Does an early post traumatic knee brace reduce the incidence of knee rotational instability?

PURPOSE: Several anterolateral stabilization procedures have been developed recently to address rotational instability of the knee. Currently, these procedures tend to be systematically used by some practitioners. However, antero-lateral structures of the knee (including the anterolateral ligament, ALL) have a self-healing potential which can reduce the need to perform an antero-lateral procedure. In this study, it was hypothesized that early post-traumatic immobilization of the knee with a knee brace would allow partial healing of antero-lateral structures and also allow control of the pivot shift, thus avoiding antero-lateral extra-articular stabilization. The objective of this study was to compare the severity of pivot shift between two groups of patients who all experienced anterior cruciate ligament (ACL) tear and respectively underwent post-traumatic immobilization of the knee versus no immobilization. METHODS: This was a comparative, multicentric (three centers' study) retrospective, consecutive study including 168 patients who underwent ACL reconstruction between May and September 2022. The application or not of post-traumatic immobilization and its duration, the severity of pivot shift observed in the operating room under general anesthesia, the presence of anterolateral lesions as revealed by MRI and the patients' pre-injury sport activity were recorded. RESULTS: A grade 3 pivot shift was found in 44 patients (27%). It was more frequently observed in the group without a brace compared to the group with a knee brace (18 patients out of 36: 50% versus 26 patients out of 132: 19.7%; p = 0.0012). Wearing a brace, whether hinged (OR = 0.221, [0.070-0.652]; p = 0.006) or not (OR = 0.232, [0.076-0.667]; p = 0.0064), was protective from the risk of developing a significant pivot shift. CONCLUSION: This study demonstrated that the presence of pivot-shift was lower in the patients that had an early post-injury knee brace before their ACL reconstruction. Based on this result, systematic brace placement could be advocated for in patients after knee trauma. LEVEL OF EVIDENCE: III, prognostic retrospective case-control study.

Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol.

PURPOSE: Despite many protocols that have been proposed, there's no consensus in the literature regarding the optimal rehabilitation program and return to sports (RTS) protocol following isolated meniscal repair. The aim of this current concept review is to look at the evidence of rehabilitation and RTS program after isolated meniscal repair, focusing on general and specific protocols per type of injury trying to give some guidelines based on the current state of knowledge. METHODS: A narrative literature review was performed searching PubMed database to identify relevant articles from January 1985 to October 2021 on rehabilitation and RTS after isolated meniscal repair. Randomized controlled trials (RCTs), prospective and retrospective cohort studies, case series, systematic reviews, meta-analyses, cadaveric studies and basic science studies were included. RESULTS: When the hoop tensile stress effect is preserved, an accelerated rehabilitation program may be suggested. Hence, partial weight bearing (20 kg) in association with ROM limited to 90° is allowed for the first four weeks, followed by weight bearing as tolerated. In contrast, when circumferential hoop fibers are disrupted, a restricted rehabilitation protocol may be recommended. In this scenario no weight bearing is allowed for the first six weeks after the surgery and range of motion (ROM) is limited to 90°. CONCLUSION: Biomechanical evidence suggests that tailoring an individualized protocol based upon the type of lesion and meniscus stability is reasonable. LEVEL OF EVIDENCE: Level V.

[Rupture of the anterior cruciate ligament in women]. / Lésions du ligament croisé antérieur chez la femme.

Rupture of the anterior cruciate ligament (ACL) is a frequent injury, and it affects women more often than men. The increased incidence in females was attributed to biological, anatomical, and mechanical differences when compared to males' counterparts. Hormones, menstrual cycle, and genetic factors are also implicated. Dynamic factor such as hip, knee and ankle biomechanics while jumping, landing, and cutting activities are established contributors to ACL rupture in females. Social and economic aspects both is sports and daily life are currently implicated in increased risk of injury and delayed return to sport. Therefore, they should be taken into consideration when studying ACL injury risk factors and when developing rehabilitation and prevention programs.

La rupture du ligament croisé antérieur (LCA) est fréquente et touche plus souvent les femmes que les hommes. L'incidence accrue chez les femmes a été attribuée à des différences biologiques, anatomiques et mécaniques. Les hormones, le cycle menstruel et les facteurs génétiques jouent aussi un rôle. Les facteurs dynamiques tels que la biomécanique de la hanche, du genou et de la cheville lors des activités de saut, d'atterrissage et de pivot sont des facteurs de risque prouvés de la rupture du LCA chez les femmes. Les aspects sociaux et économiques, tant dans le sport que dans la vie quotidienne, sont impliqués dans l'augmentation du risque de blessures et le retard du retour au sport. Ils doivent donc être pris en compte lors de l'étude des facteurs de risque de blessure du LCA et de l'élaboration de programmes de rééducation et de prévention.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft is a viable option for small-statured female patients.

PURPOSE: The choice of graft for anterior cruciate ligament (ACL) reconstruction remains controversial. The quadriceps tendon (QT) autograft is a good alternative for ACL reconstruction. However, concerns regarding its use in short-statured patients, related to donor site morbidity, anterior knee pain, or loss of muscle strength remain. This study aimed to compare muscle strength and morbidity between patients with short and normal statures following ACL reconstruction with a QT autograft. METHODS: A total of 73 female patients (mean age, 33.8 ± 11.5 years) who underwent primary ACL reconstruction between 2016 and 2019 were included. Patients were categorized into two groups: group S, with a height ≤ 163 cm, and group L, with a height > 163 cm. Muscle strength, harvesting site morbidity, and ACL-return to sport after injury scale (ACL-RSI) were evaluated, with a mean timing of the follow-up of 9.0 ± 2.3 months. RESULTS: The mean quadriceps strength for the isokinetic measurements at 60° and 240° was 65.0% and 74.0% in group S, respectively, and 70.0% and 75.7% in group L, respectively. There was no significant difference in the postoperative muscle strength or mean ACL-RSI (group S, 70.0; group L, 65.9) between the groups. No donor site morbidity was observed in either group. CONCLUSION: Muscle strength recovery, morbidity, and readiness to return to sports were similar in both groups, which supports the possibility of QT autografts for patients with a small stature. The results of this study may provide useful information for surgeons who are hesitant to perform QT autografts because of patient physique. LEVEL OF EVIDENCE: IV.

[Classification and treatment of modern traumatic meniscal tears]. / Classification et traitement modernes des déchirures méniscales traumatiques.

The menisci have several important biomechanical functions. Traumatic meniscal injuries present a wide spectrum of presentation and several types of lesions. They can concern the body of the meniscus and its fixation. An easy and clear classification of traumatic meniscus tears is essential for helping the physicians to achieve the correct surgical indication and the accurate postoperative rehabilitation protocol. The aim of this current concept review is to clearly describe some classical as well new type of meniscal and menisco-synovial lesions such as ramp lesions, root tears and instability of the lateral meniscus associated to rotational laxity. The goal is to focus on the definition, diagnosis, classification, giving some guidelines and discussing the different rehabilitation protocols.

Les ménisques sont essentiels au fonctionnement biomécanique du genou. Les lésions méniscales traumatiques peuvent se manifester par des tableaux cliniques très variés et concerner le corps du ménisque, ses attaches à l'os ou à la capsule articulaire. Une classification simple et claire des déchirures méniscales traumatiques est indispensable. Cette revue de la littérature contemporaine fait un tableau précis des lésions méniscales traumatiques classiques et « nouvelles ¼ telles que celles de la rampe, les avulsions de la racine méniscale et l'instabilité du ménisque externe associée à une laxité rotatoire du genou, en se focalisant sur la définition de chacune de ces déchirures, leur diagnostic, leur classification, afin de proposer des directives de traitement et de rééducation.

The posteromedial corner of the knee: an international expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To establish recommendations for diagnosis, classification, treatment, and rehabilitation of posteromedial corner (PMC) knee injuries using a modified Delphi technique. METHODS: A list of statements concerning the diagnosis, classification, treatment and rehabilitation of PMC injuries was created by a working group of four individuals. Using a modified Delphi technique, a group of 35 surgeons with expertise in PMC injuries was surveyed, on three occasions, to establish consensus on the inclusion or exclusion of each statement. Experts were encouraged to propose further suggestions or modifications following each round. Pre-defined criteria were used to refine item lists after each survey. The final document included statements reaching consensus in round three. RESULTS: Thirty-five experts had a 100% response rate for all three rounds. A total of 53 items achieved over 75% consensus. The overall rate of consensus was 82.8%. Statements pertaining to PMC reconstruction and those regarding the treatment of combined cruciate and PMC injuries reached 100% consensus. Consensus was reached for 85.7% of the statements on anatomy of the PMC, 90% for those relating to diagnosis, 70% relating to classification, 64.3% relating to the treatment of isolated PMC injuries, and 83.3% relating to rehabilitation after PMC reconstruction. CONCLUSION: A modified Delphi technique was applied to generate an expert consensus statement concerning the diagnosis, classification, treatment, and rehabilitation practices for PMC injuries of the knee with high levels of expert agreement. Though the majority of statements pertaining to anatomy, diagnosis, and rehabilitation reached consensus, there remains inconsistency as to the optimal approach to treating isolated PMC injuries. Additionally, there is a need for improved PMC injury classification. LEVEL OF EVIDENCE: Level V.

An isolated Posterolateral corner injury with rotational instability and hypermobile lateral meniscus: a novel entity.

PURPOSE: Although complete tear of the knee posterolateral corner (PLC) commonly occurs in combination with other knee ligamentous injuries, the incidence of isolated PLC injury was reported only 28% and overlooked in many cases. Nevertheless, an isolated PLC injury does not only provoke posterolateral instability, but also may be associated to hypermobile lateral meniscus. This study aims at showing the characteristics of isolated PLC injuries and to alert potential overlooked cases by describing their arthroscopic findings and clinical characteristics. METHODS: Seventy-one patients with a clinically proven isolated PLC injury who underwent knee arthroscopy were included in this study. Pre-operative symptoms and clinical signs at examination were recorded: Pain at the posterolateral aspect, feelings of instability, catching, locking; and for clinical signs: McMurray test, varus stress test in extension and at 30° of flexion, posterolateral drawer test at 30° and 80°, dial test at 30° and 80° of flexion. In terms of arthroscopic findings, systematic meniscal stability was performed to evaluate the presence of hypermobile lateral meniscus, "lateral drive through test" was also recorded in all cases. RESULTS: Positive Lateral Drive through test was found in 69 patients (95.8%). Hypermobile lateral meniscus was seen in all patients. CONCLUSIONS: Hyper mobile lateral meniscus was concomitant with all isolated PLC injuries in our case series. As the typical arthroscopic characteristic, lateral drive through test positive were seen in 95.8%. In order to prevent overlooking this concomitant pathology, meticulous arthroscopic observation is crucial. LEVEL OF EVIDENCE: Level IV.

In vivo static and dynamic lengthening measurements of the posterior cruciate ligament at high knee flexion angles.

PURPOSE: Rehabilitation is an important aspect of both non-operative and operative treatments of knee ligament tear. Posterior cruciate ligament (PCL) non-operative treatment consists of a step-by-step rehabilitation protocol and is well described. It goes from rest (phase I) to strengthening exercises (phase IV). More specific and high-intensity exercises such as cutting, sidestepping or jumps are, however, not described in detail, as no in vivo data exist to tell how these exercises constrain the ligaments and whether they have the same effect on all of them, in particular regarding lengthening. The goal of this study was to measure the ligament lengthening in static knee flexion based on 3D reconstructions from magnetic resonance imaging (MRI) and from motion capture and ligament simulation during dynamic exercises. METHODS: The knee of nine volunteers was first imaged in a closed-bore MRI scanner at various static knee flexion angles (up to 110°), and the corresponding lengthening of the PCL and the other major knee ligaments was measured. Then, the volunteers underwent motion capture of the knee where dynamic exercises (sitting, jumping, sidestepping, etc.) were recorded. For each exercise, knee ligament elongation was simulated and evaluated. RESULTS: According to the MRI scans, maximal lengthening occurred at 110° of flexion in the anterior cruciate ligament and 90° of flexion in the PCL. Daily living movements such as sitting were predicted to elongate the cruciate ligaments, whereas they shortened the collateral ligaments. More active movements such as jumping put the most constrain to cruciate ligaments. CONCLUSION: This study provides interesting insights into a tailored postoperative regimen. In particular, knowing the knee ligament lengthening during dynamic exercises can help better define the last stages of the rehabilitation protocol, and hence provide a safe return to play.

Multi-body optimization with subject-specific knee models: performance at high knee flexion angles.

When estimating knee kinematics from skin markers and stereophotogrammetry, multi-body optimization (MBO) has provided promising results for reducing soft tissue artefacts (STA), but can still be improved. The goal of this study was to assess the performance of MBO with subject-specific knee models at high knee flexion angles (up to 110°) against knee joint kinematics measured by magnetic resonance imaging. Eight subjects were recruited. MBO with subject-specific knee models was more effective in compensating STA compared to no kinematic and spherical constraints, in particular for joint displacements. Moreover, it seems to be more reliable over large ranges of knee flexion angle. The ranges of root mean square errors for knee rotations/displacements were 3.0°-9.2°/1.3-3.5 mm for subject-specific knee models, 6.8°-8.7°/6.0-12.4 mm without kinematic constraint and 7.1°-9.8°/4.9-12.5 mm for spherical constraints.

[Sport-related concussion]. / La commotion cérébrale dans le sport.

Sport-related concussion is a frequent and complex pathology whose physiopathological mechanisms are not completely understood yet. A recent consensus statement has been published with the objective to provide practicioners with an overview of literature and give some guidelines based on the current state of knowledge. An 11R approach (Recognise, Remove, Re-evaluate, Rest, Rehabilitation, Refer, Recover, Return to sport, Reconsider, Residual effects and sequelae, Risk reduction) is proposed to evaluate and manage sport-related concussion. There is currently no available test predicting recovery, but the risk factors for a slow recovery are now known. Return to daily activities (as school) and to full sport participation should follow the graduated return-to-school or - sport strategy, and the ultimate decision is clinically based, and made by the physician.

La commotion dans le sport est une pathologie fréquente, complexe et dont les mécanismes physiopathologiques ne sont pas encore entièrement élucidés. Un consensus international vient récemment d'être publié avec une mise à jour des connaissances scientifiques, fournissant des conseils pour le médecin de terrain. L'évaluation et la prise en charge de la commotion se résument par les 11 R : Reconnaître, Retirer, Réévaluer, Repos, Réhabilitation, Référer, Récupérer, Retour au sport, Reconsidérer, séquelles et symptômes Résiduels, prévention du Risque. Il n'existe à ce jour aucun test pouvant prédire l'évolution de la commotion, mais certains facteurs sont reconnus comme responsables d'une récupération lente. Le retour à l'école et au sport est une décision médicale, après avoir suivi un protocole de réhabilitation progressive.

Is Quadriceps Tendon Autograft a Better Choice Than Hamstring Autograft for Anterior Cruciate Ligament Reconstruction? A Comparative Study With a Mean Follow-up of 3.6 Years.

BACKGROUND: The quadriceps tendon (QT) autograft is known as an effective graft for anterior cruciate ligament (ACL) reconstruction and shows a similar functional outcome to the bone-patellar tendon-bone (BPTB) in randomized controlled trials, with a lesser incidence of complications. Up until now, only 2 studies have compared QT to hamstring tendon (HT) autograft. HYPOTHESIS: The functional outcomes of the QT technique are at least as good as those of the HT technique, with the same morbidity. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Ninety-five patients underwent isolated ACL reconstruction between January 1 and December 31, 2012. Fifty underwent ACL reconstruction with the QT and 45 with the HT. The same surgical technique, fixation method, and postoperative protocol were used in both groups. The following parameters were evaluated: surgical revisions, functional outcome (Lysholm, Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner, subjective International Knee Documentation Committee), joint stability (KT-1000, Lachman, pivot shift), anterior knee pain (Shelbourne-Trumper score), and isokinetic strength. Descriptive statistics are presented for these variables using the Student t test. RESULTS: Eighty-six patients (45 QT, 41 HT) were reviewed with a mean follow-up of 3.6 ± 0.4 years; minimum follow-up was 3 years. There were 4 reoperations in the QT group (including 1 ACL revision) and 3 in the HT group (including 2 ACL revisions) ( P > .05). The Lysholm (89 ± 6.9 vs 83.1 ± 5.3), KOOS Symptoms (90 ± 11.2 vs 81 ± 10.3), and KOOS Sport (82 ± 11.3 vs 67 ± 12.4) scores were significantly better in the QT group than in the HT group. In terms of stability, the mean side-to-side difference was 1.1 ± 0.9 mm for the QT group and 3.1 ± 1.3 mm for the HT group based on KT-1000 measurements ( P < .005). The negative Lachman component was higher in the QT group than in the HT group (90% vs 46%, P < .005). There was a trend for the negative pivot-shift component to be higher in the QT group than in the HT group (90% vs 64%, P = .052). The Shelbourne-Trumper score was the same in both groups. There was no difference between groups in terms of isokinetic strength. CONCLUSION: The use of a QT graft in ACL reconstruction leads to equal or better functional outcomes than does the use of an HT graft, without affecting morbidity.

[Current treatment strategy of meniscal lesions in athletes]. / Prise en charge actuelle des lésions méniscales chez l'athlète.

The primary goal of meniscal treatment in elite athletes is to guarantee knee function for sports performance and to prevent osteoarthritic changes. The meniscus acts not only as cushion in the femorotibial joint but also as a major secondary stabilizer with its posterior medial and lateral horns. Therefore, the integrity of the meniscal tissue is crucial for knee function and needs to be preserved, especially when the meniscal lesion is found in the periphery (vascularized zone). For ideal tissue healing, a stable knee is prerequisite.Partial meniscectomy as little as possible is only performed, if the lesion cannot be sutured, is highly degenerative or localized in the non-vascularized (white-white) area which has low to none healing potential.

La prise en charge d'une lésion méniscale chez l'athlète consiste, entre autres, à obtenir la cicatrisation de cette dernière dans le but de retrouver l'indolence et de limiter l'évolution arthrosique. Comme le ménisque est non seulement un amortisseur, mais contribue aussi hautement à la stabilité articulaire avec ses cornes postérieures interne et externe, sa préservation méniscale est primordiale, d'autant plus si elle est périphérique (zone vascularisée du ménisque), donc à fort potentiel de cicatrisation. Pour la guérison méniscale, l'intégrité ligamentaire du genou est indispensable. La méniscectomie ne doit être envisagée qu'en dernier recours lorsque la lésion n'est pas réparable, ou située dans la zone avasculaire du ménisque, qui est à faible potentiel de cicatrisation. Dans tous les cas, la méniscectomie doit être la plus économe possible.

Total knee arthroplasty after high tibial osteotomy: a comparison of opening and closing wedge osteotomy.

PURPOSE: High tibial osteotomy (HTO) is frequently used to treat varus osteoarthritis in younger patients with the goal of delaying the need for total knee arthroplasty (TKA). While it has been reported that the results of TKA following HTO are worse than those in patients without prior knee surgery, the influence of osteotomy technique (medial opening-wedge versus lateral closing-wedge) has not been explored. The purpose of this study was to evaluate the influence of HTO technique on the performance and results of TKA. METHODS: A total of 141 TKA's performed in 118 patients with prior HTO (24 opening wedge and 117 closing wedge) were reviewed at a mean follow-up of two years. Reviewed data included intra-operative factors (tourniquet time, the need for additional exposure, and intra-operative complications), clinical results (International Knee Score (IKS)) and radiographic assessment of limb alignment. RESULTS: The average IKS knee and function scores improved from 54.0 and 60.3 to 87.0 and 79.5 (p < 0.0001). There was no significant difference in IKS scores based on osteotomy technique. There was a trend toward an increased need for tibial tubercle osteotomy in the closing wedge group. There was an increased need for extensive medial release in the opening wedge group and extensive lateral release in the closing wedge group. No differences in tourniquet time, complication rates, or hip-knee-ankle angle were noted between the two groups. CONCLUSIONS: Radiographic limb alignment, patient-reported outcomes, and complication rates are equal in patients undergoing TKA after opening and closing wedge HTO.

Correlation of clinical and magnetic resonance imaging findings in hips of elite female ballet dancers.

PURPOSE: To understand why professional female ballet dancers often complain of inguinal pain and experience early hip osteoarthritis (OA). Goals were to examine clinical and advanced imaging findings in the hips of dancers compared with those in a matched cohort of nondancers and to assess the femoral head translation in the forward split position using magnetic resonance imaging (MRI). METHODS: Twenty professional female ballet dancers and 14 active healthy female individuals matched for age (control group) completed a questionnaire on hip pain and underwent hip examination with impingement tests and measurement of passive hip range of motion (ROM). All had a pelvic 1.5 T MRI in the back-lying position to assess femoroacetabular morphologic features and lesions. For the dancers, additional MR images were acquired in the split position to evaluate femoroacetabular congruency. RESULTS: Twelve of 20 dancers complained of groin pain only while dancing; controls were asymptomatic. Dancers' passive hip ROM was normal. No differences in α neck angle, acetabular depth, acetabular version, and femoral neck anteversion were found between dancers and controls. MRI of dancers while performing splits showed a mean femoral head subluxation of 2.05 mm. MRI of dancers' hips showed labral tears, cartilage thinning, and herniation pits, located in superior and posterosuperior positions. Lesions were the same for symptomatic and asymptomatic dancers. Controls had proportionally the same number of labral lesions but in an anterosuperior position. They also had 2 to 3 times fewer cartilage lesions and pits than did dancers. CONCLUSIONS: The results of our study are consistent with our hypothesis that repetitive extreme movements can cause femoral head subluxations and femoroacetabular abutments in female ballet dancers with normal hip morphologic features, which could result in early OA. Pathologic changes seen on MRI were symptomatic in less than two thirds of the dancers. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Anterior Cruciate Ligament Reconstruction and Osteoarthritis: Evidence from Long-Term Follow-Up and Potential Solutions.

OBJECTIVE: The goals of this study are to address several questions, the answers to which are key to the understanding and eventually to the prevention of this frequent source of morbidity. These questions include the following: (1) What is the natural history of anterior cruciate ligament (ACL) deficiency? (2) How important is the status of the meniscus at the time of reconstruction? (3) Does ACL reconstruction prevent the development of osteoarthritis in the long term? (4) Can we predict which patients will develop osteoarthritis? (5) What can be done? DESIGN: This study addresses the key questions above through the long-term follow-up of a cohort of patients treated with ACL reconstruction by Professor Henri Dejour in Lyon, France, supplemented with a review of the relevant literature. RESULTS: The prevalence of osteoarthritis in ACL-deficient knees is about 40% after 15 years and close to 90% after 25 to 35 years. It remains unclear whether reconstruction of the ACL significantly reduces this risk. The status of the meniscus at the time of ACL reconstruction is a strong predictor of the risk of osteoarthritis: Patients who undergo total meniscectomy are at 2- to 10-fold increased risk of developing osteoarthritis relative to those with intact menisci. Patients showing early evidence of arthritis at short- to medium-term follow-up are at high risk for progression over subsequent years. Numerous emerging techniques may provide tools to more effectively prevent and treat osteoarthritis following ACL injury in the future. CONCLUSION: Osteoarthritis following ACL injury continues to be a major problem requiring further research.

[Rehabilitation after rotator cuff repair: developments and recommendations]. / Rééducation après chirurgie de la coiffe des rotateurs: développements et recommandations.

Rehabilitation post surgical repair of the rotator cuff is an important determinant of the quality of the healing process, and of the clinical and functional results. Techniques used have been reported to favor certain of those parameters at the expense of others. Several approaches have been proposed; none has reached a consensus yet. The level of evidence in the literature does not allow for definitive recommendations and elaborating a protocol relies on clinical experience as well as expert opinion, incorporating scientific data. An initial period of rest with limited passive motion emerges though as an approach suited to the treatment of most clinical situations.

[Unicompartmental knee replacement]. / Prothèses unicompartimentales du genou.

Unicompartmental knee arthroplasties (UKA) have been created to treat primary unicompartmental knee arthritis. They are indicated in case of lower-limb deformity due to unicompartmental arthritis, but not to treat unicompartmental arthritis due to extra-articular deformity. Early failures are do to ligamentar problems or to surgical technical errors. Late failures as wear or loosening are undoubtely delayed by adequate surgical indication and technique. Indeed the 10 years PUC survival is 90%. Patient age is not a selection criteria because both young (50-60 years old) and old (> 80 years old) patients may benefit of a UKA. UKA allows a young patient to continue low-impact sports and octagenarians will benefit of the lower morbidity of UKA surgery.

Double incision iso-anatomical ACL reconstruction: the freedom to place the femoral tunnel within the anatomical attachment site without exception.

AIM: The present paper describes the rationale behind the surgical technique and the clinical results of the iso-anatomical, single bundle bone patellar-tendon bone anterior cruciate ligament (ACL) reconstruction. METHOD: Using a second incision on the distal lateral femur an outside-in femoral tunnel is drilled. Guided by a special aiming device it is possible to place the femoral tunnel in the centre of the ACL footprint in every single case. CONCLUSION: Since every crucial step of the procedure is under visual control, the technique is safe and reliable, which is mirrored by good clinical results.

ACL reconstruction and extra-articular tenodesis.

The purpose of this article is to update the orthopedic community on the role of lateral extra-articular tenodesis in the management of anterior cruciate ligament-deficient knees. Information includes historical perspective, current applications and techniques, and a review of published outcomes.

Extreme hip motion in professional ballet dancers: dynamic and morphological evaluation based on magnetic resonance imaging.

OBJECTIVE: To determine the prevalence of femoroacetabular impingement (FAI) of the cam or pincer type based on magnetic resonance imaging (MRI) in a group of adult female professional ballet dancers, and to quantify, in vivo, the range of motion (ROM) and congruence of the hip joint in the splits position. MATERIALS AND METHODS: Institutional review board approval and informed consent from each volunteer were obtained. Thirty symptomatic or asymptomatic adult female professional ballet dancers (59 hips) and 14 asymptomatic non-dancer adult women (28 hips, control group) were included in the present study. All subjects underwent MRI in the supine position, while, for the dancers, additional images were acquired in the splits position. Labral abnormalities, cartilage lesions, and osseous abnormalities of the acetabular rim were assessed at six positions around the acetabulum. A morphological analysis, consisting of the measurement of the α angle, acetabular depth, and acetabular version, was performed. For the dancers, ROM and congruency of the hip joint in the splits position were measured. RESULTS: Acetabular cartilage lesions greater than 5 mm were significantly more frequent in dancer's hips than in control hips (28.8 vs 7.1%, p = 0.026), and were mostly present at the superior position in dancers. Distribution of labral lesions between the dancers and the control group showed substantially more pronounced labral lesions at the superior, posterosuperior, and anterosuperior positions in dancers (54 lesions in 28 dancer's hips vs 10 lesions in 8 control hips). Herniation pits were found significantly more often (p = 0.002) in dancer's hips (n = 31, 52.5%), 25 of them being located in a superior position. A cam-type morphology was found for one dancer and a retroverted hip was noted for one control. Femoroacetabular subluxations were observed in the splits position (mean: 2.05 mm). CONCLUSION: The prevalence of typical FAI of the cam or pincer type was low in this selected population of professional ballet dancers. The lesions' distribution, mostly superior, could be explained by a "pincer-like" mechanism of impingement with subluxation in relation to extreme movements performed by the dancers during their daily activities.