Adult patients with ACL tears have greater tibial internal rotation in MRI compared to adolescent patients

Purpose To compare the anterior translation and internal rotation of tibia on magnetic resonance imaging (MRI) between adult and adolescent patients with anterior cruciate ligament (ACL) tears. Methods Patients who underwent isolated ACL reconstruction from January 2013 to May 2021 were retrospectively reviewed. The exclusion criteria included incomplete data, poor image quality, a prior ACL surgery, and concomitant fractures or other ligament injuries. The enrolled patients were divided into two groups based on their ages: an adult group (age > 19 years) and an adolescent group (15 to 19 years of age). Anterior tibial translation and femorotibial rotation were measured on MRI. A Student’s t-test was used for the statistical analysis comparing the adult and adolescent groups. Results A total of 365 patients (279 adults and 86 adolescents) were enrolled in the present study. The anterior tibial translation in the adult group (4.8 ± 4.4 mm) and the adolescent group (5.0 ± 4.2 mm) was not significantly different (p = 0.740). On the other hand, the tibial internal rotation in the adult group (5.6 ± 5.0 degree) was significantly greater compared to the adolescent group (4.2 ± 5.6 degree) (p = 0.030). The intraclass correlation coefficients (ICC) of the measured data from two independent observers showed excellent reliability (0.964 and 0.961 for anterior tibial translation and tibial internal rotation, respectively). Conclusion The adult patients with ACL tears exhibited significant greater tibial internal rotation compared to the adolescent patients, whereas the magnitude of the anterior tibial translation was similar in both groups. Care should be taken if clinicians plan to establish the cutoff point values for diagnosis of ACL tears using the femorotibial internal rotation angle.

Insall–Salvati index is associated with anterior cruciate ligament tears in men: A Case-controlled study

Purpose Many factors in the etiology of anterior cruciate ligament (ACL) tears, predisposing factors related to knee morphology have also been reported. This study aimed to determine whether the Insall–Salvati (IS) index, which measures patella height, is a predisposing risk factor for ACL tears. Methods The IS index, patellar length (PL), and patellar tendon length (PTL) values of patients (study group) that underwent arthroscopic reconstruction for ACL tears obtained by preoperative magnetic resonance imaging (MRI) were compared with the index values in the preoperative MRIs of patients that underwent knee arthroscopy for reasons besides ACL tears. In addition, the anterior tibial translation (ATT) of both groups was also measured and compared on MRI images. The MRI findings of the subjects included in both study groups were arthroscopically confirmed. Results The mean ages of the study group (n = 120) and control group (n = 90) were 29.1 ± 8.2 years and 31.8 ± 9.8 years, respectively. There was a statistically significant difference between the study and control groups in terms of the PL and PTL values ( p = 0.016 and p = 0.001, respectively). The IS index was statistically significantly higher in the study group with ACL tears ( p = 0.009). The ATT was 8.61 ± 4.68 mm in the study group and 3.80 ± 1.92 mm in the control group. The ATT results of both groups were evaluated, and it was found that the study group was significantly higher than the control group ( p = 0.001) Conclusions As a result of our current study, we observed higher IS index values in patients with ACL tears than in patients without ACL tears. It should be kept in mind that patella alta, which is associated with a high IS index as one of the factors of knee morphology associated with ACL tears, may play a role in the etiology of ACL tears.

MIDDLE PATH REGIMEN FOR THE MANAGEMENT OF TRAUMATIC DISLOCATION OF KNEE JOINT WITH VASCULAR DEFICIT.

Background: Dislocation of the knee joint is one of the most under-reported orthopaedic emergencies due to its ability to undergo spontaneous reduction. It carries a high risk of involving the popliteal artery and peroneal nerve both acutely, or in the long term. Due to this catastrophic potential of the condition, it has been well established that it warrants prompt diagnosis and management. It may be secondary to ultra-low, low or high velocity trauma which makes every dislocation case unique due to involvement of different joint structures, capsule or fractures of the articulating bones. A broad spectrum of treatment modalities (both conservative and surgical) has been documented for this condition, with the latter showing better results across most studies. In developing countries like India, the nancial chasm is relatively bigger with a major chunk of the population unable to bear the cost of complete surgical management. Objective: To assess the functional outcome in patients with frank knee dislocations with multiligamentous injuries and vascular decit treated by a middle path regimen of an extended period of external xator and immobilization. Method: A prospective study was undertaken from January 2018 to July 2020 involving 10 patients with knee joint dislocations with vascular decit and multiligamentous injury, treated by an extended period of external xator application and immobilization. Fasciotomy was done wherever needed, in association with split thickness skin grafting. The assessments were made using Lysholm knee scoring scale (LKSS), International Knee Documentation Committee Scores (IKDC), range of motion (ROM), antero- posterior tibial translation (AP translation) and overall patient satisfaction on every follow-up. Results: The mean LKSS score was 78.3±6.23, mean IKDC score was 68.17±5.34, mean ROM progressively increased to 135.8⁰ with a mean extension lag of 2.2⁰, while the mean AP tibial translation was noted to be 9.16 mm. No poor result or complication was reported. Conclusion: The middle path regimen provides an affordable alternative for providing a stable knee to patients who are ill-affording and are expected to have a sedentary lifestyle, without indulging into rigorous activities

Comparative Study of Efficacy of Muscle Energy Technique and Positional Release Therapy in Post ACL Reconstruction in Young Adults: A Randomised Clinical Trial

The anterior cruciate ligament (ACL), it is a dense connective tissue band originating from the medial wall of the lateral femoral condyl and inserts into the middle of the intercondylar region on the tibia. It is regarded as a crucial component in the knee joint because it resists anterior tibial translation and rotational load. Young athletes who participate in sports that demand turning, decelerating, and jumping are at high risk for ACL injury. People who participate in Pivoting sports are likely to have them (e.g. football, basketball, netball, soccer, European team handball, gymnastics, downhill skiing). Environmental (e.g., high friction between shoes and the playing surface) and anatomical variables are also risk factors for ACL injury (e.g. narrow femoral intercondylar notch). Knee instability causes a reduction in activity, which can result in a decrease in knee-related quality of life. ACL injury risk factors have been classified as either internal or external to a person. Type of competition, footwear and surface, and environmental conditions are all external risk factors. Anatomical, hormonal, and neuromuscular risk factors are all internal risk factors. Aim and Objective: to compare the efficacy of Myofacial Release Technique versus Positional Release Therapy on range of motion post ACL reconstruction. Methodology: In this study total 45 patients with post ACL reconstruction will be divided into two groups, one group will receive muscle energy technique and other group will received positional release therapy. The treatment will be given for 5 sessions per week for six weeks. The assessment will be done at day one of treatment at the end of treatment at the end of first week and at the end of six week. Discussion: This study will find the better technique for improving Range of motion Post ACL reconstruction. Conclusion: Conclusion of the study will be drawn after the statistical analysis of the data gathered from the individuals enrolled in the study.

Manual Lachman Test Underestimates Tibial Translation Compared to Standardized Generated Force: A Biomechanical Study of Cadaveric Anterior Cruciate Ligament Repair Using Internal Brace (205)

Objectives: With an increasing incidence over time, anterior cruciate ligament (ACL) rupture can produce functionally limiting knee instability that requires operative treatment to address the instability as well as prevent the development of osteoarthritis. Anteroposterior instability forms the basis of the most sensitive physical exam maneuver to examine the ACL for rupture, the Lachman test. This investigation has two goals: to assess the precision and accuracy of the manual Lachman test by comparing anterior tibial translation generated to that of a standardized applied force Lachman test, and to compare the anteroposterior stability of cadaver specimens with simulated ACL ruptures which were repaired with and without internal suture tape augmentation. Methods: The tibial plateau in ten cadaveric knees was divided into medial, middle and lateral reference points, which were monitored digitally during testing using Optotrak. Intact knees were subjected to both manual Lachman tests at 30 degrees of flexion and standardized 150N force Lachman tests utilizing a hook and pulley system with force transducer. The ACL’s of all specimens were then transected, and the ACL deficient knees were subjected to both the manual and standardized Lachman tests. The specimens were then randomly divided into two groups to be repaired with or without internal suture tape augmentation, and subsequently underwent 100, 250, and 500 cycles from 90 degrees of flexion through full extension with a frequency of .1Hz, after which the same standardized Lachman test was performed on all repaired specimens. Comparison of variances were made using a two-sample F-Test for variances. Comparison of means were made using a two sample t-test assuming unequal variances and one-way ANOVA. Significance was set at p </= 0.05. Results: Comparing ACL intact to ACL deficient states, the standardized Lachman test detected a significant difference in tibial translation at the medial (14.1mm versus 20.3mm, p=.031), middle (17.5mm versus 24.6mm, p=.011), and lateral (14.8mm versus 21.5mm, p=.050) reference points while the manual Lachman test only detected a significant difference at the middle (12.6mm versus 19.8mm, p=.026) reference point. In ACL deficient knees, there was a statistically significant underestimation in tibial translation when using the manual method as compared to the standardized method (17.4mm versus 22.3mm, p=0.046). When comparing the precision of the testing methods, F-Tests for variance did not yield significant differences between variances in measured tibial translation for the manual and standardized Lachman tests in either intact or ACL deficient knees. There were no statistically significant differences in measured tibial translation between specimens with intact ACL, ACL repair, and ACL repair with internal brace at the medial (14.1mm versus 13.7mm versus 16.45mm, p=0.462), middle (17.5mm versus 16.6mm versus 18.3mm, p=0.767), lateral (14.8mm versus 15.9mm versus 15.9mm, p=0.934), or call (15.5mm versus 15.2mm versus 16.9mm, p=0.748) reference points. Conclusions: Tibial translation generated by Lachman tests performed manually may be underestimated when compared to Lachman tests performed with a standard force, lending to difficulty detecting the ACL deficient state. ACL repair both with and without internal brace augmentation allowed for a return to pre-rupture levels of anteroposterior stability.

Arthroscopic Centralization for Lateral Meniscal Injuries Reduces Laxity in the Anterior Cruciate Ligament–Reconstructed Knee

Background: A lateral meniscal (LM) disorder is one factor that causes rotational laxity after anterior cruciate ligament (ACL) reconstruction (ACLR). There are different types of irreparable meniscal disorders, one of which is a massive meniscal defect. Hypothesis/Purpose: The purpose of this study was to evaluate the kinematic effects of arthroscopic centralization on an irreparable LM defect. The hypothesis was that arthroscopic centralization for an irreparable LM defect with concomitant ACLR would improve knee rotational stability. Study Design: Controlled laboratory study. Methods: A total of 14 fresh-frozen human cadaveric knees were tested in 4 states: (1) intact ACL and intact lateral meniscus, (2) reconstructed ACL and intact lateral meniscus, (3) reconstructed ACL and lateral meniscus defect, and (4) reconstructed ACL and centralized lateral meniscus. Anatomic ACLR was performed using an 8 mm–diameter hamstring tendon graft. An LM defect (20% of the anteroposterior length) was created arthroscopically, and arthroscopic centralization was performed. Kinematics were analyzed using a 6 degrees of freedom robotic system under 4 knee loads: (1) an 89.0-N anterior tibial load, (2) a 5.0-N·m external rotation tibial torque, (3) a 5.0-N·m internal rotation tibial torque, and (4) a simulated pivot-shift load with a combined 7.0-N·m valgus and 5.0-N·m internal rotation tibial torque. Results: LM centralization reduced anterior tibial translation similar to that of the ACLR intact LM state under anterior tibial loading (~2 mm at 30° of flexion) and showed 40% to 100% of tibial displacement in the 4 knee states under simulated pivot-shift loading. The procedure overconstrained the knee under internal rotation tibial torque and simulated pivot-shift loading. Conclusion: Arthroscopic centralization reduced knee laxity after ACLR for a massive LM defect in a cadaveric model. Clinical Relevance: In cases involving irreparable LM injuries during ACLR, consideration should be given to arthroscopic centralization for reducing knee laxity. However, the procedure may overconstrain the knee in certain motions.

Experimental validation of a new technique for the assessment of posterior tibial translation (ABC angle) after posterior cruciate ligament rupture

Background The aim of this cadaver study was to evaluate an original technique for measuring posterior tibial translation based on an angle value instead of a distance value, with and without posterior stress application. It was hypothesized that an angle measurement of the posterior tibial translation would confirm the presence of a PCL tear with the knee flexed and completely extended. Method Using fresh cadavers, a set of strict lateral views were taken by fluoroscopy with the knee at 0°, 45° and 90° flexion on the intact knee and after transecting the PCL. The primary endpoint was the change in the posterior translation measured using a new technique, the ABC angle. This measurement was compared to the conventional posterior translation distance measurement with and without a posterior stress placed on the knee. Results Application of a posterior stress revealed clear changes in posterior translation after PCL transection with the knee at 0° for the angle technique and at 45° and 90° for the two techniques (p < 0.05). Contrary to the reference method, the ABC angle method found a statistically significant difference in posterior translation with the knee in extension. Conclusion Our technique provides a reliable radiographic measurement of posterior translation with the knee in extension, which should make it easier to acquire radiographs in patients who have pain with knee flexion. This angular measurement also has the advantage of not needing length calibration contrary to the reference technique. Level of evidence IV

The correlation between posterior tibial slope and dynamic anterior tibial translation and dynamic range of tibial rotation

Purpose The amount of passive anterior tibial translation (ATT) is known to be correlated to the amount of posterior tibial slope (PTS) in both anterior cruciate ligament-deficient and reconstructed knees. Slope-altering osteotomies are advised when graft failure after anterior cruciate ligament (ACL) reconstruction occurs in the presence of high PTS. This recommendation is based on studies neglecting the influence of muscle activation. On the other hand, if dynamic range of tibial rotation (rTR) is related to the amount of PTS, a “simple” anterior closing-wedge osteotomy might not be sufficient to control for tibial rotation. The purpose of this study was to evaluate the correlation between the amount of PTS and dynamic ATT and tibial rotation during high demanding activities, both before and after ACL reconstruction. We hypothesized that both ATT and rTR are strongly correlated to the amount of PTS. Methods Ten subjects were studied both within three months after ACL injury and one year after ACL reconstruction. Dynamic ATT and dynamic rTR were measured using a motion-capture system during level walking, during a single-leg hop for distance and during a side jump. Both medial and lateral PTS were measured on MRI. A difference between medial and lateral PTS was calculated and referred to as Δ PTS. Spearman’s correlation coefficients were calculated for the correlation between medial PTS, lateral PTS and Δ PTS and ATT and between medial PTS, lateral PTS and Δ PTS and rTR. Results Little (if any) to weak correlations were found between medial, lateral and Δ PTS and dynamic ATT both before and after ACL reconstruction. On the other hand, a moderate-to-strong correlation was found between medial PTS, lateral PTS and Δ PTS and dynamic rTR one year after ACL reconstruction. Conclusion During high-demand tasks, dynamic ATT is not correlated to PTS. A compensation mechanism may be responsible for the difference between passive and dynamic ATT in terms of the correlation to PTS. A moderate-to-strong correlation between amount of PTS and rTR indicates that such a compensation mechanism may fall short in correcting for rTR. These findings warrant prudence in the use of a pure anterior closing wedge osteotomy in ACL reconstruction. Trial registration Netherlands Trial Register, Trial 7686. Registered 16 April 2016—Retrospectively registered. Level of evidence Level 2, prospective cohort study

The Comparison of Clinical Result between Primary Repair of the Anterior Cruciate Ligament with Additional Internal Bracing and Anatomic Single Bundle Reconstruction—A Retrospective Study

Background: The current standard of treatment of anterior cruciate ligament (ACL) is reconstruction (ACLR). This technique has some disadvantages: poor proprioception, donor site morbidity and the inability to restore joint kinematics. ACL repair could be an alternative treatment. The purpose of the study was to compare the stability and the function after ACL primary repair versus single-bundle ACLR. Methods: In a retrospective study, 12 patients underwent primary ACL repair with internal bracing, 15 patients underwent standard ACLR. Follow-up examinations were evaluated at up to 2 years postoperatively. One patient in the ACL repair group was lost to follow-up due to re-rupture. The absolute value of anterior tibial translation (ATT) and the side-to-side difference in the same patient (ΔATT) were evaluated using the GNRB arthrometer. The Lysholm knee scoring was obtained. Re-ruptures and other complications were recorded. Results: Anterior tibial translation (ATT) was significantly decreased in the ACL repair group compared with the ACLR group (5.31 mm vs. 7.18 mm, respectively; p = 0.0137). Arthrometric measurements demonstrated a mean side-to-side difference (ΔATT) 1.87 (range 0.2 to 4.9) mm significantly decreased compared to ACLR 3.36 (range 1.2–5.6 mm; p = 0.0107). The mean Lysholm score was 85.3 points in the ACL repair group and 89.9 in ACLR group. No significant differences between ACL repair and ACLR were found for the Lysholm score. There was no association between AP laxity and clinical outcomes. There were two complications in the internal bracing group: one patient had re-rupture and was treated by ACLR, another had limited extension and had arthroscopic debridement. Conclusions: Anterior tibial translation was significantly decreased after ACL repair. Additionally, the functional results after ACL repair with internal bracing were comparable with those after ACLR. It should be noted that the two complications occurred. The current study supports further development of ACL repair techniques.

The Influence of the Femoral Condyle Sagittal Curvature on ACL Rupture

Purpose: The femoral condyle diameter may influence anterior tibial translation whose main stabilizer is the ACL. The aim of this study is to determine the influence of the size of the lateral and medial femoral condyles on ACL rupture. Methods: 41 matched pairs of subjects were included in the study who had suffered knee injury and were either professional or recreational athletes engaged in track and field or sports involving intensive rotation movements. The experimental group was composed of patients with ACL rupture, while the control group comprised patients with joint distortion without ACL. The diameter of the medial and lateral condyles were measured on sagittal MRI images of these patients’ knees. Results: Subjects with ACL rupture had a highly statistically significantly shorter diameter of the lateral condyle as compared to their matched pairs from the control group (p<0.01). Also, the lateral condyle of the subjects with ACL rupture had a significantly lesser diameter as compared to the medial condyle (p<0.01), which was not the case in patients without ACL rupture (p>0.05). Patients with intact ACL demonstrated significant indirect correlation of the diameter of both femoral condyles with the valgus angle of the lower leg (p<0.01). Conclusions: The shorter diameter of the lateral femoral condyle is connected with ACL rupture, both in women and men. The lack of correlation between the diameter of the femoral condyles and the valgus angle of the lower leg also represents a factor connected to ACL rupture.