Approaching the ruptured anterior cruciate ligament

Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series)

Knee injuries are a common presentation to the ED and are often difficult to assess and definitively diagnose due to the patient's acute pain, effusion and guarding. The quality of ED care provided to patients with fractures or soft tissue injuries of the knee is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common knee injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 2250 articles, of which 54 were included in the review (n = 8 primary articles, n = 28 systematic reviews, n = 18 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the knee in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is consistent evidence to support undertaking a thorough history and physical examination, including the application of special tests and clinical decision rules for imaging. In the undifferentiated knee injury, expedited follow up and further imaging is recommended to improve patient outcomes and cost-effectiveness.

Overrepresentation of the COL3A1 AA genotype in Polish skiers with anterior cruciate ligament injury

Although various intrinsic and extrinsic risk factors for anterior cruciate ligament (ACL) rupture have been identified, the exact aetiology of the injury is not yet fully understood. Type III collagen is an important factor in the repair of connective tissue, and certain gene polymorphisms may impair the tensile strength. The aim of this study was to examine the association of the COL3A1 rs1800255 polymorphism with ACL rupture in Polish male recreational skiers. A total of 321 male Polish recreational skiers were recruited for this study; 138 had surgically diagnosed primary ACL ruptures (ACL-injured group) and 183 were apparently healthy male skiers (control group – CON) who had no self-reported history of ligament or tendon injury. Both groups had a comparable level of exposure to ACL injury. Genomic DNA was extracted from the oral epithelial cells. All samples were genotyped on a real-time polymerase chain reaction instrument. The genotype distribution in the ACL-injured group was significantly different than in CON (respectively: AA=10.1 vs 2.2%, AG=22.5 vs 36.1, GG=67.4 vs 61.8%; p=0.0087). The AA vs AG+GG genotype of COL3A1 (odds ratio (OR)=5.05; 95% confidence interval (CI), 1.62-15.71, p=0.003) was significantly overrepresented in the ACL-injured group compared with CON. The frequency of the A allele was higher in the ACL-injured group (21.4%) compared with CON (20.2%), but the difference was not statistically significant (p=0.72). This study revealed an association between the COL3A1 rs1800255 polymorphism and ACL ruptures in Polish skiers.

State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians

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

Diagnostic value of medical history and physical examination of anterior cruciate ligament injury: comparison between primary care physician and orthopaedic surgeon

PURPOSE

Well-designed validity studies on the clinical diagnosis of anterior cruciate ligament (ACL) injury are scarce. Our purpose is to assess the diagnostic value of ACL-specific medical history assessment and physical examination between primary and secondary care medical specialists.

METHODS

Medical history assessment and physical examination were performed by both an orthopaedic surgeon and a primary care physician, both blinded to all clinical information, in a secondary care population. A knee arthroscopy was used as reference standard. A total of 60 participants were divided into an index group with an arthroscopically proven complete ACL rupture and a control group with an arthroscopically proven intact ACL.

RESULTS

The orthopaedic surgeon recognized 94 % of the participants with an ACL rupture through a positive medical history combined with a positive physical examination; of the participants with an intact ACL, 16 % were misclassified by the orthopaedic surgeon. The primary care physician recognized 62 % of the participants with an ACL rupture and misclassified 23 % of the participants with an intact ACL. Physical examination appeared to have no additional value for the primary care physician.

CONCLUSIONS

Combined medical history and physical examination have strong diagnostic value in ACL rupture diagnostics performed by an orthopaedic surgeon, whereas for the primary care physician, only medical history appeared to be of value. For current practice, this could mean that only orthopaedic surgeons can perform an ACL physical examination with accuracy.

LEVEL OF EVIDENCE

III.

Evaluation and management of traumatic knee injuries in the emergency department

Posttraumatic knee pain is a common presentation in the emergency department (ED). The use of clinical decision rules can rule out reliably fractures of the knee and reduce the unnecessary cost and radiation exposure associated with plain radiographs. If ligamentous or meniscal injury to the knee is suspected, the ED physician should arrange for expedited follow- up with the patient's primary care physician or an orthopedic specialist for consideration of an MRI and further management. Patients presenting after high-energy mechanisms are at risk for occult fracture and vascular injuries. ED providers must consider these injuries in the proper clinical setting.

Ligamentous injuries of the knee: anterior cruciate, medial collateral, posterior cruciate, and posterolateral corner injuries

This article discusses athletic injuries of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and posterolateral corner. Best evidence to date validates that conservative management of ACL ruptures is a reasonable strategy. Current data also seem to advocate nonoperative management of PCL injuries. All isolated MCL injuries, regardless of grade, are usually treated with a brief period of immobilization and symptomatic management. Although the surgical literature often advocates surgical treatment of posterolateral corner injuries, there have been no randomized trials substantiating that these injuries are best treated surgically.

Modulation of cell attachment and collagen production of anterior cruciate ligament cells via submicron grooves/ridges structures with different cell affinity

This study aimed to investigate the effects of submicron-grooved topography and surface cell affinity on the attachment, proliferation and collagen synthesis of anterior cruciate ligament (ACL) cells. Two grooved polystyrene (PS) surfaces (equal groove/ridge width of 800 nm) with a groove depth of 100 or 700 nm were fabricated and modified by oxygen plasma treatment, dopamine deposition and conjugation of RGD-containing peptides to enhance cell affinity. The elongation and alignment of ACL cells was enhanced by grooved structures with increasing groove depths regardless of surface chemistry. On the other hand, cell spreading and proliferation mainly depended on surface chemistry, in accordance with surface cell affinity: O(2) plasma < dopamine deposition < RGD conjugation. The synthesis of type I collagen was the highest by the ACL cells cultured on the 700 nm grooved surface conjugated with RGD peptides, indicating that both surface grooved topography and chemistry play a role in modulating collagen production of ACL cells. Furthermore, the type I collagen deposited on the 700 nm PS surface was aligned with grooves/ridges. Our results indicated that both ligand presentation and cell alignment are important in the physiological activities of ACL fibroblasts. Such information is critical for design of biomaterials for ACL tissue engineering.