous anterior cruciate ligament reconstruction and primary total knee arthroplasty via propensity score matching.

Although the survival rate of total knee arthroplasty (TKA) in patients treated with anterior cruciate ligament reconstruction (ACLR) is not as favorable as that in patients treated with primary TKA without ligament reconstruction, the exact survival rates and complications associated with these procedures are still controversial. Therefore, the purpose of the current study was to compare the revision rates of TKA in patients with knee osteoarthritis (OA) with a previous ACLR and those of patients with primary TKA with no history of knee surgery by using propensity score matching analysis. A list of patients who underwent TKA from January 1, 2008 to May 31, 2019 was obtained from the Korean National Health Insurance database. Among these, 460 patients underwent TKA in a knee with a previous ACLR and 569,766 patients who underwent primary TKA due to degenerative OA. We performed propensity scoring matching to compare the revision rates including septic revision due to prosthetic joint infection after TKA and perioperative complication rates within 90days after revision TKA between the two groups. Matched patients were assigned to one of the two groups (group A: 2,201 patients who underwent TKA due to primary OA, group B: 448 patients who underwent TKA in a knee with a previous ACLR) based on the propensity score. The total number of revisions per 1000 person-years was significantly higher in group B than in group A (10.16 vs 4.66, respectively). Group B showed a higher risk of revision than group A at 10years post-TKA (hazard ratio: 2.49, 95% confidence interval: 1.30-4.77). However, group B showed a similar risk of septic revision as group A (p = 0.44). Perioperative complications within 90days after TKA showed no significant differences between the groups. Surgeons should be aware of the relatively higher revision rate of TKA in patients who had previously undergone an ACLR compared to that in patients who underwent primary TKA.

Automatic segmentation of human knee anatomy by a convolutional neural network applying a 3D MRI protocol

BackgroundTo study deep learning segmentation of knee anatomy with 13 anatomical classes by using a magnetic resonance (MR) protocol of four three-dimensional (3D) pulse sequences, and evaluate possible clinical usefulness.MethodsThe sample selection involved 40 healthy right knee volumes from adult participants. Further, a recently injured single left knee with previous known ACL reconstruction was included as a test subject. The MR protocol consisted of the following 3D pulse sequences: T1 TSE, PD TSE, PD FS TSE, and Angio GE. The DenseVNet neural network was considered for these experiments. Five input combinations of sequences (i) T1, (ii) T1 and FS, (iii) PD and FS, (iv) T1, PD, and FS and (v) T1, PD, FS and Angio were trained using the deep learning algorithm. The Dice similarity coefficient (DSC), Jaccard index and Hausdorff were used to compare the performance of the networks.ResultsCombining all sequences collectively performed significantly better than other alternatives. The following DSCs (±standard deviation) were obtained for the test dataset: Bone medulla 0.997 (±0.002), PCL 0.973 (±0.015), ACL 0.964 (±0.022), muscle 0.998 (±0.001), cartilage 0.966 (±0.018), bone cortex 0.980 (±0.010), arteries 0.943 (±0.038), collateral ligaments 0.919 (± 0.069), tendons 0.982 (±0.005), meniscus 0.955 (±0.032), adipose tissue 0.998 (±0.001), veins 0.980 (±0.010) and nerves 0.921 (±0.071). The deep learning network correctly identified the anterior cruciate ligament (ACL) tear of the left knee, thus indicating a future aid to orthopaedics.ConclusionsThe convolutional neural network proves highly capable of correctly labeling all anatomical structures of the knee joint when applied to 3D MR sequences. We have demonstrated that this deep learning model is capable of automatized segmentation that may give 3D models and discover pathology. Both useful for a preoperative evaluation.

The posterior cruciate ligament-posterior femoral cortex angle: a reliable and accurate MRI method to quantify the buckling phenomenon of the PCL in ACL-deficient knees.

The aim was to validate a new MRI method to measure the buckling phenomenon of the PCL, representative of anterior tibial translation, by comparing its reliability and accuracy to identify anterior cruciate ligament (ACL)-deficient knees with existing methods. Patients were selected retrospectively and separated into a group of primary ACL injuries and ACL-intact knees. Exclusion criteria were: skeletal immaturity, PCL or a concomitant collateral ligament injury, signs of osteoarthritis (> 1 Kellgren and Lawrence score), tibial plateau fracture, previous ACL reconstruction or displaced meniscal bucket handle tear. The assessment of the curvature of the anterolateral bundle of the PCL was performed on T2 sagittal MRI slices according to 3 methods: (1) the PCL angle (PCLA), (2) the PCL inclination angle (PCLIA) and (3) a new method: the PCL-posterior cortex angle (PCL-PCA), representing the angle between the vertical part of the PCL-ALB and the posterior diaphyseal cortex of the femur. For each method, the inter- and intra-observer reliability was measured. The ability to discriminate both ACL-deficient and ACL-intact knees was evaluated using ROC curves. Twenty-four patients were included in each group. Intra-observer reliability was excellent for all 3 methods (ICCs > 0.90). Inter-observer reliability was excellent for the PCL-PCA (ICC > 0.90) and good for the PCLA and the PCLIA (ICCs between 0.75 and 0.90). The PCL-PCA had the highest precision (lowest standard error of measurement: 2.7°). It yielded an excellent discrimination between the ACL and CTL groups (AUC 0.80 [0.67-0.93]) with the highest sensitivity (71% [52.8-89.2]) and specificity (88% [75-100]) for a positive threshold when the angle was ≤ 22.7°. The PCLA and PCLIA methods led to acceptable discrimination and lower sensitivities and specificities (PCLA: AUC 0.71, sensitivity 63%, specificity 79%, threshold ≤ 117.9°; PCLIA: AUC 0.62, sensitivity 50%, specificity 83%, threshold ≤ 21.4°). In comparison with previously described methods, the PCL-PCA was the most reliable and accurate method to measure the PCL buckling phenomenon on MRI in anterior cruciate ligament (ACL)-deficient knees. It offers an easy and objective method for the follow-up of ACL-injured patients and can therefore be recommended for routine use. IV.

Evaluating the diagnostic pathway for acute ACL injuries in trauma centres: a systematic review

ObjectiveThis review sought to evaluate the literature on the initial assessment and diagnostic pathway for patients with a suspected Anterior Cruciate Ligament (ACL) tear.MethodsMEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies, PRISMA guidelines were followed. Studies were included if they used at least one assessment method to assess for ACL injury and participants were assessed at an acute trauma centre within 6-weeks of injury. Article quality was evaluated using the QUADAS-2 checklist.ResultsA total of 353 studies were assessed for eligibility, 347 were excluded for the following reasons: injuries were not assessed in an acute trauma setting, injuries were not acute, participants had previous ACL injuries or chronic joint deformities affecting the knee, participants were under 18, or participants included animals or cadavers. A total of six studies were included in the review. Common assessment methods included: laxity tests, joint effusion, inability to continue activity, and a history of a ‘pop’ and ‘giving way’ at the time of injury. Diagnostic accuracy varied greatly between the assessment method and the assessing clinician. Gold standard diagnostics were MRI and arthroscopy. A weighted meta-mean calculated the time to reach diagnosis to be 68.60 days [CI 23.94, 113.24]. The mean number of appointments to reach diagnosis varied from 2–5. Delay to surgery or surgical consultation ranged from 61 to 328 days.ConclusionClinicians in the Emergency Department are not proficient in performing the assessment methods that are used for diagnosis in acute ACL injury. Reliance on specialist assessments or radiological methods inevitably increases the time to reach a diagnosis, which has repercussions on management options. There is an ever-growing demand to improve diagnostic accuracy and efficiency; further exploration into quantitative measures of instability would aid the assessment of peripheral joint assessment.

Is There an Association in Young Patients Between Quadriceps or Hamstring Strength After ACL Reconstruction and Graft Rupture?

Background:Younger patients who sustain anterior cruciate ligament (ACL) ruptures are at high risk for reinjury after ACL reconstruction. Restoring muscle strength before return to sports (RTS) is regarded as an important factor in reducing the reinjury risk, and quadriceps and hamstring strength assessment is commonly included in RTS testing. However, it is not clear whether reduced strength is a risk factor for subsequent graft rupture in this patient population.Purpose:To investigate the association between quadriceps and hamstring strength at 12 months after primary ACL reconstruction and ACL graft rupture in young patients.Study Design:Case-control study; Level of evidence, 3.Methods:The cohort consisted of 210 patients (100 men and 110 women) who were younger than 20 years at the time of primary ACL reconstruction with a hamstring tendon autograft and who had no previous contralateral ACL injury. Isokinetic strength testing (60 and 180 deg/s) of knee flexors and extensors was performed at 12 months postoperatively, and the limb symmetry index (LSI) for each strength outcome was calculated. RTS rates and the incidence of further ACL graft ruptures were recorded.Results:Measures of central tendency (mean and median) of LSI values ranged from 88 to 98. The percentage of patients with LSI ≥90 was 57% to 69% for quadriceps strength and 45% to 47% for hamstring strength. Overall, 19 patients (9%) sustained an ACL graft rupture. No significant differences were found between the patients who sustained an ACL graft rupture and those who did not in terms of quadriceps and hamstring strength at 12 months. No significant associations were found between achieving LSI ≥90 for quadriceps peak torque and subsequent ACL graft rupture.Conclusion:In young patients who underwent an ACL reconstruction, no association was noted between quadriceps and hamstring strength at 12 months postoperatively and subsequent graft ruptures. The role of strength testing as part of the RTS criteria after ACL reconstruction, and specifically the use of limb symmetry thresholds, warrants further investigation and clarification.

3D CAIPIRINHA SPACE versus standard 2D TSE for routine knee MRI: a large-scale interchangeability study.

To perform a large-scale interchangeability study comparing 3D controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA) sampling perfection with application optimized contrast using different flip angle evolutions (SPACE) TSE with standard 2D TSE for knee MRI. In this prospective study, 250 patients underwent 3 T knee MRI, including a multicontrast 3D CAIPIRINHA SPACE TSE (9:26 min) and a standard 2D TSE protocol (12:14 min). Thirty-three (13%) patients had previous anterior cruciate ligament and/or meniscus surgery. Two radiologists assessed MRIs for image quality and identified pathologies of menisci, ligaments, and cartilage by using a 4-point Likert scale according to the level of diagnostic confidence. Interchangeability of the protocols was tested under the same-reader scenario using a bootstrap percentile confidence interval. Interreader reliability and intermethod concordance were also evaluated. Despite higher image quality and diagnostic confidence for standard 2D TSE compared to 3D CAIPIRINHA SPACE TSE, the protocols were found interchangeable for diagnosing knee abnormalities, except for patellar (6.8% difference; 95% CI: 4.0, 9.6) and trochlear (3.6% difference; 95% CI: 0.8, 6.6) cartilage defects. The interreader reliability was substantial to almost perfect for 2D and 3D MRI (range κ, 0.785-1 and κ, 0.725-0.964, respectively). Intermethod concordance was almost perfect for all diagnoses (range κ, 0.817-0.986). Multicontrast 3D CAIPIRINHA SPACE TSE and standard 2D TSE protocols perform interchangeably for diagnosing knee abnormalities, except for patellofemoral cartilage defects. Despite the radiologist's preference for 2D TSE imaging, a pursuit towards time-saving 3D TSE knee MRI is justified for routine practice. • Multicontrast 3D CAIPIRINHA SPACE and standard 2D TSE protocols perform interchangeably for diagnosing knee abnormalities, except for patellofemoral cartilage defects. • Radiologists are more confident in diagnosing knee abnormalities on 2D TSE than on 3D CAIPIRINHA SPACE TSE MRI. • Despite the radiologist's preference for 2D TSE, a pursuit towards accelerated 3D TSE knee MRI is justified for routine practice.

ACL Reconstruction Patients Have Increased Risk of Knee Arthroplasty at 15 Years of Follow-up: Data from the Norwegian Knee Ligament Register and the Norwegian Arthroplasty Register from 2004 to 2020.

Background:Anterior cruciate ligament (ACL) injury is considered a risk factor for osteoarthritis. The primary aim of the present study was to investigate the cumulative risk of, and risk factors associated with, a subsequent knee arthroplasty after an ACL reconstruction at up to 15 years of follow-up. The secondary aim was to compare the relative risk of knee arthroplasty after ACL reconstruction compared with that in the general population.Methods:Data were analyzed by combining data from 2 national registries, the Norwegian Knee Ligament Register and the Norwegian Arthroplasty Register. The cumulative risk of knee arthroplasty after undergoing ACL reconstruction was calculated as 1 minus the corresponding Kaplan-Meier estimate, and possible risk factors for knee arthroplasty after ACL reconstruction were assessed in a Cox regression model with hazard ratios (HRs) as estimated effect measurements. The relative risk of knee arthroplasty for patients managed with ACL reconstruction as compared with that in the general population was calculated in stratified age groups.Results:From the study population of 27,122 knees, 115 knees underwent knee arthroplasty. We found a 1.1% (95% confidence interval [CI], 0.9 to 1.4) cumulative risk of knee arthroplasty 15 years after ACL reconstruction. Deep cartilage injury, ICRS (International Cartilage Repair Society) grade 3 to 4 (HR, 4.8; 95% CI, 3.1 to 7.6), revision of the ACL (HR, 3.9; 95% CI, 2.2 to 7.1), and a 2-year postoperative KOOS Sport/Recreation subscore of <44 (HR, 3.1; 95% CI, 1.5 to 6.2) were important risk factors for knee arthroplasty. We found a higher risk of knee arthroplasty at the age of 30 to 39 years after a previous ACL reconstruction as compared with the general population (relative risk, 3.3; 95% CI, 1.6 to 6.7).Conclusions:Fifteen years after an ACL reconstruction, the overall cumulative risk of knee arthroplasty was 1.1%. Cartilage injury at the time of ACL reconstruction, revision ACL reconstruction, and a KOOS Sport/Recreation subscore of <44 (at 2 years postoperatively) were major risk factors for subsequent knee arthroplasty. We found a 3.3-times higher risk of knee arthroplasty at the age of 30 to 39 years after a previous ACL reconstruction as compared with that in the general population.Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparative study between quadriceps tendon sling and semitendinosus graft for medial patellofemoral ligament reconstruction

Background Acute patellar dislocation is a common knee injury. The main injured structure is the medial patellofemoral ligament (MPFL). This ligament is the main static stabilizer against lateral patellar dislocation. Many surgical techniques have been described for the management of MPFL tear. The gold standard graft used for reconstruction is the hamstring. This study was done to compare the results of quadriceps tendon sling with semitendinosus graft for MPFL reconstruction (MPFLR). Patients and methods A prospective comparative study was held on 62 patients in El-Hadra University hospital between March 2018 and November 2019. Patients were divided into two groups. Group A had quadriceps graft and group B had semitendinosus graft for MPFLR. Patients were matched for age, sex, and body mass index. All cases were assessed clinically and functionally over 12 months of follow-up. Results There was no statistically significant difference between the 2 groups regarding Lysholm, Tegner, International Knee Documentation Committee, Visual Analog Scale, and Kujala scores. However, there was a statistically significant difference regarding the SCAR score. Conclusion Quadriceps tendon sling is a reliable alternative for MPFLR, especially in patients with small patellae or previous anterior cruciate ligament reconstruction.

Graft Selection in Contemporary Anterior Cruciate Ligament Reconstruction

In the last decade, there have been significant advances in our understanding of anterior cruciate ligament (ACL) reconstruction. Recent prospective cohort studies have identified risk factors for ACL reconstruction graft failure such as younger patient age, increased activity level, nonanatomic tunnel placement, and the use of allograft. Among these, the most easily modifiable risk factor is graft choice. Given that the surgeon's recommendation has been shown to be one of the most important factors behind patients' graft choice, it is critical that the operating surgeon have a thorough understanding of all the ACL graft options available to choose the graft that would be most suitable for the patient's personalized reconstruction (i.e., patient's anatomy, sport, level of competition, age, risk factors for failure, and graft used in previous ACL surgery). The purpose of this review is to provide an up-to-date understanding of the current ACL graft reconstruction options. The indications, advantages, and disadvantages of the different ACL reconstruction graft options available will be discussed.

A Prediction Model for Primary Anterior Cruciate Ligament Injury Using Artificial Intelligence.

Background:Supervised machine learning models in artificial intelligence (AI) have been increasingly used to predict different types of events. However, their use in orthopaedic surgery has been limited.Hypothesis:It was hypothesized that supervised learning techniques could be used to build a mathematical model to predict primary anterior cruciate ligament (ACL) injuries using a set of morphological features of the knee.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Included were 50 adults who had undergone primary ACL reconstruction between 2008 and 2015. All patients were between 18 and 40 years of age at the time of surgery. Patients with a previous ACL injury, multiligament knee injury, previous ACL reconstruction, history of ACL revision surgery, complete meniscectomy, infection, missing data, and associated fracture were excluded. We also identified 50 sex-matched controls who had not sustained an ACL injury. For all participants, we used the preoperative magnetic resonance images to measure the anteroposterior lengths of the medial and lateral tibial plateaus as well as the lateral and medial bone slope (LBS and MBS), lateral and medial meniscal height (LMH and MMH), and lateral and medial meniscal slope (LMS and MMS). The AI predictor was created using Matlab R2019b. A Gaussian naïve Bayes model was selected to create the predictor.Results:Patients in the ACL injury group had a significantly increased posterior LBS (7.0° ± 4.7° vs 3.9° ± 5.4°; P = .008) and LMS (–1.7° ± 4.8° vs –4.0° ± 4.2°; P = .002) and a lower MMH (5.5 ± 0.1 vs 6.1 ± 0.1 mm; P = .006) and LMH (6.9 ± 0.1 vs 7.6 ± 0.1 mm; P = .001). The AI model selected LBS and MBS as the best possible predictive combination, achieving 70% validation accuracy and 92% testing accuracy.Conclusion:A prediction model for primary ACL injury, created using machine learning techniques, achieved a >90% testing accuracy. Compared with patients who did not sustain an ACL injury, patients with torn ACLs had an increased posterior LBS and LMS and a lower MMH and LMH.

Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study.

Background:Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment.Purpose:To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL–Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation).Results:At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL–Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months.Conclusion:The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.