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Purpose: This study aims to develop and externally validate a treatment algorithm to predict nonoperative treatment success or failure in patients with anterior cruciate ligament (ACL) rupture. Methods: Data were used from two completed studies of adult patients with ACL ruptures: the Conservative versus Operative Methods for Patients with ACL Rupture Evaluation study (development cohort) and the KNee osteoArthritis anterior cruciate Ligament Lesion study (validation cohort). The primary outcome variable is nonoperative treatment success or failure. Potential predictor variables were collected, entered into the univariable logistic regression model and then incorporated into the multivariable logistic regression model for constructing the treatment algorithm. Finally, predictive performance and goodness‐of‐fit were assessed and externally validated by discrimination and calibration measures. Results: In the univariable logistic regression model, a stable knee measured with the pivot shift test and a posttrauma International Knee Documentation Committee (IKDC) score <50 were predictive of needing an ACL reconstruction. Age >30 years and a body mass index > 30 kg/m2 were predictive for not needing an ACL reconstruction. Age, pretrauma Tegner score, the outcome of the pivot shift test and the posttrauma IKDC score are entered into the treatment algorithm. The predictability of needing an ACL reconstruction after nonoperative treatment (discrimination) is acceptable in both the development and the validation cohort: area under the curve = resp. 0.69 (95% confidence interval [CI]: 0.58–0.81) and 0.68 (95% CI: 0.58–0.78). Conclusion: This study shows that the treatment algorithm can acceptably predict whether an ACL injury patient will have a(n) (un)successful nonoperative treatment (discrimination). Calibration of the treatment algorithm suggests a systematical underestimation of the need for ACL reconstruction. Given the limitations regarding the sample size of this study, larger data sets must be constructed to improve the treatment algorithm further. Level of Evidence: Level II. [ABSTRACT FROM AUTHOR]

Purpose: The pivot‐shift test is used to clinically assess knee instability in patients with anterior cruciate ligament (ACL) lesions; however, it has low interobserver reliability. Dynamic radiostereometry (dRSA) is a highly precise and noninvasive method for the objective evaluation of joint kinematics. The purpose of this study was to quantify precise knee kinematics during a pivot‐shift test using dRSA imaging. Method: Eight human donor legs, including hemipelvises, were evaluated. Arthroscopic intervention was performed inducing ligament lesions in the ACL, and anterolateral ligament (ALL) section was performed as a capsular incision. The pivot‐shift test was recorded with dRSA on knees with intact ligaments, ACL‐deficient and ACL + ALL‐deficient knees. Results: A pivot‐shift pattern was identifiable after ligament lesion, as a change in tibial posterior drawer velocity from 7.8 mm/s (95% CI: 3.7; 11.9) in ligament intact knees to 30.4 mm/s (95% CI 23.0; 38.8) after ACL lesion to 35.1 mm/s (95% CI 23.4; 46.7) after combined ACL‐ALL lesion. The anterior‐posterior drawer excursion increased from 2.8 mm (95% CI 2.1; 3.4) in ligament intact knees to 7.2 mm (95% CI 5.5; 8.9) after ACL lesion to 7.6 mm (95% CI 5.5; 9.8) after combined lesion. A statistically significant increase in tibial external rotation towards the end of the pivot‐shift motion was observed when progressing from intact to ACL + ALL‐deficient knees (p < 0.023). Conclusion: This experimental study demonstrates the feasibility of dRSA to objectively quantify the kinematic laxity patterns of the knee during the pivot‐shift test. The dynamic parameters obtained through dRSA revealed the kinematic changes from ACL to combined ACL‐ALL ligament lesion. Level of Evidence: Not applicable. [ABSTRACT FROM AUTHOR]

Introduction: Anterior cruciate ligament (ACL) reconstruction remains associated with the risk of re-rupture and persisting rotational instability. Additional extraarticular anterolateral stabilization procedures stabilize the tibial internal rotation and lead to lower ACL failure rate and improved knee stability. However, data for additional stabilization of tibial external rotation is lacking and the importance of an anteromedial stabilization procedure is less well evaluated. Aim of this study is to investigate the influence of an extraarticular anteromedial stabilization procedure for the stabilization of the tibial external rotation and protection of the ACL from these rotational forces. Methods: Internal and external rotations of the tibia were applied to a finite element (FE) model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Five additional anatomic structures (Anteromedial stabilization/anteromedial ligament, AML, augmented superficial medial collateral ligament, sMCL, posterior oblique ligament, POL, anterolateral ligament, ALL, and popliteal tendon, PLT) were added to the FE model separately and then combined. The force histories within all structures were measured and determined for each case. Results: The anteromedial stabilization or imaginary AML was the main secondary stabilizer of tibial external rotation (90% of overall ACL force reduction). The AML reduced the load on the ACL by 9% in tibial external rotation which could not be achieved by an augmented sMCL (-1%). The AML had no influence in tibial internal rotation (-1%). In the combined measurements with all additional structures (AML, ALL, PLT, POL) the load on the ACL was reduced by 10% in tibial external rotation. Conclusion: This study showed that an additional anteromedial stabilization procedure secures the tibial external rotation and has the most protective effect on the ACL during these external rotational forces. [ABSTRACT FROM AUTHOR]

Introduction: Anterior cruciate ligament (ACL) reconstruction is considered the first line treatment in ACL rupture. However, some patients return to high intensity sport activities and show a normal knee function without ACL reconstruction. Therefore, aim of this study was to evaluate the rate and prognostic factors of spontaneous healing in patients with ACL rupture and the short-term functional outcome. Methods: The rate, prognostic factors and short-term functional results of spontaneous healing in patients with ACL rupture were evaluated in 381 patients. Morphology of ACL rupture and extent of posterior tibial slope (PTS) were classified by MR- and x-ray imaging. In patients with normal knee stability in anesthesia examination and healed ACL during the arthroscopy 6 weeks after trauma ACL reconstruction was canceled. IKDC -, Tegner Activity Score, KT 1000 testing and radiological characteristics were collected 12 months postoperatively in these patients. Results: 14.17% of the patients with ACL rupture showed a spontaneous healing after 6 weeks. Femoral ACL-rupture (p < 0.02) with integrity of ligament stump > 50% (p < 0.001), without bundle separation (p < 0.001) and decreased PTS (p < 0.001) was found significantly more often in patients with a spontaneous healed ACL. The average IKDC score was high at 84,63 in patients with healed ACL at 1 year follow-up, but KT 1000 testing was inferior compared to non-injured side. Conclusion: Spontaneous healing of a ruptured ACL happened in 14% of the patients. Especially in low-demand patients with femoral single bundle lesions without increased posterior tibial slope delayed ACL surgery should be considered to await the possibility for potential spontaneous ACL healing. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to generate more information on the etiology and pathogenesis of medial (MM) and lateral (LM) meniscus root tears. Our hypothesis was that root tears of the MM predominantly result from degenerative damage, whereas root injuries of the LM are mainly of traumatic origin. Methods: Consecutively, 53 patients with a root tear of the medial meniscus (MMRT) and 51 patients with a root tear of the lateral meniscus (LMRT) were included in this study. The diagnosis was confirmed radiologically by MRI as well as arthroscopically. In addition to patient-specific data such as age, BMI and trauma history, the leg axis was determined and accompanying injuries (ligamentous and chondrogenic) were documented. Results: The mean age of the MMRT group was 57.2 (± 11.2) years, and that of the LMRT group 33.9 (± 11.4) years. The BMI was significantly higher in the MMRT group compared to the LMRT (30.5 vs. 25.1). 82.4% of patients in the LMRT group demonstrated an accompanying anterior cruciate ligament (ACL) rupture, whereas only 5.7% of the MMRT were associated with an ACL injury. A trauma was described in only 13.2% of patients of the MMRT group in contrast to 88.2% of the LMRT group. An extrusion > 3 mm of the MM in the coronal plane of MRI images could be detected in 86.8% of patients, whereas in the LMRT group, it was 15.7%. The mechanical varus angle was 5.6° in the MMRT group and 2.4° in the LMRT group. The rate and degree of concomitant cartilage damage in the affected compartment was significantly higher in the group with medial root injuries than in the group with lateral root tears. Conclusions: The root injuries of the MM and LM show significant differences in terms of patient age, etiology and accompanying injuries. Root injuries to the medial meniscus are mostly of non-traumatic origin and more likely to occur in the context of medial osteoarthritis and varus deformity of the knee. Lateral root tears tend to be predominantly traumatic and are frequently associated with ACL ruptures. However, in the MMRT group, a small subgroup with a traumatic etiology and in the LMRT group a small subgroup of patients with non-traumatic etiology could be identified. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to assess the diagnostic value of the "lever sign test" to diagnose ACL rupture and to compare this test to the two most commonly used, the Lachman and anterior drawer test. Method: This prospective study was performed in the ED of the Cliniques Universitaires Saint-Luc (Brussels, Belgium) from March 2017 to May 2019. 52 patients were included undergoing knee trauma, within 8 days, with an initial radiograph excluding a fracture (except Segond fracture or tibial spine fracture). On clinical investigation, patients showed a positive lever sign test and/or a positive Lachman test and/or a positive anterior drawer test. Exclusion criteria were a complete rupture of the knee extensor mechanism and patellar dislocation. All the physicians involved in this study were residents in training. An MRI was performed within 3 weeks for all included patients after the clinical examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were investigated for all three tests with MRI used as our reference standard. Results: Forty out of 52 patients suffered an ACL rupture (77%) and 12 did not (23%). The sensitivity, specificity, PPV and NPV of the lever sign test were respectively 92.5%, 25% 82% and 50%. Those of the Lachman test were 54%, 54.5%, 81% and 25%, and those of the anterior drawer test were 56%, 82%, 90.5% and 37.5%. Twelve out of 40 ACL ruptures (30%) were diagnosed exclusively with a positive lever sign test. Conclusion: When investigating acute ACL ruptures (< 8 days) in the ED, the lever sign test offers a sensitivity of 92.5%, far superior to that of other well-known clinical tests. The lever sign test is relatively pain-free, easy to perform and its visual interpretation requires less experience. Positive lever sign test at the ED should lead to an MRI to combine high clinical sensitivity with high MRI specificity. [ABSTRACT FROM AUTHOR]

Introduction: ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated. Materials and methods: One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. Results: In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039). Conclusion: In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment. [ABSTRACT FROM AUTHOR]

Purpose: An enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears. Methods: Thirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified. Results: Three patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05). Conclusion: Primary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Introduction: Anterior cruciate ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatment are still debated, including conservative management vs. various surgical techniques. The lack of long-term reports has been highlighted in the literature.Aim: To evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis.Methods: Retrospective study. All surgeries performed by same surgeon. A total of 42 patients included. All patients had pre-operative radiological studies.Subjects: 30 males and 12 females. Average age: 12.5 years (range 11-14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000 and plain radiographs. Standardized rehabilitation protocol.Results: No instability or leg length discrepancy was recorded. Average pre-operative Tegner-Lysholm and Pedi-IKDC scores were 55 and 40, respectively, with a score of 94.8 (p < 0.05) and 94.78, respectively, at final follow-up (p < 0.05). Average post-operative (1 month) Tegner-Lysholm score: 75 (range: 62-79). Median post-operative Tegner activity: 8. Mean side-to-side (KT-1000): 1.2 mm. A total of 22 patients could go back to pre-injury sport activity, with an average rehabilitation of 7.3 months.Discussion: A significant number of cases were included in our structured standardized study and follow-up. Functional scores were excellent overall. Excellent results are testified by a final achievement of 22 patients going back to pre-injury sport activity, which is in keeping with the literature. Our experience exhibited a low complication rate and no metalwork failure. We correlate our results to the use of the Over the Top technique with lateral extra-articular tenodesis.Conclusion: The studied procedure seems to be an excellent option and an effective, feasible and safe technique when treating ruptured ACLs in skeletally immature patients. [ABSTRACT FROM AUTHOR]

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Purpose: Despite public recognition, obesity is a growing epidemic affecting an estimated 34% of adults and 20% of children in the U.S.Population: As such, the number of ACL reconstructions performed in this population is likely to increase. The goal of this study is to evaluate the risk that increasing BMI poses for additional surgery at the time of ACL reconstruction.Methods: A retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program's (ACS-NSQIP) database for the years 2005-2015 was conducted. Logistic regressions were used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of ACL reconstruction. Internal derangement was defined as any CPT code for treatment of a meniscus tear, chondral lesion, or loose body removal. Surgeries for multi-ligamentous knee injuries were excluded.Results: A total of 11,403 patients undergoing ACL reconstruction were identified. 41.9% of patients had an associated CPT code for internal derangement. As BMI increased, there was a corresponding increase in the odds of additional surgery. Specifically, for every 1.0 increase in BMI, the risk of additional surgery increased by 1.6% (p < 0.001). Compared to patients with a BMI of 18.5-24.9, those with a BMI 25-29.9 had an odds ratio (OR) of 1.112, BMI 30-34.9 had an OR of 1.137, BMI 35-39.9 had an OR of 1.249, and those ≥ 40 had an OR of 1.442 for additional surgery (p < 0.001).Conclusions: This nationally-representative, population-based study demonstrates that patients with elevated BMI are much more likely to require additional surgery in the setting of primary ACL reconstruction. This risk correlates with increasing BMI. Surgeons should keep these risks in mind when evaluating and counseling patients for surgery in the setting of ACL reconstruction.Level Of Evidence: Case-control study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: It was the aim to assess all published original research dealing with dynamic repair of the anterior cruciate ligament (ACL) and to provide a semi-quantitative analysis of clinical outcome reports.Methods: Both OVIS and MEDLINE databases were utilized for allocation of articles. All preclinical and clinical studies related to dynamic intraligamentary stabilization (DIS) were identified. Results were tabulated and semi-quantitative analysis performed.Results: Twenty-three articles related to DIS were identified. The predominant level of evidence ranged between II and IV, with only one level I study. Reported failure rates ranged between 4% and 13.6%. Most clinical studies only reported revision rates without referring to failure of restoring stability. Highest success was achieved with proximal ACL ruptures. Both the level of physical activity and  patient age have been found to influence the risk of failure.Conclusion: There is sufficient evidence to support that DIS repair may be an effective modality for the treatment of acute proximal tears of the ACL. However, comparative studies are lacking. Upcoming studies should compare the technique to ACL reconstruction with failure as an endpoint. Comparison to rigid methods of proximal fixation is also necessary to justify the need for dynamic fixation. Overall, there is evidence to suggest the potential space for ACL repair in the decision tree for individualized treatment planning. The best outcome will be in the hands of the best patient selectors.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Repairs of the posterior horn of the lateral meniscus can be technically challenging. In contrast to medial meniscus repairs, the capsule around the posterior segment attachment of the lateral meniscus is quite thin. This study evaluates the clinical results of an arthroscopic all-inside repair technique for unstable, vertical, lateral meniscus tears, using a suture repair placed directly into the popliteus tendon.Methods: A retrospective analysis of prospectively collected data from the SANTI database was performed. All patients who had undergone combined ACL reconstruction with lateral meniscus all-inside repair, using sutures placed in the popliteus tendon, between 2011 and 2015, were included. Patients were reviewed clinically at 1 and 2 years' follow-up. At final follow-up, all patients were contacted to identify if they underwent further surgery or had knee pain, locking or effusion. Symptomatic patients were recalled for clinical evaluation by a physician and Magnetic Resonance Imaging of the knee. Operative notes for those undergoing further surgery were reviewed and rates and type of re-operation, including for failed lateral meniscal repair were recorded.Results: Two hundred patients (mean age 28.6 ± 10.2 years) with a mean follow-up of 45.5 ± 12.8 months (range 24.7-75.2) were included. The mean Subjective International Knee Documentation Committee (IKDC) at final follow-up was 85.0 ± 11.3. The post-operative mean side-to-side laxity measured at 1 year was 0.6 ± 1.0 mm. Twenty-six patients underwent re-operation (13%) at a mean follow-up of 14.8 ± 7.8 months. The ACL graft rupture rate was 5.0%. Other causes for re-operation included medial meniscus tear (2.5%), cyclops lesion (1.5%) and septic arthritis (0.5%). The lateral meniscus repair failure rate was 3.5%. No specific complications relating to placement of sutures in the popliteus tendon were identified.Conclusion: Arthroscopic all-inside repair of unstable, vertical, lateral meniscus tears using a suture placed in the popliteus tendon is a safe technique. It is associated with a very low failure rate with no specific complications.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

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Purpose: This study explored the effects of Pilates on the muscle strength, function, and instability of patients with partial anterior cruciate ligament (ACL) injuries in situations in which a non-surgical treatment option is preferred.Methods: Fifty participants 20-45 years of age who were diagnosed with isolated ACL injuries were included in the study. The participants were randomly assigned to either the Pilates exercise group (n = 24) or the control group (n = 26). The subjects in the Pilates exercise group performed basic mat exercises that focused on the muscle strength and flexibility of the lower limbs and core muscles during each class session, which met three times per week for 12 weeks. The control group did not receive any treatment or home exercise programme. All patients were evaluated using the Lysholm Knee Scale, the Cincinnati Knee Rating System, and isokinetic quadriceps and hamstring strength. Patient satisfaction regarding improvement in knee stability was assessed using the Global Rating of Change scale.Results: The Pilates group experienced significant improvement over the control group as measured by the difference in quadriceps strength at 12 weeks (p = 0.03). Both groups showed some clinical change over time, but the Pilates group improved for all outcome measurements at the 12-week follow-up, and the control group only improved for functional outcomes. Patient satisfaction with the level of knee stability based on the Global Rating of Change scale was higher in the Pilates group than in the control group.Conclusion: Although both groups exhibited improvements in knee strength and functional outcomes, the results suggest that Pilates is a superior management approach over a control treatment for increasing quadriceps strength in participants with partial ACL injury. Pilates may provide clinicians a novel option when choosing a treatment for a partial ACL injury. Further study is needed to determine whether certain subgroups of individuals might achieve an added benefit with this approach.Level Of Evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this cross-sectional study was to evaluate the angle of inclination of the native anterior cruciate ligament (ACL) in both the sagittal and coronal planes and to evaluate these findings based on sex, height, BMI, and skeletal maturity.Methods: Inclusion criteria for the study included patients undergoing routine magnetic resonance imaging (MRI) of the knee at a single outpatient orthopedic center who had an intact ACL on MRI. Measurements of the angle of inclination were made on MRIs in both the sagittal and coronal planes. Patients were compared based on sex, height, BMI, and skeletal maturity.Results: One-hundred and eighty-eight patients were included (36 skeletally immature/152 skeletally mature; 98 male/90 female). The overall angle of inclination was 74.3° ± 4.8° in the coronal plane and 46.9° ± 4.9° in the sagittal plane. Skeletally immature patients (coronal: 71.8° ± 6.1°; sagittal: 44.7° ± 5.5°) were significantly different in both coronal and sagittal planes (P = 0.04 and 0.01, respectively) from skeletally mature patients (coronal: 75.3° ± 4.7°; sagittal: 47.4° ± 4.7°). There were no differences based on sex, height, or BMI.Conclusions: There are differences between the angle of inclination findings in this study and other studies, which could be due to MRI and measurement techniques. Clinically, skeletal maturity may be important to account for when using the ACL angle of inclination to evaluate anatomic ACL reconstruction.Level Of Evidence: Prognostic retrospective study, Level of evidence III. [ABSTRACT FROM AUTHOR]

Purpose: Anterior cruciate ligament (ACL) ruptures are often associated with primary meniscal and cartilage lesions. Late reconstruction of ACL-deficient knees may increase the risk of developing secondary meniscal and cartilage lesions; hence, the timing of ACL repair is of the utmost importance. Because meniscus outcome is also a potential predictor for osteoarthritis (OA), this study compared ACL repair within the first 6 months after injury to that of surgery conducted 7-12 months after injury with regard to the incidence of meniscal and cartilage lesions.Methods: This prospective cross-sectional study included all complete isolated primary ACL ruptures treated in our institution within 1 year after trauma over a 12-month period. Exclusion criteria were revision ACL, complex ligament injuries, previous knee surgery, and missing injury data. Cartilage lesions were classified according to the score established by the International Cartilage Repair Society (ICRS score) and meniscal tears according to their treatment options.Results: Two hundred and thirty-three of 730 patients (162 men, 71 women) with ACL repair met the inclusion criteria. 86.3 % of surgical interventions were conducted within 6 months and 13.7 % after 6 months of trauma. Severe cartilage lesions grade III-IV did not significantly differ between the different time points of ACL repair (<6 months 39.9 %; >6 months 31.3 %; p = n.s.). Medial meniscus lesions received significantly higher meniscal repair in early compared to delayed ACL repair. Significantly higher rate of meniscal repair of the medial meniscus was seen in cases of early ACL repair compared to delayed (<6 months 77.2 %, >6 months 46.7; p = 0.022). The rate of medial meniscal repair in early ACL repair was significantly higher for women (89.5-0 %; p = 0.002), however, not for men (73.3-53.8 %; p = n.s.). No differences were found for lateral meniscal lesions, with regard to neither the different time points (p = n.s.) nor the sex (p = n.s.).Conclusions: Because of the significantly higher rate of prognostically advantageous meniscal repair, the recommendation for an ACL reconstruction within 6 months after trauma was made to preserve the meniscus and reduce the risk of developing OA.Level Of Evidence: Prospective cross-sectional cohort study, Level II. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of anterolateral ligament (ALL) injury in patients with acute anterior cruciate ligament (ACL) rupture and to analyse its associated injury patterns.Methods: Ninety patients with acute ACL rupture for which MRI was obtained within 8 weeks after the initial trauma were retrospectively identified. Two radiologists assessed the status of the ALL on MRI by consensus. The presence or absence of an ALL abnormality was compared with the existence of medial and lateral meniscal tears diagnosed during arthroscopy. Associated collateral ligament and osseous injuries were documented with MRI.Results: Forty-one of 90 knees (46 %) demonstrated ALL abnormalities on MRI. Of 49 knees with intact ALL, 15 (31 %) had a torn lateral meniscus as compared to 25 torn lateral menisci in 41 knees (61 %) with abnormal ALL (p = 0.008). Collateral ligament (p ≤ 0.05) and osseous injuries (p = 0.0037) were more frequent and severe in ALL-injured as compared with ALL-intact knees.Conclusion: ALL injuries are fairly common in patients with acute ACL rupture and are statistically significantly associated with lateral meniscal, collateral ligament and osseous injuries.Key Points: • ALL injuries are fairly common in patients with acute ACL rupture. • ALL injuries are highly associated with lateral meniscal and osseous injuries. • MRI assessment of ACL-injured knees should include evaluation of the ALL. [ABSTRACT FROM AUTHOR]

Purpose: A new clinical test for the diagnosis of ACL rupture is described: the so-called "Lever Sign". This prospective study on four groups of patients divided subjects on the basis of MRI findings (complete or partial ACL lesion) and the clinical phase of the injury (acute or chronic). The hypothesis was that this manual test would be diagnostic for both partial and complete tears of the ACL regardless of the elapsed time from injury.Methods: A total of 400 patients were evaluated and divided into four, equal-sized groups based on time elapsed from injury and MRI findings: Group A (acute phase with positive MRI for complete ACL rupture), Group B (chronic phase with positive MRI for complete ACL rupture), Group C (acute phase with positive MRI for partial ACL rupture), and Group D (chronic phase with positive MRI for partial ACL rupture). Clinical assessment was performed with the Lachman test, the Anterior Drawer test, the Pivot Shift test, and the Lever Sign test. The Lever Sign test involves placing a fulcrum under the supine patient's calf and applying a downward force to the quadriceps. Depending on whether the ACL is intact or not, the patient's heel will either rise off of the examination table or remain down. Additionally, the Lever Sign test was performed on the un-injured leg of all 400 patients as a control.Results: All tests were nearly 100 % sensitive for patients with chronic, complete tears of the ACL. However, for patients with acute, partial tears, the sensitivity was much lower for the Lachman test (0.42), Anterior Drawer test (0.29), and Pivot Shift test (0.11), but not the Lever Sign test (1.00).Conclusion: In general, chronic, complete tears were most successfully diagnosed but acute, partial tears were least successfully diagnosed. The Lever Sign test is more sensitive to correctly diagnosing both acute and partial tears of the ACL compared with other common manual tests. The clinical relevance is that some ACL ruptures may be more accurately diagnosed. [ABSTRACT FROM AUTHOR]

Purpose: Well-designed validity studies on the clinical diagnosis of anterior cruciate ligament (ACL) injury are scarce. Our purpose is to assess the diagnostic value of ACL-specific medical history assessment and physical examination between primary and secondary care medical specialists. Methods: Medical history assessment and physical examination were performed by both an orthopaedic surgeon and a primary care physician, both blinded to all clinical information, in a secondary care population. A knee arthroscopy was used as reference standard. A total of 60 participants were divided into an index group with an arthroscopically proven complete ACL rupture and a control group with an arthroscopically proven intact ACL. Results: The orthopaedic surgeon recognized 94 % of the participants with an ACL rupture through a positive medical history combined with a positive physical examination; of the participants with an intact ACL, 16 % were misclassified by the orthopaedic surgeon. The primary care physician recognized 62 % of the participants with an ACL rupture and misclassified 23 % of the participants with an intact ACL. Physical examination appeared to have no additional value for the primary care physician. Conclusions: Combined medical history and physical examination have strong diagnostic value in ACL rupture diagnostics performed by an orthopaedic surgeon, whereas for the primary care physician, only medical history appeared to be of value. For current practice, this could mean that only orthopaedic surgeons can perform an ACL physical examination with accuracy. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: There is a lack of consensus regarding appropriate criteria attesting patients' unrestricted sports activities after ACL reconstruction. Purpose of this study was to perform a systematic review about strength deficits to find out if a strength test might be a return to play criterion. Data source: Pubmed central, Google Scholar. Study eligibility criteria: English language articles. Interventions: Strength tests after ACL reconstruction with autologous tendon grafts. Methods: A systematic search for articles about muscle strength after ACL reconstruction was performed. Results: Forty-five articles could be identified. All articles identified reported strength deficits after ACL reconstruction in comparison to control subjects. Some of these deficits persisted up to 5 years after surgery. Knee flexor strength is more impaired after ACL reconstruction with hamstring grafts and quadriceps strength after BPTB ACL reconstruction. Conclusion: Strength deficits of hip, knee and ankle muscles are reported after ACL reconstruction. Muscular strength test may be an important tool to determine if an athlete can return to competitive sports after ACL reconstruction. [ABSTRACT FROM AUTHOR]

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected. [ABSTRACT FROM AUTHOR]

The interactions between different tissues within the knee joint and between different kinematic DOF and joint flexion during normal gait were investigated. These interactions change following ACL transection, in both short (4 weeks) and long (20 weeks) term. Ten skeletally mature sheep were used in control ( N = 5) and experimental ( N = 5) groups. The 6-DOF stifle joint motion was first measured during normal gait. The control group were then euthanized and mounted on a unique robotic testing platform for kinetic measurements. The experimental group underwent ACL transection surgery, and kinematics measurements were repeated 4 and 20 weeks post-operatively. The experimental group were then euthanized and underwent kinetic assessment using the robotic system. Results indicated significant couplings between joint flexion vs. abduction and internal tibial rotation, as well as medial, anterior, and superior tibial translations during both normal and ACL-deficient gait. Distinct kinetic interactions were also observed between different tissues within the knee joint. Direct relationships were found between ACL vs. LM/MM, and PCL vs. MCL loads during normal gait; inverse relationships were detected between ACL vs. PCL and PCL vs. LM/MM loads. These kinetic interaction patterns were considerably altered by ACL injury. Significant inter-subject variability in joint kinematics and tissue loading patterns during gait was also observed. This study provides further understanding of the in vivo function of different tissues within the knee joint and their couplings with joint kinematics during normal gait and over time following ACL transection. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to test whether low-grade Lachman test (i.e. Grade 0-1+) and a negative pivot shift at 6-12 weeks post-ACL rupture in recreational alpine skiers can be used to predict good function and normal knee laxity in nonoperated patients at minimum 2 years after the injury. Methods: Office registry was used to identify 63 recreational alpine skiers treated by the senior author within 6 weeks of a first-time ACL injury between 2003 and 2008. Of these, 34 had early ACL reconstruction but 29 patients were observed and re-evaluated. Office charts and MRI were reviewed. Inclusion criteria for this study were as follows: ACL rupture documented on MRI after the injury, and minimum 2-year follow-up. Exclusion criterion was contralateral knee ligament injury. Of the 29 patients treated nonoperatively, 17 had low-grade Lachman and negative pivot shift tests within 6-12 weeks after the injury and were recommended to continue follow-up without surgery. Of these 17 patients, 6 were lost to follow up, but 11 patients were recalled and evaluated at more than 2 years after the injury. They completed Marx and Tegner activity level and IKDC subjective scores, physical examination of the knee and KT-1000 anterior laxity assessment. Results: Median age at injury was 43 years (range 29-58). Median follow-up was 42 months (range 30-68). Mean IKDC subjective score at latest follow-up was 91.6 ± 6.7. Median Tegner score was 6 (range 6-9) before the injury and 6 (range 4-6) at latest follow-up ( p = n.s). Median Marx score was 6 (range 0-16) before the injury and 4 (range 0-12) at latest follow-up ( p = 0.03). Ten patients had Lachman Grade 0-1+, and one had Lachman Grade 2+ at latest follow-up. KT-1000 showed mean side-to-side difference of 0.8 ± 1.6 mm, and less than 3 mm difference in the 10 patients with Lachman Grade 0-1+. Conclusion: Recreational alpine skiers who sustain ACL injury should be re-evaluated at 6-12 weeks after the injury rather than being operated acutely. If they have negative Lachman and pivot shift tests at that point, they can be treated without surgery since good outcome and normal knee anterior laxity at more than 2 years after the injury is expected. Level of evidence: Case series, Level IV. [ABSTRACT FROM AUTHOR]

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Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

CL reconstruction in adolescents undergoing or being beyond the final growth spurt can be performed as in adults without major concern of growth disturbance. Whereas for the young athlete with wide-open physis a lot of controversy still exists about the technical aspect of the procedure to minimise the risk of growth disturbance. Between 10/1997 and 10/2002 31 children graded Tanner stage 1 or 2 (median age 11 years) with an intraligamental rupture of the anterior cruciate ligament were enrolled. Seventeen patients with coexisting intraarticular damage (meniscus, osteochondral flake) underwent transphsyeal reconstruction of the ACL with the use of an autogenous semitendinosus tendon graft, whereas 14 patients without coexisting pathologies received a nonoperative regime. Growth disturbance, functional and radiographic outcome could be evaluated in 28 patients at a median of 70 months after initial treatment. No patient had clinical or radiological evidence for varus/valgus malalignment or leg length discrepancy. The mean of subsequent body growth within the study population was 20.3 cm. Patients operated on revealed significant ( P < 0.05) better clinical (KT-1000 side-to-side difference, pivot shift) and functional results according to the IKDC (median, 95 vs. 87), Lysholm (median, 93 vs. 84) and the Tegner score. More than half of the conservatively treated patients (58%) had subsequent surgery due to persistent instability. Transphyseal reconstruction of intraligamental ACL ruptures with an autologous ST graft yielded superior clinical results if compared to a nonoperative treatment in immature prepubescent patients being Tanner stage 1 and 2. [ABSTRACT FROM AUTHOR]

High tibial osteotomy (HTO) is an accepted surgical technique for the treatment of medial compartmental arthrosis of the knee in younger patients. Compared to total knee arthroplasty, HTO may be a good choice in patients who wish to continue with heavy labor and/or impact sports. Based on the rehabilitation protocol after HTO, impact sports, such as running, jumping rope, and full sports activities, are generally permitted 6 months postoperatively. Jumping rope is an excellent form of aerobic exercise, and when done properly, jumping rope can lead to a dramatic improvement in rehabilitation and full sports activities. However, an adequate evaluation should be performed prior to initiating impact sports. We present the case of a ruptured anterior cruciate ligament that occurred in a patient with an unintended increase in the tibial slope after an opening wedge HTO who was jumping rope. [ABSTRACT FROM AUTHOR]

We propose a new technique, with double bundle, double tibial tunnels with a bridge between them, using the hamstrings as auto-grafts, retaining either their central or peripheral attachment. A prospective series of 41 patients underwent primary reconstruction of the anterior cruciate ligament by one surgeon, arthroscopically and electronically assisted; 37 were men and 4 were women with a mean age of 24.7 years. The mean follow-up was19.05 (12–30) months. Normal function and joint stability was achieved. The patients returned to full occupational activities within 3–6 months after the operation. The function of hamstrings was not disturbed. Two patients have sustained a new injury without rupture of the grafts. The Noulis-Lachman test was negative in 35 knees. Positive Pivot shift, post-operatively, was present in 15.45% of patients. The IKDC score was 84.55. In the proposed ACL reconstruction technique, the two tendons are transferred and used as grafts, with gracillis and semitendinosus retaining their distal and central attachment, respectively; the former superimposed upon the latter while entering the femoral tunnel. The tibial tunnels leave a bone bridge ranging between 12 and 15 mm within the footprints of ACL. The two bundles are tensioned, each at different angle. This configuration imitates both the anatomy and the function of ACL and controls not only the anterior translation, but also the rotatory stability. With this innovative technique, the final outcome is improved, thus being closer to normal, as evidenced from previous experiments and the present prospective series. [ABSTRACT FROM AUTHOR]

The use of the BPTB-autograft is a very common method for ACL reconstruction. Nevertheless, the problem of the typical donor-site-morbidity is unresolved. Recently, a transplant of quadriceps tendon, with an attached bone block (BQT) has been increasingly relied upon. The purpose of this study was to examine the clinical results of a group of patients after arthroscopic ACL reconstruction using either BPTB or quadriceps tendon autograft after a minimum follow-up of 2 years in terms of knee joint stability and function using both subjective and objective criteria. Retrospective study. A total of 260 patients with ACL ruptures were operated between 1995 and 2000; 124 received a BQT-autograft, including 8 revisions; 136 patients received a BPTB-autograft, exclusively primary interventions. The results were evaluated using the IKDC-, Noyes- and Lysholm-Scores. It was possible to re-evaluate 194 patients after a minimum follow-up period of 2 years, 64 of 260 patients (25%) were lost to follow-up. Ninety-seven percent of the operated knee joints in the BPTB-group were judged as normal or almost normal with the IKDC evaluation, as were 83% in the BQT-group (P < or = 0.001). The BQT-group showed a significantly better result in the evaluation of the donor-site-morbidity. We found no significant differences in the functional outcome according to the Lysholm- and Noyes-Score. In comparison to the results after using a BQT-transplant for reconstruction of a ruptured ACL the use of the BPTB-transplant is in favour concerning patient satisfaction and IKDC evaluation. For patients with activities involving kneeling or prolonged flexion of the knee joint BQT-transplants can be a good alternative, however. [ABSTRACT FROM AUTHOR]

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Copyright of Arthroskopie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The knee radiographs of 77 patients were examined by two physicians not involved in the operation a mean of 41.2 months after implantation of a synthetic ligament (Trevira hochfest). They evaluated the increase of degenerative osteoarthritis on a five-grade scale (0-4) by Jonasch and Mohing as modified by Holz, and using the IKDC score. Fifty patients with acute rupture had the synthetic ligament implanted for protection of anterior cruciate repair. Twenty-seven patients had a salvage procedure with the alloplastic ligament functioning as a prosthesis. Both examiners found a statistically significant increase of degenerative arthritis. Patients with acute anterior cruciate tears had a lower degree of osteoarthritis on the day of surgery compared to the patients with chronic insufficiency, but the postoperative increase was identical in both groups. Statistical analysis revealed correlations between osteoarthric changes and several factors such as concomitant meniscus or posterior cruciate injury and demonstrated no correlation to the grade of postoperative stability or injuries to the medial or lateral collateral ligaments or capsule. [ABSTRACT FROM AUTHOR]

Copyright of Arthroskopie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A group of 94 male and 12 female patients who all suffered from ACL ruptures had a follow-up examination after a period of 14 to 21 years (m = 17.2 years). Each of them had undergone a primary arthrotomy with total or partial meniscectomy. In none of the cases, however, had operative repair of the ACL rupture been performed. The most frequent concomitant injury was a torn medial meniscus which occurred in 74.5% of the cases whereas a damaged lateral meniscus was found in 17.0% of the cases only. Chondromalacia of tibia, femur or patella was observed in 42.5% of the cases. Over 60% of the patients resumed their former sports activities, although in nearly 30% of these cases at a lower level whereas one third of the patients had to practice some other sport or were even forced to give up sports completely. 61.3% still complained about instability of the knee joint, 73.6% of the patients with partial or total meniscectomy had developed osteoarthritis of grade III and IV. [ABSTRACT FROM AUTHOR]