ACL Reconstruction Using Quadrupled Semitendinosus Versus Double-Stranded Semitendinosus and Gracilis Autograft: 2-Year Results From a Prospective Randomized Controlled Study.

BACKGROUND: A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results. PURPOSE: To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively. RESULTS: A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group. CONCLUSION: The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure.

Multi-omics profiling reveals dysregulated ribosome biogenesis and impaired cell proliferation following knockout of CDR2L.

BACKGROUND: Cerebellar degeneration-related (CDR) proteins are associated with paraneoplastic cerebellar degeneration (PCD) - a rare, neurodegenerative disease caused by tumour-induced autoimmunity against neural antigens resulting in degeneration of Purkinje neurons in the cerebellum. The pathogenesis of PCD is unknown, in large part due to our limited understanding of the functions of CDR proteins. To this end, we performed an extensive, multi-omics analysis of CDR-knockout cells focusing on the CDR2L protein, to gain a deeper understanding of the properties of the CDR proteins in ovarian cancer. METHODS: Ovarian cancer cell lines lacking either CDR1, CDR2, or CDR2L were analysed using RNA sequencing and mass spectrometry-based proteomics to assess changes to the transcriptome, proteome and secretome in the absence of these proteins. RESULTS: For each knockout cell line, we identified sets of differentially expressed genes and proteins. CDR2L-knockout cells displayed a distinct expression profile compared to CDR1- and CDR2-knockout cells. Knockout of CDR2L caused dysregulation of genes involved in ribosome biogenesis, protein translation, and cell cycle progression, ultimately causing impaired cell proliferation in vitro. Several of these genes showed a concurrent upregulation at the transcript level and downregulation at the protein level. CONCLUSIONS: Our study provides the first integrative multi-omics analysis of the impact of knockout of the CDR genes, providing both new insights into the biological properties of the CDR proteins in ovarian cancer, and a valuable resource for future investigations into the CDR proteins.

Differences Between Traumatic and Degenerative Medial Meniscus Posterior Root Tears: A Systematic Review.

BACKGROUND: Intact meniscus roots are a prerequisite for normal meniscal function, including even distribution of compressive forces across the knee joint. An injury to the root disrupts the hoop strength of the meniscus and may lead to its extrusion and the development of osteoarthritis. A medial meniscus posterior root tear (MMPRT) is often thought to have a primary degenerative pathogenesis. However, there is mention of some cases of MMPRTs where the patients have a solely traumatic injury to a previously healthy meniscus. PURPOSE: To describe a subpopulation of patients with traumatic MMPRT. STUDY DESIGN: Systematic review; Level of evidence, 5. METHODS: The Web of Science database (www.webofscience.com) was queried using the Medical Subject Headings term "medial root tear." Articles were reviewed, and those evaluated for MMPRTs in a degenerative meniscus were excluded. A total of 25 articles describing cases of acute traumatic causes were included in this study. For these articles, the patient characteristics, injury mechanisms, and concomitant injuries evaluated were recorded and pooled. RESULTS: The search revealed 660 articles, and 25 were selected for inclusion. A total of 113 patients with a traumatic MMPRT were identified and included in this review. The study population had a mean age of 27.1 years and a high share of men (64%). Also, this review displays how most patients with traumatic MMPRTs also suffer concomitant injuries (68%). CONCLUSION: The findings in this review support our hypothesis that there is a unique subgroup with acute traumatic MMPRTs that have unique patient characteristics, injury mechanisms, and combined injuries, compared with previously published reviews on MMPRTs.

Previous cartilage surgery is associated with inferior patient-reported outcomes after knee arthroplasty.

PURPOSE: The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients. METHODS: Fifty-eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors. RESULTS: Mean follow-up post knee arthroplasty surgery was 7.6 years (range 1.2-20.3) in the cartilage cohort and 8.1 (range 1.0-20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow-up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (-1.2, 18.6), Sport and recreation 8.9 (-1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5). CONCLUSION: Previous cartilage surgery was associated with inferior patient-reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores. LEVEL OF EVIDENCE: Level III.

Self-assessment of range of motion in patients undergoing surgery for a unilateral shoulder condition.

OBJECTIVE: This study aimed to investigate the agreement of patient-assessed and researcher/physician-assessed measurements of the difference in range of motion between the unaffected and affected shoulders in 55 patients undergoing arthroscopic surgery for a unilateral shoulder condition. METHODS: The investigation included 55 patients (17 women and 38 men; median age=53 years; range=26-74) with a symptomatic unilateral shoulder condition and a surgically treatable diagnosis. Images of a model/researcher performing active shoulder abduction, flexion, external rotation, and internal rotation were created. Each image was paired with a degree diagram or a level system (for internal rotation) on the back for the patient to accurately self-evaluate and record. Each patient was instructed to attentively examine the figures and perform the movements with the same posture as depicted. On the day of surgery, prior to the procedure, 2 independent researchers who were not involved in the patient's care used a standard goniometer to assess the same active movements that the patient had previously self-assessed. For agreement analyses, the intraclass correlation coefficient and Bland-Altman plots were calculated for continuous data (abduction, flexion, and external rotation), and Cohen's weighted kappa was calculated for ordinal categorical data (internal rotation). RESULTS: The intraclass correlation coefficient for abduction, flexion, and external rotation was 0.93 (excellent) 95% CI (0.87, 0.96), 0.89 (good) 95% CI (0.81, 0.94), and 0.72 (moderate) 95% CI (0.52, 0.84), respectively. Cohen's kappa for internal rotation (measured as reaching levels on the back) was 0.63 (moderate). CONCLUSION: We believe that patient-assessed measurements of abduction (intraclass correlation coefficient 0.93) and flexion (intraclass correlation coefficient 0.89) can be used as a valid substitute (for measurements by a clinician or researcher). Patient-assessed measurements for external rotation (intraclass correlation coefficient 0.72) and internal rotation (kappa 0.63) are in moderate agreement and should be used more cautiously as substitutes. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

The Long-Term Risk of Knee Arthroplasty in Patients with Arthroscopically Verified Focal Cartilage Lesions: A Linkage Study with the Norwegian Arthroplasty Register, 1999 to 2020.

BACKGROUND: Focal cartilage lesions are common in the knee. The risk of later ipsilateral knee arthroplasty remains unknown. The purposes of the present study were to evaluate the long-term cumulative risk of knee arthroplasty after arthroscopic identification of focal cartilage lesions in the knee, to investigate the risk factors for subsequent knee arthroplasty, and to estimate the subsequent cumulative risk of knee arthroplasty compared with that in the general population. METHODS: Patients who had undergone surgical treatment of focal cartilage lesions at 6 major Norwegian hospitals between 1999 and 2012 were identified. The inclusion criteria were an arthroscopically classified focal cartilage lesion in the knee, an age of ≥18 years at the time of surgery, and available preoperative patient-reported outcomes (PROMs). The exclusion criteria were osteoarthritis or "kissing lesions" at the time of surgery. Demographic data, later knee surgery, and PROMs were collected with use of a questionnaire. A Cox regression model was used to adjust for and investigate the impact of risk factors, and Kaplan-Meier analysis was performed to estimate cumulative risk. The risk of knee arthroplasty in the present cohort was compared with that in the age-matched general Norwegian population. RESULTS: Of the 516 patients who were eligible, 322 patients (328 knees) consented to participate. The mean age at the time of the index procedure was 36.8 years, and the mean duration of follow-up was 19.8 years. The 20-year cumulative risk of knee arthroplasty in the cartilage cohort was 19.1% (95% CI, 14.6% to 23.6%). Variables that had an impact on the risk of knee arthroplasty included an ICRS grade of 3 to 4 (hazard ratio [HR], 3.1; 95% CI, 1.1 to 8.7), an age of ≥40 years at time of cartilage surgery (HR, 3.7; 95% CI, 1.8 to 7.7), a BMI of 25 to 29 kg/m 2 (HR, 3.9; 95% CI, 1.7 to 9.0), a BMI of ≥30 kg/m 2 (HR, 5.9; 95% CI, 2.4 to 14.3) at the time of follow-up, autologous chondrocyte implantation (ACI) at the time of the index procedure (HR, 3.4; 95% CI, 1.0 to 11.4), >1 focal cartilage lesion (HR, 2.1; 95% CI, 1.1 to 3.7), and a high preoperative visual analog scale (VAS) score for pain at the time of the index procedure (HR, 1.1; 95% CI, 1.0 to 1.1). The risk ratio of later knee arthroplasty in the cartilage cohort as compared with the age-matched general Norwegian population was 415.7 (95% CI, 168.8 to 1,023.5) in the 30 to 39-year age group. CONCLUSIONS: In the present study, we found that the 20-year cumulative risk of knee arthroplasty after a focal cartilage lesion in the knee was 19%. Deep lesions, higher age at the time of cartilage surgery, high BMI at the time of follow-up, ACI, and >1 cartilage lesion were associated with a higher risk of knee arthroplasty. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Predictors of Osteoarthritis Development at a Median 25 Years After Anterior Cruciate Ligament Reconstruction Using a Patellar Tendon Autograft.

BACKGROUND: Few studies have investigated the outcome ≥20 years after an anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone autograft, and there is a wide range in the reported rates of radiographic osteoarthritis (OA). PURPOSE: To report on radiographic OA development and to assess risk factors of knee OA at a median 25 years after ACLR with a bone-patellar tendon-bone autograft. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Unilateral ACLRs performed at a single center from 1987 to 1994 were included (N = 235). The study population was followed prospectively with clinical testing and questionnaires. Results from the 3-month, 12-month, and median 25-year follow-up are presented. In addition, a radiographic evaluation was performed at the final follow-up. Radiographic OA was defined as Kellgren-Lawrence grade ≥2 or having undergone ipsilateral knee replacement surgery. Possible predictors of OA development included patient age, sex, time from injury to surgery, use of a Kennedy ligament augmentation device, any concomitant meniscal surgery, and return to preinjury sports after surgery. RESULTS: At long-term follow-up, 60% (141/235) of patients had radiographic OA in the involved knee and 18% (40/227) in the contralateral knee (P < .001). Increased age at surgery, male sex, increased time between injury and surgery, a Kennedy ligament augmentation device, and medial and lateral meniscal surgery were significant predictors of OA development in univariate analyses. Return to preinjury level of sports after surgery was associated with less development of OA. In the multivariate model, medial meniscal surgery and lateral meniscal surgery were independently associated with OA development. The adjusted odds ratio was 1.88 (95% CI, 1.03-3.43; P = .041) for medial meniscal surgery and 1.96 (95% CI, 1.05-3.67; P = .035) for lateral meniscal surgery. Patients who had developed radiographic signs of OA had significantly lower Knee injury and Osteoarthritis Outcome Score and Lysholm scores at long-term follow-up. CONCLUSION: At 25 years after ACLR, 60% of patients had developed OA in the involved knee, and these patients reported significantly lower subjective outcomes. Medial meniscal surgery and lateral meniscal surgery were independent predictors of OA development at long-term follow-up.

The Effect of Posterior Tibial Slope on the Risk of Revision Surgery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A significant proportion of patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) later experience graft failure. Some studies suggest an association between a steep posterior tibial slope (PTS) and graft failure. PURPOSE: To examine the PTS in a large cohort of patients about to undergo ACLR and to determine whether a steep PTS is associated with later revision surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review of a cohort undergoing isolated ACLR between 2002 and 2012 (with 8-19 years of follow-up) was conducted. Preoperative sagittal radiographs of knees in full extension were used for measurements of the PTS. There were 2 independent examiners who performed repeated measurements to assess the reliability of the method. Statistical analyses were performed to compare the PTS in the groups with and without later revision surgery. RESULTS: A total of 728 patients, with a mean age of 28 years at the time of surgery, were included. Overall, 10% (n = 76) underwent revision surgery during the observation period. The group of injured knees had a significantly steeper PTS compared with the group of uninjured knees (9.5° vs 8.7°, respectively; P < .05). The mean PTS in the no revision group was 9.5° compared with 9.3° in the revision group (not significant). Dichotomized testing of revision rates related to PTS cutoff values of ≥10°, ≥12°, ≥14°, ≥16°, and ≥18° showed no association of PTS steepness (not significant) to graft failure. Patients with revision were younger than the ones without (mean age, 24 ± 8 vs 29 ± 10 years, respectively) and had a shorter time from injury to ACLR (mean, 14 ± 27 vs 24 ± 44 months, respectively) as well as a smaller graft size (8.2 vs 8.4 mm, respectively; P = .040). CONCLUSION: The current study did not find any association between a steep PTS measured on lateral knee radiographs and revision ACL surgery. However, a steeper PTS was seen in the group of injured knees compared with the group of uninjured (contralateral) knees. Independent of the PTS, younger patients, those with a shorter time from injury to surgery, and those with a smaller graft size were found to undergo revision surgery more often.

Ultrasound-Assisted Endoscopic Removal of Pretibial Cysts Related to Biointerference Screw Degradation.

We report on the treatment of cases of painful subcutaneous pretibial cyst due to broken and displaced materials of only partly absorbed bioabsorbable interference screws used for anterior cruciate ligament reconstruction. Ultrasound examination was used to both make the definite diagnosis and determine the exact localization of dislodged screw parts. The broken and loose bioabsorbable screw parts and surrounding cyst-like structure were removed endoscopically by a soft-tissue resector.

Effect of Early Residual Laxity After Anterior Cruciate Ligament Reconstruction on Long-term Laxity, Graft Failure, Return to Sports, and Subjective Outcome at 25 Years.

BACKGROUND: In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction (ACLR), and its clinical effect is undetermined. PURPOSE: To investigate whether a 3- to 5-mm increase in anterior translation 6 months after ACLR affects the risk of graft failure, rate of return to sports, and long-term outcome. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: From a cohort of 234 soccer, team handball, and basketball players undergoing ACLR using bone-patellar tendon-bone graft, 151 athletes were included who attended 6-month follow-up that included KT-1000 arthrometer measures. A tight graft was defined as <3-mm side-to-side difference between knees (n = 129), a slightly loose graft as 3 to 5 mm (n = 20), and a loose graft as >5 mm (n = 2). Graft failure was defined as ACL revision surgery, >5-mm side-to-side difference, or anterolateral rotational instability 2+ or 3+ at 2-year follow-up. Finally, a 25-year evaluation was performed, including a clinical examination and questionnaires. RESULTS: The rate of return to pivoting sports was 74% among athletes with tight grafts and 70% among those with slightly loose grafts. Also, return to preinjury level of sports was similar between those with slightly loose and tight grafts (40% vs 48%, respectively), but median duration of the sports career was longer among patients with tight grafts: 6 years (range, 1-25 years) vs 2 years (range, 1-15 years) (P = .01). Five slightly loose grafts (28%) and 6 tight grafts (5%) were classified as failures after 2 years (P = .002). Thirty percent (n = 6) of patients with slightly loose grafts and 6% (n = 8) with tight grafts had undergone revision (P = .004) by follow-up (25 years, range, 22-30 years). Anterior translation was still increased among the slightly loose grafts as compared with tight grafts at long-term follow-up (P < .05). In patients with tight grafts, 94% had a Lysholm score ≥84 after 24 months and 58% after 25 years, as opposed to 78% (P = .02) and 33% (P = .048), respectively, among patients with slightly loose grafts. CONCLUSION: A slightly loose graft at 6 months after ACLR increased the risk of later ACL revision surgery and/or graft failure, reduced the length of the athlete's sports career, caused permanent increased anterior laxity, and led to an inferior Lysholm score.

Failed Meniscal Repairs After Anterior Cruciate Ligament Reconstruction Increases Risk of Revision Surgery.

BACKGROUND: Failed anterior cruciate ligament (ACL) reconstruction (ACLR) can lead to reduced quality of life because of recurrent episodes of instability, restrictions in level of activity, and development of osteoarthritis. A profound knowledge of the causes of a failed surgery can ultimately help improve graft survival rates. PURPOSE: To investigate the patient-related risks of inferior outcomes leading to revision surgery after ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: From a prospective cohort of primary ACLRs performed at a single center, patients who required later revision surgery were matched with a control group of uneventful primary ACLRs. Patient characteristics, data from the preoperative examinations, KT-1000 arthrometer laxity testing, Tegner activity scale, International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, and perioperative data from the initial surgery were included. RESULTS: A total of 100 revision cases and 100 matched controls, with a median follow-up time of 11 years, were included in the study. Those who had undergone revision surgery were younger at the time of reconstruction and had a shorter time from injury to surgery than their matched controls (P = .006). The control group-of uneventful ACLRs-had a higher incidence of meniscal repair at reconstruction (P = .024). Also, the revision group more frequently experienced later failure of the previous meniscal repair (P = .004). Surgeon experience was not found to affect the risk of revision ACL surgery. Those who had undergone ACL revision surgery had more frequently received a hamstring tendon graft size of <8 mm (P = .018) compared with the controls. CONCLUSION: The current study demonstrated that failed meniscal repair and a hamstring tendon graft size of <8 mm were associated with primary ACLR failure. Also, younger age at the time of surgery and shorter time from injury to surgery were found to affect the risk of undergoing revision ACL surgery.

Clinical outcome after mosaicplasty of knee articular cartilage defects of patellofemoral joint versus tibiofemoral joint.

BACKGROUND: The purpose was to investigate survival of cartilage repair in the knee joint by osteochondral autograft transfer stratified by location of the lesion; patellofemoral joint (N = 26) versus the medial or lateral femoral condyles (N = 58). METHODS: For survival analyses, "failure" was defined as the event of a patient reporting a poor Lysholm score (below 65 points) or undergoing a knee replacement procedure. RESULTS: The survival distribution was not significantly different between the patellofemoral joint and the tibiofemoral joint groups. CONCLUSIONS: The current study suggest that similar long-term outcome can be expected after OAT procedures for the patellofemoral or tibiofemoral joint. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Long-Term Survival after Microfracture and Mosaicplasty for Knee Articular Cartilage Repair: A Comparative Study Between Two Treatments Cohorts.

OBJECTIVE: To investigate survival of cartilage repair in the knee by microfracture (MFX; n = 119) or mosaicplasty osteochondral autograft transfer (OAT; n = 84). DESIGN: For survival analyses, "failure" was defined as the event of a patient reporting a Lysholm score <65 or undergoing an ipsilateral knee replacement. The Kaplan-Meier method was used for construction of a survival functions plot for the event "failure." Log rank (Mantel-Cox) test was used for comparison of survival distributions in the 2 groups. RESULTS: The long-term failure rate (62% overall) was significantly higher in the MFX group (66%) compared with the OAT group (51%, P = 0.01). Furthermore, the mean time to failure was significantly shorter (P < 0.001) in the MFX group, 4.0 years (SD 4.1) compared with the OAT group, 8.4 years (SD 4.8). In the OAT group, the survival rate stayed higher than 80% for the first 7 years, and higher than 60% for 15 years, while the survival rate dropped to less than 80% within 12 months, and to less than 60% within 3 years in the MFX group, log rank (Mantel-Cox) 20.295 (P < 0.001). The same pattern was found in a subgroup of patients (n = 134) of same age (<51 years) and size of treated lesion (<500 mm2), log rank (Mantel-Cox) 10.738 (P = 0.001). The nonfailures (48%) were followed for median 15 yeas (1-18 years). CONCLUSIONS: MFX articular cartilage repairs failed more often and earlier than the OAT repairs, both in the whole cohort and in a subgroup of patients matched for age and size of treated lesion, indicating that the OAT repair is the more durable. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Return to Play and Long-term Participation in Pivoting Sports After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is a common and feared injury among athletes because of its potential effect on further sports participation. Reported rates of return to pivoting sports after ACL reconstruction (ACLR) vary in the literature, and the long-term consequences of returning have rarely been studied. PURPOSE: To examine the rate and level of return to pivoting sports after ACLR, the duration of sports participation, and long-term consequences of returning to pivoting sports. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: All primary ACLRs with a bone-patellar tendon-bone autograft between 1987 and 1994 (N = 234) in athletes participating in team handball, basketball, or soccer before injury were selected from a single-center quality database. A long-term evaluation (median, 25 years; range, 22-30 years) was performed using a questionnaire focusing on return to pivoting sports, the duration of sports activity after surgery, later contralateral ACL injuries, revision surgery, and knee replacement surgery. Participants were stratified into 2 groups depending on the time between injury and surgery (early, <24 months; late, ≥24 months). RESULTS: A total of 93% of patients (n = 217) responded to the questionnaire. Although 83% of patients returned to pivoting sports after early ACLR, only 53% returned to preinjury level. Similar return-to-sport rates were observed in males and females (P > .05), but males had longer sports careers (median, 10 years; range, 1-23 years) than females (median, 4 years; range, 1-25 years; P < .001). The incidence of contralateral ACL injuries was 28% among athletes who returned to sports versus 4% among athletes who did not return (P = .017) after early ACLR. The pooled reinjury rate after return to preinjury level of sports was 41% (30%, contralateral injuries; 11%, revision surgery). The incidence of contralateral ACL injuries was 32% among females versus 23% among males (P > .05) and, for revision surgery, was 12% among females versus 7% among males (P > .05) after returning to sports. Having a late ACLR was associated with an increased risk of knee replacement surgery (9% vs 3%; P = .049) when compared with having an early ACLR. CONCLUSION: ACLR does not necessarily enable a return to preinjury sports participation. By returning to pivoting sports after ACLR, athletes are also facing a high risk of contralateral ACL injuries. Long-term evaluations in risk assessments after ACLR are important, as a significant number of subsequent ACL injuries occur later than the routine follow-up.

Computed Tomography Assessment of Anatomic Graft Placement After ACL Reconstruction: A Comparative Study of Grid and Angle Measurements.

BACKGROUND: The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement. PURPOSE: To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone-patellar tendon-bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate. RESULTS: The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic (P < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups (HAM: 0.009; BPTB: 0.065; REV: 0.041). CONCLUSION: The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts.

Osteochondral Autograft Transplant (Mosaicplasty) for Knee Articular Cartilage Defects.

Osteochondral autograft transplant (mosaicplasty) is a cartilage repair procedure for patients with knee articular cartilage lesions of a substantial size (>3 cm2). Patient selection is key to a successful result; patients with established osteoarthritis or systematic disorders such as rheumatoid arthritis should not undergo surgery. An exercise program involving neuromuscular training for a minimum of 3 months should be attempted before proceeding to osteochondral autograft transplant. The procedure can, in many cases, be performed arthroscopically. Patients should, however, provide consent for a mini-arthrotomy as this might be needed to achieve optimal access for graft harvesting and insertion. The procedure, in general, consists of 4 major steps. (1) At the initial arthroscopic examination, the size and localization of the defect are assessed after a proper debridement has been performed. The number and size of autografts needed can thereafter be assessed. (2) Graft harvesting is then performed from the periphery of the non-weight-bearing trochlea. (3) To prepare for graft insertion at the recipient site, a drill guide is inserted perpendicular to the joint surface in the defect to allow graft sockets to be reamed. (4) Grafts should be spaced approximately 3 mm apart to avoid confluence of tunnels and weakening of condyles. The orientation and depth of insertion of the grafts are key to mimic the native curvature of the affected joint surface. After an initial phase of non-weight-bearing focusing on range of motion, a gradual increase in neuromuscular exercises is recommended. Patients are typically advised to delay their return to sports until 6 months at the earliest. Results after mosaicplasty have shown that the procedure improves subjective outcomes, compared with baseline function, for up to 10 years after surgery. The additional effect over traditional microfracture treatment is, however, reduced over time. A study evaluating early factors affecting outcomes after cartilage repair procedures (including mosaicplasty) found that a series of factors, such as the time from the onset of symptoms to surgery, number and size of lesions, location and quality of surrounding cartilage, as well as concomitant meniscal injuries, were important3.

Long-term results after surgical treatment of subacromial pain syndrome with or without rotator cuff tear.

PURPOSE: Some studies suggest a common degenerative path might contribute to a range of shoulder diseases involving subacromial pain syndrome and full-thickness rotator cuff tears. One could therefore theorize arthroscopic subacromial decompression and rotator cuff repair as interventions at different stages of a degenerative shoulder disease. Few studies have compared long-term outcomes after these two procedures. METHOD: Matched case-controls undergoing arthroscopic rotator cuff repair combined with subacromial decompression (N = 180) or subacromial decompression only (N = 180) were evaluated pre- and 7.5 years postoperatively using QuickDASH score, VAS of function, VAS of pain and VAS of satisfaction. New surgery and complications were recorded. Baseline characteristics were related to outcomes to investigate predictors of good/poor outcome. RESULTS: A general improvement from baseline was seen - from 51 to 14 (QuickDASH) in the combined group and from 53 to 16 in the decompression only group. No differences in outcomes were seen between groups (n.s.). Age above 55 at surgery predicted better VAS of function (P = .04) while acute onset of symptoms predicted better QuickDASH in the combined group (P = 0.03). None in the decompression group had undergone later rotator cuff repair. CONCLUSION: Major improvements in pain/function were seen at mid- to long-term after isolated arthroscopic subacromial decompression and combined decompression/rotator cuff repair. Several patient-specific factors predicting worse outcomes were identified.

Early determinants of long-term clinical outcome after cartilage repair surgery in the knee.

PURPOSE: To identify early determinants of clinical outcome after knee cartilage repair. METHODS: 205 patients were evaluated before surgery and at median 14-years follow-up. RESULTS: Baseline factors predicting a good outcome were: single lesion; normal appearing cartilage surrounding the lesion; high baseline Lysholm score; short duration of symptoms; non-involvement of the patella-femoral joint; young age; and small defect. Factors predicting a poor outcome were: multiple lesions; low baseline Lysholm score; degenerative cartilage surrounding the lesion; long symptom duration; meniscal lesion; and large defect. CONCLUSIONS: The choice of surgical method seem to be less important than other patients-specific predictors. LEVEL OF EVIDENCE: Case series, Level IV.

Protruding anterior medial meniscus-An indirect sign of posterior cruciate ligament deficiency.

BACKGROUND: to examine if PROTruding of the Anterior Medial Meniscus (PROTAMM) could be an indirect sign of PCL deficiency by comparing PROTAMM to passive posterior tibial sagging (PSS) for chronic PCL rupture on routine MRI. METHODS: Patients with PCL reconstruction between 2011 and 2016 were included in a case control study. Primarily cases with combined ACL/PCL injury were excluded. Secondary exclusion criteria were bony fractures, medial meniscus pathology and poor quality MRIs. Three (blinded) observers reviewed the pre-operative MRIs according to a pre-defined protocol. RESULTS: After applying the inclusion and primary exclusion criteria 16 patients were identified in the PCL rupture group. The control group consisted of 15 patients. After reviewing the MRIs, 6 were excluded due to secondary exclusion criteria. Mean PPS measured 4.8 mm (±â€¯4.4 mm) in the PCL rupture group and 1.8 mm (±2.9 mm) in the control group, p = 0.05. Mean PROTAMM was 3.6 mm (±0.6 mm) in the PCL rupture group and 0.7 mm (±0.9 mm) in the control group, p = 0.004. CONCLUSION: We found a mean PROTAMM of 3.6 mm in patients with PCL rupture. We suggest that this sign, after knee injury in an otherwise normal medial meniscus, is a promising indirect sign of PCL deficiency compared to PPS. Implementation of this sign in clinical practice may improve the sensitivity of routine non-weight bearing MRI in identifying PCL deficient knees.