The influence of anesthesia- body mass index and chronicity of the injury on the reliability of diagnostic tests for anterior cruciate ligament rupture

This study aimed to analyze the accuracy and interobserver reliability of the four common diagnostic tests for anterior cruciate ligament (ACL) rupture. The effect of anesthesia, chronicity of the injury and patient’s body mass index (BMI) on the reliabilities was also assessed. Patients who underwent arthroscopic knee surgery were examined before the surgery and under anesthesia by three observers categorized based on their experience levels. One hundred two patients were evaluated to determine the accuracy of these tests. Sixty-two patients with ACL rupture were further examined to assess the effect of BMI (≤ 25 kg/m2, or > 25 kg/m2) and chronicity (≤ 4 or > 4 weeks) of the injury on reliabilities with using the Fleiss kappa method. The Lachman test performed under anesthesia had the highest sensitivity (100%, 100%, and 96.7%). In contrast, pivot shift and lever sign tests had the lowest sensitivity both in awake (24.2%, 17.7%, 8.1% and 37.1%, 33.8%, 29%) and anesthetized condition (75.8%, 75.8%, 67.7% and 41.9%, 43.5%, 40.3%). Specificities of the tests except pivot shift were negatively affected when performed under anesthesia. The reliability of the anterior drawer test was perfect under anesthesia. The lever sign test had the highest reliability in the awake condition in patients with a BMI of > 25 kg/m2. Furthermore, the reliabilities of the anterior drawer, Lachman, and pivot-shift tests in awake condition were found to be increased in patients with a chronic injury. Finally, the examiner’s experience is not important for the physical diagnosis of ACL rupture.

Clinical outcomes of anterior tibiofibular ligament’s distal fascicle transfer versus ligament reconstruction with InternalBrace™ for chronic ankle instability patients

Purpose Treatment of chronic ankle instability (CAI) for ankle sprain patients remains a challenge. If initial treatments fail, surgical stabilization techniques including ligament reconstruction should be performed. Anterior tibiofibular ligament (ATiFL) distal fascicle transfer for CAI was recently introduced. The goal of the study is to assess the 1-year clinical effectiveness of ATiFL’s distal fascicle transfer versus ligament reconstruction with InternalBrace™ (Fa. Arthrex, Naples). Methods Between October 2019 and February 2021, 25 patients (14 males and 11 females) scheduled for ligament reconstruction treatment of CAI were enrolled after propensity score matching. Twelve underwent ligament reconstruction with InternalBrace™ (InternalBrace™ group) and thirteen underwent ATiFL’s distal fascicle transfer (ATiFL’s distal fascicle transfer group). We recorded the American Orthopedic Foot & Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), anterior drawer test grade, patient satisfaction and complications. All results of this study were retrospectively analyzed. Results Statistically significant (p = 0.0251, independent-samples t test) differences in the AOFAS can be found between the ATiFL’s distal fascicle transfer group and the InternalBrace™ group. No substantial changes in the VAS (p = 0.1778, independent-samples t test), patient satisfaction (p = 0.1800, independent-samples t test) and anterior drawer test grade (p = 0.9600, independent-samples t test) were found between the two groups. There was one patient with superficial wound infection and one patient with sural nerve injury in the InternalBrace™ group and ATiFL’s distal fascicle transfer group, respectively. Conclusion This is the first study that assessed a cohort of CAI patients and suggests that the ATiFL’s distal fascicle transfer operation has the potential to attain good-to-excellent clinical outcomes after 1-year recovery. The AOFAS scores were significantly higher for patients with ATiFL’s distal fascicle transfer, indicating that this technique may be considered a viable option for both patients and their surgeon, while long-term outcomes should be investigated in the future.

The Ratio of Stress to Nonstress Anterior Talofibular Ligament Length on Ultrasonography: Normative Values

Background: Stress ultrasonography (US) has been shown to be a valid procedure for evaluating chronic anterior talofibular ligament (ATFL) injury. The ratio of stress/nonstress ATFL length (ATFL ratio) as measured on US is clinically useful; however, there are no published normative data concerning this ratio. Purpose: To report a normative value of the ATFL ratio on US and evaluate the relationships between sex, generalized joint laxity (GJL), and the grade of anterior drawer test (ADT). Study Design: Cross-sectional study; Level of evidence, 3. Methods: The ATFL lengths were prospectively measured in the stress and nonstress positions (manual maximal anterior drawer position) for participants with noninjured ankles from March 2020 to March 2021. GJL was defined as a Beighton score ≥4. A manual ADT was also performed. The ATFL ratio was calculated, and the relationships between sex, GJL, and ADT grade were evaluated. Results: A total of 333 ankles in 184 participants (mean age, 24.5 ± 2.7 years; range, 20-33 years) were eligible for the analysis. GJL was found in 69 ankles (20.7%). The mean ATFL ratio was 1.08 ± 0.04 (95% CI, 1.08-1.09; range, 1.01-1.24), and there was a significant difference between male (1.07 ± 0.04; 95% CI, 1.07-1.08; range, 1.02-1.23) and female (1.09 ± 0.04; 95% CI, 1.08-1.10; range, 1.01-1.24) ankles ( P = .001). In male ankles, the ATFL ratio was significantly greater in participants with GJL (1.11 ± 0.06 vs 1.07 ± 0.03; P = .02) or a higher grade of ADT (grade 2 vs grade 1: 1.11 ± 0.06 vs 1.07 ± 0.03, P = .002). These findings were not observed in female ankles. Conclusion: The normative value of the ATFL ratio on stress US was 1.07 ± 0.04 in men and 1.09 ± 0.04 in women. The ATFL ratio was affected by the presence of GJL in men but not in women. These findings will be useful for future studies seeking to establish the cutoff value of the ATFL ratio for diagnosing chronic lateral ankle stability on stress US.

Kinematic Analysis of Lateral Meniscal Oblique Radial Tears in the Anterior Cruciate Ligament–Deficient Knee

Background: Lateral meniscal oblique radial tears (LMORT) occur frequently in conjunction with anterior cruciate ligament (ACL) disruption and are anatomically distinct from meniscus root tears. Hypothesis/Purpose: The purpose of this study was to characterize the effects of LMORT types 3 (LMORT3) and 4 (LMORT4) lesions on joint stability and meniscal extrusion in ACL-deficient knees. Our hypothesis was that both lesions would promote significant increases in anterior translation and meniscal extrusion, with the LMORT4 lesion having a greater effect. Study Design: Controlled laboratory study. Methods: Two matched pairs of cadaveric knees (n = 4) were used to optimize the testing sequence. Additional cadaveric knees with LMORT3 (n = 8) and LMORT4 (n = 8) lesions created after ACL transection underwent robotic kinematic testing for anterior drawer and pivot-shift simulations with associated ultrasound-measured meniscal extrusion at clinically relevant knee flexion angles. Results: Optimization testing showed no differences on the effect of LMORT4 lesions for anterior translation and lateral meniscal extrusion with ACL-intact versus ACL-deficient knees. ACL deficiency and LMORT3 and LMORT4 lesions with ACL deficiency were associated with significantly greater anterior translation compared with ACL-intact state for both anterior drawer and pivot-shift testing at all flexion angles ( P < .001). ACL deficiency with either LMORT3 or LMORT4 lesion was associated with significantly greater anterior translation than was ACL deficiency only ( P < .005) for anterior drawer testing at 90° of flexion. Meniscal extrusion was greater with LMORT3 and LMORT4 lesions compared with ACL deficiency only ( P < .05) for anterior drawer at 60° of flexion and for pivot shift at 15° of flexion. The LMORT4 lesion demonstrated increased anterior translation for anterior drawer ( P = .003) at 60° of flexion (12%) as well as for pivot shift at 15° of flexion (7%) and 30° of flexion (13%) ( P < .005) compared with ACL deficiency only. Conclusion: In this cadaveric model, the addition of an LMORT3 or LMORT4 lesion increased anterior laxity for both the anterior drawer and the pivot shift when compared with an isolated ACL tear. Lateral meniscal extrusion was also exacerbated by these LMORT lesions. Clinical Relevance: LMORT lesions, distinct from meniscus root tears, occur frequently in conjunction with ACL tears. This study characterized the biomechanical consequences of LMORT3 and LMORT4 lesions on joint stability and meniscal function, highlighting the importance of diagnosing and treating LMORT lesions at the time of ACL reconstruction.

Diagnostic Accuracy of Clinical Tests in Knee Joint Injuries: A Single Centered Experience

OBJECTIVES: The accuracy of clinical tests (Lachman, McMurray, Anterior Drawer) in the diagnosis of knee joint injuries in comparison to arthroscopy taken as gold standard. METHODOLOGY: This cross-sectional study was conducted at the Department of Orthopedic Surgery, Khyber Teaching Hospital, Peshawar for 3 years. Total of 48 patients were recruited in the study. Data was collected after ethical approval from the hospital ethical committee using consecutive non-probability sampling techniques. Written informed consent was obtained from the patients. Arthroscopy examination was taken as a gold standard. Data analysis was performed using statistical software SPSS 21 and MEDCALC online software for calculating sensitivity and specificities of the clinical tests. RESULTS: Mean age was 26.4+6.5 years. Lachman and Anterior Drawer tests were noted to have 91.67% and 66.67% sensitivity for anterior cruciate ligament while McMurray test was noted only 66.67% sensitive for both meniscal injuries. On the other hand, Lachman was 95.8% specific, McMurray was 77.78%, and Anterior Drawer was 79.2% specific. Regarding accuracy, Lachman was 93.7%, McMurray 70.8% and Anterior Drawer was 72.9% accurate. CONCLUSION: Among clinical examination and specific examination tests, Lachman has high sensitivity, specificity and accuracy followed by Anterior Drawer test and MacMurray for diagnosing anterior cruciate ligament and meniscal injuries of knee joint.

Arthroscopic Two-Point Suture Bridge Fixation Technique for the Treatment of Anterior Cruciate Ligament Tibial Avulsion Fractures

This study aimed to present and evaluate a new arthroscopic technique that uses two-point suture fixation for anterior cruciate ligament (ACL) tibial avulsion fractures. A total of 15 patients diagnosed with ACL tibial avulsion fracture underwent arthroscopic suture fixation from November 2018 to October 2019 and were treated using two-point suture fixation. The patients were followed up and evaluated according to Lysholm scores, International Knee Documentation Committee (IKDC) subjective scores, Tegner activity level scales, anterior drawer testing, and KT-1000 arthrometer testing. The mean follow-up period was 18 months (12 to 24). All patients had a negative Lachman test and anterior drawer test at final follow-up and showed the radiological union of avulsion fracture at 12-week postoperative radiograph. The Lysholm score improved significantly postoperatively with a mean score of 94.26±3.63 (87 to 98; p < 0.001). The Tegner score improved significantly postoperatively from 3.61 ±1.37 to 7.14±1.51 (P < 0.001). The KT-1000 measured value decreased significantly postoperatively from 7.3±1.5 to 1.4 ±1.2 (P < 0.001). The IKDC category was abnormal or severely abnormal preoperatively, and all patients improved to normal or nearly normal at final follow-up. Arthroscopic treatment using the two-point suture fixation technique is effective for ACL avulsion fracture and can restore the function and stability of the knee joint.

Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal

Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman’s, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman’s test. Though not significant, IKDC scores and Lysholm’s scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.

LEVER SIGN TEST FOR CHRONIC ACL INJURY: A COMPARISON WITH LACHMAN AND ANTERIOR DRAWER TESTS

ABSTRACT Objective: This study aims to evaluate the sensitivity and specificity of the lever sign test in patients with and without chronic Anterior Cruciate Ligament (ACL) injuries in an outpatient setting and the inter-examiner agreement of surgeons with different levels of experience. Methods: 72 consecutive patients with a history of previous knee sprains were included. The Lachman, anterior drawer, and Lever Sign tests were performed for all subjects in a randomized order by three blinded raters with different levels of experience. Sensitivity, specificity, positive predictive value, negative predictive value, and inter-rater agreement were estimated for all tests. Results: Among the 72 patients, the prevalence of ACL injuries was 54%. The lever test showed sensitivity of 64.1% (95% CI 0.47-0.78) and specificity of 100% (95% CI 0.87-1.00) for the senior examiner. For the less experienced examiner the sensitivity was 51.8% and the specificity was 93.7%. Positive predictive values (PPV) and negative predictive values (NPV) were 100% and 70.2%, respectively. Conclusion: Lever Sign test shows to be a maneuver of easy execution, with 100% specificity and 100% PPV. Moderate agreement between experienced examiners and low agreement among experienced and inexperienced examiners was found. This test may play a role as an auxiliary maneuver. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.

Diagnostic Accuracy of Clinical Tests Assessing Ligamentous Injury of the Talocrural and Subtalar Joints: A Systematic Review With Meta-Analysis

Context: Ankle sprains are the most common acute musculoskeletal injury. Clinical tests represent the first opportunity to assess the sprain’s severity, but no systematic review has compared these tests to contemporary reference standards. Objective: To determine the diagnostic accuracy of clinical tests assessing the talocrural and subtalar joint ligaments after ankle sprain. Data Sources: CINAHL, EMBASE, MEDLINE, hand-searching, and PubMed-related article searches (inception to November 18, 2020). Study Selection: Eligible diagnostic studies compared clinical examination (palpation, joint laxity) against imaging or surgery. Studies at a high risk of bias or with high concerns regarding applicability on Quality Assessment of Diagnostic Accuracy Studies-2 were excluded from the meta-analysis. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 3a. Data Extraction: True-positive, false-negative, false-positive, and true-negative findings were extracted to calculate sensitivity, specificity, and likelihood ratios. If ordinal data were reported, these were extracted to calculate Cohen’s kappa. Results: A total of 14 studies met the inclusion criteria (6302 observations; 9 clinical tests). No test had both sensitivity and specificity exceeding 90%. Palpation of the anterior talofibular ligament is highly sensitive (sensitivity 95%-100%; specificity 0%-32%; min-max; n = 6) but less so for the calcaneofibular ligament (sensitivity 49%-100%; specificity 26%-79%; min-max; n = 6). Pooled data from 6 studies (885 observations) found a low sensitivity (54%; 95% CI 35%-71%) but high specificity (87%; 95% CI 63%-96%) for the anterior drawer test. Conclusion: The anterior talofibular ligament is best assessed using a cluster of palpation (rule out), and anterior drawer testing (rule in). The talar tilt test can rule in injury to the calcaneofibular ligament, but a sensitive clinical test for the ligament is lacking. It is unclear if ligamentous injury grading can be done beyond the binary (injured vs uninjured), and clinical tests of the subtalar joint ligaments are not well researched. The generalizability of our findings is limited by insufficient reporting on blinding and poor study quality. Registration: Prospero ID: CRD42020187848. Data Availability: Data are available in a public, open access repository on publication, including our RevMan file and the CSV file used for meta-analysis: http://doi.org/10.5f281/zenodo.4917138

A New Arthroscopic Tightrope Suture-Button Fixation Procedure for Tibial Eminence Avulsion Fracture

This case-series outcome study presents a new arthroscopic technique for tibial eminence avulsion fracture (TEAF) with double-tunnel using two tightrope suture buttons. From May 2017 to July 2020, we performed a new arthroscopic technique for TEAF with double tunnels, using two tightrope suture buttons on 13 patients. Clinical assessments included anterior drawer, Lachman, and pivot shift tests, the International Knee Documentation Committee (IKDC), Lysholm knee scores, visual analog scale (VAS) scores, and range of motion (ROM). An independent observer noted conditions before surgery and during the last follow-up. The patients had an average follow-up of 26.2 months, ranging from 15 to 37 months. During the last postsurgical follow-up, the anterior drawer, Lachman, and pivot shift tests were negative in all the cases. According to the IKDC, Lysholm, and VAS final scores, all patients presented a significant knee function improvement at last follow-ups compared with preoperatively. The study shows that satisfactory results about an anatomic reduction of the fragment, knee stability, function, and strength can be achieved with the new arthroscopic technique for TEAF with double tunnels using two tightrope suture buttons. This study is a therapeutic case series and its level of evidence is IV.