Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment.

PURPOSE: The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS: For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE: Level V.

Management after acute injury of the anterior cruciate ligament (ACL), part 2: management of the ACL-injured patient.

PURPOSE: The aim of this consensus project was to create a treatment algorithm for the management of the ACL-injured patient which can serve as an aid in a shared decision-making process. METHODS: For this consensus process, a steering and a rating group were formed. In an initial face-to-face meeting, the steering group, together with the expert group, formed various key topic complexes for which various questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS: During this consensus process, 15 key questions were identified. The literature search for each key question resulted in 24 final statements. Of these 24 final statements, all achieved consensus. CONCLUSIONS: This consensus process has shown that ACL rupture is a complex injury, and the outcome depends to a large extent on the frequently concomitant injuries (meniscus and/or cartilage damage). These additional injuries as well as various patient-specific factors should play a role in the treatment decision. The present treatment algorithm represents a decision aid within the framework of a shared decision-making process for the ACL-injured patient. LEVEL OF EVIDENCE: Level V.

Pneumorrhachis: A rare cause of headache in a patient with a traumatic spinal cord injury due to gunshot wound.

CONTEXT: A pneumorrhachis (PR) is a rare phenomenon in which air is found in the spinal canal. There are multiple etiologies, including iatrogenic, nontraumatic, and traumatic. Most traumatic PR are asymptomatic and resolve on their own, but a subset are symptomatic and require urgent surgical intervention. This case describes a traumatic PR in which a headache was the primary symptom. FINDINGS: A 17-year-old male sustained a gunshot wound to the left flank with associated bilateral pulmonary lacerations, multiple rib fractures, and T5-7 vertebral body fractures with displaced bony fragments causing spinal cord injury with resultant paraplegia (T3 AIS-A) was admitted to inpatient rehabilitation. Three weeks into his course of rehabilitation, he developed throbbing headaches that were found to be caused by a subarachnoid PR. He underwent a T4-7 laminectomy with repair of dural tear and theco-pleural-bronch-fistula closure, and his headaches subsequently resolved. DISCUSSION/CLINICAL RELEVANCE: This case demonstrated that a headache can be a presenting symptom of a subarachnoid PR.

Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG).

BACKGROUND: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined. PURPOSE: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL. STUDY DESIGN: Consensus statement. METHODS: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests. RESULTS: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements. CONCLUSION: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.

Clinical examination of partial ruptures of the anterior cruciate ligament: A retrospective case-control study.

BACKGROUND: Anterior drawer test, Lachman test including evaluation of the endpoint, and pivot shift test have been commonly applied clinically in diagnosing anterior cruciate ligament (ACL) injury but how they function in the appraisal of partial ACL tears is less known. The aims of this study were to examine the diagnostic values of the commonly used knee function tests on patients in detecting ACL injury including partial injury patterns, to assess each of the test's predictive values on the specific ACL injury pattern, and to assess if using multiple tests collectively for the diagnosis of the injury could improve diagnostic accuracy. METHODS: We evaluated 36 consecutive patients who underwent ACL single bundle augmentation surgery. Those patients were matched by gender and age to 36 patients with a complete rupture of the ACL. Data was obtained from the patients' records. The rupture pattern was confirmed by arthroscopy. An examination under anesthesia was routinely performed by two surgeons who were blinded to the rupture pattern prior to surgery. RESULTS: Collectively using both Lachman test and pivot shift test increases ability to distinguish between partial tears and complete ruptures. When comparing partial PL tears and complete ruptures the pivot shift test is more important than the Lachman test. In diagnosing a complete rupture, the evaluation of the endpoint during the Lachman test is more sensitive than the evaluation of the anterior tibial translation during the Lachman test. CONCLUSION: Based on the findings of this study, a diagnostic algorithm has been implemented and is presented in this manuscript.

Variation in the shape of the tibial insertion site of the anterior cruciate ligament: classification is required.

PURPOSE: To propose a classification system for the shape of the tibial insertion site (TIS) of the anterior cruciate ligament (ACL) and to demonstrate the intra- and inter-rater agreement of this system. Due to variation in shape and size, different surgical approaches may be feasible to improve reconstruction of the TIS. METHODS: One hundred patients with a mean age of 26 ± 11 years were included. The ACL was cut arthroscopically at the base of the tibial insertion site. Arthroscopic images were taken from the lateral and medial portal. Images were de-identified and duplicated. Two blinded observers classified the tibial insertion site according to a classification system. RESULTS: The tibial insertion site was classified as type I (elliptical) in 51 knees (51 %), type II (triangular) in 33 knees (33 %) and type III (C-shaped) in 16 knees (16 %). There was good agreement between raters when viewing the insertion site from the lateral portal (κ = 0.65) as well as from the medial portal (κ = 0.66). Intra-rater reliability was good to excellent. Agreement in the description of the insertion site between the medial and lateral portals was good for rater 1 and good for rater 2 (κ = 0.74 and 0.77, respectively). CONCLUSION: There is variation in the shape of the ACL TIS. The classification system is a repeatable and reliable tool to summarize the shape of the TIS using three common patterns. For clinical relevance, different shapes may require different types of reconstruction to ensure proper footprint restoration. Consideration of the individual TIS shape is required to prevent iatrogenic damage of adjacent structures like the menisci. LEVEL OF EVIDENCE: III.

Area of the tibial insertion site of the anterior cruciate ligament as a predictor for graft size.

PURPOSE: To determine the distribution of different sizes of the area of the tibial insertion site among the population and to evaluate whether preoperative MRI measurements correlate with intraoperative findings to enable preoperative planning of the required graft size to cover the tibial insertion site sufficiently. The hypothesis was that the area of the tibial insertion site varies among individuals and that there is good agreement between MRI and intraoperative measurements. METHODS: Intraoperative measurements of the tibial insertion site were taken on 117 patients. Three measurements were taken in each plane building a grid to cover the tibial insertion site as closely as possible. The mean of the three measurements in each plane was used for determination of the area. Two orthopaedic surgeons, who were blinded to the intraoperative measurements, took magnetic resonance imaging (MRI) measurements of the area of the tibial insertion site at two different time points. RESULTS: The intraoperative measured mean area was 123.8 ± 21.5 mm2. The mean area was 132.8 ± 15.7 mm2 (rater 1) and 136.7 ± 15.4 mm2 (rater 2) when determined using MRI. The size of the area was approximately normally distributed. Inter-rater (0.89; 95 % CI 0.84, 0.92; p < 0.001) and intrarater reliability (rater 1: 0.97; 95 % CI 0.95, 0.98; p < 0.001; rater 2: 0.95; 95 % CI 0.92, 0.96; p < 0.001) demonstrated excellent test-retest reliability. There was good agreement between MRI and intraoperative measurement of tibial insertion site area (ICCs rater 1: 0.80; 95 % CI 0.71, 0.87; p < 0.001; rater 2: 0.87; 95 % CI 0.81, 0.91; p < 0.001). CONCLUSION: The tibial insertion site varies in size and shape. Preoperative determination of the area using MRI is repeatable and enables planning of graft choice and size to optimally cover the tibial insertion site. LEVEL OF EVIDENCE: III.