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Aims Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction. This study uses standing MRI to investigate changes in contact area, contact centroid location, and tibiofemoral alignment between ACL-injured knees and healthy controls, to examine the effect of ACL reconstruction on these parameters. Methods An upright, open MRI was used to directly measure tibiofemoral contact area, centroid location, and alignment in 18 individuals with unilateral ACL rupture within the last five years. Eight participants had been treated nonoperatively and ten had ACL reconstruction performed within one year of injury. All participants were high-functioning and had returned to sport or recreational activities. Healthy contralateral knees served as controls. Participants were imaged in a standing posture with knees fully extended. Results Participants’ mean age was 28.4 years (SD 7.3), the mean time since injury was 2.7 years (SD 1.6), and the mean International Knee Documentation Subjective Knee Form score was 84.4 (SD 13.5). ACL injury was associated with a 10% increase (p = 0.001) in contact area, controlling for compartment, sex, posture, age, body mass, and time since injury. ACL injury was associated with a 5.2% more posteriorly translated medial centroid (p = 0.001), equivalent to a 2.6 mm posterior translation on a representative tibia with mean posteroanterior width of 49.4 mm. Relative to the femur, the tibiae of ACL ruptured knees were 2.3 mm more anteriorly translated (p = 0.003) and 2.6° less externally rotated (p = 0.010) than healthy controls. ACL reconstruction was not associated with an improvement in any measure. Conclusion ACL rupture was associated with an increased contact area, posteriorly translated medial centroid, anterior tibial translation, and reduced tibial external rotation in full extension. These changes were present 2.7 years post-injury regardless of ACL reconstruction status. Cite this article: Bone Joint J 2021;103-B(9):1505–1513.

Introduction: The anterior cruciate ligament (ACL) is a crucial ligament structure of the knee that plays a significant role in knee joint stability and competitive sports performance. In order to reestablish knee stability, ACL reconstruction (ACLR) in the presence of rupture has been recognized as the most common surgical management procedure. Case: This study reported six cases of chronic ACL rupture reconstruction using peroneus longus tendon graft. All patients underwent an arthroscopic ACL repair procedure in Sanglah Hospital Bali. In terms of functional outcome, all patients were assessed using the scoring of AOFAS for the ankle and IKDC for the knee. Result: The functional outcomes of the IKDC and AOFAS score were good from all six patients who already underwent ACL reconstruction using peroneus longus graft with a minimum follow-up of one year. Discussion: Chronic ACL ruptures were successfully treated using the peroneus longus tendon graft. Intraoperatively, there were no significant problems from the harvested peroneus longus tendon graft and ACL reconstruction with the graft. All patients showed no complications, including the local infection following the operation. Rehabilitation procedure post-ACL reconstruction was performed at the Rehabilitation Unit in Sanglah General Hospital. Conclusion: Peroneus longus tendon graft is considered a suitable choice of graft for ACL reconstruction. It presented satisfactory results, effectiveness, and safety based on the AOFAS and IKDC scores.

Purpose To determine the accuracy of detection, injury rate and inter- and intrarater reproducibility in visualizing lesions to the anterolateral ligament (ALL) and the deep portion of the iliotibial tract (dITT) in anterior cruciate ligament (ACL) deficient knees. Methods Ninety-one consecutive patients, out of those 25 children (age 14.3 ± 3.5 years), with diagnosed ACL tears were included. Two musculoskeletal radiologists retrospectively reviewed MRI data focusing on accuracy of detection and potential injuries to the ALL or dITT. Lesion were diagnosed in case of discontinued fibers in combination with intra- or peri-ligamentous edema and graded as intact, partial or complete tears. Cohen’s Kappa and 95% confidence intervals (95% CI) were determined for inter- and intrarater reliability measures. Results The ALL and dITT were visible in 52 (78.8%) and 56 (84.8%) of adult-and 25 (100%) and 19 (76.0%) of pediatric patients, respectively. The ALL was injured in 45 (58.5%; partial: 36.4%, compleate: 22.1%) patients. Partial and comleate tears, where visualized in 21 (40.4%) and 16 (30.8%) adult- and seven (28.0%) and one (4%) peditric patients. A total of 16 (21.3%; partial: 13.3%, compleate: 8.0%) dITT injuries were identified. Partal and complete lesions were seen in seven (12.5%) and five (8.9%) adult- and three (15.8%) and one (5.3%) pediatric patients. Combined injuries were visualized in nine (12.7%) patients. Inter-observer (0.91–0.95) and intra-observer (0.93–0.95) reproducibility was high. Conclusion In ACL injured knees, tears of the ALL are observed more frequently compared to lesions to the deep iliotibial tract. Combined injuries of both structures are rare. Clinically, the preoperative visualization of potentially injured structures of the anterolateral knee is crucial and is important for a more personalized preoperative planning and tailored anatomical reconstruction. The clinical implication of injuries to the anterolateral complex of the knee needs further investigation. Level of evidence II.

While there has been significant interest in the documentation of return to sport outcomes following anterior cruciate ligament (ACL) injury, the elite level female athlete has not been a focus of this research. This is despite women being at increased risk for ACL injury and considerable global growth in women participating in sport. Therefore, the focus of this review was to examine the available literature regarding return to sport outcomes in elite level women with an ACL injury. The topics of discussion focus on return to sport rates, timing and determinants of return to sport, longevity of play, return to sport performance, and further ACL injury. Knee health in the longer term is also briefly discussed along with the limitations of the existent literature.

Highlights • The PCL angle in ACL-deficient knee might be false-negative in the presence of bucket handle tear. • There must be always high suspicious of ACL insufficiency in case of medial bucket handle tear. • Profound knowledge of clinical examination patient’s history is absolutely mandatory to examine ACL insufficiency., Introduction Chronic anterior cruciate ligament (ACL) tear might be difficult to diagnose on MRI. Indirect signs might be a typical meniscal or cartilage lesion, or a spontaneous anterior drawer visualized by a decreased angle of the posterior cruciate ligament (PCL). Presentation of case A 27-year-old former ballet dancer was admitted to the emergency department for a locked left knee, without never having experienced previous symptoms of giving way or locking. The MRI performed revealed a medial meniscus bucket handle tear, without traumatic bone marrow oedema or ligament injury. The PCL angle was 130°. A former MRI of her left knee performed 1 year previously to investigate on the recurrent catching of her left knee showed a grade III medial meniscal tear of the posterior horn, and buckling of the PCL angle of 100°, as a sign of chronic ACL rupture. During arthroscopy and medial meniscal repair, the ACL showed complete loss of tension, and was therefore reconstructed simultaneously to enable proper meniscal healing. Discussion and conclusion Chronic ACL insuffiency is a major risk factor for subsequent medial meniscus tear, especially bucket handle tear. The locked knee might unable proper pre-operative clinical examination. The preoperative MRI therefore being the only possibility to diagnose concomitant ligamentous injury. This is the first case reported in literature showing, that a positive PCL angle sign might be falsely negative due to a locked medial meniscus bucket handle tear.

Background:The mechanisms of noncontact anterior cruciate ligament (ACL) injuries are an enormously debated topic in sports medicine; however, the late phases of injury have not yet been investigated.Hypothesis:A well-defined posterior tibial translation can be visualized with its timing and patterns of knee flexion after ACL injury.Study Design:Case series.Level of Evidence:Level 4.Methods:A total of 137 videos of ACL injuries in professional male football (soccer) players were screened for a sudden posterior tibial reduction (PTR) in the late phase of noncontact ACL injury mechanism. The suitable videos were analyzed using Kinovea software for sport video analysis. The time of initial contact of the foot with the ground, the foot lift, the start of tibial reduction, and the end of tibial reduction were assessed.Results:A total of 21 videos exhibited a clear posterior tibial reduction of 42 ± 11 ms, after an average of 229 ± 81 ms after initial contact. The tibial reduction occurred consistently within the first 50 to 60 ms after foot lift (55 ± 30 ms) and with the knee flexed between 45° and 90° (62%) or more than 90° (24%).Conclusion:A rapid posterior tibial reduction is consistently present in the late phases of noncontact ACL injuries in some male soccer players, with a consistent temporal relationship between foot lift from the ground and consistent degrees of knee flexion near or above 90°.Clinical Relevance:This study provides insight into the late phases of ACL injury. The described mechanism, although purely theoretical, could be responsible for commonly observed intra-articular lesions.

Background: Reported rates of graft rupture and contralateral anterior cruciate ligament (ACL) rupture after ACL reconstruction (ACLR) are higher among pediatric patients than adults. Previous series may have underestimated postoperative event risk because of small sample sizes and high proportions of dropouts. Purpose: To calculate rates of graft rupture and contralateral ACL rupture after ACLR in a large pediatric series. Study Design: Case series; Level of evidence, 4. Methods: ACLRs performed in our tertiary care children’s hospital system over a period of >7 years were identified through billing review. Cases were sorted based on operative technique, with all-epiphyseal ACLRs considered separately. Transphyseal ACLRs were divided into 2 groups based on patient age, with a cutoff of 16 years. Clinic follow-up data as well as prospectively collected survey data were used to note graft rupture and contralateral ACL rupture events. Rates of graft rupture and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis. Results: The final data set included 996 patients. A total of 161 patients underwent all-epiphyseal ACLR. Of the remaining transphyseal surgeries, 504 patients were Conclusion: This is the largest series of pediatric ACLRs yet reported, and it shows that the risks of another ACL injury after first-time ACLR are higher than previously reported. The risk of contralateral ACL rupture was lower than that for graft rupture. Our methods, including prospective follow-up surveys and survival analysis to generate cumulative rate estimates, provide a best-practice example for future case series calculations. Our results provide insight into the postoperative course of pediatric patients undergoing ACLR and are crucial for preoperative patient and family counseling. Understanding these risks may also influence return-to-play decisions.

Background Only limited data are available regarding postural stability between anterior cruciate ligament (ACL)-injured patients with medial meniscus (MM) tear and those with lateral meniscus (LM) tear. The purpose of this study was to compare preoperative postural stability for both involved and uninvolved knees in ACL rupture combined with MM and LM tears. It was hypothesized that there would be a significant difference in postural stability between these two groups. Methods Ninety-three ACL-injured patients (53 combined with MM tears vs. 40 combined with LM tears) were included. Static and dynamic postural stability were evaluated with the overall stability index (OSI), anterior–posterior stability index (APSI), and medial–lateral stability index (MLSI) using stabilometry. Knee muscle strength was evaluated using an isokinetic testing device. Results In the static postural stability test, none of the stability indices showed significant differences between the two groups for both knees (p > 0.05). In the dynamic postural stability test for involved side knees, the OSI and APSI were significantly higher in the LM tear group compared to the MM tear group (OSI: 2.0 ± 0.8 vs. 1.6 ± 0.5, p = 0.001; APSI: 1.5 ± 0.6 vs. 1.3 ± 0.5, p = 0.023), but not the MLSI (p > 0.05). In the static and dynamic postural stability tests in each group, there were no significant differences between the involved and uninvolved side knees (p > 0.05). There was no significant difference in the knee muscle strength between the two groups (p > 0.05). All postural stability showed no significant correlation with knee muscle strength (p > 0.05). Conclusion Dynamic postural stability was poorer in patients with ACL rupture combined with LM tear than in those with MM tear. Therefore, close monitoring for postural stability would be necessary during preoperative and postoperative rehabilitation, especially for patients with ACL rupture combined with LM tear. Level of evidence: Level III

Background Within the emergency department (ED) setting, anterior cruciate ligament (ACL) rupture is commonly misdiagnosed, leading to improper treatment and potential meniscal injury and total joint replacement. Utilizing traditional clinical tests to diagnosis ACL rupture leads to the correct diagnosis in about 30% of cases. The lever sign is a new and effective clinical test used to diagnose ACL rupture with 100% sensitivity. Objective We aim to study if the lever sign used in the ED setting is more sensitive to diagnose ACL rupture than traditional tests. Methods Patients between 12 and 55 years of age were examined utilizing either traditional methods or the lever sign. Diagnostic findings in the ED were compared with those of a sports medicine specialist using magnetic resonance imaging as the diagnostic standard. A survey was given to ED providers to collect data on diagnosis and physician confidence in diagnosis. Results The sensitivity of the lever sign was 100% (94.7% accuracy, 93.75% specificity), whereas the sensitivity of the anterior drawer/Lachman test was 40% (87.5% accuracy, 100% specificity). Physician confidence in diagnosis was higher utilizing the lever sign vs. the anterior drawer/Lachman test at 8.45 (±1.82) compared with 7.72 (±1.82) out of 10, respectively. There was no statistically significant association between diagnostic accuracy with either test and level of training of the ED provider. Conclusion Implementation of the lever sign in the ED setting resulted in a higher sensitivity, higher physician confidence in screening test diagnosis, and a decrease in the number of undiagnosed ACL ruptures.

Background Sagittal-oblique technique clearly shows partial rupture because its’ double angulation follows the specific course of the patient’s ligament, due to approximate orientation of the external rotation of the foot. Sagittal-oblique technique provides a higher number of slices presenting the whole course of ACL Objective To value the role of sagittal- oblique technique of MRI adding to the standardized MRI technique in the diagnosis of anterior cruciate ligament injuries. Patients and Methods The study was approved by the hospital ethical committee and all patients agreed to participate in the study. We prospectively evaluated 20 patients with MRI examination of the knee. Patients presented with painful knee joint due to trauma of knee soft tissue structures. They were 9 females and 11 males, ranging in age from 26 to 67 years. Mean age is 39.80 years. Results Accuracy of standard MRI protocol of the knee comparing to additional technique is identical in detection of a complete ACL rupture. Presentations of the partial ruptures of ACL using sagittal-oblique technique were more sensitive than presentation using standard MR protocol. There was statistically significant difference between MRI detection of the ruptured ACL between additional techniques. Sagittal-oblique technique provides a higher number of MRI slices showing the whole course of the ACL and requires a shorter scan time. Conclusion The addition of oblique sagittal technique to the standard MRI imaging improved diagnostic accuracy for detecting partial tear of the ACL. However, oblique sagittal technique is just as precise as the standard MR technique for the evaluation of a complete rupture of the ACL, so it should be used in cases of suspicion of partial rupture of the ACL

Background: Evaluating concomitant injury in patients with anterior cruciate ligament (ACL) rupture is important for predicting long-term results. Meniscofemoral ligament (MFL) rupture has been observed in patients with anterior cruciate ligament rupture in arthroscopic evaluation for ruptured ACL. Objectives: The objective of this study was to investigate the concomitant meniscofemoral ligaments injury in patients with anterior cruciate ligament ruptures via magnetic resonance imaging (MRI). Methods: A total of 200 patients (with ruptured ACL, n = 100; with intact ACL, n = 100) were retrospectively evaluated via MRI. In the group with ruptured ACL; the patients who were diagnosed as having noncontact ACL injuries and had undergone primary ACL reconstructions were included. The control group included 100 patients with suspected ACL rupture (from a similar injury mechanism) and whose MRI revealed an intact ACL. In the group with ruptured ACL, the time from injury to MRI was evaluated. A comparison of the presence of anterior MFL (aMFL) and posterior MFL (pMFL) between the two groups was evaluated. Results: In the ACL ruptured group, a significantly lower presence of aMFL or pMFL was observed compared to the control group (P = 0.001). The time from injury to MRI was significantly higher in the patients with absent MFL defined in MRI relative to the other groups (P = 0.001). Conclusions: We observed absence of MFLs (aMFL and pMFL) in a significant majority of patients with ruptured ACLs. Furthermore, we found a significant relationship between the time from injury to MRI and absence of MFL in the ruptured ACL group.

De-Sheng Chen,* Tong-Fu Wang,* Jia-Wang Zhu, Bo Zhu, Zeng-Liang Wang, Jian-Gang Cao, Cai-Hong Feng, Jun-Wei Zhao Department of Sports Medicine and Arthroscopy, Tianjin Hospital of Tianjin University, Tianjin, People’s Republic of China*These authors contributed equally to this workCorrespondence: Jia-Wang ZhuDepartment of Sports Medicine and Arthroscopy, Tianjin Hospital of Tianjin University, Tianjin, People’s Republic of ChinaEmail zhulingelou@126.comPurpose: We aim to present an unsupervised machine learning application in anterior cruciate ligament (ACL) rupture and evaluate whether supervised machine learning-derived radiomics features enable prediction of ACL rupture accurately.Patients and Methods: Sixty-eight patients were reviewed. Their demographic features were recorded, radiomics features were extracted, and the input dataset was defined as a collection of demographic features and radiomics features. The input dataset was automatically classified by the unsupervised machine learning algorithm. Then, we used a supervised machine learning algorithm to construct a radiomics model. The t-test and least absolute shrinkage and selection operator (LASSO) method were used for feature selection, random forest and support vector machine (SVM) were used as machine learning classifiers. For each model, the sensitivity, specificity, accuracy, and the area under the curve (AUC) of receiver operating characteristic (ROC) curves were calculated to evaluate model performance.Results: In total, 5 demographic features were recorded and 106 radiomics features were extracted. By applying the unsupervised machine learning algorithm, patients were divided into 5 groups. Group 5 had the highest incidence of ACL rupture and left knee involvement. There were significant differences in left knee involvement among the groups. Forty-three radiomics features were extracted using t-test and 7 radiomics features were extracted using LASSO method. We found that the combination of LASSO selection method and random forest classifier has the highest sensitivity, specificity, accuracy, and AUC. The 7 radiomics features extracted by LASSO method were potential predictors for ACL rupture.Conclusion: We validated the clinical application of unsupervised machine learning involving ACL rupture. Moreover, we found 7 radiomics features which were potential predictors for ACL rupture. The study indicated that radiomics could be a valuable method in the prediction of ACL rupture.Keywords: unsupervised machine learning, supervised machine learning, radiomics, anterior cruciate ligament rupture

Background: The anterolateral ligament is a special ligamentous structure traversing the knee joint along its anterolateral part, originating from the lateral femoral epi-condyle, with an oblique course through the joint capsule to be inserted at the anterolateral tibial surface just posterior to Gerdy's tubercle. Evaluation of anterolateral ligament has been done by MRI. The rate of its visualization is by MRI is varying from 50 to 100%. There is a significant increase in the incidence of association between the anterolateral ligament and ACL lesions as detected by MRI.Aim of Study: The present study was aimed to give a comprehensive evaluatation for the ability of MRI to diagnose anterolateral ligaments injuries in patients with acute tears of the anterior cruciate ligaments.Material and Methods: A retrospective study on ninety six patients underwent ACL reconstruction was done. The MRI knee studies of those patients were done within two months after the initial injury and the anterolateral ligament pattern was evaluated; either non-detectable, normal or path-ological. Two expert musculoskeletal radiologists evaluated the images.Results: The present study revealed that 20 (21%) cases of the 96 ACL injured cases, Anterolateral Ligament (ALL) could not be detected (21 %), while 76 (79%) could be detected with MRIs. Twenty cases of the visualized ALLs were seen intact (26%), on the other hand, 56 knees (74%) showed imaging abnormalities. The site of injury of the ALL was involving mainly the distal segment (tibial part) in 34 cases (61%), the proximal segment (femoral part) was less common in 14 cases (25%) and both parts were injured in 8 cases (14%).Conclusion: Anterolateral Ligament (ALL) are commonly associated with acutely ruptured Anterior Cruciate Ligament (ACL). Therefore, MRI findings together with clinical corre-lations are still essential factors in the surgical decision reconstruction of ALL avoiding unsatisfactory results post ACL reconstruction alone.

Outcomes following long-term injuries such as anterior cruciate ligament rupture are unsatisfactory. To improve outcomes, we must improve rehabilitation practices. One aspect of the return-to-sport process that has received limited attention is on-field rehabilitation. This article is part 1 of a 2-part series aimed at discussing the important elements of on-field rehabilitation and illustrating how they can be applied across a 5-stage on-field rehabilitation program following anterior cruciate ligament reconstruction. The intention of on-field rehabilitation is to support athletes in their transition back to sport after injury, from standard rehabilitation to return to the team or practice. In part 1, we describe 4 pillars of high-quality on-field rehabilitation: (1) restoring movement quality, (2) physical conditioning, (3) restoring sport-specific skills, and (4) progressively developing chronic training load. In part 2, we describe how these pillars may be combined into a 5-stage on-field rehabilitation program to help athletes transition to team practice and match play following anterior cruciate ligament reconstruction.

Neuromuscular fatigue is a commonly accepted risk factor for anterior cruciate ligament (ACL) injury. It has been proposed that fatigue leads to transient reductions in muscle strength, and deleterious changes in lower limb kinematics and kinetics, during potentially hazardous tasks such as cutting or landing. The purpose of this clinical commentary is to (1) highlight the complexity of fatigue; (2) discuss the theoretical basis by which it is thought to contribute to ACL injury; and (3) critically discuss the evidence underpinning this hypothesis. Despite a significant amount of research, none of the published fatigue protocols appear to have any consistent effect on any lower limb kinematic or kinetic variables known to increase ACL injury risk. On the contrary, fatigued athletes appear to land with greater peak knee and hip flexion angles, and lower landing forces than unfatigued athletes-all of which are considered favourable movement strategies for reducing ACL loading. These data support recent analyses demonstrating no relationship between player workload in training and competition and the occurrence of ACL injury in sport.

Double radial tears of the lateral meniscus are rare injuries that typically occur in the setting of an acute anterior cruciate ligament rupture. Full-thickness radial tears of the meniscus body and root render the meniscus nonfunctional from a loss of hoop stress resistance. Repair of these tears can normalize contact pressures in the lateral compartment and delay arthritic changes. We describe our technique for repairing a lateral meniscus body radial tear and concomitant posterior root tear, via inside-out suture repair and transtibial suture repair, respectively. This investigation was performed at Mayo Clinic.

Background: Studies have shown that the anterolateral ligament contributes to knee stability. This study aims to compare the results of postoperative physical examinations, knee joint stability tests, and functional assessment tests of patients with intact anterolateral (AL) ligaments and patients with ruptured anterolateral (AL) ligaments. Material and method: This study consisted of 101 patients, with at least a 12-month follow-up period, who underwent an anterior cruciate ligament reconstruction between 2010 and 2016, and whose AL ligaments were evaluated by the radiologist with the preoperative and postoperative magnetic resonance images (MRI). Of these patients, 41 had intact AL ligament (Group 1) in MRI and other 60 had ruptured AL ligament (Group 2). Groups were compared according to postoperative physical examinations, knee joint stability tests, and functional assessment tests. Results: The average Lysholm score of Group 1 was 94.9 (range: 81–100), and the score of Group 2 was 87.2 (range: 74–100). The modified Cincinnati score of Group 1 was 28.7 (24–30), while the score of Group 2 was 25.6 (21–30). The average IKDC subjective knee evaluation score of Group 1 was 91.9 (range: 83–100), and the score of Group 2 was 86.6 (range: 75–100). The average thigh atrophy value was 1.5 centimeters (cm) in Group 1 and 2.4 cm in Group 2. Thirty-three patients in Group 1 were able to jump over 85% of the distance in single-legged hop test compared to the intact side, while 16 patients in Group 2 were able to jump over this distance successfully. As a result of the analysis, it was determined that the Lysholm activity scoring results, the Modified Cincinnati scoring results, IKDC subjective knee evaluation results, two-cycle IKDC activity scale results, comparison of thigh diameters and one leg hop tests of two groups showed a statistically significant difference, and the results of the patients with intact AL ligaments who underwent an ACL reconstruction were found to be better (p < 0.05). No significant difference was found in other examinations and tests. Conclusion: Since the rupture of the AL ligament has negative effects on functional outcomes, we think that the reconstruction of the AL ligament in the same session with the ACL reconstruction or later will have a positive effect on functional outcomes. © 2019 IJS Publishing Group Ltd

Background:Contemporary anterior cruciate ligament (ACL) suture repair techniques have been subject to renewed interest in recent years. Although several clinical studies have yielded good short-term results, high-quality evidence is lacking in regard to the effectiveness of this treatment compared with ACL reconstruction.Hypothesis:Dynamic augmented ACL suture repair is at least as effective as anatomic single-bundle ACL reconstruction for the treatment of acute ACL rupture in terms of patient self-reported outcomes at 2 years postoperatively.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:After stratification and randomization, 48 patients underwent either dynamic augmented ACL suture repair or ACL reconstruction with a single-bundle, all-inside, semitendinosus technique. The International Knee Documentation Committee (IKDC) subjective score at 2 years postoperatively was the primary outcome measure. Patient-reported outcomes (IKDC subjective score, Knee injury and Osteoarthritis Outcome Score, Tegner score, visual analog scale for satisfaction), clinical outcomes (IKDC physical examination score, leg symmetry index for the quadriceps, hamstrings strength, and jump test battery), and radiological outcomes as well as adverse events including reruptures were recorded. Analyses were based on an intention-to-treat principle.Results:The lower limit for the median IKDC subjective score of the repair group (86.2) fell within the prespecified noninferiority margin, confirming noninferiority of dynamic augmented ACL suture repair compared with ACL reconstruction. No statistical difference was found between groups for median IKDC subjective score (repair, 95.4; reconstruction, 94.3). Overall, 2 reruptures (8.7%) occurred in the dynamic ACL suture repair group and 4 reruptures (19.0%) in the ACL reconstruction group; further, 5 repeat surgeries—other than for revision ACL surgery—took place in 4 patients from the dynamic ACL suture repair group (20.8%) and in 3 patients from the ACL reconstruction group (14.3%).Conclusion:Dynamic augmented ACL suture repair is not inferior to ACL reconstruction in terms of subjective patient-reported outcomes as measured with the IKDC subjective score 2 years postoperatively. However, for reasons other than revision ACL surgery due to rerupture, a higher number of related adverse events leading to repeat surgery were seen in the dynamic augmented ACL suture repair group within 2 years postoperatively.Clinical Relevance:Dynamic augmented ACL suture repair might be a viable treatment option for patients with an acute ACL rupture.Registration:NCT02310854 ( ClinicalTrials.gov identifier).

Objective To assess whether a clinically relevant difference exists in patients’ perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens. Design Open labelled, multicentre, parallel randomised controlled trial (COMPARE). Setting Six hospitals in the Netherlands, between May 2011 and April 2016. Participants Patients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months. Interventions 85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment). Main outcomes Patients’ perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months. Results Between May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups −9.3, −14.6 to −4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group. Conclusions In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction. Trial registration Netherlands Trial Register NL 2618.

The purpose of this study was to determine the most reliable radiographic measurement method to evaluate PTS as a risk factor for ACL reconstruction failure. Patients who underwent ACL reconstruction or ACL revision reconstruction between January 2009 and December 2014 by a single surgeon were included. Fifty-two consecutive patients who underwent ACL revision reconstruction were compared to a random selection of 52 patients who underwent primary ACL reconstruction and a control group of 52 patients without ACL injury. ACL reconstruction was performed using either ipsilateral (primary) or contralateral (revision) quadrupled hamstring autograft. Lateral knee radiographs were evaluated using three methods: (1) longitudinal axis, (2) anterior tibial cortex axis, and (3) posterior tibial cortex. A significant difference was found between subjects who underwent ACL reconstruction and control knees (6.79° vs. 5.31°, p = 0.046) using the posterior tibial cortex method. No other statistical significance was found between groups. A multiple linear regression analysis found that the PTS as measured by any method was not affected by the patient’s age, sex, height, weight, and BMI. All methods of measurement for PTS demonstrated excellent (ICC > 0.90) intra-rater and inter-rater reliability, but only the posterior tibial cortex method maintained excellent intra-rater and inter-rater reliability (ICC > 0.90) when evaluating patients with ACL revision reconstruction. The posterior tibial cortex measurement is the most reliable method for analyzing the PTS on lateral knee radiographs in patients undergoing ACL revision reconstruction.

Background: Anterior cruciate ligament (ACL) tears are debilitating injuries frequently suffered by athletes. ACL reconstruction is indicated to restore knee stability and allow patients to return to prior levels of athletic performance. While existing literature suggests that patient-reported outcomes are similar between bone–patellar tendon–bone (BTB) and hamstring tendon (HT) autografts, there is less information comparing return-to-sport (RTS) rates between the 2 graft types. Purpose: To compare RTS rates among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft. Study Design: Systematic review; Level of evidence, 4. Methods: The MEDLINE, Embase, and Cochrane Library databases were searched, and studies that reported on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Studies that utilized ACL repair techniques, quadriceps tendon autografts, graft augmentation, double-bundle autografts, allografts, or revision ACL reconstruction were excluded. RTS information was extracted and analyzed from all included studies. Results: Included in the review were 20 articles investigating a total of 2348 athletes. The overall RTS rate in our cohort was 73.2%, with 48.9% returning to preinjury levels of performance and a rerupture rate of 2.4%. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 81.0%, with 50.0% of athletes returning to preinjury levels of performance and a rerupture rate of 2.2%. Patients after primary ACL reconstruction with an HT autograft had an overall RTS rate of 70.6%, with 48.5% of athletes returning to preinjury levels of performance and a rerupture rate of 2.5%. Conclusion: ACL reconstruction using BTB autografts demonstrated higher overall RTS rates when compared with HT autografts. However, BTB and HT autografts had similar rates of return to preinjury levels of performance and rerupture rates. Less than half of the athletes were able to return to preinjury sport levels after ACL reconstruction with either an HT or BTB autograft.

SUMMARY High-energy tibial plateau fractures are associated with knee fracture dislocations and concomitant ligamentous injury. Both bony and ligamentous injuries can require surgical fixation, often requiring a multidisciplinary team and staged treatment. This article and accompanying video describe the workup and treatment of a Moore type 4 tibial plateau rim compression fracture with posterolateral corner and anterior cruciate ligament rupture that underwent open reduction internal fixation of the tibial plateau with posterolateral corner reconstruction and then staged anterior cruciate ligament reconstruction with quad tendon autograft.

Background: Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common. Purpose: To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection. Study Design: Systematic review. Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was “doxycycline cruciate ligament.” Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group. Results: Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study. Conclusion: Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.

Background:The long-term prevalence of knee osteoarthritis (OA) after anterior cruciate ligament (ACL) injury is unknown, especially in patients without a history of ACL surgery.Purpose:To (1) describe the prevalence of radiographic OA, symptomatic OA, and knee replacement surgery 32 to 37 years after acute ACL injury and to (2) compare the prevalence of radiographic OA, symptomatic OA, and knee symptoms between patients allocated to early ACL surgery or no ACL surgery and patients who crossed over to ACL surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Participants aged 15 to 40 years at the time of ACL injury were allocated to surgical (augmented or nonaugmented ACL repair) or nonsurgical ACL treatment within 14 days of injury. At 32 to 37 years after the initial injury, 153 participants were followed up with plain weightbearing radiographs and completed 4 subscales from the Knee injury and Osteoarthritis Outcome Score (KOOS). Radiographic OA was defined as Kellgren and Lawrence grade 2 or higher. Symptomatic OA was defined as radiographic OA plus knee symptoms measured with the KOOS.Results:Participants allocated to ACL surgery (n = 64) underwent surgery at a mean ± SD of 5 ± 4 days (range, 0-11 days) after injury. Of the 89 participants allocated to no ACL surgery, 53 remained nonsurgically treated, 27 had ACL surgery within 2 years, and 9 had ACL surgery between 3 and 21 years after injury. In the total sample, 95 participants (62%) had radiographic tibiofemoral OA, including 11 (7%) who had knee replacement. The prevalence of radiographic tibiofemoral OA was lower in the group allocated to ACL surgery compared with the group who never had ACL surgery (50% vs 75%; P = .005). The prevalence of symptomatic OA (50% in the total sample) and patellofemoral radiographic OA (35% in the total sample) was similar between groups.Conclusion:Patients allocated to early ACL surgery, performed a mean 5 days after injury, had a lower prevalence of tibiofemoral radiographic OA at 32 to 37 years after injury compared with patients who never had ACL surgery. The prevalences of symptomatic OA, radiographic patellofemoral OA, and knee symptoms were similar irrespective of ACL treatment. Overall, the prevalence of OA after ACL injury was high.Registration:NCT03182647 (ClinicalTrials.gov identifier)

Anterior cruciate ligament (ACL) rupture is a common, debilitating condition that leads to early-onset osteoarthritis and reduced quality of human life. ACL rupture is a complex disease with both genetic and environmental risk factors. Characterizing the genetic basis of ACL rupture would provide the ability to identify individuals that have high genetic risk and allow the opportunity for preventative management. Spontaneous ACL rupture is also common in dogs and shows a similar clinical presentation and progression. Thus, the dog has emerged as an excellent genomic model for human ACL rupture. Genome-wide association studies (GWAS) in the dog have identified a number of candidate genetic variants, but research in genomic prediction has been limited. In this analysis, we explore several Bayesian and machine learning models for genomic prediction of ACL rupture in the Labrador Retriever dog. Our work demonstrates the feasibility of predicting ACL rupture from SNPs in the Labrador Retriever model with and without consideration of non-genetic risk factors. Genomic prediction including non-genetic risk factors approached clinical relevance using multiple linear Bayesian and non-linear models. This analysis represents the first steps toward development of a predictive algorithm for ACL rupture in the Labrador Retriever model. Future work may extend this algorithm to other high-risk breeds of dog. The ability to accurately predict individual dogs at high risk for ACL rupture would identify candidates for clinical trials that would benefit both veterinary and human medicine.

Sinding Larsen-Johansson syndrome is an osteochondrosis injury of patella commonly seen in adolescence age group between 10 to 14 years old. This is an interesting case of Sinding Larsen-Johansson syndrome reported in 33 years old football athlete. This is 33 years old football athlete who is active in participating many football tournaments for 18 years presented with anterior knee pain for 1 month subsequently had traumatic sports injury in one of the football matches. He was diagnosed with complete anterior cruciate ligament rupture, with medial and lateral meniscus injury. MRI confirmed the diagnosis with additional finding of chronic Sinding Larsen-Johansson syndrome. He was rested from football match, and had an intensive physiotherapy focusing on eccentric muscle strengthening exercise. The symptom of anterior knee pain was improved with improvement of the instability. This article discussed in detail on Sinding Larsen-Johansson Syndrome.

The purpose of this study was to identify the anatomical risk factors and determine the role of meniscal morphology in noncontact anterior cruciate ligament (ACL) rupture. A total of 126 patients (63 with noncontact ACL rupture and 63 age- and sex-matched controls) with intact menisci were included in this retrospective case–control study. On knee magnetic resonance imaging (MRI), meniscal morphometry (anterior, corpus, and posterior heights and widths of each meniscus), tibial slope (medial and lateral separately), notch width index, roof inclination angle, anteromedial bony ridge, tibial eminence area, and Q-angle measurements were assessed. The data were analyzed using multiple regression analyses to identify independent risk factors associated with ACL rupture. Using a univariate analysis, medial and lateral menisci anterior horn heights (p

Background: Several single-nucleotide variants (SNVs) in collagen genes have been reported as predisposing factors for anterior cruciate ligament (ACL) tears. However, the evidence is conflicting and does not support a clear association between genetic variants and risk of ACL ruptures. Purpose: To assess the association of previously identified candidate SNVs in genes encoding for collagen and the risk of ACL injury in a population of elite female athletes from high-risk team sports. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 851 female Norwegian and Finnish elite athletes from team sports were included from 2007 to 2011. ACL injuries acquired before inclusion in the cohort were registered by interview. The participants were followed prospectively through 2015 to record new complete ACL injuries. Six selected SNVs were genotyped ( COL1A1: rs1800012, rs1107946; COL3A1: rs1800255; COL5A1: rs12722, rs13946; COL12A1: rs970547). Results: No associations were found between ACL rupture and the SNVs tested. Conclusion: The study does not support a role of the 6 selected SNVs in genes encoding for collagen proteins as risk factors for ACL injury. Clinical Relevance: Genetic profiling to identify athletes at high risk for ACL rupture is not yet feasible.

To monitor longitudinal changes of cartilage oligomeric matrix protein (COMP) in synovial fluid (sf) and serum (s) over 5 years after acute anterior cruciate ligament (ACL) rupture, and to compare results from two commercial COMP immunoassays.Bio-fluids were collected from 121 patients on six occasions over 5 years after acute ACL injury, and from 25 knee healthy reference subjects. Concentrations of sf- and sCOMP were measured by AnaMar (sCOMP-Ana) and by BioVendor (sf- and sCOMP-Bio) immunoassays; other biomarkers were previously assessed. We used ANCOVA for group comparisons and linear mixed models for associations between biomarkers over 5-years with P 0.05 considered a statistically significant difference or association.Compared to the reference group, sfCOMP-Bio concentrations were 2-fold elevated within 6 weeks after ACL injury and remained elevated 5 years thereafter, whereas sCOMP-Bio and sCOMP-Ana concentrations were no different from reference levels at any time point. Over the 5-year period, there was an association between sCOMP-Bio and sCOMP-Ana concentrations, although neither sCOMP-Bio nor sCOMP-Ana associated with sfCOMP-Bio. sfCOMP-Bio associated with SF ARGS-aggrecan, urine type I and II collagens (uNTX-I and uCTX-II) and SF cytokines, while sCOMP-Bio associated inversely with uCTX-II, uNTX-I and SF cytokines.The local process after an acute ACL injury generates increased SF COMP concentrations in the injured knee up to 5 years after injury. This response is not detected in serum. Discrepancies in associations between sCOMP measured by BioVendor and AnaMar immunoassays with other biomarkers indicate differences in detected COMP fragments.

The aim of the present study was to analyse VEGFA rs699947, rs1570360, and rs2010963 polymorphisms with susceptibility to anterior cruciate ligament rupture (ACLR) in a Polish population. The study included 412 physically active Caucasian participants. The study group consisted of 222 individuals with surgically diagnosed primary ACLR qualified for ligament reconstruction (ACLR group). The control group consisted of 190 apparently healthy participants without any history of ACLR (CON group). Three polymorphisms within the VEGFA (rs699947, rs1570360, and rs2010963) gene were chosen for investigation due to their significance in the angiogenesis signalling pathway and previous associations with risk of ACLRs. Both single-locus and haplotype-based analyses were conducted. No significant differences in the allele and genotype frequency distributions were noted for the rs699947 and rs1570360 polymorphisms. In contrast, rs2010963 was associated with risk of ACLR in the codominant (p=0.047) and recessive model (p=0.017). In the latter, the CC genotype was overrepresented among individuals with ACL rupture (23.4% vs 14.2%, OR=1.85 [1.11-3.08]). Two VEGFA haplotypes were associated with ACLR under the additive (global score=11.39, p=0.022) and dominant model (global score=11.61, p=0.020). The [C;G;G] haplotype was underrepresented in the ACLR group (52.2% vs. 60.3%), whereas the [C;G;C] haplotype was overrepresented (2.9% vs 0.5%). The results obtained suggest a potential correlation between the VEGFA rs2010963 polymorphism and ACLR risk, suggesting that harbouring this specific C allele may be an unfavourable risk factor for a knee injury in Caucasian participants from Poland.

Purpose To evaluate the prevalence and characteristics of anterolateral ligament (ALL) injuries with a ruptured acute anterior cruciate ligament (ACL) and to analyze the presence of concomitant bone contusions and meniscal lesions. Methods From March 2015 to March 2017, we retrospectively analyzed 378 patients who underwent primary ACL reconstructions. Using magnetic resonance imaging, we evaluated the presence of ALL injury and concomitant lesions within 3 weeks of the injury. Meniscal tears were also identified on representative arthroscopic images. Results Following the inclusion criteria, we included a total of 275 patients in this study. The mean duration from ACL rupture to magnetic resonance imaging examination was 5.0 ± 6.0 days. We visualized ALL in 98.2% of patients, of whom 64% had ALL injuries (10.9%, 4.7%, and 48.4% were complete ruptures, Segond fracture, and partial ruptures, respectively). We found that ALL injuries were most commonly found in the femoral location. The intra- and interobserver agreement on the severity of ALL injury (κ = 0.83 and 0.81, respectively) and the location of ALL injury (κ = 0.85 and 0.84, respectively) were excellent. The association between ALL injury and lateral meniscal lesions was significant (P = .03). In particular, the proportion of the lateral meniscal posterior horn radial tears was significantly larger in nonintact ALL than in intact ALL (P = .042). The correlation between the severity of ALL injury and the degree of bone contusion at lateral compartments was significant but weak (P Conclusions We found that more than half of acute ACL ruptures have ALL injuries. The presence of ALL injury was significantly associated with the presence of lateral meniscal lesions, especially lateral meniscal posterior horn radial tears, or lateral bone contusions. Interestingly, the severity of ALL injury significantly correlated with the degree of lateral bone contusions. Level of Evidence Level III, diagnostic cross-sectional study.

To analyze and compare clinical outcomes after anterior cruciate ligament (ACL) reconstruction 5 and 10 years postsurgery between patients with concomitant intra-articular injuries and those with isolated ACL injury at reconstruction.Registrations were made using a web-based protocol by physicians for baseline and surgical data. Patients registered their Knee Injury and Osteoarthritis Outcome Score (KOOS) preoperatively and at 5 and 10 years postsurgery. The exclusion criteria for the present study were revisions of previously unregistered ACL surgeries, non-ACL surgeries, patients for whom 10-year follow-up data had not yet been collected, and the proportion of index surgeries that were revision or contralateral interventions.There were 1,295 KOOS scores available for patients 5 years postsurgery, and 1,023 10 years postsurgery from a baseline of 2,751 index reconstructions. A deterioration between the 5- and 10-year scores was observed for patients with concomitant meniscus injury on the KOOS subscales for pain (P = .015), symptoms (P = .005), sport and recreation (P = .011), and knee-related quality of life (QoL) (P = .03) compared with patients with isolated ACL injury. Correspondingly, KOOS subscale score deterioration was seen for combined concomitant cartilage and meniscus injuries for pain (P = .005), symptoms (P = .009), sport and recreation (P = .006), and QoL (P.001). The largest deteriorations were found in sport and recreation (-5.9 points; confidence interval [CI] -10.1, -1.1) and QoL (-6.5 points; CI -10.3, -2.8) subscale scores for patients with concomitant meniscal and cartilage injuries. A similar pattern was not seen between patients with concomitant cartilage injury and isolated ACL injury.The present study reveals that concomitant meniscus injuries at the index operation, either in isolation or in combination with cartilage lesions, render a deterioration of scores on the KOOS outcome subscales for pain, sport and recreation, and quality of life between 5- and 10-year postsurgery follow-up of ACL-reconstructed patients. No such deterioration was seen for patients who had isolated ACL injury.Level III, retrospective analysis of prospectively collected data.

Physiotherapy Management In Post Op Reconstruction Anterior Cruciate Ligament Sinistra Grade III Due To Rupture In RSPAD Gatot Soebroto. Therefore the role of physiotherapy is very important in optimizing the motion and function in patients with post op reconstruction Anterior Cruciate Ligament sinistra Grade III due to Rupture. Physiotherapy may begin on the first day after reconstruction, the exercises being performed depending on the phases based on the day after reconstruction of the Anterior Cruciate Ligament rupture are performed.Based on the above explanation, the authors raised cases after reconstruction of Anterior Cruciate Ligament rupture as the final task implementation. The case discussed is the condition of a patient of Post Op Reconstruction Anterior Cruciate Ligament Sinistra Grade III due to Rupture at Central Hospital of Gatot Subroto.Keywords: Physiotherapy, Anterior Cruciate Ligament Sinistra, Rupture

The use of Kinesio tape (KT) to improve proprioception is a matter of considerable debate. In comparison, the rupture of the anterior cruciate ligament is a sufficiently well-investigated injury with a proven compromise of proprioception. The objective of the present study was to assess a supportive effect on proprioception after KT application, taking the anterior cruciate ligament (ACL) rupture as an example. Forty-eight patients who had suffered an ACL rupture, confirmed clinically and by magnetic resonance imaging, and who were treated conservatively or were awaiting surgery were included in this study. In all patients, a gait analysis was performed on the affected leg before and after KT application. In addition, the IKDC score, the Lysholm score, stability using the Rolimeter, and the angle reproduction test were determined. Thirty-nine men and nine women who had had an ACL rupture for at least 3 weeks were included in the study. Significant improvements were achieved on the affected knee joint for the gait analysis parameters touchdown and unrolling, cadence, stability and stance phase as well as an extension of the hip joint. The Lysholm score improved from 79.3 to 85.8 (p

Objective: to determine the influence of rs12722 (C/T)COL5A1 gene variation on ACL rupture in Europeans of Ural region of Russia. Materials and methods: the case group included 173 patients with diagnosed anterior cruciate ligament (ACL) ruptures; control group included 370 asymptomatic persons. Both groups were similar on a sex, age, growth, weight and BMI. Results: the following genotypic frequencies were observed (in %): case group - a T/T of 34,1, C/T of 46,8, C/C of 19,1; control group - a T/T of 25,4, C/T of 50,8, C/C 23,8. Genotypic frequencies in both groups met Hardy-Weinberg equilibrium. Significant difference of allelic frequencies was revealed between two groups (p = 0,039). Persons with a T/T genotype had a significantly increased risk of ACL ruptures in comparison with persons with C/T + C/C genotypes (x2 = 4,408, p = 0,036, OR = 1,52, 95% confidence interval: 1,027 - 2,249). Conclusions: this is the first study that shown the association of rs12722 COL5A1 gene variation with risk of an ACL rupture in Russian population.

The authors conducted an analysis of national and foreign scientific publications dedicated to the problems in treatment of patients with ruptures of the anterior cruciate ligament of the knee joint. The results of the analysis demonstrated that such lesions still remain the key knee pathology resulting from sports injuries that significantly affect knee function and require timely reconstructive surgical correction. Based on the study the key areas of improvement in treatment for mentioned category of patients have been identified. This is the biomechanically justified single bundle anatomical ACL reconstruction which is currently widely applied in the clinical practice by using of an isometrically located autograft. Such technique represents a radically new stage in the development of treatment methods for young and middle-aged patients with high functional demands.

The occurrence of posterior root tear of both the lateral and medial menisci, combined with anterior cruciate ligament rupture, is rare. Problems may be encountered such as the difficulty to access the medial meniscal root tear, the confusing circumstances about which structure to repair first, and the possibility of the tunnel for each repair to become taut inside the tibial bone. We present the arthroscopy technique step by step to overcome the difficulties in an efficient and time-preserving manner.

As female athlete sports participation has continued to increase, the rate of anterior cruciate ligament (ACL) rupture in female athletes has also increased. Individualized, patient-specific treatment is crucial to achieving optimal outcomes; ACL reconstruction must accurately restore native ACL anatomy and address any concomitant injury to secondary stabilizers. Rehabilitation programs should target hip, core, and trunk neuromuscular control; allow adequate time for graft ligamentization; and address the psychosocial needs of the athlete.

Severe metallosis following medial unicompartmental knee arthroplasty (UKA) is relatively rare. It is usually due to long-standing wear of the polyethylene component, resulting in frictional wear between the femoral and tibial metallic components. Biomechanical and cadaveric studies have shown the effects of anterior cruciate ligament (ACL) transection following medial UKA. We describe a case of a 58-year-old male who developed attritional rupture of the ACL 16 months following medial UKA leading on to early accelerated failure over the next 8 months. The patient underwent revision to total knee arthroplasty with good outcome. The clinical effect of spontaneous ACL transection on medial UKA causing abnormal posteromedial wear of polyethylene component and tibial tray, massive metallosis, and worsening of mechanical axis can be demonstrated in this case report. Keywords: Massive metallosis, Metallosis following UKA, Medial unicompartmental knee arthroplasty, Attritional ACL rupture, Early accelerated failure of UKA

Background: Anterior cruciate ligament (ACL) injury is a well-known risk factor for the development of posttraumatic osteoarthritis (PTOA). However, whether using continuous passive motion (CPM) with or without additional treadmill exercise (TRE) in early ACL injury might provide chondroprotective effects and further decrease the risk of PTOA has yet to be determined. Hypothesis: CPM may offer an enhanced chondroprotective effect, but TRE may attenuate that effect due to the mechanical stress on the joint and inflammatory cytokines in the joint. Study Design: Controlled laboratory study. Methods: Thirty adult New Zealand White male rabbits were randomly allocated to sedentary (SED), CPM, TRE, or CPM+TRE groups. Each rabbit underwent an ACL transection (ACLT) on the right knee, with the contralateral knee used as an internal control (sham). The 4 joint surfaces (ie, medial and lateral femoral condyles and tibial plateaus) were evaluated 4 weeks after surgery for gross appearance, histological characteristics, and quantitative osteoarthritis (OA) scores. Results: Overall, at the end of testing, the CPM group experienced the best protective therapeutic effects in all compartments. In gross appearance, CPM resulted in normal articular surfaces, while the TRE and SED groups exhibited surface abrasion. Histological analysis showed significant differences in articular cartilage status. The CPM group had significantly better histological OA scores ( P < .01), corresponding to the smoothest cartilage surface and sound chondrocyte and collagen arrangement. This group also showed abundant glycosaminoglycan (GAG) content and a sound growth microenvironment, with significantly lower expression levels of the inflammatory cytokine tumor necrosis factor α and the apoptotic marker caspase 3. In contrast, the TRE and SED groups showed several features of damage: distinct graded cartilage abrasion; damaged collagen fibers, corresponding to noticeable collagen type X (osteoarthritic cartilage); reduced cartilage thickness; fewer cartilaginous cells; and the appearance of chondrocyte clusters. These groups also showed loss of GAG, corresponding to higher levels of inflammatory cytokines and apoptosis of articular chondrocytes. Furthermore, the CPM+TRE group displayed visible pathological changes in the superficial cartilage, indicating that early loading exercise may contribute to osteoarthritis. The sham treatment showed no difference in the changes in all compartments between groups. Conclusion: Immediate CPM therapy produces a superior in situ microenvironment for reducing the occurrence of PTOA after ACL injury without reconstruction in rabbits. Clinical Relevance: These data suggest that immediate application of CPM therapy may be necessary to create a sound microenvironment in joints and possibly to decrease the risk of PTOA without or while awaiting ACL reconstruction. In contrast, both early active loading exercise and inactivity lead to the development of PTOA.

Small animal models are critical for studies of sports-related knee injury and disease such as posttraumatic osteoarthritis (PTOA) following anterior cruciate ligament (ACL) rupture. In such models, ACL damage can be achieved by surgical transection or, using a more recent innovation, by noninvasive biomechanical means. Whether these approaches differentially alter normal mechanics is unknown. Furthermore, while surgical reconstruction of ruptured ACL can greatly improve joint stability, its effect on PTOA development is also unclear. Our primary purpose was to characterize rodent knee joint mechanics in two models of ACL rupture using a novel quantitative laxity mechanical test. Our secondary aim was to characterize a new reconstruction technique using autograft tail tendon, and to assess its effect on joint mechanics. Our hypothesis was that surgical ACL transection would have a greater effect on joint mechanics. A total of 24 rat knee specimens underwent surgical or biomechanical ACL rupture and were stabilized using a new reconstruction technique using autograft tail tendon. Joint mechanics were assessed three times; preinjury, postinjury, and again after reconstruction, using quantitative joint laxity testing. Primary test readouts were maximum anteroposterior (AP) laxity, loading curve slope, and energy absorption. Student's t-tests were performed to identify intragroup differences. All surgical transections were completed successfully; maximum load in the biomechanical model was 67 ± 7.7 N, with a coefficient of variation of 11.43%. Surgical transection caused increased AP laxity, while biomechanical injury nonsignificantly increased this parameter. In both cases, these changes recovered to baseline by reconstruction. Loading curve slope was reduced in both models and was also returned to baseline by repair. Energy absorption followed the same pattern except it remained significantly different from baseline postreconstruction in the surgical group. This study supports our hypothesis knee joint mechanics is differentially affected by injury mechanism in a small animal model. We also report a novel reconstruction technique in this model, using autograft tail tendon.

Anterior cruciate ligament (ACL) rupture is one of the most frequently encountered traumatic ligamentous lesions of the knee. Several intrinsic and extrinsic factors are linked to this lesion. Anatomical factors increase the anterior translation of the knee and thus promote the stretching and rupture of the anterior cruciate ligament. Objectives: To determine the anatomical risk factors favouring ACL rupture by comparing morphometric parameters of patients with knee ACL rupture to patients without ACL rupture, as well as the intercondylar notch index and the tibial slopes of the two groups and describing the ruptured ACLs and associated signs. Materials and Methods: We conducted a case-control descriptive analytical study in imaging centres of the General Henri Mondor of Aurillac Hospital Centre in France (CHM) and the Jordan Medical Centre of Yaounde in Cameroon (CMJ). MRI exam protocols included T1 SE, T2 SE, proton density and Fat Sat sequences, with slices in all three planes. Morphometry knee variables measured in our study were: intercondylar notch index and the tibial slopes. These measurements were obtained from images stored in DICOM format and post processing software OsiriX MD® for CMJ patients and Explore® for CHM patients. Results: The study included 92 individuals, 38 in the case group and 54 in the control group. The mean age was 36.6 years for both groups; 35.5 years for the cases and 37.4 years for the controls. The sex ratio was 1.87 men for 1 woman in both groups; 2.16 men for 1 woman for the case group. 53% of ACL ruptures are partial, with the predominant direct sign being morphologic and signal abnormalities of the ACL. The most significant indirect sign of ACL rupture was mirror-image bone contusion that was observed in 47.3% of cases. In the case group, the mean lateral tibial slope was 4.003°, whereas it was 2.92° in the control group. The comparison of means was estimated at approximately 0.039 (p < 0.05), corresponding to a statistically significant difference. The means of the intercondylar notch indices were: 0.28 for the case group and 0.26 for the control group. The means of the median slopes were 4.93 for the case group and 4.90 for the control group. Conclusion: The increase in the lateral tibial slope was a risk factor for anterior cruciate ligament rupture in our study population. Intercondylar notch index and medial tibial slope did not show any statistical significant difference.

Bilateral simultaneous anterior cruciate ligament ruptures are very rare and only a few cases have been previously reported in the orthopedic literature. We present a case of simultaneous bilateral ACL tears in an actor who sustained injuries after landing from a guitar jump during a theatre performance. The patient underwent a two-stage bilateral ACL reconstruction using bone-patellar-tendon-bone autograft.

To investigate whether Kinesio tape (KT) application improves proprioception, balance, and functional performance in patients with anterior cruciate ligament rupture (ACLr). This retrospective analysis included 48 male patients with surgically-untreated ACLr who attended the Sports Medicine and Rehabilitation Center, Qingdao Municipal Hospital, China between June 2017 and June 2018. KT was applied to induce a detoning effect on the quadriceps muscle and toning effect on the ischiocrural muscles. Proprioception, balance, and functional performance were assessed before and 1 and 7 days after KT application using the Lysholm scale, anteroposterior shift of the tibia (APST), active angle reproduction test (AART), modified star excursion balance test (mSEBT), and single-hop distance (SHD). KT resulted in significant improvements in Lysholm scale at 1 day (83.00 [6.50] vs. 76.00 [5.25], P

Background:Although the femoral tunnel position is crucial to anatomic single-bundle anterior cruciate ligament (ACL) reconstruction, the recommendations for the ideal femoral footprint position are mostly based on cadaveric studies with small sample sizes, elderly patients with unknown ACL status, and 2-dimensional techniques. Furthermore, a potential difference in the femoral ACL footprint position and ACL orientation between ACL-ruptured and ACL-intact knees has not been reported in the literature.Hypothesis:The femoral ACL footprint position and ACL orientation vary significantly between ACL-ruptured and matched control ACL-intact knees.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Magnetic resonance images of the knees of 90 patients with an ACL rupture and 90 matched control participants who had a noncontact knee injury without an ACL rupture were used to create 3-dimensional models of the femur and tibia. The ACL footprints were outlined on each model, and their positions (normalized to the lateral condyle width) as well as ACL orientations were measured with an anatomic coordinate system.Results:The femoral ACL footprint in patients with an ACL rupture was located at 36.6% posterior and 11.2% distal to the flexion-extension axis (FEA). The ACL orientation was 46.9° in the sagittal plane, 70.3° in the coronal plane, and 20.8° in the transverse plane. The ACL-ruptured group demonstrated a femoral ACL footprint position that was 11.0% more posterior and 7.7% more proximal than that of the control group (all P < .01). The same patients also exhibited 5.7° lower sagittal elevation, 3.1° higher coronal plane elevation, and 7.9° lower transverse plane deviation (all P < .01). The optimal cutoff value of the femoral ACL footprint position to prevent an ACL rupture was at 30% posterior and 12% distal to the FEA.Conclusion:The ACL femoral footprint position might be a predisposing factor to an ACL rupture. Patients with a >30% posterior and

Anterior drawer, Lachman and pivot shift tests are commonly used for assessing anterior cruciate ligament (ACL). Relying only on a single test may result in missed diagnosis because some ACL scarring pattern may provide some degree of anterior stability. We present a 20-year old male with complete ACL rupture but positive pivot shift test only, MRI shows total ACL rupture and confirmed during arthroscopic reconstruction with scarring to posterior cruciate ligament. Thorough physical examination may help raise suspicion to ACL remnant scarring pattern in order not to miss ACL rupture in arthroscopy.

Clinical Scenario: Anterior cruciate ligament (ACL) ruptures are one of the most common injuries in young athletic populations. The leading treatment for these injuries is ACL reconstruction (ACL-r); however, nonoperative treatments are also utilized. Following ACL-r, patients experience prolonged muscle weakness and atrophy of the quadriceps muscle group, regardless of rehabilitation. Nonoperative treatment plans following ACL injury exist, but their outcomes are less familiar, in spite of providing insight as a nonsurgical “control” for postsurgical rehabilitation outcomes. Therefore, the purpose of this critically appraised topic was to evaluate quadriceps strength and function following nonoperative ACL rehabilitation using objective and subjective measures including isokinetic dynamometry, the single-leg hop test, and the International Knee Documentation Committee (IKDC) subjective knee form. Focused Clinical Question: What are the effects of nonoperative treatment on peak isokinetic knee-extensor torque, the single-leg hop tests, and the IKDC in patients who have sustained an ACL rupture? Summary of Key Findings: Patients who underwent nonsurgical ACL treatment produced limb symmetry index, with the side-to-side torque difference expressed as a percentage, and values at or above 90% for all 4 single-leg hop tests and strength tests similar to ACL-r patients. All studies showed individuals had higher IKDC scores at baseline collection when compared with patients who underwent ACL-r but showed lower IKDC scores at long-term follow-up compared with ACL-r patients. Clinical Bottom Line: Nonoperative treatments of ACL injuries yield similar long-term results in quadriceps strength as ACL-r. Due to the quality of evidence and the absence of randomized controlled trials on this topic, these outcomes should be considered with caution. Strength of Recommendation: The Oxford Centre for Evidence-Based Medicine taxonomy recommends a grade of B for level 2 evidence with consistent findings.

Context: Manual perturbation training improves knee functional performance and mitigates abnormal gait in patients with anterior cruciate ligament (ACL) rupture. However, manual perturbation training is time- and labor-intensive for therapists. Objective: To investigate whether perturbation training administered using a mechanical device can provide effects similar to manual training on clinical measures and knee biomechanics after ACL rupture. Design: Prospective cohort (therapeutic) study. A 2 × 2 analysis of variance was used for statistical analysis. Setting: A clinical and biomechanical laboratory. Patients: Eighteen level I/II patients with acute ACL ruptures participated in this preliminary study. Intervention: Nine patients received mechanical perturbation training on an automated mechanical device (mechanical group), and 9 patients received manual perturbation training (manual group). Outcome Measures: Patients completed performance-based testing (quadriceps strength and single-legged hop tests), patient-reported questionnaires (Knee Outcome Survey-Activities of Daily Living Scale, Global Rating Score, and International Knee Documentation Committee 2000), and 3-dimensional gait analysis before (pretesting) and after (posttesting) training. Results: There was no significant group-by-time interaction found for all measures (P ≥ .18). Main effects of time were found for International Knee Documentation Committee 2000 (pretesting: 69.10 [10.95], posttesting: 75.14 [7.19]), knee excursion during weight-acceptance (pretesting: 16.01° [3.99°]; posttesting: 17.28° [3.99°]) and midstance (pretesting: 14.78° [4.13°]; posttesting: 16.92° [4.53°]) and external knee-flexion moment (pretesting: 0.43 [0.11] N m/kg/m; posttesting: 0.48 [0.11] N m/kg/m) (P ≤ .04). After accounting for pretesting groups’ differences, the mechanical group scored significantly higher on triple hops (mechanical: 96.73% [6.65%]; manual: 84.97% [6.83%]) and 6-m timed hops (mechanical: 102.07% [9.50%]; manual: 91.21 [9.42%]) (P ≤ .047) compared with manual group. Conclusion: The clinical significance of this study is the mechanical perturbation training produced effects similar to manual training, with both training methods were equally effective at improving patients’ perception of knee function and increasing knee excursion and external flexion moment during walking after acute ACL rupture. Mechanical perturbation training is a potential treatment to improve patients’ functional and biomechanical outcomes after ACL rupture.

An osteochondral fracture of the posterolateral tibial plateau associated with an anterior cruciate ligament (ACL) injury in a 24-year-old boy is reported. Anterior cruciate ligament rupture is accompanied by bone contusions resulting from the impact of the posterolateral tibial plateau on the anterior part of the lateral femoral condyle. The osteochondral fracture of the posterolateral tibial plateau matched the site where the bone bruise is observed. Keywords: Osteochondral fracture, Anterior cruciate ligament injury, Posterolateral tibial plateau, Fibular head osteotomy

Background The diagnosis of anterior cruciate ligament tear can be made by physical examination and magnetic resonance imaging (MRI) in the supine position. In cases where the tear is partially evaluated on MRI, the choice of treatment may vary. The purpose of the study was to investigate the efficiency of MRI at maximum knee flexion in the prone position and to compare the images with findings of the ACL detected during surgery. Materials and methods Sixty-one patients with partial ACL tears with meniscal and cartilage lesions requiring arthroscopic knee surgery were included in the study between 2017 and 2019. MRI of these patients was prescribed at maximum knee flexion in the prone position. Then, an arthroscopic operation was performed on 61 patients and the findings (intact, partial or total tear of ACL) were recorded. The ACL was evaluated as being intact and partial or total tear. The statistical significance of the efficacy of MRI in the supine position with the knee at maximum flexion in the prone position was compared. Results It was found that, of 61 patients with suspected partial ACL tears, 25 patients had intact ACLs, 22 patients had partial tears and 14 patients had total ACL tears, through the interpretation of MRIs of the prone position by the radiologist. In the arthroscopic surgery of 61 patients, 20 patients had intact ACLs, 27 patients had a partial tear and 14 patients had a total tear. The MRI results with maximum knee flexion in the prone position were more compatible with the findings of the arthroscopic surgery. Conclusions It could be considered that MRI with maximum knee flexion in the prone position may also be guiding in the diagnosis and treatment of patients with partial anterior cruciate ligament rupture.