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A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

Context: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. Methods: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in- person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. Results: There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval, 1.3 to 10.4; P = .01). Conclusion: A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups. [ABSTRACT FROM AUTHOR]

Background: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). Methods: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. Results: We included 142275 patients, of whom 36379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). Conclusion: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines. Contexte : Plusieurs interventions diagnostiques ou thérapeutiques d'usage courant pour l'arthrose du genou ne s'appuient sur aucune ligne directrice fondée sur des données probantes. L'objectif de cette étude était d'établir la proportion de patients qui ont subi une arthroscopie ou une épreuve d'imagerie par résonnance magnétique (IRM), et l'intervalle entre ces interventions et l'arthroplastie pour prothèse totale du genou (PTG). Méthodes : Nous avons procédé à une étude de cohorte rétrospective à partir de données administratives de population en Ontario, au Canada. Nous avons établi la proportion de patients soumis à une arthroscopie du genou dans les 10 années ou une IRM dans les 3 années précédant une PTG primaire. Nous avons aussi calculé le taux d'arthroscopies par diagnostic. Nous faisons état du moment de chacune par rapport à la PTG, des taux par région, et les différences de taux avec le temps. Résultats : Nous avons inclus 142 275 patients, dont 36 379 (25,57%) ont subi une arthroscopie du genou (intervalle médian 2,8 ans [intervalle interquartile (IIQ) 1,1-6,0]); 22% d'entre eux ont reçu leur PTG dans l'année suivante et 52% dans les 3 années suivantes. Les taux d'arthroscopies pour un diagnostic d'arthrose ont régulièrement diminué, tandis que les diagnostics liés à des problèmes de ménisque ont augmenté pendant la période de l'étude (p < 0,0001). On a noté une variation significative d'une région à l'autre. Dans cette cohorte, 23,2% des patients (n = 32 989) avaient subi une IRM avant leur PTG, avec des taux significativement croissants avec le temps (p < 0,0001). Conclusion : Dans une proportion substantielle, les patients souffrant d'arthrose du genou ont subi des interventions diagnostiques et thérapeutiques pré-PTG qui sont contraires aux lignes directrices de pratique clinique., Osteoarthritis (OA) of the knee is one of the most common chronic health conditions and is a leading contributor to health care service use. (1-3) The disease typically involves slow [...]

Background: New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)–injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. Purpose: To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL–deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. Results: Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR (P <.05). All reconstructions restored VR to the intact state except at 90° of knee flexion (P <.05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position (P <.05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT (P <.05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion (P <.05). Conclusion: In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. Clinical Relevance: In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs. [ABSTRACT FROM AUTHOR]

Background: Injuries to the deep medial collateral ligament (dMCL) and partial superficial MCL (psMCL) can cause anteromedial rotatory instability; however, the contribution of each these injuries in restraining anteromedial rotatory instability and the effect on the anterior cruciate ligament (ACL) load remain unknown. Purpose: To investigate the contributions of the different MCL structures in restraining tibiofemoral motion and to evaluate the load through the ACL after MCL injury, especially after combined dMCL/psMCL injury. Study Design: Controlled laboratory study. Methods: Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. Tibiofemoral kinematic parameters were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8-N·m valgus rotation, 4-N·m external tibial rotation (ER), 4-N·m internal tibial rotation, and a combined 89-N anterior tibial translation and 4-N·m ER for both anteromedial rotation (AMR) and anteromedial translation (AMT). The kinematic parameters of the 3 different MCL injuries (dMCL; dMCL/psMCL; dMCL/superficial MCL (sMCL)) were recorded and reapplied either in an ACL-deficient joint (load sharing) or before and after cutting the ACL (ACL load). The loads were calculated by applying the principle of superposition. Results: The dMCL had the largest effect on reducing the force/torque during ER, AMR, and AMT in extension and the psMCL injury at 30° to 90° of knee flexion (P <.05). In a comparison of the load through the ACL when the MCL was intact, the ACL load increased by 46% and 127% after dMCL injury and combined dMCL/psMCL injury, respectively, at 30° of knee flexion during ER. In valgus rotation, a significant increase in ACL load was seen only at 90° of knee flexion. Conclusion: The psMCL injury made the largest contribution to the reduction of net force/torque during AMR/AMT at 30° to 90° of flexion. Concomitant dMCL/psMCL injury increased the ACL load, mainly during ER. Clinical Relevance: If a surgical procedure is being considered to treat anteromedial rotatory instability, then the procedure should focus on restoring sMCL function, as injury to this structure causes a major loss of the knee joint's capacity to restrain AMR/AMT. [ABSTRACT FROM AUTHOR]

Background: Injuries to the medial collateral ligament (MCL), specifically the deep MCL (dMCL) and superficial MCL (sMCL), are both reported to be factors in anteromedial rotatory instability (AMRI); however, a partial sMCL (psMCL) injury is often present, the effect of which on AMRI is unknown. Purpose: To investigate the effect of a dMCL injury with or without a psMCL injury on knee joint laxity. Study Design: Controlled laboratory study. Methods: Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. The anterior cruciate ligament (ACL) was cut first and last in protocols 1 and 2, respectively. The dMCL was cut completely, followed by an intermediary psMCL injury state before the sMCL was completely sectioned. Tibiofemoral kinematics were measured at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 4 N·m of external tibial rotation, 4 N·m of internal tibial rotation, and combined 89 N of anterior tibial translation and 4 N·m of external tibial rotation for both anteromedial rotation (AMR) and anteromedial translation. The differences between subsequent states, as well as differences with respect to the intact state, were analyzed. Results: In an ACL-intact or -deficient joint, a combined dMCL and psMCL injury increased external tibial rotation and VR compared with the intact state at all angles. A significant increase in AMR was seen in the ACL-intact knee after this combined injury. Cutting the dMCL alone showed lower mean increases in AMR compared with the psMCL injury, which were significant only when the ACL was intact in knee flexion. Moreover, cutting the dMCL had no effect on VR. The ACL was the most important structure in controlling anteromedial translation, followed by the psMCL or dMCL depending on the knee flexion angle. Conclusion: A dMCL injury alone may produce a small increase in AMRI but not in VR. A combined dMCL and psMCL injury caused an increase in AMRI and VR. Clinical Relevance: In clinical practice, if an increase in AMRI at 30° and 90° of knee flexion is seen together with some increase in VR, a combined dMCL and psMCL injury should be suspected. [ABSTRACT FROM AUTHOR]