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Background: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. Study Design: Cohort study; Level of evidence, 2. Methods: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). Results: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, –0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, –0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC ( P = .0001), from 28.8 to 32.4 points for the CKRS ( P = .04), from 11.2 to 7.9 points for the Marx ( P < .0001), and from 75.7 to 91.6 points for the ADLS ( P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. Conclusion: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.

© 2018, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). The structure and function of the anterolateral complex (ALC) of the knee has created much controversy since the ‘re-discovery’ of the anterolateral ligament (ALL) and its proposed role in aiding control of anterolateral rotatory laxity in the anterior cruciate ligament (ACL) injured knee. A group of surgeons and researchers prominent in the field gathered to produce consensus as to the anatomy and biomechanical properties of the ALC. The evidence for and against utilisation of ALC reconstruction was also discussed, generating a number of consensus statements by following a modified Delphi process. Key points include that the ALC consists of the superficial and deep aspects of the iliotibial tract with its Kaplan fibre attachments on the distal femur, along with the ALL, a capsular structure within the anterolateral capsule. A number of structures attach to the area of the Segond fracture including the capsule-osseous layer of the iliotibial band, the ALL and the anterior arm of the short head of biceps, and hence it is not clear which is responsible for this lesion. The ALC functions to provide anterolateral rotatory stability as a secondary stabiliser to the ACL. Whilst biomechanical studies have shown that these structures play an important role in controlling stability at the time of ACL reconstruction, the optimal surgical procedure has not yet been defined clinically. Concern remains that these procedures may cause constraint of motion, yet no clinical studies have demonstrated an increased risk of osteoarthritis development. Furthermore, clinical evidence is currently lacking to support clear indications for lateral extra-articular procedures as an augmentation to ACL reconstruction. The resulting statements and scientific rationale aim to inform readers on the most current thinking and identify areas of needed basic science and clinical research to help improve patient outcomes following ACL injury and subsequent reconstruction. Level of evidence V.

The purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences related to the preferred graft, femoral tunnel positioning, fixation and tensioning methods, antibiotic and anti-thromboembolic prophylaxis, and use of tourniquet and drains. A systematic search of PubMed, Web of Science, and Cochrane Library was performed. Inclusion criteria were surveys of ACL reconstruction trends and preferences published in the past 5 years (2011–2016), involving members of national societies of orthopaedics. Information regarding survey modalities, population surveyed, graft choice both in the general or in the athletic population, surgical technique, fixation, use of antibiotic, tourniquet, drains, and anti-thromboembolic prophylaxis was extracted. Eight national surveys were included from Europe (three), North or Latin America (three), and Asia (two). Overall, 7,420 questionnaires were sent, and 1,495 participants completed the survey (response rate ranging from 16 to 76.6%). All surveys reported the hamstring tendon (HT) autograft as the preferred graft, ranging from 45 to 89% of the surveyed population, followed by bone-patellar tendon-bone (BPTB) graft (2–41%) and allograft (2–17%). Only two surveys focusing on graft choice in athletic population underlined how in high-demand sportive population the graft choices changes in favor of BPTB. Single-bundle reconstruction was the preferred surgical technique in the four surveys that investigated this issue. Five surveys were in favor of anteromedial (AM) portal and two in favor of trans-tibial technique. Suspension devices for femoral fixation were the preferred choice in all but one survey, while interference screws were the preferred method for tibial fixation. The two surveys that investigated graft tensioning were in favor of manual tensioning. The use of tourniquet, antibiotics, drains, and anti-thromboembolic prophylaxis were vaguely reported. A trend toward the preference of HT autograft was registered in all the surveys; however, sport participation has been highlighted as an important variable for increased use of BPTB. Single-bundle reconstruction with AM portal technique and suspension femoral fixation and screws fixation for the tibia seem the preferred solution. Other variables such as tensioning, antibiotic, anti-thromboembolic prophylaxis, tourniquet use, and drains were investigated scarcely among the surveys; therefore, no clear trends could be delineated. This is a Level V, systematic review of expert opinion study.

SummaryRotation combined with translation; compose the three-dimensional motion of the knee subluxation in anterior cruciate ligament deficient knee. The worldwide scientists were focused initially on the translation part of this complex 3D motion, but since the beginning of the century there was a large interest on knee rotational laxity study. Lot of paper reported new devices and results with an explosion since the beginning of the decade. The purpose of this review is to provide an extensive critical analysis of the literature and clarify the knowledge on this topic. We will start with a dismemberment of different rotational laxities reported: the rotation coupled with translation in 2D tests such as Lachman test and anterior drawer test; the rotational envelope considering the maximum internal external rotation; and the “active rotation” occurring in 3D Pivot-shift (PS) test. Then we will analyze the knee kinematics and the role of different anterior cruciate ligament (ACL) bundle on rotation. A review of different mechanical and radiological devices used to assess the different rotations on ACL deficient knees will be presented. Two groups will be analyzed, dynamic and static conditions of tests. Navigation will be described precisely; it was the starter of this recent interest in rotation studies. Opto electronic and electromagnetic navigation systems will be presented and analyzed. We will conclude with the last generation of rotational laxity assessment devices, using accelerometers, which are very promising.

Purpose The purpose of the present study was to investigate if the donor age of nonirradiated Achilles tendon allograft could influence the clinical results of revision anterior cruciate ligament (ACL) reconstruction. Methods All patients that underwent ACL revision between 2004 and 2008 with at least 4 years of follow-up were included. For all the patients that met the inclusion criteria, the age of the graft donor was obtained from the tissue bank. Lysholm score was administered to patients that met inclusion criteria. In addition, patients were divided in two groups based on the donor age ( Results Fifty-two patients were evaluated at a mean 4.8 ± 0.8 years follow-up with Lysholm score. The Lysholm significantly improved from 62.3 ± 6.6 at preoperative status to 84.4 ± 12.3 at final follow-up. The mean donor age was 48.7 ± 8.4 years; a significant difference in Lysholm score was noted between patients that received an allograft with a donor age Conclusion Donor age of nonirradiated Achilles tendon allograft influenced the mid-term results of revision ACL reconstruction, thus advising the use of grafts from young donors. Level of Evidence Level III, retrospective comparative study.

Background: When anterior cruciate ligament (ACL) reconstruction fails, a revision procedure may be performed to improve knee function, correct instability, and allow return to activities. The results of revision ACL reconstruction have been reported to produce good but inferior patient-reported and objective outcomes compared with primary ACL reconstruction, but the degree to which this is the case varies widely among published studies and may be influenced by heterogeneity of patients, techniques, and endpoints assessed. For those reasons, a systematic review may provide important insights. Questions/purposes: In a systematic review, we asked: (1) What is the proportion of revision ACL reconstruction cumulative failures defined as rerupture or objective failure using prespecified clinical criteria at mean followup of at least 5 years? (2) What are the most common complications of revision ACL reconstruction? Methods: A systematic review was performed by searching PubMed/Medline, EMBASE, and CENTRAL. We included studies that reported the clinical evaluation of revision ACL reconstruction with Lachman test, pivot shift test, side-to-side difference with KT-1000/2000 arthrometer, and with a mean followup of at least 5 years. We excluded studies that incompletely reported these outcomes, that reported only reruptures, or that were not in the English language. Extracted data included the number of graft reruptures and objective clinical failure, defined as a knee that met one of the following endpoints: Lachman test Grade II to III, pivot shift Grade II to III, KT-1000/2000 > 5-mm difference, or International Knee Documentation Committee Grade C or D. For each study, we determined the proportion of patients who had experienced a rupture of the revision ACL graft as well as the proportion of patients who met one or more of our clinical failure endpoints. Those proportions were summed for each study to generate a percentage of patients who met our definition of cumulative failure. Complications and reoperations were recorded but not pooled as a result of inconsistency of reporting and heterogeneity of populations across the included studies. Of the 663 screened studies, 15 articles were included in the systematic review. Because one study reported two separate groups of patients with different treatments, 16 case series were considered in the evaluation. Results: The proportion of reruptures (range, 0%–25%) was > 5% in only four of 16 series and > 10% in only one of them. The objective clinical failures (range, 0%–82%) was > 5% in 15 of 16 series and > 10% in 12 of them. The proportion exceeded 20% in five of 16 series. The cumulative failures (range, 0%–83%) was > 5% in all except one series and > 10% in 12 of 16 series; five series had a cumulative failure proportion > 20%. The most frequent complications were knee stiffness and anterior knee pain, whereas reoperations were primarily débridement and meniscectomies. Conclusions: Considering rerupture alone as a failure endpoint in patients who have undergone revision ACL reconstruction likely underestimates the real failure rate, because the percentage of failures noticeably increases when objective criteria are also considered. Whether patient-reported and subjective scores evaluating knee function, level of activity, satisfaction, and pain might also contribute to the definition of failure may be the focus of future studies. Level of Evidence: Level IV, therapeutic study.

© 2017, European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA). Persistent rotatory knee laxity is increasingly recognized as a common finding after anterior cruciate ligament (ACL) reconstruction. While the reasons behind rotator knee laxity are multifactorial, the impact of the anterolateral knee structures is significant. As such, substantial focus has been directed toward better understanding these structures, including their anatomy, biomechanics, in vivo function, injury patterns, and the ideal procedures with which to address any rotatory knee laxity that results from damage to these structures. However, the complexity of lateral knee anatomy, varying dissection techniques, differing specimen preparation methods, inconsistent sectioning techniques in biomechanical studies, and confusing terminology have led to discrepancies in published studies on the topic. Furthermore, anatomical and functional descriptions have varied widely. As such, we have assembled a panel of expert surgeons and scientists to discuss the roles of the anterolateral structures in rotatory knee laxity, the healing potential of these structures, the most appropriate procedures to address rotatory knee laxity, and the indications for these procedures. In this round table discussion, KSSTA Editor-in-Chief Professor Jón Karlsson poses a variety of relevant and timely questions, and experts from around the world provide answers based on their personal experiences, scientific study, and interpretations of the literature. Level of evidence V.

Purpose: During anterior cruciate ligament (ACL) injury, the large external forces responsible for ligament rupture cause a violent impact between tibial and femoral articular cartilage, which is transferred to bone resulting in bone bruise detectable at MRI. Several aspects remain controversial and await evidence on how this MRI finding should be managed while addressing the ligament lesion. Thus, the aim of the present review was to document the evidence of all available literature on the role of bone bruise associated with ACL lesions. Methods: A systematic review of the literature was performed on bone bruise associated with ACL injury. The search was conducted in September 2017 on three medical electronic databases: PubMed, Web of Science, and the Cochrane Collaboration. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used. Relevant articles were studied to investigate three main aspects: prevalence and progression of bone bruise associated with ACL lesions, its impact on the knee in terms of lesion severity and joint degeneration progression over time and, finally, the influence of bone bruise on patient prognosis in terms of clinical outcome. Results: The search identified 415 records and, after an initial screening according to the inclusion/exclusion criteria, 83 papers were used for analysis, involving a total of 10,047 patients. Bone bruise has a high prevalence (78% in the most recent papers), with distinct patterns related to the mechanism of injury. This MRI finding is detectable only in a minority of cases the first few months after trauma, but its presence and persistence have been correlated to a more severe joint damage that may affect the degenerative progression of the entire joint, with recent evidence suggesting possible effects on long-term clinical outcome. Conclusion: This systematic review of the literature documented a growing interest on bone bruise associated with ACL injury, highlighting aspects which could provide to orthopaedic surgeons evidence-based suggestions in terms of clinical relevance when dealing with patients affected by bone bruise following ACL injury. However, prospective long-term studies are needed to better understand the natural history of bone bruise, identifying prognostic factors and targets of specific treatments that should be developed in light of the overall joint derangements accompanying ACL lesions. Levels of evidence: IV, Systematic review of level I–IV studies.

Importance Meniscal tears are frequently associated with anterior cruciate ligament (ACL) injury and the correct management of this kind of lesion during ACL-reconstruction procedure is critical for the restoration of knee kinematics. Although the importance of meniscus in knee biomechanics is generally accepted, the influence of medial and lateral meniscus in stability of ACL-deficient knee is still unclear. Objective The aim of this study was to review literature, which analysed effects in cadaveric specimens of meniscal tear and meniscectomy of medial and lateral meniscus on laxity in the ACL-deficient knee. Evidence review Authors performed a systematic search for cadaveric studies analysing the effect of medial and lateral meniscus tears or resection on kinematics of ACL-deficient knee. Extracted data included year of publications, number of human cadaver knee specimens, description of apparatus testing and instrumented kinematic evaluation, testing protocol and results. Findings Authors identified 18 studies that met inclusion and exclusion criteria of current review. The major finding of the review was that the works included reported a difference role of medial and lateral meniscus in restraining ACL-deficient knee laxity. Medial meniscus tear or resection resulted in a significant increase of anterior tibial displacement. Lateral meniscus lesions or meniscectomy on the other hand significantly increased rotation and translation under a coupled valgus stress and internal-rotation torque/pivot shift test. Conclusions Medial and lateral meniscus have a different role in stabilising the ACL-deficient knee: while the medial meniscus functions as a critical secondary stabilisers of anterior tibial translation under an anterior/posterior load, lateral meniscus appears to be a more important restraint of rotational and dynamic laxity. Level of evidence Level IV, systematic review of level I–IV studies.

Purpose: The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months. Methods: Sixty-two ACLR patients performed a test battery at an average of 6.5 ± 0.7 and 9.5 ± 0.9 months after ACLR. All patients underwent a standardized rehabilitation protocol. The test battery consisted of the following tests: a jump-landing task assessed with the Landing Error Scoring System (LESS), three single-leg hop tasks (single-leg hop test, triple-leg hop test, side hop test), isokinetic quadriceps and hamstring strength at 60, 180 and 300°/s and two questionnaires (IKDC and ACL–RSI). Cut off criteria were set as Limb Symmetry Index (LSI) > 90% (for isokinetic strength and for single-leg hop tasks), LESS < 5, IKDC score within 15th percentage of healthy subjects and ACL–RSI > 56 respectively. Results: At 6 months, two patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACLR. Conclusions: The percentages of patients passing all RTS criteria were low at both 6 and 9 months after ACLR. Quadriceps strength revealed persistent deficits and the lack of improvement in the IKDC score questionnaires shows insufficient self-reported knee function for RTS. Level of evidence: III.

Purpose: To investigate whether an increased magnitude of quantitative rotatory knee laxity is associated with a greater level of generalized joint laxity in ACL-injured and contralateral knees. Methods: A total of 103 patients were enrolled across four international centers to undergo anatomic ACL reconstruction. Rotatory knee laxity was evaluated preoperatively, both in the awake state and under anesthesia, using the standardized pivot shift test. Two devices were used to quantify rotatory knee laxity; an inertial sensor, measuring the joint acceleration, and an image analysis system, measuring the lateral compartment translation of the tibia. The presence of generalized joint laxity was determined using the Beighton Hypermobility Score. The correlation between the level of generalized joint laxity and the magnitude of rotatory knee laxity was calculated for both the involved knee and the non-involved knee. Further, patients were dichotomized into low (0-4) or high (5-9) Beighton Score groups. Alpha was set at < 0.05. Results: Ninety-six patients had complete datasets, 83 and 13 in the low and high Beighton Score groups respectively. In anesthetized patients, there was a significant correlation between the degree of Beighton Score and quantitative pivot shift when analyzing the non-involved knee using the image analysis system (r = 0.235, p < 0.05). When analyzing the same knee, multivariate analysis adjusted for meniscal injury, age and gender revealed an increased odds ratio for patients with increased lateral compartment translation to be part of the high Beighton Score group (OR 1.86, 95% CI 1.10-3.17, p < 0.05). No other correlation was significant. When analyzing the dichotomized subgroups, no significant correlations could be established. Conclusion: The findings in this study suggest that there is a weak correlation between generalized joint laxity and the contralateral healthy knee, indicating increased rotatory knee laxity in these patients. Generalized joint laxity does not appear to correlate with rotatory knee laxity in ACL-injured knees. Level of evidence: Prospective cohort study; level of evidence, 2.

Background: It is still uncertain how surgical reconstruction of the anterior cruciate ligament (ACL) is able to restore rotatory laxity of the involved joint. The desired amount of restraint applied by the ACL graft, as compared with the healthy knee, has not been fully clarified. Purpose: To quantify the ability of single-bundle anatomic ACL reconstruction using hamstring tendons in reducing the pivot-shift phenomenon immediately after surgery under anesthesia. Study Design: Case series; Level of evidence, 4. Methods: An inertial sensor and image analysis were used at 4 international centers to measure tibial acceleration and lateral compartment translation of the knee, respectively. The standardized pivot-shift test was quantified in terms of the side-to-side difference in laxity both preoperatively and postoperatively with the patient under anesthesia. The reduction in both tibial acceleration and lateral compartment translation after surgery and the side-to-side difference were evaluated using the Wilcoxon signed-rank test. Alpha was set at P < .05. Results: A total of 107 patients were recruited for the study, and data were available for 89 patients. There was a statistically significant reduction in quantitative rotatory knee laxity between preoperatively (inertial sensor, 2.55 ± 4.00 m/s2; image analysis, 2.04 ± 2.02 mm) and postoperatively (inertial sensor, –0.54 ± 1.25 m/s2; image analysis, –0.10 ± 1.04 mm) between the involved and healthy joints, as measured by the 2 devices ( P < .001 for both). Postoperatively, both devices detected a lower rotatory laxity value in the involved joint compared with the healthy joint (inertial sensor, 2.45 ± 0.89 vs 2.99 ± 1.10 m/s2, respectively [ P < .001]; image analysis, 0.99 ± 0.83 vs 1.09 ± 0.92 mm, respectively [ P = .38]). Conclusion: The data from this study indicated a significant reduction in the pivot shift when compared side to side. Both the inertial sensor and image analysis used for the quantitative assessment of the pivot-shift test could successfully detect restoration of the pivot shift after anatomic single-bundle ACL reconstruction. Future research will examine how pivot-shift control is maintained over time and correlation of the pivot shift with return to full activity in patients with an ACL injury.

BACKGROUND: Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions. PURPOSE: The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction. MATERIAL AND METHODS: A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well. RESULTS: Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively. CONCLUSIONS: In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

At the current state of the art in anterior cruciate ligament (ACL) reconstruction, multiple techniques have been presented but none has given clearly defined and improved results.One of the main issues concerns the choice of graft. The concept of using xenograft tissue, defined as a graft tissue from one species and destined for implantation in an unlike species, was introduced in order to try to overcome the mechanical and biological concerns associated with synthetic materials and the safety and quality concerns and availability problems of allograft tissue. Xenograft tissue carries the risk of producing an immunological reaction. In order to try to overcome or attenuate the immune response against porcine xenograft tissue, the Z-Process® (Aperion Biologics Inc, San Antonio, Texas, USA) has been developed and used to produce the Z-Lig® family of devices for ACL reconstruction procedures. Z-Lig® is a tendon graft with or without bone blocks, sourced from animal tissue in a manner consistent with what has normally been sourced from human tissue, and processed to overcome anti-Gal-mediated rejection and to attenuate other immunological recognition in humans. All this while ensuring sterility, viral inactivation and preservation of mechanical proprieties appropriate for an ACL reconstruction device. The Z-Lig® device has been tested in skeletally mature monkeys and given interesting and promising results from the preclinical performance and safety profile point of view. On this basis, it was possible to proceed with the first clinical trial involving humans, which gave similar encouraging results.The Z-Lig® device has also been implanted in Italy at the Rizzoli Orthopaedic Institute in Bologna, as a part of international multicenter prospective randomized blinded controlled study aimed at comparing xenograft with allograft tissue.

The pivot shift test is the only physical examination test capable of predicting knee function and osteoarthritis development after an ACL injury. However, because interpretation and performance of the pivot shift are subjective in nature, the validity of the pivot shift is criticized for not providing objective information for a complete surgical planning for the treatment of rotatory knee laxity. The aim of ACL reconstruction was eliminating the pivot shift sign. Many structures and anatomical characteristics can influence the grading of the pivot shift test and are involved in the genesis and magnitude of rotatory instability after an ACL injury. The objective quantification of the pivot shift may be able to categorize knee laxity and provide adequate information on which structures are affected besides the ACL. A new algorithm for rotational instability treatment is presented, accounting for patients’ unique anatomical characteristics and objective measurement of the pivot shift sign allowing for an individualized surgical treatment. Level of evidence V.

The pivot shift test is an important clinical tool used to assess the stability of the knee following an injury to the anterior cruciate ligament (ACL). Previous studies have shown that significant variability exists in the performance and interpretation of this manoeuvre. Accordingly, a variety of techniques aimed at standardizing and quantifying the pivot shift test have been developed. In recent years, inertial sensors have been used to measure the kinematics of the pivot shift. The goal of this study is to present a review of the literature and discuss the principles of inertial sensors and their use in quantifying the pivot shift test.

The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.

Allowing a patient to return to sport and unrestricted physical activity after ACL injury and reconstruction is one of the most challenging and difficult decisions an orthopaedic surgeon has to make. Indeed, many factors have to be taken into account before it can be considered safe for a patients to load a reconstructed knee. The current literature contains plenty of studies aimed at evaluating return to sport, and the factors that may affect or predict this outcome, e.g. intrinsic factors like genetics, biology, type of lesion, anatomical features, motivation and psychology, and extrinsic factors such as graft type, surgical technique, rehabilitation protocols, and biological support. It is possible that awareness of these issues could help the clinician to optimise outcomes, and possibly avoid failures too, although as yet no universal criteria for resuming sport have been produced.

The main purpose of this article was to describe in detail, from the perspective of the clinical end user, a previously presented non-invasive methodology, applied in the treatment of anterior cruciate ligament injury, in which inertial sensors are used to quantify the pivot shift test. The outcomes obtained and relative considerations were compared with findings emerging from a review of the relevant updated literature.The detailed description here provided covers the system, the parameters identified and the testing procedure; it also includes the technical specifications of the hardware, the features introduced in the updated version of the software and the application of the system in clinical practice.The comparison of the technical considerations and clinical results with the updated literature confirmed the system’s optimal ergonomics, good reproducibility and clinical reliability.The novel approach here analyzed has been shown to overcome the weaknesses of other available devices and systems. Therefore, since it can be considered a new paradigm in the quantification of pivot shift test, we can recommend its routine use in clinical practice.

Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopedic procedures performed worldwide. In this regard, magnetic resonance imaging (MRI) represents a useful pre-operative tool to confirm a disruption of the ACL and to assess for potential associated injuries. However, MRI is also valuable post-operatively, as it is able to identify, in a non-invasive way, a number of aspects and situations that could suggest potential problems to clinicians. Graft signal and integrity, correct tunnel placement, tunnel widening, and problems with fixation devices or the donor site could all compromise the surgical outcomes and potentially predict the failure of the ACL reconstruction. Furthermore, several anatomical features of the knee could be associated to worst outcomes or higher risk of failure. This review provides a practical guide for the clinician to evaluate the post-surgical ACL through MRI, and to analyze all the parameters and features directly or indirectly related to ACL reconstruction, in order to assess for normal or pathologic conditions.