Anterior Cruciate Ligament Tears Research Articles

A modified anterior cruciate ligament reconstruction with BTB autograft

Background. Central third of the patellar tendon is a well know graft for anterior cruciate ligament (ACL) reconstruction. However, it’s usage can be difficult in case of long patella tendon, which causes graft length discrepancy. The aim of this article is to evaluate the results of arthroscopic anterior cruciate ligament reconstruction with a help of original method of bone patella tendon bone graft preparation. Methods. 26 males operated for ACL tear have been included in the study. On the preoperative MRI scans the approximate length of ACL, tibial tunnel, patella tendon length and tibial bone plug length have been measured. The technique of tibial bone plug cut was optimized based on preoperative MRI assessment. Results. In all cases, MRI-based assessments were consistent with intraoperative measurements, hence there was possible to avoid graft length discrepancy. In a period of 12 weeks the average score on the step-and-holds test was 23.8±1.1, the single-leg squat test was 6.7±0.9 and the Y-balance test was 83.2±1.4. The average IKDS score was 64.9±5.7. Conclusion. The proposed method is appropriate for anterior cruciate ligament reconstruction in patients with long patella tendon.

A mechanical study of the influence of ankle joint angle on translational traction of soccer boots

The shoe–surface interaction for soccer players has both safety and performance implications. This interaction has been widely researched in terms of outsole configuration and surface type. However, these investigations, particularly those involving translational traction, often neglect the approach angle of the foot in terms of a real-world setting. This investigation considers the foot position prior to injuries such as anterior cruciate ligament tears, and observes how the translational traction alters with various angles for simulated plantarflexion, dorsiflexion, calcaneal inversion and calcaneal eversion. It was hypothesised that, as these angles increased, the translational traction would decrease as there would be less contact area between the boot and the surface compared to the neutral, flat footform. A custom-built testing apparatus recorded the translational traction of a soccer boot moving in four different directions at different loading angles on both a natural grass and artificial grass playing surface. A one-way ANOVA was performed, with a post-hoc Tukey Test to determine the significant differences between the translational traction between each angle. It was found that the geometry of the outsole configuration, more specifically, the apparent contact area between the shoe and surface played a significant role in the level of traction obtained. These results highlight the importance of stud geometry, particularly with respect to movements when the foot is angled as it would be in a potential injury scenario. Manufacturers should consider the profile of studs relative to the expected movements to not induce excessive traction, which could lead to potential foot fixation and injury.

Anterior cruciate ligament tear detection using gated recurrent unit and flexible fitness dependent optimizer

Anterior Cruciate Ligament (ACL) tear is a common knee injury that can be diagnosed using Magnetic Resonance Imaging (MRI). In this study, a novel approach has been proposed for improving the accuracy of ACL tear detection using an optimized Gated Recurrent Unit (GRU) model. The GRU model is a type of Recurrent Neural Network (RNN) that can capture the temporal features of MRI images. The optimization of the GRU model is based on a modified metaheuristic technique, called the Flexible Fitness Dependent Optimizer (FFDO). The FFDO is a flexible and problem-dependent algorithm that can find the best solutions to optimize problems by generating and evaluating a set of candidate solutions based on a fitness function. The proposed approach is applied to the MRNet dataset, and the results are compared with 17 state-of-the-art methods. The results show that the proposed approach can achieve a high accuracy of97.95%for ACL tear detection, which is higher than the existing deep learning and machine learning methods. The proposed approach can also achieve high values for other performance metrics, such as specificity, sensitivity, precision, MCC, F1-score, and AUC. The proposed approach can effectively extract the essential features of knee MRI images that are indicative of ACL tears with high diagnostic accuracy.

Poster 353: Impact of Meniscus and Cartilage Treatment on Return to Sport Following Anterior Cruciate Ligament (ACL) Reconstruction

Background: Anterior cruciate ligament (ACL) tears are a common injury in athletes. ACL tears often occur with other injuries, including cartilaginous injuries. There is a lack of research regarding cartilage treatment on return to sport (RTS) following ACL reconstruction. Purpose: To evaluate the impact of meniscus and/or cartilage (meniscus-cartilage) treatment on return to sport (RTS) rates and time to return to sport following ACL reconstruction with hamstring tendon (HT), patellar tendon (BPTB), and quadriceps tendon (QT) grafts. Methods: Competitive and recreational athletes between the ages of 13-24 who had an ACL reconstruction between 2010-2022 were included. Activity level, sport, graft type, cartilage treatment, RTS testing result data, and time to RTS were collected. Chi-square statistics and Wilcoxon rank sum tests were used, and statistical significance was set to p<0.05. Results: There were 855 total patients with 354 HT, 361 BPTB, and 140 QT grafts of which 275 did not have meniscus-cartilage treatment and 580 received meniscus-cartilage treatment. Females comprised 52% of ACL reconstructions without meniscus-cartilage treatment and 42% of ACL reconstructions with meniscus-cartilage treatment. The median age was 18 and 17 for those receiving meniscus-cartilage treatment and those without treatment, respectively. Median time to RTS was 27.86 weeks for 151 patients without meniscus-cartilage treatment and 30.49 weeks for 299 patients receiving meniscus cartilage-treatment (p=0.0253). The median 6-meter timed hop ratio was 1.01 for 21 athletes with meniscus-cartilage treatment and 0.965 for 12 athletes without meniscus-cartilage treatment (p=0.0492). Median isokinetic quadriceps testing at 300 degrees per second was 85% of the contralateral leg for 170 athletes with meniscus-cartilage treatment and 85% for 67 athletes without meniscus-cartilage treatment (p=0.7181). Return to previous level of play occurred in 91/104 (87.5%) of those without meniscus-cartilage treatment and 196/220 (89%) of those with meniscus-cartilage treatment (p=0.6742). ACL and non-ACL reinjuries occurred in 18% (49/272) of those without and 20% (118/577) of those with meniscus-cartilage treatment (p=0.4047). Conclusions: Time to clearance to return to sport occurred more quickly in those without meniscus-cartilage treatment. Six-meter timed hop testing results were superior in those receiving meniscus-cartilage treatment. This study will aid orthopaedic surgeons and their athletes while addressing common concomitant injuries during ACL reconstruction.

Poster 336: Reliability of Preoperative MRI in the Prediction of ACL Tear Type

Objectives: Anterior cruciate ligament (ACL) tears are among the most frequent ligament injuries in the United States. Most of these injuries are treated surgically, depending on patient-specific factors. Management of these injuries includes nonoperative management with stepwise rehabilitation or surgical treatment with ACL repair or reconstruction. Patient goals, a clinical evaluation, and preoperative MRI imaging are generally assessed to inform the choice of treatment. Classification of ACL tear-type based on stump morphology is critical to preoperative planning, as it can determine a patient’s eligibility for ACL preservation techniques. We aim to determine the efficacy of preoperative magnetic resonance imaging (MRI) in predicting ruptured ACL stump morphology and thus assist in preoperative planning and decision-making. Methods: This retrospective observational study utilized chart review from the case log of a single surgeon at an urban tertiary institution. The review identified patients who underwent the Bridge Enhanced ACL Repair (BEAR) procedure between January 1, 2022 and August 31, 2023. The inclusion criteria included patients who underwent a primary ACL repair with the BEAR technique and had adequate intraoperative and MRI images available for review. Patients excluded were those with inadequate intraoperative imaging or MRI imaging that was unavailable for review. For each patient included, the two senior authors assessed the morphology of the ACL stump on MRI (sagittal T2, coronal T2) and intraoperative arthroscopy images in a blinded manner and assigned a classification grade to each. The MRI-based morphology and the intraoperative image morphology of the tears were classified based on a system validated by DeFelice et al, which includes types 1 to 5 based on the location of the tear from most proximal to most distal. The correlation between the preoperative MRI assessment and the intraoperative arthroscopic assessment was interrogated using simple linear regression quantified with the Pearson correlation coefficient. Results: A total of 35 patients that underwent the BEAR procedure were identified. One patient was excluded due to inadequate intraoperative images. Of the remaining patients, 13 (38.2%) were male and 21 (61.8%) were female. The average patient age was 31, with a median age of 28. Most patients were injured while skiing (32.4%), while the second and third most prevalent mechanisms of injury were nonsports-related (23.4%) and soccer injuries (17.6%), respectively. Of the MRI tears that were analyzed, 9 (26.5%) were classified as type 1, 19 (55.9%) were type 2, and 5 (14.7%) were type 3. There were no tears identified as types 4 or 5 tears. Of the arthroscopic images that were analyzed, 21 (61.8%) were classified as type 1, 10 (29.4%) were type 2, 3 (8.8%) were type 3. Similarly, there were no tears identified as types 4 or 5. MRI accurately predicted the ACL tear type seen arthroscopically 55.9% (19/34) of the time. Of the (15) cases in which MRI did not correlate with the arthroscopic tear type, the MRI classification grade was within 1 grade of the arthroscopic grade 93.3% of the time (14/15). In the cases in which MRI was not correct in its grading, 93.3% of them (14/15) were classified as too high of a grade (MRI perceiving the tear to be more distal than it was in actuality). The Pearson correlation coefficient assessing the correlation between MRI identified tear type and arthroscopy identified tear type was 0.56. Conclusions: MRI accurately predicted the ACL tear type seen arthroscopically in only 55.9% of patients. In >90% of incorrect predictions, arthroscopy determined the ACL tear to be one classification more proximal than predicted by MRI. Our results demonstrate that while preoperative MRI can be useful in identifying approximate ACL tear location, it is essential to examine the ACL at time of arthroscopy for final determination of ACL stump size and viability for ACL restoration procedures. Moreover, a greater percentage of patients may be eligible for an ACL restoration procedure than predicted by preoperative MRI, highlighting the importance of discussing both ACL repair and ACL reconstruction with patients preoperatively. [Figure: see text]

Magnetic Resonance Imaging Evaluation of Anterolateral Ligament Tear in Association with Anterior Cruciate Ligament Tear: A Review

Abstract Anterolateral ligament evaluation on magnetic resonance imaging (MRI) is a relatively recent topic, which has come into the limelight in the last decade. The objective of this review article is to study the association of anterolateral ligament tear in anterior cruciate ligament tear on 1.5 T MRI, which can aid in planning the reconstruction procedure.

Transparency Matters: Assessing Harms Reporting Compliance in Randomized Controlled Trials Underpinning the AAOS Clinical Practice Guideline for Anterior Cruciate Ligament Injuries

Background: The American Academy of Orthopaedic Surgeons (AAOS) has developed a clinical practice guideline (CPG) for management of anterior cruciate ligament (ACL) injuries. Primary studies such as randomized controlled trials (RCTs) are cited as evidence for the guidelines. Given the influence that these trials have on patient care, adherence to standardized protocols for conducting and reporting RCTs is essential. Purpose: To evaluate the CONSORT (Consolidated Standards of Reporting Trials) Extension for Harms–related reporting of RCTs cited as supporting evidence for the AAOS CPG on the management of ACL tears. Study Design: Cross-sectional study. Methods: The reference section of the AAOS guideline for ACL tears was first screened for RCTs cited in the CPG. Next, each RCT was evaluated for adherence to the CONSORT Extension for Harms checklist. Both identification of RCTs and assessment of adherence were performed in a masked and duplicate process. Descriptive statistics were used to summarize adherence to CONSORT Extension for Harms items. A Pearson correlation test was conducted to assess the relationship between the year of publication and adherence to CONSORT harms reporting. Results: The sample included 113 RCTs, of which 16 (14.2%) were published before the CONSORT Extension for Harms was implemented in 2004. Sample sizes ranged from 24 to 4564 participants, with a mean of 228. None of the included RCTs included all 18 items in the CONSORT Extension for Harms checklist. The mean number of checklist items reported was 4 (of 18; 22.2%). A moderate, positive, and statistically significant correlation was found between the RCT publication year and the adherence with reporting of the CONSORT Extension for Harms (t111 = 3.54; P < .001) (r = 0.32; 95% CI, 0.14-0.47). Conclusion: Harms were infrequently reported in RCTs cited as supporting evidence in the AAOS CPG for the management of ACL tears. One encouraging finding was the positive correlation between the year when RCTs were published and how well they adhered to reporting harms. Efforts to improve adverse event reporting are warranted, as RCTs are commonly used to make clinical decisions in orthopaedic surgery.

The Role of Magnetic Resonance Imaging in the Evaluation of Knee Pain.

Objectives This study aimed to characterize and compare the features of traumatic and non-traumatic lesions causing knee pain through magnetic resonance imaging (MRI). Method The study was conducted at a tertiary care center, with data sourced from patients visiting the outpatientand in-patient departments. It involved a descriptive cross-sectional research design focusing on patients referred for knee MRI scanning. The sample size was calculated using Cochran's formula as 112 for symptomatic patients with knee pain with a 95% confidence interval. The MRI findings in 112 patients were analyzed and associated with a history of trauma. Results The average age recorded was 35.38 years. Females made up 41.07% (n=46) of the sample, while males accounted for 58.93% (n=66).Among the participants, the majority (n=82; 71.43%) had a history of trauma, and the most common MRI finding wasjoint effusion (n=74; 66.1%). The second most common was anterior cruciate ligament (ACL) injuries (n=71; 63.4%), followed bymeniscus injury (n=40; 35.71%). The study confirms that those with history oftrauma are at a higher risk (p<0.05) of sustaining injuries like meniscus and ACL tears, collateral ligament damage, bone contusions, chondromalacia patella, and joint effusion. Conclusion In conclusion, the consistency of our findings with existing studies reinforces the pivotal role of MRI in the evaluation of knee pain. Despite its limitations, including cost and accessibility, MRI remains a gold standard for diagnosing a wide range of knee pathologies, offering unparalleled detail and accuracy that significantly enhance clinical decision-making and patient outcomes.

Poster 354: Tibiofemoral Bone Shape Features Are Associated with Re-Tear after Anterior Cruciate Ligament Reconstruction

Introduction: Knee bony morphology is linked to anterior cruciate ligament (ACL) injury, ACL graft failure, and osteoarthritis (OA) risk, and employing tools such as statistical shape modeling could identify individuals prone to these joint conditions. Re-tear after ACL reconstruction remains a common and devastating complication, and therefore, recognizing patients at high risk of graft failure before primary ACL reconstruction is crucial for potential intervention to reduce failure rates. Magnetic resonance imaging (MRI) is most commonly obtained in the setting of possible ACL injury and before ACL reconstruction surgery, yet currently available MRI-based bone shape assessment methods require high-resolution sequences or manual segmentation, limiting feasibility of large-scale analysis. The development of automated tools for bone shape extraction from clinical MRI could allow for three-dimensional statistical shape modeling across large datasets. We established an automated pipeline for bone segmentation from proton density (PD)-weighted MRI scans, aiming to extract knee bony morphology from preoperative clinical MRIs in patients with ACL injuries. We hypothesized that our segmentation pipeline could uncover specific tibiofemoral joint bone shape features associated with ACL re-tear after reconstruction. Objective: To identify bone shape features prior to initial primary ACL reconstruction in patients with eventual ACL graft re-tear compared to those with a known, intact ACL graft. Methods: Patients who retrospectively experienced a subsequent re-tear after reconstruction within three years of initial injury were compared to those without a re-tear within three years (20 without subsequent re-tear, 22 with subsequent re-tear for distal femur; 22 without subsequent re-tear, 19 with subsequent re-tear for proximal tibia). The control group had MRI scans at 3 years after reconstruction that confirmed an intact ACL graft. An automatic femur and tibia segmentation framework was developed by training two deep convolutional neural networks using clinical, two-dimensional PD-weighted knee MRI sequences (3.5 mm slice thickness) from patients with ACL tears. Using the segmentation pipeline, bone was automatically segmented from preoperative clinical PD-weighted knee MRI sequence (3 mm slice thickness), three-dimensional triangulated meshes were generated, scaled to a reference, and aligned and matched to an atlas using Iterative Closest Point algorithm. Modes of shape variance were extracted from principal component analysis (PCA). The effect of each mode is modeled by three-dimensional surfaces for each specific shape feature. Modes were considered statistically significant if the mean principal component score between groups was p&lt;0.05 using Students T-test. Results: Statistical shape modeling of the femoral condyles using 15 PCA modes reveals significant differences (p &lt; 0.05) in Modes 1 and 4 at the initial injury in patients who subsequently experienced ACL re-tear after reconstruction compared to those without re-tear. Femur Mode 1 is characterized by a narrower intercondylar notch width, a wider medial condylar width, and an increased ratio of femoral condylar offset in patients with ACL re-tear. Femur Mode 4 illustrates a more prominent trochlear sulcus and increased surface area along the lateral femoral condyle relative to the medial condyle in patients with ACL re-tear. The initial 15 PCA modes of the distal femur collectively account for 75.04% of the normalized accumulated total variance. Statistical shape modeling of the tibial plateau with 15 PCA modes reveals that Mode 7 is significantly different (p &lt; 0.05) at the initial injury in patients who experienced subsequent ACL re-tear after reconstruction compared to those without re-tear. Tibia Mode 7 indicates diminished ACL facet prominence, a squared lateral tibial plateau, and a broader, flatter tibial spine in patients with subsequent ACL re-tear. The first 15 PCA modes of the proximal tibia collectively explain 73.60% of the normalized accumulated total variance. Conclusions: Using an automatic bone segmentation pipeline on preoperative clinical MRIs, we identify specific shape features in the tibiofemoral joint associated with ACL re-tear after reconstruction. Patients with subsequent ACL re-tear exhibit a variety of distinct three-dimensional morphology differences, including reduced intercondylar notch width, wider medial condylar width, increased lateral tibial plateau convexity, and broader, lateralized tibial spine, uncovered using statistical shape modeling. Statistical shape modeling identifies three-dimensional morphology patterns, thus capturing differences otherwise unaccounted for by traditional two-dimensional measurements. This approach offers predictive potential for patients at risk of ACL re-tear, improving treatment decisions for those with high-risk morphologic features.

Can artificial intelligence help improve the rehabilitation of anterior cruciate ligament injuries in basketball players?

For basketball players, a torn anterior cruciate ligament (ACL) can be devastating [1]. This injury often necessitates reconstructive surgery, followed by a grueling rehabilitation process that can sideline an athlete for months, jeopardizing their career trajectory [2]. However, a new beacon of hope is emerging on the horizon: artificial intelligence (AI). This powerful technology is not just a tool but a potential game-changer, rapidly transforming the way ACL recovery is approached. It offers the potential for faster, more personalized, and ultimately more successful outcomes for athletes eager to return to the court, inspiring a new era in sports medicine [3].

The Effect of Sportsmetrics Training on Landing Technique in Female Volleyball Players With Dynamic Knee Valgus

Background and Aims The most serious and severe injuries among female volleyball players is the knee injury, especially the anterior cruciate ligament (ACL) tear. Its key risk factors are dynamic knee valgus (DKV) and abnormal alignment during jump landing. One of the successful protocols regarding the prevention of knee injuries in female volleyball players is professional sportsmetrics volleyball training. In the present study, the effect of this protocol on DKV correction and landing error scoring system (LESS) was investigated. Methods The current research is quasi-experimental with a pre-test-post-test design. The statistical sample included 30 female volleyball players (Mean±SD age: 20.83±2.22 years, Mean±SD height: 168.16±6.47 cm, Mean±SD weight: 59.13±7.4 kg, Mean±SD body mass index (BMI): 20.83±1.52 kg/m2, and Mean±SD sports experience: 5.46±1.8 years) who were randomly divided into the training (15 people) and control (15 people) groups. Double leg squat and LESS tests were used to evaluate DKV and landing error. The exercise group participated in the present protocol for 6 weeks, three sessions per week. Each session was approximately 90 minutes, including warm-up exercises, sportsmetrics volleyball training, and cool-down. The analyses of covariance were used to evaluate the data at a significant level of P=0.05. Results The results of covariance analysis showed that performing these exercises significantly reduced (P=0.01) DKV (from 23.13 to 7.86) and landing error (from 17.46 to 7.6). In other words, the training group experienced a 66% decrease in DKV and a 56% decrease in landing error after performing six weeks of sportsmetrics volleyball training. Conclusion Sportsmetrics volleyball training has successfully improved performance and prevented ACL injury in female volleyball players. According to the present study results, performing these exercises leads to correct DKV and improves lower extremity alignment and landing technique. Therefore, performing sportsmetrics volleyball training is strongly recommended for female volleyball players with DKV.

Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years.

Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes. To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR. Case series; Level of evidence, 4. All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not. A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not. At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.

Is Partial ACL Tear a Cause of Painful Swollen Knees?

Abstract Study Design: Retrospective case series. Objective: In this study, we will identify if partial ACL tear is a common hidden cause of chronic pain and swelling of the knee in adults. And we will evaluate the effectiveness of arthroscopic selective bundle reconstruction in the management of this condition. Background: The Anterior Cruciate Ligament (ACL) has two anatomical bundles, the anteromedial (AM) and the posterolateral (PL), each bundle was named according to the site of its tibial insertion.[1] Partial ACL tear is evident and symptomatic when the percentage of the torn fibers is more than 50% of ligament fibers. AM bundle is more liable to injury than PL.[2] Symptomps of partial ACL tear may be giving way and instability but persistent knee pain and swelling is often present as the main presenting symptom of the patient due to micro-instability of the knee, The primary complication of longstanding partial ACL tears is early knee degeneration.[3] Patients and Methods: 37 patients with chronic knee pain and swelling, related to activity and resistant to non-operative treatment, underwent diagnostic knee arthroscopy. In 3 cases diagnostic arthroscopy revealed osteochondral ulcers of the medial compartment of the knee managed by drilling and 4 cases showed non-specific synovitis managed by arthroscopic synovectomy. 30 of these patients, who were included in this study, were found to suffer from partial ACL tear and underwent single bundle reconstruction, 18 of them underwent selective AM bundle reconstruction while preserving PL bundle. Twelve patients underwent selective PL bundle reconstruction with AM bundle preservation. Semitendinosus tendon graft was utilized for all reconstructions. The femoral side was always fixed with an adjustable loop (Zimmer), and the tibial side with a biodegradable interference screw. Lysholm score[4] was used to assess the outcomes. Patients with severe degenerative disorders, lower limb mal-alignment and multiple ligamentous injuries of the knee were excluded from our study. Results: Marked decrease in the knee pain and swelling postoperatively. The preoperative score had a mean value of 66.17±10.39. At 2 years, the postoperative score was 96.1±6.71, indicating a highly statistically significant improvement (P value 0.001). Hypothesis: Partial ACL tears are the commonest hidden cause of pain and swelling of the knee among young adults. Conclusion: Arthroscopic selective bundle reconstruction diminishes knee pain and swelling with a very satisfactory postoperative clinical outcomes.

Poster 341: Nonoperative Treatment of MCL Tears in ACL/MCL Injuries Does Not Increase ACL Retear Rates

Objectives: There continues to be controversy regarding the treatment of medial collateral ligament (MCL) tears when torn in conjunction with the anterior cruciate ligament (ACL). There is a push to acutely repair or reconstruct the MCL in this setting due to lower revision rates following the ACL reconstruction (ACLR). However, most nonoperative treatment philosophies are focused on immobilization through bracing instead of the more rigid casting approach. The purpose of this study was to determine if there was a difference in ACL retear rates or postoperative stability between those with ACL/MCL injuries and isolated ACL injuries when the MCL was treated nonoperatively, including rigid casting prior to the ACLR. Methods: Between 1982 and 2022, 6047 patients planning to have an ACLR were enrolled into the study. The population was determined with inclusion criteria of a primary ACLR using a patellar tendon graft with minimum 1-year follow up. Patients were excluded with revision ACLR, lateral side or posterior cruciate ligament involvement, or lacking postoperative KT data. Patients were divided into two groups, isolated ACLR (N = 5670) and ACL/MCL (N = 377). All MCL tears were treated nonoperatively and when indicated, they were casted in 30° of flexion and changed weekly until a solid end point was achieved and patients had the ability to bear full weight on the involved side. Once medial side stability was attained, preoperative rehabilitation commenced and range of motion was normalized before the ACLR. Postoperatively, all patients followed the same accelerated rehabilitation program. The KT manual maximum (MM) difference between knees, in millimeters, was used for analysis. Graft retear rate was determined through subjective surveys sent yearly to each patient after surgery. To reduce confounding bias in the analysis, the ACL/MCL patients were control matched 1:1 to the isolated ACL injury patients based on sex, age, postoperative activity rating, and surgery timing, which led to 304 patients in each group. Results: Prior to matching, both groups had similar mean ages and rates of having postoperative activity levels ≥7, however, the ACL/MCL group showed higher rates of males (69.0%) and subacute surgery (71.9%) compared to the isolated ACLR group (59.7% males and 56.6% subacute surgery). After matching, the mean age for both groups was similar (ACL/MCL: 24.6 years, isolated ACLR: 24.9 years) and they showed identical rates of males, postoperative activity rating ≥7, and subacute surgery at 66.4%, 90.4%, and 73.0%, respectively. The KT MM difference for the ACL/MCL group was not statistically significantly different when compared to the isolated ACLR group (1.8mm vs 1.6mm; p=0.196). The ACL retear rate for the ACL/MCL group was 7.9% compared to 6.6% for the isolated ACLR group, which was not statistically significantly different, p = 0.531. Conclusions: When the MCL is treated nonoperatively, including the use of a cast, before an ACLR, postoperative stability and rates of ACL retears are similar to those with an isolated ACL tear. Due to similar outcomes for both groups, surgeries to the MCL, and thus potential complications that can come with it, can be avoided. We postulate that the lack of differences in laxity and retear rates for the ACL/MCL group may be due to more rigid cast immobilization for the MCL, as opposed to bracing. Further study is needed to evaluate this hypothesis.

Poster 347: Return to Sports of ACL Primary Repair Versus Autograft ACL Reconstruction at 2-year Follow-Up

Objectives: To evaluate the psychological readiness to return to sports (RTS), and assess the rates of RTS at preinjury level in patients undergoing anterior cruciate ligament (ACL) primary repair (ACLPR) with suture versus autograft ACL reconstruction (ACLR) at minimum 2-year follow-up (FU). Methods: Consecutive patients &lt;50 years old and a preinjury Tegner score of ≥5, undergoing either ACLPR or ACLR by a single surgeon, between January 2018 and April 2021, were considered for eligibility. Surgical indication for either ACLPR with suture augmentation or autograft ACLR (58% hamstring- and 42% quadriceps tendon graft) was based on intra-operatively determined ACL tear type and tissue quality. ACLPR was performed in all patients with proximal type I or II types and good to excellent tissue quality, whereas ACLR was only performed when tear characteristics contraindicated ACL repair. To evaluate success of RTS, activity level (Tegner Activity Scale), psychological readiness to RTS (ACL-Return to Sport After Injury [RSI] score) and instrumented anterior-tibial translation side-to-side difference (ATT-SSD) were evaluated at minimum 2-year FU. Results: A total of 181 patients (100 ACLPR, 81 ACLR), were evaluated at final FU (mean ± SD (range), 3.2 ± 0.9 (2 to 5) years). A significantly greater number of patients undergoing ACLPR returned to their preinjury activity level (73% vs. 47%, p &lt; .001), and further presented significantly better ACL-RSI scores (75.3 ± 22.2 vs. 66.6 ±24.2, p = .023) at minimum 2-year FU. Instrumented knee laxity revealed similar results for both treatment groups (ACLPR, 0.80 ±1.2 mm vs. ACLR, 0.97 ± 1.2 mm, p = .449). Conclusions: Patients undergoing ACLPR demonstrate greater return to preinjury activity level and greater confidence in their operated knee when performing their respective sport at 2-year FU compared to ACLR.

Paper 26: Role of Age on Survival of Anterior Cruciate Ligament Primary Repair at minimum 5-year follow-up

Objectives: Short-term follow-up of anterior cruciate ligament (ACL) primary repair (ACLPR) presented increased failure risk (37%) in patients ≤21 years of age (y/o), however low rates in patients &gt;21 y/o (3.5%). Mid- and long-term clinical evidence for contemporary anterior cruciate ligament primary repair (ACLPR) is lacking, whereas outcomes of historical ACL repair were shown to deteriorate at midterm follow-up after initial good short-term outcomes. This study evaluates age-differentiated survival rates of ACLPR at 5-year FU to assess whether the previously presented rates at 2-year FU can be maintained at 5-year FU. Methods: The first 113 consecutive patients with proximal ACL tears undergoing ACLPR by a single surgeon, from 04/2008 to 09/2017, were prospectively followed up. Indication for ACLPR was determined if a proximal type I or II tear and good to excellent tissue quality was present. Failure and re-operation rates, patient reported outcome measurements (PROMs) (IKDC score, Lysholm score, Forgotten Joint score, ACL-RSI score, and Tegner Activity Scale Difference) and instrumented anterior-tibial translation side-to-side difference (ATT-SSD) were recorded at minimum 5-year FU. Results: A total of 96 patients (85%) with a mean final FU of 7.2 ±2.3 (5.0 – 12.8) years were evaluated. Ipsilateral reinjury rates for patients ≤21 y/o, from 2- to 5-year FU, remained stable (40.0%) with no additional failure recorded. Six additional re-injuries were detected in patients &gt;21 y/o, leading to a failure rate of 9.8% at 5-year FU. Mean time to failure following surgery was 17 ±11 months in patients ≤21 y/o versus 26 ±16 months in patients &gt;21 y/o. Re-operation rates for patients ≤21- and &gt;21 y/o were 0.0% and 4.0% respectively. PROMs showed no significant differences as compared to outcomes at 2-year FU (p &lt;.001) and 5-year ATT-SSD was 0.75 ±1.2 mm. Conclusions: ACLPR is correlated with a high risk of early failure (40.0% at 17 ±11 months) in patients &lt; 21 y/o, however no additional subsequent re-injuries were reported at minimum final 5-year FU. In contrast, patients &gt;21 y/o demonstrate low failure rates at 2- (3.5%) and 5-year FU (9.8%).

Poster 356: Patient Perception of Autograft Options in ACL Reconstruction Using a Validated Online Survey Marketplace

Objectives: Anterior cruciate ligament (ACL) reconstruction is the gold standard treatment for ACL tears. ACL graft reconstruction is commonly performed with an autograft. Common autograft modalities include bone-patellar tendon-bone (BPTB), quadriceps tendon (QT), and hamstring tendon (HT) grafts. This study sought to evaluate the general population’s perception of the use of BPTB, QT, and HT autografts in ACL reconstruction. Methods: A prospective cohort study was performed utilizing a 36-question survey. Participants were paid, and the survey was distributed via a clinically validated, public, online marketplace in June 2023. After collecting baseline demographics, participants were queried on whether they held a preference for autograft type without additional information. All respondents then sequentially completed a pre-education survey to assess baseline knowledge, reviewed information from an evidence-based information sheet (Figure 1), and a post-education survey to assess understanding of the provided material. Upon completion, participants were again asked which treatment modality they would prefer. Additionally, participants were queried on whether they would be willing to change their preference based on surgeon recommendation. Finally, participants were asked to rank the factor that was most influential to their final decision. Results: In total, there were 491 participants that completed the survey. The average age was 39.9 (range, 19-72), there were 244 males, 241 females and 6 that preferred not to respond. 362 (74%) patients reported earning at least a bachelor’s degree and 362 (74%) reported that they did not work in healthcare. Prior to participant education, 19.3% (n=95) preferred BTB, 18.7% (n=92) preferred QT, 12.6% (n=62) preferred HT, and 53.4% (n=262) had no preference. Following education, a significantly greater number of participants chose each graft type; 37.7% (n=185, p&lt;0.01) preferred BTB, 21.6% (n=106, p&lt;0.01) preferred QT, 13.8% (n=68, p&lt;0.01) preferred HT. Significantly fewer participants had no preference 26.9% (n=132, p&lt;0.01). The average score on the pre-information test was 35.0% while the average score on the post-information test was significantly greater, 50.0% (p&lt;0.01). The most important factors in autograft decision making were surgeon preference (n=357, 72.7%), the provided information (n=104, 21.2%), and previous experiences (n=30, 6.1%). In total, 424 (86.4%) participants said they would switch their graft preference if their surgeon recommended it. Conclusions: The primary finding of this study was that surgeon preference is the most influential factor for the general population when surveyed about their graft preferences for ACL reconstruction with autograft. This study showed that 86% of participants were willing to switch their preference if their surgeon recommended switching. Additionally, significantly more patients chose a specific graft type (BTB, QT, HT) after reading an evidence-based information sheet on the graft types. The findings of this study imply that informed patients are capable of participating in medical decision making with respect to their graft choices in ACL reconstruction, and that providing educational information can help surgeons and patients work together to optimize their care. [Figure: see text]

Management of Abhighatajanya janu sandhigata vata with special reference to anterior cruciate ligament tear through Ayurvedic management: A case report

Individuals like dancers can suffer from knee difficulties and there is no upper age limit for such knee joint-related disorders. During standing, walking, jogging, etc., the complex structure of the knee joint absorbs a lot of stress. Acute injuries to the joint may cause discomfort, swelling, and difficulty moving, which could be signs of a ruptured or broken ligament. The severity of the condition depends on the source of injury and the involved structures. Despite being less severe, some of them will still be uncomfortable and functionally restrictive. The symptoms of Janu sandhigata vata as described in Ayurveda may be correlated with signs and symptoms related to damage to the knee joint. A case where the patient was diagnosed as Abhighatajanya janu sandhigata vata with special reference to anterior cruciate ligament tear was managed by Ayurveda approaches that are presented here. The Ayurveda treatment protocol comprises Tikta ksheera basti (~therapeutic enema), Janu seka (~therapeutic streaming over the knee), Dashanga lepa (~anointment), and Sandhaniya upanaha (~poultice application). The treatment has resulted in significant improvement in the functioning of the affected knee joint. This case has demonstrated the role of Ayurveda treatment protocols and management strategies in such ligament and meniscal injuries, without any surgical intervention.

Pigmented villonodular synovitis of knee with concomitant partial tear of anterior cruciate ligament in skeletally immature patient: A case report

Pigmented villonodular synovitis (PVNS) is benign but locally aggressive proliferative disorder that affects synovial joint, tendon sheaths, and bursae. PVNS is rare in child, while concurrent Anterior Cruciate Ligament (ACL) tear in PVNS is uncommon finding. Previous study reported ACL tear might be a risk factor in adult PVNS but lack of record for pediatric PVNS. We report a case of uncommon concomitant ACL partial tear in an already rare pediatric PVNS. A nine-year old female with pain and swelling on left knee, occurred intermittent every 2 months for 1 year prior to surgery. There was moderate knee movement restriction with history of fall from bicycle 1 year before surgery. No history of knee instability was reported. X-ray only denote joint swelling, while MRI shows intraarticular bodies suspected synovial chondromatosis with hyperintense signal sign of partial ACL tear. The patient underwent arthroscopic evaluation which exhibit intraarticular hyperemic and hypertrophic synovium with loosening anteromedial ACL bundle. Arthroscopic synovectomy was then performed followed by range of motion training and muscle strengthening rehabilitation program. Post-operative histopathological result confirms PVNS assessment. 1 year follow up post-surgery shows no recurrence of pain or swelling with free movement of left knee joint and no disturbance or instability while walking. In this case, partial ACL tear may contribute as risk factor of PVNS in child. Arthroscopic synovectomy with physical rehabilitation program shows good functional result with no recurrence at 1-year follow up.

Aging alters the subchondral bone response 7 days after noninvasive traumatic joint injury in C57BL/6JN mice.

Posttraumatic osteoarthritis (PTOA) commonly develops following anterior cruciate ligament (ACL) injuries, affecting around 50% of individuals within 10-20 years. Recent studies have highlighted early changes in subchondral bone structure after ACL injury in adolescent or young adult mice, which could contribute to the development of PTOA. However, ACL injuries do not only occur early in life. Middle-aged and older patients also experience ACL injuries and PTOA, but whether the aged subchondral bone also responds rapidly to injury is unknown. This study utilized a noninvasive, single overload mouse injury model to assess subchondral bone microarchitecture, turnover, and material properties in both young adults (5 months) and early old age (22 months) female C57BL/6JN mice at 7 days after injury. Mice underwent either joint injury (i.e., produces ACL tears) or sham injury procedures on both the loaded and contralateral limbs, allowing evaluation of the impacts of injury versus loading. The subchondral bone response to ACL injury is distinct for young adult and aged mice. While 5-month mice show subchondral bone loss and increased bone resorption postinjury, 22-month mice did not show loss of bone structure and had lower bone resorption. Subchondral bone plate modulus increased with age, but not with injury. Both ages of mice showed several bone measures were altered in the contralateral limb, demonstrating the systemic skeletal response to joint injury. These data motivate further investigation to discern how osteochondral tissues differently respond to injury in aging, such that diagnostics and treatments can be refined for these demographics.