Meniscal tears associated with anterior cruciate ligament injury

Bone Bruises and Concomitant Meniscus and Cartilage Damage in Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-Analysis

(1) Background: Bone bruises in acute anterior cruciate ligament (ACL) injuries are closely linked to the occurrence of simultaneous meniscal and cartilage damage. Despite the frequent occurrence of associated injuries including bone bruises, meniscus, and cartilage damage in patients with ACL injuries, a systematic review of the relationships between the presence of bone bruises and the extent of meniscus and cartilage injuries has yet to be conducted. (2) Methods: Multiple comprehensive databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched for studies that evaluated the relationship between bone bruises and meniscus or cartilage injuries following ACL injuries. Study selection, data extraction, and meta-analysis were performed. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessments, and Review Manager 5.3 was used for data analysis. (3) Results: Data were extracted from 22 studies encompassing a total of 2891 patients with ACL injuries. Among the included studies, six studies investigated the relationships between bone bruises and medial meniscus (MM) or lateral meniscus (LM) injuries, while three studies investigated the relationships between bone bruises and cartilage injuries. There were no significant correlations between the presence of bone bruises and MM injuries (relative risk (RR) = 1.32; p = 0.61). A quantitative analysis indicated that individuals with bone bruises had a 2.71-fold higher likelihood of sustaining LM injuries than those without bone bruises (RR = 2.71; p = 0.0003). The analysis confirmed a significant relationship between bone bruises and cartilage injuries (RR = 6.18; p = 0.003). (4) Conclusions: Bone bruises occur most frequently in the lateral compartment. Bone bruises resulting from ACL injuries are related to accompanying LM injuries and cartilage injuries. Knowing these associations and the frequency of injuries may allow orthopedic surgeons to promptly address ACL-related meniscus and cartilage injuries on MRI results and in future clinical practice.

Impact of Surgical Timing on Functional Outcomes after Anterior Cruciate Ligament Reconstruction

Objectives: Although acute anterior cruciate ligament reconstruction (ACLR) is often avoided because of postoperative joint stiffness, delayed ACLR can lead to a longer recovery time and can have a negative impact on physical function due to detraining. This study aimed to determine the effects of acute ACLR on postoperative outcomes, including muscle strength, performance, and return to sports. Methods: A total of 110 patients who underwent anatomical ACLR using hamstring autografts were included in this study and were divided into three groups: acute (ACLR performed within 2 weeks after ACL injury), 2-6 weeks (ACLR performed between 2 and 6 weeks after injury), and 6-12 weeks (ACLR performed between 6 and 12 weeks after injury). Several parameters were evaluated, including range of motion, knee joint stability, isokinetic knee strength, performance, and return to sports. Results: No significant differences were found in the range of motion or knee joint stability between the groups. The acute group exhibited significantly greater quadriceps strength at 3 months postoperatively than the other groups (p < 0.05). The single-leg hop test showed that 66.7%, 38.7%, and 33.3% of the patients in the acute, 2-6 weeks, and 6-12 weeks groups, respectively, recovered to an LSI of 90% or greater (p = 0.09, Cramer's V = 0.27). All patients in the acute group were able to return to sports (p = 0.14; Cramer's V = 0.28). Conclusions: Acute ACLR is advantageous for the early recovery of strength and performance without adverse events. Acute ACLR may shorten the time spent away from sports activities.

Intra- and interobserver reliability of two classification systems for posterolateral tibial plateau fractures in the setting of an ACL rupture

Background

Posterolateral tibial plateau impaction fractures occur frequently associated with anterior cruciate ligament (ACL) tears. Some authors advocate operative treatment of high-grade impaction fractures, which has led to the development of classification systems. Our study aims (1) to describe and compare the intra- and interobserver reliability of the two most used classifications and (2) to assess correlations between the grade of bony posterolateral tibial injury, patient characteristics and short-to mid-term revision rate after ACL reconstruction.

Materials and methods

In a retrospective series of 163 patients who underwent ACL reconstruction, two reviewers independently evaluated the preoperative MRI scans. Conform the Menzdorf and Bernholt classification the presence and grade of an associated posterolateral impaction fracture were assessed. Statistical analyses were performed to test for both study hypotheses.

Results

171 primary ACL cases were evaluated. Mean follow-up time was 41 months (range 12-154, SD = 17.1). Mean age was 32 years (range 13-59, SD = 12). Posterolateral impaction fractures were present in 111 (64.9 %) and 120 (70.0 %) cases, according to the Menzdorf and Bernholt classification. A Segond fracture was present in 19 (11.1 %) cases. Kappa value was 0.47 for intra- and 0.52 for the interobserver reliability for the Menzdorf classification (moderate reliability). For the Bernholt classification kappa values were 0.66 and 0.61, respectively (good reliability). A Segond fracture correlated significantly with the presence of a posterolateral impaction fracture (p < 0.05). A significant association was present between patients necessitating ACL revision surgery and patients for whom operative intervention for the posterolateral impression was advised following the Menzdorf classification (p < 0.001).

Conclusion

Inter- and intraobserver reliability testing for classifying posterolateral tibial fractures resulted in moderate to good reliability. High-grade posterolateral tibial fractures should be identified, selective treatment should be considered as they are associated with higher revision rates after ACL reconstruction if left untreated.

Magnetic Resonance Imaging Indirect Signs for Anterior Instability of the Lateral Meniscus in Pediatric and Adolescent Patients

BACKGROUND

Anterior instability (AI) of the LM is potentially debilitating in young patients. The use of magnetic resonance imaging (MRI) to diagnose AI is limited due to the lack of reliable and accurate MRI findings. The ability to identify AI preoperatively would potentially improve the diagnosis and treatment of this pathology. This study presents a novel MRI finding ("phantom sign") for the detection of AI of the LM and demonstrates its reliability and accuracy.

METHODS

Three independent blinded reviewers performed retrospective review of preoperative MRI for all patients who underwent LM repair between July 1, 2019, and March 31, 2022, at a single center. Positive phantom sign was defined as abnormal signal intensity on MRI of the anterior horn of the LM on the coronal sequence at the anterior tibial insertion of the anterior cruciate ligament (ACL). Preoperative MRI was also evaluated for other signs of LM anterior instability. Intrarater and inter-rater reliability was assessed for rater scoring of presence of pathology on MRI. Predictive ability of each imaging finding with at least good (ICC 0.6 or above) reliability was also evaluated based on documented intraoperative findings.

RESULTS

Fifty-five preoperative MRIs of arthroscopically treated LM tears were reviewed. Median age was 15 years (range 6 to 20), and 21 patients (38.2%) were female. Twenty-seven patients (49.1%) had a discoid meniscus. LM AI was present on arthroscopy for 25 knees (45.45%), and among these, 21 had discoid morphology. Interrater reliability was substantial for phantom sign (ICC 0.71, 97.5% CI: 0.55-0.82), posterior displacement (ICC 0.71, 97.5% CI: 0.55-0.82), and posterior "megahorn" (ICC 0.76, 97.5% CI: 0.62-0.85). On predictive analysis, phantom signs were 98% sensitive and 76.7% specific for LM AI. Posterior displacement and posterior megahorn were specific for AI (both 93.34%), though with limited sensitivity (32% and 28.6%, respectively).

CONCLUSIONS

Phantom sign is a reliable and sensitive MRI finding for anterior instability, even in the absence of frank displacement on preoperative MRI. A positive finding should prompt a thorough arthroscopic evaluation of the anterior horn of the LM.

LEVEL OF EVIDENCE

Level III-case control study.

Effect of knee bracing on clinical outcomes following anterior cruciate ligament reconstruction: A prospective randomised controlled study

Objectives

While there is a consensus against bracing after anterior cruciate ligament (ACL) reconstruction, the question of its potential benefits, especially in cases involving meniscus repair, as well as its routine use by the majority of clinicians, remains a topic of debate. This study aims to assess the effectiveness of bracing in relation to clinical scores after ACL reconstruction, regardless of meniscus surgery.

Methods

This randomised controlled study involved patients aged 15-55 years who underwent arthroscopic ACL reconstruction surgery. All eligible patients were assigned into two groups: one group received an adjustable frame with a four-point fixation knee brace for a four-week period, while the other did not.A single experienced surgeon performed standard anatomical single-bundle ACL reconstruction. All patients, irrespective of whether they underwent meniscus repair, followed the same rehabilitation protocol. Knee functional questionnaires, including the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, Visual Analogue Scale (VAS), and examinations, were collected preoperatively, at six months, one year, and two years postoperatively. The study employed an intention-to-treat analysis and multilevel mixed-effects generalised linear models to compare continuous outcomes between the groups, adjusting for the times of follow-up.

Results

A total of 84 patients (42 patients per group) comprised of 75 males (89 %) and average age of 30 ± 9.4 years old. Patient-reported function, physical examination findings, and surgical characteristics were comparable between the two groups. (P-value >0.05) Both groups demonstrated significant improvement in IKDC and Lysholm scores at the end of the two-year follow-up period. (P-value <0.0001) In multivariate analysis, bracing was significantly associated with lower Tegner activity scale than the non-brace group after adjustment for VAS and time (coefficient -0.49, 95 % confidence interval -0.87, -0.10, P-value = 0.013). None of the graft ruptures were reported, and there was no significant difference of return to sports between the groups at the end of the follow-up.

Conclusion

The study suggests that knee bracing after ACL reconstruction, regardless of any additional meniscus procedures, fails to enhance subjective or objective outcomes and could potentially have a negative impact on the Tegner activity scale, although the difference is not clinically significant. The routine use of a postoperative brace should be discontinued.

Level of evidence

Level I, Randomised controlled trial with no negative criteria.

Association Between MRI Signal Intensity of the Repaired Lateral Meniscus and Residual Anterolateral Knee Laxity After ACL Reconstruction

Background

Anterolateral knee laxity (ALLx) has been linked to tears of the lateral meniscus (LM) and anterior cruciate ligament (ACL) injury.

Purpose

To investigate the longitudinal relationship between the signal intensity (SI) of the repaired LM on magnetic resonance imaging (MRI) and residual ALLx after ACL reconstruction (ACLR).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 87 patients who underwent double-bundle ACLR and lateral meniscal repair (mean age, 23.5 years; body mass index, 23.7 kg/m2; 56 women) at a single institution between 2010 and 2019. Proton density-weighted (PDW) and T2-weighted (T2W) MRI was performed at 3, 6, and 12 months postoperatively, and the SI ratio (SIR) was calculated as (SI of the repaired LM)/(SI of the posterior cruciate ligament). At the 12-month follow-up, ALLx was evaluated using the pivot-shift test; an International Knee Documentation Committee grade ≥1 indicated residual ALLx.

Results

Overall, 12 patients (13.8%) exhibited ALLx at 12 months postoperatively. At 3 months postoperatively, the SIR on PDW images (SIR-PDW) was significantly higher in patients with ALLx versus those without ALLx (1.98 ± 0.77 vs 1.49 ± 0.52, respectively; P = .007); there was no difference in the SIR on T2W images between the groups. SIR-PDW at 3 months postoperatively was correlated negatively with patient age (r = -0.308, P = .004). When patients were stratified into a younger (≤22 years; n = 53; ALLx = 7 [13.2%]) and an older (>22 years; n = 34; ALLx = 5 [14.7%]) group, the area under the receiver operating characteristic curves (AUCs) for SIR-PDW in the younger group were statistically significant for predicting the prevalence of ALLx at all follow-up times (AUCs, 0.733-0.788) with optimal cutoff values of 2.00 at 3 months, 1.50 at 6 months, and 1.50 at 12 months. Logistic regression analysis revealed that if younger patients consistently had higher SIR-PDW values than the cutoff values, they were more likely to have residual ALLx (odds ratios, 10.24-23.57).

Conclusion

For younger patients who underwent both ACLR and lateral meniscal repair, higher MRI SI of the repaired LM was associated with a higher prevalence of residual ALLx.

Epidemiology and distribution of cruciate ligament injuries in children and adolescents, with an analysis of risk factors for concomitant meniscal tear

Introduction

To investigate the epidemiological features and prevalence of cruciate ligament injuries (CLI) in children and adolescents, and to examine the potential risk factors associated with concomitant meniscal tear (MT) among this population.

Methods

The demographic data and injury details of children and adolescents with CLI from Southeast China were analyzed to describe their distribution characteristics, alongside an analysis of the prevalence of MTs, the most frequent complication. In addition, binary logistic analysis was employed to ascertain the risk factors linked to MT in individuals suffering from CLI.

Results

A total of 203 patients with CLI (n = 206) met the inclusion criteria, with a male-to-female ratio of 2.3:1. Notably, a higher proportion of females were aged ≤16 years old compared to males, who predominated in patients aged >16 years (P = 0.001). Among children and adolescents, anterior cruciate ligament (ACL) injuries were the primary type of CLI, accounting for 88.18% (179/203) of all cases. The majority of cases (132/203, 65.02%) were sustained during sports activities, and sprains were the predominant mechanism of injury (176/203, 86.7%). Additionally, the most common associated injury was an MT (157/203, 77.34%). The posterior horn is the most frequently affected site for both medial MT (62.93% out of 73 cases) and lateral MT (70.19% out of 73 cases). Moreover, vertical tears constituted the majority of medial MTs (59.48% out of 116 cases). Furthermore, patients with a higher BMI faced an increased risk of associated MT in comparison to non-overweight patients (88% vs. 73.86%; P = 0.038). Each increase in BMI unit was linked with a 14% higher probability of associated MT occurrence in children and adolescents with CLI (OR = 1.140; P = 0.036).

Discussion

ACL injuries are a common form of knee ligament injury among children and adolescents, especially those over the age of 16, and are often the result of a sprain. Meniscal posterior horn injury is the most commonly associated injury of youth with CLI. Additionally, overweight or obese people with CLI are at a greater risk of developing MT.

Meniscal Repair Outcome in 3829 Patients With a Minimum Follow-up From 2 Years Up to 5 Years: A Meta-analysis on the Overall Failure Rate and Factors Influencing Failure

BACKGROUND

The importance of meniscal repair is widely accepted because of the association of loss of meniscal tissue with the development of early-onset knee arthritis. Many factors influencing the results of meniscal repair have been reported, but results remain controversial.

PURPOSE

This meta-analysis determines the pooled meniscal repair failure rate of studies with a minimum follow-up of 2 years up to 5 years, with a mean follow-up of 43 months. Moreover, selected failure-influencing factors are analyzed.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

PubMed and Scopus were searched for studies published between January 2000 and November 2021 reporting on meniscal repair outcome with a minimum follow-up of 24 months. The overall pooled failure rate and pooled failure rates for possible predictors were calculated. Random-effect models were used to pool failure rates, and effect estimates in the form of odds ratios with 95% CIs were established.

RESULTS

The initial literature search identified 6519 studies. A total of 51 studies met the inclusion criteria. In total, 3931 menisci were included with an overall failure rate of 14.8%. Subgroup analysis revealed a significantly lower failure rate for meniscal repair with concomitant anterior cruciate ligament (ACL) reconstruction compared with knees without any reported injury to the ACL (8.5% vs 14%; P = .043). The pooled failure rate for lateral meniscal repair was significantly lower than that for medial meniscal repair (6.1% vs 10.8%; P = .031). Pooled failure rates of all-inside and inside-out repair were not significantly different (11.9% vs 10.6%; P > .05).

CONCLUSION

This meta-analysis on close to 4000 patients demonstrates an overall meniscal repair failure rate of 14.8% at a minimum follow-up from 2 years up to 5 years. Meniscal repair remains a procedure with a high failure rate, especially within the first 2 postoperative years. This review and meta-analysis also identified clinically relevant factors associated with favorable outcomes such as concomitant ACL reconstruction or repair of the lateral meniscus. All-inside meniscal repair with the latest-generation devices yields failure rates of <10%. The failure mechanism and the time of failure is poorly documented; further studies are needed for a better understanding of the retear mechanism.

Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury

PURPOSE

To compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) with immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

METHODS

Current Procedural Terminology code 29888 was queried from January 2012 to April 2020. Patients younger than 22 years who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age older than 22 years, treatment after 6 months, revision ACLR, concurrent osteotomy, or multiligamentous injury. All patients required a minimum 1-year follow-up. Demographics and intraoperative pathology were recorded. Data were analyzed for factors affecting intra-articular injury and stratified by sport.

RESULTS

Of 927 patients (739 SM, 188 SI), the mean age was 16.63 and 14.00 years for the SM and SI cohorts, respectively (P < .001). There were more SM males (51.4%) compared to SI males (81.9%) (P < .001); however, in univariate analysis, sex did not significantly affect the rates of meniscal (P = .519) or chondral injury (P = .961). In total, 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (P < .001) and underwent higher rates of partial meniscectomy (P = .022). Male sex conferred meniscal injury (95% confidence interval [CI], 0.43-0.81; P = .001). Body mass index prognosticated medial meniscal (95% CI, 1.01-1.06; P = .002) and medial chondral injuries (95% CI, 1.02-1.09; P < .001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95% CI, 0.00-0.06; P = .002), lateral meniscal tear (95% CI, 0.00-0.75; P = .034), and chondral injury (95% CI, 0.00-0.49; P = .049). In sport subanalysis, soccer anterior cruciate ligament (ACL) injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (P = .016, P = .003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes (P = .001) via contact mechanisms (P = .025).

CONCLUSIONS

Skeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status affect risk of sports-related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Effect of Lateral Extra-articular Tenodesis in an ACL-Reconstructed Knee With Partial Medial Meniscectomy: A Biomechanical Study

BACKGROUND

Knee laxity increases with medial meniscectomy in anterior cruciate ligament (ACL)-reconstructed knees; however, the biomechanical effect of an additional lateral extra-articular tenodesis (LET) is unknown.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine the kinematic effect of a LET in knees that underwent combined ACL reconstruction (ACL-R) and partial medial meniscus posterior horn (MMPH) meniscectomy. It was hypothesized that the addition of LET would reduce laxity in the ACL-reconstructed knee.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen human cadaveric knees (mean age, 41.5 years) were tested using a robotic system under 3 loads: (1) 89.0 N of anterior tibial (AT) load, (2) 5 N·m of internal rotation (IR) tibial torque, and (3) a simulated pivot shift-a combined valgus of 7 N·m and IR torque of 5 N·m-at 0°, 15°, 30°, 45°, 60°, and 90° of knee flexion. Kinematic data were acquired in 4 states: (1) intact, (2) ACL-R, (3) ACL-R + partial MMPH meniscectomy (MMPH), and (4) ACL-R + partial MMPH meniscectomy + LET (MMPH+LET).

RESULTS

In response to AT loading, there was a significant increase seen in AT translation (ATT) in the MMPH state at all knee flexion angles compared with the ACL-R state, with the highest increase at 90° of knee flexion (mean difference, 3.1 mm) (P < .001). Although there was a significant decrease in ATT at 15° of knee flexion with MMPH+LET (P = .022), no significant differences were found at other knee flexion angles (P > .05). In MMPH with IR torque, a significant increase was observed in IR at all knee flexion angles except 90° compared with the ACL-R state (range, 2.8°-4.9°), and this increase was significantly decreased at all flexion angles with the addition of LET (range, 0.7°-1.6°) (P < .05).

CONCLUSION

Performing a partial MMPH meniscectomy increased ATT and IR in response to AT and IR loads compared with the isolated ACL-R state in a cadaveric model. However, when the LET procedure was performed after partial MMPH meniscectomy, a significant decrease was seen at all knee flexion angles except 90° in response to IR and torque, and a significant decrease was seen at 15° of knee flexion in response to AT load.

CLINICAL RELEVANCE

LET may be a useful adjunct procedure after ACL-R with partial MMPH meniscectomy to reduce knee laxity.

Meniscal and Chondral Injury Patterns in Athletes With Anterior Cruciate Ligament Tear

Anterior cruciate ligament (ACL) tears are a prevalent and debilitating injury among athletes, often accompanied by concurrent meniscal and chondral injuries. This study aimed to present a comprehensive investigation into the patterns and prevalence of meniscal and chondral injuries in athletes with ACL tears. This is a cross-sectional study conducted on 600 athletic patients with ACL tears planned for reconstruction in a duration of five years. A combination of advanced imaging techniques, arthroscopic evaluations, and clinical data was used to provide a comprehensive understanding of the injury profiles of the participant athletes. Those findings were duly recorded and analyzed accordingly. Out of 600 patients, 67% (402) had at least one meniscal or chondral injury while the rest 33% (198) had isolated ACL injuries only. Of the patients, 18% (108) were those who had both meniscal and chondral injuries present. Amongst the 57% (342) of patients who had meniscal injuries, injuries to the medial meniscus, lateral meniscus, and both the meniscus were present in 51% (175), 32% (109), and 17% (58) of patients, respectively. Amongst all associated meniscal injuries (n1 = 404), around 52% (210) tears were present in the body of the meniscus, 31% (125) in the posterior horn, and 17% (69) in the anterior horn. Overall, it was noted that 22.77% (92) of meniscal tears were bucket handle tears of the medial meniscus, 16.08% (65) were complex tears of the posterior horn of the lateral meniscus, and 9.60% (39) were complex tears of the posterior horn of the medial meniscus. Amongst 600 patients, 28% (168) of patients had at least one chondral injury present in association with ACL tear. Further, amongst the total number of chondral lesions reported (n2 =297) in ACL-deficient knees, around 55% (163) of lesions were located on medial femoral condyle, 10% (30) were located on undersurface of patella, 10% (30) were global changes, 7% (20) were on lateral femoral condyle, and 5% (15) were located on medial articulating surface of knee. A total of 61% (181) of chondral lesions were grade II, 21% (62) were grade III, 10%(30) were grade IV, and the least noted were 8% (24) grade I chondral lesions. The study concludes that medial meniscus injury was the most common meniscal injury in ACL-deficient knees and the bucket handle tear of the medial meniscus was the most common type of meniscal tear followed by the complex tear of the posterior horn of the medial meniscus. Further, the study also concludes that the medial femoral condyle is the most common site of chondral lesions in ACL-deficient knees.

Concomitant Lateral Meniscus Tear is Associated with Residual Rotatory Knee Instability 1 Year after Anterior Cruciate Ligament Reconstruction: Case-cohort Study

Lateral meniscus tear (LMT) accompanied by anterior cruciate ligament (ACL) injuries has been reported to provoke rotatory instability of the affected knee joint. Unfortunately, these previous papers did not determine whether LMT-derived rotatory knee instability is residual because only preoperative or time zero data exists. This study aimed to longitudinally investigate how the prevalence of comorbid LMT is associated with residual rotatory knee instability (RKI) 1 year after ACL reconstruction (ACLR). A total of 327 patients who underwent double-bundle ACLR (average age: 23.4 years, body mass index: 23.5 kg/m2, 215 females). The patients were divided into three groups based on arthroscopy: 1) intact lateral meniscus (LM); 2) unrepaired LMT; 3) repaired LMT. At the 1-year follow-up, the pivot-shift test was performed. The prevalence of RKI, determined according to IKDC grades (grade ≥1 denoted RKI), was compared with chi-square or Fisher's exact tests. Thirty-eight patients (11.6%) had RKI; 203 subjects (62.1%) showed LMT, and 124 patients were diagnosed with an intact LM. Out of the 203 patients, 79 (38.9%) underwent LM repair. RKI was more prevalent in the LMT group than in the intact group (13.8% versus 8.1%, p = 0.117; Odds ratio: 1.499 [95%CI: 0.864 - 2.600]). In addition, the prevalence of RKI was significantly higher in the LM-repair group than in the intact-LM group (17.7% versus 8.1%, p = 0.038; Odds Ratio: 2.455 [95%CI: 1.032 - 5.842]). Medial meniscus tear (MMT) was detected in 113 patients (34.6%); RKI prevalence was not statistically different between the intact-MM group and the MMT group (12.2% versus 10.6%, p = 0.681). The current cohort study clarified that LMT comorbid with ACL injury was longitudinally associated with increased RKI prevalence 1 year after ACLR. Therefore, patients who underwent both ACLR and LM repair demonstrated a significantly higher prevalence of residual RKI.

The Principles of Knee Joint Preservation: Operative Treatment Strategies

➤ Joint alignment, meniscal status, and ligament stability are codependent factors involved in knee joint preservation, and any injury or imbalance can impact the knee articular cartilage status and can result in adverse clinical outcomes.➤ Cartilage preservation procedures in the knee will not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligamentous instability.➤ Lower-extremity varus or valgus malalignment is a risk factor for the failure of an anterior cruciate ligament (ACL) reconstruction. It represents an indication for a high tibial osteotomy or distal femoral osteotomy in the setting of failed ACL reconstruction, and may even be considered in patients who have an initial ACL injury and severe malalignment.➤ An elevated posterior tibial slope increases the risk of failure of ACL reconstruction, whereas a decreased posterior tibial slope increases the risk of failure of posterior cruciate ligament reconstruction.

Navigating ACL Injuries Amid the COVID-19 Pandemic: A Retrospective Analysis

Introduction In the United Kingdom, musculoskeletal injuries represent a substantial proportion of primary care appointments, and within this category, acute knee injuries are prominent in accident and emergency department cases. Notably, diagnosing anterior cruciate ligament (ACL) injuries is a recognized challenge, often leading to extended diagnostic delays. The COVID-19 pandemic has significantly affected the management of musculoskeletal disorders, driven by reduced surgical capacities, creating a backlog of patients awaiting necessary surgical interventions. Delayed ACL reconstruction poses risks of prolonged knee instability and secondary injuries. To address these concerns, this study evaluates the impact of COVID-19 on the timeline from ACL injury diagnosis to MRI and surgical intervention, with a specific focus on an internal acute knee clinic pathway designed to expedite the evaluation, diagnosis, and management of soft tissue knee injuries. Methods In this cross-sectional study, we retrospectively reviewed all the patients who underwent primary ACL reconstruction from January 2019 to November 2022 in a district general teaching hospital (DGH). Besides demographic data of the patients, we recorded the dates of injury, primary presentation, first knee specialist review, knee MRI, and ACL reconstruction surgery, as well as the injury-to-surgery, injury-to-MRI, and MRI-to-surgery periods. Patients were divided based on the date of operation to pre- and post-COVID, and outcomes were compared to see the possible effects of COVID-19. Data were analyzed using a quantitative and qualitative test with a P < 0.05 significance level. Results Our cohort included 97 patients, and the mean age of patients was 30.6 years (17-53 years). The median time of injury-to-MRI was 46.5 days during the pre-COVID period, which decreased to 44 days in the post-COVID period (P = 0.596). The median time of injury-to-surgery was 287.5 days during the pre-COVID period, which increased to 289 days in the post-COVID period (P = 0.019). The median MRI-to-surgery duration was 200 days during the pre-COVID period, which increased to 225 days in the post-COVID period (P = 0.006). Around 35% of patients had an MRI prior to getting evaluated by a specialist. Conclusion The COVID-19 pandemic had a significant impact on the management of ACL injuries, with delays in elective knee clinics and surgery potentially leading to delays in the diagnosis and management of such injuries. However, our study showed that the delay from ACL injury to subsequent surgery actually reduced post-pandemic due to hospital-based acute knee pathway, which is particularly important in the context of associated meniscal injury that can worsen while patients wait for surgery.

Meniscal repair failure following concurrent primary anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry

PURPOSE

This study aimed to identify the risk factors for meniscal repair failure following concurrent primary anterior cruciate ligament (ACL) reconstruction.

METHODS

Prospective data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation were reviewed. Meniscal repairs performed during concurrent primary ACL reconstruction were included. Repair failure was defined as a subsequent reoperation involving meniscectomy of the repaired meniscus. Multivariate survival analysis was performed to identify the risk factors for failure.

RESULTS

A total of 3,024 meniscal repairs were analysed with an overall failure rate of 6.6% (n = 201) at a mean follow-up of 2.9 years (SD 1.5). The risk of medial meniscal repair failure was higher with hamstring tendon autografts (adjusted HR [aHR] = 2.20, 95% CI 1.36-3.56, p = 0.001), patients aged 21-30 years (aHR = 1.60, 95% CI 1.30-2.48, p = 0.037) and in patients with cartilage injury in the medial compartment (aHR = 1.75, 95% CI 1.23-2.48, p = 0.002). The risk of lateral meniscal repair failure was higher in patients aged ≤ 20 years (aHR = 2.79, 95% CI 1.17-6.67, p = 0.021), when the procedure was performed by a low case volume surgeon (aHR = 1.84, 95% CI 1.08-3.13, p = 0.026) and when a transtibial technique was used to drill the femoral graft tunnel (aHR = 2.30, 95% CI 1.03-5.15, p = 0.042).

CONCLUSION

The use of a hamstring tendon autograft, younger age and the presence of medial compartment cartilage injury are risk factors for medial meniscal repair failure, whereas younger age, low surgeon volume and a transtibial drilling technique are risk factors for lateral meniscal repair failure.

LEVEL OF EVIDENCE

Level II.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear

PURPOSE

The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender.

METHODS

Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%).

RESULTS

Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001).

CONCLUSION

Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury.

LEVEL OF EVIDENCE

Level III.

Functional Outcomes Following Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction Using the Sironix Titanium Button and the Polyetheretherketone (PEEK) Button: A Retrospective Observational Study

Background Anterior cruciate ligament (ACL) injury is most common among athletes compared to the general population. ACL reconstruction is a clinical standard for restoring joint mechanical stability and enabling sports return. The purpose of the study is to evaluate the safety and functional outcomes after arthroscopic ACL reconstruction using the Sironix titanium button and the polyetheretherketone (PEEK) button. Methods A total of 31 subjects who have undergone arthroscopic ACL reconstruction using the Sironix titanium button and PEEK button between August 2022 and January 2023 were included in the study. Demographic data, surgery details, and other baseline characteristics of the subjects were collected from the hospital records. The primary objective of the study was to assess the functional outcome using the International Knee Documentation Committee (IKDC) questionnaire. The secondary objectives were to determine the pre- and post-surgery activity levels using the Tegner Activity Score (TAS) and Lysholm score. Quality of life evaluation was done by using the Quality of Life (QoL) subscale from the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Single Assessment Numerical Evaluation (SANE). Device-related adverse effect information was recorded. Results The mean (SD) of the total IKDC score of 31 subjects at baseline and post-surgery was 51.4 (2.84) and 91.8 (2.59) out of 100, respectively. The mean (SD) of TAS pre-injury and post-surgery was 5.3 (1.47) and 5.4 (1.38) out of 10, respectively. The total mean (SD) value of the total Lysholm Score at baseline and post-surgery was 53.9 (3.72) and 91.4 (3.61) out of 100, respectively. The mean (SD) value of the quality of life subscale of the KOOS score was 91.2 (3.91) out of 100. The total mean (SD) value of the SANE score that had affected joint/region of interest today was 97.4 (1.78), while for the opposite side today, it was 99.5 (0.85) out of 100. There were no adverse device effects reported in this study. Conclusion Based on the score assessment, it was observed that the performance of Sironix knee implant devices, Proloop-Titanium adjustable loop button, T-Button A® Closed PEEK button, and Surestitch® All Inside Meniscal Repair Implant (Healthium Medtech Limited, Bengaluru, Karnataka, India) was effective and safe with no adverse effects. Therefore, Sironix knee implants are considered safe and effective in ACL reconstruction and meniscus repair surgery.

Previous Isolated Medial Bucket-Handle Meniscus Repair Significantly Increases Risk of Subsequent Ipsilateral Anterior Cruciate Ligament Reconstruction

Purpose

(1) To define the incidence of surgically treated isolated bucket-handle meniscus tears (BHMTs); (2) to investigate risk of subsequent ipsilateral anterior cruciate ligament reconstruction (ACLR) in patients who underwent previous isolated bucket handle (BH) meniscus repair; and (3) to investigate the risk of subsequent ACLR for various types of surgically treated meniscal tears.

Methods

A retrospective review of a national database was conducted to identify patients, aged 10 to 40 years, who underwent primary isolated BH meniscus surgery from 2015 to 2020. Patients were stratified by operative method. A control group of 500,000 age-matched patients was randomly selected to establish a benchmark rate of ACLR. Kaplan-Meier analysis was performed to compare the timing and incidence of subsequent ipsilateral ACLR after primary isolated BH meniscus surgery to the control group within 2 and 5 years.

Results

In total, 1,767 patients with isolated BHMTs treated with surgery were identified and met inclusion criteria. The incidence of isolated BHMTs among all surgically treated (repair or meniscectomy) meniscal injuries was 1.67%. Isolated BH repairs had significantly greater odds of ACLR within 5 years compared to the control group (odds ratio [OR] 6.09; 95% confidence interval [CI] 2.86-12.99; P < .001). Medial BH repairs had the greatest odds of ACLR within 5 years (OR 9.15; 95% CI 4.27-19.57; P < .001). Lateral BH repair was not associated with subsequent ipsilateral ACLR within 5 years (OR 2.63; CI 0.37-18.90; P = .340).

Conclusions

Isolated BHMTs comprised 1.67% of all surgically treated meniscal injuries. Patients who underwent prior surgery for isolated BHMT were at increased risk of undergoing subsequent ipsilateral ACLR compared with the general population. Isolated medial BHMTs treated with repair had the highest risk for subsequent ACLR.

Level of Evidence

Level III, retrospective cohort study.

Incidence and type of meniscal tears in multilligament injured knees

PURPOSE

Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery.

METHODS

Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury.

RESULTS

A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries p = 0.025; lateral-sided injuries p = 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (p < 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (p < 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (p < 0.001).

CONCLUSIONS

Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.

Effect of Increased Time to Surgery on the Ability of MRI to Rule Out Medial Meniscal Tears in Young Athletes With ACL Injury

Background

The prevalence of meniscal tears in patients with anterior cruciate ligament (ACL) injury increases with extended time between injury and ACL reconstruction.

Purpose/Hypothesis

The purpose of this study was to determine if there is a relationship between time from magnetic resonance imaging (MRI) to ACL reconstruction and the predictive value of MRI to diagnose meniscal tears in the young active population. It was hypothesized that increased time between MRI and ACL reconstruction would lead to a decrease in the negative predictive value of MRI in diagnosing meniscal tears, as more injuries may accrue over time in the ACL-deficient knee.

Study Design

Case series; Level of evidence, 4.

Methods

Included were patients aged 13 to 25 years at the authors' institution who underwent primary ACL reconstruction from January 2017 to June 2020. Time from MRI to surgery as well as descriptions of medial and lateral meniscal tears on both MRI and operative reports were documented. Time from MRI to surgery was divided into 4 intervals: 0 to 6 weeks, >6 weeks to 3 months, >3 to 6 months, and beyond 6 months. Multivariable analysis was used to determine the positive and negative predictive values of MRI in diagnosing a meniscal tear as compared with arthroscopic findings.

Results

A total of 432 patients were included with a mean age of 17.9 ± 3.4 years. The mean time from MRI to surgery was 70.5 ± 98 days. There was a significant decrease in the negative predictive value of MRI to identify a medial meniscal tear in patients who underwent ACL reconstruction >6 months after imaging (odds ratio, 0.16 [95% CI, 0.05-0.53]; P = .003). This same relationship was not shown for lateral meniscal tears, nor was any other predictor significant.

Conclusion

The utility of MRI to rule out a medial meniscal tear significantly diminished in the young athletic population when >6 months passed between MRI and ACL reconstruction. These data suggest these tears occur between the time of the MRI and surgery and that the medial meniscus is more susceptible than the lateral meniscus to new injury once the ACL has torn.

Deficits in Dynamic Balance and Hop Performance Following ACL Reconstruction Are Not Dependent on Meniscal Injury History

Background

Athletes often exhibit persistent deficits in dynamic balance and hop performance in their involved limb following ACL reconstruction. However, it is unclear how meniscal injury history affects inter-limb asymmetry.

Purpose

The purpose of this study was to compare inter-limb asymmetry in dynamic balance and hop performance in athletes with and without a history of concomitant meniscal injury.

Study Design

Cross-sectional study.

Methods

Dynamic balance and hop test data were analyzed for 34 adolescent athletes who had undergone ACL reconstruction; 19 athletes had sustained an isolated ACL tear, while 15 had sustained an ACL tear along with a meniscus injury. Athletes who had sustained a meniscus injury were sub-divided into those who underwent a meniscal repair (n = 9) versus a partial meniscectomy (n = 6). Dynamic balance was assessed using the Y-Balance Test, while hop performance was assessed using the single and triple hop tests. Data were recorded at the time of return-to-sport testing (5-11 months post-surgery). For each variable, mixed-model analysis of variance, with a between-subjects factor of group (isolated ACL tear, meniscal repair, partial meniscectomy) and a within-subjects factor of limb (involved, uninvolved), was conducted.

Results

The groups exhibited similar degrees of inter-limb asymmetry in dynamic balance and hop test performance, as there was not a group-by-limb interaction effect for the Y-Balance Test distances (p ≥ 0.43) or hop test distances (p ≥ 0.96). However, there was a main effect of limb for the anterior and posteromedial Y-Balance Test distances and the single and triple hop test distances (p ≤ 0.004). For each variable, performance was worse for the involved limb, compared to the uninvolved limb.

Conclusion

It appears that deficits in dynamic balance and hop performance among adolescent athletes who have undergone ACL reconstruction are not dependent on meniscal injury/surgery history.

Level of Evidence

3.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

Functional Resistance Training After Anterior Cruciate Ligament Reconstruction Improves Knee Angle and Moment Symmetry During Gait: A Randomized Controlled Clinical Trial

PURPOSE

The purpose of this study was to determine 1) whether progressive functional resistance training (FRT) during walking would improve knee biomechanical symmetry after anterior cruciate ligament (ACL) reconstruction and 2) whether the mode of delivery of FRT would have a differential effect on symmetry.

METHODS

Thirty individuals who underwent primary ACL reconstruction at a single institution volunteered for this study. Participants were randomized into one of three groups: 1) BRACE, 2) BAND, or 3) CONTROL. The BRACE group received FRT with a novel robotic knee brace along with real-time kinematic feedback. The BAND group received FRT with a custom resistance band device along with real-time kinematic feedback. The CONTROL group received only real-time kinematic feedback. Participants in all groups received training (2-3/week for 8 weeks) while walking on a treadmill. Knee angle and moment symmetry were calculated immediately prior to beginning the intervention and within 1 week of completing the intervention. Statistical Parametric Mapping was used to assess differences in biomechanical symmetry between groups across time.

RESULTS

There was a significant interaction in knee moment symmetry from 21 and 24% of the stance phase (P = .046), in which the BAND group had greater improvements following training compared with both BRACE (P = .043) and CONTROL groups (P = .002). There was also a significant time effect in knee angle symmetry from 68 to 79% of the stance phase (P = .028) and from 97 to 100% of the swing phase (P = .050) in which only the BRACE group showed significant improvements after the intervention (stance: P = .020 and swing: P < .001).

CONCLUSION

The results of this randomized controlled clinical trial indicate that 8 weeks of progressive FRT during treadmill walking in individuals with ACL reconstruction improves knee angle and moment symmetry during gait. The findings suggest that FRT could serve as a potential therapeutic adjuvant to traditional rehabilitation after ACL reconstruction and can help restore knee joint biomechanical symmetry.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Strain-Dependent Diffusivity of Small and Large Molecules in Meniscus

Due to lack of full vascularization, the meniscus relies on diffusion through the extracellular matrix to deliver small (e.g., nutrients) and large (e.g., proteins) to resident cells. Under normal physiological conditions, the meniscus undergoes up to 20% compressive strains. While previous studies characterized solute diffusivity in the uncompressed meniscus, to date, little is known about the diffusive transport under physiological strain levels. This information is crucial to fully understand the pathophysiology of the meniscus. The objective of this study was to investigate strain-dependent diffusive properties of the meniscus fibrocartilage. Tissue samples were harvested from the central portion of porcine medial menisci and tested via fluorescence recovery after photobleaching to measure diffusivity of fluorescein (332 Da) and 40 K Da dextran (D40K) under 0%, 10%, and 20% compressive strain. Specifically, average diffusion coefficient and anisotropic ratio, defined as the ratio of the diffusion coefficient in the direction of the tissue collagen fibers to that orthogonal, were determined. For all the experimental conditions investigated, fluorescein diffusivity was statistically faster than that of D40K. Also, for both molecules, diffusion coefficients significantly decreased, up to ∼45%, as the strain increased. In contrast, the anisotropic ratios of both molecules were similar and not affected by the strain applied to the tissue. This suggests that compressive strains used in this study did not alter the diffusive pathways in the meniscus. Our findings provide new knowledge on the transport properties of the meniscus fibrocartilage that can be leveraged to further understand tissue pathophysiology and approaches to tissue restoration.

Acute and subacute anterior cruciate ligament reconstructions are associated with a higher risk of revision and reoperation

PURPOSE

(1) Report concomitant cartilage and meniscal injury at the time of anterior cruciate ligament reconstruction (ACLR), (2) evaluate the risk of aseptic revision ACLR during follow-up, and (3) evaluate the risk of aseptic ipsilateral reoperation during follow-up.

METHODS

Using a United States integrated healthcare system's ACLR registry, patients who underwent primary isolated ACLR were identified (2010-2018). Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision, with a secondary outcome evaluating ipsilateral aseptic reoperation. Outcomes were evaluated by time from injury to ACLR: acute (< 3 weeks), subacute (3 weeks-3 months), delayed (3-9 months), and chronic (≥ 9 months).

RESULTS

The final sample included 270 acute (< 3 weeks), 5971 subacute (3 weeks-3 months), 5959 delayed (3-9 months), and 3595 chronic (≥ 9 months) ACLR. Medial meniscus [55.4% (1990/3595 chronic) vs 38.9% (105/270 acute)] and chondral injuries [40.0% (1437/3595 chronic) vs 24.8% (67/270 acute)] at the time of ACLR were more common in the chronic versus acute groups. The crude 6-year revision rate was 12.9% for acute ACLR, 7.0% for subacute, 5.1% for delayed, and 4.4% for chronic ACLR; reoperation rates a 6-year follow-up was 15.0% for acute ACLR, 9.6% for subacute, 6.4% for delayed, and 8.1% for chronic ACLR. After adjustment for covariates, acute and subacute ACLR had higher risks for aseptic revision (acute HR 1.70, 95% CI 1.07-2.72, p = 0.026; subacute HR 1.25, 95% CI 1.01-1.55, p = 0.040) and aseptic reoperation (acute HR 2.04, 95% CI 1.43-2.91, p < 0.001; subacute HR 1.31, 95% CI 1.11-1.54, p = 0.002) when compared to chronic ACLR.

CONCLUSIONS

In this cohort study, while more meniscal and chondral injuries were reported for ACLR performed ≥ 9 months after the date of injury, a lower risk of revision and reoperation was observed following chronic ACLR relative to patients undergoing surgery in acute or subacute fashions.

Proteomic Profile Analysis of Synovial Fluid in Patients With Anterior Cruciate Ligament Tears

BACKGROUND

Anterior cruciate ligament (ACL) tears are associated with posttraumatic osteoarthritis, but the early biological changes that initiate joint degeneration after this injury are not well characterized. ACL tears typically result in effusion in the knee, which may provide insight into the initial response of the joint to injuries.

HYPOTHESIS

Patient- and injury-specific factors are associated with the proteomics of synovial fluid in knees with ACL tears.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Synovial fluid was collected from 105 patients (38 male, 67 female) with an acute traumatic ACL tear. Patient- and injury-specific factors such as age, sex, body mass index, time from injury, presence/absence of concomitant meniscal tears, and location of concomitant bone bruises (if present) were recorded. The protein concentration of synovial fluid was measured, followed by benchmarking of samples for multi-affinity high-abundance protein depletion. An isotropically labeled high-resolution nano-liquid chromatography with tandem mass spectrometry-based proteomic approach was used to determine the synovial fluid protein profile. Data were processed, quality controlled, and analyzed computationally for each patient and injury factor.

RESULTS

The proteomics of synovial fluid from ACL tears was associated with patient sex, injury pattern, and location of bone bruises but not with patient age, body mass index, or time from injury. Knees with an isolated ACL tear had higher glutathione peroxidase 1 (GPX1) and plastin 3 levels than knees with an ACL tear and meniscal tear. A bone bruise on the lateral femoral condyle was associated with elevated leptin and glucose-6-phosphate dehydrogenase (G6PD) levels. A bone bruise on the lateral tibial plateau was associated with decreased GPX1 levels. Male patients had higher matrix metalloproteinase 9 and lower G6PD levels than female patients.

CONCLUSION

Patient sex, injury pattern, and bone bruise location were important determinants of the proteomic profile of effusion resulting from ACL tears.

CLINICAL RELEVANCE

Longitudinal follow-ups to see if and how proteomic differences relate to clinical outcomes and mechanistic studies to assess the role that specific proteins play in the joint are warranted. Ultimately, these investigations could lead to better approaches to predict clinical outcomes and identify possible interventions to optimize outcomes in these patients.

The Effects of Korean Medicine Treatment for Meniscus Tears: A Retrospective Chart Review

Changes in symptoms and dysfunction related to meniscus tears following the use of Korean medicine for ≥ 4 days were studied. The medical charts of 53 cases of diagnosed meniscus tears (magnetic resonance imaging) with an admission Numeric Rating Scale (NRS) score ≥ 4, between 2017 and 2022 were retrospectively reviewed. Treatments included acupuncture, pharmacopuncture, herbal treatment, Chuna therapy, and physiotherapy. The NRS, Western Ontario and McMaster Universities Osteoarthritis Index, and European Quality of Life 5 Dimensions were performed at admission and discharge. There were 42 females and 11 males in this study. Patients were more likely to be in their 60s (38.18%), have an unknown etiology (81.13%), and have complex tears (50.94%). After receiving a combination of alternative Korean medicine during hospitalization, the mean NRS score improved from 6.82 ± 1.19 to 3.66 ± 1.83 (p < 0.001), the Western Ontario and McMaster Universities Osteoarthritis Index score improved from 46.47 ± 20.99 to 37.98 ± 19.23 (p < 0.001), and the mean European Quality of Life Five Dimensions score improved from 0.61 ± 0.18 to 0.68 ± 0.14 (p < 0.001) after treatment. These results suggest that Korean medicine treatment of meniscus tears alleviated pain and improved physical function.

Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries

Background: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population.

Methods: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed.

Result: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions.

Conclusion: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.

Platelet-rich plasma therapy or arthroscopic surgery on repair of anterior cruciate ligament rupture

The Anterior Cruciate Ligament (ACL) rupture reduces knee stability. In old patients with ACL rupture, surgery is not recommended due to the person's low level of activity and knee osteoarthritis. Platelet-rich plasma (PRP) is a good treatment option in inflammatory cases in orthopedics. Hence, the aim of this study was to assess and comparison of the effect of PRP and arthroscopic surgery on anterior cruciate ligament rupture. This is a clinical trial that was performed in 2020-2021 in Tehran. 100 patients were randomly divided into two groups. The first group of patients underwent ACL tendon repair surgery by arthroscopy and tendon graft. The second group were treated by PRP injection. Both groups of patients were visited from 3 months to 14 months after surgery or PRP treatments. The pain was assessed by Visual Analogue Scale (VAS), we also used Knee Score by the Oxford Score Knee Outcome Scale (OKS) to assess patient's functions. The mean VAS score was 3.05 ± 2.47 in patients in surgery group and mean VAS score was 4.39± 2.66 in patients in the PRP group (p = 0.03). These data showed significant improvements in VAS score in both groups with higher improvements in surgical group. After procedures, the ROM was 120.33 ± 19.60º in surgery group and 109.31 ± 17.22º in PRP group (p = 0.03). Patients in both groups had significantly decreased pain severity after 14 months, but the patients in the surgical treatment group had significantly lower pain and higher ROM compared to PRP group.

Analysis of Health-Related Quality of Life and Clinical Evaluations in Patients with the Triad of Combined Knee Injuries

Combined knee injuries of the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and medial meniscus were called "the unhappy triad" in the past. With recent advances in diagnostic technology, combined ACL, MCL, and lateral meniscus injuries are now known to be the predominant triad. We examined and verified the treatment outcomes of the triad of combined knee injuries from both patient-based subjective evaluation and objective assessments. We studied 49 knees (49 patients) with combined injuries of the ACL, MCL, and lateral meniscus. These cases were divided into those who underwent simultaneous ACL and MCL reconstruction (group A, 18 cases) and those who underwent ACL reconstruction only because MCL injury could be treated conservatively (group B, 31 cases). Clinical evaluation was conducted preoperative and 24 months or longer after surgery. The methods included patient-reported outcomes using Short Form-36, and conventional assessments using Lysholm's score, visual analogue scale (VAS), and quantitative measurement of knee instability using Telos SE. Compared with presurgical scores, the postsurgical Short Form-36 scores showed improvements in all eight subscales, all reaching the national standard values. Significant improvements were observed in the five subscales in group A and seven subscales in group B. Furthermore, significant improvements in Lysholm's score, VAS pain score, and quantitative knee instability were achieved in both groups. This study demonstrated successful clinical outcomes in patients with a triad of knee injuries who were treated with lateral meniscus repair or partial meniscectomy and either combined MCL/ACL reconstruction or ACL reconstruction alone.

Computed Tomography Imaging under Artificial Intelligence Reconstruction Algorithm Used in Recovery of Sports Injury of the Knee Anterior Cruciate Ligament

This study aimed to analyze the influence of artificial intelligence (AI) reconstruction algorithm on computed tomography (CT) images and the application of CT image analysis in the recovery of knee anterior cruciate ligament (ACL) sports injuries. A total of 90 patients with knee trauma were selected for enhanced CT scanning and randomly divided into three groups. Group A used the filtered back projection (FBP) reconstruction algorithm, and the tube voltage was set to 120 kV during CT scanning. Group B used the iDose4 reconstruction algorithm, and the tube voltage was set to 120 kV during CT scanning. In group C, the iDose4 reconstruction algorithm was used, and the tube voltage was set to 100 kV during CT scanning. The noise, signal-to-noise ratio (SNR), carrier-to-noise ratio (CNR), CT dose index volume (CTDI), dose length product (DLP), and effective radiation dose (ED) of the three groups of CT images were compared. The results showed that the noise of groups B and C was smaller than that of group A (P < 0.05), and the SNR and CNR of groups B and C were higher than those of group A. The images of patients in group A with the FBP reconstruction algorithm were noisy, and the boundaries were not clear. The noise of the images obtained by the iDose4 reconstruction algorithm in groups B and C was improved, and the image resolution was also higher. The agreement between arthroscopy and CT scan results was 96%. Therefore, the iterative reconstruction algorithm of iDose4 can improve the image quality. It was of important value in the diagnosis of knee ACL sports injury.

Stress on the posteromedial region of the proximal tibia increased over time after anterior cruciate ligament injury

PURPOSE

Anterior cruciate ligament (ACL) injury induces anterior and rotatory instability of the knee. However, the effect of this instability on the stress distribution in the knee joint in living participants is not clear. The aim of this study was to compare the distribution pattern of subchondral bone density across the proximal tibia in the knees with and without ACL injury, and to investigate the correlation between the distribution patterns of the subchondral bone density and the duration of ACL-deficiency.

METHODS

Radiographic and computed tomography (CT) data pertaining to 20 patients with unilateral ACL injury without combined injury (ACL-deficient group) and 19 nontraumatic subjects (control group) were collected retrospectively. Subchondral bone density of the proximal tibia was assessed using CT-osteoabsorptiometry. Both the medial and lateral compartments of the proximal tibia were divided into three subregions of equal width in the sagittal direction. The percentage of high subchondral bone density areas (HDA%) in each subregion was quantitatively analyzed.

RESULTS

HDA% of the posteromedial region was significantly higher in the ACL-deficient group (mean: 21.6%) than in the control group (14.7%) (p = 0.002). In contrast, HDA% of the anteromedial region was significantly lower in the ACL-deficient group (9.4%) than in the control group (15.3%) (p = 0.048). The logarithm of the time elapsed from ACL injury to CT examination showed a significant correlation with HDA% in the posteromedial region (p = 0.032).

CONCLUSIONS

Subchondral bone density in the posteromedial region significantly increased after ACL injury and correlated with the duration of ACL-deficiency in semi-log manner in meniscus intact knees. The increase in stress on the posteromedial region after ACL injury, which induces a change in the subchondral bone density, justifies early ACL reconstruction after ACL injury.

Significant risk of arthrolysis after simultaneous anterior cruciate ligament reconstruction and treatment of dislocated bucket-handle meniscal tear

INTRODUCTION

Postoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step.

HYPOTHESIS

Treatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension.

MATERIAL AND METHODS

A retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0±11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0±10.4 years. Patients were classified according to age of ACL tear, as acute (<6 weeks), subacute (6 weeks to 6 months), or chronic (>6 months).

RESULTS

Risk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p=0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7-97.2) and 97.1% (95% CI, 94.3-99.9) respectively (p=0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p>0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p=0.421) or specifically in Group A (p=0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months' follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p=0.128).

CONCLUSION

The present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness.

LEVEL OF EVIDENCE

IV, retrospective exposure/non-exposure cohort study.

Significance of the broad non-bony attachments of the anterior cruciate ligament on the tibial side

Knowledge of the anatomy of the anterior cruciate ligament (ACL) is important to understand the function and pathology of the knee joint. However, on the tibial side of ACL, its structural relationships with the articular cartilage and lateral meniscus remain unclear. Furthermore, conventional research methods are limited to analyzing the bone attachments. We provide a comprehensive, three-dimensional anatomical description of the tibial side of the ACL that questions the principle that “a ligament is necessarily a structure connecting a bone to another bone.” In our study, 11 knees from 6 cadavers were used for macroscopic anatomical examinations, serial-section histological analyses, and three-dimensional reconstructions. The attachments of the tibial side of ACL consisted of attachments to the bone (102.6 ± 27.5 mm²), articular cartilage (40.9 ± 13.6 mm²), and lateral meniscus (6.5 ± 4.6 mm²), suggesting that the ACL has close structural relationships with the articular cartilage and lateral meniscus. Our study demonstrates that the tibial side of the ACL is not attached to the bone surface only and provides new perspectives on ligamentous attachments. Considering its attachment to the articular cartilage would enable more accurate functional evaluations of the mechanical tensioning of the ACL.

S, J.S. ST, Nair RR. Comparison of Fixed- and Variable-Loop Button Fixation in Arthroscopic Anterior Cruciate Ligament Reconstruction

Introduction

With the advent of fixed- and variable-loop suspensory fixation devices for arthroscopic anterior cruciate ligament (ACL) reconstruction, a maximum number of grafts can be placed within the femoral tunnel. Although several biomechanical studies have been conducted comparing these two devices, only a few comparative clinical studies are available. This study was conducted to compare the functional outcomes of arthroscopic ACL reconstruction using fixed-loop devices with those of variable-loop devices by determining their effect on graft laxity clinical assessment and patient-reported outcome scores.

Methodology

Out of 32 patients (27 males and five females) who underwent primary ACL reconstruction using tripled hamstring autograft, fixed- and variable-loop devices were used for 13 and 19 patients, respectively. Thirteen patients in each group were evaluated over a period of one year using the Lysholm knee score. Six patients in the variable-loop group had only six months of follow-up. Anterior drawer and Lachman tests were performed at six-month and one-year follow-ups, respectively.

Results

The mean ages of patients in the fixed- and variable-loop groups were 34.5\begin{document}\pm\end{document}11 and 34.1\begin{document}\pm\end{document}9.1 years, respectively. The Lysholm knee score at six weeks was fair in 7.7% of the patients in the fixed-loop group when compared to 52.6% of those in the variable-loop group (p<0.05). All the other parameters were comparable between the two groups. One patient in each group had ligament laxity at six-month and one-year follow-up, respectively.

Conclusion

This study showed no statistically significant difference in graft laxity or functional outcomes of arthroscopic ACL reconstruction with fixed- and variable-loop devices, except for a better patient-reported outcome score in the variable-loop group at six weeks of follow-up. Hence, there is a need for more comparative studies in this direction.

Outcomes of Combined Lateral Meniscus Posterior Root Repair and Anterior Cruciate Ligament Reconstruction

Background:

Lateral meniscus posterior root tears (LMPRTs) almost always occur in association with anterior cruciate ligament (ACL) tears. Their repair is advocated to restore the stabilizing and load-sharing functions of the meniscus.

Purpose:

To study the functional outcomes of combined arthroscopic repair of LMPRTs and ACL reconstruction (ACLR).

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors evaluated patients who underwent simultaneous arthroscopic ACLR and LMPRT repair. All patients had chronic injuries, with a mean time since ACL rupture of 7.9 months. Patient characteristics, Lachman and pivot-shift test results, type of LMPRT, associated injuries, and surgery details were documented. Pre- and postoperative functional status was assessed using the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. An independent single-tunnel transtibial repair using 2 SutureTapes was performed for Forkel type 1 and 3 tear root avulsions, while side-to-side suture repair was performed for type 2 radial/oblique tears. The Wilcoxon signed rank test and minimal clinically important difference (MCID) of the IKDC score were used for statistical analysis.

Results:

Included were 25 patients with a mean age of 29.6 ± 6.5 years. Of these, 22 patients (88%; 95% CI, 73.1%-100%) had a high-grade (grade 2 or 3) preoperative pivot shift. Diagnosis of the LMPRT on magnetic resonance imaging (MRI) scans was possible only in 5 patients (20%). At final evaluation, performed at 37.4 ± 7.1 months postoperatively, all functional scores had improved significantly from preoperatively: IKDC score, from 47.6 ± 9.5 to 81.8 ± 11.5; KOOS, from 45.5 ± 10.9 to 86.5 ± 10.3, and Lysholm score, from 49.0 ± 11.5 to 88.8 ± 7.6 (P < .001 for all). Twenty-four patients (96%) achieved the MCID for the IKDC score. All knees had a negative pivot shift at final analysis, and no patient underwent revision ACLR or LMPRT repair.

Conclusion:

LMPRT repair combined with ACLR led to good short-term clinical outcomes in this study. An LMPRT may frequently go undetected on preoperative MRI scans, but a high-grade pivot shift is present in a large majority of these patients.

Survival and Risk Factor Analysis of Arthroscopic Ramp Lesion Repair During Anterior Cruciate Ligament Reconstruction

BACKGROUND

There is a lack of research on the management of ramp lesions associated with anterior cruciate ligament (ACL) injuries. Furthermore, there has been no report of the risk factors for failure of ramp lesion sutures, linked to either the technique used (all-inside suture implant vs suture hook through a posteromedial portal) or the type of lesion (location in the red zone or meniscocapsular junction, longitudinal extension, partial- or full-thickness tear).

PURPOSE

To evaluate the results of arthroscopic repair of ramp lesions and determine the risk factors associated with ramp lesion repair failure, with special focus on their subtype and the suture technique.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All patients who underwent arthroscopic ramp lesion repair in association with ACL reconstruction between November 2015 and January 2018 were evaluated retrospectively. The following parameters were studied: demographics; clinical history; clinical findings including International Knee Documentation Committee score, complications, time from injury to surgery, side-to-side laxity, and pivot shift; and surgical findings including subtype, surgical management, and type and number of sutures. Failure of the ramp lesion repair was defined at secondary arthroscopy.

RESULTS

Among the 248 lesions analyzed, 18 (7.3%) failures were documented. The failures occurred in 21.1% of repairs managed with the all-inside device versus 4.3% of sutures managed with the suture hook (P = .003). Among the 6 factors included in the Cox model, the only one identified as a risk factor for failure was the type of repair (P = .003), with a risk for the all-inside device that was >5-fold higher than that for the suture hook repair (corresponding hazard ratio, 5.1 [95% CI, 1.8-14.5]). No other complications involving the surgical technique or device were registered.

CONCLUSION

An arthroscopic all-inside technique of meniscal repair of ramp lesions appeared to be safe and effective. It provided excellent healing of the repaired meniscus, with an overall failure rate of 7.3%. The type of suture was associated with failure of the ramp lesion repair, with a significantly higher risk with the all-inside device than with suture hook repair sutures.

Prevalence of anterolateral ligament injuries and lateral meniscus tear on MR imaging in patients with both-bundle tear vs. selective bundle incomplete tear of the anterior cruciate ligament

OBJECTIVES

We investigated the prevalence of anterolateral ligament (ALL) injury and lateral meniscus (LM) tear in cases with both-bundle tear and selective bundle incomplete tear of the anterior cruciate ligament (ACL).

METHODS

A total of 174 cases of magnetic resonance (MR) images that had an ACL tear and underwent arthroscopic ACL reconstruction were retrospectively reviewed. ACL injury was classified into both bundle, anteromedial bundle, and posterolateral bundle (PL) on arthroscopic finding. The ALL was divided into three portions: femoral, meniscal, and tibial. ALL injury was scored into three groups: grade 0 is intact; grade 1 is stranding and edema surrounds the expected location of the ALL; grade 2 is clear discontinuity of the ALL consistent with rupture. Traumatic LM tear was also assessed on MR images.

RESULTS

The total prevalence of ALL injury was 36.2% (reader 1) and 42.0% (reader 2). ALL injury was statistically related to the selective bundle tear (p = 0.002 and 0.004, readers 1 and 2). PL bundle tear was significantly correlated with the ALL injury (p value < 0.001, readers 1 and 2, both). The location and grade of ALL injury were not significantly correlated with the type of ACL injury. LM tear was not significantly related to the types of ACL tear (p = 0.208 and 0.907, readers 1 and 2) and ALL injury (p value = 0.096 and 0.383, readers 1 and 2).

CONCLUSIONS

ALL injury was significantly related to the PL bundle tear of the ACL. LM tear was not significantly correlated with the types of ACL injury and ALL injury.

KEY POINTS

• Anterolateral ligament (ALL) injury was significantly related to the posterolateral bundle (PL) tear of the anterior cruciate ligament (ACL). • Lateral meniscus (LM) tear was not significantly correlated with the types of ACL injury and ALL injury. • Clinicians and radiologists should be aware of these relationships and scrutinize ALL injury in cases with PL bundle tears, even with an incomplete ACL injury.

The Multivariate Relationship Between Primary Anterior Cruciate Ligament Reconstruction Timing and Revision Rates: A 10-Year Analysis

Background and objective

The optimal timing of anterior crucial ligament reconstruction (ACLR) remains a matter of controversy. A revision procedure is performed to improve knee function, correct instability, and enable a safe return to daily function when primary ACLR fails. The present study aimed to determine if the timing of primary ACLR is predictive of revision surgery.

Methods

All patients who underwent primary ACLR at the West Virginia University from January 2008 to December 2018 were identified. Patients were initially grouped into early (≤30 days) and late (>30 days) ACLR based on the onset of the initial injury. The major outcome measure of this study was the incidence of revision ACLR following primary ACLR.

Results

A total of 233 primary ACLRs were included. The incidence of ACLR revisions was 9.4%. The timing of primary ACLR, when categorized into early and late ACLRs, was not found to influence revision risk (p=0.384). Additionally, the damaged anatomical structures based on the postoperative diagnosis at the time of ACLR did not influence the odds of revision ACLR (p=0.9721).

Conclusion

Our study found that the timing of primary ACLR did not influence the revision rates when categorizing primary surgery time into early and late subgroups.

Anterior cruciate ligament reconstruction with lateral extraarticular tenodesis better restores native knee kinematics in combined ACL and meniscal injury

PURPOSE

To determine if anterior cruciate ligament (ACL) reconstruction (ACLR) with lateral extraarticular tenodesis (LET) is beneficial for restoring knee kinematics with concomitant meniscal pathology causing rotatory knee instability.

METHODS

Twenty patients with an ACL tear were randomized to either isolated ACLR or ACLR with LET. Patients were divided into four groups based on the surgery performed and the presence of meniscal tear (MT): ACLR without MT, ACLR with MT, ACLR with LET without MT, and ACLR with LET with MT. Kinematic data normalized to the contralateral, healthy knee were collected using dynamic biplanar radiography superimposed with high-resolution computed tomography scans of patients' knees during downhill running. Anterior tibial translation (ATT) and tibial rotation (TR) as well as patient-reported outcome measures (PROMs) were analyzed at 6- and 12-months postoperatively.

RESULTS

At 6 months, ACLR with LET resulted in significantly decreased ATT at heel strike compared to ACLR (ACLR without MT: 0.3 ± 0.8 mm and ACLR with MT: 1.4 ± 3.1 mm vs. ACLR with LET without MT: - 2.5 ± 3.4 mm and ACLR with LET with MT: - 1.5 ± 1.2 mm ATT, p = 0.02). At 6 months, at toe off ACLR with LET better restored ATT to that of the contralateral, healthy knee in patients with meniscal pathology, while in patients without meniscal pathology, ACLR with LET resulted in significantly decreased ATT (1.0 ± 2.6 mm ATT vs. - 2.6 ± 1.7 mm ATT, p = 0.04). There were no significant differences in kinematics or PROMs between groups at 12 months.

CONCLUSION

For combined ACL and meniscus injury, ACLR with LET restores native knee kinematics at toe off but excessively decreases ATT at heel strike in the early post-operative period (6 months) without altering knee kinematics in the long term. Future large-scale clinical studies are needed to better understand the function of LET and ultimately improve patient outcomes.

LEVEL OF EVIDENCE

III.

Tibiofemoral bony morphology features associated with ACL injury and sex utilizing three-dimensional statistical shape modeling

Statistical shape modeling was employed to assess three-dimensional (3D) bony morphology between distal femurs and proximal tibiae of anterior cruciate ligament (ACL) injured knees, the contralateral uninjured knees of ACL injured subjects, and knees with no history of injury. Surface models were created by segmenting bone from bilateral computed-tomography scans of 20 subjects of their ACL injured knees and non-injured contralateral knees, and 20 knees of control subjects with no history of a knee injury. Correspondence particles were placed on each surface, and a principal component analysis determined modes of variation in the positions of the correspondence particles describing anatomical variation. ANOVAs assessed the statistical differences of 3D bony morphological features with main effects of injury state and sex. ACL injured knees were determined to have a more lateral femoral mechanical axis and a greater angle between the long axis and condylar axis of the femur. A smaller anterior-posterior dimension of the lateral tibial plateau was also associated with ACL injured knees. Results of this study demonstrate that there are more bony morphological features predisposing individuals for ACL injury than previously established. These bony morphological parameters may cause greater internal and valgus torques increasing stresses in the ACL. No differences were determined between the ACL injured knees and their uninjured contralateral knees demonstrating that knees of ACL injured individuals are at similar risk for injury. Further understanding of the effect of bony morphology on the risk for ACL injury could improve individualized ACL injury treatment and prevention.

Effects of different surgical procedures for meniscus injury on two-year clinical and radiological outcomes after anterior cruciate ligament reconstructions. -TMDU MAKS study

BACKGROUND

The treatment of meniscus injuries combined with anterior cruciate ligament (ACL) reconstruction would be important to improve outcomes after ACL reconstruction. However, the effects of treatment methods for meniscus after ACL reconstruction have not been thoroughly investigated. The objective of this study was to investigate the effects of treatment methods for meniscus on clinical and radiological outcomes at 2 years after ACL reconstruction.

METHODS

Three-hundred and eighteen patients with primary ACL reconstruction using autologous hamstring tendon registered in our multicenter study database and who were followed up for 2 years were included. They were then divided into 3 groups, the no meniscal lesion/untreated group (n = 149), the meniscal repair group (n = 139), and the meniscal resection group (n = 30). Patient-based subjective evaluations (Lysholm score, Knee injury and Osteoarthritis Outcome score and International Knee Documentation Committee subjective score), objective evaluations (Lachman test, pivot shift test and KT measurement), and radiological measurements (medial and lateral joint space width) were compared among the 3 groups preoperatively and at 2 years follow-up.

RESULTS

All subjective scores and objective evaluations significantly improved in all groups without significant differences among the groups postoperatively. Regarding radiological findings, the medial joint space width significantly decreased only in the resection group during the 2-year period, and the medial joint space width in the resection group was significantly smaller than that of the other groups at the 2-year follow-up. Moreover, the medial joint space width significantly decreased during the 2-year period when MM was resected.

CONCLUSIONS

In radiological findings, medial meniscus resection decreased medial joint space width two years after ACL reconstruction. On the other hand, treatment methods for meniscus neither significantly affected subjective nor objective findings until the 2-year follow-up.

LEVEL OF EVIDENCE

Ⅱ, Cohort study.

Meniscus repair with simultaneous anterior cruciate ligament reconstruction: Clinical outcomes, failure rates and subsequent processing

PURPOSE

To retrospectively analyze the clinical outcomes of meniscus repair with simultaneous anterior cruciate ligament (ACL) reconstruction and explore the causes of failure of meniscus repair.

METHODS

From May 2013 to July 2018, the clinical data of 165 patients who were treated with meniscus surgery and simultaneous ACL reconstruction, including 69 cases of meniscus repair (repair group) and 96 cases of partial meniscectomy (partial meniscectomy group) were retrospectively analyzed. The exclusion criteria were as follows: (1) ACL rupture associated with fracture, collateral ligament injury, or complex ligament injury; (2) a history of knee surgery; or (3) a significant degree of osteoarthritis. The 69 patients in the repair group were divided into the non-failure group (62 cases) and the failure group (7 cases) depending on the repair effect. Postoperative outcomes of the repair group and the partial meniscectomy group were compared. General conditions and postoperative outcomes of the failure group and the non-failure group were compared. During the median follow-up period of 28 months (range, 4 - 65 months) after the second arthroscopy, postoperative outcomes of seven patients in the failure group were summarized. SPSS 25.0 statistical software was used for statistical analysis. A p value less than 0.05 was considered statistically significant.

RESULTS

Seven patients in the failure group who underwent the second arthroscopy were followed up for (30 ± 17.4) months and their postoperative outcomes were summarized. Compared with the partial meniscectomy group, the International Knee Documentation Committee scores of patients in the repair group improved significantly (p = 0.031). Compared with the non-failure group, more patients in the failure group were younger than 24 years (p = 0.030). The median follow-up period was 39.5 months. All patients recovered well after subsequent partial meniscectomy and relieved clinical symptoms. Visual analog scale scores decreased significantly (p = 0.026), and the International Knee Documentation Committee and Lysholm scores improved significantly (p = 0.046 for both).

CONCLUSION

The failure rate of meniscus repair in this study was 10.1% (7/69), all of which were medial meniscus tears. However, the surgical outcomes of ACL reconstruction were not affected, and there might be a role for graft protection. Therefore, meniscus retears can be successful treated by performing subsequent partial meniscectomy in patients with repair failure.

Lateral femoral notch sign and posterolateral tibial plateau fractures and their associated injuries in the setting of an anterior cruciate ligament rupture

INTRODUCTION

ACL injury is one of the most common injuries of the knee joint in sports. As accompanying osseous injuries of the ACL rupture a femoral impression the so-called lateral femoral notch sign and a posterolateral fracture of the tibial plateau are described. However, frequency, concomitant ligament injuries and when and how to treat these combined injuries are not clear. There is still a lack of understanding with which ligamentous concomitant injuries besides the anterior cruciate ligament injury these bony injuries are associated.

MATERIALS AND METHODS

One hundred fifteen MRI scans with proven anterior cruciate ligament rupture performed at our center were retrospectively evaluated for the presence of a meniscus, collateral ligament injury, a femoral impression, or a posterolateral impression fracture. Femoral impressions were described according to their local appearance and posterolateral tibial plateau fractures were described using the classification of Menzdorf et al. RESULTS: In 29 cases a significant impression in the lateral femoral condyle was detected. There was a significantly increased number of lateral meniscal (41.4% vs. 18.6% p = 0.023) and medial ligament (41.4% vs. 22.1%; p = 0.040) injuries in the group with a lateral femoral notch sign. 104 patients showed a posterolateral bone bruise or fracture of the tibial plateau. Seven of these required an intervention according to Menzdorf et al. In the group of anterior cruciate ligament injuries with posterolateral tibial plateau fracture significantly more lateral meniscus injuries were seen (p = 0.039).

CONCLUSION

In the preoperative planning of ACL rupture accompanied with a positive femoral notch sign, attention should be paid to possible medial collateral ligament and lateral meniscus injuries. As these are more likely to occur together. A posterolateral impression fracture of the tibial plateau is associated with an increased likelihood of the presence of a lateral meniscal injury. This must be considered in surgical therapy and planning and may be the indication for necessary early surgical treatment.

The majority of athletes fail to return to play following anterior cruciate ligament reconstruction due to reasons other than the operated knee

PURPOSE

The purpose of this study is to evaluate the reasons why athletes do not return to play (RTP) following anterior cruciate ligament (ACL) reconstruction from a large single-centre database.

METHODS

The institutional ACL registry was screened for patients that had undergone a primary ACLR and had RTP status reported at 24-month follow-up. The reasons that patients were unable to RTP at 24 months were evaluated. The ACL-Return to Sport Index (ACL-RSI) was evaluated at baseline and 24-month follow-up to evaluate psychological ability to RTP.

RESULTS

At 2 years, 1140 patients returned to play, and 222 had not returned to play. The most common reasons athletes were unable to return was fear of reinjury (27.5%), lack of confidence in performance on return (19.4%) and external life factors (16.6%), i.e. work commitments and family reasons. Other reasons for athletes not returning to play were residual knee pain (10%) and subsequent injury (5%). The ACL-RSI score was significantly lower at diagnosis (40.3 vs. 49.3; p = 0.003) and 2 years (41.8 vs. 78.7; p < 0.0001) in athletes who did not return to play vs. those that did RTP.

CONCLUSION

The majority of patients that report they have not returned to play do so due to external life and psychological factors associated with their injury, including fear of reinjury and lack of confidence in performance. A small minority of patients were unable to return due to residual knee symptoms or reinjury. Pre-operative psychological assessment and intervention may identify those less likely to RTP and provide an opportunity for targeted interventions to further improve RTP outcomes.

LEVEL OF EVIDENCE

III.

Strong association of meniscus tears with complete Anterior Cruciate Ligament (ACL) injuries relative to partial ACL injuries

BACKGROUND

Anterior Cruciate Ligament (ACL) injuries are often associated with meniscus tears. These meniscus tears in long term may affect the functional outcomes after ACL reconstruction. The present study aims to identify the incidence and relative association of meniscus injuries in complete and partial ACL injuries.

METHODS

This was a retrospective study. Patients were divided into 2 groups; group I: partial ACL tear and group 2: complete ACL tear. Both groups were assessed for meniscal tears; either isolated medial/lateral or combined and odds ratio was measured between two groups.

RESULTS

A total of 43 and 219 patients were enrolled in group I and II respectively. The mean age (years) in group I and II were 25.32 ± 7.12 and 28.64 ± 10.84 respectively. There were a total of 5 and 28 females in group I and II respectively. Mean pre-injury Tegner score in group I and II was 7.02 ± 2.87 and 6.82 ± 3.14 respectively. Mean time from injury to surgery (months) in group I and II was 8.04 ± 6.43 and 7.62 ± 4.83 respectively. In group 1 There were a total of 6 with lateral meniscus tears, 9 with medial meniscus tears And 3 with combined meniscal tears in group 1 while in group 2, 47 had lateral meniscal tears, 71 had medial meniscal tears and 71 had combined tears. Group II patients had stronger association for isolated meniscal tears compared to group I, with an odds ratio of 5.05(p < 0.05). Combined meniscal tears had non-significant relation in two groups (p = 0.58).

CONCLUSION

Partial ACL injuries present with less risk of acquiring isolated meniscus tears, compared to complete ACL injuries.

Diagnostic value of clinical tests and Mri for meniscal injury in patients with anterior cruciate ligament injury: Case series study

Introduction and importance

Meniscal tear is one of the most common knee injuries and knee surgery procedures. It is frequently associated with an anterior cruciate ligament (ACL) injury. We conducted this study, on patients with ACL reconstruction surgeries, which were occasionally accompanied by meniscal tears, in order to determine the diagnostic value of clinical examinations for meniscal tear, both individually and in combination, in correlations to magnetic resonance imaging (MRI) scans, with the goal of improving clinical diagnosis for patients with meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.

Case presentation

50 patients were thoroughly clinically examined, using Joint line tenderness, Thessaly test, McMurray's test, Apley's test followed by MRI, before their scheduled ACL reconstruction arthroscopic surgeries. The meniscal tears were then identified during the procedure, and were treated, if necessary. The data before and after the surgery was taken into calculating, with arthroscopic findings serving as the gold standard. Results: the sensitivity, specificity and accuracy of each clinical tests and MRI scans respectively were: for medial meniscus, Joint line tenderness (70%; 53,3%; 60%); McMurray's test (80%; 73,3%: 76%); Apley's test (65%; 70%; 68%); Thessaly test(70%; 76,7%; 74%); MRI (90%; 83,3%; 86%); lateral meniscus: Joint line tenderness (73%; 66,7%; 70%); McMurray's test (69,2%; 75%: 72%); Apley's test (69,2%; 70,8%; 70%); Thessaly test (73,1%; 75%; 74%); MRI (88,5%; 87,5%; 88%). However, when combining at least two positive tests into a single composite test, the diagnostic value is considerably enhanced with sensitivity, specificity and accuracy of 85%, 73,3%, 78% for medial meniscus, 92,3%, 87,5%, 90% for lateral meniscus.

Clinical discussion

Clinical tests are essential for diagnosis of meniscal tears, although inconsistent. A composite test consisting of at least two positive tests can considerably enhance the diagnostic value, even comparable to MRI scans. However, after the clinical examination, MRI is still necessary for the diagnostic process of meniscal injuries in particular, as well as meniscal injuries associated with cruciate ligament knee injuries.

Conclusion

The combination of clinical tests and MRI images will give a precise diagnosis as well as surgical indication for meniscus injury in patients with anterior cruciate ligament tear.

•

Meniscus tear is frequently associated with ACL injury

•

Identifying, classifying and grading meniscus lesion is very important because it can assist surgeon in providing appropriate treatment plans (meniscectomy or repair) and having an accurate prognosis for patients.

•

Determine the diagnostic value in term of clinical in correlation with preoperative MRI images is the purpose of this study

The effect of meniscal pathology and management with ACL reconstruction on patient-reported outcomes, strength, and jump performance ten months post-surgery

BACKGROUND

The purpose of this study was to examine the differences in patient-reported outcome measures, isokinetic strength, plyometric ability and ability to meet return to play criteria ten months after anterior cruciate ligament (ACL) reconstruction surgery between those who underwent meniscectomy, those who underwent meniscal repair and those with no meniscal intervention alongside ACL reconstruction surgery.

METHODS

Three hundred and thirteen athletes with clinically and radiologically confirmed ACL ruptures were included in this study. Participants were grouped according to their intra-operative procedures (isolated ACL reconstruction surgery n = 155, ACL reconstruction surgery with meniscectomy n = 128, ACL reconstruction surgery with meniscal repair n = 30). Participants completed patient-reported outcome measures questionnaires (Marx Activity Rating Scale, the ACL Return to Sport after Injury and the International Knee Documentation Committee Score) and completed a battery of objective functional testing including isokinetic dynamometry and jump performance testing (countermovement jump and drop jump) between 9 and 11 months after surgery.

RESULTS

No significant between-group differences were identified in any metric relating to patient-reported outcome measures (p = .611), strength and jump measures (p = .411) or the ability to achieve symmetry-based return to play criteria (p = .575).

CONCLUSIONS

Clinically, these results suggest that concomitant meniscal surgery has no significant effects on patient-reported outcome measures, strength and jump metrics at the return to play stage post-operatively and can inform the pre-operative counselling of those awaiting ACL reconstruction surgery with likely meniscal intervention.

Association Between Meniscal Allograft Tears and Early Surgical Meniscal Allograft Failure

BACKGROUND

Meniscal allograft transplantation (MAT) has become a viable treatment option for patients with symptomatic meniscal deficiency. Some patients experience early surgical meniscal allograft failure attributed to causes that have not yet been sufficiently clarified.

PURPOSE

To evaluate the prevalence, types, and distribution of arthroscopically confirmed meniscal allograft tears and the associated effect on surgical meniscal allograft survival.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing MAT with a minimum 2-year follow-up were retrospectively reviewed. Descriptive and surgical data were collected. Type and location of arthroscopically confirmed meniscal allograft tears were recorded and compared between medial and lateral allografts and suture-only and bone block fixation. A survival analysis was conducted to evaluate the effect of meniscal allograft tears on surgical meniscal allograft survival.

RESULTS

This study included 142 patients (54% male; mean ± SD age, 29.6 ± 10.4 years) with a mean follow-up of 10.3 ± 7.5 years. The prevalence of meniscal allograft tears was 32%, observed at a median of 1.2 years (interquartile range, 2.8 years) after MAT. The posterior horns were most frequently affected, followed by the posterior roots, midbodies, anterior horns, and anterior roots. The most frequently observed tear types were root tears (43%), followed by longitudinal, horizontal, radial, complex, bucket-handle, and meniscocapsular separation tears. A statistically significant association was found between meniscal allograft tear types and fixation techniques (P = .027), with root tears predominant after suture-only as compared with bone block fixation (57% vs 22%). Patients with meniscal allograft root tears were a mean of 5.4 years (95% CI, 1.6-9.2 years; P = .007) younger than were patients without root tears. The 1-year surgical meniscal allograft survival rate was significantly lower for torn versus intact meniscal allografts (75% vs 99%; P < .001).

CONCLUSION

Meniscal allograft root tears were predominant, associated with younger patient age, and more often observed when using the suture-only fixation technique versus the bone block fixation technique. Torn meniscal allografts were associated with early surgical graft failure when compared with intact meniscal allografts, resulting in a significantly lower 1-year survival rate.

The Epidemiology of Meniscus Injury

Meniscus surgery is one of the most commonly performed orthopedic procedures worldwide. Modifiable risk factors for meniscus injury include body mass index, participation in athletics and occupation. Nonmodifiable risk factors include age, sex, lower extremity alignment, discoid meniscus, ligamentous laxity, and biconcave tibial plateau. Conditions commonly associated with meniscal injury are osteoarthritis, anterior cruciate ligament injury, and tibial plateau fractures. Tear type and location vary by patient age and functional status. Surgical management of meniscus injury is typically cost-effective in terms of quality-adjusted life years. The purpose of this review is to provide an overview of meniscal injury epidemiology by summarizing tear types and locations, associated conditions, and factors that increase the risk for meniscal injury. The economic burden of meniscus injury and strategies to prevent injury to the meniscus are also reviewed.