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Purpose: The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture. Methods: The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction. Results: The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8 mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8 mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8 mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8 mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8 mm. Conclusions: A DLFNS > 1.8 mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8 mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Objective: To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears. Design: Prospective diagnostic study. Settings: Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling. Participants: Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2). Interventions: Not applicable. Main outcome measures: History elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated. Results: Forty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24). Conclusion: Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence and MRI characteristics of the spectrum of posterolateral corner (PLC) injuries occurring in association with anterior cruciate ligament (ACL) rupture.Materials and Methods: We carried out a level IV, retrospective case series study. All patients clinically diagnosed with an ACL rupture between July 2015 and June 2016 who underwent MRI of the knee were included in the study. In addition to standard MRI knee reporting, emphasis was placed on identifying injury to the PLC and a description of involvement of these structures by two musculoskeletal radiologists. Association with PLC involvement was sought with concomitant injuries using correlation analysis and logistic regression.Results: One hundred sixty-two patients with MRI following ACL rupture were evaluated. Thirty-two patients (19.7%) had an injury to at least one structure of the PLC, including the inferior popliteomeniscal fascicle (n = 28), arcuate ligament (n = 20), popliteus tendon (n = 20), superior popliteomeniscal fascicle (n = 18), lateral collateral ligament (n = 8), popliteofibular ligament (n = 7), biceps tendon (n = 4), iliotibial band (n = 3), and fabellofibular ligament (n = 1). Seventy-five percent of all patients with combined ACL and PLC injuries had bone contusions involving the lateral compartment of the knee. The presence of these contusions strongly correlated with superior popliteomeniscal fascicle lesions (p < 0.05). There was no correlation between injuries to other structures of the PLC and other intra-articular lesions.Conclusion: Missed injuries of the PLC lead to considerable morbidity. The relevance of this study is to highlight that these injuries occur more frequently than previously described and that an appropriate index of suspicion, clinical examination, and MRI are all required to reduce the risk of missed diagnoses. The results of this study support previous suggestions that the rate of concomitant PLC injury in the ACL-deficient knee is under-reported. The rate of combined injuries in this series was 19.7%. The key message of this paper is that PLC injury is common in the presence of ACL injury and should be sought both clinically and radiologically. [ABSTRACT FROM AUTHOR]

The cruciate ligaments are components of the knee capsuloligamentous system providing vital neurosensory and biomechanical function. Since most historical primary ACL repair attempts were unsuccessful, reconstruction has become the preferred surgery. However, an increased understanding of the efficacy of lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet-rich plasma and stem cells has prompted reconsideration of what was once believed to be impossible. A growing number of in vivo animal studies and prospective clinical studies are providing increasing support for this intervention. The significance of ACL repair rather than reconstruction is that it more likely preserves the native neurosensory system, entheses, and ACL footprints. Tissue preservation combined with restored biomechanical function increases the likelihood for premorbid neuromuscular control system and dynamic knee stability recovery. This recovery should increase the potential for more patients to safely return to sports at their desired intensity and frequency. This current concepts paper revisits cruciate ligament neurosensory and neurovascular anatomy from the perspective of knee capsuloligamentous system function. Peripheral and central nerve pathways and central cortical representation mapping are also discussed. Surgical restoration of a more physiologically sound knee joint may be essential to solving the osteoarthritis dilemma. Innovative rehabilitative strategies and outcome measurement methodologies using more holistic and clinically relevant measurements that closely link biomechanical and neurosensory characteristics of physiological ACL function are discussed. Greater consideration of task-specific patient physical function and psychobehavioral links should better delineate the true efficacy of all ACL surgical and non-surgical interventions. Level of evidence IV. [ABSTRACT FROM AUTHOR]

Purpose: The pivot shift test is quantified subjectively during assessment of patients presenting with suspected Anterior Cruciate Ligament (ACL) tears and has a low interobserver reproducibility. The Kinematic Rapid Assessment (KiRA) is a triaxial accelerometer that makes it possible to non-invasively quantify tibial acceleration during the pivot shift test. Abolishing pivot shift is considered to be a key element in surgical reconstruction but is incomplete in 25-38% of patients.Methods: Patients were included prospectively. Inclusion criteria were patients requiring ACL reconstruction associated with at least one of the following factors corresponding to the patient who have a high risk of rupture either by their sports activity, a failure case, or the notion of important rotational laxity: the patient practiced a competitive pivot-contact sport, revision ACL reconstruction (besides STG (semitendinosus-gracilis graft) repair), subjective explosive rotational laxity, Segond fracture, and TELOS value of >10 mm. Standardized pre- and postoperative pivot shift tests were immediately performed under anesthesia in both knees.Results: Forty-three patients were included. Mean preoperative variations in tibial acceleration in the healthy and injured knees were 1.2 ± 0.1 and 2.7 ± 0.3 m/s2, respectively, p < 0.01. A statistically significant decrease in immediate postoperative mean variations in acceleration in the injured knee occurred: 1.5 ± 0.3 m/s2, p < 0.01. There was no longer any statistical difference between postoperative contralateral healthy knees and operated knees (n.s).Conclusions: Combined ACL reconstruction associated with anterolateral tenodesis suppress acute pathologic tibial acceleration in the pivot shift.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The presence of anterolateral ligament of the knee is still controversial, and some physicians prefer to call this structure anterolateral complex (ALC) to infer plural nature of structures involved. The purpose of this study was to describe the scanning techniques and to classify various sonographic appearances of the tibial-side ALC of the knee in subjects with anterior cruciate ligament (ACL) injury. It was hypothesized that sonographic abnormity of the ALC would be associated with ACL injury history.Methods: Patients with a history of unilateral ACL injury were prospectively recruited, and the ALC was sonographically evaluated. During the evaluation, the lateral femoral epicondyle was visualized in anatomic transverse view first. At this location, the ALC was typically most conspicuous between the short head of the biceps femoris muscle and the posterior and deep aspect of the iliotibial band superficial to the origin of the lateral collateral ligament. The ALC was followed distally to the broad insertion centralizing to the area posterior to Gerdy's tubercle. The appearance of the distal insertion of the ALC was classified based both on echogenicity and on the presence of a Segond fracture as follows: Grade 0: isoechoic to the rest of the ALC, Grade 1: hypoechoic, Grade 2: anechoic, and Grade 3: Segond fracture. The uninjured side was similarly scanned for comparison.Results: A total of 28 patients (13 men; mean age 22.1 ± 8.1 years old with range: 12-44; mean body mass index 25.0 with range: 18.9-39.2) were included in this study. The average time from injury to sonograhpic evaluation was 4 months (range: 2 days to 1 year). Of 28 ACL-deficient knees, 19 were (68%) graded as Grade 0 in the distal insertion of the ALC, 7 (25%) as Grade 1, 1 (3.5%) as Grade 2, and 1 (3.5%) as Grade 3. Contralateral knees showed 25 knees (89%) with Grade 0 and 3 knees (11%) with Grade 1.Conclusion: ACL injury history was associated with a higher incidence of sonographic abnormalities within the distal insertion of the anterolateral complex.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Recent anatomical and radiological studies of the anterior cruciate ligament (ACL) suggest the ACL length and orientation change during knee flexion, and an open MRI sequencing during knee flexion enables a dynamic ACL analysis. This study's goal is to describe a normal ACL using a 1T open MRI and, in particular, variations in length and insertion angles at different degrees of flexion. Twenty-one volunteers with clinically healthy knees received a dynamic MRI with their knees in hyperextension, neutral position, and flexed at 45° and 90° angles. For each position, two radiologists measured the ACL lengths and angles of the proximal insertion between the ACL's anterior edge and the roof of the inter-condylar notch. Additionally, we measured the ACL's and the tibial plateau's distal angle insertion between their anterior edges and then compared these with the nonparametric Wilcoxon test. The ACL had a significant extension between the 90° flexion and all other positions (hyperextension: 31.75 ± 2.5 mm, neutral position: 32.5 ± 2.6 mm, 45°: 35.6 ± 1.6 mm, 90°: 35.6 ± 1.6 mm). There was also a significant increase of the angle insertion between the proximal 90° flexion and all other positions, as well as between hyperextension and bending to 45° (hyperextension: 2.45° ± 3.7°, neutral: 13.4° ± 9.7°, 45°: 33 25 ± 9.3, 90: 51.85° ± 9.3°). Additionally, there is a significant increase in the distal angle insertion for all positions (hyperextension: 133.2° ± 5.4°, neutral position: 134.95° ± 4.4°, 45°: 138.35° ± 5.9°, 90°: 149.15° ± 8.6°). Our study is the first to exhibit that a dynamic MRI has a significant ACL extension in vivo during bending. This concept opens the way for further studies to improve the diagnosis of traumatic ACL injuries using a dynamic MRI. [ABSTRACT FROM AUTHOR]

Background: Associations of lateral/medial knee instability with anterior cruciate ligament (ACL) injury have not been thoroughly investigated. The purposes of this study were to investigate whether lateral/medial knee instability is associated with ACL injury, and to clarify relevant factors for lateral/medial knee instability in ACL-injured knees.Methods: One hundred and nineteen patients with unilateral ACL-injured knees were included. Lateral/medial knee instability was assessed with varus/valgus stress X-ray examination for both injured and uninjured knees by measuring varus/valgus angle, lateral/medial joint opening, and lateral/medial joint opening index. Manual knee instability tests for ACL were evaluated to investigate associations between lateral/medial knee instability and anterior and/or rotational instabilities. Patients' backgrounds were evaluated to identify relevant factors for lateral/medial knee instability. Damage on the lateral collateral ligament (LCL) on MRI was also evaluated.Results: All parameters regarding lateral knee instability in injured knees were significantly greater than in uninjured knees. There were significant correlations between lateral knee instability and the Lachman test as well as the pivot shift test. Patients with LCL damage had significantly greater lateral joint opening than those without LCL damage on MRI. Sensitivity of LCL damage on MRI to lateral joint opening was 100%, while its specificity was 36%. No other relevant factors were identified. In medial knee instability, there were also correlations between medial knee instability and the Lachman test/pivot shift test. However, the correlations were weak and other parameters were not significant.Conclusions: Lateral knee instability was greater in ACL-deficient knees than in uninjured knees. Lateral knee instability was associated with ACL-related instabilities as well as LCL damage on MRI, whereas MRI had low specificity to lateral knee instability. On the other hand, the association of medial knee instability on ACL-related instability was less than that of lateral knee instability.Levels Of Evidence: Level IV, case series with no comparison group. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to evaluate the mid-term outcomes of anatomic anterior cruciate ligament (ACL) reconstruction using two anteromedial (AM) portals by comparing with short-term follow-up results. Materials and Methods: Fifty patients who were treated by ACL reconstruction using a two AM portal technique were evaluated retrospectively. The follow-up period was at least 5 years. The mean follow-up period was 68.5±13.9 months. The mid-term clinical outcomes were compared with short-term (≥12 months) results. For the assessment of knee stability, anterior tibial translation was evaluated using the Lachman test and the KT- 2000. Rotational stability was evaluated using pivot shift test. For clinical assessment, the Lysholm and International Knee Documentation Committee scores were used. Results: The average anterior translation was 2.1±1.4 mm at the short-term follow-up and 2.8±1.8 mm at the mid-term follow-up. Stability and midterm clinical outcomes were not significantly improved compared to the short-term follow-up results. At the mid-term follow-up, anteroposterior (AP) instability assessed by the KT-2000 was slightly increased, but still acceptable. On the other clinical physical evaluation, there was no statistically significant difference. Conclusions: The short-term and mid-term outcomes of ACL reconstruction using the two AM portal technique were not significantly different except for AP stability although the value was less than 3 mm at both follow-ups. Therefore, this operative technique could be considered a satisfactory alternative for ACL reconstruction. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to compare the geometry and position of the femoral tunnel between the anteromedial portal (AMP) and outside-in (OI) techniques after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction. Materials and Methods: We evaluated 82 patients undergoing single-bundle ACL reconstruction with hamstring autografts using either the AMP (n=40) or OI (n=42) technique. The locations of the tunnel apertures were assessed by postoperative 3-dimensional computed tomography imaging. The femoral graft bending angle, femoral tunnel aperture shape, femoral tunnel length, and posterior wall breakage were also measured. Results: The mean femoral tunnel position parallel to the Blumensaat line was more caudally positioned in the AMP group than in the OI group (p=0.025) The mean femoral graft angle in the OI group (99.6°±7.1°) was significantly more acute than that of the AMP group (108.9°±10.2°, p<0.001). The mean height/width ratio of the AMP group (1.21±0.20) was significantly more ellipsoidal than that of the OI group (1.07±0.09, p<0.001). Conclusions: The mean femoral tunnel position was significantly shallower in the AMP technique than in the OI technique. The OI technique might be more disadvantageous than the AMP technique in terms of the more acute bending angle. [ABSTRACT FROM AUTHOR]

Background and objectives: A radiologist’s work in detecting various injuries or pathologies from radiological scans can be tiresome, time consuming and prone to errors. The field of computer-aided diagnosis aims to reduce these factors by introducing a level of automation in the process. In this paper, we deal with the problem of detecting the presence of anterior cruciate ligament (ACL) injury in a human knee. We examine the possibility of aiding the diagnosis process by building a decision-support model for detecting the presence of milder ACL injuries (not requiring operative treatment) and complete ACL ruptures (requiring operative treatment) from sagittal plane magnetic resonance (MR) volumes of human knees. Methods: Histogram of oriented gradient (HOG) descriptors and gist descriptors are extracted from manually selected rectangular regions of interest enveloping the wider cruciate ligament area. Performance of two machine-learning models is explored, coupled with both feature extraction methods: support vector machine (SVM) and random forests model. Model generalisation properties were determined by performing multiple iterations of stratified 10-fold cross validation whilst observing the area under the curve (AUC) score. Results: Sagittal plane knee joint MR data was retrospectively gathered at the Clinical Hospital Centre Rijeka, Croatia, from 2007 until 2014. Type of ACL injury was established in a double-blind fashion by comparing the retrospectively set diagnosis against the prospective opinion of another radiologist. After clean up, the resulting dataset consisted of 917 usable labelled exam sequences of left or right knees. Experimental results suggest that a linear-kernel SVM learned from HOG descriptors has the best generalisation properties among the experimental models compared, having an area under the curve of 0.894 for the injury-detection problem and 0.943 for the complete-rupture-detection problem. Conclusions: Although the problem of performing semi-automated ACL-injury diagnosis by observing knee-joint MR volumes alone is a difficult one, experimental results suggest potential clinical application of computer-aided decision making, both for detecting milder injuries and detecting complete ruptures. [ABSTRACT FROM AUTHOR]

Background: Reestablishing knee stability is the core of the treatment of ACL (Anterior Cruciate Ligament) injury. Some patients still have a feeling of instability of the knee after ACL injury treatment. This unstable feeling may be caused by central nervous system changes after ACL rupture. Methods: To identify the central changes after ACL rupture, EEG spectra were recorded to compare ACL patients and healthy controls when they were walking, jogging, and landing. Results: There was a significant increase in delta, theta, alpha and beta band power during walking, jogging and landing in ACL patients. We also found an asymmetry phenomenon of EEG only in the ACL patients, mainly in the frontal area and central-parietal area. The asymmetry of beta band power extended to the frontal and the central area during jogging and landing task. Conclusions: There were significant differences in EEG power spectra between the ACL patients and healthy people. ACL patients showed high EEG band power activities and an asymmetry phenomenon. EEG power changes were affected by movements, the asymmetry extended when performing more complicated movements. [ABSTRACT FROM AUTHOR]

The movement information of the human body can be recorded in the plantar pressure data, and the analysis of plantar pressure data can be used to judge whether the human body motion function is normal or not. A two-meter footscan® system was used to collect the plantar pressure data, and the kinetic and dynamic gait characteristics were extracted. According to the different description of gait characteristics, a set of models was established according to various people to present the movement of lower limbs. By the introduction of algorithm in machine learning, the FCM clustering algorithm is used to cluster the sample set and create a set of models, and then the SVM algorithm was used to identify the new samples, so as to complete the normal and abnormal motion function identification. The multimodel presented in this paper was carried out into the analysis of the anterior cruciate ligament deficiency. This method demonstrated being effective and can provide auxiliary analysis for clinical diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the influence of joint aspiration on the sensitivity of physical examination for diagnosing acute anterior cruciate ligament (ACL) lesion in the second outpatient-department (OPD) follow-up referred from emergency department (ED).Methods: This retrospective study included sixty patients underwent ACL reconstruction with initial visit at ED. They were divided into two groups based on the presence or absence of joint aspiration at ED. All participants were referred to second OPD follow-up within 7-14days after the injury. Clinical manifestation (including visual analogue scale (VAS) for pain, range of motion (ROM), and severity of knee effusion) and physical examination (Lachman test and pivot shift test) were checked in ED and the second OPD follow-up.Results: The group of patients with joint aspiration (G1) showed substantial decreases in mean values of VAS for pain (p=0.005), ROM (p=0.001), and effusion level (p<0.001), even higher VAS and effusion level and lower ROM at the initial visit of ED than the other group (G2). The sensitivity of positive Lachman and pivot shift test was significantly (p<0.05) increased following knee joint aspiration. Positive Lachman test was recorded at 76.5% in the second follow-up in G1, which was significantly (p=0.047) higher than that (47.6%) in G2. The percentage of positive pivot shift test was recorded at 76.5% in the second follow-up in G1, which as significantly (p<0.001) higher than that (31.0%) in G2.Conclusions: Knee joint aspiration in acute ACL injury with suspected hemarthrosis could be considered as a diagnostic procedure. Joint aspiration in early medical attendance might be able to lower pain scores or raise the sensitivity of physical examination for diagnosing acute ACL injury at follow up visit in orthopedic outpatient department.Level Of Evidence: Retrospective cohort study III. [ABSTRACT FROM AUTHOR]

Aim: The purpose of the study was to improve the ultrasonographic assessment of the anterior cruciate ligament by an inclusion of a dynamic element. The proposed functional modification aims to restore normal posterior cruciate ligament tension, which is associated with a visible change in the ligament shape. This method reduces the risk of an error resulting from subjectively assessing the shape of the posterior cruciate ligament. It should be also emphasized that the method combined with other ultrasound anterior cruciate ligament assessment techniques helps increase diagnostic accuracy. Methods: Ultrasonography is used as an adjunctive technique in the diagnosis of anterior cruciate ligament injury. The paper presents a sonographic technique for the assessment of suspected anterior cruciate ligament insufficiency supplemented by the use of a dynamic examination. This technique can be recommended as an additional procedure in routine ultrasound diagnostics of anterior cruciate ligament injuries. Results: Supplementing routine ultrasonography with the dynamic assessment of posterior cruciate ligament shape changes in patients with suspected anterior cruciate ligament injury reduces the risk of subjective errors and increases diagnostic accuracy. This is important especially in cases of minor anterior knee instability and bilateral anterior knee instability. Conclusions: An assessment of changes in posterior cruciate ligament using a dynamic ultrasound examination effectively complements routine sonographic diagnostic techniques for anterior cruciate ligament insufficiency. [ABSTRACT FROM AUTHOR]

Purpose To quantitatively evaluate longitudinal changes in water and lipid in knee bone marrow with and without bone marrow edema-like lesions (BMELs) in subjects with acutely ruptured anterior cruciate ligaments (ACLs) or osteoarthritis (OA) using three-dimensional magnetic resonance spectroscopic imaging (3D MRSI). Material and methods Ten ACL and 10 OA subjects who presented with BMEL and seven BMEL-free controls were scanned at 3 T. All ACL and OA subjects had one-year follow-up scans. 3D MRSI was acquired in BMEL and adjacent bone marrow, and water content (WC) and unsaturated lipid index (UI) were calculated in each region of interest. Results At baseline, ACL BMEL WC was significantly higher than ACL non-BMEL, OA BMEL, and control WC; ACL non-BMEL WC, ACL BMEL UI, and OA BMEL WC were significantly higher than control. ACL BMEL WC decreased significantly one year post-reconstruction; UI decreased non-significantly (p = 0.09). No significant changes in OA BMEL or ACL and OA non-BMEL WC and UI were observed. Conclusion 3D MRSI is a powerful method of quantitatively assessing the biochemical composition of bone marrow in OA and ACL-injured knees, which may serve as imaging markers to improve comprehension of primary and secondary OA pathology. [ABSTRACT FROM AUTHOR]

Muscle activation during landing is paramount to stabilise lower limb joints and avoid abnormal movement patterns. Delayed muscle activity onset measured by electromyography (EMG) has been suggested to be associated with anterior cruciate ligament (ACL) injury. Therefore, the aim of this systematic review and meta-analysis was to test the hypothesis if ACL-injured patients display different results for muscle onset timing during standard deceleration tasks compared to healthy control participants. PubMed, Embase, Scopus and ScienceDirect databases were systematically searched over the period from January 1980 to February 2015, yielding a total of 1461 citations. Six studies meeting inclusion criteria underwent quality assessment, data extraction and re-computing procedures for the meta-analysis. The quality was rated “moderate” for 2 studies and “poor” for 4. Patients included and procedures used were highly heterogeneous. The tasks investigated were single leg hopping, decelerating from running or walking, tested on a total of 102 ACL-injured participants and 86 controls. EMG analyses of the muscles vastus lateralis, vastus medialis, lateral and medial hamstrings revealed trivial and non-significant standardised mean differences (SMD<0.20; p>0.05) between patients and control participants. Furthermore, no differences were found between the contralateral leg of patients and controls for muscle activity onset of the medial and lateral gastrocnemius (SMD<0.20; p>0.05). Based on 3 studies, the involved legs of ACL-injured patients showed overall earlier muscle activity onset compared to control participants for the medial gastrocnemius (SMD = 0.5; p = 0.05). Similar results were found for the lateral gastrocnemius (SMD = 2.1; p<0.001), with a greater effect size but based only on a single study. We conclude that there are no differences between leg muscles of ACL-injured patients and healthy controls regarding the muscle activity onset during landing. However, current evidence is scarce and weak, which highlights the need for further research in this area. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the frequency of meniscal tear and the location of tear associated with anterior cruciate ligament (ACL) injury. Subjects and Methods: We studied 549 patients (552 knees) who were diagnosed with ACL injury by arthroscopy at our center between January 2006 and March 2014 (8 years and 3 months). The subjects comprised 289 males and 263 females ranging in age from 13 to 66 (mean 26.1) years. The cause of injury was sports-related in 89.1 %, and the mean interval from injury to initial arthroscopy was 23 months. The patients were divided into two groups: arthroscopy performed within 8 weeks after injury (acute group; 256 knees) and more than 8 weeks after injury (chronic group; 296 knees). Frequency of meniscal tear and location of tear were compared between two groups. Results: The incidence of meniscal tear diagnosed by arthroscopic examination was 79.2 % (437 of 552 knees) in all subjects; 72.7 % (186 of 256 knees) in acute group and 84.8 % (251 of 296 knees) in chronic group, and was significantly higher in chronic group. Regarding the locations of meniscal tears, in acute group (186 knees), medial meniscal tear only was found in 20 knees (10.8 %), lateral meniscal tear only in 129 knees (69.4 %), and bilateral (including medial and lateral) meniscal tears in 37 knees (19.9 %). In chronic group (251 knees), medial meniscal tear only was found in 62 knees (24.7 %), lateral meniscal tear only in 85 knees (33.9 %), and bilateral meniscal tears in 104 knees (41.4 %). Lateral meniscal tear was commonly associated with acute ACL injury, while medial meniscal tear with chronic ACL injury. Bucket handle tear was observed in 25 knees (medial: 17 knees, lateral: 8 knees) in acute group, and 81 knees (medial: 69 knees, lateral: 12 knees) in chronic group, and was more common in the chronic group. Conclusion: The incidence of meniscal tear associated with ACL injury is higher in chronic cases; the number of medial meniscal tears is particularly high, many of which require meniscectomy. Early ACL reconstruction is recommended also for the prevention of secondary meniscal tear. [ABSTRACT FROM AUTHOR]

Anterior cruciate ligament (ACL) injuries are relatively common and can lead to knee dysfunction. The classic presentation is a non-contact twisting injury with an audible pop and the rapid onset of swelling. Prompt evaluation and diagnosis of ACL injuries are important. Acute treatment consists of cessation of the sporting activity, ice, compression, and elevation with evaluation by a physician familiar with ACL injuries and their management. The diagnosis is made with the use of patient history and physical examination as well as imaging studies. Radiographs may show evidence of a bony injury. MRI confirms the diagnosis and evaluates the knee for concomitant injuries to the cartilage, menisci and other knee ligaments. For active patients, operative treatment is often recommended while less-active patients may not require surgery. The goal of this review is to discuss the diagnosis of an ACL injury and provide clear management strategies for the primary-care sports medicine physician. [ABSTRACT FROM AUTHOR]

The prevalence of anterior cruciate ligament (ACL) injuries in skeletally immature athletes has increased dramatically over the past decade. Many attribute this to increased training, single-sport specialization and year-round competitive play. ACL injuries most commonly occur in athletic activities that involve cutting, pivoting, jumping and landing. Non-operative treatment consisting of activity modification, physical therapy and specialized bracing may have a role; however, recent data suggest that this may not be optimal in young, active patients. Surgical treatment has become more favorable, specifically for athletes with aspirations of higher-level sports participation. To minimize growth plate disturbances and potential for limb malalignment, the patient’s skeletal age, pubertal status and remaining growth potential must be taken into consideration. We provide a review on how to evaluate, manage and treat the skeletally immature athlete with an ACL injury. [ABSTRACT FROM PUBLISHER]

Purpose: There is a large number of publications evaluating neuromuscular risk factors for anterior cruciate ligament (ACL) injury in athletes. However, most of them have involved the female athlete and, in addition, the gastrocnemius muscles have been less investigated by far compared with the quadriceps and hamstring. The purpose of this study was to investigate the role of the gastrocnemius muscles as neuromuscular risk factors for ACL injury in male soccer players, through tensiomyography (TMG). Methods: All competitive male soccer players with confirmed ACL tear included in this study underwent resting TMG assessment of gastrocnemius medialis (GM) and gastrocnemius lateralis muscles of the uninjured side. The same values were obtained from a sex-, and sports level-matched control group in both sides. The maximal displacement ( D), delay time ( T), contraction time ( T), sustained time ( T), and half-relaxation time ( T) were obtained for both muscles. TMG values of the uninjured side in ACL-injured group were compared with the mean values between both sides in the control subjects. Results: There were no significant between-group differences in demographic characteristics. Most TMG parameters of the gastrocnemius muscles were not significantly different between the two groups. Only the GM- T ( p = 0.02) and GM- D ( p = 0.006) were significantly higher in the ACL-injured group compared with control group. Conclusions: Neuromuscular characteristics in terms of mechanical and contractile properties of the gastrocnemius muscles may not be significant risk factors for ACL injury in male soccer players. Level of evidence: Prognostic study, Level II. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the role of mechanical and contractile properties of skeletal muscles of the thigh, assessed through tensiomyography (TMG), as risk factors for anterior cruciate ligament (ACL) injury in male soccer players. Methods: Male soccer players with confirmed ACL tear included in this study underwent resting TMG assessment of thigh muscles of the uninjured side. The same values were obtained from a sex-, sports level-matched control group in both sides. The maximal displacement ( Dm), delay time ( Td), contraction time ( Tc), sustained time ( Ts), and half-relaxation time ( Tr) were obtained for the following muscles in all subjects: vastus medialis ( VM), vastus laterals ( VL), rectus femoris ( RF), semitendinosus ( ST), and biceps femoris ( BF). TMG values of the uninjured side in ACL-injured group were compared to mean values between both sides in the control subjects. Results: There were 40 ACL-injured and 38 control individuals. The vast majority of TMG parameters were higher in the uninjured side of ACL-injured individuals compared to the control group. The VL- Tr, RF- Tc, RF- Ts, RF- Tr, and BF- Dm values were significantly higher in the uninjured side compared to the control group. Quadriceps muscles demonstrated more significant between-group differences than hamstring muscles. Specifically, RF was the muscle where most significant between-group differences were found. Conclusions: Resistance to fatigue and muscle stiffness in the hamstring muscles may be risk factors for ACL injury in male soccer players. In addition, a predominant impairment in TMG characteristics of the quadriceps over hamstrings may indicate an altered muscular co-contraction (imbalance) between both muscle groups, which might be another risk factor for ACL injury in this population. These findings should be taken into account when screening athletes at high risk of ACL injury and also to design adequate prevention programs for ACL injury in male soccer players. Level of evidence: Prognostic study, Level II. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present investigation was to identify possible factors associated with returning to football on an average 3.2 ± 1.4 years after anterior cruciate ligament (ACL) reconstruction in both male and female football players. Methods: The players were recruited from a patient database of football players that have undergone an ACL reconstruction between 2004 and 2007 at the Capio Artro Clinic, Sophiahemmet in Stockholm, Sweden. Special attention was paid to gender, age, type of graft for ACL reconstruction, associated injuries, anterior knee laxity, thigh muscle torques and symptoms/problems during, and/or after physical activity. In the beginning of the summer of 2009, 205 players (37.9 %) out of 541 players filled out a questionnaire designed to evaluate physical activity and knee function in a sports-specific setting. A detailed dropout analysis showed that females responded to a higher degree than males. No other significant differences between responders and non-responders were found. Results: Fifty-four per cent ( n = 111) had returned to football, and 46 % ( n = 94) had not. Using logistic regression analyses, we found that the female gender ( p = 0.036, OR 0.518), cartilage injury ( p = 0.013, OR 0.368), and pain during physical activity ( p = 0.002, OR 0.619) were significant negative predictors for returning to football after ACL reconstruction and rehabilitation. For players with all three significant factors, only 10 % returned to football compared to 76.5 % of those without any of these factors. Conclusions: Female gender, cartilage injury, and knee pain during physical activity were independent negative predictors for returning to football after ACL reconstruction. At a mean follow-up of 3.2 ± 1.4 years after ACL reconstruction, pain during physical activity was reported to be the most common symptom/problem in football players. The clinical relevance of this study is to improve the treatment of ACL injured football players focusing on female gender and knee pain. Furthermore, ACL injury prevention should be highlighted in football players, especially female players. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: This study proposes a simple and noninvasive instrument called the 'Rotatometer' to measure tibiofemoral rotation and investigates its clinical applicability to the assessment of static rotational knee laxity. Methods: The degree of tibiofemoral rotation was measured for a sample of 94 healthy volunteers with 188 knees by using the Rotatometer. The measurement was made by two independent and blinded examiners in three sessions at one-month intervals. The normative rotational profile and its relationship with gender and age were evaluated, and inter-observer reliability and intra-observer reliability were calculated. Results: Males showed 62° ± 5° of external rotation, whereas females, 64° ± 5°. Males showed 44° ± 5° of internal rotation, whereas females, 49° ± 4°. Females showed significantly higher degrees of rotation than males. Tibiofemoral rotation was not correlated with age, and external rotation and internal rotation had a moderate positive relationship. Inter-observer reliability ranged from 0.84 to 0.91 for external rotation and 0.90 to 0.95 for internal rotation, and intra-observer reliability ranged from 0.69 to 0.89 for external rotation and 0.87 to 0.95 for internal rotation. Conclusions: The results suggest the Rotatometer to be a simple and noninvasive device with high inter- and intra-observer reliability. The device can provide a normative rotational profile for reference purposes and thus can be used to determine the preoperative and postoperative rotational status of knees with anterior cruciate ligament injuries and compare results from different reconstruction techniques. Level of evidence: Diagnostic study, Level III. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the difference in the concentrations of testosterone, 17-β estradiol and progesterone between female patients with and without ACL rupture and the possible effect of these hormones on generalised joint laxity. Methods: Female subjects with non-contact knee joint injury were included in this study. They were divided into two groups: the examined group, consisting of female subjects with ACL rupture, and the control group, consisting of female patients without ACL rupture. In the next step, the patients from these two groups were paired off on the basis of three factors: the level of professional sports involvement (including the type of sports activity), the side of the body where the injury had occurred (left or right) and the age of the subjects. In the end, there were 12 pairs (24 subjects). The concentrations of sex hormones were established from saliva specimens with the aid of the Salimetrics enzyme immunoassay. Generalised joint laxity was tested with the aid of the 'laxity score' according to Beighton, Solomon and Soskolne. Results: Female subjects with ACL rupture had significantly lower concentrations of testosterone ( p < 0.01), significantly lower concentrations of 17-β estradiol ( p < 0.05) and significantly lower concentrations of progesterone ( p < 0.01) than female subjects with intact ACL. Conclusions: Decreased concentrations of testosterone, 17-β estradiol or progesterone may be a risk factor leading to ACL rupture. The concentrations of these hormones do not affect generalised joint laxity. Additional research on a larger group of patients is necessary to further determine the effects of these hormones on generalised joint laxity and ACL ruptures. Young female athletes with lower concentrations of sex hormones are more prone to anterior cruciate ligament rupture which is why they need to reduce their sports activities during the pre-ovulatory phase of the menstrual cycle, when these concentrations are additionally reduced. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background: Available methods for screening anterior cruciate ligament (ACL) injury risk are effective but limited in application as they generally rely on expensive and time-consuming biomechanical movement analysis. A potentially efficient alternative to biomechanical screening is skilled movement analysis via visual inspection (ie, having experts estimate injury risk factors based on observations of athletes' movements). Purpose: To develop a brief, valid psychometric assessment of ACL injury risk factor estimation skill: the ACL Injury Risk Estimation Quiz (ACL-IQ). Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 660 individuals participated in various stages of the study, including athletes, physicians, physical therapists, athletic trainers, exercise science researchers/students, and members of the general public in the United States. The ACL-IQ was fully computerized and made available online (www.ACL-IQ.org). Item sampling/reduction, reliability analysis, cross-validation, and convergent/discriminant validity analyses were conducted to refine the efficiency and validity of the assessment. Results: Psychometric optimization techniques identified a short (mean time, 2 min 24 s), robust, 5-item assessment with high reliability (test-retest: r = 0.90) and high test sensitivity (average difference of exercise science professionals vs general population: Cohen d = 2). Exercise science professionals and individuals from the general population scored 74% and 53% correct, respectively. Convergent and discriminant validity was demonstrated. Scores on the ACL-IQ were best predicted by ACL knowledge and specific judgment strategies (ie, cue use) and were largely unrelated to domain-general spatial/decision-making ability, personality, or other demographic variables. Overall, 23% of the total sample (40% of exercise science professionals; 6% of general population) performed better than or equal to the ACL nomogram. Conclusion: This study presents the results of a systematic approach to assess individual differences in ACL injury risk factor estimation skill; the assessment approach is efficient (ie, it can be completed in <3 min) and psychometrically robust. The results provide evidence that some individuals have the ability to visually estimate ACL injury risk factors more accurately than other instrument-based ACL risk estimation methods (ie, ACL nomogram). The ACL-IQ provides the foundation for assessing the efficacy of observational ACL injury risk factor assessment (ie, does simple skilled visual inspection reduce ACL injuries?). The ACL-IQ can also be used to increase our understanding of the perceptual-cognitive mechanisms underlying injury risk assessment expertise, which can be leveraged to accelerate learning and improve performance. [ABSTRACT FROM AUTHOR]

Background: No standardized return-to-activity or sport guidelines currently exist after anterior cruciate ligament (ACL) reconstruction. Isokinetic testing and unilateral hop testing, which have construct validity, are often used to make the determination of when a patient is ready to return to sport. Neither of these measures has been reported to be predictive of subsequent injuries. Purpose: To compare the performance on 2 functional tests of ACL reconstruction patients released to return to activity versus those who have not been released based on clinical impairment measures. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 98 patients were examined by the treating orthopaedic surgeon 6 months after ACL reconstruction for traditional impairment measures, including swelling, range of motion, strength, and graft stability. After this examination, all subjects completed the functional testing, consisting of the Functional Movement Screen (FMS) and the Lower Quarter Y Balance Test (YBT-LQ), by an experienced tester who was blinded to the results of the clinical examination. On the basis of the clinical examination, all patients were grouped as being ready to return to sport or not being ready. Performance on the functional tests, as measured by overall performance and side-to-side asymmetry, was compared between the 2 groups using independent-samples t tests (P < .05). Results: No difference existed between the groups with regard to the descriptive characteristics, with the exception that the group not cleared was younger (21.0 ± 7.4 years) than the group that was cleared (25.6 ± 13.2 years). Performance on the YBT-LQ revealed that no differences existed between groups when examining reach symmetry for any of the reach directions. In addition, no differences were found between groups when looking at the average reach score normalized to limb length for either the surgical or nonsurgical leg. Patients in the cleared group exhibited a similar score on the FMS (12.7 ± 2.9) compared with the non-cleared group (12.8 ± 2.7). Similarly, no differences were observed for the number of asymmetries; however, both groups averaged 1 asymmetry during the testing. Conclusion: Clinical impairment measures do not appear to be related to measured functional ability. Performance on both functional tests, the FMS and YBT-LQ, at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury, based on currently published research. [ABSTRACT FROM AUTHOR]

Background: The pivot-shift (PS) examination is used to demonstrate knee instability and detect anterior cruciate ligament (ACL) injury. Prior studies using inertial sensors identified the ACL-deficient knee with reasonable accuracy, but none addressed the more difficult problem of using these sensors to determine whether a subject has an ACL deficiency and to correctly assign a PS grade to a patient's knee. Hypothesis: Inertial sensor data recorded during a PS examination can accurately predict ACL deficiency and the PS score assigned by the examining physician. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 32 patients with unilateral ACL deficiency and 29 with intact ACLs in both knees had inertial sensor modules strapped to the tibia and femur of each limb for preoperative PS testing under anesthesia. Support vector machine (SVM) methodsassessed PS grades on the basis of these data, with the examiner's clinical grading shift used as ground truth. A fusion of regression and SVM classification techniques diagnosed ACL deficiency. Results: The clinically determined PS grades of all 122 knees were as follows: 0 (n = 69), +1 (n = 23), +2 (n = 27), and +3 (n = 3). The SVM classification analysis was 77% accurate in correctly classifying these grades, with 98% of computed PS grades fallingwithin ±1 grade of the clinically determined value. The system fusion algorithm diagnosed ACL deficiency in an individual with anoverall accuracy of 97%. This method yielded 6% false negatives and 0% false positives. Conclusion: This study used inertial sensor technology with SVM algorithms to accurately determine clinically assigned PS grades in ACL-intact and ACL-deficient knees. By extending the assessment to a separate group of patients without ACL injury, the inertial sensor data demonstrated highly accurate diagnosis of ACL deficiency. [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: Rupture of the anterior cruciate ligament (ACL) is a common injury, often presenting with a typical injury pattern. Historically, the literature indicates that the accuracy of diagnosis of ACL ruptures is poor at the initial medical consultation. The aims of this study were to determine: the mechanism of injury; changes in accuracy of diagnosis of ACL ruptures at initial presentation over the last decade; and the effect of subsequent delay in diagnosis and definitive treatment. Methods: A prospective cohort of one hundred and thirty-two consecutive patients who underwent ACL reconstruction between 2005 and 2009 were analysed. The median age of the patients was 18 years (12-57). Sixteen patients were excluded due to chronic ACL injury. Results: One hundred and sixteen patients (117 ACL ruptures) were included in the analysis. A typical injury pattern was documented in 87 (74.4 %) of cases. The most common sporting activities associated with an ACL injury were football (35.3 %), skiing (21.6 %) and rugby (10.3 %). The majority of patients (67.5 %) sought medical attention within 1 week from time of injury. The correct diagnosis of an ACL rupture was made in 33 cases (28.2 %) at the initial medical consultation. The diagnosis was made following medical consultation in 13 (11.1 %) of cases with the use of magnetic resonance imaging and 6 (5.1 %) cases at arthroscopy. The median time to diagnosis was 6 weeks (0-192), and the median time to ACL reconstruction was 24 weeks (1-240). A delay in diagnosis of >6 months was associated with a medial meniscal tear rate of 72.2 % compared to 23.1 % if the diagnosis was made within 4 months of the injury ( p < 0.05). Conclusions: Despite a 'typical' mechanism of injury leading to ACL rupture, the rate of initial diagnosis in the UK still remains poor. This often leads to an unnecessary delay in the diagnosis and subsequent treatment and increases the risk of secondary injury to the knee. A delay in diagnosis of >6 months was associated with an increased medial meniscal tear rate. Patients who present with a 'typical' injury pattern should therefore be referred for further assessment by a knee specialist within 6 weeks. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

The purpose of this article is to provide primary care physicians and other members of the medical community with an updated, general review on the subject of anterior cruciate ligament (ACL) tears. We aim to enhance awareness of these injuries and to prepare those practicing in the primary care setting to address these injuries. Because ACL injuries are quite common, it is very likely that a primary care physician will encounter these injuries and need to address them acutely. The current literature is replete with new concepts and controversies regarding ACL injuries, and this article provides a concise review for our target audience in regard to the care of a patient with an ACL injury. This article is composed of an overview with current epidemiologic data, basic anatomy and physiology, clinical presentation, physical examination findings, imaging modalities, and treatment options. After reading this short article, a medical care provider should understand ACL injuries and their appropriate management. [ABSTRACT FROM AUTHOR]

Objective: To determine the diagnostic accuracy of magnetic resonance imaging (MRI) in injuries related to anterior cruciate ligament and menisci and compare its effectiveness with that of arthroscopy. Methods: This retrospective cross-sectional study was conducted in the department of Radiology & Medical Imaging of Dallah Hospital, Riyadh, Kingdom of Saudi Arabia from September 2012 to March 2014. Fifty four patients (including 30 men and 24 women) with internal derangement of knee referred from the orthopedic consulting clinics underwent MR imaging followed by arthroscopic evaluation. The presence of meniscal and ligamentous abnormality on the imaging was documented by two trained radiologist. Findings were later compared with arthroscopic findings. Results: The sensitivity, specificity and accuracy of MR imaging for menisci and ACL injury were calculated: 100% sensitivity, 88.4% specificity, 90% positive predictive value, 100% negative predictive value, and 94.4% accuracy were noted for medial meniscal injury. Similarly, MR had sensitivity of 85.7%, specificity of 95%, positive predictive value of 85.7%, negative predictive value of 95%, and accuracy of 92.5% for lateral meniscal injuries. Likewise, anterior cruciate ligament had 91.6% sensitivity, 95.2% specificity, 84.6% positive predictive value, 97.5% negative predictive value, and 94.4% accuracy. Conclusion: MRI is extremely helpful in identifying meniscal and anterior cruciate ligaments tears. MR imaging has high negative predictive value making it better choice as screening tool compared to diagnostic arthroscopic evaluation in most patients with soft tissue trauma to knee. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the diagnostic value of oblique coronal and sagittal imaging with orthogonal views for diagnosis of anterior cruciate ligament (ACL) graft failure following reconstruction. It details the methodology in determining the diagnostic efficacy of oblique views of knee magnetic resonance imaging (MRI). It implies that combined oblique sagittal and coronal images of the ACL can provide better anatomic evaluation, specificity, and accuracy of diagnoses.

Background: Although ultrasound (US) has a wide range of applications in orthopedic diagnostics, sonographic evaluation of traumatic anterior cruciate ligament (ACL) insufficiency is still inadequate. There is a growing need for diagnostic tests that allow for simple and reliable assessment of ACL instability. This investigation aims to evaluate feasibility of sonographic technique for diagnosing complete ACL insufficiency. Materials and Methods: Eighty three consecutive patients suspected of ACL injury were examined with sonographic, dynamic test of anterior instability. The translation of the intercondylar eminence against the patellar tendon was measured in the injured and opposite (injured) knee. Subsequent magnetic resonance imaging was performed on all patients. Forty-seven of them underwent a further arthroscopy. Five patients have been examined for the 2nd time to evaluate interclass and intraclass agreement and bias. Results: Complete ACL insufficiency has been confirmed in 37 patients. In those individuals, the total anterior knee translation and the difference between two joints (side-to-side difference) were significantly increased (8.67 mm standard deviation [SD] 2.65 mm in the affected knee versus 2.88 mm SD 1.26 mm in uninjured joint; P < 0.001). Based on a threshold of 2.0 mm for the side-to-side difference and 5.0 mm for the absolute translation, the sonographic test was found to have a sensitivity and specificity of 91.9% and 95.6%, respectively. Conclusions: The present technique supports the clinician with additional fast and noninvasive diagnostic procedure that can facilitate the evaluation of anterior knee instability. [ABSTRACT FROM AUTHOR]

Background: Individuals with Anterior Cruciate Ligament (ACL) injury often show altered movement patterns, suggested to be partly due to impaired sensorimotor control. Here, we therefore aimed to assess muscular activity during movements often used in ACL-rehabilitation and to characterize associations between deviations in muscular activity and specific altered movement patterns, using and further exploring the previously developed Test for substitution Patterns (TSP). Methods: Sixteen participants (10 women) with unilateral ACL rupture performed Single and Double Leg Squats (SLS; DLS). Altered movement patterns were scored according to TSP, and Surface Electromyography (SEMG) was recorded bilaterally in six hip, thigh and shank muscles. To quantify deviations in muscular activity, SEMG ratios were calculated between homonymous muscles on injured and non-injured sides, and between antagonistic muscles on the same side. Correlations between deviations of injured/non-injured side SEMG ratios and specific altered movement patterns were calculated. Results: Injured/non-injured ratios were low at transition from knee flexion to extension in quadriceps in SLS, and in quadriceps and hamstrings in DLS. On injured side, the quadriceps/hamstrings ratio prior to the beginning of DLS and end of DLS and SLS, and tibialis/gastrocnemius ratio at end of DLS were lower than on non-injured side. Correlations were found between specific altered movement patterns and deviating muscular activity at transition from knee flexion to extension in SLS, indicating that the more deviating the muscular activity on injured side, the more pronounced the altered movement pattern. "Knee medial to supporting foot" correlated to lower injured/ non-injured ratios in gluteus medius (rs = -0.73, p = 0.001), "lateral displacement of hip-pelvis-region" to lower injured/non-injured ratios in quadriceps (rs = -0.54, p = 0.03) and "displacement of trunk" to higher injured/ non-injured ratios in gluteus medius (rs = 0.62, p = 0.01). Conclusions: Deviations in muscular activity between injured and non-injured sides and between antagonistic muscular activity within injured as compared to non-injured sides indicated specific alterations in sensorimotor control of the lower limb in individuals with ACL rupture. Also, correlations between deviating muscular activity and specific altered movement patterns were suggested as indications of altered sensorimotor control. We therefore advocate that quantitative assessments of altered movement patterns should be considered in ACL-rehabilitation. [ABSTRACT FROM AUTHOR]

Background: Interpretation of Lachman testing when evaluating the status of the anterior cruciate ligament (ACL) typically includes a numerical expression classifying the amount of translation (Grade I, II, III) in addition to a categorical modifier (Grade A [firm] or B [absent]) to describe the quality of the passive anterior tibial translation's endpoint. Most clinicians rely heavily on this tactile sensation and place value in this judgment in order to render their diagnostic decision; however, the reliability and accuracy of this endpoint assessment has not been well established in the literature. Purpose: The purpose of this study was to determine the intertester reliability of endpoint classification during the passive anterior tibial translation of a standard Lachman test and evaluate the classification's ability to accurately predict the presence or absence of an ACL tear. Study design: Prospective, blinded, diagnostic reliability and accuracy study. Methods: Forty-five consecutive patients with a complaint of knee pain were independently evaluated for the endpoint classification during a Lachman test by two physical therapists before any other diagnostic assessment. The 21 men and 24 women ranged in age from 20 to 64 years (mean +/- SD age, 40.7 +/- 14) and in acuity of knee injury from 30 to 365 days (mean +/- SD, 238 +/-157). Results: 17 of the 45 patients had a torn ACL. The agreement between examiners on A versus B endpoint classification was 91% with a kappa coefficient of 0.72. In contrast, classification agreement based on the translational amount had an agreement of 65% with a weighted kappa coefficient of 0.52. The sensitivity of the endpoint grade alone was 0.81 with perfect specificity resulting in a positive likelihood ratio of 6.2 and a negative likelihood ratio of 0.19. The overall accuracy of the Lachman test using the endpoint assessment grade alone was 93% with a number needed to diagnose of 1.2. Conclusions: Nominal endpoint classification (A or B) from a Lachman test is a reliable and accurate reflection of the status of the ACL. The true dichotomous nature of the test's interpretation (positive vs. negative) is well-served by the quality of the endpoint during passive anterior tibial translation. [ABSTRACT FROM AUTHOR]

This study investigated sex-specific effects of surface instability on kinetics and lower extremity kinematics during drop jumping and landing. Ground reaction forces as well as knee valgus and flexion angles were tested in 14 males (age: 23±2 years) and 14 females (age: 24±3 years) when jumping and landing on stable and unstable surfaces. Jump height was found to be significantly lower (9%, p<0.001) when drop jumps were performed on unstable vs. stable surface. Significantly higher peak ground reaction forces were observed when jumping was performed on unstable versus stable surfaces (5%, p=0.022). Regarding frontal plane kinematics during jumping and landing, knee valgus angles were higher on unstable compared to stable surfaces (19-32%, p<0.05). Additionally, at the onset of ground contact during landings, females showed higher knee valgus angles than males (222%, p=0.027). Sagittal plane kinematics indicated significantly smaller knee flexion angles (6-35%, p<0.05) when jumping and landing on unstable vs. stable surfaces. During drop jumps and landings, women showed smaller knee flexion angles at ground contact compared to men (27-33%, p<0.05). These findings imply that knee motion strategies were modified by surface instability and sex during drop jumps and landings. [ABSTRACT FROM AUTHOR]

The patellar ligament angle (PLA) was assessed in 105 normal stifle joints of 79 dogs and 33 stifle joints of 26 dogs with a ruptured cranial cruciate ligament (CrCL). The PLA of stifles with complete CrCL rupture was significantly lower than that of normal stifles, particularly at a flexion angle of 60~80° in both plain and stress views. If the PLA was ~90.55° on the stress view with a 60~80° flexion angle, the dog was diagnosed with a complete rupture of the CrCL with a sensitivity of 83.9% and specificity of 100%. In conclusion, measuring the PLA is a quantitative method for diagnosing complete CrCL rupture in canines. [ABSTRACT FROM AUTHOR]

Background: Stress radiography is a widely used diagnostic tool to assess injury to the anterior and posterior cruciate ligaments and the medial and lateral structures of the knee. However, to date, numerous techniques have been reported in the literature with no clear consensus as to which methodology is best for assessing ligament stability. Questions/purposes: The purpose of this review was to identify which stress radiographic techniques have support in the literature for the diagnosis of acute or chronic knee ligament injuries, to define which technique is most accurate and reliable for diagnosing knee ligament injuries, and to compare the use of stress radiography with other diagnostic tests. Methods: Two independent reviewers performed a systematic review of PubMed (MEDLINE), the EMBASE library, and the Cochrane Controlled Trials Register for English language studies published from January 1970 to August 2013 on the diagnosis of knee ligament injuries using stress radiography. Information describing the ligament(s) investigated, stress radiographic technique, magnitude of force, measures of accuracy and reliability, and comparative diagnostic tests were extracted. Risk of bias was assessed using the QUADAS-2 tool. Results: A total of 16 stress techniques were described for stress radiography of the knee. The diagnostic accuracy of stress radiography including the sensitivity, specificity, and positive and negative predictive values varied considerably depending on the technique and choice of displacement or gapping threshold. Excellent reliability was reported for the diagnosis of anterior cruciate ligament, posterior cruciate ligament, varus, and valgus knee injuries. Inconsistencies were found across studies regarding the efficacy of stress radiography compared with other diagnostic modalities. Conclusions: Based on the multitude of stress techniques reported, varying levels of diagnostic accuracy, and inconsistencies regarding comparative efficacy of stress radiography to other diagnostic modalities, we are not able to make specific recommendations with regard to the best stress radiography technique for the diagnosis of knee ligament injuries. Additional comparative studies using consistent methodology and appropriate blinding are necessary to further define differences in accuracy and reliability both among stress radiography techniques and between stress radiography and other diagnostic tests. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this preliminary study was to evaluate the use of a gyroscope sensor to record rotations of the tibia about its long axis during a clinical pivot shift examination. Methods: Ten patients with a unilateral ACL injury were tested under anaesthesia prior to surgery. Each ankle was placed in neutral position, wrapped and stabilized with athletic tape, and a small aluminium plate was taped to the bottom of the foot. A data recovery module was attached to the bottom of each plate using a swivel bracket that allowed alignment of the gyro axis with the long axis of the tibia. The module contained a triaxial gyroscope, battery and circuitry for wireless data broadcast to a laptop computer. Ten pivot shift tests were performed on both knees, and the surgeon's clinical grading of the pivot shift was noted for each limb. Mean values (10 trials) of peak tibial rotational velocity and integrated tibial rotation were compared between knees for each patient during the pivot shift reduction event (external tibial rotation during knee flexion). Results: Five patients (50 %) had significantly greater tibial rotation in their injured knee, four showed no difference between knees, and one had significantly greater rotation in the normal knee ( p < 0.05). Seven patients (70 %) showed greater peak rotational velocity in their injured knee, and three had no difference between the knees ( p < 0.05). Correlations of rotation and rotational velocity with clinical pivot shift grade were weak ( r = 0.09 and 0.19, respectively). Conclusions: Foot gyroscope measurements did not correctly identify the injured limb in all patients. Peak rotational velocity during the reduction event was a better indicator of ACL deficiency than the integrated rotation. If this technology is to be more useful clinically, gyroscope data may have to be combined with accelerometer data, perhaps with sensors mounted on both the tibia and femur. Level of evidence: Diagnostic case-control study, Level III. [ABSTRACT FROM AUTHOR]

Background Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. Methods Study Design: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. Results A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. Conclusion Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. Clinical relevance Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury. [ABSTRACT FROM AUTHOR]

Purpose: The main purpose of this study was to evaluate the usefulness of the bell-hammer sign in the diagnosis of partial tears of the anterior cruciate ligament (ACL) of the knee on MRI. Methods: A retrospective study was performed including all patients who underwent ACL reconstruction for partial or complete tears from 2008 to 2009. The diagnosis of partial or complete ACL tears was based on the appearance of the ligament bundles and the signal quality on MRI. On arthroscopy, which is considered the gold standard, each bundle was classified as normal, partially or completely torn depending on the extent of the rupture and the quality of the remaining fibres. The study included 312 patients, 83 women and 229 men (mean age 33.3 ± 19.6 years). A diagnosis of a tear was made in all patients on preoperative MRI. Arthroscopy did not show any normal ACL, 247/312 (79.2 %) complete tears and 65/312 (20.8 %) partial tears, 50/65 (76.9 %) on the anteromedial bundle (AM) and 15/65 (23.1 %) the posterolateral bundle. Results: The bell-hammer sign was found on MRI in 13/312 patients (4.5 %). It involved 9/65 (13.8 %) partial tears, all in the AM bundle, and 4/247 (1.6 %) complete tears, significantly more frequent in cases of partial rupture ( p < 0.0001). MRI diagnosed a partial tear in 15/65 cases without the bell-hammer sign (sensitivity CI = 23.1 ± 10 %, specificity CI = 95.9 ± 2.5 %) and with the bell-hammer sign in 23/65 cases (sensitivity CI = 35.4 ± 11 %, specificity CI = 93.9 ± 3 %). The association of the bell-hammer sign with conventional radiological diagnostic criteria has improved diagnosis performance of MRI for partial tears but not significantly (ns). Conclusion: The most important interest of the bell-hammer sign in the day-to-day clinical work is to suggest partial tears on MRI. It aids making a diagnosis, but its absence does not exclude partial ACL rupture. Level of evidence: Diagnostic study, Level II. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to investigate the efficacy of additional oblique magnetic resonance imaging (MRI) for the diagnosis of anterior cruciate ligament (ACL) tear and evaluation of ACL remnant tissue. Methods: We retrospectively reviewed the records of 54 knees. Three independent readers evaluated the MR images by the use of three methods: orthogonal sagittal images only (method A); orthogonal sagittal and additional oblique sagittal images (method B); and orthogonal sagittal and oblique coronal images (method C). The sensitivity, specificity, and accuracy for the diagnosis of an ACL tear and the detection of the condition of the ACL remnant tissue by the use of each method were calculated in comparison with arthroscopic findings as the reference standard. Results: The arthroscopic records revealed 27 knees with intact ACLs and 27 with torn ACLs. Among the 27 knees with torn ACLs, 9 did not have continuous remnant tissue and 18 had certain remnant tissue attached to the femur or the posterior cruciate ligament. The specificities and accuracies of methods B and C for diagnosing an ACL tear were higher than those for method A. The sensitivity, specificity, and accuracy of method C for the detection of ACL remnant tissue were higher than those for method A and B. Conclusions: Additional use of oblique MRI improved the accuracy of diagnosis of ACL tear and showed a reasonable level of efficacy in detecting ACL remnant tissue. Level of evidence: Level IV (case series). [ABSTRACT FROM AUTHOR]

The aim of this study was to compare findings from clinical examinations, MRI scans and arthroscopy in ACL injury of the knee in order to assess the diagnostic significance of both examination findings. This study was conducted to manage the reliability of clinical diagnosis in ACL tear injuries. All patients attending our clinic with knee pain from 2009 to 2013 underwent systematic and thorough clinical assessment. Of 103 patients with knee problems arthroscopy ACL tears was diagnosed in 73. All these patients underwent therapeutic arthroscopic knee surgery. The clinical diagnosis was evaluated and confirmed during this procedure. The accuracy, sensitivity and specificity were calculated based on these arthroscopic findings. The MRI accuracy of clinical diagnosis in our study was 82.5% for ACL tears. Accuracy for two of three clinical examination tests of clinical diagnosis in our study was 96% and 94% for ACL tears. According to our obtained correlation between clinical examinations, MRI scan and arthroscopy for ACL injuries, we concluded that carefully performed clinical examination can give equal or better diagnosis of ACL injuries in comparison with MRI scan. Our study revealed MRI scan high sensitivity and specificity and not so high accuracy for ACL injuries of the knee joint in comparison with arthroscopy. MRI is an appropriate screening tool for therapeutic arthroscopy, making diagnostic arthroscopy unnecessary in most patients. According to our findings we can conclude that a positive anterior drawer test and a positive Lachman clinical examination test is more accurate for predicting, i.e. diagnosis of ACL tear. On the ither hand, MRI scan findings showed less accuracy for predicting, i.e. diagnosis of ACL tear. According to many studies of clinical examination tests compared (correlated) with arthroscopy, the accuracy of predicting ACL tears depends on the level of the skilled orthopaedic or trauma surgeon's hands. Based on these findings, we feel that MRI, except in certain circumstances, is an expensive and unnecessary diagnostic test in patients with suspected meniscal and ACL pathology. [ABSTRACT FROM AUTHOR]

Purpose: To compare the performance of 3D-FSE-Cube MRI to arthroscopy, the reference test for the diagnosis of partial anterior cruciate ligament (ACL) tears. Methods: A retrospective study was performed including all patients who underwent surgery for an ACL tear in our Sports Surgery Unit from January 2008 to December 2009. All patients underwent a preoperative MRI, conventional 2D or 3D-Cube. The diagnosis of a partial tear was based on the appearance of the ligament bundles and signal quality on MRI, and on the continuity of the fibers on arthroscopy and the quality of the remaining ligament. Sixty-four of the 312 included patients underwent MRI 3D-Cube and 248 conventional 2D-MRI. The series included 82 women and 223 men, mean age 33.3 ± 19.6 years. Arthroscopy did not reveal any normal ACL, 247/312 (79.2 %) complete tears, and 65/312 (20.8 %) partial tears, with 50/65 (76.9 %) involving the anteromedial bundle and 15/65 (23.1 %) the posterolateral. Results: The results of MRI 3D-Cube were as follows: sensitivity 95 % CI = 62.5 ± 23.7 %, specificity 95 % CI = 93.7 ± 6.9 %, likelihood ratio LR(+) = 9.9, LR(−) = 0.4 and accuracy 85.9 %. Results of conventional 2D-MRI were as follows: sensitivity 95 % CI = 10.2 ± 8.5 %, specificity 95 % CI = 96.5 ± 2.5 %, LR(+) = 2.9, LR(−) = 0.9 and accuracy 79.4 %. The diagnostic performance of MRI 3D-Cube was better than conventional 2D-MRI. Conclusion: The diagnostic performance of MRI 3D-Cube in partial ACL tears was good and significantly better than conventional 2D-MRI. The likelihood of having a positive test was 9.9 times higher in a patient with a partial tear. A negative result did not exclude this diagnosis. Level of evidence Retrospective case series, Level IV. [ABSTRACT FROM AUTHOR]

Tears of the anterior cruciate ligament (ACL) are common knee injuries experienced by athletes and people with active lifestyles. It is important for members of the healthcare team to take an evidence-based approach to the diagnosis, surgical management, and postoperative rehabilitation of patients with an ACL-deficient knee. Mechanism of ACL injury and diagnostic testing is consistent throughout the literature. Patients frequently opt for ACL reconstruction, and many surgical techniques for ACL reconstruction are available with no clear consensus regarding superiority. Surgeon preference dictates the type of reconstruction and graft choice utilized. No standardized pre- and postoperative rehabilitation protocol exists. However, rehabilitation plays an important role in functional outcomes. A comprehensive rehabilitation program is needed pre- and postoperatively to produce positive patient outcomes. [ABSTRACT FROM AUTHOR]

Summary: Introduction and aim: Anterior cruciate ligament (ACL) tears are common injuries. Despite the diagnosis being in essence a clinical one, this has often proved unreliable. The objective of this study was to ascertain the delay to diagnosis of ACL injury from initial presentation and subsequent delay to review by a knee specialist. Methods: The study involved a retrospective review of 130 patient case notes in a consecutive series of patients undergoing primary ACL reconstruction. Details regarding mechanism of injury, dates of initial and subsequent clinic attendances and the treating health-care professional were recorded. Other information included dates of magnetic resonance imaging (MRI) scans and when a patient first saw a knee specialist. From this, delays to clinical or radiological diagnosis were calculated. Results: There were 82 acute and 48 chronic ACL injuries. Overall, the initial treating practitioner made the diagnosis in only 25 patients, yielding a diagnostic rate of 19.2%. Diagnoses made on MRI scan accounted for 38.5% of cases, the remainder being diagnosed clinically. The mean delay to diagnosis of ACL rupture was 65 days, and only 53 patients were diagnosed within 30 days of initial presentation. A total of 15 patients had undergone arthroscopy, eight of which were diagnostic. The mean delay to consulting a soft-tissue knee surgeon was 165 days. In the acute group, the initial diagnostic rate was only 7.3% and the mean delay to diagnosis was 82 days, with 29 patients diagnosed within 30 days. Conclusions: Despite 78% of the patients having a typical mechanism of ACL injury, and most attending acutely via the Emergency Department (ED), diagnosis of this common injury remains tardy. There has been at best only minor improvement in the diagnostic rate and delays, certainly of acute ACL injury, since a study in 1996. The overall clinical diagnostic rate remains disconcertingly low as does the delay to consulting a soft-tissue knee specialist. [ABSTRACT FROM AUTHOR]

Acute injuries to the lower extremity are among the most common affecting young athletes and are frequently evaluated in the emergency department. Accurate diagnosis is essential to guide appropriate management to improve outcome, shorten time to recovery and return to sport/activity, and prevent complications. This article will describe the evaluation and management of acute, sportsrelated, lower extremity injuries, including review of frequently injured anatomical structures, physical examination techniques, indications for imaging, initial treatment, and guidelines for follow-up and return to sport. [ABSTRACT FROM AUTHOR]

Background:A disadvantage of pivot-shift maneuvers is that the examiner has to subjectively evaluate the degree of pivot shift observed. It is unknown whether the various maneuvers are biomechanically identical.Purpose:To compare biomechanical features of 3 clinical maneuvers for the anterior cruciate ligament (ACL)–deficient knee: the pivot-shift test, the jerk test, and the N-test.Study Design:Controlled laboratory study.Methods:A total of 28 patients with an isolated ACL injury were examined by use of 3 pivot-shift maneuvers (pivot-shift test, jerk test, and N-test). An electromagnetic sensor system was used to evaluate the 3-dimensional knee kinematics of each patient’s injured and uninjured knees during each maneuver. Peak coupled anterior tibial translation (pCAT) and maximal acceleration of posterior translation (APT) were measured relative to results during a flexion-extension motion in each test.Results:The pCAT of the pivot-shift test was significantly greater than that of both the jerk test and the N-test (P = .0020 and P < .0001, respectively); there was no statistical difference in pCAT between the jerk test and the N-test. The APT of the N-test was significantly greater than that of both the pivot-shift test and the jerk test (P < .0001), while there was no statistical difference between the pivot-shift and the jerk tests. There was no correlation between pCAT and APT in each test.Conclusion:The pivot-shift test, jerk test, and N-test have different biomechanical characteristics to induce the pivot-shift phenomenon in the ACL-deficient knee. The pivot-shift test produced the largest side-to-side difference in pCAT, whereas the N-test provoked the largest side-to-side difference in APT.Clinical Relevance:The biomechanical differences in pivot-shift maneuvers are caused by technical differences, and clinicians should understand these biomechanical differences while practicing the maneuvers. The electromagnetic sensor system is clinically useful for quantifying the pivot-shift phenomenon. [ABSTRACT FROM AUTHOR]

The article discusses a study on National Basketball Association (NBA) Players and their performance and return-to-sports (RTS) after anterior cruciate ligament reconstruction (ACLR). It mentions that the study evaluated NBA players underwent ACLR between 1975 and 2012, high rate of return to play such as 86 percent in NBA and 98 percent in professional basketball, and linear regression analysis. The study concluded high rate of return in NBA with reduced performance level after ACLR.