Strong association of meniscus tears with complete Anterior Cruciate Ligament (ACL) injuries relative to partial ACL injuries.

BACKGROUND: Anterior Cruciate Ligament (ACL) injuries are often associated with meniscus tears. These meniscus tears in long term may affect the functional outcomes after ACL reconstruction. The present study aims to identify the incidence and relative association of meniscus injuries in complete and partial ACL injuries. METHODS: This was a retrospective study. Patients were divided into 2 groups; group I: partial ACL tear and group 2: complete ACL tear. Both groups were assessed for meniscal tears; either isolated medial/lateral or combined and odds ratio was measured between two groups. RESULTS: A total of 43 and 219 patients were enrolled in group I and II respectively. The mean age (years) in group I and II were 25.32 ± 7.12 and 28.64 ± 10.84 respectively. There were a total of 5 and 28 females in group I and II respectively. Mean pre-injury Tegner score in group I and II was 7.02 ± 2.87 and 6.82 ± 3.14 respectively. Mean time from injury to surgery (months) in group I and II was 8.04 ± 6.43 and 7.62 ± 4.83 respectively. In group 1 There were a total of 6 with lateral meniscus tears, 9 with medial meniscus tears And 3 with combined meniscal tears in group 1 while in group 2, 47 had lateral meniscal tears, 71 had medial meniscal tears and 71 had combined tears. Group II patients had stronger association for isolated meniscal tears compared to group I, with an odds ratio of 5.05(p < 0.05). Combined meniscal tears had non-significant relation in two groups (p = 0.58). CONCLUSION: Partial ACL injuries present with less risk of acquiring isolated meniscus tears, compared to complete ACL injuries.

There is an Association of Synovial Interleukin-6 Levels With Chondral Damage in Anterior Cruciate Ligament-Deficient Knees.

Background: Osteoarthritis (OA) in the anterior cruciate ligament (ACL)-deficient knee is seen in approximately 50% of affected patients. Possible causes include biochemical or biomechanical changes. Purpose: We sought to study the correlation between inflammatory cytokines and chondral damage in ACL-deficient knees. Methods: Seventy-six male patients who underwent ACL reconstruction were enrolled in a cross-sectional study. Synovial fluid was aspirated before surgery and analyzed for levels of the inflammatory cytokines tumor necrosis factor-α, interleukin-1 (IL-1), and interleukin-6 (IL-6). At the time of ACL reconstruction, the severity of chondral damage was documented as described by the Outerbridge classification. Results: Patients with grade 2 or higher chondral damage were observed to have elevated IL-6 levels when compared to patients who had no chondral damage. Interleukin-6 levels had no correlation with the duration of injury. Conclusion: Elevated levels of IL-6 in synovial fluid were associated with chondral damage in ACL-deficient knees. Further study is warranted to determine whether inflammatory cytokines contribute to the development of OA of the knee after ACL injury.

Pre-operative Joint Inflammation has no Bearing on Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction at 1-Year Follow-Up; a Prospective Study.

BACKGROUND: To study the effect of pre-operative joint inflammation on clinical outcome at 1 year follow-up following ACL reconstruction surgery. METHODS: Male patients, aged 18-40 years, suffering from isolated ACL injury were included. All patients were randomly divided into two groups based on the type of graft used: Group A: semitendinosus gracilis graft with preserved insertions (STG-PI), Group B: bone-patellar tendon-bone graft (BPTB). Patients were categorised based on the time of presentation after injury: (a) within 6 weeks of injury, (b) between 6 and 12 weeks of injury, (c) after 12 weeks of injury. Synovial fluid levels of Interlukin-1, Interlukin-6 and TNF-α were measured in all the ACL deficient knees by taking a joint fluid sample intra-operatively. RESULTS: The total number of patients in the study was 59; 23 in group A (STG-PI) and 36 in group B (BPTB). Mean age of patients was 26 ± 5.146 years. 14 out of 59 (23.7%) patients presented within 6 weeks of injury, 16 (27.11%) patients presented between 6 and 12 weeks after injury and 29 (49.1%) patients presented after 12 weeks of injury. IL-6 levels were significantly high in group with < 6 weeks of injury than in group with > 12 weeks since injury. IL-6 had significant correlation with VAS scores, KT 1000, Lysholm knee scores and Tegner level of activity. There was no difference in outcome (pain scores, mechanical stability, Lysholm knee score and Tegner level of activity) at 1 year follow-up when patients with different time intervals since injury were compared. CONCLUSION: The clinical outcome in terms of pain score, mechanical stability, functional scores and return to sporting activity is comparable, irrespective of the time since injury, at short term follow-up.

Femoral tunnel length has no correlation with graft rupture: A retrospective cohort study.

BACKGROUND: Literature is controversial on femoral tunnel length as a risk factor for graft injury if the graft length in the tunnel is kept constant at ≥15 mm. METHODS: A total of 1079 sportspersons, meeting our inclusion criteria, were assessed for graft rupture. Patients with femoral tunnel length (FTL) ≤30 mm were labeled as Group 1, while those with FTL > 30 mm were labeled as Group 2. Both groups were compared for potential risk factors for graft injury keeping graft length in the tunnel at ≥15 mm and statistical analysis was performed to study whether the femoral tunnel length acted as an additional risk factor. RESULTS: Of 1079 sportspersons, 37 suffered from graft rupture. Patients with FTL > 30 mm were included in Group 1(n = 22) and patients with FTL ≤ 30 mm (n = 15) were included in Group 2. Both groups were comparable for risk factors for ACL injury: age (P = 0.37), gender (P = 0.53), mode of re-injury (P = 0.38), graft diameter (P = 0.71), level of sports activity (P = not significant), duration from injury to index surgery (P = 0.74), duration from index surgery to re-injury (P = 0.52), timing of return to sports after index surgery (P = 0.30), duration of sporting activity before second injury (P = 0.31), Tegner's level (P = not siginificant), Notch width index (P = 0.12) posterior slope (P = 0.77) and height (P = 0.41). CONCLUSION: Because the graft length in the tunnel was kept at optimum and the risk factors for ACL injury were comparable in both groups at a follow up period, we suggest that femoral tunnel length is not a risk factor for graft failure.

Vitamin D deficiency in athletes and its impact on outcome of Anterior Cruciate Ligament surgery.

BACKGROUND: Vitamin D deficiency is a worldwide pandemic problem. With vitamin D having some role in exercise-induced inflammation, skeletal muscle mass and endurance, we studied its effect on functional outcome of athletes' post-Anterior Cruciate Ligament (ACL) reconstruction. METHODS: A total of 153 patients who underwent primary ACL reconstruction were enrolled in the study. All patients were screened for vitamin D levels preoperatively. Patients were divided into 3 groups on basis of vitamin D levels; Group 1 patients had < 20 ng/ml, group 2 patients 20-30 ng/ml and group 3 > 30 ng/ml. All patients were followed up for a minimum of 2 years. RESULTS: A total of 153 patients were enrolled in study. The average age of the patients was 24.12 ± 2.12 years in group 1, 25.24 ± 3.20 years in group 2 and 24.74 ± 2.86 in group 3. The mean follow-up of patients was 2.8 ± 1.2 years. At 2 years, the mean Lysholm score was 96.12, 96.49 and 97.0, respectively (p = 0.75); mean WOMAC score was 3.33, 3.38 and 3.20, respectively (p = 0.91); mean difference between the pre-injury and post-surgery Tegner level of sports activity at 2 years follow-up was 0.78, 0.78 and 0.85, respectively (P = 0.51) and graft failure rate was 5.88%, 1.96% and 1.96%, respectively (p = 0.43). CONCLUSION: Vitamin D has no effect on functional outcome and graft rupture rates in patients' post-primary ACL reconstruction. LEVEL OF EVIDENCE: Prospective Cohort Study (Level III).

Effect of COVID-19 on surgical management of open fractures and infection rates: A tertiary care experience in Indian set-up.

BACKGROUND: Open fractures form one of the most common musculoskeletal injuries and are often complicated by infection. In this unprecedented situation, the additional infection rates, further add to the burden of the already compromised healthcare setup. The present study is done to see the effect of COVID-19 on management of open fractures. METHODS: A retrospective evaluation of patients with open fractures from March 25th, 2020 to July 21st, 2020 (group 1) and March 25th, 2019 to July 21st, 2019 (group 2) was performed. These patients were assessed for demographic details, diagnosis, type of surgery, delay from injury to admission, delay from admission to surgery, postoperative hospital stay, acute infection rates, readmission rates and associated injuries. RESULTS: A total of 52 patients with 59 open fractures in 2020 and 89 patients with 101 open fractures in 2019 met the inclusion criteria. The mean age was 34.76 years and 32.74 years in 2020 and 2019 respectively. Road side accidents were predominant in both the groups, comprising of 38 (73.07%) and 67 (75.28%) respectively(n.s.); adult patients were 42 (80.76%) and 79 (88.76%) respectively(n.s.); paediatric patients were 10 (19.23%) and 10 (11.23%) respectively(n.s.); tibia was the most common bone involved, comprising of 14 (23.72%) and 27 (26.73%) open fractures respectively(n.s.); external fixator was the most commonly used implant during COVID-19 time with 42 (71.18%) and 51 (50.49%) respectively(p = 0.005); the infection rate was 25.42% and 20.79% respectively(n.s.); the time for administration of first intravenous antibiotic dose was on 6.75 h and 4.04 h respectively(p < 0.0001); average time between the admission and surgical debridement was 24.04 h and 19.32 h respectively(n.s.); referral cases were 33 (63.46%) and 44 (49.43%) respectively(n.s.); re-admission rates were 7/52 (13.46%) and 10/89(11.23%) respectively(n.s.). CONCLUSION: Despite the decrease in total trauma cases, a delay in presentation to the emergency room/administration of first dose of antibiotic and increase in temporary fixation in form of external fixator was observed. Further, an increase in infection rates, referral cases and readmission rates were observed, though not statistically significant.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion": A Randomized Clinical Trial.

BACKGROUND: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. PURPOSE: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. MATERIALS AND METHODS: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. RESULTS: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. CONCLUSION: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Anterior cruciate ligament tear due to non-contact mode of injury associated with higher incidence of meniscal and chondral damage.

BACKGROUND: Forces acting on the knee are different in contact and non-contact mode of injuries causing anterior cruciate ligament (ACL) tear. Purpose of this study was to determine the effect of mode of injury on the occurrence of meniscal tear and chondral damage in ACL tear. METHOD: 72 athletes with acute ACL injury (<3 months) were enrolled in the study. Depending on the mode of injury, athletes were divided into two groups - group A (non-contact mode of injury) and group B (contact mode of injury). 49/72 athletes had the non-contact mode of injury (group A), and 23/72 athletes had contact mode of injury (group B). Meniscal tear and chondral damage seen at the time of ACL reconstruction surgery was noted. All athletes were assessed at 12 months follow-up for return to sports, Lysholm score, and WOMAC score. RESULTS: In group A, 35/49 (71%) athletes and in group B, 9/23(39%) athletes had meniscal tear (p = 0.009). Medial meniscus was more commonly injured in group A [24/49] as compared to group B (5/23; p = 0.03). Chondral damage was also more commonly seen in group A [26/49] as compared to group B (5/23; p = 0.01). At one-year follow-up, 65% of the athletes from group B returned to sports as compared to 57% of the athletes from group A (p-value = 0.6). WOMAC score in group A and B was 95.5 ±â€¯4.88 and 96 ±â€¯4.39 respectively (p = 0.67). Lysholm score in group A and B was 1.02 ±â€¯1.7 and 0.96 ±â€¯1.2 respectively (p = 0.88). CONCLUSION: Non-contact mode of injury was associated with a higher incidence of meniscal tear and chondral damage. However, the mode of injury does not affect the functional outcome of ACL reconstruction surgery.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft.

PURPOSE: To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction. METHOD: One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears. RESULTS: Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04). CONCLUSIONS: The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury. LEVEL OF EVIDENCE: III.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion:" A Randomized Clinical Trial.

BACKGROUND: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. PURPOSE: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. MATERIALS AND METHODS: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. RESULTS: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. CONCLUSION: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Is anterior cruciate ligament graft rupture (after successful anterior cruciate ligament reconstruction and return to sports) actually a graft failure or a re-injury?

PURPOSE: The objective of this study is to discuss the fact that whether graft rupture after successful anterior cruciate ligament (ACL) reconstruction surgery is due to graft failure or re-injury to the reconstructed ACL. METHODS: In total, 340 sportspersons, meeting our inclusion criteria, were assessed for rupture of ipsilateral ACL graft and ACL injury of the contralateral knee. Patients with ipsilateral ACL graft rupture were labelled as group 1, while those with contralateral ACL injury were labelled as group 2. Both groups were compared for potential risk factors for ACL injury, and statistical analysis was performed to study whether the graft acted as an additional risk factor. RESULTS: Of the 340 sportspersons, 25 patients suffered a total of 26 injuries. Ipsilateral graft rupture rate was 2.4% (8 of 340) at a mean follow-up of 25.5 ± 40.57 months, and the contralateral ACL injury rate was 5.3% (18 of 340) at a mean follow-up of 18.11 ± 19.97 months, with an overall re-injury rate of 7.6%. Both groups were comparable for risk factors for ACL injury: age ( p = 0.255), gender ( p = 0.534), mode of re-injury ( p = 0.523), level of sports activity, type of graft used ( p = 0. 918), graft diameter ( p = 0.607), duration from injury to index surgery ( p = 0.492), duration from index surgery to re-injury ( p = 0.638), timing of return to sports after index surgery ( p = 0.303), duration of sporting activity before second injury ( p = 0.657), and Tegner's level of sports activity ( p = 0.486). CONCLUSION: Because the rate of contralateral ACL injury is higher than the ipsilateral graft rupture and the risk factors for ACL injury are comparable in both groups at a follow-up period, which is suggestive of ligamentization of the graft, we suggest that it might be an ACL re-injury rather than graft failure. Level of Evidence: Level III (Retrospective cohort study).

The role of meniscal tears and meniscectomy in the mechanical stability of the anterior cruciate ligament deficient knee.

BACKGROUND: The role of an intact meniscus in providing mechanical stability to the knee of anterior cruciate ligament (ACL) deficient and ACL reconstructed patients has not been well studied. METHODS: This was a prospective cohort study. A total of 205 patients undergoing ACL reconstruction were enrolled, of which 61 had normal menisci, 49 had a tear in the posterior horn of the medial meniscus (PHMM) (tear <40% of width = 19; >40% of width = 30), 35 had a tear in the lateral meniscus (<40% of width = 15; >40% = 20), 13 had a tear in the body and/or anterior horn of the medial meniscus (<40% of width = 6; >40% = 7) and 47 patients had a tear in both menisci. Patients with a tear in both menisci were excluded. The anterior translation of the tibia (ATT) was calculated preoperatively and postoperatively at three months and six months using KT-1000. Partial meniscectomy was performed in all unstable meniscal tears. RESULTS: The mean age at the time of surgery was 25.2 ±â€¯5.1 years. Patients with a normal meniscus showed side to side difference in KT-1000 of 4.8 ±â€¯2.5 mm whereas those with a <40% tear and >40% tear in PHMM had a difference of 5.36 ±â€¯3.07 mm (P = 0.46) and 7.08 ±â€¯2.78 mm (P = 0.0002), respectively. Patients with a lateral meniscus <40% and >40% tear had a mean difference of 5.68 ±â€¯2.96 mm (P = 0.22) and 5.95 ±â€¯2.39 mm (P = 0.09), respectively. Patients with body and/or anterior horn of medial meniscus <40% and >40% had a difference of 5.41 ±â€¯1.11 mm (P = 0.59) and 5.78 ±â€¯2.38 mm (P = 0.35), respectively. At three months and six months KT-1000 differences of 2.3 ±â€¯1.2 mm and 2.1 ±â€¯1.2 mm were seen in patients with normal meniscus; 2.26 ±â€¯1.51 mm and 2.16 ±â€¯0.9 mm with partial meniscectomy of the PHMM <40%; 2.65 ±â€¯1.53 mm and 2.4 ±â€¯1.35 mm with partial meniscectomy of the PHMM >40%; 2.27 ±â€¯1.19 mm and 2.07 ±â€¯1.52 mm with partial meniscectomy of the lateral meniscus <40%; and 2.27 ±â€¯1.44 mm and 2.07 ±â€¯1.14 mm with partial meniscectomy of the lateral meniscus >40%; 2.55 ±â€¯1.56 mm and 1.91 ±â€¯1.09 mm with partial meniscectomy in body and/or anterior horn of medial meniscus <40% and 2.07 ±â€¯1.81 and 2.14 ±â€¯1.10 mm with partial meniscectomy in body and/or anterior horn of medial meniscus >40% (P > 0.05). CONCLUSION: PHMM acts as a secondary stabilizer of the knee joint in the absence of functional ACL. There is no effect of partial meniscectomy on mechanical stability of the knee in ACL reconstructed patients. Medial or lateral partial meniscectomy performed at the time of ACL reconstruction does not affect the stability of ACL reconstructed knee. However, the presence of a concomitant tear in PHMM is associated with increased instability in ACL deficient knee.

Incidence, Risk Factors, and Management of Infection Following Anterior Cruciate Ligament Reconstruction Surgery.

BACKGROUND: Infection after anterior cruciate ligament reconstruction surgery (ACLRS) is a rare complication. Although there are number of studies from various Caucasian population but only few studies are available from Asian population. The aim of the study is to assess the incidence, risk factors and, clinical outcome using our treatment protocol. MATERIALS AND METHODS: Out of 1468 arthroscopic ACLRS, 26 patients with clinical suspicion of infection were critically analysed in terms of laboratory reports of arthrocentesis, erythrocyte sedimentation rate, C-reactive protein and risk factors such as the type of graft, gender, diabetes mellitus, smoking, intraarticular steroid injection, and obesity. At final followup, all these patients were evaluated using visual analog scale (VAS), Lysholm knee score, and Tegner activity level. RESULTS: In nine patients, culture did not show any growth and they showed improvement with arthrocentesis and oral antibiotics. These patients were labeled as suffering from aseptic effusion. In the remaining 17 patients, there was no clinical improvement or instead worsening of symptoms after arthrocentesis and oral antibiotics. These patients were labeled as suffering from an infection and underwent surgical debridement along with administration of injectable antibiotics. The history of intraarticular steroid injection before ACLRS was a significant risk factor for developing infection (P = 0.001). At mean followup of 2.8 years, mean VAS improved to 1.18 ± 0.99 from 6.2 ± 2.3. The mean Lysholm knee score and Tegner's activity level at the final followup were 79.2 ± 10.52 and 4.8 ± 2.30, respectively. CONCLUSION: The incidence of infection was 1.2% (17/1468). The step-ladder approach of differentiating between aseptic effusion and infection and accordingly, following a treatment protocol, i.e., oral antibiotics alone or surgical debridement along with injectable antibiotics or additional debridement of graft in refractory patients, yielded satisfactory results.

Functional Outcome of Modified Weaver Dunn Technique for Acromioclavicular Joint Dislocation.

BACKGROUND: The debate about the ideal surgical procedure for acromioclavicular joint (ACJ) dislocation is still unresolved and newer techniques are being evolved continuously. The present study evaluates functional outcome of ACJ reconstruction using the modified Weaver Dunn procedure. MATERIALS AND METHODS: 35 patients (26 males, 9 females) with ACJ dislocation, between the age group of 18-48 years (mean age 31 years), were operated using modified Weaver Dunn procedure at our center from May 2005 to June 2010. The dominant side was involved in 25 patients (22 right, 13 left). The mean period from the time of injury to the surgery was 14 days (range 4-26 days). All the patients were assessed with Oxford shoulder score and the time required to return to preinjury level was recorded. RESULTS: At the mean followup of 95 months (range 72-120 months), the mean Oxford Shoulder Score improved from 25 ± 7.2 to 43 ± 6.9. 85% (30 out of 35) patients had satisfactory results, while 15% (5 out of 35) had mild shoulder dysfunction using this scoring system. Five patients had radiological evidence of Grade 2 ACJ subluxation. Out of these five patients, two developed ossification around the coracoclavicular ligament. Three patients had intermittent mild pain without any functional disability, and one had a moderate restriction of shoulder movements. CONCLUSION: ACJ reconstruction, using the modified Weaver Dunn procedure in ACJ dislocation, is a reproducible procedure and provides a good functional outcome.

Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons.

PURPOSE: To compare the results of bone-patellar tendon-bone graft (BPTB), semitendinosus-gracilis graft with preserved insertions (STGPI) and semitendinosus-gracilis-free graft (STGF) in terms of graft failure, objective mechanical stability, functional outcome, and return to sports in elite and recreational sports persons. It was hypothesized that the STGPI graft provided superior outcome as compared to the other two grafts. METHODS: Two hundred and forty-nine elite and recreational players who underwent ACL reconstruction surgery, with BPTB graft (N = 80), STGPI graft (N = 85), and STGF graft (N = 84) with a minimum follow-up of 2 years, were assessed using clinical tests, knee arthrometer (KT 1000™), single-leg hop test, Lysholm knee score, Tegner's activity scale, and return to sports. Groups were matched in terms of age, gender, mode of injury, side involved, the level of sports, associated injuries, and mean follow-up. RESULTS: The median age of the patients was 24 years (range 16-46 years), with 227 males and 22 females, with a mean follow-up of 61.8 ± 25.9 months. At the final follow-up, the mean side-to-side difference by KT 1000™ was significantly superior in BPTB group (1.4 ± 2.1 mm) as compared to STGPI (1.9 ± 2.0 mm) and STGF group (2.5 ± 2.0 mm) (p = 0.002). The mean Lysholm knee score, Limb symmetry index (LSI) using single-leg hop test and the mean difference in pre-injury and post-surgery level of Tegner's activity scale were not significantly different. The rate of graft failure was significantly higher in STGF group (7.1%) as compared to BPTB (1.2%) and STGPI (1.2%) groups (p = 0.043). CONCLUSION: BPTB graft is a better graft in terms of mechanical stability than STGPI and STGF grafts. STGPI graft and BPTB graft are superior to STGF graft in terms of graft failure rate. However, there is no statistically significant difference amongst the three grafts in terms of return to sports and clinical tests of instability. STGPI graft is another option in the clinical setting with low graft failure rate like that of BPTB graft and with the added advantage of not having significant donor site morbidity. LEVEL OF EVIDENCE: III.

Retained Drain after Anterior Cruciate Ligament Surgery : A Silent Threat to an Athlete's Career: A Case Report.

INTRODUCTION: Breaking of surgical drain during the removal and retention of broken drain fragment is an avoidable complication. Such a complication brings disrepute to the operating team and causes psychological as well as further surgical trauma to the patient as a return to the operating room is required many a times to remove the retained drain fragment. CASE REPORT: We report a case of an undetected retained drain fragment inside the knee joint of a 24-year-old male international kabaddi player, who remained asymptomatic for 5 months, when the residual drain fragment was removed arthroscopically. No such case has been reported earlier in the literature after arthroscopic surgery. CONCLUSION: Retained drain fragment after arthroscopic surgery can stay silent for months. Hence, a high index of suspicion should be maintained by surgeons to detect such a complication at the earliest. We suggest that every arthroscopic surgeon should follow a standard protocol while inserting and removing the drain to avoid this mistake.

Outcome of Hamstring Autograft With Preserved Insertions Compared With Free Hamstring Autograft in Anterior Cruciate Ligament Surgery at 2-Year Follow-up.

PURPOSE: To compare mechanical stability, functional outcome, and level of return to sports activity in patients undergoing anterior cruciate ligament (ACL) reconstruction with a free hamstring graft versus a graft with preserved insertions at 2-year follow-up. METHODS: This study was a prospective, single-blind (the evaluator was blinded), randomized trial of 110 adult professional athletes who were randomly allocated into 2 groups. Group 1 consisted of 55 patients who underwent ACL reconstruction with hamstring tendon autograft with preserved insertions (technique 1), and group 2 consisted of 55 patients who underwent ACL reconstruction with free hamstring tendon autograft (technique 2). An anteromedial portal was used for drilling of the femoral tunnel in all cases. Patients were assessed for a minimum follow-up of 2 years with clinical tests, the Activities of Daily Living Function Scale and Sports Function Scale (Cincinnati knee score), knee arthrometer (KT-1000) testing, and the Tegner activity scale. RESULTS: The average age of the patients was 27.0 ± 7.5 years in group 1 and 27.2 ± 5.7 years in group 2. At 24 months, the mean side-to-side difference by KT-1000 testing was 1.4 in group 1 and 2.2 in group 2 (P < .0001); the mean Cincinnati knee score (Activities of Daily Living Function Scale and Sports Function Scale) was 418.5 (median, 420; range, 400-420) and 406.8 (median, 420; range, 350-420), respectively (P < .0001); and the mean difference between the preinjury and postsurgery Tegner level of sports activity was 0.3 and 1.08, respectively (P = .027). CONCLUSIONS: Although ACL reconstruction using hamstring autograft with preserved insertions resulted in statistically superior anterior stability, a better functional outcome, and a closer return to the preinjury level of sports activity as compared with free autograft, no clinically significant difference was proved. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Equation-based precise prediction of length of hamstring tendons and quadrupled graft diameter by various anthropometric variables for knee ligament reconstruction in Indian population.

Preoperative prediction of hamstring tendon lengths and graft diameter for anterior cruciate ligament (ACL) reconstruction enables better preoperative planning. Presently, no study exists for Indian population where both derivation and verification of a mathematical equation for accurate prediction of hamstring graft dimensions have been done. This study was conducted in two phases: First phase ( derivation cohort): devoted to the study of correlation of length of hamstring tendons and graft diameter with various anthropometric measurements in 123 patients undergoing ACL reconstruction. Length of semitendinosus (ST) was observed to have a strong correlation with leg length ( r = 0.719), whereas that of gracilis (G) had a strong correlation with patient height ( r = 0.768). Quadrupled diameter (QD) had a strong correlation with patient height and thigh length ( r = 0.685 and 0.680, respectively). Using Pearson correlation coefficient, multiple stepwise linear regressions, and analysis of variance test, predictive equations were developed to predict the length of ST and G and QD. Second phase ( verification cohort): This was a blinded prospective study done on 300 patients to further authenticate and test the accuracy of equations developed. Here, a steady correlation was found between the observed and predicted values of length of ST, G and QD, with correlation coefficients being 0.838, 0.847, and 0.767, respectively. Thus, we can safely conclude that clinically measurable anthropometric variables can reliably predict hamstring graft dimensions. This is likely to prove useful in better preoperative planning of ligament reconstructions.

Correlation of femoral tunnel length with body height, limb length, and thigh length in Indian patients undergoing anterior cruciate ligament reconstruction.

PURPOSE: To measure the femoral tunnel length created through a far medial portal and determine its correlation with body height, limb length, and thigh length in 404 Indian patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: 364 male and 40 female Indian patients aged 18 to 51 (mean, 26.8) years underwent ACL reconstruction by a single surgeon using the hamstrings tendon autograft. Their body height, limb length, and thigh length were measured by a single assessor, as was the femoral tunnel length. RESULTS: The mean femoral tunnel length was 34.5 mm. It was <30 mm in 28 patients and <25 mm in 2 patients. The correlation coefficients of the femoral tunnel length with body height, limb length, and thigh length were 0.485 (p<0.0001), 0.426 (p<0.0001), and 0.304 (p<0.0001). No patient had posterior wall blowout fracture. CONCLUSION: The femoral tunnel length positively correlated with body height, limb length, and thigh length in 404 Indian patients.

Delay in surgery predisposes to meniscal and chondral injuries in anterior cruciate ligament deficient knees.

BACKGROUND: Despite improvements in instability after anterior cruciate ligament (ACL) reconstruction, associated intraarticular injuries remain a major cause of concern and important prognostic factor for long term results as it may lead to osteoarthritis. Delay in ACL reconstruction has been in variably linked to increase in these injuries but there is lack of consensus regarding optimal timing of reconstruction. The goal of this study was to investigate delay in surgery and other factors, associated with intraarticular injuries in ACL deficient knees. MATERIALS AND METHODS: A total of 438 patients (42 females; 396 males) enrolled for this prospective observational study. The average age of patients was 26.43 (range 17-51 years) years with a mean surgical delay of 78.91 (range 1 week - 18 years) weeks after injury. We analyzed the factors of age, sex, surgical delay, instability, and level of activity for possible association with intraarticular injuries. RESULTS: Medial meniscus injuries had a significant association with surgical delay (P = 0.000) after a delay of 6 months. Lateral meniscus injuries had a significant association with degree of instability (P = 0.001). Medial-sided articular injuries were significantly affected by age (0.005) with an odds ratio (OR) of 1.048 (95% confidence interval [CI] of 1.014-1.082) reflecting 4.8% rise in incidence with each year. Lateral-sided injuries were associated with female sex (P = 0.018) with OR of 2.846 (95% CI of 1.200-6.752). The level of activity failed to reveal any significant associations. CONCLUSION: Surgical delay predicts an increase in medial meniscal and lateral articular injuries justifying early rather than delayed reconstruction in ACL deficient knees. Increasing age is positively related to intraarticular injuries while females are more susceptible to lateral articular injuries.