IKDC Subjective Score Research Articles

Comparison of Results in ACL Reconstruction in Women under 30 Years Old at a Minimum of 2 Years’ Follow-Up between a Bone–Tendon–Bone (BTB) Technique with the Patellar Tendon and a Hamstring Technique Combined with Anterolateral Ligament Reconstruction

Background: Anterior cruciate ligament (ACL) rupture is a frequent injury among athletes, particularly women. Various techniques have shown effectiveness, but their impact on laxity and clinical outcomes varies. This study aims to compare the rupture rates of patellar tendon (PT) reconstruction versus hamstring reconstruction (HR) combined with anterolateral ligament reconstruction (ALLR) in young women. The secondary objectives include comparing functional ACL-RSI and subjective IKDC scores, as well as the Tegner scale, between these two groups. The hypothesis is that adding ALLR to HR will result in rupture rates and functional scores similar to those of PT reconstruction. Methods: Between 2015 and 2019, 96 patients were treated at two facilities, with 70 having an average follow-up of 44 ± 14.5 months: 35 underwent PT reconstruction, and 35 had HR combined with ALLR. Patients were re-evaluated remotely after at least 2 years using a standardised questionnaire and assessing subjective IKDC, ACL-RSI, and Tegner scores. Results: Rupture rates were 5.7% in both groups. The mean subjective IKDC score was 81% for the HR + ALLR group versus 80.8% for the PT group (p = 0.09). The mean ACL-RSI score was 66% for HR + ALLR versus 68% for PT (p = 0.78). The HR + ALLR group lost an average of 0.4 points on the Tegner scale postoperatively, while the PT group lost an average of 0.77 points (p = 0.09). Conclusions: Hamstring surgery combined with anterolateral surgery provides subjective results, as assessed by patients using subjective scales and questionnaires, that are as good as those obtained with PT surgery in young women. Notwithstanding, the results are not corroborated by clinical or radiological examination.

Single-plug osteochondral autograft transplantation for knee osteochondritis dissecans: Clinical improvement and long-term survivorship at a minimum ten year follow-up.

Osteochondritis dissecans (OCD) can lead to detrimental effects in the affected joints. Osteochondral autologous transplantation (OAT) allows to restore the articular surface with an autologous osteochondral unit. While short-term results are documented, there is a lack of long-term data. Aim of this study was to analyze the long-term clinical results of single-plug OAT for the treatment of knee OCD. Twenty patients (14 men, 6 women) were treated with single plug-OAT. Mean age was 23.6 ± 9.9 years and BMI was 23.3 ± 3.6kg/m2. Lesion size was 2.3 ± 1.6 cm2 and defects included 14 medial femoral condyles (MFC) and 6 lateral femoral condyles (LFC). Patients were followed up prospectively at baseline, 24 months, 60 months, and at minimum ten years (12.6 ± 2.0 years) using the IKDC subjective score and through an overall judgment on treatment satisfaction. The activity level was evaluated with the Tegner score and adverse events and failures were also recorded. Factors influencing the clinical outcomes, including age, sex, BMI, lesions size, and lesion location were also investigated. No severe adverse events and no surgical failures were reported and 85.0% of patients were satisfied at a minimum ten year follow-up. Subjective IKDC showed a significant and stable improvement at all follow-ups, passing from 45.3 ± 16.5 at baseline to 73.7 ± 16.6 at 24 months (p < 0.0005), to 72.9 ± 16.6 at 60 months (p < 0.0005), and to 74.1 ± 20.8 at long-term follow-up (p < 0.0005). Patients with OCD lesions localized on the LFC obtained lower results compared to those with MFC lesions at two years and five years (p = 0.034 and p = 0.023). The highest long-term scores were obtained in patients with lesion size lower than 2 cm2 (89.1 ± 8.8) compared to patients with lesion size between 2 and 4 cm2 (69.2 ± 15.7), and patients with lesion size larger than 4 cm2 (63.8 ± 34.6). OAT is a suitable technique to treat knee OCD in young patients and offers a high patient satisfaction and a significant improvement in terms of clinical subjective scores, with results remaining stable over time, although without reaching the pre-injury activity level. No severe adverse events and no surgical failures have been documented confirming OAT as a valid treatment option, although the best long-term results for lesions smaller than 2 cm2 and for MFC lesions should be considered when choosing this procedure to address knee OCD lesions.

Combined ACLR and lateral extra-articular tenodesis with a continuous iliotibial band autograft is a viable option in a population of athletes who participate in pivoting sports.

The aim of this study was to evaluate the clinical results, return to sport and complications after anterior cruciate ligament reconstruction (ACLR) associated with lateral extra-articular tenodesis using continuous plasty with an iliotibial band. This was a prospective multicentre study involving 186 patients who had surgery for anterior cruciate ligament (ACL) rupture. Patients with multiligament ruptures and revision surgery were excluded from the study. All patients included were involved in pivoting sports and wished to resume their activity after surgery. Patients were assessed at a minimum 2-year follow-up using functional and psychological questionnaires (subjective International Knee Documentation Committee [IKDC], Tegner, Lysholm and ACL-RSI scores), ligament assessment including instrumented laxity measurement (Rolimeter), Lachman test and pivot shiftand isokinetic testing. Return to sport was assessed using a questionnaire, and complications and repeat surgeries were recorded. At a mean follow-up of 43.1 months, the subjective IKDC, Lysholm, ACL-RSI and objective IKDC scores were significantly improved (59.8 vs. 94.5 p < 0.0001, 75 vs. 99 p < 0.0001, 60 vs. 93 p < 0.0001, IKDC A 0% vs. 72%, B 12% vs. 27%, C 60% vs. 1% D 28% vs. 0% p < 0.0001). The Tegner activity level was 9 (3-10) before the accident and 9 (3-10) at the last review. Seventy-six percent of the patients had returned to sports at the same level. The differential laxity was 6.6 mm (±1.7) preoperatively and 1.1 mm (±1.4) postoperatively. Additionally, 97% were equal in pivot shift at the last follow-up. At the 6-month isokinetic assessment, the muscle strength recovery for the quadriceps and hamstring was over 85% compared with the healthy side for 79% and 70% of the patients, respectively. Ten patients had graft rupture (5.6%). Four (2.4%) patients had a contralateral ACL rupture, and seven (4%) underwent a reoperation with meniscectomy. Anterior ligament reconstruction with lateral extra-articular tenodesis using a continuous strip of iliotibial band enables 76% of patients in a population with a high demand for sports to resume their activities at the same level. The clinical results and complication rates, particularly reruptures (5.6%), were similar to those of other techniques involving lateral extra-articular tenodesis. Level II.

A tight anterosuperior intercondylar notch may increase the risk of cyclops syndrome after anterior cruciate ligament reconstruction using a quadruple semi-tendinosus short autograft

BackgroundCyclops syndrome is loss of terminal knee extension caused by a fibrous nodule developed in the anterior intercondylar notch. The many known risk factors include preoperative motion-range limitation, tibial tunnel malposition, and tight hamstrings. The primary objective of this study was to assess whether intercondylar notch size was associated with the risk of cyclops syndrome or graft tear after anterior cruciate ligament (ACL) reconstruction using a quadruple semi-tendinosis autograft. The secondary objective was to determine whether intercondylar notch size was associated with functional outcomes. HypothesisA narrow intercondylar notch is associated with higher risks of cyclops syndrome and poor functional outcomes. MethodsConsecutive patients who underwent ACL reconstruction by quadruple semi-tendinosus autograft were included retrospectively. Preoperative magnetic resonance imaging scans were assessed by a single senior surgeon, who determined the conventional notch width index (NWI) and the anterior NWI (aNWI) for each patient. ResultsThe 120 included patients had a mean follow-up of 2.4±0.8 years. Among them, 20 (16.7%) experienced cyclops syndrome and 7 (5.8%) graft rupture. At last follow-up, 26 (21.7%) had not returned to sports and only 47 (39.2%) had returned to sports at the pre-injury level. The mean Lysholm score was 87.9±13.5 and the main subjective IKDC score was 84±13. A narrow notch was significantly associated with lower likelihoods of returning to sports (p=0.001), returning to the same sport (p<0.0001), and returning to the pre-injury sport level (p=0.004). By multivariate analysis, only the aNWI index was significantly associated with the risk of cyclops syndrome (p<0.0001). An aNWI index lower than 0.18 had 85% sensitivity and 78% specificity for predicting cyclops syndrome. ConclusionA narrow anterosuperior intercondylar notch may increase the risk of cyclops syndrome after ACL reconstruction using a quadruple semi-tendinosus graft but is not associated with the risk of graft rupture. Level of evidenceIV, retrospective observational cohort study.

Young men undergoing anterior cruciate ligament reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to those undergoing reconstruction with hamstring autograft and transtibial drilling

ObjectiveTo compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique. MethodsNinety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18–35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value ​< ​0.05 indicated statistical significance. ResultsForty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5–10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ​± ​1.9 mm vs. 2.8 ​± ​2.3 mm (p ​< ​0.01), pivot shift grade 2–3 in 4% vs. 34% (p ​< ​0.01), return to preinjury Tegner level in 51% vs. 36% (p ​= 0.1) and to preinjury Marx score in 29% vs. 11% (p ​= 0.02), and IKDC-subjective 88 ​± ​10 vs. 82 ​± ​13 vs (p ​< ​0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r ​= ​−0.314, p ​< ​0.01; r ​= ​−0.263, p ​< ​0.01; r ​= ​−0.218, p ​= ​0.03, respectively). ConclusionYoung men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling. Level of EvidenceIII (Retrospective cross-sectional comparative study).

All-Inside Anterior Cruciate Ligament Reconstruction Had Clinical Outcome Similar to the Transtibial Technique Except for Improved Side-to-Side Difference and Tegner Activity Scale: A Systematic Review and Meta-analysis

PurposeTo compare clinical outcomes of the all-inside technique with the transtibial technique in anterior cruciate ligament reconstruction based on available literature on this topic. MethodsAccording to the PRISMA checklist, we conducted a systematic search for randomized controlled trials and Cohort studies. Our comprehensive search encompassed PubMed, Embase, Cochrane Library, and Web of Science. We included RCTs and cohort studies that compared the two techniques with a minimal one-year follow-up. Two independent authors assessed RCTs using the risk of bias tool developed by the Cochrane Collaboration, and evaluated the quality of cohort studies using the Newcastle-Ottawa Scale for Assessing the Quality of Nonrandomized Comparative Trials. The subjective and objective outcomes, complication, and graft failure were obtained. The R software was used to perform the analysis. ResultsThe present analysis enrolled 9 RCTs (n= 687) and 11 cohort studies (n= 910) . After a minimal one-year follow-up in RCTs, functional outcomes such as IKDC subjective score, Lysholm score, Tegner activity scale, Knee society score, and Hop test were found to be similar between two techniques. The laxity outcomes including the IKDC objective grade and Pivot-shift test, were suggested to be comparable. There was a significant difference favoring the transtibial technique in terms of side-to-side difference (P=0.04, 95% CI= 0.08 to 0.90). The pooled data from cohort studies indicated equivalent results in terms of IKDC subjective score, Lysholm score, Side-to-side difference, IKDC objective grade, Complication, and Graft failure, with the exception of statistical difference in the Tegner activity scale (P=0.03, 95% CI= -0.50 to -0.04). ConclusionOur findings suggest that there is no difference in most outcome scores between the all-inside and transtibial techniques for anterior cruciate ligament reconstruction. There are statistically significant differences in side-to-side difference and Tegner activity scale favoring all-inside technique.

Is Anterior Cruciate Ligament Reconstruction “Silva Technique” Equal to All‐Inside Techniques? A Prospective Single‐Center Study

Background: The development of less invasive all‐inside techniques regarding anterior cruciate ligament (ACL) reconstruction surgery has been associated with various advantages, including fewer complications and reduced postoperative pain. Silva et al. described a quadruple semitendinosus graft construct and suspensory button fixation for ACL reconstruction as an alternative technique. At the end of this technique, the tibial tunnel is filled with a bone autograft plug. This paper aims to examine the incorporation of the autograft and thus evaluate whether the “Silva technique” provides the same benefits as all‐inside techniques.Methods: A prospective study assessed 31 patients undergoing ACL reconstruction surgery using the “Silva technique.” The cases involved in the study were skeletally mature patients with no previous history of ACL surgery or multiligamentous instability. All patients followed the same rehabilitation program and were examined at three standardized follow‐up visits: 4 months, 8 months, and 1 year postoperatively. Tegner–Lysholm knee score (TLKS), visual analog score (VAS) for pain, and the IKDC subjective knee score were completed at every visit. A knee MRI scan was performed at every scheduled visit to assess bone graft incorporation and remodeling.Results: TLKS scores revealed a considerable improvement compared to preoperative figures, from 57.2 points preoperatively to an average of 99.4 at the 12‐month follow‐up (p &lt; 0.0001). VAS scores were substantially ameliorated after the operation and until the second follow‐up visit, from 5 before surgery to zero 8 months after the operation, with no noteworthy alterations afterward (p &lt; 0.0001). IKDC subjective knee score outcomes were found to have increased at the last follow‐up, from 59.3 prior to surgery to 99.8 12 months postoperatively (p &lt; 0.0001). Regarding the MRI features of the bone autograft, the tibial tunnel was entirely filled by bone formation at the last MRI scan, suggesting complete integration of the autograft in all patients.Conclusions: Bone autograft employed to seal the tibial tunnel was completely incorporated in all cases 1 year postoperatively. The “Silva technique” appears to feature all the avails of all‐inside techniques, whilst it seems to be simpler and easier than them after the surgeon is familiarized with its particular aspects. It is a robust option in orthopedic surgeons’ arsenal. However, further large‐scale pertinent research is requisite to confirm the findings of this study.

Rotational stability can be enhanced in revision anterior cruciate ligament reconstruction using the over-the-top augmentation technique compared to single bundle technique

PurposeRevision anterior cruciate ligament (ACL) reconstruction is technically challenging due to mispositioned tunnels, bone loss, and tunnel enlargement, which may compromise graft fixation and result in failure. To obtain firm graft fixation and strength in one stage, we utilized an over-the-top augmentation technique using an Achilles tendon allograft in revision ACL reconstruction (OA-ACLR). This study compared OA-ACLR with single-bundle ACL reconstruction (SB-ACLR). We hypothesized that OA-ACLR would enhance the postoperative knee joint rotational stability.MethodsWe retrospectively analyzed 47 patients who underwent revisional OA-ACLR and 48 who underwent primary SB-ACLR with minimum follow-up of 6 months. Knee instability was evaluated with the anterior drawer, Lachman, and pivot shift tests preoperatively and at the final follow-up. Side-to-side differences were compared with the non-affected side at the final follow-up. Function was evaluated using the IKDC subjective and Lysholm knee scores preoperatively and at the final follow-up.ResultsThe groups did not differ in terms of sex, age, BMI, and etiology. There were no significant differences in concomitant surgical procedures, such as meniscectomy and meniscus repair, between the two groups (p = 0.335, > 0.99). Both groups significantly improved in the anterior drawer, Lachman, pivot shift tests, and IKDC and Lysholm knee scores after surgery (all p < 0.001). The OA-ACLR group showed significantly higher rotational stability in the pivot shift test than the SB-ACLR group (p = 0.017). The postoperative side-to-side difference, the IKDC and Lysholm scores showed no significant differences between the groups (p = 0.34, 0.301, 0.438).ConclusionsOA-ACLR showed enhanced rotational stability with pivot shift test compared to SB-ACLR. It may be considered a useful alternative for revision ACL reconstruction.

One-stage cartilage repair using the autologous matrix-induced chondrogenesis combined with simultaneous use of autologous adipose tissue graft and adipose tissue mesenchymal cells technique: clinical results and magnetic resonance imaging evaluation at five-year follow-up

PurposeTo evaluate medium-term outcomes of knee cartilage defects repair by autologous matrix-induced chondrogenesis combined with simultaneous use of autologous adipose tissue graft and adipose tissue mesenchymal cells, defined as LIPO-AMIC technique.MethodsThe LIPO-AMIC technique has been used in ICRS degree III–IV knee defects. Eighteen patients have been prospectively evaluated during two and five years both clinically and by MRI.ResultsPatients showed progressive significant improvement of all scores starting early at six months, and further increased values were noted till the last follow-up at 60 months. Mean subjective pre-operative IKDC score of 36.1 significantly increased to 86.4 at 24 months and to 87.2 at 60 months. Mean pre-operative Lysholm score of 44.4 reached 93.5 at two years and 93.5 at five years. MRI examination showed early subchondral lamina regrowth and progressive maturation of repair tissue and filling of defects. The mean total MOCART score showed that a significative improvement from two year follow-up (69.1 points) to last follow-up was 81.9 points (range, 30–100 points, SD 24). Complete filling of the defect at the level of the surrounding cartilage was found in 77.8%.ConclusionsAdipose tissue can represent ideal source of MSCs since easiness of withdrawal and definite chondrogenic capacity. This study clearly demonstrated the LIPO-AMIC technique to be feasible for treatment of knee cartilage defects and to result in statistically significant progressive clinical, functional and pain improvement in all treated patients better than what reported for the AMIC standard technique, starting very early from the 6-month follow-up and maintaining the good clinical results more durably with stable results at mid-term follow-up.

Revision anterior cruciate ligament reconstruction using the ipsilateral Quadriceps tendon autograft: a modular reconstructive option.

Failed ACL reconstruction is a common occurrence nowadays due to the increased incidence of ACL surgeries and return to full activities following the surgery. Several challenges might stand in the face of this revision surgery particularly the graft harvest and its suitability to the situation with possible widening of the tunnel and the avoidance of additional morbidity at the contralateral side or anterior knee pain as in patellar tendon harvest. The aim of this study is to evaluate the ipsilateral quadriceps tendon as a source of autograft in revision ACL surgery which constitutes a viable option that can potentially decrease the morbidity of the procedure, and meanwhile provide a graft substitute that can be tailored to suit the dilated tunnels commonly encountered in revision surgery, thus giving the patients a good potential for better functional outcome. Revision anterior cruciate ligament reconstruction was done in 30 patients using the ipsilateral quad tendon as a pure soft tissue or with a bony fragment. The mean subjective international Knee Documentation Committee score (IKDC score) at twoyears follow-up was 65.83 ± 7.20. There is statistically significant improvement of the objective as well as the subjective IKDC scores at the end of follow-up when compared to the preoperative as well as the 6-month evaluation figures. The KT1000 arthrometer recorded a mean of 4.50 ± 1.07. Significant improvement of the limb symmetry index was at twoyears duration. The quadriceps tendon can be a solution for several challenges that might appear during the revision ACL surgery with comparable results to other tendons and with minimal morbidity on the function of the harvested muscle tendon.

First revision ACL reconstruction combined with tibial deflexion osteotomy improves clinical scores at 2 to 7 years follow-up.

To report outcomes of first revision anterior cruciate ligament reconstruction (ACLR) with tibial deflexion osteotomy (TDO) in patients with posterior tibial slope (PTS) >10° at >2 years. The authors studied outcomes of a consecutive series of 16 patients that underwent first revision ACLR with TDO, including Lysholm score, IKDC subjective and objective scores, Lachman test, PTS, and signs of osteoarthritis. One woman was excluded because of early signs of knee arthritis, as the first revision ACLR took place 27 years following the primary ACLR. This left a final cohort of 15 patients assessed at minimum follow-up of 2 years. The final cohort comprised 14 men and 1 woman aged 25.3 ± 6.6 years (range 16-39) at first revision ACLR. At final follow-up of 4.4 ± 1.5 years (range, 2-7), PTS was corrected from 12.5 ± 1.8° (range 8-15°) to 1.9 ± 3.6° (range -4 to 8°), and none of the knees had radiographic signs of osteoarthritis. Lysholm score was 83.8±12.5, IKDC subjective score was 80.3±16.2, and IKDC objective score was A in 5 (33%), and B in 10 (67%). The net improvement exceeded the minimal clinically important difference (MCID) in 93% of patients for the IKDC subjective score and in 80% of patients for the Lysholm score. None of the knees had any retears, and only one required a reoperation to re-suture a medial meniscal tear due to trauma. At 2-7 years following revision ACLR combined with TDO, net improvement exceeded the MCID in 93% of patients for IKDC subjective score and in 80% of patients for Lysholm score, with no retears or major complications. These results suggest that TDO is a safe technique to protect the ACL graft and might be considered as of first revision ACLR to correct excessive PTS. Level IV.

Recurrent Instability Rate and Subjective Knee Function following Accelerated Rehabilitation after ACL Reconstruction in Comparison to a Conservative Rehabilitation Protocol.

The Purpose of the present study was to assess the outcome of anterior cruciate ligament reconstruction (ACLR) with an accelerated rehabilitation protocol and to compare it to a conservative rehabilitation protocol. It was hypothesized that an accelerated rehabilitation protocol, including brace-free early weight bearing, would result in a higher rate of recurrent instability and revision surgery compared to a conservative rehabilitation protocol. From 2016 to 2017, two different rehabilitation protocols for isolated ACLR were used at a high-volume knee surgery center. A total of 65 consecutive patients with isolated hamstring ACLR, of whom n = 33 had been treated with an accelerated (AccRehab) and n = 32 with a conservative rehabilitation protocol (ConRehab), were retrospectively included in the study. Patients were evaluated for recurrent instability, revision surgery, and other complications at a mean follow-up period of 64 ± 7.4 months. In addition, Tegner Activity Scale, Lysholm Score, and IKDC-subjective Score were evaluated. Statistical comparison between the two groups was performed utilizing Fisher's exact test and Student's t-test. Mean age (29.3 vs. 26.6 years) and preoperative Tegner Score (6.4 vs. 5.9) were comparable between both groups. At 64 ± 7.4 months after ACLR, six cases of recurrent instability were reported in the AccRehab group (18%) in comparison to three cases (9%) in the ConRehab group (p = n.s.). There was no significant difference regarding revision surgery and further complications. Furthermore, no significant difference was found between both groups regarding Tegner (5.5 ± 1.9 vs. 5.5 ± 1.2), Lysholm (93.6 ± 6.3 vs. 89.3 ± 10.7), and IKDC score (89.7 ± 7.9 vs. 86.7 ± 12.1). No significant disadvantage of an accelerated rehabilitation protocol following ACLR was found in terms of recurrent instability rate, revision surgery, or patient-reported outcome. However, a trend towards a higher reinstability rate was found for an accelerated rehabilitation protocol. Future level one trials evaluating brace-free early weight bearing following ACLR are desirable.

Paper 27: Preoperative Risk Factors of Subsequent Ipsilateral ACL Revision Surgery following an ACL Restoration Procedure

Objectives: To identify the preoperative risk factors for revision ACL surgery within the first two years after BEAR ACL repair procedure. Methods: Data from the prospective BEAR I, II, and III trials were used to determine preoperative risk factors for ACL revision surgery. All subjects with a complete ACL tear (ages between 13-47 years, depending on the trial), who passed all other inclusion/exclusion trial criteria, and underwent a primary BEAR procedure within 30-50 days from injury (dependent on trial) were included. Demographic data (age, sex, BMI), baseline patient-reported outcomes (IKDC Subjective Score, Marx Activity score), pre-operative imaging characteristics (ACL stump length, notch size, tibial slopes), and intraoperative findings (knee hyperextension, meniscal tear status) were evaluated to determine their contribution to ipsilateral revision ACL surgery risk. Results: 123 subjects, median age 17.6 years (IQR 16-23), including 67 (54%) females, met study criteria. 18 (15%) patients required revision ACL surgery in the first two years following the BEAR procedure. In bivariate analyses, younger age (p=.011), having a contact injury at the time of the initial tear (p=.048), and increased medial tibial slope (p=.029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified two independent predictors of revision: patient age and medial tibial slope. The odds of an ipsilateral revision surgery were decreased by 32% for each one-year increase in age (OR=0.684, 95% CI = 0.517 to 0.905, p=.008), and increased by 28% per each degree of increase in medial tibial slope (OR=1.280, 95% CI =1.024 to 1.601, p=.030). Sex, baseline IKDC or Marx score, knee hyperextension, or meniscus status were not significant predictors of revision. Conclusions: Younger age and higher medial tibial slope were predictors of increased odds of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration surgery.

The impact of bone graft type used to fill bone defects in patients undergoing ACL reconstruction with bone–patellar tendon–bone (BPTB) autograft on kneeling, anterior knee pain and knee functional outcomes

PurposeMultiple different materials are used for filling bone defects following bone–patellar tendon–bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study.MethodsA prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years).ResultsA total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients’ who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups.ConclusionThe use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

Meniscal allograft transplantation, anterior cruciate ligament reconstruction, and valgus high tibial osteotomy for meniscal-deficient, unstable, and varus knees: surgical technique and clinical outcomes.

The aim of this study was to determine the clinical and functional outcome of a salvage surgical approach with the combined procedures meniscal allograft transplantation (MAT), anterior cruciate ligament reconstruction (ACLR), and high tibial osteotomy (HTO), in a cohort of patients treated for complex knee lesions evaluated up to a mid-term follow-up. Eight patients (38.8 ± 4.6 years, 88% males) were treated arthroscopically with MAT without bone plugs combined with primary or revision ACLR and HTO and evaluated at basal, at a minimum of two years (short follow-up), and at a mean follow-up of 5.1 years (mid-term follow-up) with the VAS score for pain, Lysholm score, IKDC subjective score, WOMAC Osteoarthritis index, and Tegner score. Physical examination (Lachman and pivot-shift tests, arthrometer assessment) and radiographic evaluation (pre- and post-operative x-rays) were obtained. Complications and failures were also recorded. A statistically significant improvement was observed from baseline to five years in all clinical scores. In particular, the IKDC subjective score improved from 33.3 ± 20.7 to 73.1 ± 18.4 at short follow-up (p < 0.05), up to 78.3 ± 9.8 at the final follow-up (p < 0.05). A similar trend was demonstrated with the Lysholm, VAS, WOMAC, and Tegner score, even though only one patient reached the pre-injury activity level. Two patients had a worsening of the Kellgren-Lawrence (KL) grade from preoperative (grade 1) to final follow-up (grade 2). No major complications and surgical failures were documented. The combined procedure of MAT, ACLR, and HTO presents few complications and failures and showed to be a valid option to reduce pain, recover knee function, and slow down the osteoarthritis process even in complex patients, with good and stable results up to a mid-term follow-up.

Diagnostic Accuracy of Fine Needle Aspiration Cytology for Evaluation of Breast Lump Compared to Trucut Biopsy

Background: The primary issue after isolated intra-articular anterior cruciate ligament (ACL) surgery is the continuation of pivot shift. By limiting rotational laxity, the lateral extra-articular tenodesis (LET) treatment added to the ACL surgery improves knee stability. This study's objective was to assess the long-term clinical and radiological results of ACL restoration coupled with LET utilizing a continuous hamstring graft as the first operation. Method and Analysis: Four years postoperatively, 20 patients were examined. Collecting subjective outcome ratings (IKDC, Lysholm, KOOS, and Tegner). A clinical and radiological evaluation was conducted. The anteroposterior laxity of the knees was assessed using a rollimeter. Using SPSS version 23, the statistical analysis was conducted. The mean and standard deviation of quantitative data were used to summarize the data. Fischer's exact test was used to compare qualitative characteristics, whereas Student's t-test was used to compare mean values. A p value of 0.05 or less was regarded as significant. Result: The mean IKDC subjective score was 83.1, the mean Lysholm score was 89.02 and 75% of patients had exceptional or excellent scores. In 85% of patients, there was no pivot shift, and 60% of patients had a definitive endpoint on the Lachman test. Conclusion: The addition of primary LET to ACL restoration enhances rotational laxity control over time without raising the risk of complications.

The changing trends of the knee function after anterior and posterior cruciate ligaments reconstruction with all-inside arthroscopy technique.

We aimed to summarize the effectiveness and changing trends of reconstruction for the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries using all-inside arthroscope technique. Between May 2013 and May 2019, 29 patients with ACL and PCL ligaments rupture were included. All the patients were male, with a mean age of 25.2±2.9 years. The mean follow-up period was 2.4±0.7 years (Range, 2-4 years). Reconstruction surgery of the ACL and PCL ligaments was performed by using autologous hamstring tendon with all-inside arthroscopy technique. The anterior and posterior drawer test, Lachman test, Pivot-shift test, stress test, IKDC score, Lysholm score, Tenger score were analyzed clinically. At the last follow-up, the symptoms were improved significantly, the anterior drawer test was normal and 1 degree in 96.6%, posterior drawer test in 89.7%, pivot shift test in 96.6%, Lachman test in 93.1%, and stress test in 93.3%, the stability was improved significant(P<0.05). The IKDC-2000 standard score was normal and near normal in 96.6%. The IKDC subjective score, Lysholm score, and Tenger scores results at the last follow-up were significantly improved when compared with those before operation ( P<0.05). The changing trends of function evaluation score in the first six months were most obviously better, especially in the third month. All-inside arthroscopy technique is an effective procedure for the ACL and PCL ligaments injuries, and the first six months (especially the third month) after the reconstruction is the key period for a successful recovery. However, there was still a significant improvement at the later stage of rehabilitation.

ACL reconstruction provides superior stability than ACL repair in patients with Schenck III and IV knee joint dislocations: first results of a 12 month follow-up study

PurposeAcute knee dislocation is a rare but devastating multi-ligamentous knee injury with only limited evidence-based surgical technique recommendations. The aim of this study was a comparison of two different anterior cruciate ligament (ACL) restoration techniques as part of an early total surgical care concept: (1) repair of ACL with additional internal bracing (ACLIB) compared to; (2) ACL reconstruction with autograft (ACLR).MethodsRetrospective, clinical-study of patients with an acute type III or IV knee dislocation (according to Schenck classification), in which the ACL was treated with ACLIB or ACLR within 12 days. The PCL was sutured and internally braced in all cases. Medial and lateral complex injuries were repaired and additionally laterally augmented by an Arciero reconstruction. After a minimum 12 months follow-up different patient-reported outcome measurements (IKDC, Lysholm, VAS, Tegner Score) and instrumental stability assessment by Rolimeter -test and stress radiographs (Telos™) were analyzed. Groups were compared by t test with p < 0.05 considered significant.ResultsIn total, 20 patients (5 IIIM, 5 IIIL and 10 IV) were included in this study with an average follow-up of 13.7 ± 2.6 months. There were significant differences in instrumental stability testing (side-to-side difference (SSD) of anterior tibial translation: ACLIB 2.7 ± 1.5 mm vs. ACLR 1.3 ± 1.3; p = 0.0339) and stress radiography (SSD ACL: ACLIB 3.4 ± 2.2 mm vs. ACLR 0.4 ± 2.7; p = 0.0249) between groups. ACLIB group showed greater ROM in terms of flexion (SSD Flexion: ACLIB 7.8 ± 9.9° vs. ACLR 16 ± 7.0°; p = 0.0466; Total Flexion overall 125.5 ± 11.8°). No clinically relevant differences in patient-reported outcome scores (Lysholm Score: ACLIB 82 ± 16.4 vs. ACLR 85 ± 10.4; IKDC subjective score: ACLIB 70.4 ± 17 vs. ACLR 76.6 ± 8.3) were determined.ConclusionACLR provides superior translational stability than ACLIB in terms of instrumental testing and stress radiography. Both techniques were equivalent with respect to PROMS and led to good and excellent clinical results.Level of evidenceRetrospective cohort study, III.

Combined subchondral and intra-articular injections ofbone marrow aspirate concentrate provide stable results up to 24months.

The aim of this study was to evaluate the clinical and imaging findings up to 24months of follow-up in patients treated with combined subchondral and intra-articular bone marrow aspirate concentrate (BMAC) injections for the treatment of knee osteoarthritis (OA). Thirty consecutive patients (19 males, 11 females) aged between 40 and 75years (mean age 56.4 ± 8.1years) with unilateral symptomatic knee OA (Kellgren-Lawrence 2-3) were included in the study. Patients were treated with combined intra-articular and subchondral bone BMAC injections (total 9ml) under fluoroscopic control. IKDC subjective score, VAS for pain, KOOS, and EQ-VAS were prospectively evaluated up to 24months. Radiographs were performed at baseline and at 24months after the procedure. MRI was evaluated with the WORMS score at baseline, 6-12months, and 24months of follow-up. The statistical analysis was performed using SPSS v.19.0 and for all tests p < 0.05 was considered significant. No major complications and a 13% failure rate were reported. The IKDC subjective score remained stable from 62.6 ± 19.4 at 12months to 63.4 ± 17.1 at 24months (both p < 0.0005 compared to baseline, 40.5 ± 12.5). Similar improvements were reported for all KOOS subscales, while EQ-VAS did not report any significant improvement. VAS pain worsened from 3.0 ± 1.9 at 12months to 4.4 ± 1.8 at the final follow-up (p = 0.0001), although remaining lower compared to the baseline value of 6.3 ± 1.8 (p = 0.002). The radiographic evaluation did not reveal signs of improvement or deterioration of the OA grade. The MRI findings showed a worsening in marginal osteophytes and synovitis, but a significant reduction of bone marrow edema at 24months (p < 0.0005). Combined intra-articular and subchondral BMAC injections provided clinical and imaging benefits up to 24months for the treatment of symptomatic knee OA, with durable clinical results, a low failure rate, and a significant reduction of bone marrow edema.

Arthroscopic treatment of tibial intercondylar eminence fractures in skeletally immature patients with bioabsorbable nails

Fractures involving tibial eminence caused by ACL avulsion lesion most frequently occur paediatric patients. Satisfactory reduction in displaced fractures cannot be achieved through conservative treatment, while arthroscopy-assisted fixation technique represents the gold standard to reduce and to fix articular fractures and several effective implants have been used to treat this kind of fractures. In our retrospective study, we proposed a different arthroscopic technique to fix Type II and Type III tibial eminence fractures by using bioabsorbable nails. Nineteen patients, aged 6 to 13 years were treated with arthroscopic reduction and fixation of the fragment using bioabsorbable nails. At 6-month follow-up, all patients showed a decrease of less than 2mm of the anterior edge. All patients at maximum follow-up reached a full knee flexion/extension. IKDC subjective mean score at six-month was 88.14.2 points (range 80-95; p<0.01). For what concerns the Tegner Activity Scale, the mean value of 5.51 (range 3-7) prior to the surgery changed into 5.10.9 (range 3-6) at 6 months. No inflammatory reactions were reported and all fractures healed without complications. The objective IKDC grade A was reported in 18 patients and grade B in one patient, having a "nearly normal" range of motion item (92% compared to contralateral). Results can be compared to other surgical procedures described in the literature, having the same fast learning curve increase and limited complications, beside the fact that a second operation for metallic implants removal was avoided.