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Purpose: To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage., Methods: A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles., Results: A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01)., Conclusions: The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients., Level of Evidence: Level III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: Understanding the risk factors for loss to follow-up in prospective clinical studies may allow for a targeted approach to minimizing follow-up bias and improving the generalizability of conclusions in anterior cruciate ligament reconstruction (ACLR) and other sports-related interventions., Purpose: To identify independent risk factors associated with failure to complete (ie, loss to follow-up) patient-reported outcome measures (PROMs) at 2 years after ACLR within a well-funded prospective longitudinal cohort., Study Design: Cohort study (prognosis); Level of evidence, 2., Methods: All patients undergoing primary or revision ACLR enrolled in the prospectively collected database of the multicenter consortium between 2002 and 2008 were included. Multivariate regression analyses were conducted to determine which baseline risk factors were significantly associated with loss to follow-up at a minimum of 2 years after surgery. Predictors assessed for loss to follow-up were as follows: consortium site, sex, race, marital status, smoking status, phone number provided (home or cell), email address provided (primary or secondary), years of school completed, average hours worked per week, working status (full-time, part-time, homemaker, retired, student, or disabled), number of people living at home, and preoperative PROMs (Knee injury and Osteoarthritis Outcome Score, Marx Activity Rating Scale, and International Knee Documentation Committee)., Results: A total of 3202 patients who underwent ACLR were enrolled. The 2-year PROM follow-up rate for this cohort was 88% (2821 of 3202). Multivariate analyses showed that patient sex (male: odds ratio [OR], 1.80) and race (black: OR, 3.64; other nonwhite: OR, 1.81) were independent predictors of 2-year loss to follow-up of PROMs. Education level was a nonconfounder., Conclusion: While education level did not predict loss to follow-up, patients who are male and nonwhite are at increased risk of loss to follow-up of PROM at 2 years. Capturing patient outcomes with minimal loss depends on equitable, not equal, opportunity to maximize generalizability and mitigate potential population-level health disparities., Registration: NCT00478894 (ClinicalTrials.gov identifier).

This study aims to evaluate the trends in treatment of knee articular cartilage lesions over the past decade using data obtained from the American Board of Orthopaedic Surgery (ABOS) Part II database. The ABOS Part II database was queried from 2004 to 2013 for chondroplasty, microfracture, and osteochondral grafting procedures. All cases were analyzed for patient age and operating surgeon's fellowship training status. Univariate analysis including chi-square test for categorical variables and Student's t -test for continuous variables was performed to determine if any significant changes in practice patterns were present. Linear regression analyses were utilized to examine temporal trends in procedures performed and fellowship training status. From 2004 to 2013, 25,938 procedures addressing articular cartilage lesions from 3,586 surgeons were identified in the ABOS database. 46.8% of these orthopaedic surgeons had completed a 1-year sports medicine fellowship. Sixty-six percent of cartilage surgeries were performed by sports medicine-trained surgeons. The articular cartilage surgical volume decreased from 3,126 cases in 2004 to 1,690 cases in 2013. The most common procedure coded overall was chondroplasty (80.23%) followed by microfracture (21.37%) and osteochondral grafting (2.1%). The mean age of patients undergoing chondroplasty was 46.9 years; this was significantly higher than microfracture (mean age 40.5 years) or osteochondral grafting procedures (mean age 31.6 years), p  < 0.0005. The age of all patients undergoing cartilage surgery significantly decreased between 2004 and 2013, p  < 0.001. A dramatic decrease in reported chondroplasty volume was observed between 2011 and 2012. Concurrent osteotomies were used in <1% of procedures addressing cartilage injuries, while 65% of patients underwent concurrent meniscectomy. These described trends are most pronounced in surgeons with sports medicine fellowship training. In conclusion, knee articular cartilage surgical volume and patient age have both sharply declined since 2011, a trend driven by sports medicine-trained Part II examinees. This trend correlates with changes in billing and coding practices, as well as improved education from high-level studies., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The purpose of the study was to investigate the incidence of complete and partial peroneal nerve injuries in patients with posterolateral corner (PLC) knee injuries; additionally, to compare patient-reported outcomes among patients with and without peroneal nerve injury and to examine the factors that predict the recovery of nerve function., Methods: A retrospective chart review was performed to identify patients who underwent PLC reconstruction or repair from 2000 to 2012 with a minimum 6-month clinical follow-up. Peroneal nerve injuries were identified, and treatments and outcomes were analyzed. IKDC and KOOS outcome scores at the final follow-up were reported., Results: There were 61 PLC injuries in 60 patients. Sixteen of the 61 knees (26.2%) had a peroneal nerve injury at initial presentation; there were 13 complete and 3 partial nerve injuries. The median age was 31 years (15 men and 1 woman) and 31 years (33 men and 12 women) in the nerve and non-nerve injury cohorts, respectively. The median follow-up in the nerve injury group was 26 months (interquartile range (IQR): 12-48), and in the non-nerve injury cohort (n.s.) 61 months (IQR 22-85). All 13 complete injuries were treated with neurolysis: 3 were complete transections and 10 were stretch injuries. Of the ten stretch injuries, five (50%) spontaneously recovered full nerve function at the final follow-up. The remaining six patients chose definitive treatment with ankle-foot orthoses. Two of the three transected nerve patients underwent successful posterior tibialis transfer, and one chose ankle-foot orthoses. All three partial nerve injuries underwent neurolysis and had complete nerve recovery at the final follow-up. The median IKDC scores in the nerve injury group and the non-nerve injury group were 64.4 (IQR 47.8-73.3) and 72.8 (IQR 59.3-87.9) (n.s.), respectively, and the median Lysholm scores were 85 (IQR 83-92) and 86.5 (IQR 79-90) (n.s.), respectively. There were no significant differences in the rates of complications, secondary surgeries, mechanism of injury, KDIII injuries, or other injuries., Conclusion: This study demonstrated comparable rates of peroneal nerve injuries in PLC injuries (26.2%) to that in the literature. The rates of nerve recovery for complete disrupted injury, complete stretched injury, and partial injury were 0, 50, and 100% with an overall rate of recovery of 50%. The outcome scores were similar between patients with and without nerve injuries; however, a small cohort size led to limitations in statistical analysis. Thus, a prolonged trial of non-operative treatment is recommended for peroneal nerve injuries to allow for assessment of nerve recovery and patient outcome before entertaining surgical treatments., Level of Evidence: Level IV.

Background: The management of meniscus tears identified at the time of primary anterior cruciate ligament (ACL) reconstruction is highly variable and includes repair, meniscectomy, and nontreatment., Hypothesis/purpose: The purpose of this study was to determine the reoperation rate for meniscus tears left untreated at the time of ACL reconstruction with a minimum follow-up of 6 years. The hypothesis was that small peripheral tears identified at the time of ACL reconstruction managed with "no treatment" would have successful clinical outcomes., Study Design: Cohort study; Level of evidence, 3., Methods: Patients with meniscus tears left untreated at the time of primary ACL reconstruction were identified from a multicenter study group with a minimum 6-year follow-up. Patient, tear, and reoperation data were obtained for analysis. The need for reoperation was used as the primary endpoint, with analysis performed to determine patient and tear characteristics associated with reoperation., Results: There were 194 patients with 208 meniscus tears (71 medial, 137 lateral) left in situ without treatment with a complete follow-up for analysis. Of these, 97.8% of lateral and 94.4% of medial untreated tears required no reoperation. Sixteen tears (7.7%) left in situ without treatment underwent subsequent reoperation: 9 tears (4.3%) underwent reoperation in the setting of revision ACL reconstruction, and 7 tears (3.4%) underwent reoperation for an isolated meniscus injury. The patient age was significantly lower in patients requiring reoperation, while tears measuring ≥10 mm more frequently required reoperation., Conclusion: Lateral and medial meniscus tears left in situ at the time of ACL reconstruction did not require reoperation at a minimum 6-year follow-up for 97.8% and 94.4% of tears, respectively. These findings re-emphasize the low reoperation rate after the nontreatment of small, peripheral lateral meniscus tears while noting less predictable results for medial meniscus tears left without treatment., (© 2015 The Author(s).)

Purpose: To analyse one institution's experience with multiligament knee injuries., Methods: Over 10 years, 133 multiligament knee injuries including 130 patients were included in the study. Inclusion criteria included: (1) injury to two or more knee ligaments (2) multiligament knee repair/reconstructive surgery., Results: The average age at time of injury was 26 years old, and 76 % were male. Fifty-one (38 %) multiligament knee injuries had >2 ligaments injured. Peroneal injuries occurred in 26 patients (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism of injury was noted in 39 %. Twenty-five per cent of patients had an additional orthopaedic injury and, 11.5 % suffered additional non-orthopaedic injuries. Definitive surgical intervention was performed acutely (<3 weeks) in 47 %. Ninety-one per cent of multiligament knee injuries underwent reconstruction with or without repair. Forty-three complications occurred in 37 patients. Patients who suffered >2 ligament injury or had surgery acutely were at an increased risk of knee stiffness requiring manipulation under anaesthesia (MUA) (p = 0.016 and p = 0.047, respectively). Knees with >2 ligaments injured were associated with higher post-operative complications (p = 0.007). Knee dislocation IV knees were at increased risk to undergo revision surgery (p = 0.041). Obese patients were more likely to have a post-operative infection (p = 0.038). Repair, reconstruction or type of graft used had no impact on need for revision surgery., Conclusions: Multiligament knee injured patients undergoing surgical intervention are a highly complex patient population. This study outlines the patient population, treatment, and complications of one academic institution over 10 years. Overall complications were higher in patients with >2 ligaments injured. Knee stiffness requiring MUA was more common in patients who had >2 ligaments ruptured and those treated acutely. Knees with all four ligaments injured were more likely to undergo revision surgery., Level of Evidence: Retrospective case series, Level IV.

Background: Recent literature has shown that posterolateral corner injuries of the knee have poor results when treated with repair, when compared to reconstruction. Our study sought to compare outcomes of posterolateral knee injuries treated with repair versus reconstruction and report results from our institution, with the hypothesis that acute repairs have comparable results to reconstructions., Methods: We identified patients with posterolateral knee reconstruction or repair from January 1, 2000 to March 1, 2012. Patients returned for outcome measures, clinical exam and varus stress radiographs. Further, each patient underwent a chart review. Varus stress radiographs were obtained in 20 control knees, with no history of knee trauma, to our two cohort groups., Results: 26 knees in 25 patients (17 reconstructions and 9 repairs) were evaluated in clinic at mean of 42 months postoperatively for repairs and 38 months postoperatively for reconstructions. Average IKDC scores for reconstruction and repair were 68 and 71, respectively. Average Lysholm scores for these groups were 83 for reconstructions and 83 for repairs. No statistically significant differences existed. Average varus gapping at zero degrees was 8.21 and 8.84 millimeters (mm) for reconstructions and repairs, respectively. Average varus gapping at 20 degrees knee flexion was 11.25 mm for reconstructions and 10.34 mm for repairs. No statistically significant differences were observed in varus gapping between the two groups. Each patient chart was reviewed for complications. There were 2 failures in the 44 patient reconstruction group (4.7%) and 2 failures in the 18 patient repair group (11.1%). We noted a high rate (10/19 patients) of primarily distally-based injuries in our repair group. All failures were treated with revision reconstructions., Conclusion: We found low failure rates in both groups. All knees in the repair group were operated within three weeks of injury. Our repair knees had a high rate of distally based avulsion and, were felt to have acceptable tissue that could be successfully repaired. We recommend posterolateral knee repair in cases with distally based avulsions that can be operatively treated within 3 weeks of injury, and have good tissue quality at the time of surgery., Level of Evidence: IV.

Purpose: Our goal was to evaluate the impact of body mass index (BMI) on complications and associated injuries in patients undergoing surgical treatment for multiligamentous knee injuries (MLKIs)., Methods: Over a period of 10 years, 126 MLKIs (123 patients) were included in the study. The inclusion criteria were (1) injury to 2 or more knee ligaments, (2) multiligament repair and/or reconstruction performed by 1 of 3 sports medicine orthopaedic surgeons at our institution, and (3) minimum of 1 year of follow-up. A chart review was performed to collect demographic data, mechanism of injury, ligaments involved, complications, and associated neurovascular injuries. Lastly, patients were divided by BMI into non-obese (<30 kg/m(2)) and obese (≥30 kg/m(2)) groups., Results: Of the 126 MLKIs, 87 occurred in non-obese patients and 39 occurred in obese patients. Surgical complication rates for non-obese and obese patients were 8.05% and 15.4%, respectively (P = .21). Revisions were needed in 8.05% and 5.1% of patients in these groups, respectively (P = .72). Three wound complications were found in the obese group only. Vascular injuries were found in 2.3% and 7.7% of patients in the non-obese and obese groups, respectively (P = .17). The rates of nerve injuries were 11.49% and 20.51%, respectively (P = .18). Patients in the obese group were most likely to have an MLKI from low-energy mechanisms, disregarding sports-related injuries (51.28%, P = .02). Using a logistic model and BMI as a continuous variable, we found that a 1-unit increase in BMI increased the odds ratio of complications by 9.2%, with statistical significance (P = .0174). In addition, post hoc power analysis using previous literature showed that this study could produce satisfactory power., Conclusions: Our results indicate that (1) obese individuals are significantly more likely to have an MLKI caused by low-energy mechanisms and (2) complication rates increase by 9.2% for every 1-unit increase in BMI., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Injury to the anterior cruciate ligament (ACL) threatens an active lifestyle and exposes the patient to risk of early osteoarthritis (OA). ACL reconstruction is typically chosen by individuals to allow a return to their previous work and sports activities. Primary ACL reconstruction (ACLR) has in general been effective at restoring functional stability, but patients' modifiable predictors of both short- and long-term validated outcomes and OA are largely unknown. The Multicenter Orthopaedic Outcomes Network (MOON) consortium was established in 2002 to enroll and longitudinally follow a population cohort of ACL reconstructed patients. The objective was to establish patient-specific predictive models of clinically important outcomes. Over the past 10 years, the overarching aims of this NIAMS-funded prospective multicenter cohort of ACL reconstructions has been threefold: (1) to identify both short- and long-term prognosis and predictors of sports function, activity level, and general health through validated patient-reported outcomes, (2) to identify the symptoms and signs of OA, and (3) to quantify the incidence of ACL reconstruction graft and/or contralateral ACL failures and additional surgical procedures. This manuscript summarizes the Kappa Delta Ann Doner Vaughan Award paper and presentation at the 2012 ORS/AAOS Annual Meeting., (Copyright © 2012 Orthopaedic Research Society.)

Purpose: To evaluate the interobserver and intraobserver reliability of radiographic assessment of tunnel placement in anterior cruciate ligament reconstruction., Methods: Seven sports fellowship-trained orthopaedic surgeons in the Multicenter Orthopaedic Outcomes Network (MOON) group participated in the study. We prospectively enrolled 54 consecutive patients after primary anterior cruciate ligament reconstruction. Postoperative plain radiographs were obtained including a full-extension anteroposterior view of the knee, a lateral view of the knee in full extension, and a notch view at 45° of flexion (Rosenberg view). Three blinded reviewers performed 8 different radiographic measurements including those of Harner and Aglietti/Jonsson. Intraclass correlation coefficients were used to determine reliability of the measurements. Intrarater reliability was assessed by repeated measurements of a subset of 20 patient images from 1 institution, and inter-rater reliability was assessed by use of all 54 sets of films from a total of 4 institutions., Results: Intraobserver reliability for femoral measures ranged from none to substantial, with notch height having the worst results. Intraobserver reliability was moderate to almost perfect for tibial measures. Interobserver reliability ranged from slight to moderate for femoral measures. The Harner method for determining tunnel depth was more reliable than the Aglietti/Jonsson method. Interobserver reliability for tibial measures ranged from fair to substantial. The presence of metal interference screws did not improve reliability of measurements., Conclusions: Postoperative radiographs are easily obtained, but our results show that radiographic measurements are of quite variable reliability, with most of the results falling into the fair to moderate categories., (Published by Elsevier Inc.)

High tibial osteotomy (HTO) is a surgical procedure used to change the mechanical weight-bearing axis and alter the loads carried through the knee. Conventional indications for HTO are medial compartment osteoarthritis and varus malalignment of the knee causing pain and dysfunction. Traditionally, knee instability associated with varus thrust has been considered a contraindication. However, today the indications include patients with chronic ligament deficiencies and malalignment, because an HTO procedure can change not only the coronal but also the sagittal plane of the knee. The sagittal plane has generally been ignored in HTO literature, but its modification has a significant impact on biomechanics and joint stability. Indeed, decreased posterior tibial slope causes posterior tibia translation and helps the anterior cruciate ligament (ACL)-deficient knee. Vice versa, increased tibial slope causes anterior tibia translation and helps the posterior cruciate ligament (PCL)-deficient knee. A review of literature shows that soft tissue procedures alone are often unsatisfactory for chronic posterior instability if alignment is not corrected. Since limb alignment is the most important factor to consider in lower limb reconstructive surgery, diagnosis and treatment of limb malalignment should not be ignored in management of chronic ligamentous instabilities. This paper reviews the effects of chronic posterior instability and tibial slope alteration on knee and soft tissues, in addition to planning and surgical technique for chronic posterior and posterolateral instability with HTO.

With a rise in post-traumatic osteoarthritis, OA no longer is considered just a disease of aging. The 'gold standard' for OA diagnosis has long been planar radiographs for visualizing osteophytes, joint space narrowing and sclerotic changes. A typical magnetic resonance imaging (MRI) protocol will acquire proton density, T1, T2, and fat suppressed images that give a comprehensive picture of morphologic changes associated with injury and subsequent degenerative processes. However, the earliest events of cartilage degeneration occur within the tissue, before measureable changes in morphology. MRI methods have been proposed to display and quantify changes in composition and integrity of such elements of cartilage extracellular matrix as collagen and proteoglycan (PG) content in vivo. T1ρ the spin-lattice relaxation time in the rotating frame, has come to the forefront for visualizing water proton-PG interactions in articular cartilage. The purpose of this T1ρ MRI study was to define an objective femoral condyle-specific registration method, in which zone-dependent cartilage compositional changes could be assessed from the bone outward through the existing cartilage, at pre-ACL reconstruction and subsequent follow-up times, when the loss of thickness to surface-down cartilage erosion might occur later in the OA pathogenesis. Additionally, this study explores the effects of reducing the number of spin-lock times on the absolute T1ρ relaxation times; a major parameter in expanding T1ρ coverage to the whole joint while satisfying clinical imaging time and specific absorption rate (SAR) safety constraints. The developed image analysis tools serve as the first step toward quantitative functional assessment of cartilage health with noninvasive T1ρ MRI, which has the potential to become an important new tool for the early diagnosis of cartilage degeneration following ACL trauma.

Background: Increased knee pain at the time of anterior cruciate ligament reconstruction may potentially predict more difficult rehabilitation, prolonged recovery, and/or be predictive of increased knee pain at 2 years., Hypothesis: A bone bruise and/or other preoperative factors are associated with more knee pain/symptoms at the time of index anterior cruciate ligament reconstruction, and the presence of a bone bruise would be associated with specific demographic and injury-related factors., Study Design: Cohort study (prevalence); Level of evidence, 2., Methods: In 2007, the Multicenter Orthopaedic Outcomes Network (MOON) database began to prospectively collect surgeon-reported magnetic resonance imaging bone bruise status. A multivariable analysis was performed to (1) determine if a bone bruise, among other preoperative factors, is associated with more knee symptoms/pain and (2) examine the association of factors related to bone bruise. To evaluate the association of a bone bruise with knee pain/symptoms, linear multiple regression models were fit using the continuous scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms and pain subscales and the Short Form 36 (SF-36) bodily pain subscale as dependent variables. To examine the association between a bone bruise and risk factors, a logistic regression model was used, in which the dependent variable was the presence or absence of a bone bruise., Results: Baseline data for 525 patients were used for analysis, and a bone bruise was present in 419 (80%). The cohort comprises 58% male patients, with a median age of 23 years. The median Marx activity level was 13. Factors associated with more pain were higher body mass index (P < .0001), female sex (P = .001), lateral collateral ligament injury (P = .012), and older age (P = .038). Factors associated with more symptoms were a concomitant lateral collateral ligament injury (P = .014), higher body mass index (P < .0001), and female sex (P < .0001). Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. None of the factors included in the SF-36 bodily pain model were found to be significant. After controlling for other baseline factors, the following factors were associated with a bone bruise: younger age (P = .034) and not jumping at the time of injury (P = .006)., Conclusion: After anterior cruciate ligament injury, risk factors associated with a bone bruise are younger age and not jumping at the time of injury. Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction.

This study aimed to determine the incidence of meniscal tears and describe the tear morphology and selected treatment in patients undergoing anterior cruciate ligament (ACL) reconstruction. We also will discuss the potential market for future tissue engineering aimed at preserving meniscal function. A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 was evaluated. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into 3 potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Of the knees, 36% had medial meniscal tears and 44% had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment method was partial meniscectomy. Thirty percent of medial meniscal tears and 10% of lateral meniscal tears are eligible for all-biologic repair; 35% of medial meniscal tears and 35% of lateral meniscal tears are eligible for an advanced repair technique; and 35% of medial meniscal tears and 55% of lateral meniscal tears are eligible for scaffold replacement. Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. The results of this cohort will hopefully stimulate and focus future research and development of new tissue engineering strategies for meniscus repair.

Background: The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee., Hypothesis: The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal., Study Design: Cohort study; Level of evidence, 2., Methods: The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports., Results: Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%)., Conclusion: The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%).

Mechanical alignment has been overlooked as an important contributor to knee stability with respect to collateral ligament laxity. The detrimental effects of varus or valgus limb malalignment become more obvious when the restraining force is lost because of ligamentous injury especially on the medial or the lateral/posterolateral side. Even with repair or reconstruction of these injuries, with repetitive load, the ligament will eventually fail to restore its structure and strength, resulting in failure and secondary restraint laxity. We have found that realignment of the limb is the most important factor in restoring a functional limb. After realignment, joint laxity, if persistent, can be addressed successfully with ligamentous reconstruction. Diagnosis and treatment of limb malalignment cannot be ignored in the management of chronic ligamentous instabilities, especially those with prior failed reconstruction. Our approach to these difficult problems and the preferred techniques of osteotomies on both tibial and femoral sides are described.

Medial collateral ligament (MCL) injury is one of the most common knee injuries, especially in young athletic patients. Most MCL injuries can be managed conservatively with good results. However, a complete understanding of knee anatomy and the involved structures is necessary to make intelligent treatment decisions. We will review the anatomy and biomechanics of the MCL, classification systems for MCL injuries, and operative and nonoperative treatment for acute and chronic MCL injuries.

Background: Acute and chronic cartilage injury of the knee has an important impact on prognosis. The validity of the classification of such injuries is critical for prospective multicenter studies. The agreement among multiple surgeons at different institutions for articular cartilage lesions has not been established., Hypothesis: Arthroscopic classification of articular cartilage lesions is reliable and reproducible and can be used for multicenter studies involving multiple surgeons., Study Design: Cohort study (diagnosis); Level of evidence, 1., Methods: A total of 6 surgeons from 5 centers reviewed 31 videos of articular cartilage lesions. With grade 2 and grade 3 combined for the analysis, observed agreement ranged from 81% to 94%, and kappa ranged from 0.34 to 0.87. An additional 22 videos comprising grade 2 and grade 3 lesions were analyzed, and the observed agreement was 80%, with an overall kappa of 0.47., Conclusion: Arthroscopic grading of articular cartilage lesions is reproducible among surgeons at different centers., Clinical Relevance: Articular cartilage lesions can be reliably classified among surgeons at different sites. Such reliability is important for multicenter clinical research studies involving arthroscopic knee surgery.

Background: Establishing the validity of classification schemes is a crucial preparatory step that should precede multicenter studies. There are no studies investigating the reproducibility of arthroscopic classification of meniscal pathology among multiple surgeons at different institutions., Hypothesis: Arthroscopic classification of meniscal pathology is reliable and reproducible and suitable for multicenter studies that involve multiple surgeons., Study Design: Multirater agreement study., Methods: Seven surgeons reviewed a video of 18 meniscal tears and completed a meniscal classification questionnaire. Multirater agreement was calculated based on the proportion of agreement, the kappa coefficient, and the intraclass correlation coefficient., Results: There was a 46% agreement on the central/peripheral location of tears (kappa = 0.30), an 80% agreement on the depth of tears (kappa = 0.46), a 72% agreement on the presence of a degenerative component (kappa = 0.44), a 71% agreement on whether lateral tears were central to the popliteal hiatus (kappa = 0.42), a 73% agreement on the type of tear (kappa = 0.63), an 87% agreement on the location of the tear (kappa = 0.61), and an 84% agreement on the treatment of tears (kappa = 0.66). There was considerable agreement among surgeons on length, with an intraclass correlation coefficient of 0.78, 95% confidence interval of 0.57 to 0.92, and P < .001., Conclusions: Arthroscopic grading of meniscal pathology is reliable and reproducible., Clinical Relevance: Surgeons can reliably classify meniscal pathology and agree on treatment, which is important for multicenter trials.

BackgroundWhile revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.PurposeTo report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.Study designCase-control study; Level of evidence, 3.MethodsA total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.ResultsOf the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged

BackgroundKnees undergoing revision anterior cruciate ligament reconstruction (rACLR) have a high prevalence of articular cartilage lesions.HypothesisThe prevalence of chondrosis at the time of rACLR is associated with meniscal status and lower extremity alignment.Study designCross-sectional study; Level of evidence, 3.MethodsData from the prospective Multicenter ACL Revision Study (MARS) cohort were reviewed to identify patients with preoperative lower extremity alignment films. Lower extremity alignment was defined by the weightbearing line (WBL) as a percentage of the tibial plateau width, while the chondral and meniscal status of each weightbearing compartment was recorded at the time of surgery. Multivariable proportional odds models were constructed and adjusted for relevant factors to examine which risk factors were independently associated with the degree of medial and lateral compartment chondrosis.ResultsThe cohort included 246 patients with lower extremity alignment films at the time of rACLR. Mean (±SD) patient age was 26.9 ± 9.5 years and body mass index (BMI) was 26.4 ± 4.6. The medial compartment had more chondrosis (grade 2/3, 42%; grade 4, 6.5%) than did the lateral compartment (grade 2/3, 26%; grade 4, 6.5%). Disruption of the meniscus was noted in 35% of patients on the medial side and 16% in the lateral side. The mean WBL was 0.43 ± 0.13. Medial compartment chondrosis was associated with BMI (P = .025), alignment (P = .002), and medial meniscal status (P = .001). None of the knees with the WBL lateral to 0.625 had grade 4 chondrosis in the medial compartment. Lateral compartment chondrosis was significantly associated with age (P = .013) and lateral meniscal status (P < .001). Subjects with "intact" menisci were found to decrease their odds of having chondrosis by 64% to 84%.ConclusionThe status of articular cartilage in the tibiofemoral compartments at the time of rACLR is related to meniscal status. Lower extremity alignment and BMI are associated with medial compartment chondrosis.

BackgroundThe factors that lead to patients failing multiple anterior cruciate ligament (ACL) reconstructions are not well understood.HypothesisMultiple-revision ACL reconstruction will have different characteristics than first-time revision in terms of previous and current graft selection, mode of failure, chondral/meniscal injuries, and surgical charactieristics.Study designCase-control study; Level of evidence, 3.MethodsA prospective multicenter ACL revision database was utilized for the time period from March 2006 to June 2011. Patients were divided into those who underwent a single-revision ACL reconstruction and those who underwent multiple-revision ACL reconstructions. The primary outcome variable was Marx activity level. Primary data analyses between the groups included a comparison of graft type, perceived mechanism of failure, associated injury (meniscus, ligament, and cartilage), reconstruction type, and tunnel position. Data were compared by analysis of variance with a post hoc Tukey test.ResultsA total of 1200 patients (58% men; median age, 26 years) were enrolled, with 1049 (87%) patients having a primary revision and 151 (13%) patients having a second or subsequent revision. Marx activity levels were significantly higher (9.77) in the primary-revision group than in those patients with multiple revisions (6.74). The most common cause of reruptures was a traumatic, noncontact ACL graft injury in 55% of primary-revision patients; 25% of patients had a nontraumatic, gradual-onset recurrent injury, and 11% had a traumatic, contact injury. In the multiple-revision group, a nontraumatic, gradual-onset injury was the most common cause of recurrence (47%), followed by traumatic noncontact (35%) and nontraumatic sudden onset (11%) (P < .01 between groups). Chondral injuries in the medial compartment were significantly more common in the multiple-revision group than in the single-revision group, as were chondral injuries in the patellofemoral compartment.ConclusionPatients with multiple-revision ACL reconstructions had lower activity levels, were more likely to have chondral injuries in the medial and patellofemoral compartments, and had a high rate of a nontraumatic, recurrent injury of their graft.

Background: The time between an anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) may influence baseline knee-related and general health-related patient-reported outcome measures (PROMs). Despite the common use of PROMs as main outcomes in clinical studies, this variable has never been evaluated. Purpose: To compare baseline health-related quality of life measures and the prevalence/pattern of meniscal and articular cartilage lesions between patients who underwent acute and chronic ACLR so as to provide clinicians with benchmark PROMs in 2 different patient populations with ACL injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1192 patients from the MOON (Multicenter Orthopaedic Outcomes Network) cohort who underwent primary ACLR were eligible. “Acute” ACLR was defined as <3 months (n = 853; 71.6%) and “chronic” ACLR as >6 months (n = 339; 28.4%) from injury. Patient demographics, surgical characteristics (articular cartilage injury, medial meniscal [MM] and lateral meniscal [LM] tears), and baseline PROM scores (Marx activity rating scale, International Knee Documentation Committee [IKDC] subjective form, Knee injury and Osteoarthritis Outcome Score [KOOS], and Short Form–36 Health Survey [SF-36]) were collected to determine whether the time from injury to ACLR influences (1) baseline PROMs and (2) the pattern and prevalence of concurrent articular cartilage and meniscal injuries. Analysis of covariance models were used to adjust for confounders on baseline outcome scores (age, sex, body mass index [BMI], smoking status, competition level, education). Results: The median patient age was 23 years (interquartile range [IQR], 17-35 years), 530 (44.5%) were female, and the median BMI was 25.0 kg/m2 (IQR, 22.3-27.9 kg/m2); however, the chronic group was older, had a higher BMI, and consisted of fewer collegiate athletes. A significantly greater number of partial LM tears were seen in the acute group versus the chronic group (14.2% vs 6.5%, respectively; P < .001), but there were more meniscal tears overall (73.5% vs 63.2%, respectively; P = .001), complete MM tears (49.0% vs 22.5%, respectively; P < .001), and articular cartilage injuries (54.0% vs 32.8%, respectively; P < .001) in the chronic group versus the acute group. After controlling for confounders, patients in the chronic ACLR group reported a significantly lower baseline Marx score (7.75 vs 12.10, respectively; P < .001) but higher baseline IKDC, SF-36 physical functioning, and all KOOS subscale scores except the KOOS–quality of life subscale score compared to those in the acute ACLR group; however, only the KOOS–sports and recreation subscale exceeded the minimum clinically importance difference of 8 points (62.30 vs 48.26, respectively; P < .001). Conclusion: After controlling for age, sex, competition level, smoking, and BMI, patients in the chronic ACLR group participated in less pivoting and cutting sports but reported better pain/function. Whether decreased activity is deliberate after an ACL injury or patients who undergo chronic ACLR are simply less active and may be treated successfully without surgery warrants further investigation. Nonrandomized studies that utilize PROMs should consider time from injury in study design and data interpretation. [ABSTRACT FROM AUTHOR]

Background: Meniscal tears are frequently repaired during anterior cruciate ligament reconstruction (ACLR). Purpose: To systematically evaluate differences in clinical failures between all-inside and inside-out meniscal repairs performed during ACLR. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review was perfomed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases queried included MEDLINE, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials. All English-language studies reporting failure rates after meniscal repair with either the all-inside or inside-out technique performed in conjunction with ACLR were identified between 1980 and 2015. Studies with a minimum 2-year follow-up were included. Reported outcomes, clinical meniscal repair failures, and complications were assessed. Studies were weighted according to the size of the clinical series and mean follow-up length. Inverse-variance–weighted mixed models were used to evaluate whether there was a significant difference in pooled reoperation rates between repair techniques. Results: In total, 21 studies met inclusion criteria. Of these, 13 studies reported outcomes after all-inside repair, and 10 studies reported outcomes after inside-out repair (2 studies reported both). A total of 1126 patients were included in the analysis. The mean (±SD) follow-up for all-inside repair was 58.64 ± 22.24 months versus 76.25 ± 31.69 months for inside-out repair (P = .13). The clinical failure rate for all-inside meniscal repair performed concurrently with ACLR was 16% (121/744) compared with 10% (39/382) for inside-out repair, and this was found to be significant (P = .016). Implant irritation and device migration were the most common complications reported for all-inside repair; complication rates did not differ between the groups. Conclusion: There may be fewer early clinical failures when the inside-out technique is utilized for meniscal repair at the time of concomitant ACLR. Additional long-term studies will be useful to determine the operative success of these repairs over time. [ABSTRACT FROM AUTHOR]

Background: Many patients undergoing TKA have both knee and ankle pathology, and it seems likely that some compensatory changes occur at each joint in response to deformity at the other. However, it is not fully understood how the foot and ankle compensate for a given varus or valgus deformity of the knee. Questions/purposes: (1) What is the compensatory hindfoot alignment in patients with end-stage osteoarthritis who undergo total knee arthroplasty (TKA)? (2) Where in the hindfoot does the compensation occur? Methods: Between January 1, 2005, and December 31, 2009, one surgeon (JJC) obtained full-length radiographs on all patients undergoing primary TKA (N = 518) as part of routine practice; patients were analyzed for the current study and after meeting inclusion criteria, a total of 401 knees in 324 patients were reviewed for this analysis. Preoperative standing long-leg AP radiographs and Saltzman hindfoot views were analyzed for the following measurements: mechanical axis angle, Saltzman hindfoot alignment and angle, anatomic lateral distal tibial angle, and the ankle line convergence angle. Statistical analysis included two-tailed Pearson correlations and linear regression models. Intraobserver and interobserver intraclass coefficients for the measurements considered were evaluated and all were excellent (in excess of 0.8). Results: As the mechanical axis angle becomes either more varus or valgus, the hindfoot will subsequently orient in more valgus or varus position, respectively. For every degree increase in the valgus mechanical axis angle, the hindfoot shifts into varus by −0.43° (95% confidence interval [CI], −0.76° to −0.1°; r = −0.302, p = 0.0012). For every degree increase in the varus mechanical axis angle, the hindfoot shifts into valgus by −0.49° (95% CI, −0.67° to −0.31°; r = −0.347, p < 0.0001). In addition, the subtalar joint had a strong positive correlation (r = 0.848, r = 0.72, p < 0.0001) with the Saltzman hindfoot angle, whereas the anatomic lateral distal tibial angle (r = 0.450, r = 0.20, p < 0.0001) and the ankle line convergence angle (r = 0.319, r = 0.10, p < 0.0001) had a moderate positive correlation. The coefficient of determination (r) shows that 72% of the variance in the overall hindfoot angle can be explained by changes in the subtalar joint orientation. Conclusions: These findings have implications for treating patients with both knee and foot/ankle problems. For example, a patient with varus arthritis of the knee should be examined for fixed hindfoot valgus deformity. The concern is that patients undergoing TKA, who also present with a stiff subtalar joint, may have exacerbated, post-TKA foot/ankle pain or disability or malalignment of the lower extremity mechanical axis as a result of the inability of the subtalar joint to reorient itself after knee realignment. A prospective study is underway to confirm this speculation. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Increased knee pain at the time of anterior cruciate ligament reconstruction may potentially predict more difficult rehabilitation, prolonged recovery, and/or be predictive of increased knee pain at 2 years.Hypothesis: A bone bruise and/or other preoperative factors are associated with more knee pain/symptoms at the time of index anterior cruciate ligament reconstruction, and the presence of a bone bruise would be associated with specific demographic and injury-related factors.Study Design: Cohort study (prevalence); Level of evidence, 2.Methods: In 2007, the Multicenter Orthopaedic Outcomes Network (MOON) database began to prospectively collect surgeon-reported magnetic resonance imaging bone bruise status. A multivariable analysis was performed to (1) determine if a bone bruise, among other preoperative factors, is associated with more knee symptoms/pain and (2) examine the association of factors related to bone bruise. To evaluate the association of a bone bruise with knee pain/symptoms, linear multiple regression models were fit using the continuous scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms and pain subscales and the Short Form 36 (SF-36) bodily pain subscale as dependent variables. To examine the association between a bone bruise and risk factors, a logistic regression model was used, in which the dependent variable was the presence or absence of a bone bruise.Results: Baseline data for 525 patients were used for analysis, and a bone bruise was present in 419 (80%). The cohort comprises 58% male patients, with a median age of 23 years. The median Marx activity level was 13. Factors associated with more pain were higher body mass index (P < .0001), female sex (P = .001), lateral collateral ligament injury (P = .012), and older age (P = .038). Factors associated with more symptoms were a concomitant lateral collateral ligament injury (P = .014), higher body mass index (P < .0001), and female sex (P < .0001). Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. None of the factors included in the SF-36 bodily pain model were found to be significant. After controlling for other baseline factors, the following factors were associated with a bone bruise: younger age (P = .034) and not jumping at the time of injury (P = .006).Conclusion: After anterior cruciate ligament injury, risk factors associated with a bone bruise are younger age and not jumping at the time of injury. Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. [ABSTRACT FROM PUBLISHER]