A correlation of time with meniscal tears in anterior cruciate ligament deficiency: stratifying the risk of surgical delay

Risk factors for false positive and false negative MRI in diagnosing medial and lateral meniscal tears with concomitant ACL injury

OBJECTIVE

To determine the diagnostic performance of MRI in evaluating meniscal abnormalities in the setting of anterior cruciate ligament (ACL) injury and recognize predictors of false positive (FP) and false negative (FN) MRI diagnosis.

MATERIAL AND METHODS

Four hundred twenty patients (mean age, 27.2 years; 326 males, 94 females) who underwent arthroscopy for ACL injury between January 2017 and August 2022, and had preoperative imaging within 4 months, were retrospectively included. Images were independently interpreted by two experienced musculoskeletal radiologists, noting the presence of medial and lateral meniscal tears including tear type and location. Results were correlated with arthroscopic findings. Multivariate logistic regression was implemented to study risk factors (RF) for FP and FN MRI diagnosis.

RESULTS

The sensitivity/specificity/positive predictive value/negative predictive value/accuracy of MRI for medial meniscus tear was 97.5%/74.46%/65.63%/98.35%/82.15%; for lateral meniscus tear, it was 83.5%/93.70%/70.8%/94.55% /87.86%, with substantial interreader agreement. Female gender (odds ratio (OR), 0.434), posterior horn and posterior root tears (OR, 3.268/22.588), horizontal tear (OR, 3.134), and ramp lesion (OR, 4.964) were found RF for FP medial meniscus, and meniscal body tears (OR, 308.011) were found RF for FP lateral meniscus. RF for FN medial meniscus were meniscal tear at the posterior horn, body, and posterior root (OR, 12.371/123.000/13.045).

CONCLUSION

MRI is an effective screening tool for meniscal tears, but less accurate in detecting all medial meniscus injuries. Gender, meniscal tear location, and type increased the risk of FP medial meniscal tear on MRI, while meniscal tear location increased the risk of FP lateral meniscus and FN medial meniscus tears.

Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury

Background

In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time.

Purpose

To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears.

Study Design

Case-control study; Level of evidence, 3.

Methods

We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery.

Results

A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals.

Conclusion

Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.

Application of machine learning-based multi-sequence MRI radiomics in diagnosing anterior cruciate ligament tears

OBJECTIVE

To compare the diagnostic power among various machine learning algorithms utilizing multi-sequence magnetic resonance imaging (MRI) radiomics in detecting anterior cruciate ligament (ACL) tears. Additionally, this research aimed to create and validate the optimal diagnostic model.

METHODS

In this retrospective analysis, 526 patients were included, comprising 178 individuals with ACL tears and 348 with a normal ACL. Radiomics features were derived from multi-sequence MRI scans, encompassing T1-weighted imaging and proton density (PD)-weighted imaging. The process of selecting the most reliable radiomics features involved using interclass correlation coefficient (ICC) testing, t tests, and the least absolute shrinkage and selection operator (LASSO) technique. After the feature selection process, five machine learning classifiers were created. These classifiers comprised logistic regression (LR), support vector machine (SVM), K-nearest neighbors (KNN), light gradient boosting machine (LightGBM), and multilayer perceptron (MLP). A thorough performance evaluation was carried out, utilizing diverse metrics like the area under the receiver operating characteristic curve (ROC), specificity, accuracy, sensitivity positive predictive value, and negative predictive value. The classifier exhibiting the best performance was chosen. Subsequently, three models were developed: the PD model, the T1 model, and the combined model, all based on the optimal classifier. The diagnostic performance of these models was assessed by employing AUC values, calibration curves, and decision curve analysis.

RESULTS

Out of 2032 features, 48 features were selected. The SVM-based multi-sequence radiomics outperformed all others, achieving AUC values of 0.973 and 0.927, sensitivities of 0.933 and 0.857, and specificities of 0.930 and 0.829, in the training and validation cohorts, respectively.

CONCLUSION

The multi-sequence MRI radiomics model, which is based on machine learning, exhibits exceptional performance in diagnosing ACL tears. It provides valuable insights crucial for the diagnosis and treatment of knee joint injuries, serving as an accurate and objective supplementary diagnostic tool for clinical practitioners.

Effect of Increased Time to Surgery on the Ability of MRI to Rule Out Medial Meniscal Tears in Young Athletes With ACL Injury

Background

The prevalence of meniscal tears in patients with anterior cruciate ligament (ACL) injury increases with extended time between injury and ACL reconstruction.

Purpose/Hypothesis

The purpose of this study was to determine if there is a relationship between time from magnetic resonance imaging (MRI) to ACL reconstruction and the predictive value of MRI to diagnose meniscal tears in the young active population. It was hypothesized that increased time between MRI and ACL reconstruction would lead to a decrease in the negative predictive value of MRI in diagnosing meniscal tears, as more injuries may accrue over time in the ACL-deficient knee.

Study Design

Case series; Level of evidence, 4.

Methods

Included were patients aged 13 to 25 years at the authors' institution who underwent primary ACL reconstruction from January 2017 to June 2020. Time from MRI to surgery as well as descriptions of medial and lateral meniscal tears on both MRI and operative reports were documented. Time from MRI to surgery was divided into 4 intervals: 0 to 6 weeks, >6 weeks to 3 months, >3 to 6 months, and beyond 6 months. Multivariable analysis was used to determine the positive and negative predictive values of MRI in diagnosing a meniscal tear as compared with arthroscopic findings.

Results

A total of 432 patients were included with a mean age of 17.9 ± 3.4 years. The mean time from MRI to surgery was 70.5 ± 98 days. There was a significant decrease in the negative predictive value of MRI to identify a medial meniscal tear in patients who underwent ACL reconstruction >6 months after imaging (odds ratio, 0.16 [95% CI, 0.05-0.53]; P = .003). This same relationship was not shown for lateral meniscal tears, nor was any other predictor significant.

Conclusion

The utility of MRI to rule out a medial meniscal tear significantly diminished in the young athletic population when >6 months passed between MRI and ACL reconstruction. These data suggest these tears occur between the time of the MRI and surgery and that the medial meniscus is more susceptible than the lateral meniscus to new injury once the ACL has torn.

Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial

OBJECTIVE

To assess whether initial non-operative treatment of anterior cruciate ligament (ACL) ruptures with optional delayed ACL reconstruction leads to more meniscal procedures compared with early ACL reconstruction during the 2-year follow-up.

METHODS

We compared the number of meniscal procedures of 167 patients with an ACL rupture, who either received early ACL reconstruction (n=85) or rehabilitation therapy plus optional delayed ACL reconstruction (n=82), participating in the Conservative vs Operative Methods for Patients with ACL Rupture Evaluation trial. Patients were aged 18 to 65 years (mean 31.3, SD 10.5), 60% male sex (n=100). We evaluated the presence and location of meniscal tears by baseline MRI. We analysed and compared how many patients per randomisation group had a meniscal procedure during follow-up in the ACL injured knee, adjusted for sex, body mass index, age group and orthopaedic surgeon.

RESULTS

At baseline, 41% of the entire study population (69/167 patients) had a meniscal tear on MRI. During the 2-year follow-up, 25 patients randomised to early ACL reconstruction (29%, 25/85 patients) had a meniscal procedure, compared with 17 patients randomised to rehabilitation plus optional delayed reconstruction (21%, 17/82 patients) (risk ratio 0.67 with 95% CI 0.40 to 1.12, p=0.12). Of these patients who received early ACL reconstruction (n=82) and patients that received delayed ACL reconstruction (n=41), 5% of the patients had an additional isolated meniscal procedure after ACL reconstruction. In patients who received no ACL reconstruction (n=41), 10% (n=4) had an isolated surgical procedure for a meniscal tear during the 2-year follow-up period.

CONCLUSION

Initial non-surgical treatment of ACL ruptures followed by optional delayed ACL reconstruction does not lead to a higher number of meniscal procedures compared with early ACL reconstruction over a 2-year follow-up period.

TRIAL REGISTRATION NUMBER

NL 2618.

Knee osteoarthritis, joint laxity and PROMs following conservative management versus surgical reconstruction for ACL rupture: a meta-analysis

INTRODUCTION

Patients whose rupture of the anterior cruciate ligament (ACL) can be managed conservatively or undergo reconstruction surgery.

SOURCE OF DATA

Current scientific literature published in Web of Science, PubMed and Scopus.

AREAS OF AGREEMENT

Several studies published by July 2022 compare surgical and conservative management following ACL rupture. The latest evidence suggests that surgical management may expose patients to an increased risk of early-onset knee osteoarthritis (OA).

AREAS OF CONTROVERSY

The state of art does not recommend a systematic ACL reconstruction to all patients who tore their ACL. After the initial trauma, surgical reconstruction may produce even greater damage to the intra-articular structures compared to conservative management.

GROWING POINTS

The state of art does not recommend systematic surgical reconstruction to all patients who tore their ACL. The present study compared surgical reconstruction versus conservative management for primary ACL ruptures in terms of joint laxity, patient reported outcome measures (PROMs) and rate of osteoarthritis.

AREAS TIMELY FOR DEVELOPING RESEARCH

ACL reconstruction provides significant improvement in joint laxity compared to conservative management, but is associated with a significantly greater rate of knee osteoarthritis, despite similar results at PROM assessment.

Quality of life during the wait for ruptured anterior cruciate ligament reconstruction: a randomized controlled trial

Background:

There is a lack of prospective evidence to guide surgeons when making recommendations about the appropriate timing of surgical intervention for ruptured anterior cruciate ligament (ACL), activity modifications to reduce the risk of secondary injury before surgery, and the short- and long-term risks associated with delayed ACL reconstruction. This study aimed to determine whether longer wait times are associated with a prolonged decrease in quality of life and an increased incidence of secondary joint injury after ACL rupture.

Methods:

We recruited 53 patients who presented between 2013 and 2017 at a single sports medicine minor injury clinic with a suspected acute ACL rupture, based on clinical examination; ACL rupture was confirmed on magnetic resonance imaging. Patients were randomly allocated to undergo early reconstruction (< 12 wk after injury) or reconstruction after a regular wait time (≥ 12 wk). We compared scores on the ACL quality of life measure (ACL-QOL) and the incidence of secondary knee injury at baseline and at surgery between the 2 groups. Participants also completed the Tegner scale (level of activity) at the time of consent and within 7 days before surgery.

Results:

Twenty-eight patients were randomly assigned to the early surgery group and 25 patients to the regular wait time group. There was no difference in mean age between the 2 groups. There were no between-group differences in mean ACL-QOL score at the time of injury (28.5 [standard deviation (SD) 12.5] v. 28.5 [SD 12.6]) or at surgery (34.9 [SD 17.5] v. 38.0 [SD 17.5]). The mean wait time was significantly longer in the regular wait time group than in the early surgery group (29.6 wk [SD 13.2 wk] v. 10.6 wk [SD 5.1 wk], p = 0.001). In both groups, Tegner scale scores were significantly lower after than before ACL rupture (p < 0.001) and remained low while patients waited for surgery. There were no between-group differences in the incidence of chondral or meniscal injury at surgery, although the study was not adequately powered to draw any statistical conclusions.

Conclusion:

Wait time for ACL reconstruction may affect patients’ quality of life, as it remained diminished for a longer period when surgery was delayed. A low activity level during the waiting period was observed in both groups; this low activity level may be one reason why no between-group differences in the incidence of secondary injury were observed. The findings suggest that patients with a limited activity level during the waiting period have a low risk of secondary injuries.

Identifying Clinical and MRI Characteristics Associated with Quality of Life in Patients with Anterior Cruciate Ligament Injury: Prognostic Factors for Long-Term

BACKGROUND

Associated lesions in the diagnostic MRI may be related to worse long-term subjective outcomes. There is a lack of conclusive information about the long-term outcomes of associated injuries in anterior cruciate ligament (ACL) tears. The purpose of this study is to assess the long-term effects of associated injuries in ACL tears measured by means of a quality of life (QOL) assessment.

METHODS

A retrospective cohort study of 225 consecutive patients admitted for physical therapy with ACL injury (42 ± 12 years, 28.2% female) were conducted. All demographic and clinical variables were used to measure a QOL. Univariate and multivariable analyses were completed.

RESULTS

The mean follow-up period was 8.4 ± 2.6 years. In univariate analysis, male gender, and sports as the cause of the ACL lesion were factors significantly associated with improved International Knee Documentation Committee (IKDC) scores at the end of follow-up (all p < 0.002). In multivariable analysis, the occurrence of bone contusion was positively associated with injury (OR = 2.12) and negatively associated with sports injury (OR = 0.44) and medial collateral ligament (MCL) injury (OR = 0.48).

CONCLUSIONS

After ACL injury, male gender and sports injury were associated with better clinical outcomes.

Incidence of Total Knee Replacement in Patients With Previous Anterior Cruciate Ligament Reconstruction

OBJECTIVE

To determine the rate of total knee replacement (TKR) after anterior cruciate ligament reconstruction (ACL-R) compared to the general population.

DESIGN

Retrospective review.

SETTING

All hospitals that performed TKR and ACL-R in Manitoba between 1980 and 2015.

PARTICIPANT

All patients that underwent TKR and ACL-R in Manitoba between 1980 and 2015.

INTERVENTION

Patient factors gathered at time of surgery included: age, sex, urban or rural residence, neighborhood income quintile, and resource utilization band (RUB). Each person was matched with up to 5 people from the general population who had never had ACL-R and had not had a TKR at the time of the case ACL-R.

MAIN OUTCOME MEASURES

The rate of TKR after ACL-R.

RESULTS

Overall from 1980 to 2015, 8500 ACL-R were identified within the 16 to 60 years age group with a resultant 42 497 population matches. Sex was predominantly male. The mean age of the ACL-R group at the time of TKR was 53.7 years, whereas the mean age for the matched cohort was 58.2 years, P < 0.001. Those with ACL-R were 4.85 times more likely to go on to have TKR. Apart from age, no other risk factors examined (location, year of surgery, place of residence, income quintile, and RUB) seemed to increase risk of TKR after ACL-R.

CONCLUSION

Patients who underwent ACL-R were 5 times more likely to undergo TKR.

Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury

OBJECTIVE

To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction.

DESIGN

Prognosis systematic review (PROSPERO registration number CRD42016036788).

METHODS

We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology.

RESULTS

Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%-21% when follow-up was <2 years, 0%-29% when follow-up was 2 to 5 years, 5%-52% when follow-up was 5 to 10 years and 4%-31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low.

CONCLUSION

New meniscal tears occurred in 0%-52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

Knee and Leg Injuries

Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.

The ACL-deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta-analysis (CRD42017076897)

INTRODUCTION

The purpose of this systematic review and meta-analysis was to analyze and compare the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction.

MATERIALS AND METHODS

A systematic search for articles comparing the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction was performed. PubMed central was the database used for the literature review.

RESULTS

Forty articles out of 1836 were included. In 35 trials (88%), there was evidence of a positive correlation between the rate of meniscus and/or cartilage lesions and the time since ACL injury. This correlation was more evident for the medial meniscus in comparison with the lateral meniscus. In particular, a delay of more than 6 months was critical for secondary medial meniscus injuries [risk ratio 0.58 (95% CI 0.44-0.79)] and a delay of more than 12 months was critical for cartilage injuries [risk ratio 0.42 (95% CI 0.29-0.59)]. Additionally, there is evidence that the chance for meniscal repair decreases as the time since ACL rupture increases.

CONCLUSION

Chronic instability in the ACL-deficient knee is associated with a significant increase of medial meniscus injuries after 6 months followed by a significant increase of cartilage lesions after 12 months.

Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review

Background

Delayed anterior cruciate ligament (ACL) reconstruction may be associated with increased risk of subsequent knee joint damage and osteoarthritis (OA). The relationship between recurrent instability episodes and meniscal or cartilage damage after first-time ACL injury is unknown.

Purpose

To assess the association between recurrent knee instability episodes and prevalence of meniscal lesions, cartilage damage, and OA after first-time ACL injury.

Study Design

Systematic review; Level of evidence, 4.

Methods

Six electronic databases were systematically searched using keywords and Medical Subject Heading terms. Studies selected were of English language, included original data, had a prospective design, and provided an outcome of recurrent instability and meniscal lesions, cartilage damage, or OA after first-time ACL injury. Adjusted odds ratios (ORs) were extracted or unadjusted ORs (95% CI) were calculated. PRISMA guidelines were followed, and 2 independent raters assessed study quality using Downs and Black criteria.

Results

Of 905 potentially relevant studies, 7 were included. Sample sizes ranged from 43 to 541, and Downs and Black scores ranged from 2 to 12. Clinical and methodological heterogeneity precluded meta-analysis. Six studies reported a positive association between recurrent instability episodes and medial meniscal damage (OR range, 3.46 [95% CI, 1.24-9.99] to 11.56 [1.37-521.06]). The association between instability episodes and lateral meniscal or cartilage damage was inconsistent. No studies examined the association between instability episodes and OA.

Conclusion

This systematic review provides preliminary evidence that recurrent instability episodes after first-time ACL injury may be associated with increased odds of medial meniscal damage. This highlights the importance of early diagnosis, education, and treatment for individuals with ACL injury, all of which must include a specific focus on the prevention and management of instability episodes. High-quality, prospective cohort studies are needed that assess the effects of diagnostic and treatment delay, recurrent instability episodes on secondary meniscal and cartilage damage, and OA after an initial ACL injury.

Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work

PURPOSE

The dynamic intraligamentary stabilization (DIS) technique is based on a different treatment approach than ACL reconstruction in that it intends to promote self-healing of the ligament. It is only recommended for acute injuries (<21days). The purpose of the present study was to compare DIS and ACLR with respect to the extent of work incapacity, revision rates, secondary arthroscopies, and treatment costs during recovery.

METHODS

The study was a post-hoc analysis of prospectively collected data in the Swiss National Accident Insurance Fund (SUVA) database. All registered DIS cases treated until 31 December 2012 were included in the study. ACLR cases were matched to DIS cases using a propensity score approach and analysed in a follow-up period of 2 years after injury. Paired Student's T-test and the Chi-square test were used to compare the outcome measures.

RESULTS

All 53 DIS patients were matched to an ACLR pair. The mean time period from injury to surgery was 14days for DIS and 50days for ACLR (p<0.001). Overall work incapacity was 13% for DIS and 17% for ACLR resulting in a difference of nearly 1 month of absence from work (p=0.03). The course of postoperative work incapacity was very similar between the groups, while the work incapacity prior to surgery lower in the DIS group. We found no difference in treatment costs, secondary arthroscopies and revision rates.

CONCLUSION

DIS patients benefited from nearly one month shorter absence from work than ACLR patients. This difference is likely related to the early surgical timing that is recommended for DIS. Since no differences were found between DIS and ACLR in terms of treatment costs, secondary arthroscopies and revision rates, the study supports the choice of DIS as an additional treatment option for acute ACL injuries. Further comparative studies are proposed to improve the evidence about optimal timing and best practice in ACL treatment.

Anterior cruciate ligament reconstruction: principles of treatment

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.

Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.

Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

Dynamic intraligamentary stabilisation

Aims

The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL).

Patients and Methods

Between March 2011 and April 2012, 50 patients (34 men and 16 women) with an acute rupture of the ACL underwent primary repair using this device. The mean age of the patients was 30 years (18 to 50). Patients were evaluated for laxity, stability, range of movement (ROM), Tegner, Lysholm, International Knee Documentation Committee (IKDC) and visual analogue scale (VAS) scores over a follow-up period of two years.

Results

At final follow-up, anteroposterior translation differed from the normal knee by a mean of 0.96 mm (-2 mm to 6 mm). Median (interquartile range) IKDC, Tegner, Lysholm and VAS scores were 98 (95 to 100), 6 (5 to 7), 100 (98 to 100) and 10 (9 to 10), respectively. Pre-injury Tegner activity levels were reached one year post-operatively. A total of nine patients (18%) required a secondary intervention; five developed instability, of whom four underwent secondary hamstring reconstructive surgery, and five required arthroscopic treatment for intra-articular impingement due to scar tissue which caused a fixed flexion deformity. In addition, 30 patients (60%) required removal of the tibial screw.

Conclusion

While there was a high rate of secondary interventions, 45 patients (90%) retained their repaired ACL two years post-operatively, with good clinical scores and stability of the knee. Take home message: Dynamic intraligamentary stabilisation presents a promising treatment option for acute ACL ruptures, eliminating the need for ACL reconstruction. Cite this article: Bone Joint J 2016;98-B:793–8.

Accuracy of MRI evaluation of meniscus tears in the setting of ACL injuries

BACKGROUND

Our purpose was to evaluate the diagnostic performance of magnetic resonance imaging (MRI) for the pre-operative detection of meniscus tears requiring operative intervention, and identify factors that determined accuracy of diagnosing meniscus tears, in the setting of anterior cruciate ligament (ACL) reconstruction.

METHODS

Patients who underwent primary ACL reconstruction were retrospectively reviewed. A meniscus tear was classified as requiring treatment if it was debrided or repaired at the time of ACL reconstruction. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of pre-operative MRIs were determined for medial and lateral meniscus tears.

RESULTS

Sensitivity, specificity, PPV, and NPV of MRI were 0.90, 0.75, 0.58, and 0.95 for medial meniscus tears, respectively, and 0.67, 0.81, 0.65, and 0.82 for lateral meniscus tears. MRI-diagnosed medial meniscus tears were associated with a longer time interval between initial injury and imaging compared to ACL tears without concomitant meniscus injury on MRI (p=0.038). Vertical medial meniscus tears were less likely than other tear patterns to require treatment at the time of ACL reconstruction (p=0.03). MRI showed a higher diagnostic performance for lateral meniscus tears when surgery was performed within 30days of imaging.

CONCLUSIONS

This study demonstrates only moderate sensitivity and specificity of pre-operative MRI in the detection of meniscus tears requiring operative treatment in the setting of ACL injury. High rates of false diagnoses were observed, suggesting MRI may not be as accurate in predicting positive or negative meniscus findings at the time of ACL reconstruction as previously reported.

LEVEL OF EVIDENCE

Level III.

Risk Factors of False-Negative Magnetic Resonance Imaging Diagnosis for Meniscal Tear Associated With Anterior Cruciate Ligament Tear

PURPOSE

To identify risk factors that predict false-negative magnetic resonance imaging (MRI) diagnosis for meniscal tear coincident with anterior cruciate ligament injury using multivariate logistic regression.

METHODS

We reviewed the medical records of consecutive patients who underwent arthroscopic anterior cruciate ligament reconstruction from January 2006 through December 2014. Exclusion criteria were no meniscal tear or incomplete tear less than 10 mm in length, delay to surgery from initial injury more than 1 year, delay to surgery from preoperative MRI more than 4 weeks, revisions, fracture histories, and multiple ligament injuries. According to preoperative MRI diagnosis, the meniscal tears were sorted into true-positive MRI and false-negative MRI groups. Multivariate logistic regression was used to analyze risk factors including age, gender, body mass index, time from injury to MRI, knee instability, concomitant ligament injury, intra-articular effusion, bone contusion, cartilage injury, meniscal tear location, and meniscal tear pattern.

RESULTS

Enrolled 249 meniscal tears (159 medial and 90 lateral menisci) were sorted into true-positive MRI (n = 136) and false-negative MRI (n = 113) groups. As time from injury to MRI diagnosis increased, the risk of the false-negative MRI diagnosis decreased (adjusted odds ratio [OR], 0.859; 95% confidence interval [CI], 0.802-0.921). Meniscal tear location within the posterior one-third was a significant risk factor compared with tear within the anterior one-third (adjusted OR, 11.823; 95% CI, 2.272-61.519). Peripheral longitudinal tear pattern was also a significant risk factor (adjusted OR, 3.522; 95% CI, 1.256-9.878).

CONCLUSIONS

Significant risk factors for false-negative MRI included short time from injury to MRI diagnosis, meniscal tear location within the posterior one-third, and peripheral longitudinal tear pattern.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The effect of open kinetic chain knee extensor resistance training at different training loads on anterior knee laxity in the uninjured

BACKGROUND

The commonly used open kinetic chain knee extensor (OKCKE) exercise loads the sagittal restraints to knee anterior tibial translation.

OBJECTIVE

To investigate the effect of different loads of OKCKE resistance training on anterior knee laxity (AKL) in the uninjured knee.

STUDY DESIGN

non-clinical trial.

METHODS

Randomization into one of three supervised training groups occurred with training 3 times per week for 12 weeks. Subjects in the LOW and HIGH groups performed OKCKE resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Subjects in the isokinetic training group (ISOK) performed isokinetic OKCKE resistance training using 2 sets of 20 maximal efforts. AKL was measured using the KT2000 arthrometer with concurrent measurement of lateral hamstrings muscle activity at baseline, 6 weeks and 12 weeks.

RESULTS

Twenty six subjects participated (LOW n = 9, HIGH n = 10, ISOK n = 7). The main finding from this study is that a 12-week OKCKE resistance training programme at loads of 20 sets of 2RM, leads to an increase in manual maximal AKL.

CONCLUSIONS

OKCKE resistance training at high loads (20 sets of 2RM) increases AKL while low load OKCKE resistance training (2 sets of 20RM) and isokinetic OKCKE resistance training at 2 sets of 20RM does not.

The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee

Anterior cruciate ligament (ACL) tears are a common injury, particularly in the athletic and youth populations. The known association between ACL injury and subsequent osteoarthritis (OA) of the knee merits a more in-depth understanding of the relationship between the ACL-injured knee and osteoarthritis. ACL injury, especially with concomitant meniscal or other ligamentous pathology, predisposes the knee to an increased risk of osteoarthritis. ACL insufficiency results in deterioration of the normal physiologic knee bending culminating in increased anterior tibial translation and increased internal tibial rotation. This leads to increased mean contact stresses in the posterior medial and lateral compartments under anterior and rotational loading. However, surgical reconstruction of the ACL has not been shown to reduce the risk of future OA development back to baseline and has variability based on operative factors of graft choice, timing of surgery, presence of meniscal and chondral abnormalities, and surgical technique. Known strategies to prevent OA development are applicable to patients with ACL deficiency or after ACL reconstruction and include weight management, avoidance of excessive musculoskeletal loading, and strength training. Reconstruction of the ACL does not necessarily prevent osteoarthritis in many of these patients and may depend on several external variables.

Long-term follow-up of ACL reconstruction with hamstring autograft

PURPOSE

To investigate the differences in the incidence and severity of knee osteoarthritis (OA), joint space narrowing, knee laxity, and knee flexion and extension strength between an anterior cruciate ligament (ACL)-reconstructed knee and the contralateral non-reconstructed limb.

METHODS

Retrospective case series of patients from a single surgeon that had an ACL reconstruction with a semitendinosus/gracilis autograft more than 12 years ago. Outcome measures included radiographic analysis, International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), KT-1000, Tegner Activity Level Scale, Lysholm Knee Score, ACL quality of life score (ACL-QOL) and knee flexor/extensor strength.

RESULTS

Seventy-four patients consented and sixty-eight (43 male, 25 female) were included for analysis. Average age (SD) at the time of surgery was 31.2 (±9.1) years. At follow-up of 14.6 (1.9) years, 9% had re-ruptured their ACL, whereas 5% ruptured the contralateral ACL. Reconstructed knees had a greater incidence and severity of OA (P < 0.01). Medial meniscus surgery was a strong predictor of OA. Seventy-five per cent scored a normal or nearly normal knee on the IKDC. The mean Lysholm score was 75.8% and Tegner Activity Level Scale scores decreased (P < 0.001) from the time of surgery. Knee extension strength was greater in the contralateral knee at speeds of 60°/s (P = 0.014) and 150°/s (P = 0.012).

CONCLUSIONS

Reconstructed knees have a greater incidence and severity of OA than non-reconstructed knees, which suggests degenerative changes are secondary to ACL rupture. Medial meniscus surgery is a strong predictor of OA. Despite this, 75% of patients reported good outcomes.

Efficacy of magnetic resonance imaging evaluation for meniscal tear in acute anterior cruciate ligament injuries

PURPOSE

The objective of this study was to compare the preoperative magnetic resonance imaging (MRI) diagnostic rates of meniscal injuries combined with acute anterior cruciate ligament (ACL) injuries, as well as traumatic meniscal injuries without ACL injuries.

METHODS

From January 2005 through April 2013, 208 patients who underwent ACL reconstruction and 1,334 patients with traumatic meniscal tear injuries were examined by MRI and arthroscopy. Patients with chronic ACL injuries, revisions, fracture histories, or multiple-ligament injuries and patients with Outerbridge degenerative changes of grade 3 or greater were excluded, yielding 159 patients and 621 patients in the 2 groups, respectively. The medial meniscus (MM) and lateral meniscus (LM) examined by MRI and arthroscopy for findings of tears were compared in each group. The sensitivity, specificity, positive predictive value, and negative predictive value for MM and LM tears by MRI were compared and analyzed statistically.

RESULTS

The diagnostic sensitivity of MRI in the group with ACL injury was significantly lower than that in the ACL-intact group for the MM (P < .001) and LM (P = .040). The negative predictive value was also lower in the group with ACL injury for both the MM (P = .008) and LM (P < .001). There was no statistical difference in specificity and positive predictive value between the 2 groups.

CONCLUSIONS

This study showed that if a patient had an acute ACL tear, the sensitivity and negative predictive value of MRI for a meniscal tear were less than if there was no ACL tear, which led to the low diagnostic accuracy of MRI.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Complex cartilage cases in the athletic patient: advances in malalignment, instability, articular defects, and meniscal insufficiency

For sports medicine specialists, patients presenting with multiple coexisting knee pathologies can be some of the most difficult to treat patients, especially those with cartilage pathology. In particular, articular cartilage lesions are often incidental findings, and the decision to treat patients must be based on the lesions' confirmed contribution to patient symptomatology. The combination of malalignment, ligamentous instability, and chondral/meniscal damage in patients is challenging to treat because of the difficulty in determining both the relative contribution of each of the pathologies to patient clinical condition and the timing of performing specific corrective procedures. Corrective operations performed in isolation to treat each of the pathologies have historically produced reasonable results in patients; however, combined procedures for treatment of combined pathologies may prove essential for the success of any single procedure. This review describes the clinical evaluation of patients with multiple coexisting knee pathologies and highlights current evidence-based treatment strategies for the management of these combined disorders.

Risk factors for meniscal tears: a systematic review including meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To review and critically appraise the literature for factors that increase the risk for meniscal tears.

BACKGROUND

Meniscal tears are an important cause of disability and time lost from work, and are associated with a 4-fold increase in the long-term risk of knee osteoarthritis. Knowledge of the risk factors that lead to meniscal tears can help to correctly diagnose knee injuries and is important to the development of prevention strategies for knee osteoarthritis.

METHODS

A search of the Cochrane Database of Systematic Reviews, MEDLINE, and Embase, from 1950 to January 2012, and a hand search of reference lists of all initially selected studies, without restriction on language or date of publication, were conducted. Prospective, retrospective, and case-control studies that included individuals over 16 years of age, who had no previous meniscal injuries or surgeries, were selected. A meta-analysis for 17 risk factors was performed. Where considerable heterogeneity among studies was present or the data did not provide sufficient information to perform a meta-analysis, a qualitative synthesis was conducted.

RESULTS

Eleven studies, with a total of 7358 participants, were selected for systematic review. Data were available for meta-analysis for 10 of the 11 studies. Qualitative analysis was conducted using data from 3 of the 11 studies. Results showed strong evidence that age (older than 60 years), gender (male), work-related kneeling and squatting, and climbing stairs (greater than 30 flights) were risk factors for degenerative meniscal tears. We also found strong evidence that playing soccer and playing rugby were strong risk factors for acute meniscal tears. Waiting longer than 12 months between the anterior cruciate ligament injury and reconstructive surgery was a strong risk factor for a medial meniscal tear but not for a lateral meniscal tear.

CONCLUSION

The literature indicates a number of risk factors leading to either degenerative or acute meniscal tears, with some of these factors being potentially modifiable.

LEVEL OF EVIDENCE

Prognosis, level 2a.

Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial

OBJECTIVE

To compare, in young active adults with an acute anterior cruciate ligament (ACL) tear, the mid-term (five year) patient reported and radiographic outcomes between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction.

DESIGN

Extended follow-up of prospective randomised controlled trial.

SETTING

Orthopaedic departments at two hospitals in Sweden.

PARTICIPANTS

121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. One patient was lost to five year follow-up.

INTERVENTION

All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed.

MAIN OUTCOME MEASURE

The main outcome was the change from baseline to five years in the mean value of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS(4)). Other outcomes included the absolute KOOS(4) score, all five KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at five years.

RESULTS

Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (seven between two and five years). The mean change in KOOS(4) score from baseline to five years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points, 95% confidence interval -8.5 to 4.5; P=0.54 after adjustment for baseline score). At five years, no significant between group differences were seen in KOOS(4) (P=0.45), any of the KOOS subscales (P ≥ 0.12), SF-36 (P ≥ 0.34), Tegner activity scale (P=0.74), or incident radiographic osteoarthritis of the index knee (P=0.17). No between group differences were seen in the number of knees having meniscus surgery (P=0.48) or in a time to event analysis of the proportion of meniscuses operated on (P=0.77). The results were similar when analysed by treatment actually received.

CONCLUSION

In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN84752559.

Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial

OBJECTIVE

To compare, in young active adults with an acute anterior cruciate ligament (ACL) tear, the mid-term (five year) patient reported and radiographic outcomes between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction.

DESIGN

Extended follow-up of prospective randomised controlled trial.

SETTING

Orthopaedic departments at two hospitals in Sweden.

PARTICIPANTS

121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. One patient was lost to five year follow-up.

INTERVENTION

All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed.

MAIN OUTCOME MEASURE

The main outcome was the change from baseline to five years in the mean value of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS(4)). Other outcomes included the absolute KOOS(4) score, all five KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at five years.

RESULTS

Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (seven between two and five years). The mean change in KOOS(4) score from baseline to five years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points, 95% confidence interval -8.5 to 4.5; P=0.54 after adjustment for baseline score). At five years, no significant between group differences were seen in KOOS(4) (P=0.45), any of the KOOS subscales (P ≥ 0.12), SF-36 (P ≥ 0.34), Tegner activity scale (P=0.74), or incident radiographic osteoarthritis of the index knee (P=0.17). No between group differences were seen in the number of knees having meniscus surgery (P=0.48) or in a time to event analysis of the proportion of meniscuses operated on (P=0.77). The results were similar when analysed by treatment actually received.

CONCLUSION

In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN84752559.

Relationship of native tibial plateau anatomy with stability testing in the anterior cruciate ligament-deficient knee

PURPOSE

Recent attention has been drawn to tibial plateau slope and depth with relation to both risk of anterior cruciate ligament (ACL) tear and kinematics in the cruciate-deficient knee. The purpose was to evaluate the relationship between native proximal tibial anatomy and knee kinematics in the anterior cruciate-deficient knee.

METHODS

Twenty-two cadaveric knees underwent CT scanning to measure proximal tibia anatomy. Translation was measured during Lachman and mechanized pivot-shift tests on the intact knee and then after resection of the ACL. Pearson's correlation was calculated to assess the relationship between tibial translation of the ACL-deficient knee and tibial plateau anatomic parameters.

RESULTS

No significant correlation was found between ACL-deficient kinematic testing and tibial slope or depth (n.s.). Lateral compartment translation on Lachman and pivot-shift testing correlated with lateral compartment AP length (P = 0.007 and P = 0.033, respectively). The ratio of lateral AP length to medial AP length correlated with lateral compartment translation during the pivot shift (P = 0.002).

CONCLUSION

There was a poor correlation between native tibial slope and kinematic testing. There were, however, increases in translation during pivot-shift and Lachman testing with increased AP length of the lateral compartment. In addition, the finding of increased pivot-shift magnitude when the lateral compartment was relatively wide in the AP plane compared to the medial compartment suggests that patients with a "dominant" lateral compartment may be prone to a greater magnitude of instability after ACL injury.

Guideline on anterior cruciate ligament injury

The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.

Complications in brief: Anterior cruciate ligament reconstruction

When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.

Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature

PURPOSE

Is it rational to recommend surgical reconstruction of the torn anterior cruciate ligament to every patient? Is conservative management still a valid option?

METHOD

Through a literature review, we looked for the arguments from each side and checked their validity.

RESULTS

Unfortunately results of most studies cannot be compared because of the following reasons not exhaustively cited: studied populations differed with respect to age, sex, professional and sports activity level, lesions associated with ACL rupture, patient recruitment methods, time from injury to treatment and different therapeutic modalities. Furthermore, various methods were used to evaluate the clinical and radiological results and there was no consensus of their interpretation. Some authors assumed that the incidence of further meniscus lesions could probably be reduced if the torn ACL was surgically reconstructed. But, we have no evidence to believe that this would be due to the surgical repair rather than to a decrease of involvement in strenuous activities. At present it is not demonstrated that ACL-plasty can prevent osteoarthritis. Numerous factors could explain evolution to arthrosis whatever the treatment for the ACL-ruptured knee. Studies comparing surgical and conservative treatments confirm that ACL reconstruction is not the pre-requisite for returning to sporting activities. More recent and scientifically well-designed studies demonstrate that conservative treatment could give satisfactory results for many patients. They suggest some methods to help them choose the best treatment.

CONCLUSION

At present there are no evidence-based arguments to recommend a systematic surgical reconstruction to any patient who tore his ACL. Knee stability can be improved not only by surgery but also by neuromuscular rehabilitation. Whatever the treatment, fully normal knee kinematics are not restored. While the patients wish to go back to their sport and want everything possible done to prolong their ability to perform these activities, they should be informed that the risk of further knee lesions and osteoarthritis remains high, whatever the treatment, surgical or conservative.

LEVEL OF EVIDENCE

Systematic review of Level I, II, III and IV studies, Level IV.

Knee and leg injuries

The knee plays a significant role in ambulation and the activities of daily living. During the course of these activities and its role in weight bearing, the knee is susceptible to a variety of different forces and the emergency physician should be familiar with the diagnosis and treatment of the injuries that result. In addition to following basic trauma protocols, thorough neurovascular and musculoskeletal examinations should be performed and supplemented with appropriate imaging. Emergency physicians should also consider recent developments in knee anatomy and function when evaluating the patient with an acutely injured knee.