Editorial Commentary: Patients With Thin Hip Capsules, Capsular Redundancy, Capsular Defects, Hypermobility, Dysplasia, and Female Patients Are at Increased Risk of Hip Instability.

Patients with thin hip capsules, capsular redundancy, capsular defects, hypermobility, dysplasia, and female patients are at increased risk of hip instability. As our understanding of the factors that contribute to hip instability has increased, so too has our ability to identify "at-risk" patients, in whom we should avoid surgery or perform capsular repair or plication following hip arthroscopy to achieve optimal results. We must tailor our surgical planning accord to gender, bony morphology, capsular volume, and properties of the tissue.

Editorial Commentary: Magnetic Resonance Imaging Evaluation of the Anterolateral Complex-Is Seeing Really Believing?

The anatomic and biomechanical role of the anterolateral complex (ALC) of the knee has gained increased interest in recent years. Specifically, a keen focus has been on magnetic resonance imaging (MRI) evaluation of the ALC in the setting of anterior cruciate ligament injury. Although many of these studies are well designed and conducted, they are based on a foundation of controversial gross anatomy and MRI protocols and scanners not typically used in standard practice. Ultimately, there is a lack of correlation between MRI evidence of injury to the ALC and clinical evaluation of anterolateral rotatory laxity. So, do we believe in what we see or believe in what we feel?

Editorial Commentary: Hip Arthroscopy Capsular Management-Cut Your Cloth to Measure!

Microinstability of the hip is a relatively recent concept but one that is gaining increased acceptance. As our understanding of the factors that contribute to microinstability has increased, so too has our ability to identify "at-risk" patients, in whom a capsular repair should be considered after hip arthroscopy to achieve optimal results and avoid iatrogenic instability (dislocation or microinstability). However, each of our patients is different, and as such, we must be able to tailor our capsulotomies and repairs accordingly based on the bony morphology, capsular volume, and properties of the tissue.

Editorial Commentary: Chicken or the Egg? The Ligamentum Teres and Degenerative Hip Disease.

The ligamentum teres has traditionally been described as a vestigial remnant or redundant structure with little contribution to hip biomechanics or function. However, interest in the ligamentum teres has been renewed as evidence has emerged that it not only plays a role as a pain generator in the hip but also acts as a secondary stabilizer to supplement the work of the capsular ligaments. Furthermore, an association has been proposed between tearing of the ligamentum teres and the development of degenerative hip disease. However, the question remains, is it a cause-and-effect relationship?

The Origin of the Knee Anterolateral Ligament Discovery: A Translation of Segond's Original Work With Commentary.

Paul Segond was a French surgeon who was in practice at the end of the 19th century. A prodigious anatomist, scientist, and surgeon in his day, he is best known for his treatise on the origin of traumatic hemarthrosis of the knee following injury. In this detailed description of the anatomy of the anterolateral aspect of the knee, he describes "a pearly, resistant, fibrous band that is placed under extreme tension when the knee is forcefully rotated internally," which has more recently been described as the anterolateral ligament or a capsular thickening contributing to the anterolateral complex of the knee. His work goes on to speculate about the role of this structure in controlling internal rotation of the knee. The original study was published in French in 1879. Although this work is widely cited, one must question whether many of the citing authors have actually had the opportunity to read it. As such, we sought to unlock this treasure by translating the original study into English and exposing this illuminating, forward-thinking and historical tour de force to the broader orthopaedic community.

Strength Testing After Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study Investigating Overlap of Tests.

Barfod, KW, Feller, JA, Clark, R, Hartwig, T, Devitt, BM, and Webster, KE. Strength testing after anterior cruciate ligament reconstruction: A prospective cohort study investigating overlap of tests. J Strength Cond Res 33(11): 3145-3150, 2019-The purpose of the present study was to determine whether overlap (redundancy) exists between individual tests in a comprehensive strength testing protocol used after anterior cruciate ligament reconstruction (ACLR). If overlap is present, one or more components of the protocol could potentially be omitted to make the testing protocol more efficient, but without compromising the usefulness of the testing. Sixty-nine patients (46 male and 23 female patients; mean age 28 years) were strength tested at 6 and 12 months after ACLR as part of a prospective cohort study. The following knee flexor and extensor strength tests were performed: isokinetic concentric strength at 60 and 180°·s, isokinetic eccentric strength at 60°·s, and isometric knee flexor strength at 60° flexion. Peak and average torque values were extracted, and the ratio between the operated and non-operated limb was calculated as a limb symmetry index. Overlap of strength tests was investigated by fitting a linear regression model to the data with an R threshold of 0.56 used as an indication of overlap. Overlap between peak and mean torque was present for extensor and flexor concentric and eccentric measurements at 12 months and for concentric measurements at 6 months. Peak torque measurements were therefore used for subsequent analysis. Concentric extensor peak torque at 60 and 180°·s showed overlap at 6 months (R = 0.73) but not at 12 months (R = 0.37). No other overlap was identified. In conclusion, there is little room for omission of individual strength testing protocol components because of the lack of overlap between tests. Isometric, eccentric, and concentric tests may all provide unique information and all, therefore, should be considered for inclusion.

Editorial Commentary: Should Proximal Hamstring Surgery Make You Nervous?

In recent times, there has been an increased awareness of high-grade proximal hamstring injuries, many of which are now being managed surgically. Yet, surgical treatment of these injuries is challenging and carries potential risks of serious neurologic complications. Indeed, it is likely that postoperative neurologic complications are under-recognized. As such, knowledge of the intimate anatomic relation of the pudendal nerve and other neural structures around the proximal hamstring is essential and should provide a road map for safer and more successful surgery.

Medial meniscal and chondral pathology at the time of revision anterior cruciate ligament reconstruction results in inferior mid-term patient-reported outcomes.

PURPOSE: Anterior cruciate ligament (ACL) injuries are frequently not isolated injuries and damage to the menisci and articular cartilage surfaces is common. The concomitant presence of meniscal and chondral damage has the potential to influence patient outcomes following ACL reconstruction surgery and especially following revision ACL reconstruction where these findings are more common. However, study results regarding the mid-term outcome have been inconsistent. The purpose of this study was to compare mid-term patient-reported outcomes and return to sport in patients with and without meniscal and chondral pathology at the time of revision ACL reconstruction surgery. METHODS: A cohort of 180 patients (131 males, 49 female) with a mean age of 25.3 (SD 7.8) years participated at an average follow-up time of 4.6 (SD 1.3) years after revision ACL reconstruction surgery. All patients completed the IKDC Subjective, Marx Activity, KOOS-Quality of Life (QOL) and Single Numerical Assessment (SANE) scores. In addition, patients were asked to indicate the highest level of sport to which they had returned following their revision surgery. Any further injuries to either knee were also documented. Patients were grouped according to whether or not they had medial or lateral meniscal pathology at the time of revision surgery; and whether or not they had > 50% depth chondral damage (ICRS 3 or 4). All outcomes were compared between these groupings. RESULTS: Patients with medial meniscal pathology had significantly lower Marx, KOOS-QOL and SANE scores than patients without. There were no differences in any outcome score between patients with and without lateral meniscal pathology. Patients with ICRS 3 or 4 chondral pathology had significantly lower scores on all patient-reported outcomes as well as a lower rate of return to the same level of pre-injury sport. CONCLUSION: The presence of more severe chondral damage at the time of revision ACL reconstruction has a negative impact on functional outcomes, activity levels and return to sport rates. In addition, the presence of medial meniscal pathology was associated with significantly lower functional and quality of life scores than patients without pathology. These findings provide important clinically relevant data on the outcomes following revision ACL reconstruction with concomitant chondral and meniscal injury. LEVEL OF EVIDENCE: III.

No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review.

PURPOSE: Anterior cruciate ligament (ACL) rupture commonly occurs in conjunction with articular cartilage injury. However, there is no consensus on the most appropriate rehabilitation which should be carried out for ACL reconstruction (ACLR) and the surgical management of articular cartilage lesions of the knee. The purpose of this study was to systematically review the literature to investigate the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment. METHODS: Two reviewers independently searched five database for randomised controlled trials (RCTs), non-randomised comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the postoperative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilisation, continuous passive motion (CPM), and return to play criteria. Secondary outcomes included patient-reported outcomes. A best evidence synthesis was performed. RESULTS: The review yielded six studies which reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques utilised and especially the rehabilitation regimes. No consensus was found on weight-bearing status, postoperative immobilisation, the use of CPM, or return to play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions. CONCLUSION: This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. A list of specific rehabilitation protocols based on the cartilage restoration technique is provided. LEVEL OF EVIDENCE: IV.

Comparison of combined posterior and anterior spondylodesis versus hybrid stabilization in unstable burst fractures at the thoracolumbar spine in patients between 60 and 70 years of age.

INTRODUCTION: Surgical treatment of unstable burst fractures of the thoracolumbar spine in the elderly population is highly variable with combined posterior and anterior stabilization (CPAS) and posterior augmented stabilization with cementation of the vertebral body (hybrid) being two commonly used techniques. The aim of this study was to compare the clinical and radiographic outcomes of CPAS versus hybrid stabilization for the treatment of unstable burst fractures of the thoracolumbar spine in patients aged between 60 and 70 years. MATERIALS AND METHODS: A retrospective analysis was performed of all thoracolumbar burst fractures treated surgically in a single level I trauma center between June 2013 and February 2015. Two commonly used strategies of surgical stabilization were compared; the first consisted of initial posterior reduction and bisegmental stabilization, followed by additional anterior spondylodesis (CPAS); the second method comprised a hybrid technique with a posterior cement augmented bisegmental minimally invasive stabilization and kyphoplasty of the fractured vertebral body. Patients were evaluated clinically after a minimum follow-up of 18 months. The primary endpoint was the Oswestry Disability Index (ODI) at the latest follow-up. Secondary parameters of interest were length of in-hospital stay (LIHS), duration of surgery (DS), surgical revisions (SR), pain level (P-VAS), satisfaction level and the SF-36 score (PSC, MSC), the bisegmental postoperative Cobb angle, the reduction loss (RL), and all alignment parameters (pelvic tilt, pelvic incidence, sacral slope, lumbar lordosis, C7 plumb line). RESULTS: A total of 29 patients were included (17 females, 12 males, mean age 65.6 years ± 3.4 years). The following vertebral bodies were fractured: thoracic level (T) 12: n = 6; lumbar (L) 1: n = 14; L 2: n = 6; L 3: n = 3. CPAS was performed in 10 patients (34%), whereas the hybrid was carried out in 19 patients (66%). There were no statistical significant differences between both study groups regarding age, gender, trauma energy, fracture level, and fracture morphology. The latest follow-up was performed after a mean of 27 months (range 18-53 months). The LIHS between the treatment methods was statistically significant (p < 0.01); CPAS-mean 24 days versus hybrid-mean 12 days. DS was also significantly longer in patients treated with CPAS, 254 versus 95 min for the hybrid group (p < 0.01). No SR were necessary in either group. No significant differences were found regarding the clinical and radiological outcomes between the groups. The mean ODI score was 13.6 in the CPAS patients compared to 10.8 in the hybrid patients without significant differences between the groups. The majority of patients had no (80%) or minor (13%) limitations according to the ODI score. The P-VAS was 2.8 in CPAS and 2.9 in the hybrid group. RL was 7.1° in CPAS and 4.2° in the hybrid group. CONCLUSIONS: CPAS and hybrid stabilization provide safe and promising short- and middle-term results in patients between 60 and 70 years of age. The majority of patients demonstrated no disability or minimal limitations with either technique. CPAS resulted in prolonged inpatient hospital stays, longer duration of surgery compared to hybrid stabilization without significant differences in clinical and radiological outcome.

Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis.

PURPOSE: The role of lateral extra-articular tenodesis (LEAT) as an augment to primary anterior cruciate ligament reconstruction (ACLR) remains controversial. However, concerns exist regarding the risk of development of osteoarthritis due to over constraint of the knee. To systematically review the literature to analyse the long-term incidence of osteoarthritis in patients who had an LEAT performed in isolation or in combination with intra-articular ACLR for the treatment of ACL deficiency. METHODS: Two reviewers independently searched five databases for randomized controlled trials (RCTs), non-randomized comparative, and retrospective cohort studies (CS) with long-term radiological follow-up of patients with ACL deficiency treated with ACLR combined with LEAT or LEAT in isolation. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was the development of osteoarthritis. The studies were divided into those with moderate/severe osteoarthritis at between 5 to 10 years and >10-year follow-up. The rate of meniscal pathology at the time of the index surgery was recorded. A best evidence synthesis was performed. RESULTS: Eight studies reported on 421 patients in which an LEAT procedure was carried out. There were two high-quality RCTs and six low-quality CS. The follow-up was between 5- and 10-years in 5 studies and >10-years in 3. The presence of moderate/severe osteoarthritis was not detected in three studies and was found in 4/44 (9%) and 13/70 (18.6%) patients in the other two. At 11 year follow-up, one study demonstrated no osteoarthritis, while the other two studies reported rates of 54/100 (54%) and 17/24 (71%) respectively at >24 years. In the latter two cases, the rate of meniscal pathology was >50%. A best evidence synthesis revealed that there was insufficient evidence that the addition of a LEAT to an ACLR resulted in an increased rate of osteoarthritis. CONCLUSION: The best available evidence would suggest that the addition of a LEAT to ACLR does not result in an increase rate of osteoarthritis of the knee. In knees that have undergone a combined ACLR and LEAT, the incidence of osteoarthritis was low up to 11 years but increased thereafter. The presence of meniscal injury at the index surgery was reported to be greater predictor of the development of osteoarthritis. LEVEL OF EVIDENCE: IV.

MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee.

PURPOSE: There has been a renewed interest in the anterolateral structures of the knee, including description of the anterolateral ligament (ALL) as a distinct structure. Recognizing injury to the ALL is challenging, particularly given the subjective nature of physical examination. Consequently, focus has turned to magnetic resonance imaging (MRI) to reach a preoperative diagnosis of this region. The aim of this study was to examine the ability of 3-Tesla (3T) MRI to identify the ALL in ACL-injured patients compared to a matched control group of ACL-intact patients. The hypothesis was that the ALL would be more difficult to identify in ACL-injured patients compared to ACL-intact patients. METHODS: A prospective case control study was performed comparing 3T MRI scans of 63-patients with an ACL rupture with a control group of 64-patients without ACL injury. An experienced musculoskeletal radiologist and an orthopaedic surgeon evaluated the scans performed using standard knee protocols. The ALL was considered in three regions for analysis: femoral, meniscal, and tibial. The status of the ALL was determined as visualized or non-visualized, and the integrity was assessed as intact, attenuated, or focal discontinuity. RESULTS: The detection rate of at least a portion of the ALL was 41/64 (64%) in the control group and 45/63 (72%) in the ACL-injured cohort, respectively. The entire length of the ALL could only be identified in 15/64 (23%) of the control group and 13/63 (21%) of the ACL-injured cases. In both groups, the visibility of the ALL was poorest at the femoral region and greatest at the tibial regions. The ALL, when visualized, was deemed to be intact in 55/63 (87%) of cases. Although the inter-observer reliability was excellent for detection of the ALL in the control group (κ = 0.86), this decreased to only moderate reliability in the ACL-injured group (κ = 0.52). CONCLUSION: This study demonstrates that MRI alone should not be relied upon to make a diagnosis of ALL injury in the setting of concomitant ACL injury due to the inability to accurately visualize this structure consistently in its entirety. To make a diagnosis of ALL injury or anterolateral instability of the knee and clinical correlation remains essential. LEVEL OF EVIDENCE: Case-control study, Level III.

Ligamentum Teres Tears and Femoroacetabular Impingement: Prevalence and Preoperative Findings.

PURPOSE: To determine prevalence of ligamentum teres (LT) injuries identified during hip arthroscopy for treatment of femoroacetabular impingement (FAI) and to identify physical examination findings or radiographic characteristics specific to patients with complete LT tears that could possibly assist in a preoperative diagnosis. METHODS: Between October 2006 and June 2015, prospective data were collected on consecutive hip arthroscopies. Inclusion criterion was primary hip arthroscopy in patients aged 18 years or older. All patients in the study were treated for chondrolabral dysfunction associated with FAI. Patients with prior hip surgery were excluded. A total of 2,213 out of 3,158 hip arthroscopies met the inclusion criterion. RESULTS: Of the 2,213 hips, 233 (11%) had a normal LT, 1,947 (88%) had frayed/partially torn, and 33 (1.5%) had a torn LT. A higher prevalence of torn LT was seen in female subjects. Patients with torn LT had lower body mass index (BMI) (22.5 v 24.7; P < .01) than those with hips with normal LT. On radiographs, patients with torn LTs had a lower center edge angle and had increased odds of having a center edge angle less than 25°. Isolated cam or isolated pincer were seen more often in hips with torn LT than in hips with normal LT. Hips with torn LT were 3.1 times more likely to have a chondral defect on the femoral head than were hips with normal LT (95% confidence interval [CI], 1.2-8.7) and were 3.6 times more likely to have capsular laxity diagnosed at hip arthroscopy than were hips with normal LT (95% CI, 1.4-9.4). CONCLUSIONS: Among patients with FAI and labral pathology, complete tears of the LT were rare and were more likely to be seen in women and those with lower BMI and low center edge angles at arthroscopy. LT tears were associated with hip laxity and chondral defects of the femoral head. LEVEL OF EVIDENCE: Level IV, prognostic case series.

A quantitative analysis of hip capsular thickness.

PURPOSE: The purpose of this study was to provide a comprehensive quantitative analysis of capsular thickness adjacent to the acetabular rim in clinically relevant locations. METHODS: Dissections were performed and hip capsular measurements were recorded on 13 non-paired, fresh-frozen cadaveric hemi-pelvises using a coordinate measuring device. Measurements were taken for each clock-face position at 0, 5, 10 and 15 mm distances from the labral edge. RESULTS: The capsule was consistently thickest at 2 o'clock for each interval from the labrum with a maximum thickness of 8.3 at 10 mm [95 % CI 6.8, 9.8] and 15 mm [95 % CI 6.8, 9.7]. The capsule was noticeably thinner between 4 and 11 o'clock with a minimum thickness of 4.1 mm [95 % CI 3.3, 4.9] at 10 o'clock at the labral edge. Direct comparison between 0 and 5 mm between 9 and 3 o'clock showed that the hip capsule was significantly thicker at 5 mm from the labrum at 9 o'clock (p = 0.027), 10 o'clock (p = 0.032), 1 o'clock (p = 0.003), 2 o'clock (p = 0.001) and 3 o'clock (p = 0.001). CONCLUSIONS: The hip capsule was thickest between the 1 and 2 o'clock positions for all measured distances from the acetabular labrum and reached its maximum thickness at 2 o'clock, which corresponds to the location of the iliofemoral ligament.

A qualitative and quantitative analysis of the attachment sites of the proximal hamstrings.

PURPOSE: Proximal hamstring tears represent a challenge. Surgical repair of such tears has been reported utilizing both open and endoscopic techniques. It was hypothesized that the proximal attachments of the hamstring muscle group could be reproducibly and consistently measured from pertinent bony anatomical reference landmarks. METHODS: Fourteen fresh-frozen, human cadaveric specimens were dissected, and measurements were taken regarding the proximal attachments of the hamstring muscle group in reference to bony landmarks. A highly precise coordinate measuring device was used for three-dimensional measurements of tendon footprints and bony landmarks, and relevant distances between structures were calculated. RESULTS: The semitendinosus and long head of the biceps femoris shared a proximal origin (conjoined tendon), having an oval footprint with an average area of 567.0 mm(2) [95 % CI 481.0-652.9]. The semimembranosus (SM) footprint was crescent-shaped and located anterolateral to the conjoined tendon, with an average area of 412.4 mm(2) [95 % CI 371.0-453.8]. The SM footprint had an accessory tendinous extension that extended anteromedially forming a distinct footprint. A consistent bony landmark was found at the medial ischial margin, 14.6 mm [95 % CI 12.7-16.5] from the centre of the conjoined tendon footprint, which coincided with the distal insertion of the sacrotuberous ligament. CONCLUSION: The conjoined tendon was the largest attachment of the proximal hamstring group. Two other distinct attachment footprints were identified as the SM footprint and the accessory tendinous extension. The sacrotuberous ligament insertion served as a bony landmark. The anatomical data established in this study may aid in better restoring the anatomy during repair of proximal hamstring tears.

Preoperative diagnosis of pathologic conditions of the ligamentum teres: is MRI a valuable imaging modality?

PURPOSE: The purpose of this study was to determine the accuracy of 3-Tesla magnetic resonance imaging (MRI) in detecting ligamentum teres (LT) lesions in patients before they undergo hip arthroscopy for the treatment of femoroacetabular impingement. METHODS: From 2010 to 2011, data were prospectively collected on all patients presenting for treatment of hip pain. All patients underwent MRI followed by arthroscopic surgery. A radiologist prospectively documented MRI findings, and the surgeon recorded the findings at arthroscopy. Radiologic and surgical data included classification of the LT as not torn, hypertrophic, partially torn, or completely torn. All MR images were read by a single radiologist, and all surgery was performed by a single surgeon. Arthroscopy was considered the diagnostic gold standard. RESULTS: One hundred forty-two patients with a mean patient age of 35 years (range, 19 to 73 years) met the inclusion criteria. Only one complete LT tear was found in the study. The accuracy of MRI for the diagnosis of LT partial tears was 64%. The sensitivity and specificity of MRI for diagnosing partial tears of the LT were 9% and 91%, [corrected] respectively. The positive predictive value and negative predictive value were 31% and 67%, [corrected] respectively. The sensitivity and specificity of MRI for diagnosing hypertrophic LT were 32% and 78%, respectively. CONCLUSIONS: In this patient population, MRI demonstrated sensitivity and specificity of 34% and 50%, [corrected] respectively, in identifying any pathologic process of the LT. MRI is capable of ruling out [corrected] partial tears of the LT with high sensitivity (91%) and negative [corrected] predictive value (67%). LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

A review of Marcel Lemaire's original work on lateral extra-articular tenodesis.

This classic discusses Marcel Lemaire's original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament's role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire's procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire's fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the "modified Lemaire technique" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art.

Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients.

Background: The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis: The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design: Cohort study; Level of evidence, 3. Methods: From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results: Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion: At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.