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Purpose: The aims of the present study were (1) to evaluate the survival of patellofemoral joint (PFJ) arthroplasty in a large cohort of patients using data obtained from an Italian regional arthroplasty registry and (2) to collect clinical outcomes of a subgroup of patients, with a minimum follow-up of 4 years. The hypotheses were that PFJ arthroplasty is a procedure that had good survival and clinical outcomes, not inferior to those reported in the literature for primary total knee arthroplasty (TKA)., Methods: The Register of Orthopaedic Prosthetic Implants (RIPO) of Emilia-Romagna (ER) (Italy) database was searched for the inclusion of all PFJ arthroplasties implanted between 2003 and 2019. PFJ arthroplasties were excluded if they were implanted in patients who lived outside of the ER. The survival information was extrapolated from the RIPO considering the partial or total revision of the implant as failure; moreover, a subgroup of patients was contacted and interviewed by telephone to collect clinical outcomes. Descriptive statistics were used to summarise the data. The survival curve was calculated and plotted using the Kaplan-Meier method., Results: A total of 126 arthroplasties in 114 patients were included in the final analysis (mean age at surgery 60.1 ± 11.5 years old). The main causes of patellofemoral arthroplasty were primary osteoarthritis (88%) and posttraumatic arthritis (7%). The survival was 90.4 ± 30.6 and 78.8 ± 51.5 at 5 and 10 years of follow-up, respectively. At the latest follow-up, 23 implants failed (18.3%). The main cause of revision was osteoarthrosis progression (34.8%). A total of 44 patients were contacted by telephone to collect clinical outcomes: Western Ontario and McMaster Universities Osteoarthritis Index, functional Knee Society Score, Forgotten Joint Score and Oxford Knee Score. These patients reported good to excellent scores at a medium follow-up of 10.3 ± 4.7 years., Conclusions: The PFJ showed good survival and clinical outcomes and could be considered a valuable option for patients affected by isolated patellofemoral osteoarthritis., Level of Evidence: Level IV., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The aim of this study was to prospectively evaluate the long-term clinical results and failure rate of patients treated with complex salvage procedures using a combined mechanical and biological approach to address unicompartmental knee osteoarthritis (OA) and postpone the need for joint replacement., Methods: Thirty-nine patients (40.3 ± 10.9 years old) affected by unicompartmental OA (Kellgren-Lawrence 3) in stable joints underwent a personalized surgical treatment depending on the specific requirements of the affected compartment, including high tibial osteotomy, osteochondral scaffold, meniscal scaffold and meniscal allograft transplantation. Patients were evaluated with the International Knee Documentation Committee (IKDC), Visual Analogue Scale (VAS) and Tegner scores before surgery, at 3 years and a minimum of 10 years of follow-up., Results: A significant improvement was observed over time in all scores but worsened at the final follow-up. The IKDC subjective score improved from 46.9 ± 16.2 to 79.8 ± 16.4 at 3 years (p < 0.0005) and then decreased to 64.5 ± 21.4 (p = 0.001) at 12 years. A similar trend was confirmed for VAS and Tegner scores. Only two patients subsequently underwent knee arthroplasty, and nine more patients were considered clinical failure, for a cumulative surgical and clinical failure rate of 28.2% at the final follow-up., Conclusion: A personalized, joint-preserving, combined mechanical and biological approach, addressing alignment as well as meniscal and cartilage lesions, is safe and effective, providing a clinical benefit and delaying the need for arthroplasty in young patients affected by unicompartmental knee OA. At the final evaluation, the clinical improvement decreased, but more than two-thirds of the patients still benefited from this treatment at a long-term follow-up., Level of Evidence: Level IV case series., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: To investigate the 90° change of direction (COD) task in an extensive cohort of competitive healthy football players within the CUTtheACL study and to provide normative values and differences between males and females for full-body kinematics based on two-dimensional (2D) video analysis and scoring system., Methods: One-thousand-and-two competitive football (soccer) players (age 16.3 ± 2.8 years, 264 females) were prospectively enroled. Each player performed three preplanned 90° COD tasks per limb. The 2D evaluation was performed through objective measures (collected through three high-speed cameras) of frontal and sagittal plane joint kinematics at the cut initial foot contact (IC) and maximum knee flexion angle. A previously published scoring system was adopted to measure the movement quality of the COD task. The scoring system included five criteria (limb stability [LS], pelvis stability [PS], trunk stability [TS], shock absorption [SA], movement strategy [MS]) ranked from 0/2 (nonadequate) to 2/2 (adequate) with a maximum score of 10/10. Normative data were provided for all the variables; statistical differences between male and female players were investigated (p < 0.05)., Results: A total of 6008 valid attempts were included. Frontal plane knee projection angle (FPKPA) at initial contact was 24.4 ± 9.8° (95th percentile: FPKPA > 40°). The total score was ≤4/10 in 71.2% of the trials, the lowest subscores were LS and PS. Female players showed different movement patterns with lower hip and trunk flexion both at IC and maximum knee flexion angle (p < 0.01, ES = 0.41-0.64). Female players also showed worse scores than males in SA, MS and total score (p < 0.01)., Conclusion: Female players seem more prone to stiffer lower limb strategy and greater pelvis-trunk frontal plane instability than males. Clinicians could adopt normative data and sex-specific differences in players' movement techniques to improve ACL injury risk mitigation protocols., Level of Evidence: Level IV., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Surgeons generally consider the donor age as a factor that negatively influences the quality of allograft used in anterior cruciate ligament (ACL) reconstruction, however, the available evidence does not clearly support this statement. The purpose of the study was to investigate if donor age influences the biomechanical properties of allografts used in ACL reconstruction., Methods: A comprehensive literature search was conducted for all relevant articles using MEDLINE (PubMed), Scopus, and Cochrane Collaboration Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Studies including the analysis of the correlation between biomechanical properties of the allografts and donor age were selected. The role of donor age was labelled as 'none' if absent, 'higher' or 'lower' if the properties were higher or lower in older specimens with respect to younger. The correlation was defined as 'weak' or 'strong' according to each study definition., Results: No conflicting role of donor age was reported for modulus of elasticity, load to failure, strain, stiffness and displacement. The only parameters where the significant results were consistent were the tensile strength and the stress (low or moderate correlations). When considering the tested samples with a donor's age <65 years, a significant role of age was reported in only four out of 13 groups of graft tested (patellar tendon, fascia lata, anterior tibialis tendon and posterior tibialis tendon)., Conclusion: The current literature did not allow to state that the donor age negatively influences the biomechanical properties of allografts, making it impossible to identify a clear age cut-off value to exclude them from ACL reconstruction procedures., Level of Evidence: Level IV, systematic review., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The aim of this study was to assess how gender might affect the clinical outcome and survival of meniscal allograft transplantation (MAT)., Methods: A total of 358 patients (23.2% women, 76.8% men) were treated with fresh-frozen nonirradiated allografts implantated arthroscopically using a single- or double-tunnel technique without bone plugs and peripheral suture to the capsule with 'all-inside' stitches., Results: Patients were evaluated at baseline and 2-year follow-up with the Lysholm score, visual analogue scale (VAS) pain, the Knee Osteoarthritis Outcome Score (KOOS) subscales and Tegner score. Women presented higher body mass index (p < 0.0005), poorer baseline VAS (p = 0.012), Lysholm score (p = 0.005), KOOS symptom (p = 0.034) and KOOS pain (p = 0.030), Tegner score (preinjury and basal, p < 0.0001 and p = 0.002, respectively), a lower number of previous (p = 0.039) and concurrent (p = 0.001) anterior cruciate ligament reconstructions and a higher number of concurrent procedures (p = 0.032) and distal femoral osteotomies (p = 0.024). Worse results were documented in women at 2 years, with lower Lysholm score (p = 0.024) and Tegner score (p = 0.007) and a lower clinical survival rate (p = 0.03) (67.5% vs. 82.2%) in the overall patient cohort. However, the matched-pair analysis only confirmed a lower Tegner score value at 2 years (p = 0.016), while underlying the interplay of sex, age and concomitant cartilage lesions in determining the clinical outcome. The analysis of this large series of patients affected by postmeniscectomy syndrome and treated with MAT revealed gender differences., Conclusion: While both genders benefited from a significant improvement, the female population presents more often with older age, concomitant cartilage lesions and a lower activity level, all factors contributing towards a lower clinical success after MAT., Level of Evidence: Level III, comparative study., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The study aimed to obtain a comprehensive 3D visualization of knee specimens, including the cruciate ligaments and corresponding femoral and tibial bone insertions using a non-destructive micro-CT method., Methods: Knee specimens were fixed in anatomical positions and chemically dehydrated before being scanned using micro-CT with a voxel size of 17.5 μm. RGBA (red, green, blue, alpha) transfer functions were applied to virtually colorize each structure. Following micro-CT scanning, the samples were rehydrated, decalcified, and trimmed based on micro-CT 3D reconstructions as references. Histological evaluations were performed on the trimmed samples. Histological and micro-CT images were registered to morphologically and densitometrically assess the 4-layer insertion of the ACL into the bone., Results: The output of the micro-CT images of the knee in extension and flexion allowed a clear differentiation of the morphologies of both soft and hard tissues, such as the ACL, femoral and tibial bones, and cartilage, and the subsequent creation of 3D composite models useful for accurately tracing the entire morphology of the ligament, including its fiber and bundle components, the trajectory between the femur and tibia, and the size, extension, and morphology of its insertions into the bones., Conclusion: The implementation of the non-destructive micro-CT method allowed complete visualization of all the different components of the knee specimens. This allowed correlative imaging by micro-CT and histology, accurate planning of histological sections, and virtual anatomical and microstructural analysis. The micro-CT approach provided an unprecedented 3D level of detail, offering a viable means to study ACL anatomy., (© 2024. The Author(s).)

Purpose: The aim of this study was to quantify the impact of concomitant meniscal lesions on knee laxity using a triaxial accelerometer in a large population of patients affected by anterior cruciate ligament (ACL) injury., Methods: A total of 326 consecutive patients (261 men and 65 women, mean age 31.3 ± 11.3) undergoing primary ACL reconstruction, were preoperatively evaluated through Lachman and pivot shift tests using a triaxial accelerometer to quantify knee laxity. An analysis based on the presence of meniscal tears assessed during surgery was performed to evaluate the impact of meniscal lesions on knee laxity., Results: The anterior tibial translation (Lachman test) presented significantly higher values in patients with medial meniscal lesions (7.3 ± 1.7 mm, p = 0.049) and both medial and lateral meniscal lesions (7.7 ± 1.6 mm, p = 0.001) compared to patients without concomitant meniscal lesions (6.7 ± 1.3 mm). Moreover, patients with both medial and lateral meniscal lesions presented significantly higher values of anterior tibial translation compared to patients with lateral meniscal lesions (p = 0.049). No statistically significant differences were found between the groups in terms of tibial acceleration (pivot shift test)., Conclusion: This study demonstrated that the contribution of concomitant meniscal lesions to knee laxity can be objectively quantified using a triaxial accelerometer in ACL-injured knees. In particular, medial meniscus lesions, alone or in association with lateral meniscus lesions, determine a significant increase of the anterior tibial translation compared to knees without meniscus tears., Level of Evidence: Level IV., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev)., Methods: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate')., Results: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III)., Conclusion: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications., Level of Evidence: II., (© 2023. The Author(s).)

Purpose: The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision., Methods: The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document., Results: The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below., Conclusion: ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance., Level of Evidence: II., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision., Methods: Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document., Results: The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article., Conclusion: ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults., Level of Evidence: Level II., (© 2023. The Author(s).)

Purpose: To assess the survival rate and associated risk factors of a wide cohort of patient's underwent surgical treatment for posterior cruciate ligament (PCL)-based multiligament knee injury (MLKI) at long-term follow-up and to investigate the long-term patient's reported outcomes (PROMS) and functional activity., Methods: All cases of PCL-based MLKI performed at one single sport-medicine institution were extracted and patient's with a minimum 2 years of follow-up included. VAS, Lysholm, KOOS, Tegner Activity level scores, the incidence and time of return to sport (RTS) and return to work (RTW) were collected before, after surgery and at final follow-up. A multivariate logistic regression was performed to investigate the outcomes associated with the patient's acceptable symptoms state (PASS) for each sub-score of the KOOS. The Kaplan-Meier method with surgical failure (re-operation to one of the reconstructed ligaments) as endpoint was used to perform the survivorship analysis for the entire cohort., Results: Forty-two patients were included and evaluated at an average of 10 years. All PROMS significantly improved from pre- to post-surgery (range η p 2 0.21-0.43, p < 0.05) except for the Tegner score which significantly improved from pre-surgery and to final follow-up (η p 2  = 0.67, p < 0.001). RTW was achieved in the 95.2% after 2.4 ± 1.9 months. RTS was achieved in 78.6% after 6.7 ± 5.0 months. The higher number of surgeries were the significant negative predictors of PASS for the KOOS sub-scales Sport (p = 0.040) and Quality of Life (p = 0.046), while the presence of meniscal lesions was a significant negative predictor of PASS only for the KOOS sub-scale of Sport (p = 0.003). Six patients (14.3%) underwent reoperation and were considered as surgical failures. The global survivorship was 95.2%, 92.6%, 87.1%, and 74.7% at 2, 5, 12, and 15 years, respectively. The survivorship in patient undergoing PMC reconstruction surgery was significantly lower (p = 0.004; HR 7.1) compared to patients without a PMC lesion., Conclusion: Good-to-excellent PROMS could be obtained and maintained at long-term follow-up after surgery, with the higher number of surgeries and meniscal lesions as significant negative predictors of the PASS. Moreover, the presence of a PMC lesion significantly increases the risk of the PCL reconstruction failure., Level of Evidence: III., (© 2023. The Author(s).)

Purpose: A combined anterior cruciate ligament (ACL) reconstruction and high tibial osteotomy (HTO) is considered a valuable treatment in young patients affected by symptomatic medial osteoarthritis and ACL deficiency. However, only a few studies have investigated the outcomes of this procedure, especially in the long term. Therefore, the aim of this study is to report clinical and radiographic outcomes of ACL reconstruction and lateral closing wedge HTO at a mean of 14 years of follow-up., Methods: Patients were prospectively evaluated pre-operatively, after 6.5 ± 2.7 years and 14.3 ± 2.2 years. Patient-reported outcome measures (PROMs) were collected, knee laxity was assessed through KT-1000 arthrometer, and limb alignment and knee osteoarthritis were evaluated on long-cassette radiographs. Survivorship of the surgical procedure was calculated through the Kaplan-Meier method., Results: 32 patients were initially enrolled and completed the mid-term evaluation (6.5 ± 2.7 years), and 23 patients (72%) were available for the final evaluation at 14.3 ± 2.2 years after surgery. Statistically significant improvement was found for all the clinical scores (VAS, WOMAC, Tegner, subjective IKDC, objective IKDC) between the pre-operative status and the mid-term follow-up (p < .001). VAS, subjective IKDC and objective IKDC showed no statistically significant differences (p > .05) between the mid-term and the final follow-up; a significant decrease of WOMAC (p < .05) and Tegner (p < .001) was found from mid-term to final follow-up. Significant progression of osteoarthritis was found for all the knee compartments. The survivorship was 95.7% at 5 years, 82.6% at 10 years, and 72.8% at 15 years., Conclusions: Combined ACL reconstruction and lateral closing wedge HTO showed satisfactory clinical outcomes and survivorship at a mean of 14 years follow-up., Level of Evidence: IV., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results., Methods: All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2 years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer., Results: From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered "Complex" due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as "Isolate". The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5-6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between "Complex" and "Isolate" revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in "Complex" with respect to "Isolate" revisions. Four patients were considered as failures and occurred in patients with "Complex" revisions, none occurred in the "Isolate" (30% vs 0%; p = 0.04)., Conclusion: Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results., Level of Evidence: III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The purpose of this study was to synthesize and quantitatively assess the outcomes of ACL Revision using a quadriceps tendon (QT) graft and to compare them with those of ACL Revisions performed with hamstring tendons (HT) graft., Methods: A comprehensive search based on the PRISMA protocol was performed across PubMed, Scopus, Embase, and Cochrane Library from inception until February 2022. Clinical studies reporting the outcomes of ACL Revision with QT autograft were included. Subjective and Objective IKDC, Tegner activity level, Lysholm knee score, KOOS score, VAS for pain, knee laxity (KT-1000/2000 arthrometer, Lachman test, and pivot-shift test), and graft failure were assessed. A systematic review and meta-analysis were performed and a quality assessment of the included studies was carried out with the MINORS score., Results: Seven studies met the selection criteria and were included in the systematic review for the qualitative synthesis of data. A pooled mean of all the variables was provided for the 7 studies, while 3 studies included a control group of ACL Revision with HT and were included in a meta-analysis. A total of 420 participants with a mean age of 28.9 ± 10.5 years and a mean postoperative follow-up of 39.3 ± 16.4 months were assessed. Of these, 277 patients underwent ACL Revision with QT and 143 patients underwent ACL Revision with HT. In the QT group, average graft failure was 9.8% compared to 17.4% in the HT group. KOOS Sport and pivot-shift test showed better postoperative outcomes in QT than HT, although it was not statistically significant (p = 0.052)., Conclusion: The QT autograft was associated with an improved trend of rotatory laxity, PROMs and failure rate compared to HT autograft after revision ACL reconstruction. The QT autograft for revision ACL reconstruction is supported by the current literature. It is a viable graft that should be considered for both primary and revision ACL reconstruction., Level of Evidence: Level IV., (© 2023. The Author(s).)

Purpose: This study aimed at reporting the long-term second revision rate and subjective clinical outcomes from a cohort of patients who underwent a double-bundle (DB) ACLR first revision with allograft at a single institution., Methods: The Institutional database was searched according to the following inclusion criteria: (1) patients that underwent DB-ACL first revision with Achilles tendon allograft, (2) surgery performed between January 2000 and December 2012, (3) age at revision ≥ 18 y/o. Patients' general information, history, surgical data, and personal contacts were extracted from charts. An online survey platform was implemented to collect responses via email. The survey questions included: date of surgeries, surgical data, date of graft failure and subsequent second ACL revision surgery, any other surgery of the index knee, contralateral ACLR, KOOS score, and Tegner scores., Results: Eighty-one patients were included in the survival analysis, mean age at revision 32 ± 9.2 y/o, 71 males, mean BMI 24.7 ± 2.7, mean time from ACL to revision 6.8 ± 5.4 years, mean follow-up time 10.7 ± 1.4 years. There were 12 (15%) second ACL revisions during the follow-up period, three females and nine males, at a mean of 4.5 ± 3 years after the index surgery. The overall survival rates were 85% from a second ACL revision and 68% from all reoperations of the index knee. Considering only the successful procedures (61 patients), at final follow-up, the mean values for the KOOS subscales were 84 ± 15.5 for Pain, 88.1 ± 13.6 for Symptoms, 93 ± 11.6 for ADL, 75 ± 24.5 for Sport, and 71 ± 19.6 for Qol. Twenty-nine (48%) patients performed sports activity at the same level as before ACLR failure., Conclusions: Double-bundle ACL revision with fresh-frozen Achilles allograft yields satisfactory results at long-term follow-up, with an 85% survival rate from a second ACL revision at mean 10 years' follow-up and good patient-reported clinical scores., Level of Evidence: Level IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The aim of this study is to illustrate an overview of the registries currently operative in many countries to support the introduction of new prospective registries in other countries., Methods: The authors carried out a systematic web research in July 2021 to identify national ACL registries' annual reports and scientific literature on national ACL registries. The latest annual public registry reports were collected and analyzed in this study., Results: There are currently established national ACL registries in Norway, Denmark, Sweden, Luxembourg, New Zealand, the United Kingdom (UK), and the Kaiser Permanente National Anterior Cruciate Ligament Reconstruction Registry in the United States (US). Some differences can be found among the various registries due to the local healthcare system structure, data management rules, and general national laws., Conclusion: It is possible to develop accessible, cost-effective and entirely web-based ACL registries-as demonstrated by the Danish and Swedish registries-respecting the national legislation of different countries. This study supports the introduction of new ACL prospective registries in other countries to obtain valuable information for implementing daily clinical practice., Level of Evidence: IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To analyze the MRI features, in particular bone bruises pattern, of Anterior Cruciate Ligament (ACL) injured footballers, and to correlate them with the characteristics of injury mechanism and situation obtained from direct video footage., Methods: Nineteen professional football (soccer) players that sustained ACL injury while playing during an official match of First League Championship were included in the study. The video of injury was obtained from the Television broadcast. Knee Magnetic Resonance (MRI) was obtained within 7 days from the injury. BB and meniscal lesions were analyzed on MRI, while a video-analysis of mechanisms of ACL injury and injury dynamic were assessed from the videos., Results: The most commonly involved Bone Bruise areas in the knee were the Posterior Lateral Tibial Plateau (LTp) in 16 cases (84%) and the Central Lateral Femoral Condyle (LFc) in 11 cases (58%). Three patients (16%) had bone bruise in the Posterior Medial Tibial Plateau (MTp) while none (0%) had bone bruise in the Medial Femoral Condyle. Based on the bone bruise pattern, 11 (58%) had simultaneous LFc and LTp and were defined "Typical" while 8 (42%) had other locations or no bone bruise and were defined "Atypical". 9 out of 11 injuries (82%) of athletes with "Typical" pattern occurred with a "Pivoting" action", in contrast to only 1 case (12%) in those with "Atypical" bone bruise pattern (p = 0.0055). The most common situational mechanism pattern on video analysis was "pressing" (n = 7) accounting for the 47% of the "indirect" ACL injuries. In terms of movement pattern, ten injuries (52%) occurred during a "Pivoting" movement (7 pressing, 1 dribbling, 1 tackled, 1 goalkeeping), whereas the remaining were classified as "Planting" in four cases, "Direct Blow" in four cases and "Landing"., Conclusion: A well-defined and consistent bone bruise pattern involving the posterior tibial plateau and central femoral condyle of lateral compartment is present in footballers that sustained non-contact and indirect ACL injuries during pivoting with sudden change of direction/deceleration, while heterogeneous patterns were present in those with direct contact or injury mechanisms involving high horizontal velocity., Level of Evidence: Level IV., (© 2022. The Author(s).)

Purpose: Anterior cruciate ligament (ACL) ruptures are considered high burden injuries in sports with high pivotal activity, especially for professional footballers. A lack of evidence exists about long-term follow up of professional elite athletes who underwent ACL reconstruction. The purpose of the study is to analyze the return to play and the career of professional footballers who underwent ACL reconstruction with hamstrings, to evaluate re-rupture and reoperation at either indexed and contralateral knee, and to assess the long-term clinical subjective outcomes and satisfaction., Methods: Twenty-eight professional footballers that underwent 33 ACL reconstructions were retrospectively included in the study. All surgical interventions were performed using hamstring tendons graft and an over the top technique. Inclusion criteria were: inability to compete due to joint instability caused by total or subtotal ACL lesion, patients contracted to a professional football team at time of surgery. Exclusion criteria were: multi-ligament reconstruction or concomitant meniscal allograft transplantation. Patients were contacted by phone and a brief questionnaire about surgery was administered. Subsequently, a Lysholm knee scoring scale was obtained. After that, an online research was performed on publicly available websites in order to retrieve information of the patients included after surgery., Results: In all cases, ACL Reconstruction was performed with hamstring tendons using a non-anatomic Double-Bundle technique in 16 cases (49%), an Over-The-Top Single-Bundle technique in 9 cases (27%), and an Over-The-Top Single-Bundle plus Lateral Plasty technique in 8 cases (24%); moreover, a meniscal lesion was present in 20 cases (61%). Three (9%) of the 33 ACL reconstruction failed (2/16 Double-Bundle, 1/9 Single- Bundle, 0/8 Single-Bundle + Lateral Plasty; p = n.s.), with two of them within 12 months from surgery. Other procedures, mainly arthroscopic meniscectomies, were performed in 10 cases (30%). The first official match was played after an average of 8.0 ± 3.6 (4.6-18.2) months in 31 cases (94%). Patients were evaluated after 12.6 ± 3.3 years (6.7-17.5) from the indexed ACL reconstruction. The average Lysholm score was 94.2 ± 8.3., Conclusions: In our small case-series, professional soccer players were able to return to play at a competitive level with a hamstrings over the top technique. Patients with long careers had a high percentage of reoperation on the contralateral knee., Level of Evidence: IV., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: Abnormal joint biomechanics and poor neuromuscular control are modifiable risk factors for Anterior Cruciate Ligament (ACL) injury. Although 3D motion capture is the gold standard for the biomechanical evaluation of high-speed multidirectional movements, 2D video analysis is a growing-interest alternative because of its higher cost-effectiveness and interpretability. The aim of the present study was to explore the possible association between a 2D evaluation of a 90° change of direction (COD) and the KAM measured with gold standard 3D motion analysis., Methods: Thirty-four competitive football (soccer) players (age 22.8 ± 4.1, 18 male and 16 females) were enrolled. Each athlete performed a series of pre-planned 90° COD at the maximum speed possible in a laboratory equipped with artificial turf. 3D motion analysis was recorded using 10 stereophotogrammetric cameras, a force platform, and three high-speed cameras. The 2D evaluation was performed through a scoring system based on the video analysis of frontal and sagittal plane joint kinematics. Five scoring criteria were adopted: limb stability (LS), pelvis stability (PS), trunk stability (TS), shock absorption (SA), and movement strategy (MS). For each criterion, a sub-score of 0/2 (non-adequate), 1/2 (partially adequate), or 2/2 (adequate) was attributed to the movement, based on objective measurements. The intra-rater and inter-rater reliability were calculated for each criterion and the total score. The Knee Abduction Moment (KAM) was extracted from the 3D motion analysis and grouped according to the results of the 2D evaluation., Results: Excellent intra-rater reliability (ICC > 0.88) and good-to-excellent inter-rater reliability (ICC 0.68-0.92) were found. Significantly higher KAM was found for athletes obtaining a 0/2 score compared to those obtaining a 2/2 score in all the sub-criteria and the total score (20-47% higher, p < 0.05). The total score and the LS score showed the best discriminative power between the three groups., Conclusion: The 2D video-analysis scoring system here described was a simple and effective tool to discriminate athletes with high and low KAM in the assessment of a 90° COD and could be a potential method to identify athletes at high risk of non-contact ACL injury., Level of Evidence: IV., (© 2021. The Author(s).)

Purpose: The increasing incidence of knee injuries among children is well known by sports physicians. Papers dealing with this topic have often collected patient-reported outcomes measures (PROMs) in a retrospective manner; this limitation could lead to a misinterpretation of the results, because pediatric patients might not remember their preoperative conditions adequately. This study aims to evaluate the reliability and the reproducibility of the IKDC pediatric score when administered retrospectively at a 12-month follow-up., Methods: From September 2018 and June 2019, all patients aged 7-18 scheduled for surgery due to different knee pathologies in a single center were considered eligible. Parents were contacted by phone for consent. An open-source platform was implemented to collect the responses: two surveys were created (Q1, Q2). They included general information and the Pedi-IKDC score. Q1 was completed prospectively, while Q2 was completed 12 months after surgery. The two questionnaires were identical, and patients were carefully advised to complete Q2 recalling their health status before surgery. ICC and the concordance correlation coefficient (ρ c ) were used to assess the reproducibility between the prospective and recalled scores., Results: Sixty-six patients responded to Q1 and Q2, and the mean age was 12.9 ± 2.2 years at Q1 and 14.1 ± 2.2 years at Q2. The mean time between Q1 and Q2 was 14.1 ± 2.1 months. Between prospective-IKDC and recall-IKDC, the ICC coefficient was "poor" at 0.32 (CI 0.09 to 0.5) and the ρ c was "poor" at 0.4 (CI 0.29 to 0.51). Mean prospective-IKDC was 76.8 ± 23.52 mean recalled-IKDC was 60.4 ± 11.5 (P < 0.0001), while mean difference was -16.3 ± 2.09. Simple linear regression models showed that Δ-IKDC is independently associated with age at Q1 (R 2  = 0.2676; P0.0001)  and prospective-IKDC (R 2  = 0.653; P < 0.0001)., Conclusions: Retrospective collection of the Pedi-IKDC score is not reliable and has high recall bias. This should be avoided in children with knee conditions., Level of Evidence: III., (© 2022. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To assess the return to sport rate of young professional athletes, to analyze their careers in terms of matches played and league participation over a minimum period of 6 years after Meniscal Allograft Transplantation (MAT), as well as to assess the long-term clinical subjective outcomes and satisfaction., Methods: Thirteen professional athletes (ten soccer and one basketball players, one fencer and one wrestler) with a mean age at surgery of 23.4 ± 4.0 underwent MAT (six medial, seven lateral). The time required to return to sport, post-operative performance level and the number of reoperations were evaluated. At an average follow-up of 9.0 ± 2.8 years, Lysholm, KOOS and Cincinnati scores were administered and collected., Results: Thirteen patients (100%) returned to sports practice after an average period of 11.8 ± 3.8 months. Nine athletes (69%) returned to sports at the same pre-injury level. Overall, 93%, 85%, 62% and 55% were active until the 3rd, the 5th, the 7th and the 9th season after MAT, respectively. Seven patients (54%) underwent a reoperation after MAT, where only two of them (15%) were related to graft problems (one meniscectomy and one graft suture). Of the ten athletes that completed subjective evaluation, the mean Lysholm score was 72 ± 15 (0% "Excellent", 10% "Good", 60% "Fair", 30% "Poor"). Of the athletes with lower scores, one suffered from patellar tendon rupture, one from post-operative infection and one from a previous femoral fracture. The mean Cincinnati knee score was 77 ± 18, while the average KOOS values were 60 ± 34 for sports., Conclusion: Meniscal Allograft Transplantation (MAT) in young professional athletes involved in strenuous activities allowed all patients to return to pre-injury sport and in nearly 70% of cases at their pre-injury level. After five seasons following MAT, 85% of patients were still active or playing more than 20-30 matches per season. On the other hand, nearly 50% underwent at least one reoperation and only 70% of patients were rated as "Good", or "Fair" using the Lysholm score., Level of Evidence: IV., (© 2021. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: To evaluate the in vivo knee laxity in the presence of a partial medial meniscectomy before and after a single-bundle ACL reconstruction with a lateral plasty (SBLP) and to compare it with the knee laxity after a single-bundle ACL reconstruction (SB)., Methods: One-hundred and one patients with ACL tear were enrolled in the study and grouped according to the surgical technique and the meniscus treatment: regarding the SBLP technique (n = 55), 31 patients underwent isolated ACL reconstruction ("SBLP Isolated ACL Group"), while 24 patients underwent combined ACL reconstruction and partial medial meniscectomy ("SBLP ACL + MM Group"); regarding the SB technique (n = 46), 33 patients underwent isolated ACL reconstruction ("SB Isolated ACL Group"), while 13 patients underwent combined ACL reconstruction and partial medial meniscectomy ("SB ACL + MM Group"). Anterior-posterior clinical laxity at 30° (AP30) and 90° (AP90) of knee flexion was quantified before and after surgery through a surgical navigation system dedicated to kinematic assessment., Results: In the ACL-deficient status, the antero-posterior laxity was significantly higher in the presence of a combined MM in both the AP30 and the AP90, with no differences between the two surgical techniques. After the ACL reconstruction, both AP30 and AP90 translations decreased significantly (p < 0.0001) compared to the ACL-deficient status. No differences were found for AP30 and AP90 between SBLP Isolated ACL and SBLP + MM groups, while a significantly higher AP90 translation was found for the SB + MM group compared to the SB Isolated ACL group. Moreover, the AP90 translation in the SB ACL + MM group was significantly higher than the one of the other three groups, i.e., SBLP ACL + MM, SB, and SBLP Isolated ACL group., Conclusion: The ACL reconstruction with lateral plasty reduced the AP knee laxity caused by the medial meniscectomy in the context of an ACL surgery., Level of Evidence: Level II., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The presence and severity of bone bruise is more and more investigated in the non-contact anterior cruciate ligament (ACL) injury context. Recent studies have advocated a correlation between bone bruise and preoperative knee laxity. The aim of the present study was to investigate the correlation between bone bruise and preoperative rotatory knee laxity., Methods: Twenty-nine patients (29.1 ± 9.8 years) with MRI images at a maximum of 3 months after ACL injury (1.6 ± 0.8 months) were included. The bone bruise severity was evaluated according to the International Cartilage Repair Society (ICRS) scale for lateral femoral condyle, lateral tibial plateau, medial femoral condyle, and medial tibial plateau. The intraoperative rotational knee laxity was evaluated through a surgical navigation system in terms of internal-external rotation at 30° and 90° of knee flexion (IE30, IE90) and internal-external rotation and acceleration during pivot-shift test (PS IE, PS ACC). The KOOS score was also collected. The association between ICRS grade of bone bruise and rotational laxity or KOOS was investigated., Results: Significant correlation (p < 0.05) was found between the bone bruise severity on the medial tibial plateau and rotational laxity (IE90, PS IE, and PS ACC) and between the severity of bone bruise on femoral lateral condyle and KOOS-Symptoms sub-score. The presence of bone bruise on the medial tibial plateau was significantly associated with a lateral femoral notch sign > 2 mm (very strong odds ratio). No kinematical differences were found between none-to-deep and extensive-generalized lateral bone bruise, while higher IE30 and IE90 were found in extensive-generalized bicompartmental bone bruise than isolated extensive-generalized lateral bone bruise., Conclusion: A severe bicompartmental bone bruise was related to higher rotatory instability in the intraoperative evaluation of ACL deficient knees. The severity of edema on the medial tibial plateau was directly correlated with higher intraoperative pivot shift, and the size of edema on the lateral femoral condyle was associated with lower preoperative clinical scores., Level of Evidence: Level II., (© 2021. The Author(s).)

Purpose: To compare the results of two meniscal scaffolds, CMI and Actifit, for the treatment of partial meniscal lesions., Methods: A systematic review was performed on the PubMed, Web of Science, Scopus, Embase, and Cochrane databases in January 2021, including randomized controlled trails (RCTs) and prospective and retrospective observational studies on the clinical results of meniscal scaffolds. A meta-analysis of the clinical results was performed; the rate of failures was recorded, as well as radiological results. The quality of the included studies was assessed with a modified Coleman Methodology Score (CMS)., Results: The search identified 37 studies (31 in the last 10 years): 2 RCTs, 5 comparative studies, 26 prospective and 4 retrospective series on a total of 1276 patients (472 CMI, 804 Actifit). The quality of evidence was generally low. An overall significant improvement in all clinical scores was documented for both scaffolds. The meta-analysis showed no differences between the two scaffolds in terms of patient reported outcome measures and activity level. The meta-analysis on the risk of failures documented a risk of failures of 7% in the CMI and of 9% in the Actifit group., Conclusions: There is a growing interest on the results of meniscal scaffolds, with most studies published recently. However, long-term data on the Actifit scaffold and high-level comparative studies are missing. Both CMI and Actifit offered good clinical results with a significant and comparable improvement in symptoms and function, and with a low number of failures over time. Accordingly, with the proper indication, their use may be encouraged in the clinical practice., Level of Evidence: Level IV., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: The deceleration (pressing) is a common situational pattern leading to anterior cruciate ligament (ACL) injury in football. Although mainly assessed for performance purposes, a stronger focus on movement quality might support the screening of at-risk athletes. The aim of the present study was to describe a 2D scoring system for the assessment of the deceleration task and to associate it with the knee joint loading (knee abduction moment) evaluated through the gold standard 3D motion capture. The hypothesis was that lower 2D scores would be associated with higher knee joint loading., Methods: Thirty-four competitive football (soccer) players (age 22.8 ± 4.1, 16 females) performed a series of deceleration tasks. 3D motion analysis was recorded using ten stereophotogrammetric cameras, a force platform, and three high-speed cameras. The 2D qualitative assessment was performed via a scoring system based on the video analysis of frontal and lateral planes joint kinematics for five scoring criteria. The intra- and inter-rater reliabilities were calculated for each 2D scoring criteria. The peak knee abduction moment was extracted and grouped according to the results of the 2D evaluation., Results: An ICC > 0.94 was found for all the 2D scoring criteria, both for intra-rater and inter-rater reliability. The players with low 2D frontal plane scores and low total scores (0-4) showed significantly higher peak knee abduction moment values (p < 0.001). A significant negative rank correlation was found between the total score and the peak knee abduction moment (ρ = - 0.25, p < 0.001)., Conclusions: The qualitative 2D scoring system described successfully discerned between athletes with high and low knee joint loading during a deceleration task. The application of this qualitative movement assessment based on a detailed and accurate scoring system is suitable to identify players and patients with high knee joint loading (high knee abduction moments) and target additional training in the scenario of the primary and secondary ACL injury risk reduction., Level of Evidence: Level IV., (© 2021. The Author(s).)

Purpose: The aim of the present study was to trace knee position at the time of bone bruise (BB) and investigate how much this position departed from the knee biomechanics of an in vivo flexion-extension., Methods: From an original cohort of 62 patients, seven (11%) presented bicompartmental edemas and were included in the study. 3D models of bones and BB were obtained from MRI. Matching bone edemas, a reconstruction of the knee at the moment of BB was obtained. For the same patients, knee kinematics of a squat was calculated using dynamic Roentgen sterephotogrammetric analysis (RSA). Data describing knee position at the moment of BB were compared to kinematics of the same knee extrapolated from RSA system., Results: Knee positions at the moment of BB was significantly different from the kinematics of the squat. In particular, all the patients' positions were out of squat range for both anterior and proximal tibial translation, varus-valgus rotation (five in valgus and two in varus), tibial internal-external rotation (all but one, five externally and one internally). A direct comparison at same flexion angle between knee at the moment of BB (average 46.1° ± 3.8°) and knee during squat confirmed that tibia in the former was significantly more anterior (p < 0.0001), more externally rotated (6.1 ± 3.7°, p = 0.04), and valgus (4.1 ± 2.4°, p = 0.03)., Conclusion: Knee position at the moment of Bone bruise position was out of physiological in-vivo knee range of motion and could reflect a locked anterior subluxation occurring in the late phase of ACL injury rather than the mechanism leading to ligament failure., Level of Evidence: Level IV., (© 2021. The Author(s).)

Purpose: The aim of the study was to evaluate the long-term clinical results, reoperations, surgical failure and complications at a minimum of 20 year of follow-up of the first 8 medial CMI scaffolds implanted by a single surgeon during a pilot European Prospective study., Methods: Seven (88%) out of 8 patients were contacted. The Cincinnati Score, VAS, and Lysholm score were collected. Moreover, magnetic resonance imaging (MRI) was performed on 4 patients at the last follow-up. Complications, reoperations and failures were also investigated., Results: The average follow-up was 21.5 ± 0.5 years. One patient underwent TKA after 13 years from CMI implantation; a second patient underwent valgus high tibial osteotomy 8 years after the index surgery and another patient underwent anterior cruciate ligament hardware removal at 21 years of follow-up. At the final follow-up, 3 patients were rated as "Excellent", 1 as "Good" and 2 as "Fair" according to the Lysholm score. The Cincinnati score and the VAS were substantially stable over time. The MRI showed a mild osteoarthritis progression in 3 out of 4 patients according to the Yulish score, and the CMI signal was similar to the mid-term follow-up revealing 3 cases of myxoid degeneration and 1 case of normal signal with reduced scaffold size., Conclusion: The medial CMI is a safe procedure: satisfactory clinical results and a low failure rate could be expected even at a long-term follow-up. For this purpose, the correct indication as well as correcting axial malalignment and addressing knee instability at the time of the index surgery is mandatory. On the other hand, a mild osteoarthritis progression could be expected even after meniscus replacement., Level of Evidence: IV., (© 2021. The Author(s).)

Purpose: To assess the role of Tibial Plateau Slope (TPS) as risk factor for early Anterior Cruciate Ligament (ACL) reconstruction failure and contralateral ACL injury in a population of patients with less than 18 years of age and operated on with the same surgical technique., Methods: Ninety-four consecutive patients (mean age 15.7 ± 1.5 years) with at least 2 years of follow-up, who underwent ACL reconstruction with a single-bundle plus lateral-plasty hamstring technique in the same centre were included. Subsequent ACL injuries (ipsilateral ACL revision or contralateral ACL reconstruction) were assessed within the first 2 years after surgery. Anterior, central, posterior TPS of medial compartment were measured on lateral radiographs and compared between patients with intact graft and those with a second injury. Cut-off values with sensitivity and specificity were calculated with receiver operating characteristic (ROC) analysis. Survival analysis for second ACL injuries and multivariate analysis were performed., Results: Eight patients (9%) had ipsilateral ACL Revision and eight patients (9%) had contralateral ACL reconstruction. Patients with contralateral injury had a higher Central TPS with respect to those without second injury (12.6° ± 2.8° vs 9.3° ± 3.7°, p = 0.042). No differences were present in patients with ipsilateral ACL revision. Sensitivity and specificity for central TPS slope ≥ 12° to detect a contralateral rupture were 63% and 75% (p = 0.0092), for Anterior TPS were 100% and 52% (p = 0.0009). Patients with TPS values exceeding these cut-offs had higher rate of contralateral ACL injuries (19%vs4%, p = 0.0420) and lower 2-year survival (p = 0.0049). Multivariate analysis identified pre-operative sport level and TPS (either anterior or central) as risk factors for contralateral injuries., Conclusions: Steep tibial plateau slope ≥ 12° is associated with a higher risk of contralateral ACL injury within 2 years after ACL reconstruction in patients less than 18 years of age. However, TPS has no role in early ipsilateral re-injury after combined ACL reconstruction and lateral plasty. The clinical relevance is that both the surgeon and the patient should be aware of this higher risk and consider it in the rehabilitation phase to reduce the incidence of such injuries., Level of Evidence: III.

Purpose: The aim of this study was to describe the sagittal geometry of the trochlear groove in patients who underwent primary TKA, based on intraoperative data acquired with a navigation system., Methods: Intraoperative navigation data were collected from 110 patients. All operations were guided by a non-image-based navigation system (BLU-IGS, Orthokey Italia Srl). The trochlear groove has been described on the three anatomical planes; in particular, on the sagittal plane the hypothesis has been verified that the acquired points are referable to a circle. Using the data collected during intraoperative navigation, possible correlation between the radius of the trochlear groove and other femur dimension (length, AP dimension) was analyzed; the orientation of the trochlear sulcus with respect to the mechanical axis and the posterior condyle axis was analyzed too, searching for possible correlation between groove alignment (frontal and axial) or groove radius and the hip-knee-ankle (HKA)., Results: The average radius of curvature of the femoral trochlea was 25.5 ± 5.6 mm; the difference was not statistically significant between the men and women (n.s. p value). No correlation was found between the trochlear groove radius and the femur length (r = - 0.02) or the HKA-phenotypes (r = 0.03) and between the groove alignment and HKA-phenotypes. On axial plane, the trochlear groove was 3.2° ± 4.3° externally rotated, with respect to the posterior condylar axis; on frontal plane, the trochlear groove was 3.9° ± 5.3° externally rotated, with respect to the mechanical axis. In both cases, no statistically significant differences were found between male and female and between left and right limb (p > 0.05)., Conclusion: The present study shows that the sagittal plane geometry of the femoral trochlea in patients affected by osteoarthritis could be described accurately as a circle. The acquisition of the trochlear morphology intraoperatively can lead to more anatomically shape definition, to investigate deeper its radius of curvature and geometry. Trochlear shape could be used as landmarks for femoral component positioning, thus customizing the implant design, optimize the outcomes and improving anterior knee pain after TKA., Level of Evidence: IV.

Purpose: The aim of this study was to evaluate the efficacy of a new minimally invasive surgical technique for the reconstruction of the medial patellofemoral ligament (MPFL) with fascia lata allograft at 60-month minimum follow-up., Methods: Nineteen consecutive patients with chronic recurrent patellar dislocation were treated with MPFL reconstruction (53% isolate procedure, 47% in combination with other treatments). Seventeen patients (11 males/6 females) were available at 60-month follow-up and were clinically evaluated with validated scores. New episodes of patellar dislocation were considered failures. Radiographic and CT scan evaluation were executed preoperatively and at 60-month follow-up., Results: All clinical scores improved from preoperative assessment to 24-month and 60-month follow-up (p < 0.001). Kujala score increased from 61.2 ± 18.1 to 86.7 ± 8.7 and 82.1 ± 10.2; KOOS increased from 54.5 ± 19 to 86.8 ± 9.6 and 84.3 ± 7.6; VAS for pain decreased from 5.1 ± 2.2 to 2.4 ± 1.5 and 1.7 ± 1.2; Tegner score increased from 3 [2-4] to 5 [3-8] and 5 [3-9], respectively. Objective IKDC improved too. No significant improvements between the 24-month and 60-month follow-up evaluations were recorded. Anterior knee pain was reported in two patients (12%). Treatment failure, a new episode of patellar dislocation 25 months after the surgery, was observed in one patient (6%). Radiographic OA changes were not statistically significant between preop and 60-month follow-up. Tuberosity-troclear groove (TT-TG) distance and the patellar tilt angle were subjected to significant changes due to MPFL reconstruction and associated procedures., Conclusion: MPFL reconstruction with fascia lata allograft, alone or combined with other procedures, is a reliable treatment option for recurrent patellar dislocation with a success rate of 94% and without cartilage deterioration at 60-month follow-up., Level of Evidence: IV.

Purpose: The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures., Methods: All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods., Results: Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500-66%), while a compression system was preferred on the tibial side by 537 (71% of the sample)., Conclusions: This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community., Level of Evidence: III.

Purpose: Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique., Methods: Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated., Results: At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.)., Conclusions: Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient., Level of Evidence: IV.

Purpose: The role of the anterior cruciate ligament (ACL) in knee biomechanics in vivo and under weight-bearing is still unclear. The purpose of this study was to compare the tibiofemoral kinematics of ACL-deficient knees to healthy contralateral ones during the execution of weight-bearing activities., Methods: Eight patients with isolated ACL injury and healthy contralateral knees were included in the study. Patients were asked to perform a single step forward and a single leg squat first with the injured knee and then with the contralateral one. Knee motion was determined using a validated model-based tracking process that matched subject-specific MRI bone models to dynamic biplane radiographic images, under the principles of Roentgen stereophotogrammetric analysis (RSA). Data processing was performed in a specific software developed in Matlab., Results: Statistically significant differences (p < 0.05) were found for single leg squat along the frontal plane: ACL-deficient knees showed a more varus angle, especially at the highest knee flexion angles (40°-50° on average), compared to the contralateral knees. Furthermore, ACL-deficient knees showed tibial medialization along the entire task, while contralateral knees were always laterally aligned. This difference became statistically relevant (p < 0.05) for knee flexion angles included between 0° and about 30°., Conclusion: ACL-deficient knees showed an abnormal tibial medialization and increased varus angle during single leg squat when compared to the contralateral knees. These biomechanical anomalies could cause a different force distribution on tibial plateau, explaining the higher risk of early osteoarthritis in ACL deficiency. The clinical relevance of this study is that also safe activities used in ACL rehabilitation protocols are significantly altered in ACL deficiency., Level of Evidence: III.

Purpose: The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs., Methods: 74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis)., Results: Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence., Conclusions: Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up., Level of Evidence: Retrospective cohort study, Level III.

Purpose: The aim of this study was to report current rehabilitation recommendations after ACL reconstruction in ESSKA community, with a particular focus on the specific criteria utilized to guide activity progression METHODS: A web-based survey was developed to investigate preferences between time-based and functional ACL reconstruction rehabilitation progression milestones of ESSKA community., Results: Eight hundred and twenty completed questionnaires were received. Responders were from 86 different countries worldwide, 63% of them from European countries. Functional criteria were considered more appropriate to decide if a patient can start specific activities/exercises by 67% of the responders. Good core and lower extremity neuromuscular control were the most often used functional criteria for decision-making regarding readiness for sport-specific rehabilitation (66%), sport-specific drills without (65%) and with contact (66%). Strength assessed with an isokinetic dynamometer was considered by about half of the responders a determinant to initiate sport-specific drills without (51%-isokinetic strength, LSI > 80%) and with contact (58%-isokinetic strength, LSI > 85-90%). To determine readiness for sport-specific drills, hop tests were used by 40% of respondents for drills without contact and 48% of respondents for drills with contact., Conclusion: The results of this survey involving mainly orthopaedic surgeons indicate that functional measures are considered more appropriate than milestones based on time from surgery to guide progression through the postoperative rehabilitation process after ACLR. The main clinical relevance of this study is that updated information on collective agreement could be useful for clinicians and physiotherapists to delineate their postoperative treatments after ACLR. These results should be interpreted with caution, as this sample represents only a small portion of ESSKA community involved in knee surgery and treating patients following ACLR., Level of Evidence: III.

Purpose: The aim of the present study was to translate, cross-culturally adapt, and assess the psychometric properties of the Pedi-IKDC and Pedi-FABS scores in the Italian paediatric population with various knee pathologies., Methods: In accordance with the Paediatric Anterior Cruciate Ligament Monitoring Initiative (PAMI) research protocol, the original English versions of the questionnaires were translated into Italian. All patients aged 8-16 and scheduled for knee surgery were considered eligible in the study. An open-source platform was implemented to collect responses to the surveys which included general patient information, the questionnaires Pedi-IKDC, and Pedi-FABS. Two surveys were sent under stable clinical conditions before surgery (Q 1 and Q 2 ); a third survey was sent 3-4 months after surgery (Q 3 ). The following properties were calculated: reliability, internal consistency, criterion validity, responsiveness, and floor/ceiling effects., Results: Eighty-nine patients completed Q 1 , 81 patients completed Q 2 , and 49 patients completed Q 3 . Both questionnaires demonstrated acceptable properties. Pedi-IKDC: standard error of measurement (SEM) = 4.4, smallest detectable change (SDC) = 12.3, interclass correlation coefficient (ICC) = 0.96, Cronbach alpha (α) = 0.92, moderate-to-low correlation to Pedi-FABS, effect size (ES) = 0.79, standardized response mean (SRM) = 0.86, floor = 0%, ceiling = 22%. Pedi-FABS: SEM = 2.1, SDC = 5.8, ICC = 0.94, Cronback alpha (α) = 0.93, moderate-to-low correlation to Pedi-IKDK, ES = 0.60, SRM = 0.51, floor = 19%, ceiling = 0%., Conclusions: The Italian version of Pedi-IKDC and Pedi-FABS is valuable tools for patient assessment, by demonstrating good psychometric properties. In clinical setting, these questionnaires can be used to properly evaluate outcomes in Italian pediatric patients with knee pathologies., Level of Evidence: II.

Background: Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra-articular tenodesis (LET). Yet, few series evaluating these procedures are published., Purpose: To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra-articular procedure., Study Design: Systematic review., Methods: A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra-articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot-shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system., Results: Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16-68 years) and a weighted mean follow-up of 4.9 years (range 1-10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side-to-side arthrometric difference and 80% negative pivot-shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty-nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32-72)., Conclusion: Good mid-term results were obtained for combined revision ACL reconstruction and lateral extra-articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high-level studies supporting this technique., Level of Evidence: IV.

Purpose: To report clinical and functional results of ACL reconstruction in patients over 50 years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients., Methods: A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50 years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score., Results: A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6 years (50-75 years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2 mm (0.2-2.7 mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren-Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64 months., Conclusion: ACL reconstruction in patients older than 50 years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients., Level of Evidence: IV.

Purpose: To determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction., Methods: Patients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively., Results: A total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41-0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3-23.9], p = 0.005)., Conclusion: Non-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction., Level of Evidence: Cohort study, Level III.

Purpose: To assess the relationship between the KiRA triaxial accelerometer and the KT-1000 measurements in the intact, anterior cruciate ligament (ACL) deficient, and ACL reconstructed knee joint for the quantification of the Lachman test. Moreover, the intra- and inter-examiner repeatability of the KiRA device will be determined. It was hypothesized that the side-to-side difference of the anterior tibial translation as measured by the KiRA device would be equivalent to the one measured by the KT-1000 during the Lachman test., Methods: Sixty patients were divided into three groups and have been prospectively included in the present study. Group&#95;A composed of 20 patients with a diagnosis of an isolated ACL tear. Group&#95;B composed of 20 patients who underwent ACL reconstruction with a Single-Bundle Lateral Plasty (SBLP) technique with at least 20 years of follow-up. Group&#95;C was the control group and included 20 patients with no history of ACL lesion. Lachman test has been performed at manual-maximum load on both sides, the involved and the contralateral and analyzed with the two different devices., Results: The KiRA device in terms of side-to-side difference resulted not statistically different from the measurement of the KT-1000 arthrometer for the three study groups (n.s): Group&#95;A: (4 ± 2 mm KiRA, 4 ± 2 mm KT1000), Group&#95;B: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), Group&#95;C: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), an excellent intra- (ICC = 0.88-0.89) and inter-examiner (ICC = 0.79) agreement was found for KiRA measurements., Conclusion: The KiRA (I+, Italy) device offers a valid method to quantify the Lacham test., Level of Evidence: II.

Purpose: Aim of this study is to document if combined meniscal allograft transplantation (MAT) and ACL reconstruction can improve knee function, reduce pain and allow patients with meniscal defect and ACL lesion to resume sport activities., Methods: Fifty MAT, arthroscopically performed without bone plugs and combined with one-stage primary or revision ACL reconstruction, with or without high tibial osteotomy (HTO), were included. Patients (aged 38.2 ± 10.6 years, 87% males) were evaluated at a mean follow-up of 5 years with Lysholm, Tegner and VAS scores. Patient satisfaction was also recorded, together with complications and failures., Results: VAS and Lysholm scores improved significantly (from 63.7 to 24.5 and from 60.6 to 82.7, respectively, p < 0.001), while the Tegner score did not reach pre-injury values (p < 0.001), but it improved significantly compared to pre-surgery values (from 2.8 to 4.6, p < 0.001). Medial MAT reported significantly better results compared to lateral MAT. Patients undergoing concomitant HTO reported a significantly higher decrease of VAS. Younger patients with higher pre-operative pain and lower activity level presented higher satisfaction. Eight patients needed a reoperation. Three patients were considered surgical failures while four were considered clinical failures, for a total of 15% failures., Conclusions: Meniscal allograft transplantation combined with ACL reconstruction represents a safe and suitable treatment, which should be considered as a suitable option in the clinical practice. All evaluated patient profiles, ACL injury in a patient with post-meniscectomy syndrome, failed ACL reconstruction in patients with a meniscus defect, and ACL reconstruction in patients with malalignment due to meniscal defect, benefited from the combined MAT procedure at medium-term follow-up., Level of Evidence: IV.

Purpose: The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique., Methods: Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile]., Results: Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed., Conclusion: This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life., Level of Evidence: Case series, IV.

Purpose: The need of patellar resurfacing in total knee arthroplasty (TKA) is a subject of debate. This systematic review of overlapping meta-analyses aimed to assess and analyze current evidence regarding patellar resurfacing and non-resurfacing in TKA., Methods: A systematic literature search was performed in March 2017 in PubMed, CINAHL and Cochrane Library. Inclusion criteria were meta-analysis of randomized controlled trials that compared TKA with and without patellar resurfacing considering as outcomes re-operations rate, complications, anterior knee pain, functional scores. The quality of meta-analyses was evaluated with AMSTAR score and the most relevant meta-analysis was determined by applying the Jadad algorithm., Results: Ten meta-analyses, published between 2005 and 2015, were included in the systematic review. Two studies found a significantly increased Knee Society Score in the resurfacing group. According to four meta-analyses, anterior knee pain incidence was lower in resurfacing group. Six of the included studies described a greater risk of re-intervention in the non-resurfacing groups. The overall quality of included studies was moderate. The most relevant meta-analysis reported no differences in functional scores and incidence of anterior knee pain between the groups., Conclusions: Comparable outcomes were found when comparing patellar resurfacing and non-resurfacing in TKA. The higher risk of re-operations after non-resurfacing should be interpreted with caution due to the methodological limitations of the meta-analyses regarding search criteria, heterogeneity and the inherent bias of easier indication to reoperation when the patella is not resurfaced. There is no clear superiority of patellar resurfacing compared to patellar retention., Level of Evidence: Level II, systematic review of meta-analyses.

Purpose: Health state utility values are derived from preference-based measurements and are useful in calculating quality-adjusted life years (QALYs), which is a metric commonly used in cost-effectiveness studies. The purpose of this study was to convert the Achilles Tendon Rupture Score (ATRS) to the preference-based European Quality of Life-5 Dimension Questionnaire (EQ-5D) by estimating the relationship between the two scores using mapping., Methods: Data were collected from a randomised controlled trial, where 100 patients were treated either surgically or non-surgically for Achilles tendon rupture. Forty-three and forty-four patients in surgical group and non-surgical group completed the ATRS and the EQ-5D alongside each other during follow-up at three time points. Different models of the relationship between the ATRS and the EQ-5D were developed and analysed based on direct mapping and cross-validation. The model with the lowest mean absolute error was observed as the one with the best fit., Results: Among the competing models, mapping based on using a combination of the ATRS items four, five, and six associated with limitation due to pain, during activities of daily living and when walking on uneven ground, produced the best predictor of the EQ-5D score., Conclusions: The present study provides a mapping algorithm to enable the derivation of utility values directly from the ATRS. This approach makes it feasible for researchers, as well as medical practitioners, to obtain preference-based values in clinical studies or settings where only the ATRS is being administered. The algorithm allows for the calculation of QALYs for use in cost-effectiveness analyses, making it valuable in the study of acute Achilles tendon ruptures., Level of Evidence: II.

Purpose: To perform a systematic review aimed to determine (1) if the postural stability deficit represents a risk factor for ankle sprains; (2) the most effective postural stability evaluation to predict ankle sprains and (3) eventual confounding factors that could influence postural stability and ankle sprain risk., Methods: A systematic electronic search was performed in MEDLINE, EMBASE and CINAHL using the search terms (balance) OR (postural stability) matched with (lower limb) OR (ankle) OR (foot) and (sprain) OR (injury) on October 2 2017. All prospective studies that evaluated postural stability as risk factor for ankle sprains were included. The PRISMA Checklist guided the reporting and data abstraction. Methodological quality of all included papers was carefully assessed., Results: Fifteen studies were included, evaluating 2860 individuals. Various assessment tools or instruments were used to assess postural stability. The injury incidence ranged from 10 to 34%. Postural stability deficit was recognized as risk factor for ankle sprain (OR = 1.22-10.2) in 9 cases [3 out of 3 with Star Excursion Balance Test (SEBT)]. Among the six studies that measured the center-of-gravity sway, five were able to detect worse postural stability in athletes that sustained an ankle sprain. In nine cases, the measurement of postural stability did not show any statistical relationship with ankle sprains (four out of five with examiner evaluation). In the studies that excluded patients with history of ankle sprain, postural stability was reported to be a significant risk factor in five out of six studies., Conclusions: The ultimate role of postural stability as risk factor for ankle sprains was not defined, due to the high heterogeneity of results, patient's populations, sports and methods of postural stability evaluation. Regarding assessment instruments, measurement of center-of-gravity sway could detect athletes at risk, however, standardized tools and protocols are needed to confirm this finding. The SEBT could be considered a promising tool that needs further investigation in wider samples. History of ankle sprains is an important confounding factor, since it was itself a source of postural stability impairment and a risk factor for ankle sprains. These information could guide clinicians in developing screening programs and design further prospective cohort studies comparing different evaluation tools., Level of Evidence: I (systematic review of prospective prognostic studies).

Purpose: A better understanding of patient characteristics and the way common concomitant injuries affect the recovery of muscle function after surgery should help providers to treat patients with anterior cruciate ligament (ACL) injuries. The aim of this study was to determine whether patient characteristics, concomitant injuries and graft choice at ACL reconstruction were associated with symmetrical knee muscle function at one year. The hypothesis was that the presence of concomitant injuries would negatively influence the opportunity to achieve symmetrical knee function at the one-year follow-up., Methods: Data was extracted from the Swedish National Knee Ligament Register and a rehabilitation outcome register between August 2012 and December 2016. The patients had been evaluated with a battery of tests comprising knee extension and flexion strength, vertical jump, hop for distance and the side-hop test one year after ACL reconstruction. Univariable and multivariable logistic regression analyses were performed with achieving a limb symmetry index (LSI) of ≥ 90% in all tests of muscle function as primary outcome., Results: A total of 263 patients with a mean age of 26.7 ± 10.3 years were included in the study (47% females). No patient demographic or intra-operative predictors were found to be significant when attempting to predict the achievement of a symmetrical muscle function. Lateral meniscus injury and a patellar tendon autograft reduced the odds of achieving an LSI of ≥ 90% in knee extension strength, OR = 0.49 [(95% CI 0.25-0.97), p = 0.039] and OR = 0.30 [(95% CI 0.14-0.67), p = 0.0033] respectively. In addition, reduced odds of recovering knee extension strength were found in older patients, OR = 0.76 [(95% CI 0.60-0.98), p = 0.034]. A higher pre-injury level of physical activity increased the odds of recovering knee flexion strength, OR = 1.14 [(95% CI 1.01-1.29), p = 0.037]., Conclusion: Intra-operatively identified concomitant injuries or graft choice did not affect the likelihood of recovering symmetrical performance in five different tests of muscle function one year after ACL reconstruction. However, fewer than one in four patients achieved an LSI of ≥ 90% in all tests., Level of Evidence: Prospective observational study: Level 2.

Purpose: To determine how the incision technique for hamstring tendon (HT) harvest in anterior cruciate ligament (ACL) reconstruction affects the risk of injury to the IPBSN and clinical outcome., Methods: A systematic literature search of the MEDLINE/Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL) and EBSCOhost electronic databases and clinicaltrials.gov for unpublished studies was performed to identify comparative studies investigating injury to the IPBSN after HT ACL reconstruction by comparing at least two different incision techniques. Data were extracted for the number of patients with evidence of any neurologic deficit corresponding to injury to the IPBSN, area of sensory deficit, the Lysholm score and patient satisfaction. The mean difference (MD) in study outcome between incision groups was assessed. The relative risk (RR) and the number needed to treat (NNT) were calculated. The Chi-square and Higgins' I 2 tests were applied to test heterogeneity. Data were pooled using a Mantel-Haenszel random-effects model if the statistical heterogeneity was > 50% and a fixed-effects model if the statistical heterogeneity was < 50%. The risk of bias was evaluated according to the Cochrane Database questionnaire and the quality of evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines., Results: A total of eight studies (three randomized controlled trials (RCTs) and five comparative studies) were included, of which six compared vertical and oblique incisions, one horizontal and vertical incisions, and one compared all three techniques. HT harvest was performed through a vertical incision in 329 patients, through an oblique incision in 195 patients and through a horizontal incision in 151 patients. Considering the meta-analysis of the RCTs, the performance of a vertical incision significantly increased the risk of causing IPBSN deficiency compared with both oblique and horizontal incision [RR 1.65 (CI 1.10-2.49, p = 0.02) and RR 2.45 (CI 1.73-3.47, p < 0.0001), respectively]. A significantly larger area of sensory deficit was found with vertical incisions compared with oblique ones, with an MD of 22.91 cm 2 (95% CI 7.73-38.08; p = 0.04). No significant differences were found between the incision techniques in relation to patient-reported outcomes. The same trend was obtained after the performing a meta-analysis of all eight included studies. The quality of evidence in this meta-analysis was determined as "low" to "moderate", mostly due to inadequate methods of randomization and high heterogeneity among the included studies., Conclusion: The performance of a vertical incision to harvest HTs for ACL reconstruction significantly increased the risk of iatrogenic injury to the IPBSN compared with both oblique and horizontal incisions., Level of Evidence: Level I-III, meta-analysis of comparative studies.

Purpose: The purpose of this study was to translate the Achilles tendon Total Rupture Score (ATRS) into Italian and establish its cultural adaptiveness and validity., Methods: The original version of the ATRS was translated into Italian in accordance with the stages recommended by Guillemin. A web-based survey was developed to test the construct validity of the Italian ATRS. Eighty patients with an average age of 45.5 years (SD 11) were included in the study. The ATRS was completed twice at 5 days intervals for test-retest reliability. The intraclass correlation coefficient was used to calculate the test-retest reliability, and Cronbach's α coefficient was used for internal consistency. Validity was evaluated by external correlation (Spearman's rank correlation coefficient, r) of the ATRS with the Italian versions of the Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the 17-Italian Foot Function Index (17-FFI), the Lower Extremity Functional Scale (LEFS), and the Short-Form 36 (SF-36)., Results: The internal consistency (α = 0.97) and the test-retest reliability (ICC = 0.96) were excellent. The correlation coefficient showed strong correlation of the Italian ATRS with the VISA-A and the LEFS (r = 0.72 and r = 0.70, respectively, p < 0.0001), a weak correlation with the 17-FFI (r = -0.30, p = 0.007), and high-to-moderate correlation with the physical functioning, bodily pain, physical role functioning, social functioning, role emotional, and vitality of the SF-36 (r = 0.75, r = 0.61, r = 0.52, r = 0.49, r = 0.40 and r = 0.34, respectively, p < 0.0001)., Conclusion: The Italian version of the ATRS is a valid instrumentation to assess the functional limitations of Italian patients after Achilles tendon rupture., Level of Evidence: III.