Management of combined ACL-MCL tears: a systematic review

Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies

PURPOSE

To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature.

METHODS

A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges.

RESULTS

Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies.

CONCLUSIONS

Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Does Combined Reconstruction of the Medial Collateral and Anterior Cruciate Ligaments Provide Better Knee Function? A Systematic Review and Meta-Analysis

Objective: This study aimed to determine if medial collateral ligament reconstruction (MCLR) alongside anterior cruciate ligament reconstruction (ACLR) preserves knee functionality better than isolated ACLR in combined ACL and MCL tears. Methods: MEDLINE, EMBASE, Scopus, CENTRAL, and Web of Science were searched systematically on 31 March 2023. Studies reporting post-operative function after ACLR and ACLR + MCLR in combined injuries were included. Outcomes included International Knee Documentation Committee (IKDC) score, side-to-side difference (SSD), Lysholm, and Tegner scale values. Results: Out of 2362 papers, 8 studies met the criteria. The analysis found no significant difference in outcomes (MD = 3.63, 95% CI: [-5.05, 12.3] for IKDC; MD = -0.64, 95% CI: [-3.24, 1.96] for SSD at 0° extension; MD = -1.79, 95% CI: [-4.61, 1.04] for SSD at 30° extension; MD = -1.48, 95% CI: [-16.35, 13.39] for Lysholm scale; MD = -0.21, 95% CI: [-4.29, 3.87] for Tegner scale) between treatments. Conclusions: This meta-analysis found no significant difference in outcomes between ACLR and ACLR + MCLR, suggesting that adding MCLR does not provide additional benefits. Due to the heterogeneity and quality of the included studies, further high-quality randomized controlled trials are needed to determine the optimal treatment for combined severe MCL-ACL injuries.

Nonoperative Management, Repair, or Reconstruction of the Medial Collateral Ligament in Combined Anterior Cruciate and Medial Collateral Ligament Injuries-Which Is Best? A Systematic Review and Meta-analysis

BACKGROUND

Combined injury of the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) is a common injury pattern and accounts for 20% of all ligamentous knee injuries. Despite advancements in surgical technique, there is no up-to-date consensus regarding the superiority of nonoperative versus operative management in higher-grade MCL tears of combined ACL-MCL injuries.

PURPOSE

To interpret recent literature on treatment options and to provide an updated evidence-based approach for management of combined ACL-MCL knee injuries.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

We performed a systematic review on outcomes following treatment of concomitant ACL and MCL injuries. A computerized search was conducted in PubMed, Embase.com, and Scopus.com. Authors independently assessed eligible studies and screened titles and abstracts. Articles reporting on patients with concomitant ACL and MCL injuries with or without concomitant procedures were included. Data regarding study design, sample size, patient age and sex, length of follow-up, timing of surgery, indications, surgical methods, concomitant procedures, outcomes, and complications were recorded. Patient-reported outcomes (PROs) and functional outcomes, including Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee scores, Lysholm and Tegner scores, and range of motion, were estimated via meta-analysis and compared statistically by surgical approach.

RESULTS

In total, 18 studies were included in the systematic review with level 1 to level 4 evidence, with a total of 1,534 cases, were included in the systematic review. Of these, 16 studies with sufficient statistical reporting including 997 cases with sufficient follow-up were included in meta-analysis. Three different approaches to combined ACL-MCL injuries were identified: ACL reconstruction with (1) nonoperative MCL, (2) MCL repair, and (3) MCL reconstruction. There was no statistical difference between nonoperative versus surgically managed MCL injuries for PROs, range of motion at final follow up, or quadriceps strength.

CONCLUSION

Reconstruction of combined injury in a delayed fashion facilitates return of range of motion and may allow time for low-grade MCL tears to heal. If residual valgus or anteromedial rotatory laxity remains after a period of rehabilitation, then concomitant surgical management of ACL and MCL injuries is warranted. Avulsion MCL injuries and Stener-type lesions may benefit from early repair techniques.

The management of combined ACL and MCL injuries: A systematic review

Background

The management of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries remains contentious. Clinical outcomes of surgical, conservative, and combined approaches have been described in a range of prospective and retrospective studies. The aim of the current systematic review was to evaluate these outcomes and assess the study methodologies.

Methods

A comprehensive literature search of the following databases was performed: PubMed, OVID, Cochrane Database of Systematic Reviews and Google Scholar. Studies were assessed using the Coleman Methodology Score.

Results

52 articles were included (3 randomised controlled trials, 8 prospective comparative studies, 17 retrospective comparative studies and 24 case series). Outcome measures were heterogeneous amongst articles. The most common outcomes assessed were AP laxity, Lysholm score and medial/valgus laxity. Complications at varying follow-up times with differing grades of MCL injury were reported in 25 (48%) studies. Evidence was conflicting, with no consensus from the available published literature regarding the best method of treatment for a combined ACL and MCL injury.

Conclusions

Heterogeneous outcome measures and limited randomised controlled trials prevent advocacy of a single treatment option. Good outcomes have been reported from repair, reconstruction and conservative management of the MCL together with ACL reconstruction. Further prospective comparative data is required to evaluate MCL management choice and prognostic signs for successful nonsurgical MCL treatment.

Do Clinical Outcomes and Failure Rates Differ in Patients With Combined ACL and Grade 2 MCL Tears Versus Isolated ACL Tears?: A Prospective Study With 14-Year Follow-up

Background:

A combined injury to the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) is a common injury pattern encountered during clinical practice. Recent systematic reviews have found no consensus on the optimal method of managing this combined ligament injury pattern, and no long-term studies with modern techniques are available in the literature.

Purpose:

To compare 2 groups of patients who underwent isolated ACL reconstruction in terms of failures and clinical scores at long-term follow-up. In the first group were patients with isolated ACL tears (ACL group), while the second was composed of patients with combined ACL and MCL grade 2 tears (ACL + MCL group).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 57 patients (37 in the ACL group and 20 in the ACL + MCL group) underwent isolated ACL reconstruction with a double-bundle technique between January and December 2005. Patients were contacted for scores on the International Knee Documentation Committee subjective form, Western Ontario and McMaster Universities Osteoarthritis Index, and Tegner activity scale as well as data regarding ipsilateral or contralateral revision ACL surgery. A 2-way analysis of variance for repeated measures was used to statistically assess the differences between the groups.

Results:

Overall, 49 patients (86%) completed the survey and were therefore included in the study. The minimum follow-up was 14.6 years (range, 14.1-15.2 years). There was a significant reduction in both groups of all the outcome scores between the intermediate and final-follow-up. The number of failures was 3 of 31 (9.7%) in the ACL group and 1 of 18 (5.5%) in the ACL + MCL group; this difference was not significant. Moreover, there were no clinical differences between the groups in terms of graft failures, contralateral lesions, and clinical scores.

Conclusion:

At 14-year follow-up, no clinical difference or increased failure rate was observed between the study groups, suggesting that isolated ACL reconstruction could represent an appropriate treatment for a combined ACL and MCL grade 2 lesion.

Ultrasound-based evaluation revealed reliable postoperative knee stability after combined acute ACL and MCL injuries

Purpose

Anterior cruciate ligament (ACL) injuries are often combined with lesions of the medial collateral ligament (MCL). The aim of this study was to evaluate treatment outcome of combined acute ACL and MCL lesions using functional US and clinical examination.

Methods

Patients aged > 18 years undergoing primary ACL reconstruction with concomitant operative (group 1) or non-operative treatment of the MCL (group 2) between 2014 and 2019 were included after a minimum follow-up of 12 months. Grade II MCL injuries with dislocated tibial or femoral avulsions and grade III MCL ruptures underwent ligament repair whereas grade II injuries without dislocated avulsions were treated non-operatively. Radiological outcome was assessed with functional US examinations. Medial knee joint width was determined in a supine position at 0° and 30° of knee flexion in unloaded and standardized loaded (= 15 Dekanewton) conditions using a fixation device. Clinical examination was performed and patient-reported outcomes were assessed by the use of the subjective knee form (IKDC), Lysholm score, and the Tegner activity scale.

Results

A total of 40 patients (20 per group) met inclusion criteria. Mean age of group 1 was 40 ± 12 years (60% female) with a mean follow-up of 33 ± 17 months. Group 2 showed a mean age of 33 ± 8 years (20% female) with a mean follow-up of 34 ± 15 months. Side-to-side differences in US examinations were 0.4 ± 1.5 mm (mm) in 0° and 0.4 ± 1.5 mm in 30° knee flexion in group 1, and 0.9 ± 1.1 mm in 0° and 0.5 ± 1.4 mm in 30° knee flexion in group 2, with no statistically significant differences between both groups. MCL repair resulted in lower Lysholm scores (75 ± 19 versus 86 ± 15; p < 0.05). No significant differences could be found for subjective IKDC or Tegner activity scores among the two groups.

Conclusion

A differentiated treatment concept in combined ACL and MCL injuries based on injury patterns leads to reliable postoperative ligamentous knee stability in US-based and clinical examinations. However, grade II and III MCL lesions with subsequent operative MCL repair (group 1) result in slightly poorer subjective outcome scores.

Level of evidence

Retrospective cohort study; Level III

Comparison between single- and double-bundle anterior cruciate ligament reconstructions for knee with grade 2 medial collateral ligament injury

This research discussed clinical outcomes of anterior cruciate ligament reconstruction accompanied by conservative treatment for grade 2 medial collateral ligament injury, and comparison was performed between double-bundle and single-bundle anterior cruciate ligament reconstruction.Clinical information was retrospectively collected for 41 cases suffering anterior cruciate ligament injuries accompanied by grade 2 medial collateral ligament injuries. Within 14 days after their injuries 22 cases received single-bundle anterior cruciate ligament reconstruction (SB group), while 19 were treated with double-bundle medial collateral ligament reconstruction (DB group). Physical statuses were estimated based on International Knee Documentation Committee (IKDC) and Lysholm scores, Lachman, pivot shift and manual valgus test, and range of motion (ROM), while side-to-side difference was estimated through KT 2000 arthometer.Anterior cruciate ligament reconstruction accompanied by conservative treatment showed significantly improved anteroposterior, rotational and valgus stability, and IKDC and Lysholm scores (in comparison to pre-operative status, P < .05). Incidence of pivot shift was dramatically lower in DB group (2/19) than in SB group (7/22 and 2/22; P = .028). No substantial dissimilarity existed between DB and SB groups either in Lachman and valgus tests, KT 2000, ROM, IKDC, or Lysholm scores.Anterior cruciate ligament reconstruction accompanied by conservative treatment could achieve outstanding stability and functional manifestations for cases facing anterior cruciate ligament injury accompanied by grade 2 medial collateral ligament injury. Moreover, double-bundle anterior cruciate ligament reconstruction is superior to single-bundle operation in treating rotational instability of the knee.Level of evidence: Retrospective comparative study, Level III.

Percutaneous Arthroscopic Assisted Knee Medial Collateral Ligament Repair

Medial collateral ligament (MCL) injuries are commonly encountered alongside anterior cruciate ligament injuries. Treatment modalities have ranged from conservative management to surgical repair, augmentation, and reconstruction. Various reports have reported residual valgus instability, especially in higher-grade injuries that have been treated conservatively. The MCL provides valgus stability but also is an element of anterior stability to the tibia in addition to the anterior cruciate ligament. In addition, meniscal "lift-off" and "floating" have been described as consequences after MCL injuries, and meniscal dysfunction has been shown to lead to accelerated joint degeneration; therefore, all efforts should be made to treat these injuries adequately. We describe a simple, minimally invasive technique that involves suturing the deep MCL to the medial joint capsule, allowing better MCL healing, causing less soft-tissue scarring, and preventing meniscal extrusion.

Medial collateral ligament (MCL) reconstruction results in improved medial stability: results from the Danish knee ligament reconstruction registry (DKRR)

PURPOSE

The aim of this study was to compare outcome data after isolated and combined (MCL) plus anterior cruciate ligament (ACL) reconstruction based on objective and subjective measures using data from the (DKRR). There are only a few small-sized case studies on outcomes after MCL reconstruction. MCL reconstruction was hypothesised to improve both objective and subjective outcomes.

METHODS

All patients who were registered in the DKRR between 2005 and 2016 (N = 25,281) and who underwent isolated ACL (n = 24,683), isolated MCL (n = 103) or combined MCL plus ACL (n = 495) reconstructions were retrospectively identified. Objective (valgus knee stability and sagittal knee laxity) and subjective (Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scale score) outcomes in these three cohorts were evaluated at the 1-year follow-up by comparing pre- and post-operative values.

RESULTS

Medial stability improved significantly pre- to post-operatively after both isolated MCL and combined MCL plus ACL reconstruction, with 26 (53%) and 195 (69%) of the patients, respectively, having normal valgus stability (0-2 mm laxity). Sagittal stability was similar after MCL plus ACL reconstruction and isolated ACL reconstruction (1.7 and 1.5 mm, respectively). At the 1-year follow-up, although the KOOS of the patients in the isolated MCL and combined MCL plus ACL reconstruction cohorts improved significantly, they were lower than those of the patients in the isolated ACL reconstruction cohort.

CONCLUSION

Both isolated MCL reconstruction and combined MCL plus ACL reconstruction resulted in significant and clinically relevant improvements in the subjective outcomes from pre-operative conditions to the 1-year follow-up. Valgus stability also improved significantly, with two-thirds of patients obtaining normal valgus stability after MCL reconstruction. Subjective outcomes were similar between isolated MCL reconstruction and combined MCL plus ACL reconstructions, but were poorer than isolated ACL reconstructions.

LEVEL OF EVIDENCE

Level III.

Outcomes of Grade III Medial Collateral Ligament Injuries Treated Concurrently With Anterior Cruciate Ligament Reconstruction: A Multicenter Study

PURPOSE

To evaluate differences in repair and nonoperatively managed grade III medial collateral ligament (MCL) injuries during anterior cruciate ligament (ACL) reconstruction.

METHODS

Patients enrolled in a multicenter prospective longitudinal group who underwent unilateral primary ACL reconstruction between 2002 and 2008 were evaluated. Patients with concomitant grade III MCL injuries treated either operatively or nonoperatively were identified. Concurrent injuries, subsequent surgeries, surgical chronicity, and MCL tear location were analyzed. Patient-reported outcomes were measured at time of ACL reconstruction and 2-year follow-up.

RESULTS

Initially, 3,028 patients were identified to have undergone primary ACL reconstruction during the time frame; 2,586 patients completed 2-year follow-up (85%). Grade III MCL tears were documented in 1.1% (27 of 2,586): 16 operatively managed patients and 11 nonoperatively treated MCLs during ACL reconstruction. The baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee scores were lower in patients who underwent operative MCL treatment. Reoperation rates for arthrofibrosis were 19% after repair and 9% after conservative management (P = .48). At 2 years, both groups significantly improved; however, the nonoperative MCL group maintained superior patient-reported outcomes in terms of minimal clinically important differences, but these differences did not reach statistical significance (KOOS sports/recreation [88.2 vs 74.4, P = .10], KOOS knee-related quality of life [81.3 vs 68.4, P = .13], and International Knee Documentation Committee [87.6 vs 76.0, P = .14]). Tibial-sided MCL injuries were associated with clinically inferior baseline scores compared with femoral-sided MCL (KOOS knee-related quality of life, 34.4 vs 18.5, P = .09), but these differences resolved by 2 years. Surgical chronicity did not influence 2-year outcome.

CONCLUSIONS

Both operative and nonoperative management of MCL tears in our patient group demonstrated clinical improvements between study enrollment and 2-year follow-up. MCL surgery during ACL reconstruction was assigned to patients with worse symptoms at enrollment and was associated with worse outcomes at 2 years. A subset of patients with severe combined ACL and medial knee injuries may benefit from operative management; however, that population has yet to be defined.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Combined Anterior Cruciate Ligament, Medial Collateral Ligament, and Posterior Oblique Ligament Reconstruction Through Single Tibial Tunnel Using Hamstring Tendon Autografts

Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are the most common type of combined ligamentous injury of the knee. The optimal treatment for these combined injuries is controversial. Combined ACL and MCL-posterior oblique ligament (POL) reconstruction avoids late anteromedial rotatory instability and chronic valgus instability of the knee and decreases the increased stress on the ACL graft. Graft choice (hamstring tendon autograft, quadriceps bone-patellar tendon-bone autograft, or Achilles tendon allograft) and anatomic restoration of the medial and posteromedial corner of the knee are challenges of this combined reconstruction. This article describes a technique that allows combined ACL and MCL-POL reconstruction. The hamstring tendons from the contralateral limb are tripled and used as the ACL graft. The gracilis tendon from the ipsilateral limb is doubled and used as the MCL-POL graft. The semitendinosus tendon of the ipsilateral limb is preserved. After ACL reconstruction, the MCL-POL graft is suspended on the ACL graft at the distal end of the tibial tunnel and the graft limbs are used for open reconstruction of the MCL and POL. Three interference screws (Arthrex, Naples, FL) and 1 metal staple are used for graft fixation of this combined reconstruction.

Medial collateral ligament reconstruction is necessary to restore anterior stability with anterior cruciate and medial collateral ligament injury

PURPOSE

The purpose of this study was to compare knee kinematics and graft forces in anterior cruciate ligament (ACL) reconstruction combined with one of two superficial medial collateral ligament (sMCL) reconstruction techniques (parallel or triangular vector sMCL reconstruction).

METHODS

Twenty porcine knees were divided into two groups (n = 20), parallel or triangular vector sMCL reconstruction, with both groups having anatomic single-bundle ACL reconstruction. The knees were tested under (1) an 89-N anterior tibial load, (2) 4 Nm internal and external rotational tibial torques, and (3) a 7 Nm valgus torque.

RESULTS

With ACL/sMCL co-injuries, single-bundle ACL reconstruction alone does not restore anterior, valgus, and internal stability. Triangular vector sMCL reconstruction better restored anterior stability, and parallel sMCL reconstruction better restored valgus stability.

CONCLUSION

This study showed that single-bundle ACL reconstruction alone was not able to restore anterior tibial translation, valgus rotation, and external rotation of the intact knee with combined ACL and sMCL injuries and sMCL reconstruction was also required. The combined ACL and parallel sMCL reconstruction better restored valgus and external rotation stability, while the combined ACL and triangular vector method better restored anterior tibial translation. With combined ACL and severe sMCL injury, both ligaments should be reconstructed. The two sMCL reconstruction techniques exhibited slightly different kinematics and graft force; however, there was not enough difference to recommend one over the other.

Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series)

Knee injuries are a common presentation to the ED and are often difficult to assess and definitively diagnose due to the patient's acute pain, effusion and guarding. The quality of ED care provided to patients with fractures or soft tissue injuries of the knee is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common knee injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 2250 articles, of which 54 were included in the review (n = 8 primary articles, n = 28 systematic reviews, n = 18 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the knee in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is consistent evidence to support undertaking a thorough history and physical examination, including the application of special tests and clinical decision rules for imaging. In the undifferentiated knee injury, expedited follow up and further imaging is recommended to improve patient outcomes and cost-effectiveness.

Associated lateral/medial knee instability and its relevant factors in anterior cruciate ligament-injured knees

BACKGROUND

Associations of lateral/medial knee instability with anterior cruciate ligament (ACL) injury have not been thoroughly investigated. The purposes of this study were to investigate whether lateral/medial knee instability is associated with ACL injury, and to clarify relevant factors for lateral/medial knee instability in ACL-injured knees.

METHODS

One hundred and nineteen patients with unilateral ACL-injured knees were included. Lateral/medial knee instability was assessed with varus/valgus stress X-ray examination for both injured and uninjured knees by measuring varus/valgus angle, lateral/medial joint opening, and lateral/medial joint opening index. Manual knee instability tests for ACL were evaluated to investigate associations between lateral/medial knee instability and anterior and/or rotational instabilities. Patients' backgrounds were evaluated to identify relevant factors for lateral/medial knee instability. Damage on the lateral collateral ligament (LCL) on MRI was also evaluated.

RESULTS

All parameters regarding lateral knee instability in injured knees were significantly greater than in uninjured knees. There were significant correlations between lateral knee instability and the Lachman test as well as the pivot shift test. Patients with LCL damage had significantly greater lateral joint opening than those without LCL damage on MRI. Sensitivity of LCL damage on MRI to lateral joint opening was 100%, while its specificity was 36%. No other relevant factors were identified. In medial knee instability, there were also correlations between medial knee instability and the Lachman test/pivot shift test. However, the correlations were weak and other parameters were not significant.

CONCLUSIONS

Lateral knee instability was greater in ACL-deficient knees than in uninjured knees. Lateral knee instability was associated with ACL-related instabilities as well as LCL damage on MRI, whereas MRI had low specificity to lateral knee instability. On the other hand, the association of medial knee instability on ACL-related instability was less than that of lateral knee instability.

LEVELS OF EVIDENCE

Level IV, case series with no comparison group.

Factors associated with the status of meniscal tears following meniscal repair concomitant with anterior cruciate ligament reconstruction

PURPOSE

Anterior cruciate ligament (ACL) injuries are often accompanied by meniscal tears. Meniscal repair is typically performed during ACL reconstruction. However, retear of the meniscus after repair is frequent. The purpose of this study was to analyze the factors associated with meniscal healing after meniscal repair concomitant with ACL reconstruction.

MATERIALS AND METHODS

Eighty-seven meniscal repairs in 87 patients who received meniscal repair combined with ACL reconstruction and received second-look arthroscopy at a mean of postoperatively 15.7 months were examined retrospectively. The menisci were divided into three groups (complete heal, incomplete heal, and retear), and factors thought to affect the healing status of repaired menisci were analyzed using multivariate logistic regression analysis.

RESULTS

Meniscal healing was judged to be complete in 49 knees (56%), incomplete in 19 knees, (22%), and retear in 19 knees (22%). There were no significant differences among the three groups in age, sex, time from injury to operation, mean Tegner activity scale, tear location, or mean postoperative anteroposterior tibial translation on KT-1000. The mean length of the tear was significantly higher in the retear group. Additionally, the proportion patients with complete tear and the proportion with postoperative positive pivot shift test were significantly higher in the retear group than in the other groups. Multivariate logistic regression analysis showed that complete tear and positive pivot shift test were associated with retear.

CONCLUSIONS

These findings suggest that complete tears and residual instability are associated with retears after meniscal repair concomitant with ACL reconstruction.

Risk factors for knee instability after anterior cruciate ligament reconstruction

PURPOSE

The objective of this study was to estimate risk factors that influence postoperative instability after anterior cruciate ligament (ACL) reconstruction using multivariate logistic regression analysis.

METHODS

A total of 152 consecutive patients with symptomatic ACL insufficiency underwent arthroscopic ACL reconstruction between 2005 and 2011. Loss to follow-up and previous ligament reconstruction were exclusion criteria, resulting in 131 patients remaining for this retrospective study. The median follow-up was 55 months (range 25-100 months). Patients were sorted into two groups by anterior translation on stress radiograph and pivot shift test grade and were analysed for the statistical significance of various risk factors including age at surgery, gender, body mass index, preoperative instability, time from injury to surgery, single-bundle reconstruction with preserved abundant remnant versus double-bundle reconstruction with scanty remnant, and concomitant ligament, meniscus, and articular cartilage injury with use of multivariate logistic regression analysis.

RESULTS

Time from injury to surgery over 12 weeks was found to be a significant risk factor for postoperative instability [p < 0.001, adjusted odds ratio (OR) 6.22; 95 % confidence interval (CI) 2.14-18.06)]. Grade 2 injury of medial collateral ligament (MCL) was also a risk factor (p = 0.02, adjusted OR 13.60; 95 % CI 1.24-148.25). The other variables were not found to be a significant risk factor.

CONCLUSIONS

Among the risk factor variables, concomitant grade 2 MCL injury and surgical delay of more than 12 weeks from injury were significant risk factors for postoperative knee instability after ACL reconstruction. The overall results suggest that surgery <12 weeks from injury and meticulous attention to concomitant MCL injury should be considered.

LEVEL OF EVIDENCE

Retrospective case-control study, Level III.

Biomechanical Analysis of Internal Bracing for Treatment of Medial Knee Injuries

The internal brace technique uses a high-strength suture tie to augment injured tissues or a primary repair, allowing early rehabilitation. Anatomic repair with internal bracing is a novel and promising treatment for femoral-sided medial knee avulsion injuries of the medial collateral ligament and posterior oblique ligament. Unfortunately, biomechanical and clinical data are lacking. To evaluate this technique compared with other treatment options, 3 assays of 9 cadaveric matched pairs (54 knees) were tested to failure at 30° under valgus load in a biomechanical testing apparatus. The primary outcome measure was moment at failure (Nm), with secondary outcome measures of stiffness (Nm/°), valgus angulation at 10 Nm (°), and valgus angulation at failure (°). Repair with internal bracing was compared with the intact state, repair alone, and allograft reconstruction. The mean moment to failure (62.5±24.9 Nm) for internal bracing was significantly lower than that for intact specimens (107.2±39.7 Nm) (P=.009). Mean moment to failure and valgus angle at failure were significantly greater for internal bracing (95±31.9 Nm) than for repair (73.4±27.6 Nm) (P=.05). Internal bracing was similar to reconstruction for the primary outcome measure (53.5±26.3 Nm vs 66.9±28.8 Nm) (P=.227) and for all secondary outcome measures. These findings indicate that posteromedial knee repair with internal bracing for femoral-sided avulsions is superior to repair alone and is similar to allograft reconstruction for all parameters measured; however, this technique did not recreate biomechanical properties equivalent to the intact state. [Orthopedics. 2016; 39(3):e532-e537.].

A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament

BACKGROUND

There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL).

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.

A novel technique for combined medial collateral ligament and posterior oblique ligament reconstruction: technical note

PURPOSE

In the last year, we have performed a new technique for combined medial collateral ligament (MCL) and posterior oblique ligament (POL) reconstruction in chronic setting of anterior cruciate ligament and MCL complex deficiency. Autogenous semitendinosus tendon with the tibial attachment preserved has been used for the medial/posteromedial compartment reconstruction. We describe the operative technique.

METHODS

Between January and December 2014, 12 consecutive patients with multiligamentous injuries underwent concomitant MCL/POL using a novel technique. The usefulness of the novel technique is the semitendinosus sling on the semimembranosus tendon and the POL fixation with the knee in full extension.

RESULTS

An ideal anteroposterior and rotational stability avoiding the medial compartment over constraint was achieved, in the immediate after surgery, due to the sequence of the bundle fixations and to the semitendinosus sling below the semimembranosus tendon.

CONCLUSIONS

This technique is easily reproducible and useful and restores the medial stability immediately after surgery.

Return to Sport After Tibial Shaft Fractures: A Systematic Review

CONTEXT

Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods.

OBJECTIVE

To determine the current evidence for the treatment of and return to sport after tibial shaft fractures.

DATA SOURCES

OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014.

STUDY SELECTION

Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis.

RESULTS

A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01).

CONCLUSION

The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.

Two Cases of Contact Anterior Cruciate Ligament Rupture Combined with a Posterolateral Tibial Plateau Fracture

Background. The combined occurrence of ACL rupture with a posterolateral tibial plateau fracture has not yet been reported. Two cases of such injuries have been treated in our department for the past three years. Findings. The two patients both suffered injuries from traffic accidents. The radiological examinations showed a ruptured ACL with fracture of the posterolateral tibial plateau. Reconstruction of the ACL was performed via a standard anatomical single bundle ACL reconstruction technique with autologous tendon by arthroscopy. A posterolateral tibia plateau approach was used to reduce and fix the fractured area with the aid of lag screws. After a one-year follow-up, the two patients recovered well and physical examinations showed full knee range of motion with no evidence of ACL instability. Conclusions. The cause of this type injury of ACL rupture with a posterolateral tibial plateau fracture was thought to be by a violent internal tibial rotation/anterior tibial translation without any valgus or varus knee force mechanism during the accident. Satisfactory clinical results were achieved with a standard anatomical single bundle ACL reconstruction by arthroscopy and ORIF for the posterolateral plateau fracture. Both patients reported excellent knee function and fracture healing.

Return to sports after stress fractures of the tibial diaphysis: a systematic review

INTRODUCTION

This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs).

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport.

AREAS OF CONTROVERSY

The best time to return to sport and the optimal management modalities for TDSFs remain undefined.

GROWING POINTS

Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TDSFs.

Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review

INTRODUCTION

There is an increasing interest in platelet-rich plasma (PRP) injection as a treatment for chronic plantar fasciopathy (PF). We wished to evaluate the evidence for the use of PRP in PF/fasciitis.

SOURCES OF DATA

We performed a systematic review on the effects of PRP in PF. In June 2014, we searched Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each PRP preparation and 'plantar' (with its associated terms). We only included prospectively designed studies in humans.

AREAS OF AGREEMENT

Eight articles met the inclusion criteria, three of them were randomized. All studies yielded a significantly greater improvement in symptoms between baseline and last follow-up assessment. None of the papers recorded major complications.

AREAS OF CONTROVERSY

Only three randomized studies were identified; none of them had a true controlled group treated with placebo and one of the three studies had a very short (6 week) follow-up. A non-randomized study evaluating PRP versus corticosteroids (CCS) injections, and a randomized controlled trial comparing PRP and dextrose prolotherapy reported no statistical significant differences at 6 months. Most studies did not have a control group and imaging evaluation.

GROWING POINTS AND AREAS FOR RESEARCH

Evidence for the use of PRP in PF shows promising results, and this therapy appears safe. However, the number of studies available is limited and randomized placebo-controlled studies are required. Characterizing the details of the intervention and standardizing the outcome scores would help to better document the responses and optimize the treatment.

Management of Combined Anterior Cruciate Ligament-Posterolateral Corner Tears: A Systematic Review

BACKGROUND

A consensus on the treatment of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries is still lacking.

PURPOSE

To review the available literature on the management of these combined lesions to investigate the influence that injuries of knee posterolateral structures play in the outcome of an ACL lesion.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "posterolateral corner," "plc," "posterolateral instability," "posterolateral injury," "anterior cruciate ligament," and "acl."

RESULTS

A total of 6 studies involving 95 patients were included. For those with PLC lesions, 14 patients were treated nonoperatively, 9 underwent an early anatomic repair, while the remaining 72 underwent a reconstruction. In all 95 patients, an ACL reconstruction was performed. Sixty-seven of the 72 patients who underwent a PLC reconstruction were assessed for anteroposterior laxity, with a mean side-to-side difference of 1.5 ± 1.1 mm. Evaluated by the objective International Knee Documentation Committee (IKDC) Knee Form, 88% of the patients who underwent a PLC reconstruction were graded as good/excellent (A/B). The 9 patients who underwent an early surgical repair of the PLC lesion were evaluated by means of the objective IKDC score, with 3 patients (33%) graded as good/excellent (A/B), and by means of a clinical evaluation, with 5 of 9 patients (56%) graded as 1+ for varus laxity. For the 14 patients who were managed nonoperatively for PLC injuries, the only clinical score available was the subjective IKDC score, with a mean value of 80.5 (87.8 for the 6 patients with type A PLC injuries and 75.0 for type B PLC injuries).

CONCLUSION

There is a paucity of literature focused on the management of combined ACL and PLC injuries. Combined ACL and PLC reconstruction seems to be the most effective approach to these combined lesions. However, future work is needed to explore the long-term outcome of the different treatment options.

Minimally invasive versus open surgery for acute Achilles tendon rupture: a systematic review

INTRODUCTION

This review provides a comprehensive description of clinical, functional outcomes, and complications after open and minimally invasive surgery for Achilles tendon ruptures.

SOURCES OF DATA

We systematically searched Medline (PubMED), EMBASE, CINHAL, Cochrane, Sports Discus and Google scholar databases using the combined keywords 'open repair', 'percutaneous surgery', 'minimally invasive surgery' 'Achilles tendon rupture', 'complications', 'infections', 'wound disorders' to identify articles published in English, Spanish, French and Italian.

AREAS OF AGREEMENT

Twelve studies fulfilled our inclusion criteria. Six studies were retrospective, five were randomized controlled trials and one was a prospective investigation. Of a total of 781 patients, 375 underwent open repair and 406 percutaneous surgery. Different procedures were performed for open and minimally invasive repair.

AREAS OF CONTROVERSY

The range of motion was significantly greater after percutaneous repair than open surgery. The number of complications that occurred after open surgery was higher than after minimally invasive surgery.

GROWING POINTS

Minimally invasive surgery is less expensive and less time demanding.

AREAS TIMELY FOR DEVELOPING RESEARCH

Minimally invasive and open surgery of the Achilles tendon are grossly equivalent. However, iatrogenic neurological complications are more frequent after percutaneous repair. Novel percutaneous repairs have been proposed to minimize the risk of sural nerve injury.

Surgical management of partial tears of the anterior cruciate ligament

PURPOSE

Partial anterior cruciate ligament (ACL) tears involving the posterolateral (PL) bundle can lead to rotatory laxity of the knee, while tears involving the anteromedial (AM) bundle result in abnormal anteroposterior laxity of the knee. In this systematic review, we examine the best evidence on the management of partial tears of the ACL.

METHODS

A comprehensive search of several databases was performed from the inception of the database to December 2011, using various combinations of keywords focusing on clinical outcomes of human patients who had partial tears of ACL and who had undergone ACL augmentation. We evaluated the methodological quality of each article using the Coleman Methodology Score.

RESULTS

Ten articles published in peer-reviewed journals were identified (392 males and 242 females), with a mean modified Coleman methodology of 66.1 ± 10.2. Only two studies compared standard ACL reconstruction and augmentation techniques. No study has a sample large enough to allow establishing guidelines. Validated and standardized proprioception assessment methods should be used to report outcomes. Imaging outcomes should be compared to functional outcomes, and a control group consisting of traditional complete ACL reconstruction should be present.

CONCLUSION

There is a need to perform appropriately powered randomized controlled trials presenting clinical outcome with homogeneous score systems to allow accurate statistical analysis. ACL augmentation technique, preserving the intact AM or PL bundle of the ACL, is encouraging but currently available evidences are too weak to support his routine use in clinical practice.

ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies

BACKGROUND

Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.

PURPOSE

To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).

STUDY DESIGN

Systematic review.

METHODS

A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at critically analyzing ACL outcome studies and used to examine each study design.

RESULTS

Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in the review. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.

CONCLUSION

Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes.

Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study

PURPOSE

This study aimed to undertake a retrospective analysis of prospectively collected data comparing, at a minimum follow-up of 5 years (78.1 ± 5.3 months v 75.6 ± 4.8 months), the clinical, functional, and radiographic outcomes of 2 homogeneous groups of athletes who had undergone arthroscopic single-bundle autologous hamstring reconstruction of the anterior cruciate ligament (ACL) using a transtibial (TT) or an anteromedial portal (AMP) approach to drill the femoral tunnel.

METHODS

Ninety-four patients were operated on in 2005 and 2006, and 88 (93.6%) (73 men, 15 women) were evaluated subjectively and objectively, using the Lysholm and International Knee Documentation Committee (IKDC) scores, manual maximum displacement test with a KT-1000 arthrometer (MEDmetric, San Diego, CA) and the Lachman test, and rotational instability with the pivot shift test. Degenerative changes were assessed on radiographs according to the Fairbank classification.

RESULTS

The median age at operation was 29 years (20 to 43 years; SD, 5.4) in the TT group 1 and 28 years (19 to 45 years; SD, 6.1) in the AMP group 2. At the last appointment, the 2 groups had similar results for the Lysholm and IKDC scores (primary outcome). Patients who underwent the AMP approach had less glide pivot shift (P = .42) and Lachman (P = .47) phenomena, with no statistically significant intergroup difference. Radiography showed fewer, but not significantly different, degenerative changes in the AMP ACL reconstruction group at final follow-up (P = .47).

CONCLUSIONS

In our series, ACL reconstruction using a femoral tunnel drilled through an AMP provided better rotational stability and anterior translation than drilling the femoral tunnel using the TT technique. This difference likely is not relevant from a clinical and functional viewpoint. The 2 groups of patients were not significantly different in terms of development of degenerative changes seen radiographically at a minimum follow-up of 5 years.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness

PURPOSE

The aim of this meta-analysis was to compare the risk of stiffness between early and delayed anterior cruciate ligament (ACL) surgery in studies that use a modern accelerated rehabilitation protocol.

METHODS

Medline, Embase, and the Cochrane library were searched for studies that compared outcomes for early and delayed ACL reconstruction with a modern accelerated rehabilitation protocol. Risk ratios for stiffness were pooled using random effects meta-analysis.

RESULTS

A total of 8 studies were included in this review. The 3 randomized trials found no difference in the risk of postoperative stiffness at cutoff points of <2, <3, and <10 weeks between early surgery and delayed surgery. An analysis of the 7 studies whose outcomes could be pooled revealed no significant increase in risk of adverse outcomes with early surgery using a variety of cutoff points (1, 2, 10, 12, and 20 weeks). Sensitivity analysis of individual outcomes failed to show any significant difference between early and delayed surgery with respect to arthrofibrosis, stiffness, range of motion deficits, extension deficits, and flexion deficits.

CONCLUSIONS

If a modern surgical technique and an accelerated rehabilitation protocol are used, there is no increased risk of knee stiffness if an ACL reconstruction is performed as early as 1 week after injury.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

Augmentation techniques for rotator cuff repair

INTRODUCTION

There is a high rate of recurrence of tear and failed healing after rotator cuff repair. Several strategies have proposed to augment rotator cuff repairs to improve postoperative outcome and shoulder performance. We systematically review the literature on clinical outcome following rotator cuff augmentation.

SOURCES OF DATA

We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials, from inception of the database to 20 June 2012, using various combinations of keywords. The reference lists of the previously selected articles were then examined by hand. Only studies focusing on clinical outcomes of human patients who had undergone augmented rotator cuff repair were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS).

AREAS OF AGREEMENT

Thirty-two articles were included in the present review. Two were retrospective studies, and 30 were prospective. Biologic, synthetic and cellular devices were used in 24, 7 and 1 studies, respectively. The mean modified Coleman methodology score was 64.0.

AREAS OF CONTROVERSY

Heterogeneity of the clinical outcome scores makes it difficult to compare different studies.

GROWING POINTS

None of the augmentation devices available is without problems, and each one presents intrinsic weaknesses. There is no dramatic increase in clinical and functional assessment after augmented procedures, especially if compared with control groups.

RESEARCH

More and better scientific evidence is necessary to use augmentation of rotator cuff repairs in routine clinical practice.

Return to sports after ankle fractures: a systematic review

INTRODUCTION

This review aims to provide information on the time athletes will take to resume sports activity following ankle fractures.

SOURCES OF DATA

We systematically searched Medline (PubMED), EMBASE, CINHAL, Cochrane, Sports Discus and Google scholar databases using the combined keywords 'ankle fractures', 'ankle injuries', 'athletes', 'sports', 'return to sport', 'recovery', 'operative fixation', 'pinning', 'return to activity' to identify articles published in English, Spanish, French, Portuguese and Italian.

AREAS OF AGREEMENT

Seven retrospective studies fulfilled our inclusion criteria. Of the 793 patients, 469 (59%) were males and 324 (41%) were females, and of the 356 ankle fractures we obtained information on, 338 were acute and 18 stress fractures. The general principles were to undertake open reduction and internal fixation of acute fractures, and manage stress fractures conservatively unless a thin fracture line was visible on radiographs.

AREAS OF CONTROVERSY

The best timing to return to sports after an acute ankle fracture is still undefined, given the heterogeneity of the outcome measures and results. The time to return to sports after an acute stress injury ranged from 3 to 51 weeks.

GROWING POINTS

When facing athletes with ankle fractures, associated injuries have to be assessed and addressed to improve current treatment lines and satisfy future expectancies.

AREAS TIMELY FOR DEVELOPING RESEARCH

The best timing to return to sports after an ankle fracture has not been established yet. The ideas of the return to activity parameter and surgeon databases including sports-related information could induce research to progress.

Scaffolds for partial meniscal replacement: an updated systematic review

INTRODUCTION

Meniscectomy, a most common orthopaedic procedure, results in increased contact area of the articular surfaces of tibia and femur leading to early osteoarthritis. We systematically review the literature on clinical outcomes following partial meniscal replacement using different scaffolds.

SOURCES OF DATA

We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the selected articles were then examined by hand. Only studies focusing on investigation of clinical outcomes on patients undergoing a partial meniscal replacement using a scaffold were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS).

AREAS OF AGREEMENT

Fifteen studies were included, all prospective studies, but only 2 were randomized controlled trials. Biological scaffolds were involved in 12 studies, 2 studies investigated synthetic scaffolds, whereas 1 remaining article presented data from the use of both classes of device. The mean modified CMS was 64.6.

AREAS OF CONTROVERSY

Several demographic and biomechanical factors could influence the outcomes of this treatment modality.

GROWING POINTS

Partial replacement using both classes of scaffolds achieves significant and encouraging improved clinical results when compared with baseline values or with controls when present, without no adverse reaction related to the device.

RESEARCH

There is a need for more and better designed randomized trials, to confirm with a stronger level of evidence the promising preliminary results achieved by the current research.

Home-based vs supervised rehabilitation programs following knee surgery: a systematic review

INTRODUCTION

Following knee surgery, rehabilitation can dramatically affect the postoperative course and the final outcomes of the procedure. We systematically reviewed the current literature comparing clinical outcomes of home-based and outpatient supervised rehabilitation protocols following knee surgery.

SOURCES OF DATA

We searched Medline, CINAHL, Embase, Google Scholar, The Cochrane Library and SPORTDiscus. The reference lists of the previously selected articles were then examined by hand. Only studies comparing clinical outcomes of patients who had undergone knee surgery followed by different rehabilitation programs were selected. Then the methodological quality of each article was evaluated using the Coleman methodology score (CMS), a 10-criterion scoring list assessing the methodological quality of the selected studies.

AREAS OF AGREEMENT

Eighteen studies were evaluated in the present review. Three were retrospective studies. The remaining 15 studies were prospective randomized clinical trials. The supervised and home-based protocols did not show an overall significant difference in the outcomes achieved within the studies reviewed. The mean CMS was 77.2.

AREAS OF CONTROVERSY

The heterogeneity of the rehabilitation protocols used in the studies reviewed makes it difficult to draw definite conclusion on the subject.

GROWING POINTS

Supervision and location does not seem to directly determine the final outcomes. Numerous variables, including comorbidities and motivation, could influence the results and deserve to be accounted for in future investigations.

RESEARCH

Better designed studies are needed to show a clear superiority of one rehabilitation approach over another and its applicability to the various surgical procedures involving the knee.

Management of the greater trochanteric pain syndrome: a systematic review

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter.

SOURCE OF DATA

We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected.

AREAS OF AGREEMENT

Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months.

AREAS OF CONTROVERSY

Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS.

GROWING POINTS

Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS.

CONCLUSION

The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

Consideration of growth factors and bio-scaffolds for treatment of combined grade II MCL and ACL injury

The literature suggests that a Grade II medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury will heal naturally and not compromise patient outcome following ACL reconstruction. Evidence based on bone-patella tendon-bone autograft use is stronger than evidence supporting anatomically placed soft tissue graft use. Current ACL reconstruction practices make greater use of soft tissue grafts, differing fixation methods, and anatomically lower placement on the inner wall of the lateral femoral condyle. Anatomical graft placement aligns the femoral bone tunnel more directly with valgus knee loading forces. Differences in the soft tissue graft-bone tunnel integration and ligamentization timetable following ACL reconstruction also increase concerns regarding residual Grade II MCL laxity and functional deficiency during accelerated functional rehabilitation. MCL dysfunction may increase susceptibility to early ACL graft slippage, elongation, outright failure, and medial femoral condyle lift-off with valgus knee loading. This concept paper discusses the potential role of growth factors and bio-scaffolds for improving Grade II MCL injury healing and mechanical integrity when the injury occurs in combination with an ACL injury that is reconstructed with a soft tissue graft and an anatomical surgical approach.

Treatment of combined complete tears of the anterior cruciate and medial collateral ligaments

PURPOSE

To develop an evidence-based algorithm for the treatment of combined complete tears of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL).

METHODS

We performed a systematic review using computerized keyword searches of Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported stratified outcomes data after the treatment of combined complete tears of the ACL and MCL were included. Data on clinical measures of laxity, range of motion, and strength, as well as subjective outcome measures, were summarized.

RESULTS

Five different treatment approaches were reported. Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period.

CONCLUSIONS

ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Femoroacetabular impingement syndrome management: arthroscopy or open surgery?

PURPOSE

This review explores the scientific evidence for clinical, functional and imaging outcomes after surgical management of Femoroacetabular Impingement (FAI) syndrome, and assesses the methodological quality of the published literature reporting this issue.

METHODS

The medical literature databases of Pubmed, Medline, Ovid, Google Scholar and Embase were searched for articles published in English, Spanish, French and Italian, using a combination of the keywords 'femoro-acetabular impingement syndrome', 'postoperative outcomes', 'open surgery', and 'arthroscopic management'. To address three main questions, we extracted data on demographic features, operative techniques, postoperative rehabilitation regimens, imaging features, pre and postoperative hip scores. Complications and conversion to arthroplasty were also investigated.

RESULTS

Thirty-one studies published have reported clinical, functional and imaging outcomes after open and arthroscopic management of FAI syndrome. The modified Coleman methodology score (CMS) averaged 56.2 (range, 30-81). From extracted data, it was shown that arthroscopy, open surgery and arthroscopic surgery followed by mini open surgery are comparable for functional results, biomechanics, and return to sport. Progression of OA and conversion to hip arthroplasty are dependent on preoperative status of cartilage and osteoarthritis and type of management. Debridement and osteoplasty provide better results than debridement only. Significantly improved outcomes have been recorded in patients undergoing labral refixation than resection. The Coleman methodology score showed great heterogeneity in terms of study design and outcome assessment, and generally low methodological quality.

CONCLUSION

Although open and minimally invasive procedures allow athletes to return to professional sports activity, they are contraindicated in patients with severe osteoarthritis and cartilage degeneration.

Management of medial collateral ligament injuries in the knee: an update and review

The medial collateral ligament (MCL) is the most frequently injured ligament in the knee, with mild-to-moderate tears often going unreported to physicians. Medial collateral ligament injuries can result from both contact and noncontact sporting activities. The mainstay of treatment is nonoperative; however, operative management of symptomatic grade II and grade III injuries is considered when laxity and instability persist. The timing of surgical repair in the setting of a multiligament knee injury remains an area of controversy among surgeons, with proponents of early reconstruction of the anterior and posterior cruciate ligaments and nonoperative management of the MCL versus proponents of delayed reconstruction following nonoperative treatment of the MCL. Prophylactic bracing may continue to increase and evolve as bracing technology improves and athletic cultures change.