Shift Test Research Articles

All-inside anterior cruciate ligament reconstruction with and without anterolateral ligament reconstruction: a prospective study.

There is no clear consensus regarding the superiority of a combined anterior cruciate ligament reconstruction (ACLR) with anterolateral ligament reconstruction (ALLR) versus an isolated ACLR. In this study, we compared the postoperative stability profile, complications, and patient-reported outcomes of these procedures. Twenty-one patients with an anterior cruciate ligament (ACL) tear who were either treated by an isolated all-inside ACLR (n = 21) or a combined all-inside ACLR and ALLR (n = 20) were included. The outcomes were evaluated in the last follow-up and included the postoperative stability profile evaluated by the Lachman test, pivot shift test, and KT-1000 side-to-side difference, postoperative complications, and patient-reported outcomes evaluated by the International Knee Documentation Committee (IKDC) score and Lysholm knee scale. The baseline characteristics of the two groups were not significantly different. The residual Lachman and pivot shift were not significantly different between the two groups (P = 0.41 and P = 0.18, respectively). The mean KT-1000 side-to-side difference was 1.93 ± 1.9mm in the isolated and 1.635 ± 0.91mm in the combined group (P = 0.01). The mean improvement of the IKDC score was not significantly different between the isolated and combined groups (24.7 vs. 25.2, P = 0.28). The mean improvement of the Lysholm scale was not significantly different between the isolated and combined groups (33.5 vs. 34.1, P = 0.19). ACL re-rupture occurred in three patients of the isolated group and no patient of the combined group. The outcomes of patients in the present study support performing a combined ALL and ACL reconstruction.

Outcome of combined anatomic reconstruction of the anterior cruciate ligament with anterolateral ligament reconstruction versus with iliotibial band tenodesis

Abstract Background Isolated anterior cruciate ligament (ACL) tears without anterolateral structures injuries are treated successfully by isolated reconstruction of ACL. However, most ACL injuries are associated with the injuries of anterolateral stabilizers of the knee; mainly the iliotibial tract (ITB) and the anterolateral ligament (ALL). If ACL is only reconstructed in such a case, the incidence of postoperative rotational instability reaches 18%. New directions guided towards combined ACL reconstruction with extraarticular anatomical and nonanatomical reconstructions to improve knee rotation and translation and prevent pivot shift phenomena. Patients and methods We retrospectively reviewed all patients operated on for combined injuries of ACL and anterolateral stabilizers from February 2019 to February 2021. Preoperatively and postoperatively, all patients were examined clinically by knee stability tests: anterior drawer, Lachman, and pivot shift tests, applying the International Knee Documentation Committee score and return time to the sport. Results Forty patients were included with a mean age of 28 ± 8.33 years (range, 18–44 years). Patients were divided into two groups, group A 20 patients (18 males and two females) were treated by combined ACL with ALL reconstruction, and group B 20 patients (18 males and two females) were treated by combined ACL with ITB tenodesis. Sports injuries were the cause in 15 patients in group A and 14 in group B, while five injuries were due to nonsport activity in group A and six in group B. The mean follow-up period was 33.5 ± 2.1 months. Median postoperative subjective International Knee Documentation Committee scores in groups A and B were 95.4 and 94.25, respectively, without any statistically significant difference. Group A shows better postoperative improvement in pivot shift and one-leg hop test than group B with a significant difference (P<0.05). Conclusion No significant difference between ALL reconstruction or ITB tenodesis with ACL reconstruction according to subjective knee functions but there was a significant difference according to objective functions, also lateral knee pain was reported in group B and not observed in group A.

Arthroscopic Posteromedial Corner Reconstruction: A Novel Technique and Case Series.

This study aimed to introduce a novel arthroscopic treatment for medial and posteromedial instability of the knee and present the primary and follow-up results. All patients who underwent the arthroscopic approach to treat medial and posteromedial corner instability from 2007 to 2017 were included in this report. Overall, 45 patients were included, among which 75.6% were male. The mean age of patients was 32.2 ± 8.4 years. Overall, 44.4% and 15.6% of patients had associated meniscal injuries and chondral lesions, respectively. The mean follow-up duration of patients was 84.2 ± 25.3 months. Overall, 37 patients developed a full range of motion (82.2%), and most patients (95.6%) showed excellent quadriceps strength (grades 4 and 5). All patients had a normal or 1+ posterior drawer test, Pivot shift test, and Lachman test on physical examination. Moreover, 60% had an associated isolated anterior cruciate ligament injury, 17.8% had an isolated posterior collateral ligament injury, and 17.6% had a combination of more than one ligament injury. One patient developed septic arthritis. Two patients experienced pain, and one pain patient developed pain with a bony spur formation in the medial epicondyle. Three patients showed a 2+ medial collateral ligament (MCL) test (moderate instability) at the final follow-up, all of whom had multi-ligament injuries. All patients, except the three patients who had a failed MCL reconstruction, returned to their previous activities. This study described a novel arthroscopic treatment of MCL injury, and the results showed acceptable postoperative and clinical outcomes. As the use of minimally invasive surgery may minimize multiple complications associated with open surgery, it is suggested that further studies be conducted regarding this approach when faced with patients who have MCL injuries requiring surgery.

Short-term results of combined anterior cruciate ligament and anterolateral ligament reconstruction using a novel hamstrings graft construct in obese patients: a pilot study

Abstract Background Elevated body mass index (BMI) was associated with increased complication rates including failures in arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. We present our short-term results of our technique used for ACL reconstruction in obese patients with the aim to reduce chances for graft failure and improve outcomes. Patients and methods We present our case series of obese patients (BMI > 30) operated for ACL reconstruction during the period from January 2017 to January 2022 using a dedicated technique for ACL reconstruction. We are using hamstring tendons prepared in a single construct to reconstruct both the intra-articular ACL and the anterolateral ligament. All patients received the same surgical technique and associated injuries were operated on according to their indications and guidelines. All patients completed the subjective knee evaluation form of the International Knee Documentation Committee at the time of the procedure and at the last follow-up visit and assessment of knee laxity was performed using a KT-1000 arthrometer before the surgery and at the last follow-up. Results Twenty patients underwent anterior cruciate ligament reconstruction (ACLR) using this technique during the study period, with average follow-up period of 1 year. All cases were males, mean BMI was 32.2 (30.4–36.2), 18 cases were operated on using ipsilateral Semitendinosus and Gracilis grafts, 2 cases were operated on using contralateral knee hamstrings. All cases were instructed nonweight bearing for 6 weeks after surgery and received the same standard accelerated rehabilitation protocol. Two cases developed postoperative superficial wound infection at the graft harvest site that resolved with conservative treatment of oral antibiotics and wound care. The mean postoperative International Knee Documentation Committee score improved from 45.195 to 79.245 (P<0.001), and the mean KT-1000 arthrometer differential improved from 11.8 to 2.77 (P<0.001) and pivot shift tests were negative in the postoperative exam for all the cases. Conclusion ACLR in obese patients should be approached with care, our technique can offer a feasible solution to obtain an acceptable outcome, Further work is required to provide insight on the long-term outcome of ACLR in obese patients.

Medial meniscal lesions increase antero-posterior laxity in knees with anterior cruciate ligament injury.

The aim of this study was to quantify the impact of concomitant meniscal lesions on knee laxity using a triaxial accelerometer in a large population of patients affected by anterior cruciate ligament (ACL) injury. A total of 326 consecutive patients (261 men and 65 women, mean age 31.3 ± 11.3) undergoing primary ACL reconstruction, were preoperatively evaluated through Lachman and pivot shift tests using a triaxial accelerometer to quantify knee laxity. An analysis based on the presence of meniscal tears assessed during surgery was performed to evaluate the impact of meniscal lesions on knee laxity. The anterior tibial translation (Lachman test) presented significantly higher values in patients with medial meniscal lesions (7.3 ± 1.7 mm, p = 0.049) and both medial and lateral meniscal lesions (7.7 ± 1.6 mm, p = 0.001) compared to patients without concomitant meniscal lesions (6.7 ± 1.3 mm). Moreover, patients with both medial and lateral meniscal lesions presented significantly higher values of anterior tibial translation compared to patients with lateral meniscal lesions (p = 0.049). No statistically significant differences were found between the groups in terms of tibial acceleration (pivot shift test). This study demonstrated that the contribution of concomitant meniscal lesions to knee laxity can be objectively quantified using a triaxial accelerometer in ACL-injured knees. In particular, medial meniscus lesions, alone or in association with lateral meniscus lesions, determine a significant increase of the anterior tibial translation compared to knees without meniscus tears. Level IV.

Outcome of home-based rehabilitation program following arthroscopic anterior cruciate ligament reconstruction in nonathletic patient

Abstract Background: Rehabilitation following anterior cruciate ligament (ACL) reconstruction is thought to be important by almost all surgeons. It has even been considered by some to be as important as surgery itself. As the surgical procedure for these injuries evolved, so has the rehabilitation. A traditional approach to rehabilitation which focused on delayed weight bearing and mobilization is now being replaced by accelerated rehabilitation which advocates early weight bearing and results in early return to sports. Materials and Methods: This is a observational case-control comparative study conducted in our department from September 2019 to February 2021. About 30 cases of more than 20 years of age with comparable matching group are included in our study. Assessment of Lysholm score, International Knee Documentation Committee (IKDC) score, ACL quality of life score, and Tegner activity level is done. Functional assessment was carried out by Carioca test, one leg hop test, and Shuttle test. Assessment of clinical status is done by anterior drawer test, Lachman test, and Pivot shift test. Results: All patients participating in study although nonathletic had complaints of instability and giving away episodes of knee in their day to day activities and therefore were considered as candidates for surgery. Following an arthroscopic ACL reconstruction, they were given written home-based protocols with goals and exercises being explained to them at the time of discharge. All the patients participating in the study were able to return to their preinjury activity level as assessed by the Tegner activity scale at the final follow up. Their functional outcome as measured by Lysholm score, IKDC score, and ACL quality of life score was significantly lower when compared to an age, sex, and activity matched control group. The patients functional performance as assessed by one leg hop test, Carioca test, and Shuttle test was also below the level of what was seen in control groups. More than 90% patients had a stable knee as assessed by the anterior drawer test, Lachman test and pivot shift test (29 patients has anterior drawer of ≤5 mm, 27 patients had Lachmann test ≤5 mm and all 30 patients had pivot shift grades in absent or glide category). Conclusions: Home-based rehabilitation is an effective method of rehabilitation in low demand individuals following ACL reconstruction. In the future, adequately powered randomized controlled trials are needed to assess the usefulness of one rehabilitation protocol over other in these group of low demand patients.

Evolving concepts in the treatment of posterior shoulder instability with glenohumeral bone loss.

Posterior shoulder instability is an increasingly recognized phenomenon and comprises approximately 5% of all shoulder instability cases. Posterior shoulder instability presents a complex clinical challenge, particularly when associated with bone loss. Bone loss may be present in up to 25% of patients with posterior shoulder instability. Understanding its etiology, diagnosis, and treatment options is crucial for optimal patient outcomes. Young athletic individuals, especially football linemen and throwing athletes, are commonly affected, with symptoms ranging from insidious onset pain to noticeable changes in athletic performance. History, physical examination, and imaging, including radiographs and advanced three-dimensional imaging, play pivotal roles in diagnosis, with specific tests like the Jerk, Kim, and load and shift tests aiding in provocation. Posterior glenoid bone loss (pGBL), whether dysplastic, attritional, or acute, significantly impacts management decisions. When pGBL exceeds critical thresholds, soft tissue repair alone may be insufficient, necessitating glenoid reconstruction with bone block procedures. Both iliac crest autograft and distal tibial allograft (DTA) offer viable options, with considerations including donor site morbidity and graft integration. Surgical techniques for reverse Hill-Sachs lesions vary from subscapularis transfers to arthroscopic balloon osteoplasty, each aiming to restore native anatomy and prevent engagement. Bipolar bone loss, involving both glenoid and humeral head defects, presents additional challenges and may require combined soft tissue and bony procedures. Quantifying bone loss and understanding its implications are essential for surgical planning. While various techniques show promise, further research is needed to elucidate their long-term outcomes and refine treatment algorithms for posterior shoulder instability with bone loss.

THE ALL-INSIDE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH FIBER-LOOP AUGMENTATION

Objectives: To evaluate the functional outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction with fiber-loop augmented to reinforce the ligament, acting as a secondary stabilizer. Methods: A retrospective study was conducted on 25 patients who underwent the all-inside ACL reconstruction with the addition of fiber-loop inside the ACL graft in the Department of Joint Surgery, Military Hospital 103, from August 2022 to August 2023. Patients were evaluated pre-operatively and finally post-operatively via the Lachman test, Pivot shift test, and Lysholm score. Results: The mean follow-up was 9.84 months; the mean age was 33.04 ± 9.95 years. 24 patients (96%) were post-operatively Lachman negative. The pivot-shift test showed 96% of patients absent or glide after surgery. The Lysholm knee score at the last visit was good and very good in 96% of the patients; the mean score was 92.56 ± 4,53. Conclusion: This study showed good functional outcomes of arthroscopic ACL reconstruction with fiber-loop augmentation to reinforce the ligamental graft. There is a need for more comparative studies with longer follow-ups and large sample sizes.

Preliminary Outcomes of Scapholunate Ligament Augmentation with Internal Brace Technique

Injury to the scapholunate (SL) interosseous ligament (SLIL) is a common cause of carpal instability. Internal brace augmentation has been used in various ligament repair procedures; however, further investigation of its outcomes in hand surgery is needed. This study aimed to examine outcomes for patients who underwent SLIL repair with internal brace augmentation. Patients who underwent SLIL repair with the internal brace technique and had at least 1 year of follow-up were contacted. Available patients returned for an in-person evaluation with new radiographs and physical examination. If patients could not be contacted but had x-rays and physical examinations performed at greater than 1 year after surgery, these data were collected from their medical records. Participating patients completed the QuickDASH and Patient-Rated Wrist Evaluation surveys and rated their satisfaction with the surgery. Outcomes assessed included wrist range of motion, grip strength, scaphoid shift test, SL gap, SL angle, and radiographic evidence of radiocarpal arthritis. We collected outcomes for 14 SLIL repairs among 13 patients (12 male). Mean length of the follow-up was 41 months (n= 14, 17-64). Mean QuickDASH and Patient-Rated Wrist Evaluation scores were 6.1 (0-43.2) and 9.6 (0-65), respectively. Radiographic measurements remained stable from immediate to latest follow-up, and no radiocarpal arthritic changes were noted. However, SL gap decreased from a mean of 5.33 mm (3.4-6.7) before surgery to 3.34 mm (2-4.6) at the latest follow-up, and SL angle decreased from a mean of 79.5° (67°-97°) before surgery to 67.3° (51°-85°) at the latest follow-up. All scaphoid shift tests were stable. Therefore, SL internal brace augmentation has favorable short-term results with improvements in pain, function, satisfaction, and carpal alignment at greater than 1 year postoperatively. This technique can be an effective option for the management of SL instability in the short term. Therapeutic IV.

Evaluation of the anterolateral ligament of the knee with high resolution ultrasound

Objectives: To determine whether high-resolution ultrasound is an exam that contributes to the identification and assessment of the integrity of the anterolateral ligament of the knee in patients with anterior cruciate ligament injury. Methods: 41 patients, 16 to 55 years old, with primary lesion of the anterior cruciate ligament were evaluated. Demographic data were collected, and a Pivot Shift test was performed. An ultrasound examination was performed, with a high- resolution probe, on both patients' knees, initially, seeking the visualization of the anterolateral ligament in all its extension and later assessing its integrity, ending with an assessment of the lateral meniscus. Results: 100% of the evaluated cases, it was possible to visualize the anterolateral ligament through ultrasound with 46.3% of injuries, with the tibial portion being the most injured. 19 patients (46.3%) had anterolateral ligament injury on the same side as the anterior cruciate ligament injury, while in 19 cases (46.3%) no anterolateral ligament injury was observed on either side. 5 patients had a pivot shift test considered positive with 80% of associated anterolateral ligament injury. 31 patients had lateral meniscus injury by magnetic resonance imaging. Of the 31 patients, 25 were confirmed by ultrasound. Of the 11 patients without lesion of the lateral meniscus by MRI, none had an ultrasound lesion. Adding these two groups, 92.6% of results favorable to ultrasound, (p <0.001). Conclusion: The data obtained suggest that ultrasound contributes to the identification and assessment of the integrity of the knee anterolateral ligament in patients with anterior cruciate ligament injury. Level of Evidence IV.

Satisfactory outcomes after one-stage revision anterior cruciate ligament reconstruction using rectangular tunnel technique.

One-stage revision anterior cruciate ligament reconstruction (ACLR) with the anatomic rectangular tunnel (RT) technique using bone-patellar tendon-bone (BTB) grafts results in anatomically precise tunnel placement and secure graft fixation. This study evaluated knee joint laxity and clinical outcomes in terms of femoral tunnel overlap. It was hypothesised that there would be no significant differences in knee joint laxity or clinical outcomes regardless of femoral tunnel overlap. Between 2012 and 2021, a single surgeon conducted 196 one-stage revision ACLRs with the RT technique using BTB grafts. Patients were divided based on the presence of femoral tunnel overlap. Knee joint laxity was evaluated using the Lachman test, pivot shift test, and side-to-side difference measured with a KT-1000 arthrometer. Clinical outcomes were assessed using the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Knee Examination Form 2000. Knee joint laxity and clinical outcomes were compared between groups after a median follow-up of 2.5years (range 2.0-8.0). The study included 30 and 73 patients in the overlap and non-overlap groups, respectively. No significant differences were observed in the results of the Lachman test, pivot shift test, or KT-1000 arthrometer as well as in the Lysholm, KOOS, or IKDC scores between the two groups. Based on the IKDC scores, all patients were graded as normal or nearly normal. One-stage revision ACLR with the RT technique using BTB grafts improved knee joint laxity and had favourable clinical outcomes regardless of femoral tunnel overlap. To achieve optimal results in one-stage revision ACLR, it is crucial to create a tunnel within the anatomical attachment area and ensure proper graft fixation and tensioning. III.

Combination Test for Mean Shift and Variance Change

This paper considers a new mean-variance model with strong mixing errors and describes a combination test for the mean shift and variance change. Under some stationarity and symmetry conditions, the important limiting distribution for a combination test is obtained, which can derive the limiting distributions for the mean change test and variance change test. As an application, an algorithm for a three-step method to detect the change-points is given. For example, the first step is to test whether there is at least a change-point. The second and third steps are to detect the mean change-point and the variance change-point, respectively. To illustrate our results, some simulations and real-world data analysis are discussed. The analysis shows that our tests not only have high powers, but can also determine the mean change-point or variance change-point. Compared to the existing methods of cpt.meanvar and mosum from the R package, the new method has the advantages of recognition capability and accuracy.

Diaphragmatic breathing combined with abdominal drawing-in maneuver for walking function in post-stroke patients: a randomized controlled study protocol

BackgroundPatients with stroke frequently experience walking dysfunction. Core training can help improve balance and walking function in patients with stroke. However, core training movements in clinical practice are numerous and differently targeted. Therefore, this study will investigate the improvement of walking function in patients with combined diaphragmatic breathing maneuver (DBM) and draw-in breathing technique (ADIM) training.MethodsThis single-blind, randomized controlled preliminary will analyze the viability of DBM combined ADIM training versus routine rehabilitation therapy in patients with stroke with early to mid-stroke. Patients will be randomly assigned to either the DBM and ADIM training or the routine rehabilitation training. We will recruit 42 stroke inpatients from the Second Rehabilitation Hospital of Shanghai who meet the trial criteria and measure the balance and walking functions and improvement of that after 4 weeks of intervention. The primary outcome is the 10 m maximum walking test (10MWT). The secondary outcomes indices include the limits of stability test (LOS), Berg balance scale test (BBS), Functional Ambulation Categories test (FAC), Timed Up and Go test (TUG), trunk impairment scale test (TIS), ultrasound indicators of the diaphragm and transversus abdominis (UI), rhythmic weight shift test (RWS), walk across test (WA), Fugl-Meyer assessment of lower extremity (FMA-LE), and Barthel index of ADL test.DiscussionThe primary objective of this project was to investigate the effects of DBM combined with ADIM on balance capacity and walking function for patients with early to mid-stroke. The outcomes of this study will hold significant implications for future clinical applications in rehabilitation.Trial registrationChinese Clinical Trial Registry (ChiCTR), ID: ChiCTR2100054897. Registered on 28 December 2021.

Lever-Test Accuracy in Detecting Anterior Cruciate Ligament (ACL) Tears: A Single Institution Experience.

Background One of the most often damaged ligaments in the knee is the anterior cruciate ligament (ACL). With the increased occurrence of ACL injuries, there is a greater need for clinical diagnostics to rule in or rule out a suspected rupture. The Lever Test, a novel clinical tool for diagnosing ACL rupture, has been presented, with preliminary trials indicating encouraging results. Methods This is a prospective, blinded, diagnostic accuracy study. The aim of this study was to evaluate the accuracy of the Lever Test and other common clinical tests (Anterior Drawer Test, Lachman Test, Pivot Shift Test) for diagnosing ACL injuries. The study enrolled 23 patients who had knee pain, instability, and locking symptoms. The clinical tests were performed on the patients in supine position before, during, and after anesthesia. The results of the clinical tests were compared with MRI findings to determine the sensitivity of each test. Results The patients consisted of 17 men and six women, with a mean age of 30.4±9.95 years. 18 patients had complete tears, four had partial tears, and one had intact ACL damage. 10 (44%) complained in the right knee, 13 (56%) in the left knee, and two (9%) had a generalized ligamentous laxity. 21 (91%) complained of giving away, 22 (96%) complained of knee pain, and 10 (43%) complained of locking of the knee. On the ipsilateral leg examination, pre-operative positivity of Lever Sign was 44%, Lachman 83%, and Anterior Drawer 67%. After being given anesthesia, test positivity rates were 44% for Lever Sign and 56% for Pivot Shift. Post-operative positivity of Lever Sign was 17%, Lachman 39%, and Anterior Drawer 35%. Mcnemar test p values were significant for the difference of positivity anterior drawer test (p=0.002) and were not significant on Lever Sign (p=0.7) and Lachman tests (p=0.13). Correlation analysis showed a weak but not statistically significant interrater reliability between MRI findings and Lever Sign (p=0.846) (Kappa= 0.2). On the contralateral leg examination, the pre-operative positivity of Lever Sign was 9%, Lachman 17%, and Anterior Drawer 22% Conclusion The study suggests that the Lever Test has lower accuracy than other clinical tests when comparing the results of tests with MRI findings. As a result, Lever Test should be used in combination with other clinical tests to accurately rule out suspected ACL injuries.

The posterolateral ligament of the elbow: anatomy and clinical relevance

The posterolateral capsule was recognized in the past as an important structure for elbow stability but was later disregarded. Two recent biomechanical studies demonstrated its role in preventing posterolateral instability, and thus it should be identified as a distinct ligament: the posterolateral ligament (PLL). This study includes 2 parts: an anatomic study of the PLL's footprint and a collection of 5 cases of pathologic lesions of the PLL. Six cadaveric upper limbs were assessed. The attachments of the PLL were dissected, the footprints were marked and photographed, and the 2-dimensional area and length were measured. The mean proximal attachment dimensions were a length of 13 mm and an area of 101 mm2, and the mean distal attachment dimensions were 19 mm and 111 mm2, respectively. There were 2 cases of posterolateral elbow pain in professional cricket bowlers, diagnosed radiographically as enthesopathy of the PLL's proximal attachment on the posterior capitellum, probably due to repeated forced hyperextension of the elbow. Both patients were treated by débridement of the posterior capitellum and reattachment of the PLL, with complete resolution of symptoms. In addition, there were 3 cases of clinical posterolateral rotatory instability in young patients. Two athletes had an isolated acute tear of the PLL, and on physical examination, both had positive posterior draw test results but negative pivot-shift test results. Both underwent elbow arthroscopy and repair of the PLL with resolution of symptoms. The third patient had long-standing recurrent elbow instability, following a failed lateral ulnar collateral ligament reconstruction, in the presence of an Osborne-Cotterill lesion. He underwent revision lateral ulnar collateral ligament reconstruction, bone grafting of the bony lesion, and reattachment of the PLL, with complete resolution of symptomatic posterolateral rotatory instability. The PLL of the elbow has a significant role in the elbow's posterolateral stability. Its footprints were described, and its clinical significance was demonstrated in cases of elbow instability caused by acute ligament tears and elbow pain due to ligament enthesopathy. Surgeons should be aware of this structure and potential pathology related to its injury.

Initial clinical evaluation of a novel combined biometric, radio-frequency identification, and surface imaging system

PurposeTo evaluate and characterize the overall clinical functionality and workflow of the newly released Varian Identify system (version 2.3). MethodsThree technologies included in the Varian Identify system were evaluated: patient biometric authentication, treatment accessory device identification, and surface-guided radiation therapy (SGRT) function. Biometric authentication employs a palm vein reader. Treatment accessory device verification utilizes two technologies: device presence via Radio Frequency Identification (RFID) and position via optical markers. Surface-guidance was evaluated on both patient orthopedic setup at loading position and surface matching and tracking at treatment isocenter. A phantom evaluation of the consistency and accuracy for Identify SGRT function was performed, including a system consistency test, a translational shift and rotational accuracy test, a pitch and roll accuracy test, a continuous recording test, and an SGRT vs Cone-Beam CT (CBCT) agreement test. Results201 patient authentications were verified successfully with palm reader. All patient treatment devices were successfully verified for their presences and positions (indexable devices). The patient real-time orthopedic pose was successfully adjusted to match the reference surface captured at simulation. SGRT-reported shift consistency against couch readout was within (0.1 mm, 0.030). The shift accuracy was within (0.3 mm, 0.10). In continuous recording mode, the maximum variation was 0.2 ± 0.12 mm, 0.030 ± 0.020. The difference between Identify SGRT offset and CBCT was within (1 mm, 10). ConclusionsThis clinical evaluation confirms that Identify accurately functions for patient palm identification and patient treatment device presence and position verification. Overall SGRT consistency and accuracy was within (1 mm, 10), within the 2 mm criteria of AAPM TG302.

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.

ALL Repair and Reconstruction: Techniques From the SANTI Study Group

Background: Combining an anterior cruciate ligament (ACL) reconstruction with an anterolateral ligament (ALL) reconstruction results in significant advantages including reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to preinjury levels of sport. Indications: The previously reported indications for combined ACL and ALL reconstruction are as follows: ACL reconstruction revision; high-grade pivot shift test; long-term ACL rupture; young patients; pivoting activities; concomitant medial meniscus repair, and, specifically, regarding the ALL repair, it must be an acute surgery (within 15 days from injury). Technique Description: Several modern techniques have been described to repair and reconstruct the ALL. This technical note details a number of these techniques performed by the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. Results: First, we describe a combined ACL reconstruction and double-bundle ALL reconstruction using hamstring autograft. Secondly, we describe a single-bundle ALL reconstruction using gracilis autograft. Thirdly, we describe an ALL reconstruction technique using a knotless soft anchor, which provides shallow fixation and prevents tunnel convergence. Finally, we describe a technique for ALL repair. Conclusion: Several techniques have been described to repair and reconstruct the ALL, all offering significant advantages over an isolated ACL reconstruction. 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.

A New Algorithm to Treat Chronic Combined ACL/MCL Injuries: Let's Come Back to the “Rotatory Instability Test”

Background: Chronic combined medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries are frequent. Medial residual laxity is a risk factor for ACL rerupture. It should be treated at the same time as the ACL reconstruction (ACLR) if necessary, but there are still questions surrounding the indications for abstention or surgery of the medial plan, especially for grade 2 MCL injuries of the Fetto and Marshall classification. Indications: The purpose is to come back to a simple test, the “Rotatory Instability Test” as described by Slocum and Larson in 1968 for systematic clinical examination of the knee to improve the sensitivity and accuracy of the deep MCL (dMCL) and superficial MCL (sMCL) examination and to propose a decision-making algorithm for the treatment of the chronic combined ACL/MCL injuries based on the assessment of anteromedial rotatory instability (AMRI). Technique Description: Examination of the ACL with Lachman test, anterior drawer in neutral rotation, and pivot shift test confirm the ACL injury. Valgus laxity is tested in extension and at 20° of flexion. Then, an anterior drawer test at 90° of flexion with external rotation is done (the anterior drawer in external rotation [ADER] test) allowing to identify isolated dMCL, dMCL + sMCL, or MCL + posterior oblique ligament (POL) injuries. Discussion: As persistent medial laxity is a risk factor for ACL graft failure and there is no reliable method of instrumented laxity assessment, careful clinical examination remains essential. Systematic examination of the medial side with valgus laxity testing at 0° and 20° flexion combined with the ADER test assessment of AMRI can guide treatment of the MCL injury component. Where there is no valgus laxity and the ADER test is negative, isolated ACLR is indicated. If there is significant medial laxity at 0°, this suggests combining sMCL and POL reconstruction with ACLR. Where the knee is stable at 0° but there is valgus laxity at 20° and a positive ADER test, the dMCL can be reconstructed using a gracilis graft or a combined sMCL and dMCL reconstruction can be added to the ACLR depending on the degree of laxity. 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.

High anteromedial insertion reduced anteroposterior and rotational knee laxity on mid-term follow-up after anatomic anterior cruciate ligament reconstruction.

The position of the femoral insertion has a great influence on the laxity of the knee joint after ACLR, especially for rotational laxity. To compare the effects of different femoral tunnel positions on knee stability after arthroscopic anterior cruciate ligament reconstruction (ACLR). The clinical outcomes of 165 patients after autograft ACLR were analyzed retrospectively. The patients were separated into three groups according to the position of the femoral tunnel, as follows: low center (LC) group, 53 patients; high center (HC) group, 45 patients; and high anteromedial (HAM) group, 67 patients. The side-to-side differences (SSDs) in anteroposterior knee laxity measured using a KT-2000 arthrometer and the pivot shift test (PST) pre- and postoperatively were compared among the three groups and analyzed. After 5 years postoperatively, the SSD in the anteroposterior knee laxity in the three groups was significantly decreased postoperatively compared with preoperatively in knees; meanwhile, the negative PST rate was significantly increased in the three groups. The postoperative SSD in anteroposterior knee laxity was significantly increased in the HC group compared with the LC and HAM groups (1.5 ± 1.3 VS 1.0 ± 1.1 VS 1.0 ± 1.0, P<0.05). The negative postoperative PST rate was higher in both the LC and HAM groups than in the HC group (84.9% VS 91.0% VS 71.1%, P<0.05), and there was no significant difference in the negative PST rate between the LC and HAM groups (84.9% VS 91.0%, P>0.05). The negative postoperative PST rate was significantly higher in the HAM group than in the LC and HC groups for patients with a high degree of laxity preoperatively (31.3% VS 3.3% VS 14.4%, P>0.05). Patients in HAM group showed better control over anteroposterior laxity, rotational laxity, and subjective knee function compared to other groups post operation. Therefore, the HAM point is the closest to the I.D.E.A.L point concept, and is recommended as the preferred location for the femoral tunnel in ACLR.