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Dávid T, Kinga N, Zsófia C, Kitti R, Attila S, Marcell V. Dynamic point of care ultrasound is effective in the early diagnosis of anterior cruciate ligament injuries in children and adolescents. Injury 2024; 55 Suppl 3:111729. [PMID: 39300622 DOI: 10.1016/j.injury.2024.111729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/03/2024] [Accepted: 07/14/2024] [Indexed: 09/22/2024]
Abstract
INTRODUCTION Several studies have proven that ultrasound (US) can improve the efficiency of early diagnostics of anterior cruciate ligament (ACL) injuries. ACL US is mainly performed by sonologists or radiologists. We have very little data on how effective these tests are if they are performed by an orthopaedic surgeon. We also have no information on the applicability of ACL US in children and adolescents. In this retrospective study, we analysed the results of point of care ultrasound (POCUS), which were performed by orthopaedic surgeons on children with suspected ACL injury. MATERIALS AND METHODS We reviewed the data of children and adolescents who were examined with ultrasound between 2018 and 2021 for suspected ACL injury. ACL POCUS was done immediately after the physical examination, according to a standard technique. The tests were performed by an orthopaedic resident and young and a senior orthopaedic surgeon. The inclusion criteria were as follows: the child's age is between 0-15 years, the growth zones are open, the child later underwent MRI and/or arthroscopy, which confirmed or excluded the fact of an ACL injury. We excluded patients with incomplete recordings and documentation. RESULTS 119 children met the above criteria. The children were between 8 and 15 years old (mean = 13.29). Positive findings were found in 47, negative findings in 72 children with ACL POCUS. During the subsequent treatment, 57 children underwent only MRI examination, 11 children only arthroscopy, and 51 children both MRI and arthroscopy. The specificity of the test was measured as 0.958 and the sensitivity as 0.917 for complete ACL rupture. Regarding all ACL injuries (complete + partial), we found the sensitivity to be 83.019 and the specificity to be 95.45. The interrater agreement between radiologist and clinicians was 94.957 %. (Cohen's k: 0.8945). CONCLUSIONS POCUS can indicate functional insufficiency caused by ACL injury in children and adolescents. The biggest advantage of the test is that it is quick and simple, non-invasive. Further prospective diagnostic tests and standardized examination protocols can confirm our favourable experiences.
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Affiliation(s)
| | - Németh Kinga
- Manninger Jenő Baleseti Központ, Budapest, Hungary
| | | | - Ribes Kitti
- University of Szeged, Department of Radiology, Szent-Györgyi Albert Klinikai Központ, Hungary
| | - Szűcs Attila
- Uzsoki Hospital, Department of Orthopaedics and Trauma, Semmelweis University, Department of Traumatology, Budapest, Hungary
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Tokgoz MA, Oklaz EB, Ak O, Guler Oklaz EB, Ataoglu MB, Kanatli U. The potential of posterior cruciate ligament buckling phenomenon as a sign for partial anterior cruciate ligament tears. Arch Orthop Trauma Surg 2024; 144:2181-2187. [PMID: 38492061 PMCID: PMC11093845 DOI: 10.1007/s00402-024-05270-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 03/03/2024] [Indexed: 03/18/2024]
Abstract
INTRODUCTION Diagnosis of a partial tear of the anterior cruciate ligament (ACL) can be challenging with physical examination and imaging techniques. Although magnetic resonance imaging (MRI) has high sensitivity and specificity for diagnosing complete ACL tears, its effectiveness may be limited when it is used to diagnose for partial tears. The hypothesis of the present study is that the posterior cruciate ligament (PCL) buckling phenomenon, which is a secondary sign of complete ACL tears on MRI, may be a useful method for diagnosing partial ACL tears. MATERIALS AND METHODS The data of 239 patients who underwent knee arthroscopy in a single institution between 2016 and 2022 were analyzed retrospectively. Patients were divided into three groups based on the condition of their ligaments: partial tears, complete tears and intact ligaments. To evaluate the buckling phenomenon on sagittal T2-weighted MRI, measurements of the posterior cruciate ligament angle (PCLA) and the posterior cruciate ligament-posterior cortex angle (PCL-PCA) were conducted in each group. Subsequently, the ability of these two measurement methods to distinguish partial tears from the other groups was assessed. RESULTS Both methods provided significantly different results in all three groups. Partial tears could be distinguished from intact ligaments with 86.8% sensitivity, 89.9% specificity when PCLA < 123.13° and 94.5% sensitivity, 93.2% specificity when PCL-PCA < 23.77°. Partial tears could be distinguished from complete tears with 79.5% sensitivity, 78.4% specificity when PCLA > 113.88° and with 86.1% sensitivity, 85.3% specificity when PCL-PCA > 16.39°. CONCLUSION The main finding of the present study is that the PCLA and PCL-PCA methods are useful on MRI for diagnosing partial ACL tears. PCLA value between 113°-123° and PCL-PCA value between 16°-24° could indicate a partial ACL tear. With these methods, it is possible to distinguish partial tears from healthy knees and reduce missed diagnoses. In addition, the differentiation of partial and complete tears by these methods may prevent unnecessary surgical interventions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Mehmet Ali Tokgoz
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Mevlana Bulvarı No: 29 Yenimahalle, Ankara, Turkey
| | - Ethem Burak Oklaz
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Mevlana Bulvarı No: 29 Yenimahalle, Ankara, Turkey.
| | - Oguzhan Ak
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Mevlana Bulvarı No: 29 Yenimahalle, Ankara, Turkey
| | | | - Muhammet Baybars Ataoglu
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Mevlana Bulvarı No: 29 Yenimahalle, Ankara, Turkey
| | - Ulunay Kanatli
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mahallesi, Mevlana Bulvarı No: 29 Yenimahalle, Ankara, Turkey
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Campbell RJ, An V, Molnar R, St George J, Sivakumar BS, Symes M. Trends in Pediatric Anterior Cruciate Ligament Reconstruction in Australia: An Analysis of Australian Medicare Benefits Schedule Database From 2001 to 2020. J Pediatr Orthop 2024; 44:347-352. [PMID: 38444080 DOI: 10.1097/bpo.0000000000002646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injuries are common and increasingly prevalent in the pediatric population. However, there remain sparse epidemiological data on the surgical treatment of these injuries. The objective of this study is to assess the trends in the rate of pediatric ACL reconstruction in Australia over the past 2 decades. METHODS The incidence of ACL reconstruction from 2001 to 2020 in patients 5 to 14 years of age was analyzed using the Australian Medicare Benefits Schedule (MBS) database. Data were stratified by sex and year. An offset term was introduced using population data from the Australian Bureau of Statistics to account for population changes over the study period. RESULTS A total of 3719 reconstructions for the management of pediatric ACL injuries were performed in Australia under the MBS in the 20-year period from 2001 to 2020. There was a statistically significant annual increase in the total volume and per capita volume of pediatric ACL reconstructions performed across the study period ( P <0.0001). There was a significant increase in the rate of both male and female reconstructions ( P <0.0001), with a greater proportion of reconstructions performed on males (n=2073, 56%) than females (n=1646, 44%). In 2020, the rate of pediatric ACL reconstructions decreased to a level last seen in 2015, likely due to the effects of COVID-19. CONCLUSIONS The incidence of ACL reconstruction in skeletally immature patients has increased in Australia over the 20-year study period. This increase is in keeping with evidence suggesting poor outcomes with nonoperative or delayed operative management.
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Affiliation(s)
- Ryan J Campbell
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital
| | - Vincent An
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital
| | - Robert Molnar
- Department of Orthopaedic Surgery, St George Hospital
| | - Justine St George
- Department of Orthopaedic Surgery, The Children's Hospital at Westmead
| | - Brahman S Sivakumar
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital
- Discipline of Surgery, Sydney Medical School, The Faculty of Medicine and Health, The University of Sydney
- Department of Orthopaedic Surgery, Hornsby Ku-ring-gai Hospital, Hornsby
- Department of Orthopaedic Surgery, Nepean Hospital, Kingswood
- Department of Orthopaedic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Michael Symes
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital
- Department of Orthopaedic Surgery, St George Hospital
- St George and Southerland Clinical School, University of New South Wales Medicine, Sydney
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Gunaydin B, Ozcaglayan TIK, Sever C, Oznur M, Cetin MU, Can E, Eren OT. How Many Bundles Does the Anterior Cruciate Ligament Consist of? A Case Report. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:557-562. [PMID: 38268645 PMCID: PMC10805052 DOI: 10.14744/semb.2022.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
In some cases with anterior cruciate ligament (ACL) injury, physical examination and magnetic resolution imaging cannot clearly identify whether the ACL is intact or partially or completely ruptured. A 40-year-old female patient was admitted to our clinic with complaints of knee pain. After the requested examinations, we could not clearly identify whether the ACL was intact or partially or completely ruptured. Arthroscopic knee surgery was planned for the patient. In diagnostic arthroscopy, it was also determined that there was a multibundle ACL that was not surrounded by the synovium and was tight in the figure 4 position. The surgery was completed by repairing the meniscal tear. It was seen in the current case report that the ACL was a multibundle structure without overlying synovium around. In such cases, it is difficult to evaluate the ACL, and it should be kept in mind that there may also be variations of the ACL.
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Affiliation(s)
- Burak Gunaydin
- Department of Orthopaedics and Traumatology, Namik Kemal University Faculty of Medicine, Tekirdag, Türkiye
| | | | - Cem Sever
- Department of Orthopaedics and Traumatology, Istanbul Aydin University Faculty of Medicine, Istanbul, Türkiye
| | - Meltem Oznur
- Department of Pathology, Namik Kemal University Faculty of Medicine, Tekirdag, Türkiye
| | - Mehmet Umit Cetin
- Department of Orthopaedics and Traumatology, Namik Kemal University Faculty of Medicine, Tekirdag, Türkiye
| | - Erdem Can
- Department of Orthopaedics and Traumatology, Namik Kemal University Faculty of Medicine, Tekirdag, Türkiye
| | - Osman Tugrul Eren
- Department of Orthopaedics and Traumatology, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
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Bruder AM, Culvenor AG, King MG, Haberfield M, Roughead EA, Mastwyk J, Kemp JL, Ferraz Pazzinatto M, West TJ, Coburn SL, Cowan SM, Ezzat AM, To L, Chilman K, Couch JL, Whittaker JL, Crossley KM. Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes. Br J Sports Med 2023; 57:602-610. [PMID: 36889918 DOI: 10.1136/bjsports-2022-106099] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury. DESIGN Systematic review with meta-analysis. DATA SOURCES Seven databases were searched in December 2021. ELIGIBILITY CRITERIA Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury. RESULTS We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I2 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26). CONCLUSIONS Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls. PROSPERO REGISTRATION NUMBER CRD42021205998.
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Affiliation(s)
- Andrea M Bruder
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia .,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Adam G Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Matthew G King
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Melissa Haberfield
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Eliza A Roughead
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - John Mastwyk
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Joanne L Kemp
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Marcella Ferraz Pazzinatto
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Thomas J West
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Sally L Coburn
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Sallie M Cowan
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,Clifton Hill Physiotherapy, Melbourne, Victoria, Australia
| | - Allison M Ezzat
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura To
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,Clifton Hill Physiotherapy, Melbourne, Victoria, Australia
| | - Karina Chilman
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Jamon L Couch
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.,Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.,Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Kay M Crossley
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
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Howe D, Cone SG, Piedrahita JA, Spang JT, Fisher MB. Age- and Sex-Specific Joint Biomechanics in Response to Partial and Complete Anterior Cruciate Ligament Injury in the Porcine Model. J Athl Train 2022; 57:978-989. [PMID: 34964874 PMCID: PMC9842119 DOI: 10.4085/1062-6050-565-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
CONTEXT Pediatric anterior cruciate ligament (ACL) injury rates are increasing and are highest in female adolescents. Complete ACL tears are typically surgically reconstructed, but few guidelines and very limited data exist regarding the need for surgical reconstruction or rehabilitation for partial ACL tears in skeletally immature patients. OBJECTIVE To evaluate the effects of partial (anteromedial bundle) and complete ACL transection on joint laxity and tissue forces under anterior and rotational loads in male and female stifle joints throughout skeletal growth in the porcine model. DESIGN Descriptive laboratory study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS We studied 60 male and female Yorkshire crossbreed pigs aged 1.5, 3, 4.5, 6, and 18 months (n = 6 pigs per age per sex). MAIN OUTCOME MEASURE(S) Joint laxity was measured in intact, anteromedial bundle-transected, and ACL-transected joints under applied anterior-posterior drawer and varus-valgus torque using a robotic testing system. Loading of the soft tissues in the stifle joint was measured under each condition. RESULTS Anterior-posterior joint laxity increased by 13% to 50% (P < .05) after anteromedial bundle transection and 75% to 178% (P < .05) after ACL transection. Destabilization after anteromedial bundle transection increased with age (P < .05) and was greater in late female than late male adolescents (P < .05). In anteromedial bundle-transected joints, the posterolateral bundle resisted the anterior load. In ACL-transected joints, the medial collateral ligament (MCL) contribution was largest, followed by the medial meniscus. The MCL contribution was larger and the medial meniscus contribution was smaller in male versus female specimens. CONCLUSIONS Partial ACL transection resulted in moderate increases in joint laxity, with the remaining bundle performing the primary ACL function. Destabilization due to partial ACL transection (anteromedial bundle) was largest in late adolescent joints, indicating that operative treatment should be considered in active, late-adolescent patients with this injury. Increased forces on the MCL and medial meniscus after ACL transection suggested that rehabilitation protocols may need to focus on protecting these tissues.
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Affiliation(s)
- Danielle Howe
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, and North Carolina State University, Raleigh
- Comparative Medicine Institute, North Carolina State University, Raleigh
| | - Stephanie G. Cone
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, and North Carolina State University, Raleigh
- Comparative Medicine Institute, North Carolina State University, Raleigh
- Department of Mechanical Engineering, University of Wisconsin, Madison
| | - Jorge A. Piedrahita
- Comparative Medicine Institute, North Carolina State University, Raleigh
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh
| | - Jeffrey T. Spang
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill
| | - Matthew B. Fisher
- Joint Department of Biomedical Engineering, University of North Carolina, Chapel Hill, and North Carolina State University, Raleigh
- Comparative Medicine Institute, North Carolina State University, Raleigh
- Department of Orthopaedics, School of Medicine, University of North Carolina, Chapel Hill
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Koo YJ, Seon JK, Lee G, Koo S. Influences of Partial Anterior Cruciate Ligament Injury On Anterior Cruciate Ligament Tensional Force and Kinematic Stability During Walking. J Biomech Eng 2022; 145:1143182. [PMID: 35838323 DOI: 10.1115/1.4054982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Indexed: 11/08/2022]
Abstract
Injuries in the anterior cruciate ligament (ACL), including partial tear and lengthening of the ACL, change the dynamic function of the knee. However, there is a lack of information on the effect of ACL partial tear on knee kinematics during walking. This study aimed to investigate the effects of different levels of ACL injuries on the knee stability and ACL tensional force to identify the critical injury level. Motion data of five normal subjects were acquired along with the ground reaction force. A knee model with 14 ligaments was developed using cadaveric specimen data. The initial length and stiffness of the ACL were changed to develop ACL-injured knee models. Musculoskeletal simulations of the knee models were performed using the measured gait data. The average tibial anterior translation increased significantly by 2.6 ± 0.7 mm when the ACL stiffness decreased to 25% of its original stiffness. The average tibial anterior translation increased significantly by 2.6 ± 0.3 mm at an increase in initial length of 10%. The knee with partial ACL tear had a non-linear decrease in ACL forces owing to the increase in the level of ACL injury, while the knee with ACL lengthening had linear decreased ACL forces. The partial tear of the ACL caused translational instability, while the complete tear caused both rotational and translational instabilities during the musculoskeletal walking simulation. This study presents the effects of partial ACL injuries on joint kinematics and ACL tensional force during the dynamic motion of walking.
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Affiliation(s)
- Young-Jun Koo
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Jong Keun Seon
- Department of Orthopedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Republic of Korea
| | - Giuk Lee
- School of Mechanical Engineering, Chung-Ang University, Seoul, Republic of Korea
| | - Seungbum Koo
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
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Cone SG, Barnes RH, Howe D, Fordham LA, Fisher MB, Spang JT. Age- and sex-specific differences in ACL and ACL bundle size during adolescent growth. J Orthop Res 2022; 40:1613-1620. [PMID: 34727387 PMCID: PMC9058042 DOI: 10.1002/jor.25198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are increasingly common in adolescents, and injuries in this age-group are associated with many unique challenges. Recent large animal studies suggest that the size and function of the major bundles of the ACL change differently throughout skeletal growth. To better aid clinical treatment of pediatric partial ACL tears and better predict outcomes from age-specific treatments, there is a need to measure changes in ACL bundle size in humans during growth. As such, the objective of this study was to compare changes in the length and cross-sectional area (CSA) of the ACL and its primary bundles in adolescent human subjects. Magnetic resonance imaging (MRI) scans were analyzed to determine the visibility and integrity of the ACL and its anteromedial and posterolateral bundles. MRI scans were considered from a retrospective database of subjects ranging from 10 to 18 years of age. The ACL and its anteromedial and posterolateral bundles were segmented and reconstructed into 3D models, and length and CSA were calculated. Total ACL length and CSA were greater in males compared with females, with a statistically significant interaction between age and sex for CSA. Sex had a significant effect on the CSA of both bundles. These sex-dependent differences emerge with moderate to large effect sizes (range: d = 0.50 to d = 1.23) beginning around 13 years of age. Along with ACL bundle structure-function relationships previously established in preclinical animal models, these findings may point toward biomechanical changes in the adolescent human ACL.
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Affiliation(s)
- Stephanie G. Cone
- University of Wisconsin – Madison,University of North Carolina – Chapel Hill,North Carolina State University
| | | | - Danielle Howe
- University of North Carolina – Chapel Hill,North Carolina State University
| | | | - Matthew B. Fisher
- University of North Carolina – Chapel Hill,North Carolina State University,Correspondence: Matthew B. Fisher, PhD, Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, 4130 Engineering Building III, CB7115, Raleigh, NC, 27695, ; Jeffrey T. Spang, MD, Department of Orthopaedics, University of North Carolina School of Medicine, 3141 Bioinformatics Building, Chapel Hill, NC, 27599,
| | - Jeffrey T. Spang
- University of North Carolina – Chapel Hill,Correspondence: Matthew B. Fisher, PhD, Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina at Chapel Hill, 4130 Engineering Building III, CB7115, Raleigh, NC, 27695, ; Jeffrey T. Spang, MD, Department of Orthopaedics, University of North Carolina School of Medicine, 3141 Bioinformatics Building, Chapel Hill, NC, 27599,
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9
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Shimberg JL, Leska TM, Cruz AI, Ellis HB, Patel NM, Yen YM, Schmale GA, Mistovich RJ, Fabricant PD, Ganley TJ, Green DW, Johnson B, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes J, Sachleben B, Traver JL. Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group. Orthop J Sports Med 2022; 10:23259671221099572. [PMID: 35677019 PMCID: PMC9168882 DOI: 10.1177/23259671221099572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm–displaced fractures
of the tibial eminence and anterior cruciate ligament (ACL) insertion that
are traditionally managed nonoperatively with immobilization. Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and
therefore do not require advanced imaging or additional interventions aside
from immobilization. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 52 patients who were classified by their treating institution
with type 1 tibial spine fractures. Patients aged ≤18 years with
pretreatment plain radiographs and ≤ 1 year of follow-up were included.
Pretreatment imaging was reviewed by 4 authors to assess classification
agreement among the treating institutions. Patients were categorized into 2
groups to ensure that outcomes represented classic type 1 fracture patterns.
Any patient with universal agreement among the 4 authors that the fracture
did not appear consistent with a type 1 classification were assigned to the
type 1+ (T1+) group; all other patients were assigned to the true type 1
(TT1) group. We evaluated the rates of pretreatment imaging, concomitant
injuries, and need for operative interventions as well as treatment outcomes
overall and for each group independently. Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group,
while 8 were in the T1+ group, indicating less than universal agreement in
the classification of these fractures. Overall, 12 (25%) underwent surgical
treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required
additional surgical management including ACL reconstruction (n = 4), lateral
meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an
incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1). Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior
thought, a substantial number of patients with these fractures (>20%)
were found to have concomitant injuries. Overall, surgical management was
performed in 25% of patients in our cohort.
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Affiliation(s)
- Jilan L. Shimberg
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Tomasina M. Leska
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Aristides I. Cruz
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Henry B. Ellis
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Neeraj M. Patel
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Yi-Meng Yen
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Gregory A. Schmale
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Justin Mistovich
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Peter D. Fabricant
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Theodore J. Ganley
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Daniel W. Green
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Benjamin Johnson
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Indranil Kushare
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Jay Lee
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Scott D. McKay
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Todd A. Milbrandt
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jason Rhodes
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Brant Sachleben
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jessica L. Traver
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
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10
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Shimberg JL, Leska TM, Cruz AI, Patel NM, Ellis HB, Ganley TJ, Johnson B, Milbrandt TA, Yen YM, Mistovich RJ. A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures. J Pediatr Orthop 2022; 42:195-200. [PMID: 35067605 DOI: 10.1097/bpo.0000000000002049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Aristides I Cruz
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | - Ben Johnson
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | - R Justin Mistovich
- Case Western Reserve University
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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11
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Controversies in the management of anterior cruciate ligament injuries in skeletally immature patients. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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James EW, Dawkins BJ, Schachne JM, Ganley TJ, Kocher MS, Anderson CN, Busch MT, Chambers HG, Christino MA, Cordasco FA, Edmonds EW, Green DW, Heyworth BE, Lawrence JTR, Micheli LJ, Milewski MD, Matava MJ, Nepple JJ, Parikh SN, Pennock AT, Perkins CA, Saluan PM, Shea KG, Wall EJ, Willimon SC, Fabricant PD. Early Operative Versus Delayed Operative Versus Nonoperative Treatment of Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med 2021; 49:4008-4017. [PMID: 33720764 DOI: 10.1177/0363546521990817] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. PURPOSE/HYPOTHESIS The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non-English language manuscripts, multiligamentous injuries, and nonclinical studies. RESULTS A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P = .413) or proportion with difference ≥3 mm (P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. CONCLUSION Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.
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Affiliation(s)
- Evan W James
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Brody J Dawkins
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Jonathan M Schachne
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Theodore J Ganley
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Mininder S Kocher
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | -
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Christian N Anderson
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Michael T Busch
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Henry G Chambers
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Melissa A Christino
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Frank A Cordasco
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Eric W Edmonds
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Daniel W Green
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Benton E Heyworth
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - J Todd R Lawrence
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Lyle J Micheli
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Matthew D Milewski
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Matthew J Matava
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Jeffrey J Nepple
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Shital N Parikh
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Andrew T Pennock
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Crystal A Perkins
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Paul M Saluan
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Kevin G Shea
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Eric J Wall
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Samuel C Willimon
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
| | - Peter D Fabricant
- Investigation performed at Hospital for Special Surgery, New York, New York, USA
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13
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Liao W, Zhang Q. Arthroscopic Primary Repair for Partial Proximal Anterior Cruciate Ligament Tear in Military Personnel. Clin J Sport Med 2021; 31:e258-e264. [PMID: 32852304 DOI: 10.1097/jsm.0000000000000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/27/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the short-term clinical outcomes of arthroscopic primary repair for partial proximal anterior cruciate ligament (ACL) tear in a young, active duty military population. DESIGN Retrospective cohort study. SETTING A national tertiary-level medical and academic institution. PATIENTS Nineteen active duty military patients with partial proximal ACL tears and excellent tissue quality were included and 18 were finally analyzed. INTERVENTIONS All patients underwent arthroscopic primary repair using a suture anchor technique between March 2014 and June 2016. MAIN OUTCOME MEASURES Clinical outcomes were evaluated using anterior drawer test (ADT), Lachman test, pivot shift test, 3-km run test, 10 m × 5 shuttle run test, physical readiness test (PRT) score, Tegner activity score, Lysholm score, modified Cincinnati score, International Knee Documentation Committee (IKDC) subjective score, and magnetic resonance imaging. RESULTS At final follow-up, 17 patients had negative ADT, Lachman, and pivot shift examination findings, and 1 patient had a 1+ ADT, negative Lachman, and pivot shift result. Mean 3-km run time at final follow-up was not statistically different from that preinjury (12:55 vs 12:39, P = 0.071), nor were the 10 m × 5 shuttle run time (23.4 vs 22.9, P = 0.235), PRT score (82.5 vs 85.1, P = 0.086), and Tegner activity score (7.8 vs 7.9, P = 0.083). Mean Lysholm score at final follow-up was significantly improved compared with that preoperative (93.1 vs 70.7, P < 0.001), so were the modified Cincinnati score (90.4 vs 58.6, P < 0.001) and IKDC subjective score (88.3 vs 67.4, P < 0.001). CONCLUSIONS Arthroscopic primary repair can achieve short-term clinical success in high-demand military patients with partial proximal ACL tears and excellent tissue quality.
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Affiliation(s)
| | - Qiang Zhang
- Orthopedics, Chinese PLA General Hospital, Haidian District, Beijing, China
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14
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Gunaydin B, Kurtoglu Ozcaglayan TI, Cetin MU, Sari A, Dincel YM, Tekin C. Does anterolateral ligament injury change the treatment option in patients with partial ACL tears? Acta Orthop Belg 2021. [DOI: 10.52628/87.2.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with ACL tears with ALL injury have more clinical complaints (instability, feeling of the pop on the knee or knee sliding). patients have ALL injury with partial ACL tears, It is unclear whether the choice of treatment will be conservative or surgical.
This study aimed to determine the effect of anterolateral ligament (ALL) status, whether intact or ruptured, on the choice of conservative or surgical treatment in patients with partial anterior cruciate ligament (ACL) tears.
Between 2015 and 2019, patients with suspected partial ACL tears were identified on both physical examination and MR imaging. 122 patients who had partial ACL tears and also status of patient’s ALL could be evaluated by radiologist were included in the study, retrospectively.
Sixty-two patients who underwent ACL reconstruction were determined as group 1, and 60 patients who did not undergo ACL reconstruction were defined as group 2. In patients with partial ACL rupture with or without ACL reconstruction, it was evaluated whether a ruptured or non- ruptured ALL was effective in this decision of conservative or surgically.
The MRIs of patients with partial ACL tears were evaluated by a radiologist and it was concluded that the ALLs of 50 patients were ruptured, and 72 were intact. The ALLs of 36 patients in group 1 were ruptured, and 26 patients were intact. Fourteen patients in group 2 had ruptured ALLs, 46 patient’s ALLs were intact. Seventy-two percent of the patients with partial ACL tears who had ruptured ALLs in MRI underwent ACL reconstruction.
It was found that ACL reconstruction was performed more frequently in patients with partial ACL tears with ALL rupture. Therefore, we believe that preoperative evaluations of ALLs using MRI in patients with partial ACL tears are essential for surgical planning.
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16
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Allahabadi S, Feeley SE, Lansdown DA, Pandya NK, Feeley BT. Influential Articles on Pediatric and Adolescent Anterior Cruciate Ligament Injuries: A Bibliometric Analysis. Orthop J Sports Med 2021; 9:23259671211010772. [PMID: 34164558 PMCID: PMC8191091 DOI: 10.1177/23259671211010772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/09/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The understanding of pediatric anterior cruciate ligament (ACL) injuries and optimal treatment has evolved significantly. Influential articles have been previously evaluated using article citations to determine impact. PURPOSE To identify and characterize the 50 most cited and recent influential articles relating to pediatric and adolescent ACL injuries, to examine trends in publication characteristics, and to evaluate correlations of study citations with quality of evidence. STUDY DESIGN Cross-sectional study. METHODS The top 50 most cited articles on pediatric and adolescent ACL injuries were gathered using the Web of Science and Scopus online databases by averaging the number of citations from each database. Articles from recent years were also aggregated and sorted by citation density (citations/year). Publication and study characteristics were recorded. Level of evidence and methodologic quality were assessed where applicable using the modified Coleman Methodology Score (mCMS), modified Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Spearman correlation was used to evaluate the association between citation data and level of evidence or methodologic quality scorings. RESULTS The top 50 cited papers had a mean of 117.5 ± 58.8 citations (range, 58.5-288.5 citations), with a mean citation density of 9.4 ± 5.4 citations per year (range, 2.9-25.8 citations/year); 80% were published in 2000 or later, and 6% were considered basic science. Articles were mainly level 4 evidence (27/42; 64.3%), and none was level 1. There were moderate, significant associations between publication year and level of evidence (r S = -0.45; P = .0030) and citation density and publication year (r S = 0.59; P < .001). Mean methodologic quality scores were as follows: mCMS, 53 ± 7.2 (range, 39-68); modified Jadad scale, 3.2 ± 1.1 (range, 2-6); and MINORS, 11.2 ± 3.2 (range, 6-20). There was a significant, strong correlation between rank of mean citations and modified Jadad scale (r S = 0.76; P < .0001), suggesting poorer score associated with more mean citations. CONCLUSION Influential articles on pediatric and adolescent ACL injuries were relatively recent, with a low proportion of basic science-type articles. Most of the studies had a lower evidence level and poor methodologic quality scores. Higher methodologic quality did not correlate positively with citation data.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Sonali E. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Drew A. Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Nirav K. Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
| | - Brian T. Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco; San Francisco, California, USA
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17
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Longo UG, Salvatore G, Ruzzini L, Risi Ambrogioni L, de Girolamo L, Viganò M, Facchini F, Cella E, Candela V, Ciccozzi M, Denaro V. Trends of anterior cruciate ligament reconstruction in children and young adolescents in Italy show a constant increase in the last 15 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:1728-1733. [PMID: 32772142 DOI: 10.1007/s00167-020-06203-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this 15-year nationwide study was to investigate the trend in ACL reconstructive surgeries in patients younger than 15 years old in Italy, as well as their social and economic impact. MATERIALS AND METHODS The National Hospital Discharge records (SDO) collected by the Italian Ministry of Health in the 15-year period between 2001 and 2015 were analyzed. This contains anonymous data including patients' age, gender, ICD-9-CM codes for diagnosis and intervention, census region, region of hospitalization, length of the hospitalization, and public or private reimbursement. RESULTS 1,350 ACL reconstructions were performed in Italy in the population younger than 15 years old, with an incidence rate ranging from 0.16 to 2.04 procedures per 100,000 age-matched individuals. Similarly, the percentage of surgeries in 0-14 year old patients increased with respect to the total number of ACL reconstruction from 0.13% in 2001 to 0.95% in 2015. The age range 10-14 years is the most involved, accounting for 97.3% of surgeries recorded in the study period. The male:female ratio was 1.05 and most of these procedures were performed in the North of Italy (78.3%). CONCLUSION ACL reconstructions in patients aged 10-14 years are increasing constantly since 2001, and thus, specific actions aimed to define the best management strategy as well as national educational programs to prepare the future surgeons to this new reality are mandatory in the interest of the public health. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
| | - Giuseppe Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | | | - Laura Risi Ambrogioni
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Laura de Girolamo
- IRCCS Istituto Ortopedico Galeazzi, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Marco Viganò
- IRCCS Istituto Ortopedico Galeazzi, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Francesca Facchini
- IRCCS Istituto Ortopedico Galeazzi, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Eleonora Cella
- Medical Statistics and Molecular Epidemiology, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Massimo Ciccozzi
- Medical Statistics and Molecular Epidemiology, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
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18
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Batty LM, Firth A, Moatshe G, Bryant DM, Heard M, McCormack RG, Rezansoff A, Peterson DC, Bardana D, MacDonald PB, Verdonk PCM, Spalding T, Getgood AMJ, Willits K, Birmingham T, Hewison C, Wanlin S, Firth A, Pinto R, Martindale A, O'Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Pritchett R, Payne K, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Millan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declercq G, Vuylsteke K, Van Haver M. Association of Ligamentous Laxity, Male Sex, Chronicity, Meniscal Injury, and Posterior Tibial Slope With a High-Grade Preoperative Pivot Shift: A Post Hoc Analysis of the STABILITY Study. Orthop J Sports Med 2021; 9:23259671211000038. [PMID: 33889648 PMCID: PMC8033400 DOI: 10.1177/23259671211000038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: A spectrum of anterolateral rotatory laxity exists in anterior cruciate
ligament (ACL)–injured knees. Understanding of the factors contributing to a
high-grade pivot shift continues to be refined. Purpose: To investigate factors associated with a high-grade preoperative pivot shift
and to evaluate the relationship between this condition and baseline
patient-reported outcome measures (PROMs). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A post hoc analysis was performed of 618 patients with ACL deficiency deemed
high risk for reinjury. A binary logistic regression model was developed,
with high-grade pivot shift as the dependent variable. Age, sex, Beighton
score, chronicity of the ACL injury, posterior third medial or lateral
meniscal injury, and tibial slope were selected as independent variables.
The importance of knee hyperextension as a component of the Beighton score
was assessed using receiver operator characteristic curves. Baseline PROMs
were compared between patients with and without a high-grade pivot. Results: Six factors were associated with a high-grade pivot shift: Beighton score
(each additional point; odds ratio [OR], 1.17; 95% CI, 1.06-1.30;
P = .002), male sex (OR, 2.30; 95% CI, 1.28-4.13;
P = .005), presence of a posterior third medial (OR,
2.55; 95% CI, 1.11-5.84; P = .03) or lateral (OR, 1.76; 95%
CI, 1.01-3.08; P = .048) meniscal injury, tibial slope
>9° (OR, 2.35; 95% CI, 1.09-5.07; P = .03), and
chronicity >6 months (OR, 1.70; 95% CI, 1.00-2.88; P =
.049). The presence of knee hyperextension improved the diagnostic utility
of the Beighton score as a predictor of a high-grade pivot shift. Tibial
slope <9° was associated with only a high-grade pivot in the presence of
a posterior third medial meniscal injury. Patients with a high-grade pivot
shift had higher baseline 4-Item Pain Intensity Measure scores than did
those without a high-grade pivot shift (mean ± SD, 11 ± 13 vs 8 ± 14;
P = .04); however, there was no difference between
groups in baseline International Knee Documentation Committee, ACL Quality
of Life, Knee injury and Osteoarthritis Outcome Score, or Knee injury and
Osteoarthritis Outcome Score subscale scores. Conclusion: Ligamentous laxity, male sex, posterior third medial or lateral meniscal
injury, increased posterior tibial slope, and chronicity were associated
with a high-grade pivot shift in this population deemed high risk for repeat
ACL injury. The effect of tibial slope may be accentuated by the presence of
meniscal injury, supporting the need for meniscal preservation. Baseline
PROMs were similar between patients with and without a high-grade pivot
shift.
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Affiliation(s)
- Lachlan M Batty
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Firth
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Gilbert Moatshe
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mark Heard
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert G McCormack
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alex Rezansoff
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Devin C Peterson
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Davide Bardana
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter B MacDonald
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter C M Verdonk
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alan M J Getgood
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | | | - Kevin Willits
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Trevor Birmingham
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Chris Hewison
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Stacey Wanlin
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Firth
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Pinto
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ashley Martindale
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Lindsey O'Neill
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Morgan Jennings
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michal Daniluk
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dory Boyer
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mauri Zomar
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karyn Moon
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Raely Pritchett
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Krystan Payne
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Brenda Fan
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Bindu Mohan
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Gregory M Buchko
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laurie A Hiemstra
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Kerslake
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jeremy Tynedal
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Greg Stranges
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sheila Mcrae
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - LeeAnne Gullett
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Holly Brown
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Legary
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Longo
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mat Christian
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Celeste Ferguson
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nick Mohtadi
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Rhamona Barber
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Denise Chan
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Caitlin Campbell
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Garven
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karen Pulsifer
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michelle Mayer
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nicole Simunovic
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Duong
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Robinson
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Levy
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Matt Skelly
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Fiona Howells
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Murray Tough
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Pete Thompson
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Metcalfe
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laura Asplin
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alisen Dube
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Louise Clarkson
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jaclyn Brown
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Bolsover
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Carolyn Bradshaw
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Larissa Belgrove
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Francis Millan
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sylvia Turner
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Verdugo
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Janet Lowe
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Debra Dunne
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kerri McGowan
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Charlie-Marie Suddens
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Geert Declercq
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kristien Vuylsteke
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mieke Van Haver
- Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Nhan DT, Belkoff SM, Singh P, Sullivan BT, Klyce W, Lee RJ. Using the Remnant Anterior Cruciate Ligament to Improve Knee Stability: Biomechanical Analysis Using a Cadaveric Model. Orthop J Sports Med 2021; 9:2325967121996487. [PMID: 33889647 PMCID: PMC8033398 DOI: 10.1177/2325967121996487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/14/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Injured anterior cruciate ligament (ACL) tissue retains proprioceptive nerve
fibers, vascularity, and biomechanical properties. For these reasons,
remnant ACL tissue is often preserved during the treatment of ACL
injuries. Purpose: To assess through a cadaveric model whether reorienting and retensioning the
residual ACL via an osteotomy improves knee stability after partial ACL
tear, with substantial remnant tissue and intact femoral and tibial
attachments. Study Design: Controlled laboratory study. Methods: In 8 adult cadaveric knees, we measured anterior tibial translation and
rotational laxity at 30° and 90° of flexion with the ACL in its native state
and in 3 conditions: partial tear, retensioned, and ACL-deficient. The
partial-tear state consisted of a sectioned anteromedial ACL bundle. Results: In the native state, the translation was 10 ± 2.7 mm (mean ± SD) at 30° of
flexion and 8.4 ± 3.6 mm at 90° of flexion. Anterior translation of the
knees in the partial-tear state (14 ± 2.7 mm at 30° and 12 ± 2.7 mm at 90°)
was significantly greater than baseline (P < .001 for
both). Translation in the ACL-retensioned state (9.2 ± 1.7 mm at 30° and 7.2
± 2.1 mm at 90°) was significantly less than in the ACL-deficient state
(P < .001 for both), and translation was not
significantly different from that of the intact state. For ACL-deficient
knees, translation (20 ± 4.3 mm at 30° and 16 ± 4.4 mm at 90°) was
significantly greater than all other states (P < .001
for all). Although rotational testing demonstrated the least laxity at 30°
and 90° of flexion in the retensioned and intact states and the most laxity
in the ACL-deficient state, rotation was not significantly different among
any of the experimental states. Conclusion: In a cadaveric model of an incomplete ACL tear, a reorienting and
retensioning core osteotomy at the tibial insertion of the remnant ACL
improved anteroposterior translation of the knee without compromising its
rotational laxity. Clinical Relevance: The findings of this study support the concept of ACL tissue reorienting and
retensioning in the treatment of ACL laxity as an area for future
investigation.
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Affiliation(s)
- Derek T Nhan
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephen M Belkoff
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Prerna Singh
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian T Sullivan
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Walter Klyce
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Jay Lee
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Management of Partial Tears of the Anterior Cruciate Ligament: A Review of the Anatomy, Diagnosis, and Treatment. J Am Acad Orthop Surg 2021; 29:60-70. [PMID: 33394613 DOI: 10.5435/jaaos-d-20-00242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Partial anterior cruciate ligament (ACL) tears comprise an estimated 10% to 27% of isolated ACL injuries. Partial ACL tears may be challenging to clinically diagnose. We reviewed relevant studies focusing on the anatomy, diagnosis, imaging, and treatment of a partial injury with the goal of providing guidance to clinicians. Although a comprehensive patient history, thorough clinical examination, and imaging studies are helpful in arriving at a diagnosis, the benchmark for diagnosis remains visualization and examination of the ACL at the time of knee arthroscopy. Currently, limited data exist about the long-term outcomes of nonsurgical treatment. Some studies demonstrate that younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment. The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL. Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction. Selective bundle reconstruction has limited data available but is an option. The best evidence supports traditional ACL reconstruction for the surgical management of patients with documented nonfunctional partial tears of the ACL.
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21
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Shimberg JL, Aoyama JT, Leska TM, Ganley TJ, Fabricant PD, Patel NM, Cruz AI, Ellis HB, Schmale GA, Green DW, Jagodzinski JE, Kushare I, Lee RJ, McKay S, Rhodes J, Sachleben B, Sargent C, Yen YM, Mistovich RJ. Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study. Am J Sports Med 2020; 48:3208-3213. [PMID: 32970957 DOI: 10.1177/0363546520957666] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). PURPOSE To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. STUDY DESIGN Cross-sectional study; level of evidence, 3. METHODS We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. RESULTS There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P < .001). There was a higher rate of lateral meniscal tears (P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. CONCLUSION Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.
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Affiliation(s)
- Jilan L Shimberg
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Julien T Aoyama
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Tomasina M Leska
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Theodore J Ganley
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Peter D Fabricant
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Neeraj M Patel
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Aristides I Cruz
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Henry B Ellis
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Gregory A Schmale
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | -
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel W Green
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Jason E Jagodzinski
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Indranil Kushare
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - R Jay Lee
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Scott McKay
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Jason Rhodes
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Brant Sachleben
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Catherine Sargent
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Yi-Meng Yen
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - R Justin Mistovich
- Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Is Primary Arthroscopic Repair Using the Pulley Technique an Effective Treatment for Partial Proximal ACL Tears? Clin Orthop Relat Res 2020; 478:1031-1045. [PMID: 31876551 PMCID: PMC7170704 DOI: 10.1097/corr.0000000000001118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Attention has recently been paid to primary arthroscopic repair to treat ACL tears because of the disadvantages associated with reconstruction. However, there remain many unanswered questions and concerns about its application in the treatment of ACL tears. QUESTIONS/PURPOSES (1) Does primary arthroscopic repair using the pulley technique result in satisfactory ROM (a functional ROM with a flexion contracture of 30° or less), knee stability, and functional scores in patients with partial proximal ACL tears? (2) What complications are associated with primary arthroscopic repair using the pulley technique in patients with partial proximal ACL tears? METHODS Between January 2014 and March 2016, we treated 23 patients surgically who had partial proximal ACL tears and excellent tissue quality (defined as a remnant with mild interstitial tearing and the ability to hold sutures). All patients meeting those two criteria were treated using primary arthroscopic repair using the pulley technique. During that period, this represented 13% (23 of 183) of the patients we treated surgically for an ACL tear. Patients were excluded if they had other ACL tear types, insufficient tissue quality (defined as a severely torn remnant that was not strong enough to hold sutures), multi-ligamentous injuries, or substantial arthrosis (chondromalacia greater than Outerbridge grade 3, most of which underwent conversion to ACL reconstruction). Clinical outcomes were assessed using ROM, the anterior drawer test, the Lachman test, Lysholm score, Tegner activity score, IKDC subjective score, and radiographs. Twenty-one patients were observed for a mean (range) period of 36 months (25-49), and two were lost to follow-up. RESULTS At the most-recent follow-up examination, all patients achieved full extension and only one patient lacked full flexion, with a flexion contracture of 10°. Twenty patients had no instability on the anterior drawer test and Lachman test findings, and one patient had a 1 + anterior drawer test. The mean Lysholm score improved from a mean ± SD of 71 ± 9 before surgery to 94 ± 6 (mean difference 23 points [95% CI 20 to 25]; p < 0.001) at latest follow-up. The IKDC subjective score improved from 64 ± 10 to 86 ± 11 points (mean difference 22 points; p < 0.001). We found no difference in the Tegner score from before surgery to latest follow-up (6.3 ± 1.2 versus 6.1 ± 1.2; mean difference 0.2; p = 0.056). One patient re-ruptured his ACL 2 months after surgery in military training during an obstacle race. No complications such as infection, thrombosis, stiffness, patellofemoral pain, or implant failure were observed. CONCLUSIONS Primary arthroscopic repair using the pulley technique can achieve short-term clinical success in a carefully selected (the selection process includes first identifying the ACL injury pattern preoperatively with MRI, then confirming the diagnosis under arthroscopy, and deciding whether to perform a repair intraoperatively) subset of patients with partial proximal ACL tears and excellent tissue quality (defined as a remnant with mild interstitial tearing and the ability to hold sutures). Despite the promising clinical outcomes of our study, this technique should not be widely adopted unless it has been compared directly with ACL reconstruction, so future studies should be conducted to compare the clinical outcomes between this technique and ACL reconstruction, and longer-term follow-up is necessary to identify whether there is deterioration in the clinical outcomes over time. LEVEL OF EVIDENCE Level IV, therapeutic study.
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23
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Cone SG, Lambeth EP, Piedrahita JA, Spang JT, Fisher MB. Joint laxity varies in response to partial and complete anterior cruciate ligament injuries throughout skeletal growth. J Biomech 2020; 101:109636. [PMID: 32005549 DOI: 10.1016/j.jbiomech.2020.109636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/01/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are increasingly common in the skeletally immature population. As such there is a need to increase our understanding of the biomechanical function of the joint following partial and complete ACL injury during skeletal growth. In this work, we aimed to assess changes in knee kinematics and loading of the remaining soft tissues following both partial and complete ACL injury in a porcine model. To do so, we applied anterior-posterior tibial loads and varus-valgus moments to stifle joints of female pigs ranging from early juvenile to late adolescent ages and assessed both kinematics and in-situ loads carried in the bundles of the ACL and other soft tissues including the collateral ligaments and the menisci. Partial ACL injury led to increased anterior tibial translation only in late adolescence and small increases in varus-valgus rotation at all ages. Complete ACL injury led to substantial increases in translation and rotation at all ages. At all ages, the medial collateral ligament and the medial meniscus combined to resist the majority of applied anterior tibial load following complete ACL transection. Across all ages and flexion angles, the contribution of the MCL ranged from 45 to 90% of the anterior load and the contribution of the medial meniscus ranged from 14 to 35% of the anterior load. These findings add to our current understanding of age-specific functional properties of both healthy and injured knees during skeletal growth.
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Affiliation(s)
- Stephanie G Cone
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina - Chapel Hill, Raleigh, NC 27695, United States; Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, United States
| | - Emily P Lambeth
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina - Chapel Hill, Raleigh, NC 27695, United States
| | - Jorge A Piedrahita
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, United States
| | - Jeffrey T Spang
- Department of Orthopaedics, University of North Carolina - Chapel Hill, Chapel Hill, NC 27599, United States
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina - Chapel Hill, Raleigh, NC 27695, United States; Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695, United States; Department of Orthopaedics, University of North Carolina - Chapel Hill, Chapel Hill, NC 27599, United States.
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24
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Abstract
With increasing pediatric participation in organized sport and the early specialization of children in single sports, the number of injuries seen in the pediatric and adolescent athletic population continues to increase. Children experience acute traumatic injuries during practice and competition as well as chronic overuse injuries secondary to the repetitive stress on their developing bodies. The unique nature of the pediatric patient often requires a different diagnostic, prognostic, and treatment approach to sports injuries compared with their adult counterparts.
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25
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Cone SG, Piedrahita JA, Spang JT, Fisher MB. In Situ Joint Stiffness Increases During Skeletal Growth but Decreases Following Partial and Complete Anterior Cruciate Ligament Injury. J Biomech Eng 2019; 141:121001. [PMID: 31513698 PMCID: PMC7105148 DOI: 10.1115/1.4044582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/24/2019] [Indexed: 02/01/2023]
Abstract
Partial and complete anterior cruciate ligament (ACL) injuries occur in both pediatric and adult populations and can result in loss of joint stability and function. The sigmoidal shape of knee joint function (load-translation curve) under applied loads includes a low-load region (described by slack length) followed by a high-load region (described by stiffness). However, the impact of age and injury on these parameters is not fully understood. The current objective was to measure the effects of age and injury on the shape of joint function in a porcine model. In response to an applied anterior-posterior tibial load, in situ slack did not change (p > 0.05), despite sevenfold increases in joint size with increasing age. Joint stiffness increased from an average of 10 N/mm in early youth to 47 N/mm in late adolescence (p < 0.05). In situ ACL stiffness increased similarly, and changes in in situ joint stiffness and ACL stiffness were highly correlated across ages. With complete ACL injury, in situ slack length increased by twofold to fourfold and in situ stiffness decreased threefold to fourfold across ages (p < 0.05). Partial ACL injury resulted in less dramatic, but statistically significant, increases in joint slack and significant decreases in in situ joint stiffness in the adolescent age groups (p < 0.05). This work furthers our understanding of the interaction between joint biomechanics and ACL function throughout growth and the impact of ACL injury in the skeletally immature joint.
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Affiliation(s)
- Stephanie G. Cone
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina—Chapel Hill, Raleigh, NC 27695
| | - Jorge A. Piedrahita
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC 27695
| | - Jeffrey T. Spang
- Department of Orthopaedics, University of North Carolina—Chapel Hill, Chapel Hill, NC 27514
| | - Matthew B. Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina—Chapel Hill, 4130 Engineering Building III, 911 Oval Drive, CB 7115, Raleigh, NC 27695; Department of Orthopaedics, University of North Carolina—Chapel Hill, Chapel Hill, NC 27514
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26
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Mayo MH, Mitchell JJ, Axibal DP, Chahla J, Palmer C, Vidal AF, Rhodes JT. Anterior Cruciate Ligament Injury at the Time of Anterior Tibial Spine Fracture in Young Patients: An Observational Cohort Study. J Pediatr Orthop 2019; 39:e668-e673. [PMID: 31503222 DOI: 10.1097/bpo.0000000000001011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior tibial spine fractures (ATSF) in the skeletally immature parallel anterior cruciate ligament (ACL) tears in adult patients, yet these injuries are generally regarded as mutually exclusive. Biomechanical analysis suggests that intrinsic ACL damage occurs during ATSF, and long-term clinical studies demonstrate residual anteroposterior knee laxity following ATSF. We aim to describe prevalence, demographics, and characteristics of pediatric patients who sustained ATSF with concomitant ACL injury. METHODS We included 129 patients with ATSF over a 16-year period. Age, sex, injury mechanism, ATSF type, magnetic resonance imaging (MRI) evaluation, treatment modality, ACL injury, and concomitant meniscal/chondral injuries were analyzed. Concurrent ACL injury was confirmed either from MRI or intraoperatively. RESULTS Nineteen percent (n=25) of ATSF patients had concomitant ACL injury, with ACL injury significantly more likely in type II or type III ATSF compared with type I ATSF (P=0.03). Patients with combined ATSF/ACL injury were significantly older (P=0.02) and more likely to be male (P=0.01). Mechanism of ATSF injury was not associated with ACL injury (P=0.83). Preoperative MRI had low sensitivity (0.09) for recognizing ACL injury at the time of ATSF relative to intraoperative assessment. Half of ATSF/ACL-injured patients had additional meniscal or chondral injury, with meniscal repair or debridement required in 37.5% of the type II ATSF/ACL injury. CONCLUSIONS There are demographic characteristics, such as age (older) and sex (male), associated with a higher risk of concomitant ACL injury at the time of ATSF. Type II and type III ATSF patterns had a higher prevalence of ACL injury. MRI failed to correctly identify ACL injury at the time of ATSF. Concomitant ACL injury at the time of ATSF is highly prevalent in the skeletally immature, occurring in 19.4% of patients with ATSF. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Meredith H Mayo
- Department of Orthopaedic Surgery, University of Colorado Hospital
| | - Justin J Mitchell
- Department of Orthopaedic Surgery, University of Colorado Hospital
- The Steadman Philippon Research Institute, Vail, CO
| | - Derek P Axibal
- Department of Orthopaedic Surgery, University of Colorado Hospital
| | - Jorge Chahla
- The Steadman Philippon Research Institute, Vail, CO
| | - Claire Palmer
- Department of Orthopaedic Surgery, University of Colorado Hospital
- Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora
| | - Armando F Vidal
- Department of Orthopaedic Surgery, University of Colorado Hospital
| | - Jason T Rhodes
- Department of Orthopaedic Surgery, University of Colorado Hospital
- Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora
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27
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Fayard JM, Sonnery-Cottet B, Vrgoc G, O'Loughlin P, de Mont Marin GD, Freychet B, Vieira TD, Thaunat M. Incidence and Risk Factors for a Partial Anterior Cruciate Ligament Tear Progressing to a Complete Tear After Nonoperative Treatment in Patients Younger Than 30 Years. Orthop J Sports Med 2019; 7:2325967119856624. [PMID: 31360732 PMCID: PMC6636223 DOI: 10.1177/2325967119856624] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Partial anterior cruciate ligament (ACL) tears are observed in 10% to 27% of isolated ACL tears. There is currently no consensus on diagnosis and treatment protocols, and the outcomes of nonoperative treatment remain undefined. Purpose: To assess the incidence and risk factors for the progression of partial ACL tears to complete ruptures after nonoperative treatment in active patients younger than 30 years. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 41 patients, all younger than 30 years and active in sports, were diagnosed with a partial ACL tear, with no associated meniscal or chondral lesions on magnetic resonance imaging (MRI). All were assigned to a nonoperative treatment program. The Lachman test, ≤4-mm side-to-side difference in laxity by Rolimeter, and MRI were utilized for the diagnosis. Tegner and International Knee Documentation Committee (IKDC) scores were assessed before and after the first lesion, and the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) score was assessed at last follow-up. Postinjury Tegner and IKDC scores were assessed before the second injury for patients progressing to a complete ACL tear and at last follow-up for patients without progression. Results: At a mean of 43 months (range, 24-96 months), the partial ACL injury progressed to a complete ACL tear in 16 (39%) patients. In the remaining 25 patients without progression, the mean Tegner and IKDC scores were 7.0 and 96.0 before the injury and 5.9 and 85.7, respectively, at last follow-up. The mean ACL-RSI score was 69.3. The Tegner and IKDC scores were significantly lower at final follow-up (P = .0002 and P < .0001, respectively). Only 18 (44%) patients returned to their preinjury level of sports activities. A significantly increased risk of progression to a complete ACL tear was seen in patients ≤20 years (odds ratio, 5.19; P = .037) or patients practicing pivoting contact sports (odds ratio, 6.29; P = .026). Meniscal lesions were found in 50% of patients with a partial tear that progressed to a complete ACL tear. Conclusion: A partial ACL injury progressed to a complete ACL tear in 39% of young active patients treated conservatively, with half of the complete tears presenting with a concomitant meniscal lesion at the time of reconstruction. Age ≤20 years and participation in pivoting contact sports were identified as significant risk factors for progression to a complete tear.
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Affiliation(s)
- Jean-Marie Fayard
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Goran Vrgoc
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.,Department of Orthopaedic Surgery, University Hospital "Sveti Duh," Zagreb, Croatia
| | - Padhraig O'Loughlin
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.,Mater Private Hospital, Cork, Ireland
| | - Geoffroy Dubois de Mont Marin
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France.,Hôpital Trousseau, CHRU de Tours, Chambray-lès-Tours, France
| | - Benjamin Freychet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais D Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Mathieu Thaunat
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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A new method for diagnosis of anterior cruciate ligament tear: MRI with maximum flexion of knee in the prone position: A case control study. Int J Surg 2019; 68:142-147. [PMID: 31276834 DOI: 10.1016/j.ijsu.2019.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/13/2019] [Accepted: 06/24/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis of anterior cruciate ligament tear can be made by physical examination and magnetic resonance imaging (MRI) in the supine position. In cases where the tear is partially evaluated on MRI, the choice of treatment may vary. The purpose of the study was to investigate the efficiency of MRI at maximum knee flexion in the prone position and to compare the images with findings of the ACL detected during surgery. MATERIALS AND METHODS Sixty-one patients with partial ACL tears with meniscal and cartilage lesions requiring arthroscopic knee surgery were included in the study between 2017 and 2019. MRI of these patients was prescribed at maximum knee flexion in the prone position. Then, an arthroscopic operation was performed on 61 patients and the findings (intact, partial or total tear of ACL) were recorded. The ACL was evaluated as being intact and partial or total tear. The statistical significance of the efficacy of MRI in the supine position with the knee at maximum flexion in the prone position was compared. RESULTS It was found that, of 61 patients with suspected partial ACL tears, 25 patients had intact ACLs, 22 patients had partial tears and 14 patients had total ACL tears, through the interpretation of MRIs of the prone position by the radiologist. In the arthroscopic surgery of 61 patients, 20 patients had intact ACLs, 27 patients had a partial tear and 14 patients had a total tear. The MRI results with maximum knee flexion in the prone position were more compatible with the findings of the arthroscopic surgery. CONCLUSIONS It could be considered that MRI with maximum knee flexion in the prone position may also be guiding in the diagnosis and treatment of patients with partial anterior cruciate ligament rupture.
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Abstract
BACKGROUND Previous studies have suggested that anterior cruciate ligament (ACL) reconstruction surgeries are being performed with increased frequency in children and adolescents. The purpose of this study was to evaluate the trend in the frequency of ACL reconstructions normalized by total orthopaedic surgeries at pediatric hospitals nationwide. METHODS The Pediatric Health Information System (PHIS) database was queried for patients age 18 years or younger who underwent orthopaedic surgery at any of the PHIS-participating hospitals 2004-2014. The subset of patients who had been treated with ACL reconstruction were identified using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) procedure codes. The yearly rate was expressed as the number of ACL reconstructions per 1000 orthopaedic surgeries, and a linear model was used to fit the data to illustrate the relative trend. RESULTS In total, 470,126 orthopaedic surgeries, including 15,231 ACL reconstructions, were performed for patients 18 years or younger at 27 pediatric hospitals. ACL reconstructions were performed at a yearly rate of 32.4 per 1000 orthopaedic surgeries. Between 2004 and 2014, the number of ACL reconstructions increased 5.7-fold, whereas orthopaedic surgeries increased 1.7-fold; there was a 2.8-fold increase in ACL reconstructions relative to total pediatric orthopaedic surgeries. The 10-year relative fold increase was nearly equivalent across sexes, and the increasing trend in ACL reconstructions relative to orthopaedic surgeries was also seen across age groups. CONCLUSIONS The number of ACL reconstructions performed for children and adolescents in pediatric hospitals nationwide markedly increased by nearly 3 times relative to orthopaedic surgeries over a recent 10-year period. LEVEL OF EVIDENCE Level IV.
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Kocher MS, Heyworth BE, Fabricant PD, Tepolt FA, Micheli LJ. Outcomes of Physeal-Sparing ACL Reconstruction with Iliotibial Band Autograft in Skeletally Immature Prepubescent Children. J Bone Joint Surg Am 2018; 100:1087-1094. [PMID: 29975275 DOI: 10.2106/jbjs.17.01327] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are occurring in youth athletes with increasing frequency. Many ACL reconstruction procedures designed to allow for continued growth in patients with open physes have been described, but large series with mid- to long-term outcomes data are lacking. The purpose of the current study was to assess the clinical outcomes of a large cohort of prepubescent children who underwent a physeal-sparing, combined intra- and extra-articular ACL reconstruction with iliotibial (IT) band autograft over a 23-year period. METHODS Included in our analysis were 237 patients (240 knees) who underwent ACL reconstruction using IT band autograft at Tanner stage 1 or 2 (mean age of 11.2 ± 1.7 years). Physical examination data were analyzed for 225 of the 240 knees (mean follow-up, 25.8 months), and 137 (57%) of the knees had corresponding patient-reported clinical outcomes (patient-reported graft rupture and Pediatric International Knee Documentation Committee [Pedi-IKDC], Tegner activity scale, and Lysholm scores; mean follow-up, 6.2 years). Rates of growth arrest, IT band graft-harvest morbidity, and return to sports were analyzed. RESULTS Physical examination revealed that 96.8% of the knees were grade A on the Lachman test and 98.8% were grade A on the pivot-shift test. Graft rupture occurred in 9 (6.6%) of 137 knees, at an average of 33.5 months (range, 8.2 months to 8.0 years) postoperatively. For patients who did not sustain a graft rupture, the mean Pedi-IKDC score was 93.3 ± 11.0, the mean Lysholm score was 93.4 ± 9.9, and the mean score on the Tegner activity scale was 7.8 (mode, 7). While lateral thigh asymmetry at the IT band harvest site was noted by 48% of the subjects, only 1.6% reported associated pain. No cases of limb-length discrepancy or angular deformity were observed. CONCLUSIONS This procedure was associated with excellent functional outcomes, minimal risk of growth disturbance, and a low graft-rupture rate in skeletally immature prepubescent children. These results appear durable at mid- to long-term follow-up, at an average of >6 years postoperatively. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Barton KI, Heard BJ, Sevick JL, Martin CR, Shekarforoush SMM, Chung M, Achari Y, Frank CB, Shrive NG, Hart DA. Posttraumatic Osteoarthritis Development and Progression in an Ovine Model of Partial Anterior Cruciate Ligament Transection and Effect of Repeated Intra-articular Methylprednisolone Acetate Injections on Early Disease. Am J Sports Med 2018; 46:1596-1605. [PMID: 29668309 DOI: 10.1177/0363546518765098] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Partial anterior cruciate ligament (p-ACL) ruptures are a common injury of athletes. However, few preclinical models have investigated the natural history and treatment of p-ACL injuries. PURPOSE To (1) demonstrate whether a controlled p-ACL injury model (anteromedial band transection) develops progressive gross morphological and histological posttraumatic osteoarthritis (PTOA)-like changes at 20 and 40 weeks after the injury and (2) investigate the efficacy of repeated (0, 5, 10, and 15 weeks) intra-articular injections of methylprednisolone acetate (MPA; 80 mg/mL) in the mitigation of potential PTOA-like changes after p-ACL transection. STUDY DESIGN Controlled laboratory study. METHODS Twenty-one 3- to 5-year-old female Suffolk-cross sheep were allocated to 4 groups: (1) nonoperative controls (n = 5), (2) 20 weeks after p-ACL transection (n = 5), (3) 40 weeks after p-ACL transection (n = 6), and (4) 20 weeks after p-ACL transection + MPA (n = 5). Gross morphological grading and histological analyses were conducted. mRNA expression levels for inflammatory, degradative, and structural molecules were assessed. RESULTS p-ACL transection led to significantly more combined gross damage ( P = .008) and significant aggregate histological damage ( P = .009) at 40 weeks after p-ACL transection than the nonoperative controls, and damage was progressive over time. Macroscopically, MPA appeared to slightly mitigate gross damage at 20 weeks after p-ACL transection in some animals. However, microscopic analysis revealed that repeated MPA injections after p-ACL transection led to significant loss in proteoglycan content compared with the nonoperative controls and 20 weeks after p-ACL transection ( P = .008 and P = .008, respectively). CONCLUSION p-ACL transection led to significant gross and histological damage by 40 weeks, which was progressive over time. Multiple repeated MPA injections were not appropriate to mitigate injury-related damage in a p-ACL transection ovine model as significant proteoglycan loss was observed in MPA-treated knees. CLINICAL RELEVANCE A p-ACL injury leads to slow and progressive PTOA-like joint damage, and multiple repeated injections of glucocorticoids may be detrimental to the knee joint in the long term.
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Affiliation(s)
- Kristen I Barton
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bryan J Heard
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Johnathan L Sevick
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - C Ryan Martin
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Section of Orthopaedic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S M Mehdi Shekarforoush
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - May Chung
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yamini Achari
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Nigel G Shrive
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - David A Hart
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Challenges in the Management of Anterior Cruciate Ligament Ruptures in Skeletally Immature Patients. J Am Acad Orthop Surg 2018; 26:e50-e61. [PMID: 29239869 DOI: 10.5435/jaaos-d-17-00294] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Although initially considered rare, anterior cruciate ligament (ACL) ruptures in pediatric patients recently have increased substantially as a result of greater awareness of the injury and increased participation in youth sports. Although pediatric patients with an ACL injury and a clinically stable joint may handle the injury well and return to sports activity without requiring surgical reconstruction, young, active patients with an ACL rupture and an unstable joint may be good candidates for ACL reconstruction to prevent ongoing instability and additional joint damage. ACL reconstruction techniques have been developed to prevent physeal injury in skeletally immature patients. The surgical treatment of skeletally immature patients with an ACL rupture may differ from that of adults with an ACL rupture and presents unique challenges with regard to reconstruction technique selection, graft preparation, rehabilitation, and return to sports activity. Orthopaedic surgeons should understand various physeal-sparing ACL reconstruction techniques and the general challenges associated with the surgical management of ACL ruptures in pediatric patients.
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Yellin JL, Fabricant PD, Gornitzky A, Greenberg EM, Conrad S, Dyke JA, Ganley TJ. Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review. JBJS Rev 2018; 4:01874474-201601000-00004. [PMID: 27490007 DOI: 10.2106/jbjs.rvw.o.00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. METHODS Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. RESULTS Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. CONCLUSION We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.
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Affiliation(s)
- Joseph L Yellin
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Richard D. Wood Ambulatory Care Building, Second Floor, Philadelphia, PA 19104
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Lang PJ, Sugimoto D, Micheli LJ. Prevention, treatment, and rehabilitation of anterior cruciate ligament injuries in children. Open Access J Sports Med 2017; 8:133-141. [PMID: 28652828 PMCID: PMC5476725 DOI: 10.2147/oajsm.s133940] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
As more children and adolescents participate in competitive organized sports, there has been an increase in the reported incidence of anterior cruciate ligament (ACL) injuries in these age groups. ACL injuries in skeletally immature athletes present a challenge, as reconstruction must preserve the physis of the distal femur and of the proximal tibia to avoid growth disturbances. Historically, a skeletally immature athlete with an ACL injury was treated with a brace and activity modification until skeletal maturity, with ACL reconstruction being performed at that time in the “non-copers” who experienced instability. More recently, evidence has shown that delayed reconstruction may lead to increased damage to the meniscus and articular cartilage. As a result, early reconstruction is favored to protect the meniscus and allow continued physical activity. While adolescents at or those near skeletal maturity may be treated with standard reconstruction techniques, they may result in growth disturbances in younger athletes with significant growth remaining. In response to the growing need for ACL reconstruction techniques in skeletally immature individuals, physeal-sparing and physeal-respecting reconstruction techniques have been developed. In addition to the advancements in surgical technique, ACL injury prevention has also gained attention. This growing interest in ACL prevention is in part related to the high risk of ACL re-tear, either of the ACL graft or of the contralateral ACL, in children and adolescents. Recent reports indicate that well-designed neuromuscular training programs may reduce the risk of primary and subsequent ACL injuries.
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Affiliation(s)
- Pamela J Lang
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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Abstract
BACKGROUND All-epiphyseal anterior cruciate ligament (ACL) reconstruction is a well-described technique for skeletally immature patients. The purpose of this study was to elucidate the early complication rate and identify associated risk factors for rerupture after this procedure in children. METHODS We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children's hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg-length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with rerupture included age, body mass index, graft type, graft size, and associated injuries addressed at surgery. RESULTS A total of 103 patients (average 12.1 y old; range, 6.3 to 15.7) were analyzed. The mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 reruptures (10.7%), 1 case (<1.0%) of clinical leg-length discrepancy of <1 cm, and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained subsequent ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, body mass index, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on an average between the 6 weeks and 6 months postoperative visits (P<0.001; paired samples Student's t test). CONCLUSIONS When taken in the context of known risk of future injury in an ACL-deficient knee, all-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The rerupture rate in this cohort is slightly higher compared with ACL reconstruction in older patients. LEVEL OF EVIDENCE Level IV-retrospective case series.
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Bates NA, Schilaty ND, Nagelli CV, Krych AJ, Hewett TE. Novel mechanical impact simulator designed to generate clinically relevant anterior cruciate ligament ruptures. Clin Biomech (Bristol, Avon) 2017; 44:36-44. [PMID: 28319734 PMCID: PMC5425932 DOI: 10.1016/j.clinbiomech.2017.03.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/09/2017] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over 250,000 anterior cruciate ligament ruptures occur each year; therefore, it is important to understand the underlying mechanisms of these injuries. The objective of the current investigation was to develop and analyze an impact test device that consistently produces anterior cruciate ligament failure in a clinically relevant manner. METHOD A mechanical impact simulator was developed to simulate the ground reaction force impulse generated from landing in a physiologic and clinically relevant manner. External knee abduction moment, anterior shear, and internal tibial rotation loads were applied to the specimen via pneumatic actuators. The magnitudes of applied loads were determined in vivo from a cohort of healthy athletes. Loads were systematically increased until specimen failure was induced. Three cadaveric lower extremity specimens were tested and clinically assessed for failure. Knee specimens were physically and arthroscopically examined at baseline and at post-injury by a board certified orthopedic surgeon. FINDINGS All three specimens experienced failure at either the midsubstance or the femoral insertion site. The mean peak strain prior to failure was 18.8 (6.2)%, while the mean peak medial collateral ligament strain was 7.9 (5.9)%. INTERPRETATION A board certified orthopedic surgeon confirmed observed rupture patterns were representative of clinical cases. Peak strains were consistent with literature. The novel mechanical impact simulator will allow researchers to assess clinically relevant patterns of rupture and the data generated will inform clinician decisions. This novel machine presents the ability to assess healthy specimens as well as differences in the function of deficient and reconstructed knees.
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Affiliation(s)
- Nathaniel A. Bates
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Department of Biomedical Engineering and Physiology, Mayo Clinic, Rochester, MN, USA,Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan D. Schilaty
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Department of Biomedical Engineering and Physiology, Mayo Clinic, Rochester, MN, USA,Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Department of Biomedical Engineering and Physiology, Mayo Clinic, Rochester, MN, USA
| | - Timothy E. Hewett
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Department of Biomedical Engineering and Physiology, Mayo Clinic, Rochester, MN, USA,Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA,Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA,Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA
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Affiliation(s)
- Peter D Fabricant
- 1Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY 2Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts 3Harvard Medical School, Boston, Massachusetts
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Clinical outcomes and biomechanical analysis of posterolateral bundle augmentation in patients with partial anterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc 2017; 25:1279-1289. [PMID: 26162801 DOI: 10.1007/s00167-015-3691-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 06/30/2015] [Indexed: 01/15/2023]
Abstract
PURPOSE To examine the clinical and biomechanical results of posterolateral (PL) augmentation to reconstruct damaged PL bundle while preserving the less-damaged anteromedial bundle for partial anterior cruciate ligament (ACL) tears in comparison with double-bundle ACL reconstruction. METHODS Sixteen patients who underwent PL augmentation for partial ACL tears (Group P) and 37 patients who underwent double-bundle ACL reconstructions for complete ACL tears were examined (Group D). Anterior tibial translation (ATT) was evaluated using the KT-1000 arthrometer. ATT during the Lachman test and acceleration of posterior tibial translation (APT) during the pivot shift test were evaluated using an electromagnetic measurement system (EMS). Clinical outcomes were evaluated using the Lysholm score. Second-look arthroscopy was performed 1 year after surgery. RESULTS The mean postoperative Lysholm scores were 91.7 ± 12.2 and 94.6 ± 7.2 in Groups P and D, respectively, and there was no statistically significant difference between the two groups. The mean side-to-side difference of ATT on the KT-1000 was significantly improved in both Groups P and D. In the EMS analysis, the mean side-to-side difference of ATT and the mean APT were significantly improved in both Groups P and D. There was no significant difference in the second-look evaluation between the two groups. CONCLUSIONS The clinical and biomechanical outcomes of PL augmentation were satisfactorily comparable to those of double-bundle ACL reconstruction. PL augmentation could be a useful treatment option for patients with partial ACL tears. LEVEL OF EVIDENCE IV.
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Wojtys EM, Beaulieu ML, Ashton‐Miller JA. New perspectives on ACL injury: On the role of repetitive sub-maximal knee loading in causing ACL fatigue failure. J Orthop Res 2016; 34:2059-2068. [PMID: 27653237 PMCID: PMC6362839 DOI: 10.1002/jor.23441] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/15/2016] [Indexed: 02/04/2023]
Abstract
In this paper, we review a series of studies that we initiated to examine mechanisms of anterior cruciate ligament (ACL) injury in the hope that these injuries, and their sequelae, can be better prevented. First, using the earliest in vitro model of a simulated single-leg jump landing or pivot cut with realistic knee loading rates and trans-knee muscle forces, we identified the worst-case dynamic knee loading that causes the greatest peak ACL strain: Combined knee compression, flexion, and internal tibial rotation. We also identified morphologic factors that help explain individual susceptibility to ACL injury. Second, using the above knee loading, we introduced a possible paradigm shift in ACL research by demonstrating that the human ACL can fail by a sudden rupture in response to repeated sub-maximal knee loading. If that load is repeated often enough over a short time interval, the failure tended to occur proximally, as observed clinically. Third, we emphasize the value of a physical exam of the hip by demonstrating how limited internal axial rotation at the hip both increases the susceptibility to ACL injury in professional athletes, and also increases peak ACL strain during simulated pivot landings, thereby further increasing the risk of ACL fatigue failure. When training at-risk athletes, particularly females with their smaller ACL cross-sections, rationing the number and intensity of worst-case knee loading cycles, such that ligament degradation is within the ACL's ability to remodel, should decrease the risk for ACL rupture due to ligament fatigue failure.© 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2059-2068, 2016.
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Affiliation(s)
- Edward M. Wojtys
- MedSportDepartment of Orthopedic SurgeryUniversity of MichiganAnn ArborMichigan48109
| | - Mélanie L. Beaulieu
- Biomechanics Research LaboratoryDepartment of Mechanical EngineeringUniversity of MichiganAnn ArborMichigan48109,Department of RadiologyUniversity of MichiganAnn ArborMichigan48109
| | - James A. Ashton‐Miller
- Biomechanics Research LaboratoryDepartment of Mechanical EngineeringUniversity of MichiganAnn ArborMichigan48109
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Placella G, Bartoli M, Peruzzi M, Speziali A, Pace V, Cerulli G. Return to sport activity after anterior cruciate ligament reconstruction in skeletally immature athletes with manual drilling original all inside reconstruction at 8 years follow-up. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:635-638. [PMID: 27817976 PMCID: PMC6197601 DOI: 10.1016/j.aott.2016.03.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/12/2016] [Accepted: 03/01/2016] [Indexed: 12/22/2022]
Abstract
Objective Anterior cruciate ligament (ACL) tears are common injuries in adolescent athletes, especially in those who bear high stress on their knees due to shearing forces. The goal of the surgical procedures in skeletally immature patients is to restore joint stability avoiding the adverse effects on the growth process. The aim of this study was to verify the return of the skeletally immature professional athletes to sports in the long-term, following ACL reconstruction with the original all-inside technique and with manual drilling. Methods This study included 24 athletes (14 boys, 10 girls; mean age: 13.15 years, range: 9–14 years) who had radiographic evidence of open physes, were less than 14 years of age at the time of surgery and those with a minimum follow-up of eight years. All patients completed a questionnaire, the IKDC subjective knee evaluation form, and Tegner Activity Scale. Biomechanical outcomes of the KT-1000 arthrometer, gait analysis, and stabilometric and isokinetic results were also evaluated. A plain radiograph of both lower limbs was taken to obtain a precise measurement of the limb length and mechanical axis angles. Results The patients returned to sport activities in a mean time of 6.43 months. No rerupture or resurgery due to growth abnormalities was observed. The mean difference in length between the operated and contralateral legs was 0.4 (range: −0.2 to 0.7) cm. The mean side-to-side difference measured with the KT-1000 arthrometer was 5.2 (range: 3.5 to 7) mm in the preoperative and 0.8 (range: 0 to 2.5) mm in the postoperative measurements. Conclusion In conclusion, the original all-inside technique with manual drilling with a half tunnel and short graft seems to be a very effective technique for the surgical management of ACL injuries in pediatric/adolescent athletes. A good rate of return to sports at pre-injury levels or higher, high patient satisfaction and a decent motor and proprioceptive function is possible as shown by our analysis. Level of evidence Level IV, Therapeutic study.
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Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Patients Using Quadriceps Tendon Autograft. Sports Med Arthrosc Rev 2016; 24:159-169. [DOI: 10.1097/jsa.0000000000000128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
Dramatic increases in youth competitive athletic activity, early sport specialization, and year-round training and competition, along with increased awareness of anterior cruciate ligament (ACL) injuries in children, have led to a commensurate increase in the frequency of ACL tears in the skeletally immature. Recent understanding of the risks of nonoperative treatment and surgical delay have supported a trend toward early operative treatment. This article discusses treatment strategies for ACL injuries in children and adolescents, and offers our preferred treatment strategy for skeletally immature youth athletes with ACL tears.
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Hunt PA, Greaves I. Presentation, examination, investigation and early treatment of acute knee injuries. TRAUMA-ENGLAND 2016. [DOI: 10.1191/1460408604ta299oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute knee injuries are common presentations that frequently occur during sporting activities and can result in permanent disability. However, they often result in a single visit, seldom receive surgical intervention and, in the main, are cared for entirely by General Practitioners or Emergency Department physicians. Thorough clinical assessment and appropriate early treatment at the primary presentation is vital in order to offer the best chance of maximal functional recovery and to minimize long-term disability. This requires a sound knowledge of basic knee anatomy, careful assessment of the mechanism of injury, detection and consideration of physical ndings and the results of adjunctive investigations. This article aims to give a comprehensive review of the examination, investigation and early treatment of acute knee injuries at the primary presentation. In addition, comments on important epidemiological and aetiological factors and a brief description of basic knee anatomy are also provided.
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Affiliation(s)
- PA Hunt
- A&E Department, James Cook University Hospital, Middlesbrough, UK,
| | - Ian Greaves
- A&E Department, James Cook University Hospital, Middlesbrough, UK
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Mitchell JJ, Mayo MH, Axibal DP, Kasch AR, Fader RR, Chadayammuri V, Terhune EB, Georgopoulos G, Rhodes JT, Vidal AF. Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures. Am J Sports Med 2016; 44:2047-56. [PMID: 27159316 DOI: 10.1177/0363546516644597] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction. PURPOSE To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence. STUDY DESIGN Case series; Level of evidence, 4. METHODS We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression. RESULTS Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6). CONCLUSION Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.
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Affiliation(s)
- Justin J Mitchell
- The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Meredith H Mayo
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Derek P Axibal
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Anthony R Kasch
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Ryan R Fader
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - Vivek Chadayammuri
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA
| | - E Bailey Terhune
- Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Gaia Georgopoulos
- Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Jason T Rhodes
- Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Armando F Vidal
- Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora, Colorado, USA
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Smith JO, Yasen SK, Palmer HC, Lord BR, Britton EM, Wilson AJ. Paediatric ACL repair reinforced with temporary internal bracing. Knee Surg Sports Traumatol Arthrosc 2016; 24:1845-51. [PMID: 27141865 DOI: 10.1007/s00167-016-4150-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 04/26/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Instability following non-operative treatment of anterior cruciate ligament (ACL) rupture in young children frequently results in secondary chondral and/or meniscal injuries. Therefore, many contemporary surgeons advocate ACL reconstruction in these patients, despite the challenges posed by peri-articular physes and the high early failure rate. We report a novel management approach, comprising direct ACL repair reinforced by a temporary internal brace in three children. METHODS Two patients (aged 5 and 6 years) with complete proximal ACL ruptures and a third (aged seven) with an associated tibial spine avulsion underwent direct surgical repair, supplemented with an internal brace that was removed after 3 months. RESULTS Second-look arthroscopy, examination and imaging at 3 months confirmed knee stability and complete ACL healing in all cases. Normal activities were resumed at 4 months, and excellent objective measures of function, without limb growth disturbance, were noted beyond 2 years. CONCLUSION ACL repair in young children using this technique negates the requirement and potential morbidity of graft harvest and demonstrates the potential for excellent outcome as an attractive alternative to ACL reconstruction, where an adequate ACL remnant permits direct repair. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- James O Smith
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK
| | - Sam K Yasen
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK
| | - Harry C Palmer
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK
| | - Breck R Lord
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK
| | - Edward M Britton
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK.,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK
| | - Adrian J Wilson
- Department of Orthopaedics, North Hampshire Hospitals NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK. .,Department of Sport and Exercise, Sport and Exercise Research Centre, University of Winchester, Winchester, SO22 4NR, UK.
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Fabricant PD, Lakomkin N, Cruz AI, Spitzer E, Marx RG. ACL reconstruction in youth athletes results in an improved rate of return to athletic activity when compared with non-operative treatment: a systematic review of the literature. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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47
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Abstract
The prevalence of anterior cruciate ligament (ACL) injuries in skeletally immature athletes has increased dramatically over the past decade. Many attribute this to increased training, single-sport specialization and year-round competitive play. ACL injuries most commonly occur in athletic activities that involve cutting, pivoting, jumping and landing. Non-operative treatment consisting of activity modification, physical therapy and specialized bracing may have a role; however, recent data suggest that this may not be optimal in young, active patients. Surgical treatment has become more favorable, specifically for athletes with aspirations of higher-level sports participation. To minimize growth plate disturbances and potential for limb malalignment, the patient's skeletal age, pubertal status and remaining growth potential must be taken into consideration. We provide a review on how to evaluate, manage and treat the skeletally immature athlete with an ACL injury.
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Affiliation(s)
- Meryl Ludwig
- a 1 MedStar Georgetown University Hospital , Washington, DC 20007, USA
| | - Alfred Atanda
- b 2 Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children , Wilmington, DE 19803, USA
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Rajgopal A, Noble PC, Vasdev A, Ismaily SK, Sawant A, Dahiya V. Wear Patterns in Knee Articular Surfaces in Varus Deformity. J Arthroplasty 2015; 30:2012-6. [PMID: 26021905 DOI: 10.1016/j.arth.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 04/12/2015] [Accepted: 05/05/2015] [Indexed: 02/01/2023] Open
Abstract
This study was performed to study the relationship between the degree of varus deformity of osteoarthritic knees and the anatomic distribution of cartilage pathology. Bone wafers resected from the distal femur and proximal tibia were obtained from 107 patients (195 knees) with primary varus osteoarthritis. Severity and distribution of joint damage was scored for each articular surface and related to potential prognostic factors, including varus deformity, the ligamentous status of the knee, age, gender and BMI. There was highly significant association between varus angulation of the knee and the total damage score for the tibia (P=0.001), but not the femur (P=0.2947). The degree of deformity, and not the status of the ACL alone, determines wear pattern and provides insight for preoperative planning of TKA.
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Affiliation(s)
- Ashok Rajgopal
- Medanta Bone and Joint Institute, Medanta - The Medicity Gurgaon, Haryana, India
| | - Philip C Noble
- Institute of Orthopedic Research and Education, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Attique Vasdev
- Medanta Bone and Joint Institute, Medanta - The Medicity Gurgaon, Haryana, India
| | - Sabir K Ismaily
- Institute of Orthopedic Research and Education, Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Angraj Sawant
- Medanta Bone and Joint Institute, Medanta - The Medicity Gurgaon, Haryana, India
| | - Vivek Dahiya
- Medanta Bone and Joint Institute, Medanta - The Medicity Gurgaon, Haryana, India
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49
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Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Rev Bras Ortop 2015; 50:9-15. [PMID: 26229890 PMCID: PMC4519562 DOI: 10.1016/j.rboe.2015.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 04/15/2014] [Indexed: 01/13/2023] Open
Abstract
Partial tears of the anterior cruciate ligament (ACL) are common and represent 10–27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction.
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Affiliation(s)
| | | | | | - Pierre Chambat
- Santy Orthopedics Center, Hôpital Jean Mermoz, Lyon, France
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50
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Temponi EF, Honório de Carvalho Júnior L, Sonnery‐Cottet B, Chambat P. Lesão parcial do ligamento cruzado anterior: diagnóstico e tratamento. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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