Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up

Slope Osteotomies in the Setting of Anterior Cruciate Ligament Deficiency

➤ Posterior tibial slope (PTS) of ≥12° represents an important risk factor for both anterior cruciate ligament (ACL) injury and ACL reconstruction failure.➤ PTS measurements can significantly differ on the basis of the imaging modality and the measurement technique used. PTS should be measured on strictly lateral radiographs, with a recommended proximal tibial length of 15 cm in the image. The PTS measurement can be made by placing 2 circles to define the proximal tibial axis, 1 just below the tibial tubercle and another 10 cm below it. PTS measurements are underestimated when made on magnetic resonance imaging and computed tomography.➤ Slope-reducing osteotomies can be performed using a (1) supratuberosity, (2) tubercle-reflecting transtuberosity, or (3) infratuberosity method. The correction target remains a topic of debate. Although it is controversial, some authors recommend overcorrecting the tibial slope slightly to a range of 4° to 6°. For instance, if the initial slope is 12°, a correction of 6° to 8° should be performed, given the target tibial slope of 4° to 6°.➤ Clinical outcomes following slope-reducing osteotomies have been favorable. However, potential complications, limited data with regard to the impact of slope-reducing osteotomies on osteoarthritis, and uncertainty with regard to the effects on the patellofemoral joint are notable concerns.➤ Patients with complex deformities may need biplanar osteotomies to comprehensively address the condition.

3D visualization of the human anterior cruciate ligament combining micro-CT and histological analysis

PURPOSE

The study aimed to obtain a comprehensive 3D visualization of knee specimens, including the cruciate ligaments and corresponding femoral and tibial bone insertions using a non-destructive micro-CT method.

METHODS

Knee specimens were fixed in anatomical positions and chemically dehydrated before being scanned using micro-CT with a voxel size of 17.5 μm. RGBA (red, green, blue, alpha) transfer functions were applied to virtually colorize each structure. Following micro-CT scanning, the samples were rehydrated, decalcified, and trimmed based on micro-CT 3D reconstructions as references. Histological evaluations were performed on the trimmed samples. Histological and micro-CT images were registered to morphologically and densitometrically assess the 4-layer insertion of the ACL into the bone.

RESULTS

The output of the micro-CT images of the knee in extension and flexion allowed a clear differentiation of the morphologies of both soft and hard tissues, such as the ACL, femoral and tibial bones, and cartilage, and the subsequent creation of 3D composite models useful for accurately tracing the entire morphology of the ligament, including its fiber and bundle components, the trajectory between the femur and tibia, and the size, extension, and morphology of its insertions into the bones.

CONCLUSION

The implementation of the non-destructive micro-CT method allowed complete visualization of all the different components of the knee specimens. This allowed correlative imaging by micro-CT and histology, accurate planning of histological sections, and virtual anatomical and microstructural analysis. The micro-CT approach provided an unprecedented 3D level of detail, offering a viable means to study ACL anatomy.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision.

METHODS

Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article.

CONCLUSION

ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults.

LEVEL OF EVIDENCE

Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.

METHODS

The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.

RESULTS

The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.

CONCLUSION

ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.

LEVEL OF EVIDENCE

II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method

PURPOSE

The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev).

METHODS

The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate').

RESULTS

The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III).

CONCLUSION

This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications.

LEVEL OF EVIDENCE

II.

Protocol for a Randomized Crossover Trial to Evaluate the Effect of Soft Brace and Rigid Orthosis on Performance and Readiness to Return to Sport Six Months Post-ACL-Reconstruction

A randomized crossover trial was designed to investigate the influence of muscle activation and strength on functional stability/control of the knee joint, to determine whether bilateral imbalances still occur six months after successful anterior cruciate ligament reconstruction (ACLR), and to analyze whether the use of orthotic devices changes the activity onset of these muscles. Furthermore, conclusions on the feedforward and feedback mechanisms are highlighted. Therefore, twenty-eight patients will take part in a modified Back in Action (BIA) test battery at an average of six months after a primary unilateral ACLR, which used an autologous ipsilateral semitendinosus tendon graft. This includes double-leg and single-leg stability tests, double-leg and single-leg countermovement jumps, double-leg and single-leg drop jumps, a speedy jump test, and a quick feet test. During the tests, gluteus medius and semitendinosus muscle activity are analyzed using surface electromyography (sEMG). Motion analysis is conducted using Microsoft Azure DK and 3D force plates. The tests are performed while wearing knee rigid orthosis, soft brace, and with no aid, in random order. Additionally, the range of hip and knee motion and hip abductor muscle strength under isometric conditions are measured. Furthermore, patient-rated outcomes will be assessed.

Risk factors of cartilage lesion after anterior cruciate ligament reconstruction

Anterior cruciate ligament injury is the most common sports injury in orthopaedics, which can adversely affect knee joint function and exercise of patients. Using arthroscopy to reconstruct the anterior cruciate ligament has become the first choice for treating anterior cruciate ligament rupture. However, different degrees of articular cartilage injury of the knee can be observed in patients after anterior cruciate ligament reconstruction. More importantly, the articular cartilage injury after anterior cruciate ligament reconstruction indicates that it will develop into osteoarthritis in the long term. It is of great significance to fully understand the factors that lead to the occurrence and development of cartilage injury. This article reviews the effects of surgical methods, meniscus status, different grafts, time from injury to surgical intervention, postoperative knee joint stability, postoperative rehabilitation, knee joint anatomical factors, and demographic characteristics of patients on articular cartilage degeneration after anterior cruciate ligament reconstruction. The present review provides insights into the anterior cruciate ligament reconstruction, which can be used to investigate new treatment strategies to delay and prevent the progress of osteoarthritis. At the same time, it provides a holistic understanding of the influence of multiple factors on cartilage lesions after anterior cruciate ligament reconstruction.

Risk Factors Associated with Cartilage Defects after Anterior Cruciate Ligament Rupture in Military Draftees

This study aimed to evaluate the different clinical results and factors associated with cartilage defects in military draftees who underwent different treatments after anterior cruciate ligament (ACL) rupture. Overall, 105 patients who had sustained ACL rupture were military draftees who underwent a conscription examination for physical status assessment from January 2012 to December 2020. Patients were divided into three groups: conservative treatment after ACL rupture, status post-anterior cruciate ligament reconstruction (ACLR), but graft rupture, and status post-ACLR with graft intact. Inter-group comparisons and statistical analyses were performed for age, body mass index (BMI), thigh circumference difference, side-to-side difference in anterior knee translation by KT-2000, meniscus tear, and cartilage defect. Multivariate logistic regression analysis was used to determine the factors associated with cartilage defects. The multivariable regression model showed that BMI (odds ratio OR: 1.303; 95% CI: 1.016–1.672; p = 0.037), thigh circumference difference (OR: 1.403; 95% CI: 1.003–1.084; p = 0.034), tear of lateral meniscus (LM) and medial meniscus (MM) (OR: 13.773; 95% CI: 1.354–140.09; p = 0.027), and graft rupture group (OR: 5.191; 95% CI: 1.388–19.419; p = 0.014) increased the risk of cartilage defects. There was no correlation between cartilage defects and age, KT-2000 difference, tear of LM or MM, or graft intact group. Progression of osteoarthritis was concerned after ACL rupture, and this study identified several factors of post-ACLR graft rupture, greater thigh circumference difference, BMI, and meniscus tear of both LM and MM affecting cartilage defects, which represent early degenerative osteoarthritis changes of the knee. The results of this study should be customized for rehabilitation and military training, especially in military draftees with ACL injuries.