Editorial Commentary: A Revisit of an Old Clinical Dilemma-To Operate or Not to Operate on Acute Knee Anterior Cruciate Ligament Injuries.

There is a feeling among knee surgeons that operating on an acute anterior cruciate ligament injury will increase the incidence of arthrofibrosis. A recent systematic review and meta-analysis of 7 recent articles compared early versus delayed anterior cruciate ligament reconstruction. The conclusions were that the clinical and stability results were comparable in both groups.

Initial evaluation of posterior cruciate ligament injuries: history, physical examination, imaging studies, surgical and nonsurgical indications.

Compared with anterior cruciate ligament injuries, posterior cruciate ligament injuries are a rare event. The mechanisms are predictable and a thorough physical examination is mandatory to rule out or define combined injury patterns. Stress radiography and magnetic resonance imaging studies are very helpful adjuncts. Acute and chronic injuries require slightly different approaches. As our understanding of normal and pathologic knee joint kinematics develops, nonoperative rehabilitation goals and operative techniques continue to evolve.

The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing the healing environment.

Platelet-rich plasma (PRP) is a new technology focused on enhancing the healing response after injury of different tissue types. PRP is prepared by withdrawal of patients' peripheral blood and centrifugation to obtain a highly concentrated sample of platelets, which undergo degranulation to release growth factors with healing properties. It also contains plasma, cytokines, thrombin, and other growth factors that are implicated in wound healing and have inherent biological and adhesive properties. The prepared concentrate is then injected back into the patient at the site of morbidity. This may be intralesional, intra-articular, or surrounding the involved tissue bed. PRP preparations have been used therapeutically in various medical fields from implantology to vascular ulcers, with a more recent evolution and promising results in the field of sports medicine and arthroscopy. Sports medicine patients desire a rapid return to their preinjury level of function, and PRP may have certain applications that will speed recovery in cases of tendon, ligament, muscle, and cartilage disorders. In particular, anterior cruciate ligament reconstruction has shown better autograft maturation, improved donor site morbidity, and pain control, in addition to improved allograft incorporation. By acceleration of the biological integration of the graft by use of PRP, patients may undergo faster, more intensive rehabilitation programs and return to sports more rapidly. Because of its autogenous origin, easy preparation, and excellent safety profile, the advent of PRP has opened another therapeutic door for sports medicine physicians and orthopaedic surgeons. Future directions of PRP include improving the results of arthroscopic and related surgery, in addition to delineating correct dosage, timing, and quantification, as well as ideal techniques of PRP application.

Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest.

Increased stability has been reported with both autografts and allografts for anterior cruciate ligament (ACL) reconstruction. However, meta-analysis has shown significantly lower overall knee stability rates and more than double the abnormal stability rate with allografts. Some issues surrounding allograft sterilization (ie, risk of disease transmission) are unresolved, and cost is also a concern. Single-bundle ACL reconstruction can produce high stability rates when tunnels are properly placed, but there is evidence that double-bundle repair may offer greater rotatory stability. Cortical fixation has been associated with increased stability owing to the high stiffness of cortical bone. Anterior and posterior approaches are both recommended. The controversy related to single-bundle versus double-bundle ACL reconstruction remains unresolved.

High failure rate for electrothermal shrinkage of the lax anterior cruciate ligament: a multicenter follow-up past 2 years.

PURPOSE: The purpose of this study was to prospectively evaluate the midterm results (beyond 2 years) of thermal shrinkage on both lax native anterior cruciate ligament (ACL) and lax reconstructions and determine the effectiveness of this procedure. METHODS: This is a multicenter study in which 64 patients from 2 sites underwent electrothermal shrinkage for a lax ACL, both native and previous reconstructions. They were followed up past 2 years with KT-1000 measurements (MEDmetric, San Diego, CA). Failure criteria included subsequent operations for instability or KT-1000 measurements greater than 5 mm. Three patients were lost to follow-up. RESULTS: Among the 61 patients followed up past 2 years, failure occurred in 31 (50.8%). The failure rate for lax grafts alone was 78.9%, and there was a failure rate of 38.1% for lax native ligaments. CONCLUSIONS: Electrothermal shrinkage of lax native or reconstructed ACLs is not an appropriate treatment.

Arthroscopic meniscal repair using the BioStinger.

PURPOSE: Biodegradable devices are available for all-inside meniscal repairs. One device, the BioStinger (Linvatec, Largo, FL), is made of molded poly-L-lactic acid. The purpose of this study was to evaluate the effectiveness of and any adverse events associated with meniscus repair using this device. TYPE OF STUDY: Nonrandomized prospective cohort study. METHODS: A prospective, consecutive, 3-center meniscal repair series using BioStingers (group 1), vertical inside-out sutures (group 2), or hybrid repairs combining BioStingers and sutures (group 3) was studied. Lysholm, Tegner, Cincinnati, and IKDC activity scores were obtained and clinical outcomes and adverse events documented. RESULTS: There were 85 patients who underwent 89 meniscus repairs with an average 26.5 months of follow-up. There were 47 BioStinger repairs (group 1), 29 suture repairs (group 2), and 13 hybrid repairs (group 3). The tear length was statistically greater for the hybrid repair group (P < .5). There were 73 repairs associated with anterior cruciate ligament reconstructions and 12 repeat arthroscopies were performed. Meniscal healing failed in 6 knees (4 in group 1, 0 in group 2, and 2 in group 3). The meniscal healing failed in 7% of those associated with anterior cruciate ligament reconstructions. Mean Tegner scores improved from 2.8 to 6.3, the final IKDC activity score was 3.2 out of 4, the mean Lysholm score improved from 51 to 88, and the mean Cincinnati score improved from 44 to 84. Two BioStinger repair cases had joint-line tenderness from device migration confirmed by magnetic resonance imaging. No tenting of the skin or articular cartilage scuffing was observed. CONCLUSIONS: The success rate for the 29 suture repairs was 100% and for the 47 BioStinger repairs was 91%. These preliminary results are consistent with other repair techniques. LEVEL OF EVIDENCE: Level II, Therapeutic Prospective Cohort Study.

A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments.

Alpine skiing is a global winter recreational sport with 15 million participants in the United States alone, and an overall injury rate of 2.5 per 1,000 ski person-days. Isolated injury to the anterior cruciate ligament (ACL) or the medial collateral ligament (MCL) is common among ski injuries; however, combined injury to these structures is rare. Controversy in the management of ACL instability following alpine ski injury is diminishing with improvements in the techniques of intra-articular cruciate reconstruction. However, the management of the combined ACL-MCL injury remains something of an enigma. Evidence exists to support both surgical and nonsurgical management strategies for the medial structures, but little consensus exists for the timing of the repair. This paper highlights the mechanisms of ski injuries that can result in combined injury to the ACL and MCL. The anatomy and biomechanics of the medial complex as it relates both to stability and operative repair are reviewed, and literature on the techniques and indications used for MCL repair in the setting of a combined injury is presented. On the basis of this review, we believe that an injury to the MCL does not need to be repaired if the ACL is reconstructed after a combined injury.

Basic science in digital imaging: storage and retrieval.

This practical discussion reviews the current methods available for digital image storage and retrieval. The organization of digital images is important to allow easy retrieval of the data in the future. Examples of several software programs that will catalogue and retrieve the images are demonstrated.