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Background: Bone–patellar tendon–bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non–graft rupture-related reoperation rates. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records. Results: A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged 30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar. Conclusion: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Background: The optimum management strategy after failure of revision anterior cruciate ligament reconstruction (RACLR) is not clearly defined. The literature evaluating differences in outcomes between surgical and nonsurgical management is sparse. Purpose/Hypothesis: The purpose was to evaluate the outcomes of surgical versus nonsurgical management of failed first RACLR. It was hypothesized that the long-term clinical outcomes of second RACLR would be superior with respect to knee stability, return to sport, and patient-reported outcome measures when compared with nonsurgical treatment. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who experienced failure of first RACLR were evaluated. All participants followed the same rehabilitation protocol regardless of whether they underwent nonsurgical treatment or a second RACLR. Follow-up comprised regular clinical review and a standardized telephone interview at the end of the study period. Patient-reported outcome measures were recorded at the final follow-up. Results: A total of 41 patients with a mean follow-up of 104 ± 52.7 months (range, 40-140 months) were evaluated. Of these, 31 underwent a second RACLR, and 10 patients chose nonsurgical treatment. There was a high rate of return to sport in both groups, but patients undergoing second RACLR had significantly better Tegner (6.35 vs 4.8; P = .012), Lysholm (88.5 vs 78.3; P = .0353), Knee injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (72.6 vs 56.3; P = .0490), and KOOS Sport and Recreation scores (81.4 vs 62.5; P = .0033). Significantly more patients undergoing second RACLR achieved the Patient Acceptable Symptom State for KOOS Sport and Recreation than those who underwent nonsurgical management (74.2% vs 30%; P = .015). The most important predictor of failure to achieve a good/excellent Lysholm score in multivariate analysis was nonsurgical management ( P = .0095). Conclusion: Both second RACLR and nonsurgical management of failed first RACLR were associated with high rates of return to sport. However, second RACLR was associated with significantly better functional outcome scores with respect to Tegner, Lysholm, KOOS Quality of Life, and KOOS Sport and Recreation scores compared to nonsurgical management. In addition, nonsurgical treatment was the only significant predictor of failure to achieve a good/excellent Lysholm score at the final follow-up, and this was likely a function of inferior knee stability in that group.

Background:Recent imaging studies demonstrate that the anterolateral ligament (ALL) is frequently injured at the time of anterior cruciate ligament (ACL) rupture. The intrinsic healing potential of these injuries after ACL reconstruction (ACLR) has not been defined.Purpose/Hypothesis:The primary objective was to evaluate the rate and duration of the healing process of injured ALLs after ACLR using serial 3-dimensional magnetic resonance imaging (3D-MRI). The secondary objective was to investigate whether any patient, injury, or surgical factors influenced the healing rate. The hypothesis was that serial imaging would demonstrate that the ALL has limited healing potential.Study Design:Case series; Level of evidence, 4.Methods:Patients enrolled in the study underwent 3D-MRI (slice thickness 0.5 mm) preoperatively and at 1, 6, 12, and 24 months after ACLR. Three observers determined the grade of ALL injury according to the Muramatsu classification. Inter- and intraobserver reliabilities were calculated. The rates of injury and time points for healing were determined. Full healing was defined as a change from a preoperative Muramatsu grade of B or C (indicating partial or complete injury) to grade A (normal). Multivariate analysis was used to investigate the association of aforementioned factors with the risk of incomplete healing.Results:A total of 44 patients were enrolled in the study. Of them, 71.2% had an ALL injury on preoperative imaging. Overall, full healing of ALL injuries occurred at a rate of 3.2%, 15.2%, and 30.3% at 1, 6, and 12 months, respectively. There were no changes in the Muramatsu grade in any patient beyond 12 months postoperatively. None of the complete lesions demonstrated full healing, but the proportion of patients with a grade C injury decreased from 13.6% preoperatively to 4.5% at 12 months due to an improvement to grade B in 4 of 6 patients (66%). Inter- and intraobserver reliabilities of the classification system were almost perfect at 0.81-0.94 and 0.95-1.00, respectively. None of the potential risk factors investigated were predictive of an increased risk of nonhealing.Conclusion:ALL injuries occurred in the majority of ACL-injured knees. They had limited intrinsic healing potential, with only 30.3% healing by 12 months after ACLR. The process of healing took >6 months in half of the patients in whom it occurred. No new cases of full healing occurred beyond 12 months postoperatively. No significant risk factors for failure of full healing to occur were identified, but it is likely that this aspect of the study was underpowered.

Background: Return to sport (RTS) to the preinjury level is the main purpose after anterior cruciate ligament (ACL) reconstruction but the factors affecting the RTS are not completely known. Knee Santy Athletic Return to Sport (K-STARTS) is a composite test designed to assess readiness for RTS after ACL reconstruction. Purpose: To determine the key factors that influence K-STARTS scores in a large cohort of patients after ACL reconstruction. Study Design: Case-control study. Level of Evidence: Level 3. Methods: A retrospective analysis of prospectively collected data was undertaken. All patients who underwent ACL reconstruction surgery between March 2016 and May 2017 and also had a K-STARTS assessment at 6 months postoperatively were included. To identify factors influencing the K-STARTS score, an analysis of variance was performed. Age, sex, sports level, delay between injury and surgery, concomitant lesions, graft type, additional lateral tenodesis procedure, and participation in the RTS program were analyzed to identify factors influencing the K-STARTS score. Results: A total of 676 patients were included in the study. The K-STARTS score was significantly higher in male patients than in female patients (13.9 vs 12.4; P < 0.001), in younger patients (those aged Conclusion: Completion of a specific RTS program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological RTS test score at 6 months after ACL reconstruction. Clinical Relevance: This study shows that the completion of a specific RTS program affects positively the RTS test score at 6 months after ACL reconstruction.

Background:Preoperative grade 3 pivot shift has been reported to be associated with higher rates of anterior cruciate ligament (ACL) failure, persistent instability, and inferior patient-reported outcomes. The etiology of a high-grade pivot shift is multifactorial, and numerous factors have been suggested to be responsible. More attention has recently been focused on injury to the anterolateral structures (ALS) as a risk factor for a grade 3 pivot shift.Purpose:To determine risk factors for grade 3 pivot shift, including soft tissue and osseous parameters.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A prospective evaluation was undertaken of 200 consecutive patients undergoing acute ACL reconstruction (within 10 days of injury). An open exploration of the lateral side of the injured knee was performed at the time of the index procedure. Details regarding patient and injury characteristics were recorded, as were details of soft tissue injuries, including meniscal tears, ALS lesions, medial collateral ligament tears, and chondral injuries. Osseous parameters (tibial slope and condylar ratios) were determined per established magnetic resonance imaging protocols. A multivariate logistic regression with penalized maximum likelihood was used to identify risk factors associated with International Knee Documentation Committee (IKDC) grade 3 pivot shift.Results:The mean ± SD age of the population was 28.3 ± 9.8 years; 67.5% of patients were male. Among patients, 35 (17.5%) had a high-grade pivot shift (IKDC grade 3), and 165 (82.5%) had a low-grade pivot shift (IKDC grades 1 and 2). Univariate and multivariate logistic regression analysis demonstrated that injury to the ALS was the only significant risk factor for grade 3 pivot shift (odds ratio, 13.49; 95% CI, 1.80-1725.53).Conclusion:This comprehensive evaluation of soft tissue and osseous factors has identified that injury to the ALS is the most important risk factor for grade 3 pivot shift in acute ACL-injured knees.

Objectives: Anterior cruciate ligament (ACL) injuries are often associated with meniscal and chondral lesions. Meniscal lesions are present in up to 50% of ACL injured knees, and chondral lesions occur with an incidence of 20% to 40% in acute ACL-injured knees. The major importance of this lies in the fact that menisectomy and severe chondral damage are important predictors of poor outcomes including the subsequent development of knee osteoarthritis. Furthermore, patient reported outcomes following revision ACL reconstruction remain inferior to primary ACL reconstruction and this may, at least in part, be due to an increased incidence and severity of meniscal and chondral injuries. Although multiple studies have demonstrated that meniscal and chondral lesions are generally present at a higher rate at the time of revision ACL reconstruction when compared to primary ACL reconstruction, large studies following individual patients through primary and revision ACL reconstruction and tracking the change in the occurence of these injuries are scarce. The primary objective of this study was to determine the proportion of patients with meniscal and chondral injuries at the time of primary ACL reconstruction and determine how this rate changed by the time they underwent revision ACL reconstruction. The hypothesis was that the proportion of patients with meniscal and/or chondral lesions would be significantly greater at revision ACL reconstruction when compared to the primary procedures. Methods: Consecutive patients who underwent primary and then revision ACL reconstruction between March 1999 and February 2018 were identified using a single center registry. Patient characteristics, and intraoperative data from each procedure were collected and analyzed. This specifically included the occurrence and type of meniscal and chondral pathology. Descriptive statistics were used to evaluate the study sample using medians, descriptive data analysis was conducted depending on the nature of the criteria. Comparison between variables were assessed with student’s t test for quantitative variables and Mcnemar test for categorical variables. Statistical significance was set a t pResults: 213 consecutive patients underwent both primary ACL reconstruction and then revision surgery during the study period. The average time from primary ACLR to Revision was 46.8 ± 36.6 months (range 5-181).The mean age of patients at primary ACLR was 22.21±7.21 years. The mean age of patients at revision ACLR 26.1 ± 8.3 years. The mean IKDC for the entire population was 85.53 ± 11.59, The mean ACL-RSI score was 71.89 ± 23.95. The mean Lysholm score was 91.77±10.24. The proportion of patients with chondral lesions significantly increased from 7% at primary ACL to 15.5% at revision ACL (p < 0.05). Meniscal lesions also significantly increased from 44.6 % at primary ACLR to 70% at revision ACLR (p < 0.05). There was no significant difference in the rate of lateral meniscal lesions (11.7 vs 13.1, p > 0.05). However, the proportion of patients with a medial meniscus lesion (25.4 vs 36.2, p < 0.05) and bimeniscal lesions (7.5 vs 20.7, p < 0.05) increased significantly at revision ACL reconstruction. Conclusions: The proportion of patients with meniscal and//or chondral injuries at the time of revision ACL reconstruction is significantly higher than at the time of primary ACL reconstruction. Specifically, the rate of medial meniscus and bimeniscal injuries is significantly higher in patients undergoing revision ACL reconstruction

Background: Professional athletes are reported to be at greater risk of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR) than the nonprofessional population. However, this finding has been controversial, and confusion has arisen in the literature owing to the underpowering of previous studies. Purpose/Hypothesis: The purpose was to report the differences in the rate of SA after ACLR in a large series of patients and to perform pooled data analysis including previously published studies. The hypothesis was that professional athletes have a significantly higher risk of SA than nonprofessional athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed. Patients who underwent ACLR between January 2009 and July 2017 (with a minimum follow-up of 12 months) were considered for study eligibility. The rate of SA was determined, and multivariate analysis was used to evaluate potentially important risk factors, including participation in professional sport. Furthermore, a literature search was performed, and data were extracted from all identified relevant studies. A pooled data analysis was performed to determine differences in the risk of SA between professional and nonprofessional populations. Results: The current series comprised 4421 anterior cruciate ligament surgical procedures with 265 professional athletes. There were 15 cases of SA diagnosed over the study period (0.34%; 95% CI, 0.19%-0.56%). Ten cases occurred in professional athletes (3.8%; 95% CI, 1.82%-6.83%). The percentage of SA was 0.12% (95% CI, 0.04%-0.28%) in the nonprofessional population. Being a professional athlete was associated with a significantly increased risk of SA after ACLR (odds ratio, 21.038; 95% CI, 6.585-75.789; P < .0001). This finding was confirmed in the pooled data analysis comprising 11,416 patients including 1118 professional athletes (odds ratio, 5.03; 95% CI, 1.17-21.61). Conclusion: Professional athletes are at greater risk of SA after ACLR than nonprofessional athletes. The results of previous studies may have been conflicting owing to underpowering. The current study confirms the elevated risk by using a large clinical series and pooled data analysis to avoid the limitations of previous studies.

Background: Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction is associated with improved clinical outcomes as compared with isolated intra-articular reconstruction, but the indications are not precisely defined. It may be the case that patients with proven anterolateral injury on preoperative imaging are most likely to benefit, but the accuracy of magnetic resonance imaging (MRI) is not known. Purpose/Hypothesis: To evaluate the correlation between MRI and surgical exploration in acute ACL-injured knees. The hypothesis was that a positive correlation would be identified between imaging and surgical findings for ALL/capsule and iliotibial band (ITB) injuries and that MRI would be highly sensitive, specific, and accurate. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Between January and May 2016, patients presenting with acute ACL injuries were considered for study eligibility. Included patients underwent 1.5-T MRI, which was evaluated by 3 investigators who attributed a Ferretti grade of injury to the anterolateral structures. At the time of ACL reconstruction, a lateral exploration was undertaken, and macroscopic injuries were identified. An evaluation of correlation between MRI and surgical exploration findings was performed. Results: Twenty-six patients participated in the study, and 96% had an ALL/capsule injury. The sensitivity, specificity, and accuracy of MRI and the correlation ( K) with surgical exploration findings were as follows, respectively: any ALL/capsule abnormality—88%, 100%, 88.5%, and 0.47; differentiating partial or complete ALL/capsule tears—78.6%, 41.7%, 61.5%, and 0.23; ITB injuries—62.5%, 40%, 50%, and 0.27. The percentage agreement between MRI and surgical findings was 88% for ALL/capsule injury, 65% for ITB injury, and 53% for Ferretti grading. Conclusion: Surgical exploration demonstrates that injuries occur to the anterolateral structures in almost all acute ACL-injured knees. MRI is highly sensitive, specific, and accurate for detection of abnormalities of the ALL/capsule and shows a high percentage of agreement with surgical findings. MRI has low sensitivity, specificity, and accuracy for the diagnosis of ITB injury. The Ferretti grade could not be reliably established from MRI, and there was only fair agreement between MRI and surgical findings with respect to ITB abnormalities and determination of whether ALL/capsular tears were partial or complete.

Background: Arthrogenic muscle inhibition (AMI), a process in which quadriceps activation failure is caused by neural inhibition, is common following knee injury or surgery. No classifications exist to describe the variable presentations of AMI following knee injury. Indications: AMI can result in significant morbidity following knee injury, and it is essential to recognize and treat. It is crucial to identify patients at higher risk of postoperative complications as surgery should be delayed for specific rehabilitation programs. Understanding the pathophysiology of AMI is vital as this can guide therapeutic interventions. Technique Description: AMI following knee injury can present in a variety of ways including inhibition of the vastus medialis obliquus (VMO) muscle, extension deficits due to hamstring contracture, as well as chronic extension deficits. They also respond differently to conventional treatment modalities and often require longer and specific rehabilitation programs. Therefore, we propose a classification to define these different presentations. Results: Grade 0 is a normal VMO contraction. Grade 1a is when VMO contraction is inhibited but activation failure is reversible with simple exercises while Grade 1b requires longer and specific rehabilitation programs. Grade 2a is when VMO contraction is inhibited with an associated extension deficit due to hamstring contracture, but activation failure and loss of range of motion is reversible with simple exercises. However, Grade 2b is refractory to simple exercises, and longer and specific rehabilitation programs are required. Grade 3 is a chronic extension deficit that is irreducible without extensive posterior arthrolysis. Conclusion: In conclusion, AMI is a process in which quadriceps activation failure is caused by neural inhibition and is common following knee injury or surgery. Not taking AMI into account preoperatively can result in a very high risk of stiffness postoperatively. We propose a classification for AMI following knee injury or surgery, which describes different presentations and can be used to guide management.

Objectives: Second ACL injuries (defined as a graft rupture or contralateral ACL rupture) are common after ACL reconstruction. It is postulated that this observation could reflect a premature attempt to return to sports (RTS) and that delaying RTS until certain quality indicators or rehabilitation milestones are met could reduce the risk. There is consequently considerable interest in the application of RTS criteria. Multiple authors have reported that patients who passed a battery of tests prior to RTS, had a lower risk of re-injury and an increased rate of return to sport. However, factors influencing RTS scores have not been well studied. Therefore, the aim of this study was to determine the key factors that influence RTS test scores. Methods: A retrospective analysis of consecutive patients who underwent primary ACL reconstruction between March 2016 and May 2017, who also had a documented RTS evaluation with K-STARTS, (a validated, composite psychological and functional RTS test battery (Fig 1)) at 6 months following surgery, was undertaken. All patients underwent the same standardized rehabilitation program (Table 1) but in addition to this they were offered the opportunity to participate in a separate individualized RTS program (Table 2). If patients chose to participate in the RTS program, this would occur in addition to the standard program and not instead of it. The first session would typically occur 3 months post-operatively and comprised of ten sessions that took place over a 12-week period. Demographic data and characteristics including the frequency of pre-injury sports participation, Tegner score, time from injury to surgery, graft type, the presence of meniscal lesions, whether a lateral tenodesis was performed, and whether patients participated in the specific RTS program in addition to physiotherapy were recorded. To identify factors influencing the K-STARTS score at six months postoperatively, an analysis of variances was performed. When a significant effect was found, post hoc comparisons were made using Tukey’s HSD tests with Bonferroni’s correction. Results: 676 patients were included in the study. Outcomes of the analysis of the influence of factors on the K-STARTS score is comprehensively presented in Table 3. The K-STARTS score was significantly higher in males than females (13.9 vs 12.4, pConclusions: Completion of a specific return to sports program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological return to sports test score at 6 months after ACL reconstruction.

Objectives: The aim of this study was to report long term comparative clinical outcomes of isolated Anterior Cruciate Ligament (ACL) reconstruction versus combined ACL and Anterolateral Ligament (ALL) reconstruction in a matched pair analysis. Methods: A retrospective analysis of prospectively collected data was undertaken. Patients who underwent combined ACL and ALL reconstruction were matched 1:1 to patients who had undergone isolated ACL reconstruction using a propensity score. Matching was based upon age, BMI, side to side laxity difference, duration of time between injury and surgery, type of sports participation (e.g pivoting, contact), presence of concomitant meniscal injuries and their treatment. At the end of the study period all patients completed Lysholm, Tegner, IKDC and KOOS scores, and underwent telephone interview and medical notes review to determine whether they had experienced any complications or re-operations after the index procedure. Kaplan-Meier analysis was used to determine survivorship with respect to graft rupture rates in each group Results: 90 patients who underwent combined ACL and ALL reconstruction were matched to 90 patients who underwent isolated ACL reconstruction. The mean duration of follow up was 108.09±9.43 months (range 97-182). The combined ACLR and ALLR group had significant lower graft rupture rate (3.5%) than the isolated ACLR group (16%) (OR=5.306 ; CI =1.46-19.19 ; p=0.007) (Fig 1). There was no significant difference between groups with respect to non-graft rupture related reoperation rates (secondary meniscectomy, cyclops excision, arthroscopic lavage for infection or hemarthrosis). Contralateral ACL rupture rates were comparable between combined ACL and ALL reconstruction (16.27%) and isolated ACL reconstruction (19.5%) groups. The KOOS score was significantly higher in the combined group with respect to subdomains of pain (p=0.007) and quality of life (p=0.007). There was no significant difference in other KOOS domains, Tegner, Lysholm, or IKDC Conclusions: This study reports the first long-term results of combined ACL and ALL reconstruction. The results demonstrate a significantly lower graft failure rate when compared to isolated ACL reconstruction in a matched pair series with a minimum follow-up of 9 years.

Background:Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known.Purpose:To determine the rate of reoperation after combined ACL and ALL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort.Results:The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non–graft rupture–related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002).Conclusion:The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Background:The widespread historical abandonment of lateral extra-articular procedures in anterior cruciate ligament (ACL) injuries occurred as a result of concerns about high rates of adverse events. Recently, the popularity of lateral extra-articular procedures has resurged, warranting an urgent evaluation of their safety profile.Purpose/Hypothesis:The aim of this study was to perform an interim analysis of the ongoing SANTI randomized controlled trial to determine whether combined ACL and anterolateral ligament reconstruction (ACL + ALLR) is associated with an increased rate of adverse outcomes when compared with isolated ACL reconstruction (ACLR). The hypothesis was that there would be no significant difference between groups at a minimum follow-up of 1 year.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Recruitment commenced in November 2016. Patients scheduled for ACLR were randomized to either isolated ACLR (with bone–patellar tendon–bone [BPTB] autograft) or combined ACL + ALLR (with hamstring tendon autograft). All patients with a minimum follow-up of 1 year by March 2019 were included. The evaluated parameters included complications and reoperations, knee laxity parameters, range of motion, and scores on the Tegner, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) instruments.Results:A total of 224 patients (112 in each group) with a mean ± SD follow-up of 12.3 ± 1.9 months (range, 12-19 months) formed the study population. A significantly higher rate of reoperation for cyclops syndrome was noted in the isolated ACLR group compared with the combined ACL + ALLR group (8.9% vs 0%, respectively; P = .0012). No significant differences were found in frequency of graft rupture (ACLR, 5.4%; ACL + ALLR, 0.9%; P = .1191), range of motion deficits, pain, or reoperation for meniscectomy between groups. No cases of postoperative infection, venous thromboembolism, or arthrofibrosis were seen. Subjective IKDC (81.2 vs 86.8; P = .0048), Lysholm (88 vs 92; P = .0131), and some components of the KOOS were significantly better in the combined ACL + ALLR group.Conclusion:This study demonstrates no evidence of an increased risk of short-term adverse events after combined ACL + ALLR compared with isolated ACLR with BPTB graft.Registration:NCT03740022 ( ClinicalTrials.gov Identifier)

Background:The radiological work-up of patients with patellofemoral disorders continues to be debated. The interchangeability of the tibial tubercle–trochlear groove (TT-TG) distance between computed tomography (CT) and magnetic resonance imaging (MRI) has recently been questioned. In addition, a new measurement—the tibial tubercle–posterior cruciate ligament (TT-PCL) distance—has shown that not all patients with a pathological TT-TG distance (>20 mm) have lateralization of the tibial tubercle. Another factor to consider when looking at the position of the tibial tubercle is the knee joint rotation, defined as the angle between the femoral dorsal condylar line and the tibial dorsal condylar line.Purpose:To determine, with a larger population, if the TT-TG measurements can be used interchangeably between CT and MRI and to confirm the correlation between the TT-PCL and TT-TG distances in determining tibial tubercle lateralization.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Patients with patellofemoral disorders and MRI and CT scans of the same knee (n = 141) were identified. The TT-PCL, the knee joint rotation, and TT-TG were measured independently by 2 fellowship-trained orthopaedic surgeons. Thirty measurements were repeated on a separate occasion to allow for an assessment of the intrarater reliability. The intraclass correlation coefficient (ICC) was used to assess reliability of the measurements.Results:The mean TT-TG was 4.16 mm less on MRI ( P < .05), with the mean TT-TG ± SD being 17.72 ± 5.15 mm on CT (range, 6.97-31.33 mm) and 13.56 ± 6.07 mm on MRI (range, 2-30.04 mm). The ICC for each rater comparing the 2 imaging modalities was only fair (0.54 and 0.48). The mean TT-PCL measurement was 20.32 ± 3.45 mm (range, 10.11-32.01 mm) with excellent interobserver and intraobserver reliability (>0.75). Based on the TT-TG and TT-PCL measurements, 4 groups of patients can be established. When knee joint rotation is compared among groups, an increased TT-TG may result from true lateralization of the tibial tubercle, an increased knee joint rotation, or both.Conclusion:Based on a statistically significant mean difference (4.11 mm) and only a fair ICC (0.54 and 0.48) for raters comparing the 2 modalities, the measurements for the TT-TG cannot be used interchangeably between CT and MRI. Therefore, currently accepted values for TT-TG based on CT scans should not be applied to an MRI scan. The TT-PCL measurement is a measure of true lateralization of the tibial tubercle, while the TT-TG is an amalgamated measure of true lateralization and knee joint rotation.

Background: External rotation (ER) bracing has been shown to improve labral reduction in cadaveric studies, but this has not translated to universal improvement in re-dislocation rates in clinical series. Purpose: To systematically review and critically appraise the literature that investigates how well the labrum is actually reduced by ER in patients who have had an anterior shoulder dislocation. Study Design: Systematic review. Methods: We conducted a systematic review of the literature using the online databases Medline, EMBASE, and the Cochrane Controlled Trial Register. Studies were included if they reported on the difference in labral reduction after ER and internal rotation bracing in patients who had a traumatic anterior shoulder dislocation. Results: Of the 6 studies included, 5 assessed labral reduction on magnetic resonance imaging and 1 arthroscopically. Each study reported an overall improvement in labral reduction with ER, but anatomic reduction was not commonly achieved. This was despite the use of extreme positions that are unlikely to be well tolerated. Conclusion: External rotation results in anatomic reduction of the labrum in only 35% of cases. We postulate that failure to reduce the labrum may be a contraindication to ER bracing and propose further study to determine whether acute MRI could be used to help identify patients in whom ER achieves labral reduction in a comfortable position. This approach also has the advantage of avoiding the significant inconvenience of ER bracing in those in whom the labrum does not reduce and are therefore theoretically less likely to benefit. However, it is a novel strategy with significant resource implications and therefore warrants further study.

Background: Remnant preservation may confer important advantages in the anterior cruciate ligament (ACL)–reconstructed knee. However, the presence of a large remnant may obscure visualization and impair the ability to correctly place tunnels during surgery. Purpose: To determine whether tunnel placement during anatomic ACL reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique is consistent and precise when a large native remnant is preserved. Study Design: Case series; Level of evidence, 4. Methods: Included in this study were 99 patients undergoing an ACL reconstruction during which at least 50% of the native ACL was preserved. The femoral tunnel was created using an outside-in specific guide. The tibial tunnel was positioned in the anteromedial region of the ACL footprint, and the remnant was carefully preserved while drilling and passing the semitendinosus graft through it. Postoperatively, 3-dimensional computed tomography (3D CT) was used to evaluate tunnel placement. The mean tunnel locations were calculated and the standard deviation was used to evaluate precision of positioning. Inter- and intrareader agreement were determined to assess reliability of evaluation of tunnel position. Results: The center of the femoral tunnel was positioned at a mean 19.4% (SD, 2%) of the depth of the notch and a mean 23.1% (SD, 3.5%) of the lateral wall height. The center of the tibial tunnel was positioned at a mean 36.3% (SD, 3.8%) of the anteroposterior length of the tibial plateau and at a mean 47.0% (SD, 2.7%) of the mediolateral width. The small standard deviations demonstrate that this technique allows precise tunnel placement. The tunnel positions achieved were consistent with previous anatomic studies of femoral and tibial anteromedial bundle insertion. Intra- and interobserver reliability were high. Conclusion: Three-dimensional CT evaluation demonstrated that despite the presence of a large remnant, placement of femoral and tibial tunnels for anatomic ACL reconstruction using the SAMBBA technique is consistent and precise.

Background: Broad variation in the reported rate of magnetic resonance imaging (MRI)–detected abnormalities of the anterolateral structures of the anterior cruciate ligament (ACL)–injured knee suggests a lack of reliability that has limited the use of MRI in clinical decision making. Purpose/Hypothesis: The aim of this study was to use MRI to determine the prevalence and spectrum of abnormalities of the anterolateral structures in acute ACL-injured knees, using the contralateral uninjured knee as a reference. We hypothesized that MRI evaluation of the acutely injured knee (using the uninjured knee as a reference) would allow reliable identification of abnormalities of the anterolateral structures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with acute ACL injury underwent MRI scan of both knees. Images were evaluated by 3 observers. Inter- and intraobserver reliabilities were determined for MRI parameters of anterolateral ligament (ALL) injury by use of the kappa (κ) test. Univariate and multivariate analyses were conducted to test associations between ALL abnormality and associated injuries. Results: A total of 34 patients were evaluated. Of these, 30 patients (88.2%) had at least 1 ALL abnormality in the ACL-injured knee (increased signal: n = 27[79.4%]; increased thickness: n = 15[44.1%]; tapering: n = 7[20.6%]; irregularities in the path of the ALL fibers: n = 21[61.7%]). Asymmetries of the genicular vessels were observed in 21 patients (61.7%). ALL abnormality was significantly associated with lateral joint capsular tears ( P < .001). No correlation was found between ALL lesions and iliotibial band lesions ( P = .49). Inter- and intraobserver reliabilities were very good concerning ALL signal changes and femoral and tibial bone bruises (κ coefficient, 0.81-1). Conclusion: MRI evaluation of the ALL was associated with good and very good inter- and intraobserver reliabilities, and it demonstrated abnormalities of the ALL in the majority of acutely ACL-injured knees. The index of suspicion for ALL injury should be elevated by the presence of lesions of the lateral capsule. This suggests that the ALL is part of a wider area of the lateral capsule that is often injured simultaneously in an acute ACL tear.

Transarticular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation. A variety of approaches have been described, including extended lateral and anterolateral approaches and arthroscopically-assisted fixation for noncomminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe a novel approach to this fracture utilizing a fenestration of the olecranon fossa with a 4-cm triceps split (i.e. similar to the Outerbridge – Kashiwagi procedure) to insert a bone lever and achieve an anatomical reduction. The fracture was then fixed with headless compression screws directed from posterior to anterior. Early mobilization and rehabilitation were commenced and follow-up clinical examination and radiographs demonstrated full restoration of function with anatomical bony union. We consider that this technique comprises a feasible approach for fixing mild to moderately displaced transarticular coronal shear fractures with medial extension, where the fracture fragment is one block and there is no associated posterior comminution.

Background: Pulling the long head of the biceps tendon into the joint at arthroscopy is a common method for evaluation of tendinopathic lesions. However, the rate of missed diagnoses when using this technique is reported to be as high as 30% to 50%. Hypothesis: Tendon excursion achieved using a standard arthroscopic probe does not allow adequate visualization of extra-articular sites of predilection of tendinopathy. Study Design: Descriptive laboratory study. Methods: Seven forequarter amputation cadaveric specimens were evaluated. The biceps tendon was tagged to mark the intra-articular length and the maximum excursions achieved using a probe and a grasper in both beach-chair and lateral positions. Statistical analyses were performed using analysis of variance to compare means. Results: The mean intra-articular and extra-articular lengths of the tendons were 23.9 and 82.3 mm, respectively. The length of tendon that could be visualized by pulling it into the joint with a probe through the anterior midglenoid portal was not significantly different when using either lateral decubitus (mean ± SD, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm) or beach-chair positions (32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm). The maximum length of the overall tendon visualized in any specimen using a standard technique was 37 mm. Although there was a trend to greater excursion using a grasper through the same portal, this was not statistically significant. However, using a grasper through the anterosuperior portal gave a significantly greater mean excursion than any other technique (46.7 ± 4.31 mm; 95% CI, 42.6-50.8 mm), but this still failed to allow evaluation of Denard zone C. Conclusion: Pulling the tendon into the joint with a probe via an anterior portal does not allow visualization of distal sites of predilection of pathology. Surgeons should be aware that this technique is inadequate and can result in missed diagnoses. Clinical Relevance: This study demonstrates that glenohumeral arthroscopy does not allow visualization of common areas of pathology of the long head of the biceps tendon.