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1
Timothy, Woodacre. "Unstable Multi-Level Ligamentous Injury of the Cervical Spine in an Adolescent." International Journal of Clinical and Medical Cases (ISSN:2517-7346) 1, no. 2 (2018): 1–4. https://doi.org/10.31021/ijcmc.20181106.
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<strong>Purpose:</strong> Unstable ligamentous injuries to the cervical spine are unusual within the adolescent population, being more common in younger children. Multi-level unstable ligamentous injuries are rare. Current radiological screening techniques are performed supine. These may miss the dynamic instability of such injuries when under physiological load. <strong>Methods:</strong> We examine a case report of an adolescent suffering an atypical multi-level disc-and-ligamentous injury of the cervical spine during rugby. <strong>Results:</strong> The instability of the injury at multiple levels was not obviously apparent on CT, MRI or supine radiographs, as per standard screening protocols, and was only revealed via sequential regular erect radiographs; requiring significant intervention in the form of sequential operations. <strong>Conclusions:</strong> Sequential erect radiographs are useful and important in monitoring the stability of atypical cervical spine injuries under physiological load.
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Kollmorgen, Robert, Amy Singleton, amuel Eaddy, and Seth Phillips. "Multiligament Knee Reconstruction of the ACL, PLC, and ALL in a Floating Knee: A Case Report." Journal of Orthopaedic Case Reports 13, no. 12 (2023): 159–64. http://dx.doi.org/10.13107/jocr.2023.v13.i12.4118.
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Introduction: Ipsilateral fracture of the femur and tibia, known by the moniker “floating knee,” is a serious injury that primarily results from high-energy trauma. Up to 53% of patients with floating knee injuries have concurrent ligamentous injuries, with the anterior cruciate ligament (ACL) as the most commonly affected ligament. Approximately 10% of multi-ligament knee injuries consist of injuries to both the ACL and posterolateral corner (PLC); however, the literature reporting the management of this patient population is sparse, particularly, with a lack of consensus on the timing and protocol of surgical treatment. Well-characterized treatment guidelines are needed for patients with concomitant floating knee and multi-ligament knee injuries. Case Report: A 26-year-old, previously healthy male involved in a high-speed motor vehicle collision presented with upper and lower extremity, skull, and facial fractures, sacropelvic dissociation, and epidural hematoma. Here we describe a rare instance of a floating knee with a multi-ligament knee injury treated through early reconstruction of the ACL, PLC, and anterolateral ligament following stabilization of long bone fractures. Post-injury day 18, the patient underwent single-stage reconstruction of his multi-ligament knee injury. The timing of this was chosen to allow for capsular scar formation to aid in arthroscopy. Conclusion: Our surgical algorithm consists of allograft reconstruction using an all-inside ACL technique and a modified anatomical PLC technique. We recommend early (1–3 weeks) surgical treatment of multi-ligament knee injuries for patients without a closed head injury; however, an individualized treatment approach should be sought, considering the severity of ligamentous injuries, pre-injury activity level, extent of soft-tissue damage, and the activity goals of the patient post-injury. In patients with floating knee injuries, the proposed surgical algorithm here may be utilized for successful multi-ligament knee injury reconstruction. Keywords: Multiligament knee injuries, floating knee, multiligament knee reconstruction, allograft, arthroscopy.
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Huang, Patrick, Don Li, Logan Petit, Jack Porrino, Michael Medvecky, and Joseph Kahan. "The Multiligament Knee Injury Classification Stratifies Patients into Risk Categories." Orthopaedic Journal of Sports Medicine 8, no. 7_suppl6 (2020): 2325967120S0049. http://dx.doi.org/10.1177/2325967120s00493.
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Objectives: Our goal was to characterize the precise ligamentous injury locations and patterns of acute multi-ligament knee injuries (MLKI) and determine associated rates of dislocations, fractures, peroneal nerve palsies, and vascular injuries. Methods: All patients at a single level one trauma center who received operative treatment for MLKI between 2001 and 2019 were retrospectively identified. Demographic, injury mechanism, injury patterns, presence of dislocation, and associated injuries including vascular injury, peroneal nerve palsy, and fracture were assessed for each patient. MLKI both with and without a document knee dislocation were classified into five classes based on pattern of ligamentous tear (Figure 1). Class 1 included unicruciate tear with any combination of collateral tear. Class 2 are a bicruciate tear without collateral involvement. Class 3 are bicruciate tears with either a medial or lateral sided tear. Class 4 are bicruciate tears with both medial and lateral sided tears. Class 5 are periarticular fracture with any of the preceding ligamentous injury patterns. Rates of dislocation, vascular injury and peroneal nerve injury were analyzed among each class. Single variable statistics such as t-tests as well as multivariable techniques such as Chi square and multiple regression analysis was performed to identify patterns of injury and to predict risk of associated injuries. Results: 100 knees were identified as multiligament knee injuries. 34 of the knees (34%) were dislocated at presentation, and the remaining 66 (66%) did not have a documented knee dislocation. Patients with a documented knee dislocation had higher rates of vascular injury (24% vs. 3%, p = 0.0148), but not higher rates of peroneal nerve injury (32% vs. 20%, p = 0.0863). Patients with PLC injuries had statistically higher rates of peroneal nerve injury compared to acute multiligament knee injuries without a lateral sided injury (30% vs. 3%, p = 0.005). Rates of vascular injury between MLK Class are shown in Table 1. MLK Class was found to be predictive of vascular injury, but not of peroneal nerve injury. Conclusion: We present a new classification of multiligament knee injuries with the goal of providing a more precise diagnosis to aid in the surgical planning and decision making as well as to enhance clinical outcomes research of these complicated injury patterns. By classifying these injuries into five separate classes and further subclassified based on presence of dislocation and lateral sided injury, we are better able to predict likelihood of neurovascular injury. We hope that understanding the risks associated with each class will allow physicians to better appreciate the likelihood of potential complications of these injuries.
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Britt, Elise, Ryan J. Ouillette, Kristina P. Johnson, et al. "THE CHALLENGES OF TREATING FEMALE SOCCER PLAYERS WITH ACL INJURIES: IS THERE A BEST GRAFT CHOICE?" Orthopaedic Journal of Sports Medicine 8, no. 4_suppl3 (2020): 2325967120S0025. http://dx.doi.org/10.1177/2325967120s00254.
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Introduction: While Anterior Cruciate Ligament (ACL) injuries are common in female soccer players, the optimal graft option is currently unclear. Purpose: The purpose of this study was to compare outcomes of female soccer players undergoing an ACL reconstruction with either hamstring tendon autograft versus bone-patellar tendon-bone (BTB) autograft. Methods: A retrospective review of all skeletally mature adolescent female soccer players who underwent a primary ACL reconstruction with either hamstring tendon or BTB autograft between 2013 and 2016 was performed. Patients who had a multi-ligamentous reconstruction, a prior ACL injury, or had follow-up less than 2 years were excluded. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm, Single Assessment Numerical Evaluation (SANE), Tegner activity, visual analog pain, and satisfaction scores. Ability to return soccer as well as their pre-injury level of play and any reason that they could not return was documented. Results: Ninety-three female soccer players met the inclusion criteria of which 76% (41 BTB and 30 hamstring) were available for a minimum 2 year follow-up or had a documented graft failure prior to this time. The mean age of the cohort was 15.4±1.3 years. The BTB group had a Body Mass Index (BMI) that was significantly lower than the hamstring group (23±3 vs 25±4; p=0.02). There were no other differences in demographic, injury, or surgical variables between groups. Patient reported outcomes demonstrated that most patients did well with a mean Lysholm, SANE, Satisfaction, and pain scores of 92, 88, 8.9, and 1.1 respectively with no differences between groups. The BTB autograft group did achieve a significantly higher Tegner score (6.0 vs 4.3; p=0.004). Although not reaching significance, the BTB group had a greater percentage return to pre-injury level of play (44% vs 30%; p=0.31), or return to any level of soccer play (71% vs 53%; p=0.21 and. Of the patients that returned to soccer, 30% sustained another ACL injury (retear or contralateral tear) with no differences identified based on graft selection. Conclusion: Adolescent female soccer players undergoing an ACL reconstruction have relatively high satisfaction and outcome scores independent of autograft choice. Patients and families, however, need to be counseled that less than half of patients will return to their pre-injury level of sport and if an athlete attempts to return there is a high risk of further ACL injury.
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Ellis, Henry B., Nathan Boes, Parker Mitchell, Charles Wyatt, and Philip L. Wilson. "Can Combined Trans-physeal and Lateral Extra-Articular Pediatric ACL Reconstruction Techniques Be Employed to Reduce ACL Re-Injury While Allowing for Growth?" Orthopaedic Journal of Sports Medicine 7, no. 7_suppl5 (2019): 2325967119S0033. http://dx.doi.org/10.1177/2325967119s00332.
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Objectives: To describe outcomes, including failure rates, following a pediatric ACL reconstruction (ACLR) employing combined trans-physeal technique with hamstring autograft (TPH) and a hybrid extra-articular technique using iliotibial band autograft (ITB). Methods: Consecutive skeletally immature patients undergoing combined TPH/ITB ACLR from 1/2012 to 4/2017 were reviewed. With the goal of decreasing ACL graft re-injury in this high-risk group; this technique employed anterior-medial portal drilling for TPH, with an extra-osseous femoral ITB technique and intra-articular combined TPH/ITB grafts fixed within the tibial bone tunnel (Figure 1). Inclusion required a minimum 12 months follow up; exclusions were prior knee surgery and multi-ligamentous injury. Demographics, bone-age (hand), standing alignment XR for growth and mechanical axis grade, and PROs were documented. T-tests, Mann-Whitney tests, and Spearman’s correlation coefficients were employed. Results: 60 knees in 59 adolescents underwent the combined TPH/ITB ACLR, with 49 knees meeting inclusion criteria with a mean follow up = 23 months (r = 12-48 m). Only 1/49 knees (2%) sustained ACL re-injury. Mean age was 12.9y (11-16y) with 29 males (mean bone-age = 14.1) and 19 females (mean bone-age =13.3). There was a high level return to pre-operative sport. No families reported cosmetic, functional alignment or length concerns, and no clinical deformity was diagnosed. Outcome measures at final follow up indicated a high functional level with a mean Pedi-IKDC = 90.39 and mean Pedi-Fabs = 22.66. To critically assess growth, a cohort of 22 knees (mean age = 12.8y) with > 18 months of growth remaining at surgery were evaluated at maturity. No difference was seen in mean operative and non-operative leg growth (54.1 mm and 53.0 mm). One patient, 1/22 (4.5%), had a final LLD > 10 mm (12 mm), and peri-operative alignment difference [0-GII (central compartment) valgus]. Growth and alignment were not significantly associated with age, bone age, height, weight, demonstrated growth, or pre-operative alignment. Conclusion: Combined TPH/ITB ACLR in adolescent patients resulted in return to high activity levels (Pedi-Fabs = 22.66), and a low (2%) re-injury rate at an average of 23 months. A novel pediatric ACLR employing combined trans-physeal hamstring and extra-osseous iliotibial band grafts merits further study as a technique for reducing re-injury in high-risk, growing adolescents by maximizing articular graft size while adding anterior-lateral rotational knee control. [Figure: see text]
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Only, Arthur, Fernando Huyke-Hernández, Stephen Doxey, Logan Reitz, and Brian Cunningham. "Relationship Between Age, Cost, and Patient Reported Outcomes in Primary ACLR:." Journal of Orthopaedic Business 3, no. 3 (2023): 1–7. http://dx.doi.org/10.55576/job.v3i3.40.
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Objectives: To evaluate how surgical trends, costs, and outcomes for anterior cruciate ligament reconstruction (ACLR) vary with patient age. Design: Retrospective Cohort Study Setting: Outpatient Ambulatory Surgery Center Patients: 587 primary ACLR patients from 2009-2016. Inclusion criteria consisted of primary ACLR, complete preoperative and two-year post-operative patient reported outcome (PRO) data. Patients were excluded if they underwent non-operative management, multi-ligamentous repair, or sustained poly-trauma. Intervention: ACLR Main Outcome Measurements: ACLR failure/re-rupture, reoperation, cost of care, Knee Injury & Osteoarthritis Outcome Score (KOOS) and Single Assessment Numeric Evaluation (SANE). Results: Younger patients were prevalently female compared to older patients (p<0.0001). Graft use varied according to age, with older patients more commonly being treated with allograft (p<0.0001). There were equivalent rates of meniscal injuries (p=0.0855), but meniscal treatment differed for patients older than age 25. Older patients on average received more meniscectomies versus repairs (p=0.0009). Operative time was found to be lowest in patients 40 and older. Total implant, day-of-surgery, and two-year episode of care costs were significantly higher for older patients (respectively r=0.48, r=0.43, r=0.37; p<0.001). Re-rupture rates were similar among age groups, however younger patients underwent more reoperations (p=0.0349). While baseline and two-year KOOS and SANE differed across ages (p<0.032), two-year changes did not (p≥0.384). Conclusions: Patient characteristics, treatment techniques, costs, and PROs were found to vary according to patient age but change in PROs did not. These results provide information on how patient age and can influence value in the setting of ACLR. Keywords: Anterior Cruciate Ligament Reconstruction, KOOS, SANE, Cost, TDABC, Value-Based Care Level of Evidence: Level IV
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N Osadebey, Emmanuel, Karnesha Goins, Cierra N Harper, and Damirez Fossett. "Deformity correction in the setting of acute cervical spine trauma in a patient with ankylosing spondylitis: A case report." Journal of Case Reports and Images in Surgery 8, no. 2 (2022): 31–37. http://dx.doi.org/10.5348/100110z12eo2022cr.
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Introduction: Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy marked by symptomatic alterations in skeletal anatomy and biomechanics. Ankylosis from the ossification of ligamentous structures and adjacent joints transforms the spine from flexible to rigid and brittle, easily susceptible to fracture. The pathophysiology of the condition is also notable for a progressive debilitating cervical kyphosis known as “chin-on-chest.” Ultimately, the combination of a brittle, rigid, spine can permit trivial trauma to cause catastrophic injury, and in some instances, mortality. We discuss the multi-disciplinary approach, management concerns, and deformity correction in the setting of traumatic cervical spine fracture in a patient with ankylosing spondylitis. Case Report: A 71-year-old man with ankylosing spondylitis presented to Howard University Hospital in a delayed fashion after a ground level fall at home. Neurological examination revealed loss of all motor and sensory function below the C4 level and an absence of rectal tone. Advanced imaging discovered a fracture-dislocation at the C4-5 level producing a severe hyper-lordotic angulation deformity. The profound fracture characteristics and displacement caused spinal cord compression posteriorly and tracheoesophageal stenosis anteriorly. The patient was treated operatively in a staged dual approach fashion correcting his pathologic deformity in consideration of long-term care needs. Postoperatively, upon completion of his final neurosurgical procedure, his sensory exam notable for return of sensation from C5-T1 and he was also able to appreciate and interact with the environment around him as his viewpoint was no longer rigidly caudally oriented. The patient was discharged from the hospital to a long-term care facility in stable condition. Conclusion: Cervical fractures sustained after minor trauma in a patient with ankylosing spondylitis are not uncommon. However, surgical intervention with concomitant deformity correction in the traumatic setting is substantial undertaking with a paucity of literature on such surgical techniques. Surgical deformity correction in the acute trauma setting allowed for optimization of anticipated medical care initiatives and successfully provided newfound visual awareness of his environment, improving upon his ability to interact with the world.
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Massey, Patrick Allan, Andrew Zhang, Christine Bayt Stairs, Stephen Hoge, Trevor Carroll, and Ashley Marie Hamby. "Meniscus Repair Outcomes with and without Bone Marrow Aspiration Concentrate." Orthopaedic Journal of Sports Medicine 7, no. 7_suppl5 (2019): 2325967119S0028. http://dx.doi.org/10.1177/2325967119s00283.
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Objectives: The purpose of the current study is to review the results of meniscus repairs with and without bone marrow aspiration concentrate (BMAC). It is hypothesized that with BMAC, meniscus repair outcomes will be improved when compared to without BMAC at 1 year after surgery. Methods: This is a prospective case control study performed from August 2014 until August 2017. Patients were included if they had a meniscus repair performed with no history of prior meniscus surgery to the operative knee. Patients were excluded if there was a full thickness cartilage tear or International Cartilage Repair Society (ICRS) Grade IV cartilage tear not treated in a single staged surgery. Patients were also excluded if they did not reach the one year follow-up, had a multi-ligamentous knee injury requiring multiple staged procedures. From August 2014 until November 2015, patients had meniscus repair without BMA. Menisci were all repaired arthroscopically using inside-out, outside-in and all-inside techniques. After November 2015, all meniscus repairs were augmented with BMAC. In the BMAC group, all bone marrow was obtained from the ipsilateral femur during the time of surgery. The Biocue BMAC system (Zimmer Biomet, Warsaw Indiana) was used for bone marrow aspiration and BMAC was injected directly into the tear site after repair. Numerical data such as VAS, lysholm and IKDC was analyzed using a 2 sample T-test. Categorical data such as sex, tear location, type of tear and zone of tear were analyzed using a chi-square. Results: A total of 150 patients were initially included in the study. The average age in the control group was 26.3 versus 29.4 in the BMAC group (P=0.27). Thirty seven percent of the control group had an ACL reconstruction versus 40% in the BMAC group (P= .77). The control group improved from an average pain level of 6.1 to 1.2 and the BMAC group improved from an average pain level of 5.9 to 0.7 at the 1 year end point. Both the control group and BMAC group improved with respect to pain with no difference at the 1 year end point (P=.19). There was, however a significantly larger reduction in pain at the 6 week and 3 month time point with BMAC compared to the control group (P=.02 and P=.02 respectively). At the 1-year follow-up, the mean lysholm score improved from 43 to 92 in the control group and 43 to 90 in the BMAC group. The mean IKDC score improved from 37 to 87 in the control group and 36 to 83 in the BMAC group at the one year follow-up. Conclusion: Meniscus repair outcomes were improved at 6 weeks and 3 months post-operatively, when BMAC is used to augment meniscus repair compared to repair without BMAC. Both groups, control group and BMAC meniscus repair group had improved outcomes at 1 year post-operatively with respect to VAS, lysholm and IKDC, with no difference in complication rate.
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Liu, Jie. "EFFECT OF FOOTBALL ON REHABILITATION OF ANKLE INJURY PATIENTS." Revista Brasileira de Medicina do Esporte 28, no. 1 (2022): 62–64. http://dx.doi.org/10.1590/1517-8692202228012021_0448.
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ABSTRACT Introduction: Brief introduction: Ankle tendon and ligament sports injuries are common in football players. Objective: To continue to improve special strength training related to the characteristics of football after rehabilitation of injured ankle tendons and ligaments. Methods: Two master football sportsmen were rehabilitated by multi-point equal-length, short-arc and long-arc equal-speed training combined with balance ability exercises. Results: There were two long muscle L be maintain muscle tone plantar flexors force four times of 96 n/m, n/m 121, 140 n/m, 145 n/m than back flexors force of 63 n/m, 52 n/m, 60 n/m, 74 n/m tall. Plantar flexor fatigue was 57%, 30%, 29%, 12%, 28%, 18%, 20%, 21%. Conclusions: With the passing of time, the relative peak moment value of the right ankle plantar flexor muscle group of the two patients kept rising, the dorsiflexor muscle was basically flat, and the work fatigue index decreased step by step, indicating that the right ankle muscle strength level was significantly improved, the anti-fatigue ability was improved, and the rehabilitation treatment had a good effect. Level of evidence II; Therapeutic studies - investigation of treatment results.
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Feron, J. M., P. Bonnevialle, G. Pietu, and F. Jacquot1. "Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult." Open Orthopaedics Journal Suppl 1, no. 1 (2015): 356–60. http://dx.doi.org/10.2174/1874325001509010356.
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The traumatic floating knee in adults (FK) is a combined injury of the lower limb defined by ipsilateral fractures of the tibia and femur. The first publications emphasized the severity of injuries, the bad results after conservative treatment, the most severe functional outcome in case of articular fracture and the frequency of associated cruciate ligament injuries. The surgical management of FK has been highly modified according the improvement of the fracture fixation devices and the operative techniques. This retrospective multicentric observational study included 172 adults with a FK injury admitted in emergency in 5 different level I or II trauma centers. All the patients data were collected on an anonymized database. Results were evaluated by the overall clinical Karlström’s score at latest follow-up. Fracture union was assessed on X-rays when at least 3 out of 4 cortices were in continuity in two different radiological planes. A statistical analysis was performed by a logistic regression method. Despite some limitations, this study confirms the general and local severity of this high-energy trauma, mainly occurring in young people around the third decade. A special effort should lead to a better initial diagnosis of associated ligamentous injury: a tear of PCL can be suspected on a lateral-ray view and a testing of the knee should be systematically performed after fixation of the fracture under anesthesia. Secondary MRI assessment is sometimes difficult to interpret because of hardware artifacts. The timing of fracture fixation is discussed on a case by case basis. However, a first femoral fixation is recommended except in cases of tibia fracture with major soft tissue lesion or leg ischemia requiring the tibia fixation first. Also a tibia stabilized facilitates the reduction and fixation of a complex distal femur fracture. The dual nailing remains so far for us the best treatment in Fraser I FK. Further prospective studies are needed to validate treatment algorithms, best fixation techniques in order to decrease the rate of complication and improve the functional outcome of floating knee injuries.
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Long, Mingquan. "Modeling and analysis of knee joint impact damage in triple jump manipulators based on finite element method." International Journal of Modeling, Simulation, and Scientific Computing 10, no. 05 (2019): 1950030. http://dx.doi.org/10.1142/s1793962319500302.
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In order to study the three jump training and competition on knee joint impact damage degree, left knee joint of one healthy male athletes is used as the research object, a complete knee three-dimensional model was established based on the jumper’s knee CT scan and magnetic resonance imaging (MRI), including the femur, tibia, fibula, patella and knee major cartilage, ligaments. The multi-body dynamics analysis (MDA) and finite element analysis (FEA) method are used to calculate the three jump, jump starting, landing process of athletes knee joint impact, the state should change the status of stress, strain and displacement. The results show that in the three jump process, the load on the lateral contact area of the knee joint is the largest, the displacement is the largest, and it increases with the impact of jump and landing. This exacerbated the degree of wear and tear of the tibia, it tends to induce knee injury in athletes. The results show that the combination of finite element and MDA can better study the knee joint’s shock and vibration during the three-level jump training and competition, and these open up a new research method for the knee joint injury. It also provides a certain reference for the prevention and treatment of knee joint injury.
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Ushotanefe, U., F. E. Mbajiogu, and A. O. Sanya. "Physiotherapy utilisation by sports physicians for musculoskeletal injuries in selected elite sports in Nigeria." South African Journal of Physiotherapy 56, no. 3 (2000): 19–23. http://dx.doi.org/10.4102/sajp.v56i3.538.
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In Nigeria, the majority of injured athletes seen in sports physiotherapy units are referred by sports physicians. The extent to which a physician utilises the services of physiotherapy in sport depends largely on the level of awareness or knowledge of physiotherapy services that such physicians have. This survey evaluated the degree of utilisation of physiotherapy services for the treatment of injuries during preparation for multi-sports events by sports physicians in selected elite sporting events in Nigeria.One hundred and twenty-eight athletes, coaches, sports administrators, scientists, medical doctors and physiotherapists located at four different camping sites, were sampled. The responses between different professional groups on the non-utilisation of physiotherapy services by sports physicians during preparation for multi-sport events, was not significant. However, Nigerian professionals who were surveyed, accepted the hypothesis that sports physicians did not utilize physiotherapy services for the management of musculoskeletal injuries during training and pre-games preparation in selected elite sports in Nigeria.This retrospective study of the actual referral records at the clinic of the sports medicine centre revealed that 20 (91%) different types of musculoskeletal injuries sustained by volley ball players were referred for physiotherapy. Nine (56.3%) injuries sustained by basketball players, 62 (87.3%) by track and field athletes, and 6 (74%) by football players were referred for physiotherapy between 1992 and 1995. The majority of the injuries sustained were ligamentous sprain and muscular strain with joints of the lower limbs and the back mostly affected.
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Clark, Kenneth, Caroline Brunst, Alex Dibartola, et al. "Poster 240: Pediatric Meniscal Repair Patients are Ready to Return to Sport Six Months after Surgery According to Isokinetic Dynamometry Testing: A Retrospective Review." Orthopaedic Journal of Sports Medicine 10, no. 7_suppl5 (2022): 2325967121S0080. http://dx.doi.org/10.1177/2325967121s00801.
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Objectives: The incidence of meniscal injures in the pediatric population has been increasing over the past decade. This is likely due to more rigorous athletic activity, earlier sports specialization, year-round competition, and increasing awareness of and screening for these injuries. Many meniscal tears occur during sporting activity, and the goal of surgery is to return an athlete to play (RTP). Strength symmetry is a RTP criteria when considering return to cutting and pivoting sports. Isokinetic dynamometry testing is often done for ACL reconstruction recovery but there is currently little literature on its use in meniscal repair protocols for RTP. The purpose of this study was to establish appropriate knowledge and expectations for RTP following meniscal repair in patients ages 18 and under. It was hypothesized that patients would not meet RTP criteria based on dynamometry testing at four months post-op, but would at six months post-op. Methods: Electronic medical records were reviewed to identify patients who underwent meniscus repair at a single academic institution between 2009 and 2018. Patients were included if 18 years of age or under at the time of surgery and had concurrently undergone dynamometry testing at 4 and 6 months post-operatively. Records were reviewed for demographic data including age, sex, body mass index (BMI), and sports played. Isokinetic dynamometry testing measured quadriceps and hamstring strength at 60°/sec and 300°/sec (ft/lbs). Limb symmetry index (LSI (%)) was calculated [(involved/uninvolved) x 100%] and eligibility for RTP was deemed an LSI >85%. Results: A total of 473 patients were identified who underwent meniscus repair and dynamometry testing. Twenty-three patients met all inclusion criteria for analysis. The mean age was 16±1.24 years, with sex distribution being 52% male and 48% female. The mean BMI of 24.3±4.47. Athletes participated in the following sports (Tegner Activity Scale: 7 or higher): basketball, football, soccer, lacrosse, wrestling, volleyball, softball, track and field; including three multi-sport athletes. 83% of patients had concurrent ligamentous reconstruction at the time of meniscus surgery. Conclusions: Only 50% of patients with isolated meniscus repair met RTP criteria at 4 months. However, 75% or greater met criteria at 6 months (Table 1). Additionally, patients with a concurrent ligamentous repair were challenged to meet RTP criteria at both time points. These data suggest that formal physical therapy for greater than 6 months is beneficial to achieve suggested RTP strength criteria for those with isolated meniscus repair; furthermore, those with meniscal repair and concurrent ligamentous reconstruction will require longer episodes of care to meet RTP criteria. Future studies are needed to examine factors that lead to earlier RTP, such as; type of tear, type of sport, level of competition, and quadriceps/hamstring strength prior to surgery. [Table: see text][Table: see text]
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Singh, Amarendra B., Pulak Sharma, Himanshu Jayantrao Ashtankar, Ujjwala Raina, and Lyakat Khan. "Outcome of Single-Stage Multiple-Ligament Knee Reconstructions for Traumatic Knee Injuries." Journal of Bone and Joint Diseases 40, no. 1 (2025): 29–36. https://doi.org/10.4103/jbjd.jbjd_45_24.
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Abstract Introduction: Multi-ligament knee injuries (MLKI) present in various combinations of structures around the knee joint, with or without involvement of neurovascular structures, posing significant challenges to the treating physician and therapists. Accurate diagnosis with appropriate surgical intervention and comprehensive rehabilitation to restore function and stability is, therefore, paramount. Single stage multiple-ligament knee reconstructions have emerged as a pivotal technique in addressing these intricate injuries, aiming to restore knee stability and function, and thereby facilitating return to sports or work. This article deals with the outcomes of such surgical interventions, focusing on the efficacy, and rehabilitation timelines following single-stage reconstructions. In our study, we followed a comprehensive approach to address traumatic knee injuries, especially those involving multiple ligaments. The goal of our surgical intervention was to restore knee stability and function, while our rehabilitation protocol aimed at ensuring optimal recovery and return to work. Discussion: Studies have demonstrated that single-stage reconstructions can effectively restore knee stability, as assessed by objective measures such as the Lachman test, anterior & posterior drawer test, Varus & Valgus stress tests and postoperative imaging. Functional outcomes, often gauged through tests like the Lysholm Knee Scoring Scale and the Tegner Activity Level Scale, have also shown promising results, with many athletes achieving near pre-injury levels of knee function. Postoperative rehabilitation protocols following single-stage reconstructions are tailored to balance the healing of reconstructed ligaments while progressively restoring range of motion, strength, and functionality of the knee. The duration and intensity of rehabilitation is pivotal in determining the success of the reconstruction and the timeline for return to daily life or sports. Conclusion: Single-stage multiple-ligament knee reconstruction represent a significant advancement in the treatment of complex knee injuries in athletes. While promising in terms of restoring stability and function, the approach demands careful consideration of surgical techniques, a meticulously planned rehabilitation protocol, and a holistic understanding of the patient's goals and psychological readiness for return to work. Future research is essential to optimize these protocols and further enhance outcomes for athletes suffering from MLKIs.
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Stal, Drew, Zohair Saquib, and Geoffrey Phillips. "Rates and Types of Syndesmotic Fixation in Operatively Treated Ankle Fractures." Foot & Ankle Orthopaedics 2, no. 3 (2017): 2473011417S0003. http://dx.doi.org/10.1177/2473011417s000378.
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Category: Trauma Introduction/Purpose: Roughly 15% of ankle sprains and 23% of ankle fractures involve disruption of the syndesmotic ligaments. It has been shown that patients who require syndesmotic stabilization have worse subjective outcomes than those who do not require fixation. Recent studies have demonstrated that both Weber B and Weber C distal fibula ankle fractures can have concomitant syndesmotic injury necessitating trans-syndesmotic fixation. Significant controversy exists regarding the proper syndesmotic fixation strategy in regards to size, number and type of screws, and number of engaged cortices. The goal of our study was to establish the current practice in syndesmotic fixation in surgically-treated ankle fractures at our institution, through a retrospective review, based on fracture pattern and surgeon subspecialty training. Methods: A multi-center retrospective cohort study of 219 surgically-treated ankle fractures over a 2 year period was performed. Institutional Review Board (IRB) approval and a waiver of informed consent were obtained prior to data collection. Patient selection criteria was based on CPT codes, while exclusion criteria included open trauma, pilon fracture, history of prior ankle fracture and pediatric patients. All preoperative radiographs were reviewed for Danis-Weber classification. All intra- operative fluoroscopy, operative reports and postoperative radiographs were reviewed to confirm surgeon detection of syndesmotic injury and type of syndesmotic fixation utilized. This search included number of screws, screw size (mm) and number of engaged cortices. Surgeons were divided into three groups according to fellowship training: foot and ankle, trauma, and general. There were two foot and ankle fellowship-trained orthopaedists, five trauma fellowship-trained orthopaedists, and eight generalists whose fellowships included sports, hand, and spine. Patient demographics and medical risk factors were also recorded. Results: There were 153 Weber B and 64 Weber C cases. Of those overall, 32.4% required trans-syndesmotic fixation, with 33.8% being Weber B, and 66.2% being Weber C fractures. 15.6% of the Weber B and 73.4% of the Weber C cases required syndesmotic fixation. There was a statistically significant difference in the use of two screws versus one screw overall and for Weber C (P < 0.0009 and 0.0003 respectively). The fixation of four cortices was more common overall (59.6% of 71 cases) and for Weber C (63.8% of 47 cases). 3.5 mm screws were used in 73.2% (52/71) of cases, 4.0 mm screws in 19.7% (14/71) of cases and 4.5 mm screws in 7% (5/71) of cases. Of the 4.5 mm screws used, 80% were used in Maisonneuve injuries. Conclusion: There is variability in the literature regarding fracture pattern and the presence of syndesmotic injury. Detection and repair of the syndesmosis is critical in maximizing post-operative outcomes. While many investigators have debated the practicality of fracture classifications and pre-operative imaging in diagnosing syndesmotic injury, a high clinical and intraoperative suspicion must remain, especially when accompanying a low level fibular fracture. When diagnosed, multiple acceptable fixation options exist; however, our study shows that surgeons prefer two screws over one screw for Weber C fractures, as well as screws with a diameter of 3.5 mm with no preference in engaged cortices.
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Woodacre, Timothy. "Unstable Multi-Level Ligamentous Injury of the Cervical Spine in an Adolescent." International Journal of Clinical and Medical Cases 1, no. 2 (2018). http://dx.doi.org/10.31021/ijcmc.20181106.
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Nickoles, Todd A., James W. Eubanks, Ruth A. Lewit, et al. "The A+ criteria for pediatric blunt cerebrovascular injury: An ATOMAC+ multicenter study." Journal of Trauma and Acute Care Surgery, June 13, 2025. https://doi.org/10.1097/ta.0000000000004686.
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BACKGROUND Blunt cerebrovascular injury (BCVI) is rare but significant among injured children. Current BCVI screening criteria lack adequate diagnostic accuracy for pediatrics. This preplanned secondary analysis identified common risk factors for BCVI among a multicenter cohort of pediatric trauma centers within the ATOMAC+ Pediatric Trauma Research Network (APTRN) and derived a new set of screening criteria. METHODS A prospective, multi-institutional observational study of children <15 years old who sustained blunt trauma to the head, face, or neck (AIS > 0) who presented at one of six level I pediatric trauma centers over a 3-year period was conducted. Patients were prospectively screened using the Memphis criteria to determine need for diagnostic imaging. Additional physical and diagnostic examination findings, risk factors, and screening data were also collected for analysis. RESULTS A total of 2,283 patients were enrolled at the six trauma centers and 25 (1.09%) were diagnosed with a BCVI. Patients without two-week follow up were excluded from analysis, leaving 1327 patients for analysis. Many injuries predicted BCVI on univariate analysis in the study population (p < 0.0001). When examined with a multivariable logistic regression model, temporal fractures, sphenoid fractures, orbital roof fractures, fractures of C1–4, and/or ligamentous injuries of the cervical spine predicted BCVI in pediatric trauma patients with blunt head, face, or neck injuries. These criteria are used to define a set of screening criteria that are specific to pediatrics and practical to implement. CONCLUSION The A+ criteria for BCVI screening among pediatric trauma patients suggests a high sensitivity and specificity by including significant injuries and symptoms. These predictors of BCVI may be used to identify pediatric blunt trauma patients at high risk for BCVI while limiting radiation exposure to children. LEVEL OF EVIDENCE (Diagnostic Test/Criteria); Level II.
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Usama, Muhammad, Mubashar Ahmed Bajwa, Muhammad Umer Faheem, et al. "VALIDITY OF LELLI’S TEST IN DIAGNOSING ACUTE ACL INJURY AND ITS COMPARISON WITH THE OTHER CONVENTIONAL CLINICAL EXAMS." Journal of Ayub Medical College Abbottabad 36, no. 3 (2024). http://dx.doi.org/10.55519/jamc-03-13363.
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Background: The anterior cruciate ligament (ACL) is a vital structure in the knee responsible for preventing anterior translation; and countering rotational and valgus stress. The anteromedial and posterolateral bundles of the ACL, which are distinguished by their attachments at the tibia and femur, respectively, make up the ACL. The study is designed to evaluate the diagnostic parameters of lever sign in acute settings when compared against MRI as investigation of choice and compare them with the conventional tests. Furthermore, effect of examination-under-anaesthesia and training level of the examiner on the diagnostic accuracy will be assessed. It was a prospective observational was performed. All the patients that presented to out-patient department of GTTH, Lahore from January to July 2023 and had a final diagnosis of ACL tear were included. Methods: Assessment was done by both undergraduates and postgraduates and those who underwent arthroscopy were placed in surgical cohort and arthroscopic findings were included in final analysis. Results: Eighty-three patients were assessed. Inferential analysis demonstrated that Lelli’s test had highest sensitivity (85.9%), NPV (64%) and diagnostic accuracy (85.5%). However, Lachman was most specific (94.7%) and had highest PPV (98.1). MRI itself is highly accurate (95.83%) when compared to arthroscopic findings. Though the results of each test when performed by postgraduates and under anaesthesia were significantly better; however, least difference was noted in case of Lelli test among awake and anesthetized and pre- and post-graduates’ exams. Conclusion: The Lelli’s test is highly sensitive and accurate when compared to the three conventional tests for ACL injuries. Furthermore, the manoeuvre and its interpretation are simple and reproducible; thus, can be used by highly trained healthcare professionals on awake patients with minimal discomfort. However, further research is needed to validate its biomechanics and role in partial ACL and multi-ligamentous injuries.
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Hopper, Graeme P., Ahmer Irfan, Joanne M. Jenkins, William T. Wilson, and Gordon M. Mackay. "Posterior cruciate ligament repair with suture tape augmentation: a case series with minimum 2-year follow-up." Journal of Experimental Orthopaedics 8, no. 1 (2021). http://dx.doi.org/10.1186/s40634-021-00337-y.
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Abstract Purpose The posterior cruciate ligament (PCL) is an important stabilizer of the knee and can be damaged in up to 20% of ligamentous injuries. Numerous techniques for surgical treatment have been described in the literature with none shown to be clearly superior. The aim of this study was to assess the 2-year outcomes of PCL repair with suture tape augmentation. Methods Seventeen patients undergoing PCL repair with suture tape augmentation were prospectively followed up for a minimum of two years. One patient was lost to follow-up leaving sixteen patients in the final analysis (94.1%). Indications for this procedure were acute Grade III PCL ruptures, symptomatic chronic tears and PCL tears as part of a multi-ligament injury. Exclusion criteria were patients with retracted PCL remnants or poor tissue quality. Patient-reported outcomes were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and Marx Activity Scale. Patients with any postoperative complications were identified. Mean differences between the outcomes pre-operatively and at two years postoperatively were evaluated using paired t-tests with significance set at p < 0.05. Results The mean KOOS at 2 years was 87.0, 75.5, 93.0, 69.6 and 54.2 for pain, symptoms, ADL, sport/recreation and QOL respectively. These improved significantly from 60.2, 49.8, 65.0, 33.0 and 34.2 preoperatively (p < 0.05). The mean WOMAC scores at 2 years were 91.0, 78.3 and 93.0 for pain, stiffness and function respectively. These improved significantly from 63.0, 51.7 and 65.0 preoperatively (p < 0.01). The VAS score improved from 3.0 to 0.8 (p < 0.01) and the VR-12 score improved from 34.9 to 50.9 at 2 years (p < 0.001). However, the Marx activity scale decreased from 8.7 pre-injury to 6.3 at 2 years (N.S.). One patient (6.3%) suffered a re-rupture. Conclusion PCL repair with suture tape augmentation demonstrates satisfactory patient reported outcome measures at minimum 2-year follow-up. These figures compare favorably with success rates described in the literature for PCL reconstruction techniques. Therefore, PCL repair with suture tape augmentation is an effective treatment option in selected patients. Level of evidence IV
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Fahlbusch, H., P. Behrendt, R. Akoto, K. H. Frosch, and M. Krause. "ACL reconstruction provides superior stability than ACL repair in patients with Schenck III and IV knee joint dislocations: first results of a 12 month follow-up study." Archives of Orthopaedic and Trauma Surgery, April 16, 2023. http://dx.doi.org/10.1007/s00402-023-04884-0.
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Abstract Purpose Acute knee dislocation is a rare but devastating multi-ligamentous knee injury with only limited evidence-based surgical technique recommendations. The aim of this study was a comparison of two different anterior cruciate ligament (ACL) restoration techniques as part of an early total surgical care concept: (1) repair of ACL with additional internal bracing (ACLIB) compared to; (2) ACL reconstruction with autograft (ACLR). Methods Retrospective, clinical-study of patients with an acute type III or IV knee dislocation (according to Schenck classification), in which the ACL was treated with ACLIB or ACLR within 12 days. The PCL was sutured and internally braced in all cases. Medial and lateral complex injuries were repaired and additionally laterally augmented by an Arciero reconstruction. After a minimum 12 months follow-up different patient-reported outcome measurements (IKDC, Lysholm, VAS, Tegner Score) and instrumental stability assessment by Rolimeter -test and stress radiographs (Telos™) were analyzed. Groups were compared by t test with p < 0.05 considered significant. Results In total, 20 patients (5 IIIM, 5 IIIL and 10 IV) were included in this study with an average follow-up of 13.7 ± 2.6 months. There were significant differences in instrumental stability testing (side-to-side difference (SSD) of anterior tibial translation: ACLIB 2.7 ± 1.5 mm vs. ACLR 1.3 ± 1.3; p = 0.0339) and stress radiography (SSD ACL: ACLIB 3.4 ± 2.2 mm vs. ACLR 0.4 ± 2.7; p = 0.0249) between groups. ACLIB group showed greater ROM in terms of flexion (SSD Flexion: ACLIB 7.8 ± 9.9° vs. ACLR 16 ± 7.0°; p = 0.0466; Total Flexion overall 125.5 ± 11.8°). No clinically relevant differences in patient-reported outcome scores (Lysholm Score: ACLIB 82 ± 16.4 vs. ACLR 85 ± 10.4; IKDC subjective score: ACLIB 70.4 ± 17 vs. ACLR 76.6 ± 8.3) were determined. Conclusion ACLR provides superior translational stability than ACLIB in terms of instrumental testing and stress radiography. Both techniques were equivalent with respect to PROMS and led to good and excellent clinical results. Level of evidence Retrospective cohort study, III.
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Fine, River, William Curtis, Kaleb Stevens, et al. "Poster 277: Return to Sport after Multi-Ligament Knee Injury in Young Athletes." Orthopaedic Journal of Sports Medicine 11, no. 7_suppl3 (2023). http://dx.doi.org/10.1177/2325967123s00255.
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Objectives: While return to sport (RTS) has been well studied in young athletes after anterior cruciate ligament (ACL) reconstruction, there is a paucity of literature on RTS following reconstructive surgery for multi-ligament knee injury (MLKI). The purpose of this study is to assess level of RTS following MLKI in athletes 23 years old or younger at the time of injury and evaluate the factors associated with RTS. Methods: This was a retrospective study. We identified 116 patients at our Level 1 referral center who sustained MLKI at an age of 23 years old or younger. All 116 patients underwent operative reconstruction. Patients were contacted via mail and then completed surveys by telephone if willing to participate. Our primary outcome variable was self-reported ability to return to sport at their preoperative level or higher following surgery. Secondary variables included 2000 International Knee Documentation Committee Subjective Form (2000 IKDC-SF), ACL Return to Sport After Injury (ACL-RSI), and Short-Form 12 (SF-12) physical and mental health scales. Dependent variables included age, participation in cutting sports, number of and specific ligaments injured, and any concurrent mental health diagnoses. Results: A total of 30 (25.9%) patients completed surveys at an average follow-up of 7.8 years postoperatively (24 male, 6 female, 18.1±2.5 years old at time of injury). Of this cohort, 90% of patients returned to sport at some level, while 43.3% returned to their preoperative level or higher. Participation in cutting sports was associated with significantly lower rate of RTS at the same level or higher (p=0.017). Higher 2000 IKDC-SF and ACL-RSI scores were associated with significantly higher rate of RTS at the same level or higher (p=0.001 and 0.002, respectively). Patients who participated in higher level of sport preoperatively demonstrated a higher odds ratio (OR) of returning to their same athletic level or higher following MLKI (OR=3.516 [1.034-11.955]; p=0.044). Number of ligaments injured, age at time of injury, concurrent mental health diagnosis, and SF-12 scores were not associated with a statistically significant change in RTS at the same level or higher. Patients with concurrent ACL and MCL injuries trended toward higher rate of RTS at the same level or higher than two- or three-ligament injuries involving the ACL and PCL and/or LCL, but this was not statistically significant (50% vs. 25%, p=0.225). Conclusions: While a high percentage of young athletes return to some level of sport following MLKI, less than half return to their previous level. Those participating in cutting sports were significantly less likely to return to their pre-injury level of sport following MLKI. Participation in higher level of sport preoperatively was associated with a higher OR of return to sport at the same level or higher. Those who returned to the same level or higher reported significantly higher scores on the ACL-RSI and the 2000 IKDC-SF. There was no significant difference in those returning to sport at their previous level or higher based on SF-12 physical or mental scores, number of ligaments injured, presence of a mental health diagnosis, or age at injury. Future studies will focus on larger cohorts and any modifiable variables to obtain a functional return to sport. [Table: see text][Table: see text][Table: see text][Table: see text]
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Brinkman, Niels, Carl Nunziato, David Laverty, David Ring, Austin Hill, and Tom J. Crijns. "Surgeon Factors Rather than Patient Factors Account for Variation in Recommended Treatment Strategy for Patients with Multi-ligament Knee Injury." Journal of Orthopaedic Trauma, July 8, 2024. http://dx.doi.org/10.1097/bot.0000000000002867.
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Objectives: To seek the factors associated with timing, staging, and type of surgery in the management of multi-ligament knee injuries. Design: Cross-sectional scenario-based experiment. Setting: 15 fictional patient scenarios with randomized elements. Participants: Fracture surgeons of the Science of Variation Group, an international collaborative of musculoskeletal surgeons that studies variation in care, were invited to participate. Surgeons with limited experience treating multi-ligament knee injuries were asked to self-exclude. Outcome measures and comparisons: Surgeon recommendations for operative treatment, timing of surgery, and use of open surgery in addition to arthroscopy were measured. Patient factors (age, time from injury, contralateral fracture, knee dislocation, combinations of ruptured ligaments, pre-existing osteoarthritis) and surgeon factors (gender, practice location, years of experience, supervision of trainees) associated with surgeon recommendations were assessed. Results: Eighty-five surgeons participated, of which most were men (89%) and practiced in the United States (44%) or Europe (38%). Operative treatment was less likely among older patients (OR=0.051) and pre-existing osteoarthritis (OR=0.32), and more likely in knee dislocation (OR=1.9) and disruption of anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and lateral collateral ligament (LCL) with or without medial collateral ligament (MCL; OR=5.1 and OR=3.1, respectively). Disruption of ACL, PCL, and MCL was associated with shorter time to surgery (β=-11). Longer time to surgery was associated with contralateral fracture (β=9.2), and surgeons supervising trainees (β=23) and practicing in Europe (β=13). Surgeon factors accounted for more variation in timing than patient and injury factors (5.1% vs 1.4%, respectively). Open surgery was more likely in patients with LCL injury (OR=2.9 to 3.3). Conclusion: The observation that surgeons were more likely to operate in younger patients with more severe injury has face validity, while the finding that surgeon factors accounted for more variation in timing of surgery than patient or injury factors suggests that treatment variation is based on opinion more so than evidence. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.
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He, Jinwen, Bin Geng, Peng Xu, and Yayi Xia. "Do Age and Timing Influence the Outcomes of Single‐stage Reconstruction of Multiple Ligament Knee Injuries? 5‐10 Years Follow Up." Orthopaedic Surgery, April 21, 2024. http://dx.doi.org/10.1111/os.14067.
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ObjectivesMultiple ligament knee injuries (MLKIs) are disruptive injuries, however, there are controversies in the results of acute and delayed reconstruction. Also, clinical outcomes between patients older or younger than 40 have not been compared in MLKIs. This study was designed to investigate the influence of age and timing of reconstruction on the outcomes of single‐stage reconstruction of MLKIs.MethodsThe patients who underwent reconstruction of multiple injured ligaments because of MLKIs between May 2013 and July 2019 were added to the cohort. The postoperative complications, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) 2000 score, Tegner activity level, patient satisfaction, and SF‐36 score were compared between young (≤ 40 years old, n = 41) and old patients (n = 61); acute (≤ 3 weeks after injury, n = 75) and delayed reconstruction (n = 27), using Mann–Whitney U test or χ2 test.ResultsA total of 102 MLKI patients managed by single‐stage multi‐ligament reconstruction were retrospectively reviewed. Patients were followed up after surgery for a mean of 7.3 years (5.2‐10.7 years). At the last follow‐up, no significant difference was found in knee ROM, functional scores, and patient‐reported outcomes between patients older or younger than 40; acute and delayed reconstruction (p > 0.05). The rate of complications in the delayed reconstruction group was higher than that of the acute reconstruction group (22.2% vs 5.3%, p < 0.05). The IKDC objective scores reached grade A in 63.7%–80.4% of patients, and grade B in 11.8%–23.5% patients.ConclusionThe single‐stage reconstruction of MLKIs can obtain comparative long‐term functional and objective outcomes regardless of patients older or younger than 40; acute and delayed reconstruction, however, delayed reconstruction is related to a high rate of postoperative complications.
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Kallman, Tyler, Mark Amirtharaj, Neal Weldon, Melissa Manzer, Matthew Tao, and Elizabeth Wellsandt. "Poster 361: Changes in Anterior Tibial Translation Are Not Associated with Degradation in Weightbearing Cartilage of the Knee Following Anterior Cruciate Ligament Reconstruction." Orthopaedic Journal of Sports Medicine 12, no. 7_suppl2 (2024). http://dx.doi.org/10.1177/2325967124s00327.
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Objectives: Anterior cruciate ligament (ACL) injury is a frequent knee injury that commonly results in post-traumatic osteoarthritis (PTOA). ACL injury has been shown to increase the risk of osteoarthritis (OA) over eightfold within 11 years following injury. While the development of OA is well documented, the mechanism by which this accelerated cartilage degradation occurs is not well understood. The ACL is crucial in providing anterior-posterior and rotational stability of the tibia relative to the femur. Our previous work has demonstrated that ACLR does not restore pathologic anterior tibial translation (ATT) in the lateral or medial tibiofemoral compartment to levels present in uninjured knee. Increased static ATT, specifically the lateral tibial plateau on static magnetic resonance imaging (MRI) in ACL-deficient knees is associated with rotary instability. However’ how ATT relates to clinical outcomes, specifically the development of PTOA, has not been well studied. The objective of this study was two-fold. (1) Compare T2 relaxation times of cartilage in injured knees [a measure of water content and collagen organization of articular cartilage that indicates early cartilage breakdown] 6 months after ACL reconstruction (ACLR); (2) investigate whether greater ATT associates with longer (worse) T2 relaxation times in the lateral and medial compartment. We hypothesized that T2 relaxation times would increase (worsen) from before to 6-months post-operatively, and would be positively correlated with greater amounts of ATT. Methods: Twenty-nine participants between the ages of 15 and 35 were enrolled within one month of ACL injury but prior to ACLR. Individuals older than 35 were excluded due to possible baseline cartilage degeneration. Other exclusion criteria included previous injury or surgery to either knee, acute chondral lesions, concomitate Grade III tear to other ligaments of the knee, or open growth plates requiring altered ACLR technique. Bilateral knee quantitative MRI data were acquired on a 3-Tesla Phillips Ingenia MRI scanner T2 relaxation maps were generated by using multi-echo MRI data at each signal to fit the signal equation using Levenberg-Marquardt nonlinear least squares algorithm ( Si = the signal at echo time TEi, and S0 = signal at TE = 0) within Interactive Data Language (Harris Geospatial Solutions Inc.). Cartilage segmentation was manually segmented using ITK-SNAP software (Figure 1) The medial and lateral tibial (MTC, LTC) and femoral (MFC, LFC) condyles were divided into three weightbearing regions of interest (ROI) related to the meniscal horns in the sagittal plane (figure 1). Accuracy of segmentation and ROI boundaries were confirmed by a bord-certified, fellowship-Trained musculoskeletal radiologist. ATT was measured on MRI using the validated method described by Iwaki et al. A midsagittal point was identified halfway between the posterior cruciate ligament (PCL) insertion and the lateral edge of the LTC was identified on sagittal MRI. At the midsagittal point, a vertical line was drawn off the posterior cortex of the tibia, perpendicular to the plateau. A best-fit circle was then drawn over the posterior LFC and a second line perpendicular to the LTC was drawn off the posterior margin of the best fit circle. The distance between the two vertical lines was used to calculate ATT. Paired t tests were used to determine if T2 relaxation times differed in the injured limb from before to 6 months after ACLR. Pearson correlations were used to determine the relationship in each weightbearing ROI between 1) change in ATT and percent change in T2 relaxation times from before to 6 months after ACLR, and 2) between-limb difference in ATT before ACLR and percent change in T2 relaxation time. Results: Demographic data including age, sex, race, and pre-injury cutting and pivoting sport participation are presented in Table 1. Twenty-six (89.7%) individuals participated in level one activities (i.e. basketball, soccer) prior to injury. T2 relaxation times increased (worsened) in all weightbearing ROIs from before to 6 months after ACLR except the posterior weightbearing region in the LFC (p=0.296) and the central weightbearing region in the LTC (0.470). Neither the postoperative change in ATT nor the difference in ATT between injured and uninjured limbs before ACLR were significantly correlated with increase in T2 relaxation times (Table 3). Conclusions: The results of this study support our hypothesis that T2 relaxation times would be significantly longer, representing cartilage degradation, after ACLR, even at an early time point of 6 months post-operatively. However, greater ATT in ACL-injured knees remaining at 6 months after ACLR as well as relative to the uninjured limb before ACLR was not correlated with changes in T2 relaxation times in the weightbearing cartilage of the femur and tibia. Future work is needed to identify possible dynamic changes in cartilage loading related to early OA development following ACL injury and reconstruction.