Purpose To determine the clinical and radiographic efficacy of hyaluronic acid–based cell-free scaffold applied in combination with microfracture versus microfracture alone in patients with focal ...osteochondral lesion of the knee joint. Methods Clinical data of 43 patients between 24 and 55 years of age were evaluated. Hyaluronic acid–based cell-free scaffold was applied in combination with microfracture for 19 knees (group 1), whereas microfracture alone was the surgical intervention for 24 knees (group 2). All lesions were Outerbridge grade III or IV with a mean size of 3.6 ± 1.3 cm2 . The mean follow-up time was 25.7 months. Visual analog scale (VAS), Lysholm knee score, and Tegner activity scale were the instruments used to evaluate the clinical status. Magnetic resonance observation of cartilage repair tissue (MOCART) system was used to analyze the characteristics of repair tissue. Results Better VAS and Lysholm scores were detected in group 1 at 12 and 24 months ( P = .019 and P = .025). According to the Tegner activity scale, group 1 had also better activity level at the end of 24 months after surgery ( P = .020). The mean time from surgery to return to nonimpact sports activities was 7.8 months in group 1, whereas it was 9.2 months in group 2 ( P = .013). Complete repair with the filling of the defect was achieved in 7 (36.8%) of the knees in group 1, whereas it was 4 (16.6%) of the knees in group 2 according to the MOCART system at 24 months. Conclusions Single-stage regenerative cartilage surgery using hyaluronic acid–based cell-free scaffold in combination with microfracture for focal osteochondral lesions of the knee revealed promising clinical outcomes at 24 months of follow-up, but the clinical significance of the differences seen is simply not known. Level of Evidence Level III, retrospective comparative study.
U.S. high school athletes sustain millions of injuries annually. Detailed patterns of knee injuries, among the most costly sports injuries, remain largely unknown. We hypothesize that patterns of ...knee injuries in U.S. high school sports differ by sport and sex.
U.S. high school sports-related injury data were collected for 20 sports using the National High School Sports-Related Injury Surveillance System, High School RIO™. Knee injury rates, rate ratios (RR), and injury proportion ratios were calculated.
From 2005/2006 to 2010/2011, 5116 knee injuries occurred during 17,172,376 athlete exposures (AE) for an overall rate of 2.98 knee injuries per 10,000 AE. Knee injuries were more common in competition than in practice (rate ratio = 3.53, 95% confidence interval CI = 3.34-3.73). Football had the highest knee injury rate (6.29 per 10,000 AE) followed by girls' soccer (4.53) and girls' gymnastics (4.23). Girls had significantly higher knee injury rates than boys in sex-comparable sports (soccer, volleyball, basketball, baseball/softball, lacrosse, swimming and diving, and track and field; RR = 1.52, 95% CI = 1.39-1.65). The most commonly involved structure was the medial collateral ligament (reported in 36.1% of knee injuries), followed by the patella/patellar tendon (29.5%), anterior cruciate ligament (25.4%), meniscus (23.0%), lateral collateral ligament (7.9%), and posterior cruciate ligament (2.4%). Girls were significantly more likely to sustain anterior cruciate ligament injuries in sex-comparable sports (RR = 2.38, 95% CI = 1.91-2.95). Overall, 21.2% of knee injuries were treated with surgery; girls were more often treated with surgery than boys in sex-comparable sports (injury proportion ratio = 1.30, 95% CI = 1.11-1.53).
Knee injury patterns differ by sport and sex. Continuing efforts to develop preventive interventions could reduce the burden of these injuries.
The diagnosis and treatment of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries have evolved over the past 30 years. A detailed physical examination along with ...careful review of the magnetic resonance imaging and stress radiographs will guide decision making. Early ACL reconstruction and acute MCL repair are recommended when there is increased medial joint space opening with valgus stress in extension, a significant meniscotibial deep MCL injury (high-riding medial meniscus), or a displaced tibial-sided superficial MCL avulsion (stener lesion of the knee). Delayed ACL reconstruction to allow for MCL healing is advised when increased valgus laxity is present only at 30 degrees of flexion and not at 0 degree. However, at the time of ACL surgery, medial stability has to be re-assessed after the reconstruction is completed. In patients with neutral alignment in the chronic setting, graft reconstruction of both the ACL and MCL is recommended.
Purpose
Meniscal injuries occurring during multi-ligament knee injuries (MLKI) are underreported. The purpose of this study was to compare the incidence and type of meniscal tears seen at the time of ...multi-ligament reconstruction surgery compared to those occurring during isolated anterior cruciate ligament (ACL) surgery.
Methods
Patients undergoing surgical treatment for MLKI and ACL-only injuries between 2010 and 2020 were reviewed. Two-hundred and thirty-five patients were included in the MLKI group. There were 131 chronic injuries and 104 acute injuries. Two-hundred and twenty-two ACL-only chronic injuries were used as a control group for comparison with the chronic MLKI group. Demographic data, type of meniscal tears, ligament injury patterns (Schenck classification) and time from injury to surgery were recorded. A delayed procedure was defined by a 4-week interval after the knee injury.
Results
A meniscus was torn in 69 knees (29.4%): 36 knees (15.3%) with an isolated medial meniscus tear, 33 knees (17.9%) with an isolated lateral meniscus tear,.Nine knees (3.8%) had both menisci torn. MLKI with medial or lateral-sided bicruciate ligament injuries (KDIIIM-KDIIIL) were significantly associated with a lower rate of meniscal tears than knee injuries involving the ACL-only and medial/lateral-sided ligament injuries (KDI) (medial-sided injuries
p
= 0.025; lateral-sided injuries
p
= 0.049). Lateral-sided injuries had significantly less meniscal damage than medial-sided injuries: 22/124 (17.7%) vs. 41/100 (41%); (
p
< 0.001). No significant differences were found for frequency, type and distribution of meniscal tears between acute and chronic MLKI surgery. ACL-only chronic injuries were associated with a higher rate of meniscal tears: 123/222 knees (55.4%) vs. 35/131 (26.9%) chronic MLKI; (
p
< 0.001), mainly involving the medial meniscus: 102/222 (46%) vs. 18/131 (13.7%); (
p
< 0.001).
Conclusions
Meniscal tears were less common in the MLKI group than in the isolated ACL injury group. The degree of ligament injury patterns and the side of the injured collateral ligament influenced the type and incidence of meniscal damage. Contrary to isolated ACL injuries, a delayed procedure was not associated with a higher rate of meniscal lesions but did influence the type of treatment. Understanding of meniscal tears patterns in MLKI helps to improve the treatment management of these complex injuries.
Summary Objective To evaluate the clinical effectiveness of intraarticular IL-1 receptor antagonist (IL-1Ra) for anterior cruciate ligament (ACL) tear. Methods Eleven patients with acute ACL tear ...confirmed by magnetic resonance imaging (MRI) were randomized to receive a single intraarticular injection of IL-1Ra (anakinra 150 mg, n = 6) or equal volume of saline placebo (1 ml, n = 5). The double-blinded treatment was administered a mean 2 weeks after injury. Synovial fluid (SF) ( n = 9 patients) and sera (all patients) were available at baseline (prior to injection) and immediately prior to surgery (mean 35 days later) and analyzed for SF IL-1α, IL-1β, IL-1Ra and serum hyaluronan (HA), an indicator of synovial inflammation. The primary outcome, standardized Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, was obtained at 0 (baseline), 4, and 14 days after injection. Results Compared with placebo, the IL-1Ra group had substantially greater improvement in key outcomes over 14 days (KOOS pain P = 0.001; activities of daily living P = 0.0015; KOOS sports function P = 0.0026; KOOS quality of life (QOL) P = 0.0048; and total KOOS P < 0.0001). There were no adverse reactions in either group. SF IL-1α ( P = 0.05) and serum HA ( P = 0.03), but not IL-1β, or IL-1Ra, decreased significantly in the IL-1Ra but not the placebo treated patients. Compared with placebo, IL-1α was borderline significantly different in the IL-1Ra treated group ( P = 0.06). Conclusions Administered within the first month following severe knee injury, IL-1Ra reduced knee pain and improved function over a 2-week interval. This promising proof of concept study provides a new paradigm for studies of acute joint injury and suggests that a larger follow-up study is warranted.
Operative management of an acute anterior cruciate ligament (ACL) rupture may be required in young and active patients to stabilize the knee and return patients to desired daily activities. ACL ...reconstruction should be performed anatomically. The majority of studies show no differences between anatomic single-bundle and double-bundle ACL reconstruction with respect to patient-reported outcome scores. Double-bundle reconstruction may provide superior knee joint laxity measurements compared with the single-bundle technique. Following ACL reconstruction, the age and activity level of a patient are predictive of his or her time of return to sports and reinjury. Concomitant meniscal and/or cartilage damage at the time of surgery, in addition to a persistent knee motion deficit, are associated with the development of osteoarthritis after ACL reconstruction.
Background
The occurrence of osteoarthritis (OA), associated meniscal injuries, meniscectomy, and patient-related measures for patients treated nonoperatively after anterior cruciate ligament (ACL) ...injuries have not been well described in the literature in terms of natural history.
Hypothesis
Patients with ACL injury can achieve a low occurrence of tibiofemoral OA and good knee function when treated without ACL reconstruction.
Study Design
Cohort study (prognosis); Level of evidence, 2.
Methods
One hundred consecutive patients with an acute, complete ACL injury were observed for 15 years. All patients were primarily treated with activity modification and without ACL reconstruction. To achieve improved functional stability, supervised physical therapy was initiated early after injury. The patients were examined using anteroposterior weightbearing radiography. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used to quantify knee-related symptoms and knee function.
Results
Seventy-nine patients consented to radiographic examination and 93 completed the KOOS questionnaire. Thirteen patients (16%), all of whom were among the 35 patients whose knees were meniscectomized, developed radiographic tibiofemoral OA. In contrast, none of the remaining nonmeniscectomized and radiographed knees developed OA (n = 44) (P < .0001). Sixty-three patients (68%) had an asymptomatic knee. Twenty-two patients (23%) had undergone ACL reconstruction with a mean time of 4 years after injury.
Conclusion
The study had a favorable long-term outcome regarding incidence of radiographic knee OA, knee function and symptoms, and need for ACL reconstruction. Although risk factors for posttraumatic OA are multifactorial, the primary risk factor that stood out in this study was if a meniscectomy had been performed. Early activity modification and neuromuscular knee rehabilitation might also have been related to the low prevalence of radiographic knee OA. In patients with ACL injury willing to moderate activity level to avoid reinjury, initial treatment without ACL reconstruction should be considered.
Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequency. Treatment strategies ...have evolved as recent studies have identified unique considerations specific to the skeletally immature patient. The current literature now supports the trend toward early operative treatment to restore knee stability and prevent progressive meniscal and/or articular cartilage damage, but the optimal approach to ACL reconstruction in this age group remains controversial. Despite the reported clinical success of transphyseal reconstruction, iatrogenic growth disturbance secondary to physeal damage remains a genuine concern. The reluctance to place drill-holes across open physes has led to the development of numerous "physeal-sparing" reconstruction techniques using anatomic femoral and tibial footprints that have adequately restored anteroposterior and rotational knee stability in biomechanical studies but have demonstrated mixed results in the clinical setting. The intent of this review is to (1) highlight the unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete, (2) discuss preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury, (3) review transphyseal and physeal-sparing reconstruction techniques and highlight surgical technical considerations, (4) present clinical outcomes according to patient and technique-specific factors, and (5) review age-specific injury prevention treatment strategies and a novel treatment algorithm based on skeletal maturity. ACL reconstruction in the skeletally immature athlete typically results in a successful clinical outcome, yet the optimal surgical technique is still controversial. This review will help guide the management of ACL injuries in the pediatric athlete.
Posterior root tears of the lateral meniscus Feucht, Matthias J.; Salzmann, Gian M.; Bode, Gerrit ...
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA,
01/2015, Letnik:
23, Številka:
1
Journal Article
Recenzirano
Purpose
To summarize and discuss the current knowledge on posterior lateral meniscus root tears.
Methods
A comprehensive review of the MEDLINE database was carried out to identify relevant articles ...using different keywords (e.g. “meniscus root”, “root tear”, “meniscus avulsion”, “radial tear” and “lateral meniscus”). The reference lists of the reviewed articles were searched for additional relevant articles.
Results
Posterior lateral meniscus root tears are found in 7–12 % of patients with a tear of the anterior cruciate ligament (ACL). Biomechanical studies have found an increase in lateral compartment contact pressure of approximately 50 % after creation of a posterior lateral meniscus root tear. There is some evidence that the biomechanical consequences of these injuries are significantly influenced by the presence and integrity of the meniscofemoral ligaments. Clinical studies have found encouraging results after repair of posterior lateral meniscus root tears. Whether root repair can prevent the development of osteoarthritis is currently unknown.
Conclusion
A posterior lateral meniscus root tear is a clinical relevant but most likely underrecognized concomitant injury in patients with a tear of the ACL. This article may support clinicians in diagnosing and treating this unique type of meniscus tear.
Level of evidence
V.
Background:
A flattened posterior tibial slope may cause excessive unwanted stress on the posterior cruciate ligament (PCL) reconstruction graft and place patients at risk for PCL reconstruction ...graft failure. To date, there is a paucity of biomechanical studies evaluating the effect of posterior tibial slope on the loading properties of single-bundle (SB) and double-bundle (DB) PCL grafts.
Purpose/Hypothesis:
The purpose of this study was to quantify the effect of sagittal plane tibial slope on PCL reconstruction graft force at varying slopes and knee flexion angles for SB and DB PCL reconstructions. The null hypothesis was that there would be no differences in SB or DB PCL graft forces with changes in posterior tibial slope or knee flexion angle.
Study Design:
Controlled laboratory study.
Methods:
Ten male fresh-frozen cadaveric knees had a proximal posterior tibial osteotomy performed and an external fixator placed for tibial slope adjustment. SB (anterolateral bundle ALB only) and DB PCL reconstruction procedures were performed and tested consecutively for each specimen. The ALB and posteromedial bundle graft forces were recorded before (unloaded force) and after (loaded force) compression with a 300-N axial load. Unloaded and loaded graft forces were tested at flexion angles of 45°, 60°, 75°, and 90°. Tibial slope was varied between −2° and 16° of posterior slope at 2° increments under these test conditions.
Results:
Modeling for unloaded testing revealed that tibial slope had an independently significant and linear decreasing effect on the force of all PCL grafts regardless of flexion angle (coefficient = −1.0, SE = 0.08, P < .001). Higher knee flexion angles were significantly associated with higher unloaded graft force for all PCL grafts (P < .001). After the graft was subjected to loading, tibial slope also had an independently significant and linear decreasing effect on the loaded force of all PCL grafts regardless of flexion angle (coefficient = −0.70, SE = 0.11, P < .001). The ALB graft of DB reconstructions had a significantly lower loaded graft force than the ALB graft of the SB PCL reconstruction (coefficient = 14.8, SE = 1.62, P < .001). The posteromedial bundle graft had a significantly lower loaded graft force than the ALB graft in both reconstruction states across all flexion angles (both P < .001). Higher knee flexion angles were also significantly associated with higher loaded graft force for all graft constructs (P < .001).
Conclusion:
PCL graft forces increased as tibial slope decreased (flattened) in the loaded and unloaded states. An increased posterior tibial slope was protective of PCL reconstruction grafts. The findings of this study support the effect of tibial slope on PCL grafts that has been noted clinically, and a flat tibial slope should be considered a factor when evaluating the cause of failed PCL reconstructions.
Clinical Relevance:
The authors validated that decreased tibial slope increased the loads on PCL reconstruction grafts. Patients with flat tibial slopes in chronic tears or revision PCL reconstruction cases should be evaluated closely for the possible need of a first-stage or concurrent slope-increasing tibial osteotomy.
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