Outcome of ACL Reconstruction for Chronic ACL Injury in Knees without the Posterior Horn of the Medial Meniscus: Comparison with ACL Reconstructed Knees with An Intact Medial Meniscus

Objectives: Anterior cruciate ligament (ACL) injury of the knee is commonly associated with meniscal and chondral lesions. This study was performed to assess the relative risk factors as well as the extent of the meniscal and chondral pathology at the time of arthroscopic ACL reconstruction. Materials and Methods: In this prospective study, patients undergoing ACL reconstruction were enrolled. Association of meniscal and chondral lesions was analyzed with age, sex, body mass index (BMI), mechanism of injury (sports-related or not), time gap between injury and surgery (<3 month and >3 months), and instability episodes. Logistic regression and Pearson Chi-square test were applied for evaluating the association. Results: A total of 55 patients (mean age 30 years [19–50 years]; 45 male:10 female) underwent arthroscopic ACL reconstruction, out of which 20 (36.3%) had isolated lateral meniscus tear, 14 (25.4%) had isolated medial meniscus tear, and 3 (5.4%) had both lateral and medial meniscus tear. BMI (P = 0.031) and instability episodes (P = 0.033) were predictor for meniscal lesions. Male sex was associated with significantly higher medial (P = 0.049) and lateral meniscal (P = 0.008) lesions. The older age group (>30 years) was associated with medial meniscus lesions (P = 0.047), while the younger age group (<30 years) had significantly higher lateral meniscal lesions (P = 0.008). Chronic ACL injuries (>3 months) had a significantly higher risk of medial meniscus lesions (P = 0.006). Age (>30 years) (P = 0.002) and obesity (BMI >30 kg/m2) (P = 0.043) were predictors of chondral lesions. Conclusion: Significant association is observed between age (>30 years), male gender, obesity, and chronicity with medial meniscal injuries in patients with an ACL injury, while younger patients (<30 years) and patient operated within 3 months had a higher incidence of lateral meniscus lesions. Age and BMI (>30 kg/m2) were predictors of chondral lesions in ACL injury.

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Ramp Lesions of the Medial Meniscus in Patients Undergoing Primary and Revision ACL Reconstruction: Prevalence and Risk Factors

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119843509 ◽

2019 ◽

Vol 7 (5) ◽

pp. 232596711984350 ◽

Cited By ~ 7

Author(s):

George C. Balazs ◽

Harry G. Greditzer ◽

Dean Wang ◽

Niv Marom ◽

Hollis G. Potter ◽

...

Keyword(s):

Risk Factors ◽

Bone Marrow ◽

Acl Reconstruction ◽

Bone Marrow Edema ◽

Medial Meniscus ◽

Meniscal Tear ◽

Injury Mechanism ◽

Posterior Horn ◽

Ramp Lesion ◽

Marrow Edema

Background: Ramp lesions are peripheral tears of the posterior horn of the medial meniscus that involve the meniscocapsular attachments or red-red zone and typically occur in conjunction with anterior cruciate ligament (ACL) ruptures. Purpose: To identify the prevalence of, and risk factors for, ramp lesions in a large cohort of patients undergoing primary and revision ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: We queried our institutional registry of patients who underwent primary or revision surgical treatment for an ACL injury. Those who underwent preoperative magnetic resonance imaging (MRI) at our facility were included in the study. Clinical details were extracted and verified using electronic records. All preoperative MRI scans were reviewed by a musculoskeletal radiologist for the presence of a ramp lesion. Stable ramp lesions were defined as a peripheral posterior horn medial meniscal tear identified on MRI but either not identifiable with viewing and probing from the anterior portals or, if identified, not displaceable with anteriorly directed probing. Unstable ramp lesions were defined as peripheral posterior horn medial meniscal tears at the meniscocapsular junction that were identifiable at the time of surgery and displaced into the medial compartment with probing. The prevalence of stable and unstable ramp lesions was calculated. Demographic, injury, and imaging parameters were determined using univariate statistics. Results: A total of 372 patients were included. The overall prevalence of ramp lesions was 42% (155/372). Unstable ramp lesions were present in 73 (20%) patients, and stable ramp lesions were present in 82 (22%) patients. The presence of any ramp lesion (stable or unstable) was associated with bone marrow edema of the posteromedial tibia on MRI (odds ratio [OR], 3.0; P < .0001), a contact injury mechanism (OR, 1.8; P = .02), and a concurrent lateral meniscal tear (OR, 1.7; P = .02). No demographic, injury, surgical, or radiological variable was associated with a stable versus unstable ramp lesion. Conclusion: The overall prevalence of a ramp lesion in patients treated for ACL ruptures at our institution was 42%. The presence of bone marrow edema of the posteromedial tibia, a contact injury mechanism, or a lateral meniscal tear should alert surgeons to the potential presence of a medial meniscal ramp lesion.

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EFFECT OF SKELETAL MATURITY ON INCIDENCE OF ASSOCIATED MENISCAL AND CHONDRAL INJURIES IN ANTERIOR CRUCIATE LIGAMENT INJURED KNEES

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121s00105 ◽

2021 ◽

Vol 9 (7_suppl3) ◽

pp. 2325967121S0010

Author(s):

Brett Heldt ◽

Elsayed Attia ◽

Raymond Guo ◽

Indranil Kushare ◽

Theodore Shybut

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Medial Meniscus ◽

Skeletal Maturity ◽

Cruciate Ligament ◽

Demographic Data ◽

Meniscal Tear ◽

Lateral Meniscus ◽

Meniscus Tears ◽

Anterior Cruciate

Background: Acute anterior cruciate ligament(ACL) rupture is associated with a significant incidence of concomitant meniscal and chondral injuries. However, to our knowledge, the incidence of these concomitant injuries in skeletally immature(SI) versus skeletally mature(SM) patients has not been directly compared. SI patients are a unique subset of ACL patients because surgical considerations are different, and subsequent re-tear rates are high. However, it is unclear if the rates and types of meniscal and chondral injuries differ. Purpose: The purpose of this study is to compare associated meniscal and chondral injury patterns between SI and SM patients under age 21, treated with ACL reconstruction for an acute ACL tear. We hypothesized that no significant differences would be seen. Methods: We performed a single-center retrospective review of primary ACL reconstructions performed from January 2012 to April 2020. Patients were stratified by skeletal maturity status based on a review of records and imaging. Demographic data was recorded, including age, sex, and BMI. Associated intra-articular meniscal injury, including laterality, location, configuration, and treatment were determined. Articular cartilage injury location, grade, and treatments were determined. Revision rates, non-ACL reoperation rates, and time to surgery were also compared between the two groups. Results: 785 SM and 208 SI patients met inclusion criteria. Mean BMI and mean age were significantly different between groups. Meniscal tear rates were significantly greater in SM versus SI patients in medial meniscus tears(P<.001), medial posterior horn tears(P=.001), medial longitudinal tears configuration(P=.007), lateral Radial configuration(P=.002), and lateral complex tears(P=.011). Medial repairs(P<.001) and lateral partial meniscectomies(P=.004) were more likely in the SM group. There was a significantly greater number of chondral injuries in the SM versus SI groups in the Lateral(p=.007) and medial compartments(P<.001). SM patients had a significantly increased number of outerbridge grade 1 and 2 in the Lateral(P<.001) and Medial Compartments(P=.013). ACL revisions(P=.019) and Non-ACL reoperations(P=.002) were significantly greater in the SI patients compared to SM. No other significant differences were noted. Conclusion: SM ACL injured patients have a significantly higher rate of medial meniscus tears and medial longitudinal configurations treated with repair, and a significantly higher rate of radial and/or complex lateral meniscus tears treated with partial meniscectomy compared to the SI group. We also found a significantly higher rate of both medial and lateral compartment chondral injuries, mainly grades 1 and 2, in SM compared to SI patients. Conversely, SI ACL reconstruction patients had higher revision and subsequent non-ACL surgery rates.

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High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study

British Journal of Sports Medicine ◽

10.1136/bjsports-2020-103555 ◽

2021 ◽

pp. bjsports-2020-103555

Author(s):

Francesco Della Villa ◽

Martin Hägglund ◽

Stefano Della Villa ◽

Jan Ekstrand ◽

Markus Waldén

Keyword(s):

Acl Reconstruction ◽

Cox Regression ◽

Injury Rate ◽

Acl Injury ◽

High Rate ◽

Football Players ◽

Professional Football ◽

Cox Regression Analysis ◽

Career Length ◽

Increased Risk

BackgroundStudies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce.AimTo investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR.Study designProspective cohort study.SettingMen’s professional football.Methods118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury.ResultsMedian follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR.ConclusionsAlmost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.

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20-Year Outcomes of Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: The Catastrophic Effect of Age and Posterior Tibial Slope

The American Journal of Sports Medicine ◽

10.1177/0363546517741497 ◽

2017 ◽

Vol 46 (3) ◽

pp. 531-543 ◽

Cited By ~ 61

Author(s):

Lucy J. Salmon ◽

Emma Heath ◽

Hawar Akrawi ◽

Justin P. Roe ◽

James Linklater ◽

...

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Degenerative Change ◽

Acl Injury ◽

Hamstring Tendon ◽

Activity Level ◽

Acl Graft ◽

Hamstring Tendon Autograft ◽

Graft Rupture ◽

Tendon Autograft

Background: No well-controlled studies have compared the long-term outcome of anterior cruciate ligament (ACL) reconstruction with hamstring tendon autograft between adolescents and adults. Increased posterior tibial slopes (PTSs) have been reported in the ACL-injured versus controls, but the effect of PTS on the outcome after reconstruction is relatively unexplored. Purpose: To compare the prospective longitudinal outcome of “isolated” ACL ruptures treated with anatomic endoscopic ACL reconstruction using hamstring tendon autograft over 20 years in adolescent and adult cohorts and to examine factors for repeat ACL injury. Study Design: Case-control study; Level of evidence, 3. Methods: A single-surgeon series of 200 consecutive patients undergoing isolated primary ACL reconstruction with hamstring tendon autograft were prospectively studied. Subjects were assessed preoperatively and at 2, 7, 15, and 20 years postoperatively. Outcomes included International Knee Documentation Committee (IKDC) Knee Evaluation, IKDC subjective scores, KT-1000 instrumented laxity testing, and radiological evaluation of degenerative change and medial tibial slope. Twenty-year outcomes were compared between those who underwent surgery at the age of 18 years or younger (adolescent group, n = 39) and those who underwent surgery when older than 18 years (adult group, n = 161). Results: At 20 years, 179 of 200 subjects were reviewed (89.5%). ACL graft rupture occurred in 37 subjects and contralateral ACL injury in 22 subjects. Of those with intact ACL grafts at 20 years, outcomes were not statistically different between adolescents and adults for the variables of IKDC subjective score ( P = .29), return to preinjury activity level ( P = .84), current activity level ( P = .69), or degree of radiological degenerative change at 20 years ( P = .51). The adolescent group had a higher proportion of grade 1 ligamentous laxity testing compared with the adult group ( P = .003). Overall, ACL graft survival at 20 years was 86% for adults and 61% for adolescents (hazard ration, 3.3; P = .001). The hazard for ACL graft rupture was increased by 4.8 in adolescent males and 2.5 in adolescent females compared with adults. At 20 years, the ACL survival for adolescents with a PTS of ≥12° was 22%. The hazard for ACL graft rupture was increased by 11 in adolescents with a PTS of ≥12° ( P = .001) compared with adults with a PTS <12°. Conclusion: Repeat ACL injury after isolated ACL reconstruction is common, occurring in 1 in 3 over 20 years. In the absence of further injury, isolated ACL reconstruction using this technique was associated with good long-term outcomes with respect to patient-reported outcomes and return to sports, regardless of age. However, mild ligament laxity and ACL graft rupture after ACL reconstruction are significantly more common in adolescents, especially adolescent males, compared with adults. PTS of 12° or more is the strongest predictor of repeat ACL injury, and its negative effect is most pronounced in adolescents.

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Meniscus delivery: a maneuver for easy arthroscopic access to the posterior horn of the medial meniscus

SICOT-J ◽

10.1051/sicotj/2016007 ◽

2016 ◽

Vol 2 ◽

pp. 10 ◽

Cited By ~ 2

Author(s):

Hatem Galal Said ◽

Saumitra Goyal ◽

Tarek Nabil Fetih

Keyword(s):

Medial Meniscus ◽

Posterior Horn

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A Cam Shaped Femur Might Be A Risk Factor for ACL Injuries

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00139 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0013

Author(s):

Thomas Rudolf Pfeiffer ◽

Jeremy M. Burnham ◽

Ajay C. Kanakamedala ◽

Jonathan Daniel Hughes ◽

James J. Irrgang ◽

...

Keyword(s):

Acl Reconstruction ◽

Injury Risk ◽

Roc Analysis ◽

Femoral Condyle ◽

Academic Medical Center ◽

Acl Injury ◽

Control Group ◽

Acl Injuries ◽

Increased Risk ◽

The Mean

Objectives: Bony morphologic characteristics have been demonstrated to increase the risk of anterior cruciate ligament (ACL) injury. While posterior femoral condyle condylar offset is an aspect of distal femoral bony morphology that has been reported to influence range of motion and other aspects of knee joint kinematics, it remains unclear whether this characteristic influences the risk of ACL injury. The purpose of the study was to examine the relationship between distal femoral morphology and risks of ACL injury, reconstruction failure, and contralateral ACL injury. It was hypothesized that increased posterior femoral condylar depth, quantified as the cam ratio, would correlate with increased risk of primary ACL injuries, ACL reconstruction failures, and contralateral ACL injuries. Methods: Consecutive patients undergoing evaluation for knee complaints at an academic medical center from 2012-2016 with minimum 24-month follow-up were retrospectively reviewed. Subjects were stratified into four groups: a control group consisting of patients with no ACL injuries and three groups of patients with a primary ACL injury, failed ACL reconstruction, or previous ACL injury with subsequent contralateral ACL injury. Using lateral radiographs, the ratio of posterior condylar depth over total condylar distance was defined as the cam ratio. Analysis-of-variance (ANOVA) and post-hoc testing were used to test for differences in the mean tomahawk ratio between study groups (p<0.05). Receiver Operating Characteristic (ROC) analysis was performed to determine the optimal cam ratio cut-off for detecting increased risk for ACL injury. Results: One hundred and seventy-five patients met inclusion criteria. The mean cam ratios in the control, primary ACL injury, failed ACL reconstruction, and contralateral ACL injury groups were 61.1% (± 2.1), 64.2% (± 3.8), 64.4% (± 3.6), and 66.9% (± 4.0), respectively. Patients with a primary ACL injury, failed ACL reconstruction, or contralateral ACL injury had a significantly higher cam ratio compared to the control group (p<0.008). ROC analysis demonstrated a cam ratio of 63% or greater to be associated with an increased risk for ACL injury with a sensitivity of83% and a specificity of 71%. Conclusion: The data from this study show that an increased posterior femoral condylar depth, or cam ratio, might be associated with increased risk of ACL injury, including primary ACL injury, failed ACL reconstruction, and contralateral ACL injury. The data from this study may help clinicians identify patients at greater risk of ACL injury and re-injury. Future prospective studies will be helpful in investigating the mechanism by which an increased cam ratio increases ACL injury risk and potential strategies to mitigate the increased risk posed by this bony characteristic.

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Effect of Meniscocapsular and Meniscotibial Lesions in ACL-Deficient and ACL-Reconstructed Knees: A Biomechanical Study

The American Journal of Sports Medicine ◽

10.1177/0363546518774315 ◽

2018 ◽

Vol 46 (10) ◽

pp. 2422-2431 ◽

Cited By ~ 35

Author(s):

Nicholas N. DePhillipo ◽

Gilbert Moatshe ◽

Alex Brady ◽

Jorge Chahla ◽

Zachary S. Aman ◽

...

Keyword(s):

Internal Rotation ◽

Medial Meniscus ◽

Pivot Shift ◽

External Rotation ◽

Posterior Horn ◽

Pivot Shift Test ◽

Anterior Tibial Translation ◽

Anterior Tibial ◽

Tibial Translation ◽

Acl Deficient

Background: Ramp lesions were initially defined as a tear of the peripheral attachment of the posterior horn of the medial meniscus at the meniscocapsular junction. The separate biomechanical roles of the meniscocapsular and meniscotibial attachments of the posterior medial meniscus have not been fully delineated. Purpose: To evaluate the biomechanical effects of meniscocapsular and meniscotibial lesions of the posterior medial meniscus in anterior cruciate ligament (ACL)–deficient and ACL-reconstructed knees and the effect of repair of ramp lesions. Study Design: Controlled laboratory study. Methods: Twelve matched pairs of human cadaveric knees were evaluated with a 6 degrees of freedom robotic system. All knees were subjected to an 88-N anterior tibial load, internal and external rotation torques of 5 N·m, and a simulated pivot-shift test of 10-N valgus force coupled with 5-N·m internal rotation. The paired knees were randomized to the cutting of either the meniscocapsular or the meniscotibial attachments after ACL reconstruction (ACLR). Eight comparisons of interest were chosen before data analysis was conducted. Data from the intact state were compared with data from the subsequent states. The following states were tested: intact (n = 24), ACL deficient (n = 24), ACL deficient with a meniscocapsular lesion (n = 12), ACL deficient with a meniscotibial lesion (n = 12), ACL deficient with both meniscocapsular and meniscotibial lesions (n = 24), ACLR with both meniscocapsular and meniscotibial lesions (n = 16), and ACLR with repair of both meniscocapsular and meniscotibial lesions (n = 16). All states were compared with the previous states. For the repair and reconstruction states, only the specimens that underwent repair were compared with their intact and sectioned states, thus excluding the specimens that did not undergo repair. Results: Cutting the meniscocapsular and meniscotibial attachments of the posterior horn of the medial meniscus significantly increased anterior tibial translation in ACL-deficient knees at 30° ( P ≤ .020) and 90° ( P < .005). Cutting both the meniscocapsular and meniscotibial attachments increased tibial internal (all P > .004) and external (all P < .001) rotation at all flexion angles in ACL-reconstructed knees. Reconstruction of the ACL in the presence of meniscocapsular and meniscotibial tears restored anterior tibial translation ( P > .053) but did not restore internal rotation ( P < .002), external rotation ( P < .002), and the pivot shift ( P < .05). To restore the pivot shift, an ACLR and a concurrent repair of the meniscocapsular and meniscotibial lesions were both necessary. Repairing the meniscocapsular and meniscotibial lesions after ACLR did not restore internal rotation and external rotation at angles >30°. Conclusion: Meniscocapsular and meniscotibial lesions of the posterior horn of the medial meniscus increased knee anterior tibial translation, internal and external rotation, and the pivot shift in ACL-deficient knees. The pivot shift was not restored with an isolated ACLR but was restored when performed concomitantly with a meniscocapsular and meniscotibial repair. However, the effect of this change was minimal; although statistical significance was found, the overall clinical significance remains unclear. The ramp lesion repair used in this study failed to restore internal rotation and external rotation at higher knee flexion angles. Further studies should examine improved meniscus repair techniques for root tears combined with ACLRs. Clinical Relevance: Meniscal ramp lesions should be repaired at the time of ACLR to avoid continued knee instability (anterior tibial translation) and to eliminate the pivot-shift phenomenon.

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