LiaX is a surrogate marker for cell envelope stress and daptomycin non-susceptibility in Enterococcus faecium.

Daptomycin (DAP) is often used as a first-line therapy to treat vancomycin-resistant Enterococcus faecium infections, but emergence of DAP non-susceptibility threatens the effectiveness of this antibiotic. Moreover, current methods to determine DAP minimum inhibitory concentrations (MICs) have poor reproducibility and accuracy. In enterococci, DAP resistance is mediated by the LiaFSR cell membrane stress response system, and deletion of liaR encoding the response regulator results in hypersusceptibility to DAP and antimicrobial peptides. The main genes regulated by LiaR are a cluster of three genes, designated liaXYZ. In Enterococcus faecalis, LiaX is surface-exposed with a C-terminus that functions as a negative regulator of cell membrane remodeling and an N-terminal domain that is released to the extracellular medium where it binds DAP. Thus, in E. faecalis, LiaX functions as a sentinel molecule recognizing DAP and controlling the cell membrane response, but less is known about LiaX in E. faecium. Here, we found that liaX is essential in E. faecium with an activated LiaFSR system. Unlike E. faecalis, E. faecium LiaX is not detected in the extracellular milieu and does not appear to alter phospholipid architecture. We further postulated that LiaX could be used as a surrogate marker for cell envelope activation and non-susceptibility to DAP. For this purpose, we developed and optimized a LiaX enzyme-linked immunosorbent assay (ELISA). We then assessed 86 clinical E. faecium bloodstream isolates for DAP MICs and used whole genome sequencing to assess for substitutions in LiaX. All DAP-resistant clinical strains of E. faecium exhibited elevated LiaX levels. Strikingly, 73% of DAP-susceptible isolates by standard MIC determination also had elevated LiaX ELISAs compared to a well-characterized DAP-susceptible strain. Phylogenetic analyses of predicted amino acid substitutions showed 12 different variants of LiaX without a specific association with DAP MIC or LiaX ELISA values. Our findings also suggest that many E. faecium isolates that test DAP susceptible by standard MIC determination are likely to have an activated cell stress response that may predispose to DAP failure. As LiaX appears to be essential for the cell envelope response to DAP, its detection could prove useful to improve the accuracy of susceptibility testing by anticipating therapeutic failure.

Diet quality, Self-efficacy and Health Literacy in Adults with Chronic Kidney Disease: A Cross-Sectional Study.

OBJECTIVE: Adherence to high quality dietary patterns is associated with lower risk of disease progression and all-cause mortality in chronic kidney disease (CKD). Self-efficacy and health literacy are recognised as factors that may lead to better adherence to high quality diets. However, these associations are not well studied in CKD. This study aims to explore the relationship between health literacy, self-efficacy, and diet quality in CKD. METHODS: Participants with CKD stages 3a-5 recruited from three large tertiary hospitals were assessed using the Self-Efficacy for Managing Chronic Disease 6-item scale (SEMCD-6), the Health Literacy Questionnaire (HLQ) and the Australian Eating Survey (AES) Food Frequency Questionnaire. Diet quality was measured using the Australian Recommended Food Score (ARFS). Associations were examined using multivariable linear regression models, adjusted for sex and type 2 diabetes (T2D) diagnosis. RESULTS: Sixty participants were included in the analysis. Mean age of participants was 74.5 years old and 58% were male. The mean ARFS was poor (Mean=29.9±9.1/73) and characterised by high intake of processed foods and animal protein, and low intake of fruit and vegetables. Mean SEMCD-6 was high (7.12±2.07/10). Self-efficacy and health literacy domains 6 - Actively engage with healthcare providers and 7 - Navigating healthcare system independently predicted diet quality in the adjusted model for sex and T2D. CONCLUSION: Adults with CKD report suboptimal diet quality. The results suggest that self-efficacy and aspects of health literacy should be considered when designing interventions aimed at improving diet quality in people with CKD.

Never Assume Successful Treatment of Septic Arthritis: Bacteria Isolated at Revision ACL Reconstruction 3 Years After Primary ACL Reconstruction "Successfully" Treated for Infection.

LEVEL OF EVIDENCE: Level IV.

The deltoid ligament complex is reliably visualised as four fascicles in two layers with 3D volumetric MRI in the ankles of 20 asymptomatic volunteers.

PURPOSE: The anatomy of the deltoid ligament is complex. There is agreement on the presence of superficial and deep layers but the number and frequency of fascicles remains controversial. Identifying injuries to specific components of the deltoid ligament may inform decision-making on their management. The anatomy was reviewed to establish the number and dimension of fascicles visible with three-dimensional (3D) volumetric magnetic resonance images (MRI). METHODS: Twenty ankles from asymptomatic healthy volunteers were imaged with 3D volumetric MRI. The presence of individual fascicles was recorded and measured in 3D. RESULTS: The median age of participants was 26 years (range: 20-37) of which 13 (65%) were female. All 20 ankles had a deltoid ligament formed of four fascicles in two layers: three fascicles in the superficial layer; tibionavicular (mean dimensions 22.5 × 10.0 × 2.4 mm), tibiospring (16.6 × 6.7 × 1.9 mm) and tibiocalcaneal (23.8 × 4.6 × 1.8 mm) and a deep layer consisting of the tibiotalar fascicle, which could be divided into two parts: anterior tibiotalar (mean dimensions 10 × 5.6 × 4.1 mm) and the significantly larger posterior tibiotalar (14.2 × 13.8 × 17.5 mm, p < 0.01). There were no additional fascicles observed. CONCLUSIONS: The deltoid ligament complex was consistently visualised as four fascicles (tibionavicular, tibiospring, tibiocalcaneal, tibiotalar) in two layers (superficial and deep) in all 20 ankles. The posterior part of the tibiotalar fascicle was the thickest of all the fascicles in the deltoid ligament. It is, therefore, possible to accurately identify the components of the deltoid ligament, and 3T MRI can be used to assess fascicle-specific injury, which will guide treatment and rehabilitation. LEVEL OF EVIDENCE: Level III.

Ligament augmentation and reconstruction system (LARS) synthetic grafts are safe and effective for medial collateral ligament and posterolateral corner reconstructions in elite athletes.

PURPOSE: This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra-articular knee ligament reconstructions in elite athletes by reporting return-to-play (RTP) rates and levels, career longevity and complications. METHODS: A consecutive series of all extra-articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy-six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTP was defined as competing at professional level or national/international level in amateur sport. RESULTS: There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty-two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty-seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty-six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP. CONCLUSION: Utilising LARS to augment extra-articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications. LEVEL OF EVIDENCE: Level IV.

Lateral extra-articular tenodesis at primary ACL reconstruction increases career length in professional rugby players.

PURPOSE: To assess the effect of preoperative and surgical factors on return to play (RTP) rates and career longevity of professional rugby athletes after primary anterior cruciate ligament (ACL) reconstruction (ACL-R). METHODS: A retrospective review of a consecutive cohort of professional rugby players undergoing primary ACL-R by the senior author between 2005 and 2019 was undertaken. Athletes were included if they were under contract with a professional rugby team at the time of injury and had a minimum of 2-year follow-up. Univariate and multivariate analyses were performed to determine significant predictors of RTP rate, time and career longevity. RESULTS: One hundred and eighteen rugby players with 125 ACL-Rs were identified. Return to professional rugby was achieved in 115/125 (92%) of cases at an average of 9.6 months and those athletes participated at the professional level for 5.9 ± 3.4 years after ACL-R. Younger age (p = 0.006) and ACL-R with a concomitant lateral extra-articular tenodesis (LET) (p = 0.013) were predictors of a longer career. A Cox proportional hazards model that controlled for age revealed that athletes who underwent ACL-R with an LET had increased career longevity compared to those with an ACL-R without LET (hazard ratio = 2.74, p = 0.021). No factors were significantly associated with RTP rate or RTP time. CONCLUSION: In professional rugby players undergoing primary ACL-R, those having ACL-R with a concomitant LET and younger age predicted increased career longevity. Rugby players who underwent LET at the time of ACL-R had an 18% greater chance of still playing professionally at 5 years compared to those who underwent ACL-R alone. LEVEL OF EVIDENCE: Level III.

A prospective observational study of pH testing to confirm ongoing nasogastric tube position.

AIMS AND OBJECTIVES: To measure the reliability of pH testing to confirm ongoing nasogastric tube (NGT) position and to document associated complications. BACKGROUND: Confirming NGT position is essential, as use of an incorrectly positioned tube can cause harm. Substantial evidence examines initial confirmation of NGT position, yet limited evidence exists considers NGT displacement which is identified via ongoing NGT position tests. In the NHS, pH testing is recommended to confirm ongoing NGT position; however, there may be an association with excess X-rays and missed enteral nutrition and/or medications. DESIGN: Prospective observational study using STROBE checklist. METHODS: Data collected from medical records of 136 patients with NGTs in a London NHS Trust included pH tests, test results and complications related to ongoing pH tests which failed to confirm the tube was positioned in the stomach, that is, X-rays, and disruptions to enteral nutrition and medication. Cohen's Kappa determined pH test reliability. RESULTS: Of 1381 pH tests conducted to confirm NGT position, five (0.3%) correctly identified an NGT displacement, and one (0.07%) failed to identify displacement before use. The reliability of ongoing pH tests using Cohen's Kappa was minimal (0.29). Ongoing pH tests that failed to confirm a correctly positioned NGT led to 31 (22.8%) patients having X-rays, 24 (17.6%) missing >10% of prescribed enteral nutrition and 25 (18.4%) missing a critical medication. CONCLUSION: Ongoing NGT position testing using pH tests did not prevent the use of a displaced tube, and more than one-fifth of patients required X-rays to confirm a correctly position NGT, contributing to missed medications and enteral nutrition. RELEVANCE TO CLINICAL PRACTICE: Caution should be used when confirming ongoing NGT position with a pH test. Future guidelines should balance the risk of using a displaced tube with potential delays to nutrition and/or medication. More research is needed to explore alternative methods of ongoing NGT position testing.

A Comparative Effectiveness Study of Speech and Surgical Outcomes: Study Overview.

AIMS: To provide an overview of the Cleft Outcomes Research NETwork (CORNET) and the CORNET Speech and Surgery study. The study is (1) comparing speech outcomes and fistula rate between two common palate repair techniques, straight-line closure with intra-velar veloplasty (IVVP) and Furlow Double-Opposing Z-palatoplasty (Furlow Z-plasty); (2) summarizing practice variation in the utilization of early intervention speech-language (EI-SL) services; and (3) exploring the association between EI-SL services and speech outcomes. DESIGN: Prospective, longitudinal, observational, comparative effectiveness, multi-center. SITES: Twenty sites across the United States. PARTICIPANTS: One thousand two hundred forty-seven children with cleft palate with or without cleft lip (CP ± L). Children with submucous cleft palate or bilateral sensorineural severe to profound hearing loss were excluded from participation. INTERVENTIONS: Straight-line closure with IVVP or Furlow Z-plasty based on each surgeon's standard clinical protocol. MAIN OUTCOME MEASURE(S): The primary study outcome is perceptual ratings of hypernasality judged from speech samples collected at 3 years of age. Secondary outcomes are fistula rate, measures of speech production, and quality of life. The statistical analyses will include generalized estimating equations with propensity score weighting to address potential confounders. CURRENT PROGRESS: Recruitment was completed in February 2023; 80% of children have been retained to date. Five hundred sixty two children have completed their final 3-year speech assessment. Final study activities will end in early 2025. CONCLUSIONS: This study addresses long-standing questions related to the effectiveness of the two most common palatoplasty approaches and describes CORNET which provides an infrastructure that will streamline future studies in all areas of cleft care.

Paediatric rhabdomyolysis: A UK centre's 10-year retrospective experience.

AIMS: To describe the aetiologies of paediatric rhabdomyolysis and explore the medium-term renal consequences. METHODS: Retrospective, single-centre review of children with rhabdomyolysis. RESULTS: Two hundred and thirty-two children met inclusion criteria for the analysis. Mean age at presentation was 8.4 (SD ± 5.5) years. The commonest aetiology was infection (28%), with viral myositis making up the clear majority (75%). Trauma was identified as a cause in 18% of children, seizures in 10% and immune-mediated mechanisms in 8%. Acute kidney injury (AKI) was present in 32% of the cases overall. Children with AKI tended to be younger, with higher peak creatine kinase (CK) and active urinary sediment on urinalysis at presentation. AKI and the need for renal replacement therapy (RRT) were associated with a prolonged hospital stay (15 (interquartile range, IQR 6.5-33) vs. 2 (IQR 0-7) days). A total of 18 children and young people required RRT, with a mean duration of 7.1 ± 4.3 days. Those who received RRT were more likely to have abnormalities on urinalysis at presentation (46% vs. 5%). Over the period of the study, 9% of children died and 2% met criteria for a diagnosis of chronic kidney disease. CONCLUSIONS: This large paediatric rhabdomyolysis case series provides new and unique insights into the condition. Our results highlight the common aetiologies and provide evidence of good renal recovery overall, even in the most severely affected cases. Abnormalities of urinalysis appear to be important in predicting the development of AKI and the need for RRT.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction.

PURPOSE: To demonstrate return to play (RTP) rates, the level of RTP and time taken to RTP in different sports after anterior cruciate ligament reconstruction (ACL-R) and compare the differences between football and rugby. The secondary aims were to compare the differences in intra articular injuries and their treatments and reoperation rates between these sports. METHODS: A retrospective review of a consecutive series of all primary ACL-R undertaken by the senior author between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 year post-primary autograft ACL-R. The outcomes measured were RTP (defined as participation in a professional match or in national/international-level competition in amateur sports), time to RTP after surgery and RTP level (Tegner score). RESULTS: Three hundred and ninety-four elite athletes, with 420 ACL-Rs were included. 235 (55.9%) were in footballers and 125 (29.8%) were in rugby players. 399 (95.0%) of all elite athletes returned to competition at an average of 10.3 months after ACL-R. 386 (90.2% played at the same or higher level post-surgery. Although there was no difference in RTP rates between different sports, rugby players RTP significantly faster than footballers (9.6 vs 10.6 months, (p = 0.027). Footballers were more likely to rupture their ACL during jumping/landing manoeuvres and to receive a PT graft than rugby players. There were no other significant differences between football and rugby players regarding patient characteristics, intraoperative findings, re-rupture and re-operation rates. CONCLUSIONS: Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers. LEVEL OF EVIENCE: Level IV.

Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI.

PURPOSE: Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI. METHODS: Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed. RESULTS: Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery). CONCLUSION: Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex. LEVEL OF EVIDENCE: Level III.

Stop Consonant Production in Children with Cleft Palate After Palatoplasty.

The current study examined stop consonant production in children with cleft lip and/or palate (CP ± L) 2-6 months following palatal surgery.Prospective comparative study.Multisite institutional.Participants included 113 children with repaired CP ± L (mean age = 16 months) who were participating in the multicenter CORNET study.Parents of participants were asked to record approximately two hours of their child's vocalizations/words at home using a Language ENvironmental Analysis (LENATM) recorder. Four ten-minute audio-recorded samples of vocalizations were extracted from the original recording for each participant and analyzed for presence of oral stop consonants. A minimum of 100 vocalizations were required for analysis.Preliminary findings indicate that at least one oral stop was evident in the consonant inventory for 95 of the 113 children (84%) at the time of their post-surgery 16-month recording, and 80 of these children (71%) were producing two or more different stops. Approximately 50% of the children (57/113) produced the three voiced stops, and eight of the children (7%) were producing all six stop consonants.The findings of this study suggest that the majority of children with repaired CP ± L from English-speaking homes are producing oral stops within six months following palatal surgery. Similar to same-age children without CL ± P, voiced stops were more frequently evident in the children's inventories than voiceless stops. In contrast to findings of previous reports suggesting place of articulation differences, a somewhat comparable percentage of children in this study produced voiced bilabial, alveolar, and velar stops.

Transcribing toddler vocalizations: comparison of a modified naturalistic listening approach with phonetic transcription.

Previous investigations have demonstrated that naturalistic listening in real time (NLRT) can be used reliability to assess prelinguistic vocalizations and is less time-consuming than phonetic transcription. The current investigation was performed to examine the correspondence of syllable and consonant information obtained using a modified naturalistic listening in real time (NLRT) methodology compared to broad phonetic transcription for 20 toddlers with repaired cleft palate. A forty-minute vocalization sample was obtained for each toddler. Two listeners listened to each recording independently and coded the number of syllables and consonant types produced by each toddler using NLRT. Each recording was phonetically transcribed by each listener 2 to 16 months following the NLRT analysis. High reliability was evident between the modified NSRT method and phonetic transcription for identification of both syllables and consonants. Differences were evident in the actual number of syllables and consonants identified between the two types of assessment across the 20 participants. Possible explanations for those differences are addressed. The results of this investigation indicate that the modified NLRT procedure is a reliable method for determining consonant/inventories of young children. It is less labor intensive than traditional phonetic transcription and may be useful clinically when documentation of early sound development is needed to support early intervention decisions.

Plasma nervonic acid levels were negatively associated with attention levels in community-living older adults in New Zealand.

The global population is aging. Preserving function and independence of our aging population is paramount. A key component to maintaining independence is the preservation of cognitive function. Metabolomics can be used to identify biomarkers of cognition before noticeable deterioration. Our study investigated the plasma metabolome of 332 community-living New Zealanders between 65 and 74 years of age, using gas chromatography-mass spectrometry. Six cognitive domains were assessed. Of the 123 metabolites identified using an in-house mass spectral libraries of standards, nervonic acid had a significant, inverse association with the attention domain (P-value = 1.52E- 4; FDR = 0.019), after adjusting for covariates (apolipoprotein E -ε4 genotype, sex, body fat percentage (standardised by sex), age, education, deprivation index, physical activity, metabolic syndrome, polypharmacy, smoking status, and alcohol intake) and multiple testing. Attention is defined as the ability to concentrate on selected aspects of the environment while ignoring other stimuli. This is the first study to identify nervonic acid as a potential biomarker of attention in older adults. Future research should confirm this association in a longitudinal study.

Evidence-based rationale for treatment of meniscal lesions in athletes.

Meniscal injuries in elite athletes are a common cause of missed game time and even have the potential to be career shortening. In this patient group, care must be paid not only to the pathology, but also to a player's contract status, time in the season, specific demands of his/her sport and position on the field, and future consequences. Successful treatment requires the clinician to understand the player's goals and needs, communicate effectively between all stakeholders, and a have knowledge of the challenges posed by the different types of meniscal tear seen in this population. Paramount is the distinction between injuries to the medial and lateral meniscus. Deficiency of the lateral meniscus, as a result of a tear or a meniscectomy, leads to frequent early problems and inexorably to chondral degeneration thereby affecting an athlete's ability to perform. Therefore, it is strongly recommended to repair the majority of lateral meniscal tears. Medial meniscal tears pose a more challenging treatment dilemma, as the success of partial meniscectomy in achieving reproducible, early return to play must be balanced against the long-term degenerative consequences. Many meniscal tears are correctly treated non-operatively.Level of evidence V.

Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers.

PURPOSE: Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates. METHODS: A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. RESULTS: Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent effusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). CONCLUSION: Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation. LEVEL OF EVIDENCE: Level IV.

Anterolateral complex injuries occur in the majority of 'isolated' anterior cruciate ligament ruptures.

PURPOSE: The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. METHODS: Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. RESULTS: Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). CONCLUSION: There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.

High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury.

PURPOSE: In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures. METHODS: Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. RESULTS: Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. CONCLUSION: The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. LEVEL OF EVIDENCE: III.

Medial meniscal ramp lesions in ACL-injured elite athletes are strongly associated with medial collateral ligament injuries and medial tibial bone bruising on MRI.

PURPOSE: Medial menisco-capsular separations (ramp lesions) are typically found in association with anterior cruciate ligament (ACL) deficiency. They are frequently missed preoperatively due to low MRI sensitivity. The purpose of this article was to describe demographic and anatomical risk factors for ramp lesions, and to identify concomitant lesions and define their characteristics to improve diagnosis of ramp lesions on MRI. METHODS: Patients who underwent anterior cruciate ligament (ACL) reconstruction between September 2015 and April 2019 were included in this study. The presence/absence of ramp lesions was recorded in preoperative MRIs and at surgery. Patients' characteristics and clinical findings, concomitant injuries on MRI and the posterior tibial slope were evaluated. RESULTS: One hundred patients (80 male, 20 female) with a mean age of 22.3 ± 4.9 years met the inclusion criteria. The incidence of ramp lesions diagnosed at surgery was 16%. Ramp lesions were strongly associated with injuries to the deep MCL (dMCL, p < 0.01), the superficial medial collateral ligament (sMCL, p < 0.01), and a small medial-lateral tibial slope asymmetry (p < 0.05). There was also good correlation between ramp lesions and bone oedema in the posterior medial tibia plateau (MTP, p < 0.05) and medial femoral condyle (MFC, p < 0.05). A dMCL injury, a smaller differential medial-lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. MRI sensitivity was 62.5% and the specificity was 84.5%. CONCLUSION: The presence on MRI of sMCL and/or dMCL lesions, bone oedema in the posterior MTP and MFC, and a smaller differential medial-lateral tibial slope than usual are highly associated with ramp lesions visible on MRI. Additionally, a dMCL injury, a flatter lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. Knowledge of the risk factors and secondary injury signs associated with ramp lesions facilitate the diagnosis of a ramp lesion preoperatively and should raise surgeons' suspicion of this important lesion. LEVEL OF EVIDENCE: Diagnostic study, Level III.

High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes.

PURPOSE: The purpose of the study is to assess return to play rate and timing of elite athletes treated for multi-ligament knee injuries with modern surgical techniques. METHODS: A retrospective review was performed of all professional or national/international level athletes treated for a multi-ligament knee injury by the senior author in the period from February 2001 to October 2019, with a minimum of 2-year follow-up. The study cohort consisted of 136 elite athletes who underwent surgery of two or more knee ligaments. Outcomes measures were return to play (RTP), defined as return to elite level sport, return to play time, and further surgical procedures. RESULTS: One hundred and twenty (88.2%) athletes returned to elite level sport at an average of 12.8 months from operation. In unicruciate injuries, ACL and PCL-based injuries had similar return to play rates (89.1% vs. 87.5% respectfully, n.s.) although mean RTP time was longer in those with PCL-based injuries (15.2 vs. 11.9 months, p < 0.01). Bicruciate injuries had longer RTP times compared to unicruciate injuries (mean RTP 16.0vs. 12.4 months, p < 0.05) but were able to return at a similar rate (83.3% vs. 88.9%, n.s.). Medial and lateral sided injuries had similar RTP rates (89.3% vs. 87.9%, n.s.) though lateral sided injuries took longer before returning to play (13.4 vs. 11.6 months, p < 0.05). Further surgery was required in 54 (39.9%) patients including 25 (18.4%) manipulations under anaesthesia. Four (2.9%) of the athletes underwent revision ligament surgery. CONCLUSION: Modern surgical techniques used in the treatment of multi-ligament knee injuries can lead to high return to play rates in elite athletes. LEVEL OF EVIDENCE: IV.