Time Of Anterior Cruciate Ligament Reconstruction Research Articles

Ramp lesions of the medial meniscus are associated with greater preoperative anterior knee laxity in anterior cruciate ligament injury.

To assess the incidence of ramp lesions in anterior cruciate ligament (ACL) injuries and to compare preoperative knee laxity between the patients with and without ramp lesions by using an electromagnetic measurement system (EMS). Two hundred six patients who underwent primary ACL reconstruction with preoperative EMS measurements were retrospectively enrolled in the present study. The diagnoses of the ramp lesions were made by arthroscopic inspections. The patients with ramp lesions and no other meniscal lesions were allocated to 'ramp group', and the patients without any meniscal lesions were allocated to 'control group'. Before ACL reconstruction under general anaesthesia, the side-to-side difference (SSD) in anterior tibial translation (ATT) during Lachman test (mm) and tibial acceleration (m/s2) of posterior tibial reduction during the pivot-shift test was measured using the EMS. The SSD in tibial internal/external rotation angle (°) at 30, 60 and 90 were further measured using the EMS. The SSD in ATT using KT-2000 was also measured. Knee laxity measurements were compared between two groups using unpaired Student's t test. Ramp lesions were observed in 30 patients (14.7%). Subsequently, 17 patients were allocated to 'ramp group' and 77 patients to 'control group', and there were no statistical differences with regard to background demographics. ATT-SSD during Lachman test was significantly greater in 'ramp group' (9.1 [95% confidence interval, CI: 5.7-12.5] mm vs. 6.2 [95% CI: 5.1-7.3] mm, p = 0.037). However, SSD in ATT with KT-2000, tibial acceleration during pivot-shift test, and SSD in tibial rotational angles were not significantly different between the two groups. Presence of ramp lesion was associated with increased anterior knee laxity during Lachman test, suggesting ramp lesions may need to be addressed at the time of ACL reconstruction. IV.

Factors Affecting Outcomes and Complications of Primary Anterior Cruciate Ligament Reconstruction: A Retrospective Study of 110 Patients.

Anterior cruciate ligament injury poses a major effect on the quality of life of patients. Anterior cruciate ligament reconstruction (ACLR) remains the mainstay of treatment. To (1) test for the correlation of patients' characteristics such as body mass index (BMI), age, smoking status, and postoperative infrapatellar numbness with the subjective outcome of primary ACLR and (2) investigate whether postsurgical complications can be related to the studied patients' characteristics. Case series; Level of evidence, 4. Demographic data and operational notes from patients who underwent primary ACLR at the institute between 2011 and 2022 were extracted. Patients' surgical outcomes were evaluated subjectively using the International Knee Documentation Committee (IKDC) score and the Knee injury and Osteoarthritis Outcome Score (KOOS). Pre- and postoperative scoring were completed at postoperative follow-up in December of 2022, patients completed both the IKDC and the KOOS questionnaires. Patients were asked to rate their knee function out of 10 before and after surgery. This rating was based on the patients' self-assessment of their functional ability without the use of a formal instrument. Knee function was assigned as better, worse, or the same through a comparison of patients' reported scores before and after surgery. Male patients comprised 108 (98.2%) of the total cohort, the mean ± SD age at the time of surgery was 27.92 ± 7.39 years, and BMI was 26.54 ± 3.89. The mean follow-up time was 48.92 ± 27.99 months. Most patients did not need postsurgical intervention (n = 97; 88.2%), while 4 (3.6%), 7 (6.4%), and 2 (1.8%) needed revision, debridement, or both, respectively. The mean IKDC score and KOOS, respectively, were 74.37 ± 20.17 and 85.50 ± 14.83. Patients' BMI had a significant effect on IKDC score (74.68 ± 20.0; P < .001), and infrapatellar numbness after surgery also affected patients' IKDC score (P = .002) and KOOS (P = .043). The age at the time of ACLR was associated with contralateral leg surgery (P = .017). This study showed that higher BMI and infrapatellar numbness negatively affect the subjective outcomes after primary ACLR. Older age at the time of primary ACLR was associated with a higher likelihood of surgery in the contralateral leg.

MCL pie crusting for concomitant medial meniscal surgery does not appear to adversely influence primary ACL reconstruction functional outcomes

ObjectivesMedial collateral ligament “pie-crusting” (MCLPC), selective release of the superficial MCL, has been shown to improve the arthroscopic access to the posterior horn of the medial meniscus without adversely affecting the outcomes of isolated meniscal surgery. However, whether MCL PC, to address concomitant meniscal lesions during anterior cruciate ligament reconstruction (ACLR) surgery, adversely affects ACLR outcomes is unknown. The aim of this study was to assess whether patients who had undergone MCLPC at the time of ACLR had similar post outcomes to patients undergoing isolated ACLR. Methods55 consecutive patients (33 male and 22 female), with minimum 2-year follow-up, who had undergone MCLPC with concomitant primary ACLR (PC group) were retrospectively matched on the basis of age, sex and follow-up with 55 patients who underwent isolated primary ACLR. Post-operative outcome measures (PROMs) included the Knee injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee score, Tegner activity score, the EuroQol five-dimension health questionnaire and EuroQol visual analogue scale. ResultsThe two groups’ median postoperative EQ 5D-VAS, EQ 5D-index and Tegner scores were similar. The difference between pre-operative and post-operative KOOS scores was similar for the two group for all subscales except the ADL subscale which was higher in the MCLPC group (24, IQR ​= ​6–32) than in the isolated ACLR group (5, IQR ​= ​0–9.74). The median post op IKDC score was 84 in the MCLPC group and compared with 90 in the isolated ACLR group. However, the difference between pre-operative and post-operative IKDC scores was higher in patients in the MCLPC group (40, IQR ​= ​25–49) than in the isolated ACLR group (32, IQR ​= ​19.6–46.8). ConclusionsMCLPC, performed at the time of ACLR does not appear to adversely affect the functional post-operative outcomes. Level of evidenceIV.

Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Contributing Factors and Potential Treatments.

Anterior cruciate ligament (ACL) injuries result in abnormal knee motion and long-term joint degradation. ACL reconstruction (ACLR) is done with the aim of restoring normal knee kinematics and slowing the joint degradation process. It does appear that this inevitably happens and can be impacted by a multitude of factors. The aim of this review was to examine the factors that influence the progression of osteoarthritis (OA) after ACLR and examine possible treatments that can aid in slowing that progression. A systematic review was conducted by searching all levels of evidence for all studies in English that assessed risk factors for developing OA after ACL reconstruction, had a minimum follow-up of 10 years, and used radiographical outcomes to measure the presence of OA. Studies on trial treatments to reduce osteoarthritis after ACL reconstruction were also included. It was found that among the factors associated with an increased risk of post-ACLR OA are meniscal lesions, meniscectomy, increased age at the time of ACLR, increased time from injury to surgery, male sex, reduced range of motion, smaller thigh girth, graft complications, and failure. Additionally, in performing the ACLR, anteromedial femoral tunnel placement, higher graft tension, and following guidelines for performing anatomic ACLR have been shown to reduce the risk of OA as well. Patients should be adequately counselled on their risk pre-operatively for informed decision-making. Surgeons should also be aware of potential risk factors and how they can be mitigated.

After 40 days intra-articular injury, risk profile increases linearly with time to surgery in adolescent patients undergoing primary anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) injuries are becoming more common in youth athletes. Time-to-surgery has been shown to significantly affect the rates of concurrent injuries at the time of ACL reconstruction (ACLR). The purpose of this study was to evaluate if time-to-surgery in ACLR impacts observances of intra-articular injuries and to categorize injury profile in relation to time. An Institutional Review Board-approved retrospective cohort study was conducted. Included subjects were aged 21 and below and underwent primary ACLR within 6 months of injury between January 2012 and April 2020. Skeletal maturity was determined via imaging. Laterality, location and severity/pattern of meniscal and chondral injuries were recorded. Multivariate logistic regression was utilized to identify risk factors for intra-articular pathology. Cut-off analyses were added to regression models to identify trends of concurrent injuries. Eight hundred and fifty patients met the inclusion criteria. Patients with observed articular cartilage injuries had a significantly longer time-to-surgery of 66 days (p = 0.01). Risk factors for chondral injury were time-to-surgery (p = 0.01) and skeletal maturity (p = 0.01), while medial meniscal tears were prognosticated by time-to-surgery (p = 0.03), skeletal maturity (p = 0.01) and body mass index (p = 0.00). Cut-off analysis showed that after 40 days the proportion of patients with observed chondral injury increased with time to surgery and that there were significantly different observances of chondral (p = 0.00) and medial meniscal (p = 0.03) injuries in the 6-week model, as compared to the continuous time model. Longer time-to-surgery in ACLR is associated with higher rates of concomitant intra-articular pathology, especially chondral injuries. After 40 days, the observed rates of intra-articular injury increase proportionately with time from injury. A 6-week categorical model best stratifies intra-articular injury risk profile. Risk factor analysis identified skeletally mature patients with delayed surgery of >12 weeks to be at the highest risk for both chondral and medial meniscal injuries after an ACLR. Level III.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years.

The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. Level II, prospective comparative cohort study, before and after intervention.

Lateral extra-articular tenodesis at primary ACL reconstruction increases career length in professional rugby players.

To assess the effect of preoperative and surgical factors on return to play (RTP) rates and career longevity of professional rugby athletes after primary anterior cruciate ligament (ACL) reconstruction (ACL-R). A retrospective review of a consecutive cohort of professional rugby players undergoing primary ACL-R by the senior author between 2005 and 2019 was undertaken. Athletes were included if they were under contract with a professional rugby team at the time of injury and had a minimum of 2-year follow-up. Univariate and multivariate analyses were performed to determine significant predictors of RTP rate, time and career longevity. One hundred and eighteen rugby players with 125 ACL-Rs were identified. Return to professional rugby was achieved in 115/125 (92%) of cases at an average of 9.6 months and those athletes participated at the professional level for 5.9 ± 3.4 years after ACL-R. Younger age (p = 0.006) and ACL-R with a concomitant lateral extra-articular tenodesis (LET) (p = 0.013) were predictors of a longer career. A Cox proportional hazards model that controlled for age revealed that athletes who underwent ACL-R with an LET had increased career longevity compared to those with an ACL-R without LET (hazard ratio = 2.74, p = 0.021). No factors were significantly associated with RTP rate or RTP time. In professional rugby players undergoing primary ACL-R, those having ACL-R with a concomitant LET and younger age predicted increased career longevity. Rugby players who underwent LET at the time of ACL-R had an 18% greater chance of still playing professionally at 5 years compared to those who underwent ACL-R alone. Level III.

A higher incidence of chondral injuries on the medial femoral condyle in concomitant ACL ruptures, no significant difference in treatment:A systematic review.

The associated damage to articular cartilage in anterior cruciate ligament (ACL) injured patients is a well-recognized phenomenon; however, there is a relative paucity in the literature regarding the different treatment techniques and outcomes. The purpose of this systematic review was to identify patients treated for acute ACL rupture and associated cartilage injury, with interest in the surgical management of these chondral injuries and any difference in patient-reported outcome measures (PROMs) differing techniques. A systematic review was performed looking for treatment or management of International Cartilage Repair Society grade 3 or 4 articular cartilage injury at the time of ACLreconstruction. Seventeen studies fit the criteria, a total of 892 patients were included, 64.6% were male with a mean age of 33.7and the average time to follow-up was 41.7 months. 68.2% of the lesions were on the medial femoral condyle (MFC) with a mean lesion size of 3.9 cm2. Six different operative methods of dealing with chondral lesions were identified, there was no significant difference in PROMs between the techniques, although there was a significant difference between the preoperative and postoperative outcome measures. The systematic review found that chondral defects on the MFC are more common in concomitant ACL injuries, despite the pattern of bone bruising being more common on the lateral femoral condyle as reported in the literature. It also found no significant difference in the PROMs between the six different techniques identified for the concomitant management of ACL reconstruction and chondral defects. Level II.

Medial Meniscectomy at the Time of ACL Reconstruction Is Associated With Postoperative Anterior Tibial Translation: A Retrospective Analysis.

Medial meniscal pathology and management have not been associated with postoperative anterior tibial translation (ATT) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate the role of medial meniscal injury and treatment on pre- and postoperative ATT in the setting of primary ACLR. More specifically, the association between repairable medial meniscal tears, medial meniscectomy, and postoperative ATT, along with rates of revision surgery, was examined. Cohort study; Level of evidence, 3. A retrospective review was performed for patients who underwent ACLR between January 1, 2010 and December 31, 2015 at a single center. Descriptive data were obtained from an institutional database for a total of 396 patients included in this study and followed for 1 year postoperatively. Statistical analysis was performed to examine associations of meniscal treatment with postoperative ATT measurements made by KT-1000 arthrometer. A total of 243 patients underwent isolated ACLR with autograft, 72 patients underwent autograft ACLR and partial medial meniscectomy (MMx) (ACLR + MMx), and 81 patients underwent autograft ACLR and medial meniscal repair (MMR) (ACLR + MMR). Patients with ACLR + MMx had higher mean age and body mass index compared with patients in the other groups. Patients who underwent ACLR + MMx had greater postoperative side-to-side ATT compared with patients undergoing ACLR (1.55 mm vs 1.07 mm; P = .04) or patients undergoing ACLR + MMR (1.55 mm vs 1.01 mm; P = .03). The ACLR + MMx group was less likely to have symmetric (<3-mm side-to-side difference) postoperative ATT compared with the ACLR group (85% vs 93%; P = .03). There was no difference in postoperative ATT between ACLR and ACLR + MMR. Postoperative return to the operating room was greater in the ACLR + MRR group compared with the ACLR + MMx group (21.9% vs 8.2%; P = .05). MMx at the time of ACLR led to higher postoperative ATT compared with isolated ACLR or ACLR + MMR.

Poster 365: Impact of Graft Type and Meniscal Status on Patellofemoral Cartilage Early after ACL Reconstruction

Objectives: Anterior cruciate ligament reconstruction (ACLR) restores passive knee stability but does not reduce the rate of osteoarthritis (OA). Meniscal status, requiring repair or meniscectomy, is a known component of degenerative progression. Regarding the patellofemoral joint (PFJ) specifically, traditional imaging modalities have shown some evidence that patellar tendon autograft (BPTB) is associated with an increased risk of OA. T2 relaxation time using quantitative MRI (qMRI) is an established method to identify early cartilage changes. However, T2 relaxation in the PFJ as a function of graft type and meniscal status has not been previously evaluated. We aimed to evaluate the effect of autograft type (BPTB, hamstring [HT] and quadriceps tendon [QT]) as well as concomitant meniscal surgery (repair or meniscectomy) at the time of ACLR on T2 relaxation time in PFJ cartilage. We hypothesized that BPTB grafts, concomitant meniscal repair, and meniscectomy would result in higher (worse) T2 relaxation times at 6 months after ACLR. We also evaluated the effect of abnormal joint loading during gait on the PFJ cartilage. We hypothesized that T2 relaxation times would not differ in any group after controlling for knee joint loading during walking. Methods: Thirty-four participants aged 15-35 years were enrolled prospectively within 1 month of ACL injury. Exclusion criteria included prior knee injury or surgery, concomitant grade III tear to other knee ligaments that was symptomatic or required surgical intervention and presence of chondral damage. Sagittal qMRIs were obtained within 1 month of injury (but prior to ACLR) and 6 months after ACLR. Articular cartilage of the PFJ was manually segmented using ITK-SNAP software (Penn Image Computing and Science Laboratory, University of Pennsylvania) and was confirmed for accuracy by a board-certified, fellowship-trained musculoskeletal radiologist (Figure 1). Mean T2 relaxation times were extracted from the trochlear and patellar cartilage. Non-physiological T2 relaxation times less than 10 ms and greater than 90 ms were excluded. Gait biomechanics were captured using two in-ground force plates (Bertec Corporation, Columbus, OH) sampled at 1,080 Hz and retroreflective markers with an 8-camera motion capture system (Qualisys, Göteborg, Sweden) sampled at 120 Hz. Data was processed using Visual 3D software (C-motion, Bethesda, MD). Using an inverse dynamic approach, joint angle and force plate data were used to calculate the knee flexion moment (KFM) impulse normalized to mass and height during the stance phase. Separate one-way ANOVAs were used to evaluate the relationship between graft type and concomitant meniscus surgery with the percent change in T2 relaxation time in PFJ cartilage from baseline to 6 months after ACLR. To determine the influence of gait biomechanics on T2 relaxation time across groups, general linear models were used with the interlimb ratio (involved/uninvolved) of KFM impulse as a covariate. Results: The 34 participants had a mean age of 19.0±4.7 years, and 21 (61.8%) were female. Grafts used during ACLR included 22 BPTB, 4 HT and 8 QT. Seventeen participants (50.0%) had a concomitant meniscus repair and 3 (8.8%) had a meniscectomy. Overall, T2 relaxation time increased 8.7±7.3% in the patellar cartilage (pre-ACLR: 39.1±2.6 ms, 6 months: 42.4±3.6 ms, p&lt;0.001) and 7.1±7.3% in the trochlear cartilage (pre-ACLR: 46.3±2.6 ms, 6 months: 49.5±2.7 ms, p&lt;0.001). The change in T2 relaxation time 6 months after ACLR did not differ based on graft type in either the patellar (p=0.729) or trochlear cartilage (p=0.525) (Figure 2). Group differences remained insignificant after controlling for knee loading (KFM impulse) during gait (patellar: p=0.594; trochlear: p=0.222). Meniscal status was also not associated with a change in T2 relaxation time in either the patellar (p=0.392) or trochlear cartilage (p=0.190) (Figure 3) although there was a trend toward higher T2 relaxation times in those with a concomitant meniscus repair or meniscectomy. Group differences remained statistically insignificant after controlling for the KFM impulse during gait (patellar: p=0.400; trochlear: p=0.197). Conclusions: Our findings provide insufficient evidence that graft type is associated with worse quantitative chondral changes within the PFJ at 6 months following ACLR. While meniscal status is a known risk factor for increased contact pressure in the involved compartment and subsequent degenerative progression, our data does not demonstrate statistically significant changes to the PFJ cartilage when meniscal tears were present, likely due to the limited sample size and large variation within groups. Future work with larger cohorts is needed to confirm our findings and further investigate the role that graft type and meniscal status may play within the PFJ after ACLR. [Figure: see text][Figure: see text][Figure: see text]

Repair of bucket handle meniscus tears improves patient outcomes versus partial meniscectomy at the time of ACL reconstruction.

The aim of this study was to examine demographic and surgical factors that influence patient-reported knee function in patients who undergo anterior crucial ligament reconstruction (ACLR) with concurrent bucket-handle meniscal tear (BHMT) procedures. We hypothesized that repair of BHMT in the setting of concomitant ACLR and shorter time from injury to surgery would lead to improved patient-reported outcomes. Forty-one patients (mean age: 28.0 ± 9.8 years, 72% male) with BHMT at the time of ACLR completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) via online survey at an average of 15.2 months postop. Patient demographics and surgical characteristics, including time from injury to surgery, were compared between repair (n = 22) and meniscectomy (n = 19) groups using one-way analysis of variances; distributions of sex, graft source, BHMT compartment and zone were compared between groups using χ 2 tests. The association between IKDC-SKF score, demographics and surgical characteristics was evaluated using multivariable linear regression. A priori alpha level was p < 0.05. Meniscal repair and meniscectomy groups differed based on graft source and BHMT zone but not IKDC-SKF score (p = 0.085). Patients undergoing ACLR with autograft (p = 0.003) and with red-red zone BHMT (p < 0.001) more often underwent meniscal repair. The regression model demonstrated longer time from injury to surgery (p = 0.049), red-red tear zone (p = 0.04) and meniscectomy (p = 0.008); these were predictive of poorer IKDC-SKF scores. BHMT repair was more likely performed in ACL autograft and on red-red zone tears. Longer time from injury to surgery is an indicator of poorer IKDC-SKF score, as this may increase the risk of concomitant pathologies. White-white zone BHMTs are associated with better IKDC-SKF scores than red-red zone BHMTs, which may be due to the smaller volume of tissue removed during meniscectomy of white-white zone tears and the avoidance of iatrogenic complications of meniscal repair. Level III, therapeutic study.

Analysis of the Swedish Knee Ligament Register: Concomitant injuries, revision surgery and smoking render worse results.

To analyse the 52,199 patients in the Swedish Knee Ligament Register (SKLR) preoperatively, and the patients reaching 5- and 10-year follow-ups who underwent anterior cruciate ligament reconstruction (ACLR), revision ACLR and ACLR on the contralateral side (CACLR). The main hypothesis was that patients undergoing revision ACLR would have worse patient-reported outcome measurements (PROMs) than the primary ACLR group at 10 years and that smoking and concomitant injuries would result in poorer outcomes for all groups. Data from 2005 to 2021 were extracted from the SKLR. Only patients whose ACLR surgery was registered in the SKLR were included for revision ACLR and CACLR. The PROMs consist of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the knee-specific PROM (EQ-5D-3L). PROMs were analysed as a whole and in subgroups based on sex, smoking, graft choice and concomitant injuries. Poorer KOOS were seen for revisions compared with primary ACLRs at both the 5- and 10-year follow-ups (p = 0.003). Smokers had significantly poorer KOOS than nonsmokers (p < 0.001) preoperatively in all groups, however only in the primary ACLR group at 5 and 10 years. At 10 years, patients who had undergone CACLR had lower KOOS than primary ACLRs (p = 0.03). Concomitant injuries resulted in statistically, significantly poorer KOOS for both primary ACLRs and CACLRs preoperatively and at the follow-ups. The PROMs for revision ACLRs have worse KOOS scores at 10 years compared with the primary ACLRs. The presence of concomitant meniscal or cartilage injuries at the time of ACLR or CACLR were associated with worse PROMs. Level III.

Nonanatomic femoral tunnel placement increases the risk of subsequent meniscal surgery after ACLR: Part II-Patients without recurrent ACL injury.

The purpose of this study was to identify risk factors for subsequent meniscal surgery following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients without recurrent ACL injury. Patients aged ≥14 years who underwent primary ACLR with minimum 1-year follow-up and without recurrent ACL injury were retrospectively reviewed. Patient demographics and surgical data at the time of ACLR were collected. Postoperative radiographs were used to measure femoral and tibial tunnel position, and posterior tibial slope. Univariate and multivariate analyses were performed to identify risk factors for subsequent meniscal surgery. Of 629 ACLRs that fulfilled the inclusion criteria, subsequent meniscal surgery was performed in 65 [10.3%] patients. Multivariate analysis revealed that medial meniscal repair at the time of ACLR, younger age, anterior femoral tunnel position and distal femoral tunnel position were significantly associated with subsequent meniscal surgery (p < 0.001, p = 0.016, p = 0.015, p = 0.035, respectively). The frequency of femoral tunnel placement >10% outside of the literature-established anatomic position was significantly higher in those who underwent subsequent meniscal surgery compared to those who did not (38.3% vs. 20.3%, p = 0.006). Posterior tibial slope and ACL graft type were not significantly associated with subsequent meniscal surgery. Medial meniscal repair at the time of ACLR, younger age and nonanatomic femoral tunnel placement were risk factors for subsequent meniscal surgery in patients without recurrent ACL injury. Femoral tunnel placement <10% outside of the native anatomic position is important to reduce the risk of subsequent meniscal surgery. Level IV.

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis

Background: The addition of an iliotibial band–based lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has been shown to reduce failure rates. However, there are concerns as to the potential overconstraint of tibiofemoral kinematics that may increase the risk of cartilage degradation. To date, no clinical study has investigated the effect of LET on patellofemoral joint articular cartilage health. Hypothesis: It was hypothesized that at 2 years postoperatively, (1) the addition of LET at the time of ACLR would have no effect on cartilage health on magnetic resonance imaging (MRI), and (2) higher cartilage relaxation values would be associated with worse patient-reported and functional outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A subset of patients from the STABILITY 1 randomized controlled trial were included. All patients underwent primary ACLR with a hamstring autograft. Patients were randomized to either LET augmentation or not. Cartilage status in the patellofemoral joint between the ACLR group and ACLR+LET group was compared using 2-year postoperative quantitative MRI and the ACL osteoarthritis scores of both the surgical and the contralateral nonsurgical knees. Objective functional outcomes and patient-reported outcome measures (PROMs) were attained. Results: A total of 92 patients (43 patients in the ACLR group; mean age, 18.9 ± 3.2 years; 60.5% female; and 49 patients in the ACLR+LET group; mean age, 18.7 ± 3.2 years, 63.3% female) were included. No significant differences were seen in the mean values (ms) for adjusted T1ρ/T2 relaxation times in the medial patella (47.8/42.2 vs 47.3/43.2), central patella (45.5/42.5 vs 44.1/42.7), lateral patella (48.2/43.5 vs 47.3/43.0), medial trochlea (54.7/50.9 vs 56.4/50.9), central trochlea (53.3/51.1 vs 53.1/52.0), and lateral trochlea (54.9/52.1 vs 53.9/52.6) between the ACLR and ACLR+LET groups. No difference in overall ACL osteoarthritis scores was observed (P = .99). An increase in medial patellar T2 relaxation times was associated with a decreasing International Knee Documentation Committee score (P = .046), Knee injury and Osteoarthritis Outcome Score (KOOS) Symptoms subscale score (P = .01), and total KOOS (P = .01). Conclusion: There was no statistical difference in patellofemoral cartilage health between knees 2 years after primary ACLR with hamstring tendon autograft with or without LET. Statistically significant correlations were found between quantitative MRI relaxation times, functional outcome scores, and PROMs; however, the correlations were weak and the clinical significance is unknown. Registration: NCT02018354 (ClinicalTrials.gov identifier).

Arthroscopic Repair of a Lateral Meniscus Oblique Radial Tear

Background: Lateral meniscal oblique radial tears (LMORTs) are the most common type of lateral meniscal tears and occur concomitantly with anterior cruciate ligament (ACL) tears in up to 12% of cases. Four types of LMORTs have been classified in the literature based on proximity to the meniscal root and extent of the tear. Type 1 and 2 LMORTs represent partial and complete posterior root tears less than 10 mm from the root insertion. Type 3 and 4 LMORTs are partial and complete posterior radial meniscus tears greater than 10 mm from the root insertion. Indications: Type 3 and 4 LMORTs can and should be addressed with an all-inside side-to-side repair at the time of ACL reconstruction. LMORTs that are not repaired at the time of ACL reconstruction can contribute to persistent instability and meniscal extrusion. Technique Description: Diagnostic arthroscopy is performed to evaluate the posterior aspects of both the medial and lateral meniscus. The medial leaflet is commonly flipped into the notch and scarred to ACL remnant. After identifying and isolating the medial leaflet, an arthroscopic suture passer is used to pass a suture from inferior to superior through the medial leaflet. A second suture is passed from inferior to superior through the lateral leaflet. This is used to shuttle the suture pass through the medial leaflet to the bottom of the meniscus, where it can be tied in a horizontal mattress fashion. The sutures are tied down with aide of an arthroscopic knot pusher. A second set of sutures is passed and used to shuttle a second suture that would be tied posterior to the first suture, again in a horizontal mattress fashion. This allows reduction of the fragments in apposition across the tear. Postoperatively, patients are allowed range of motion from 0° to 90° and to toe touch weightbearing for the first 4 weeks. Patients are advanced to weightbearing as tolerated at 5 weeks. Typical return to sport ranges from 6 to 9 months postoperatively. Results: Results have been published for 2-year outcomes of type 3 and 4 LMORT repairs and have demonstrated persistent improved patient-reported outcomes as well as healing rates that are greater than 80% and in some series approach nearly 100%. Discussion/Conclusion: Arthroscopic all-inside side-to-side surgical repair is a durable and reliable treatment option for patients presenting for ACL reconstruction with concomitant type 3 or 4 LMORT. 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.

Incidence of and Risk Factors for Medial Meniscal Lesions at the Time of ACL Reconstruction: An Analysis of 4697 Knees From the SANTI Study Group Database

Background: Medial meniscal (MM) lesions (MMLs) are a common finding at the time of anterior cruciate ligament reconstruction (ACLR). It is recognized that evaluation of the posteromedial compartment reduces the rate of missed MML diagnoses. Purpose: To determine the incidence of MMLs in patients undergoing ACLR, when using a standardized arthroscopic approach that included posteromedial compartment evaluation, as well as to determine how the incidence of MMLs changed with increasing time intervals between injury and surgery, and to investigate what risk factors were associated with their presence. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of prospectively collected data was performed. All patients who underwent primary ACLR between January 2013 and March 2023 were considered for study eligibility. The epidemiology was defined by categorizing and reporting the incidence and categorizing the spectrum of MM tear types. Risk factors associated with MMLs were analyzed using a logistic regression model. Results: MMLs were identified in 1851 (39.4%) of 4697 consecutive patients undergoing ACLR. The overall incidence of MMLs was 33.1% for the period of 0 to 3 months, 38.7% for the period of 3 to 12 months, and 59.6% for the period of >12 months. The overall incidence of MMLs increased with longer durations of time between injury and surgery, along with significant increases in complex, bucket-handle, ramp, and/or flap lesions. The largest increase in incidence of MMLs was observed for complex MM tear patterns. Risk factors associated with MMLs included time between injury and surgery >3 months (odds ratio [OR], 1.320; 95% CI, 1.155-1.509; P < .0001) and >12 months (OR, 3.052; 95% CI, 2.553-3.649; P < .0001), male sex (OR, 1.501; 95% CI, 1.304-1.729; P < .0001), body mass index (BMI) ≥25 (OR, 1.193; 95% CI, 1.046-1.362; P = .0088), and lateral meniscal lesion (OR, 1.737; 95% CI, 1.519-1.986; P < .0001). Conclusion: Overall, MMLs were identified in 39.4% of 4697 patients undergoing ACLR when posteromedial compartment evaluation was performed in addition to standard anterior viewing. The incidence of MMLs and the complexity of tear types increased significantly with increasing time intervals between the index injury and ACLR. Secondary risk factors associated with an increased incidence of medial meniscal tears include male sex, increased BMI, and lateral meniscal lesions.

Patients with higher numbers of allergies have lower levels of anti-inflammatory cytokines and increased pain at the time of ACL reconstruction

BackgroundSynovial fluid biomarkers are well studied indicators of inflammation and healing in the setting of orthopedic injuries. However, it has not been studied if patients with one or more allergies have a difference in the concentrations of synovial fluid inflammatory cytokines compared to patients without allergies. The purpose of the current study is to analyze the concentration of 10 pro- and anti-inflammatory cytokines in the synovial fluid of isolated ACL injury patients with and without at least one allergy. Study DesignRetrospective Case-Control. MethodsA database of patients who underwent surgery for isolated ACL injury between September 2011 and July 2023 was analyzed. All patients had SF aspirated from the operative knee prior to the surgical incision and the concentrations of pre- and anti-inflammatory biomarkers were quantified. From this cohort, 24 patients were identified to have allergies by chart review. These patients were matched 1:1 to 24 patients without allergies based on age and sex. ResultsThere were no significant differences between the allergy and no allergy cohorts with respect to age (28.5 ± 10.3 vs. 29.5 ± 8.9, p = 0.76) and sex (70.8 % female vs. 70.8 % female, p = 1.00). The allergy cohort had a decreased concentration of TIMP-1 (492.41 ± 616.20 ng/mL vs. 1041.48 ± 942.04 ng/mL, p = 0.03) and IL-1Ra (101.70 ± 93.37 pg/mL vs. 359.94 ± 399.77 pg/mL, p = 0.01) compared to patients without allergies. A linear regression analysis found a significant association between increasing number of patients reported allergies and decreasing concentration of TIMP-1 (β = -231.59, p = 0.03) and IL-1Ra (β = -71.69p = 0.03) concentrations when controlling for age and sex. Finally, the allergy cohort was found to have a significantly higher value for the VAS pain scale at the time of surgery (26.84 ± 24.73 vs. 7.37 ± 10.98, p < 0.01) compared to those without an allergy. ConclusionPatients undergoing ACL reconstruction with at least one allergy were found to have decreased concentrations of the anti-inflammatory cytokines TIMP-1 and IL-1Ra in their synovial fluid compared to those without allergies on the day of surgery. Furthermore, an increase in total number of allergies was found to be an associated with a decrease in TIMP-1 and IL-1Ra levels. Finally, the allergy cohort also had a higher value for the VAS pain scale at the time of surgery, implicating the role of a patient’s innate immune system to their biologic and symptomatic response to injury.

Incidence and risk factors for medial meniscus lesions at the time of ACL reconstruction: An analysis of 4697 knees

Incidence and risk factors for medial meniscus lesions at the time of ACL reconstruction: An analysis of 4697 knees

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.

Risk Factors for Concomitant Meniscal Injury With Sport-Related Anterior Cruciate Ligament Injury.

Previous studies of concomitant meniscal injury in athletes with anterior cruciate ligament (ACL) injury have examined age, sex, body mass index (BMI), injury mechanism, and time from injury to surgery as potential risk factors. To identify additional risk factors for concomitant meniscal injury, including preinjury joint laxity and lower extremity alignment, in athletes with sport-related ACL injury. Cross-sectional study; Level of evidence, 3. This study included 180 participants aged 13 to 26 years who underwent ACL reconstruction (ACLR) after a first-time ACL injury sustained during participation in sport. Contralateral lower extremity alignment and joint laxity were used as surrogate measures for the injured knee before trauma. Concomitant meniscal tear patterns were identified at the time of ACLR. Sex-specific analyses were conducted. Concomitant meniscal injury was observed in 60.6% of the subjects. The prevalence of concomitant injury was higher in male than female participants (69.9% vs 54.2%; P = .035) due to a higher prevalence of lateral meniscal injuries (56.2% vs 38.3%; P = .018). Among male patients, there was a significant difference in the prevalence of concomitant lateral meniscal tear according to sport participation (≥9 vs <9 h/week: 67.4% vs 35.7%; P = .032). Among male patients, the likelihood of concomitant injury to both the lateral and medial menisci increased by 28.8% for each 1-mm decrease in navicular drop. Among female patients, the likelihood of concomitant injury to the lateral meniscus increased by 15% per degree increase in genu recurvatum and 14% per degree decrease in standing quadriceps angle, with similar effects on the likelihood of concurrent injury to both the lateral and medial menisci. Measures of lower extremity alignment and genu recurvatum previously identified as risk factors for ACL injury were also associated with concomitant meniscal injury in female patients while other risk factors, including BMI and joint laxity, were not. Increased time spent participating in sport and navicular drop were associated with concomitant meniscal injury in male patients.