Restoring the Preoperative Phenotype According to the Coronal Plane Alignment of the Knee Classification After Total Knee Arthroplasty Leads to Better Functional Results.

BACKGROUND: Mechanical alignment after total knee arthroplasty (TKA) is still widely used in the surgical community, but the alignment finally obtained by conventional techniques remains uncertain. The recent Coronal Plane Alignment of the Knee (CPAK) classification distinguishes 9 knee phenotypes according to constitutional alignment and joint line obliquity (JLO). The aim of this study was to assess the phenotypes of osteoarthritic patients before and after TKA using mechanical alignment and to analyze the influence of CPAK restoration on functional outcomes. METHODS: This retrospective multicenter study included 178 TKAs with a minimum follow-up of 2 years. Patients were operated on using a conventional technique with the goal of neutral mechanical alignment. The CPAK grade (1 to 9), considering the arithmetic Hip-Knee-Ankle angle (aHKA) and the JLO, was determined before and after TKA. Functional results were assessed using the following patient-reported outcome measures: Knee Injury and Osteoarthritis Outcome Score, the Simple Knee Value, and the Forgotten Joint Score. RESULTS: A true neutral mechanical alignment was obtained in only 37.1%. Isolated restoration of JLO was found in 31.4%, and isolated restoration of the aHKA in 44.9%. Exact restoration of the CPAK phenotype was found in 14.6%. Restoration of the CPAK grade was associated with an improvement in the "daily living": 79.2 ± 5.3 versus 62.5 ± 2.3 (R2 = 0.05, P < .05) and "Quality of life" Knee Injury and Osteoarthritis Outcome Score subscales: 73.8 ± 5.0 versus 62.9 ± 2.2 (R2 = 0.02, P < .05). CONCLUSIONS: This study shows that few neutral mechanical alignments are finally obtained after TKA by conventional technique. A major number of patients present a postoperative modification of their constitutional phenotype. Functional results at 2 years of follow-up appear to be improved by the restoration of the CPAK phenotype, JLO, and aHKA. LEVEL OF CLINICAL ART EVIDENCE: III, Retrospective Cohort Study.

Anterior cruciate ligament injuries in elite ski jumping reliably allow return to competition but severely affect future top performance.

PURPOSE: In recent years, anterior cruciate ligament (ACL) injuries have been frequently observed in ski jumping. However, available data in this discipline are very scarce. Therefore, the purpose of this study was to investigate whether an ACL injury in elite-level ski jumping limits the performance level after ACL reconstruction (ACLR). METHODS: Both male and female elite-level ski jumpers from five national A-teams who suffered an ACL injury were identified retrospectively by searching available media reports and Fédération Internationale de Ski (FIS) database. World Cup (WC) results and time-out-of-competition before ACL injury and after ACLR were compared. Only athletes who suffered the injury during or after the 2009-2010 season and who participated in at least one WC competition before the injury were included in this study. The level of athletes' performance from two full seasons before until three seasons after the injury was compared. RESULTS: Eighteen elite-level ski jumpers (11 males/seven females) were eligible for the study. All male and four female athletes returned to professional competition after ACLR. One female athlete ended her career due to prolonged recovery and two have not yet recovered due to a recent injury. The mean return-to-competition (RTC) time was 14.6 months in males and 13.5 months in females. The mean WC placement decreased after the ACL injury: two seasons before injury the mean position was 17.9 ± 11.0 (n = 12), one season before it was 22.4 ± 12.8 (n = 15). After recovery, the mean placement in seasons 1-3 was: 26.4 ± 8.9 (n = 7), 25.7 ± 10.3 (n = 13), 33.6 ± 12.2 (n = 10) (p = 0.008). Among the athletes returning to competition, only six males and three females reached their preinjury level and only one male and one female (compared to seven males and three females preinjury) reached an individual top-3 placement after ACLR, accounting for less than 10% of podiums compared to preinjury. CONCLUSION: Only 60% of the professional ski jumpers reached the preinjury level and less than 15% reached a top-3 placement after the ACL injury. These results support the fact that ACL tear during a ski jumping career may be a significant factor limiting high-level performance. In terms of clinical relevance, the findings implicate the need to analyse the reasons of these very low rates of return to elite-level performance, to analyse ACL injury and RTC rates at lower levels of performance and to develop specific prevention strategies in order to reduce the number of ACL injuries in this sport. LEVEL OF EVIDENCE: Level IV.

Presentation of an intraosseous suspensory fixation technique for pediatric and adult ACL reconstruction.

The aim is to present a technique for pediatric and adult ACL reconstruction using an intraosseous suspensory fixation. This technique uses a 4-strands hamstring graft fixed in the femoral tunnel, with a loop locked in a polyetheretherketone (PEEK) cage. The ACLip® device offers an inside-out drilling system and a closer fixation to the joint than an extracortical button fixation. The technique can be easily used both in adults and in skeletally immature patients. The first practical experience shows promising results regarding the safety and the effectiveness of the technique. Level of evidence: IV.

A systematic approach to managing complications after proximal tibial osteotomies of the knee.

Proximal tibial osteotomy (PTO) is an effective procedure for active and young adult patients with symptomatic unicompartmental osteoarthritis and malalignment. They were considered technically demanding and prone to various complications related to the surgical technique, biomechanical or biological origin. Among the most important are hinge fractures and delayed or non-healing, neurovascular complications, loss of correction, implant-related problems, patellofemoral complaints, biological complications and changes in limb length. Being aware of these problems can help minimizing their prevalence and improve the results of the procedure.The aim of this narrative review is to discuss the potential complications that may occur during and after proximal tibial osteotomies, their origin and ways to prevent them.

The posterior cruciate ligament-posterior femoral cortex angle (PCL-PCA) and the lateral collateral ligament (LCL) sign are useful parameters to indicate the progression of knee decompensation over time after an ACL injury.

PURPOSE: The posterior cruciate ligament-posterior cortex angle (angle between the most vertical part of the anterolateral PCL bundle and the posterior diaphyseal cortex of the femur; PCL-PCA) is the most accurate approach to describe the PCL buckling phenomenon observed in anterior cruciate ligament (ACL)-deficient knees. The aim of this study was to determine whether the PCL-PCA is associated with chronicity of the ACL rupture, the meniscal status, preoperative knee laxity or imaging signs such as the lateral collateral ligament (LCL) sign or the posterior tibial slope (PTS) in ACL-injured knees. METHODS: Patients with a primary ACL reconstruction (ACLR) after physeal closure were selected retrospectively from a hospital-based ACL registry from 2015 to 2021. Exclusion criteria were: previous ipsilateral/contralateral knee surgery, previous ipsilateral ACL or meniscal tear, ipsilateral PCL and/or collateral ligament injuries or tibial plateau fracture. The ACL deficiency was defined as chronic if time from injury to MRI was > 6 months. The meniscal status was assessed during ACLR, separately for the medial and lateral meniscus, and classified into no tear, minor or major unstable tear. The MRI analyses included the assessment of the PCL-PCA and the LCL sign. PTS was assessed from the lateral plain radiographs of the injured knee. The side-to-side difference in anterior tibial translation (ATT) at 200N was obtained with the GNRB. RESULTS: Eighty-two patients (forty-eight males/thirty-four females) were included in this study. The median PCL-PCA was 16.2° (Q1-Q3: 10.6-24.7) and differed between acute (18.4°) and chronic (10.7°) injuries (p < 0.01). The median PCL-PCA was significantly lower (- 4.6°) in patients with a positive LCL sign (p = 0.03) No significant association could be found between PCL-PCA and meniscal status, PTS or preoperative anterior knee laxity (Lachman, pivot shift and ATT in millimetres). CONCLUSION: The PCL-PCA was significantly lower in chronic ACL injuries and in patients with a positive LCL sign, indicating a higher buckling phenomenon of the PCL in these patients. These results support the fact that PCL-PCA and the LCL sign may be useful parameters to indicate the progression of knee decompensation over time after an ACL injury, and therefore may constitute a helpful tool to optimise treatment choice and timing of ACL reconstruction if necessary. LEVEL OF EVIDENCE: III.

Improving the reliability of measurements in orthopaedics and sports medicine.

A large space still exists for improving the measurements used in orthopaedics and sports medicine, especially as we face rapid technological progress in devices used for diagnostic or patient monitoring purposes. For a specific measure to be valuable and applicable in clinical practice, its reliability must be established. Reliability refers to the extent to which measurements can be replicated, and three types of reliability can be distinguished: inter-rater, intra-rater, and test-retest. The present article aims to provide insights into reliability as one of the most important and relevant properties of measurement tools. It covers essential knowledge about the methods used in orthopaedics and sports medicine for reliability studies. From design to interpretation, this article guides readers through the reliability study process. It addresses crucial issues such as the number of raters needed, sample size calculation, and breaks between particular trials. Different statistical methods and tests are presented for determining reliability depending on the type of gathered data, with particular attention to the commonly used intraclass correlation coefficient.

Construction and validation of a functional diagnostic score in anterior cruciate ligament ruptures of the knee in the immediate post-traumatic period. Preliminary results of a multicenter prospective study.

INTRODUCTION: Knee ligament injuries are frequent and their number is constantly increasing with the development of sports activities. Dynamic knee maneuvers usually make it possible to diagnose anterior cruciate ligament (ACL) injuries but they remain difficult to perform in the early post-traumatic phase. This leads to the almost systematic use of MRI scans, many of which turn out to be superfluous. The aim of this study was to construct a screening score based solely on history-taking, in order to help diagnose ACL injuries, and to define thresholds that could help inform recommendations for MRI usage. The hypothesis was that this score could distinguish a population of patients with a ruptured ACL from a population of patients with other knee injuries. MATERIAL AND METHODS: This prospective multicenter study included 166 patients. Patients were included if they were between 18 and 55 years of age, with knee trauma that had occurred in the last 10 days, and without a bone fracture on standard radiographs. They were excluded if the trauma required immediate surgical management and if they had a history of knee trauma. The screening score was completed by the physician. The score included the following items: assessment of pain, immediate post-traumatic functional impairment, notion of a "pop", feeling of instability and presence of a swelling. An MRI was systematically performed and the patient consulted a referring physician to compare the initial score with the diagnosis. RESULTS: Eighty-six patients had an injured ACL and 80 had a healthy ACL. Two thresholds could be identified. For a score lower than 4, the risk of an ACL injury was low with a sensitivity of 96% and a negative predictive value of 87%. For a score above 8, the ACL injury was highly probable with a specificity of 88% and a positive predictive value of 83%. DISCUSSION/CONCLUSION: The score was able to distinguish a population of patients with a ruptured ACL from a population of patients with other knee injuries. These preliminary results confirm that the selected items are relevant and that the score can help improve the diagnostic orientation of patients with recent knee trauma. Increasing the sample size in combination with an analysis of influencing factors will determine whether the performance of this score can be refined. LEVEL OF EVIDENCE: II prospective multicenter study.

MCID and PASS in Knee Surgeries. Theoretical Aspects and Clinical Relevance References.

The application and interpretation of patient-reported outcome measures (PROM), following knee injuries, pathologies, and interventions, can be challenging. In recent years, the literature has been enriched with metrics to facilitate our understanding and interpretation of these outcome measures. Two commonly utilized tools include the minimal clinically important difference (MCID) and the patient acceptable symptoms state (PASS). These measures have demonstrated clinical value, however, they have often been under- or mis-reported. It is paramount to use them to understand the clinical significance of any statistically significant results. Still, it remains important to know their caveats and limitations. In this focused report on MCID and PASS, their definitions, methods of calculations, clinical relevance, interpretations, and limitations are reviewed and presented in a simple approach.

Lateral-medial asymmetry of posterior tibial slope and small lateral tibial plateau articular surface depth are morphological factors of lateral meniscus posterior root tears in ACL-injured patients.

PURPOSE: To investigate whether knee morphological features, patient characteristics, and intraoperative findings are associated with a lateral meniscus (LM) posterior root tear (LMPRT) in anterior cruciate ligament (ACL) injuries with the integrated data from two academic centres. METHODS: This retrospective study used registry data acquired prospectively at two academic centres. Patients with ACL reconstruction (ACLR) with LMPRT and no other LM injury were selected (LMPRT group) from each database. The control group included patients who underwent ACLR without LM tears. Patients were matched to the LMPRT group according to age and gender (1:1). Morphological factors evaluated on preoperative magnetic resonance image scans included lateral femoral condyle (LFC) anterior-posterior diameter, height, and depth; lateral tibial plateau (LTP) articular surface (AS) depth and sagittal plane depth; and lateral and medial posterior tibial slopes (PTSs). LFC height and depth ratios, LTP AS depth and sagittal plane depth ratios, and lateral-to-medial slope asymmetry were computed from previous measurements. Patient characteristics and intraoperative findings were extracted and compared between both groups. RESULTS: The study included 252 patients (126 in each group). The lateral-medial asymmetry of PTS was greater in the LMPRT group (1.2° vs 0.3°, p < 0.05), and the LTP AS depth was smaller in the LMPRT group (31.4 mm vs 33.2 mm, p < 0.01). There were no differences in LFC morphology between the control and LMPRT groups. Pivot shift grade (p < 0.05), percentage of complete ACL tears (p < 0.05), and medial meniscus ramp lesions (p < 0.05) were significantly higher in the LMPRT group. CONCLUSION: LMPRT was associated with significantly increased lateral-medial asymmetry of PTS and significantly smaller LTP AS depth. LMPRT was also associated with an increase in the preoperative pivot shift grade and the presence of a medial meniscus ramp lesion. These morphological characteristics are rather simple to measure and would serve as helpful indicators to preoperatively detect LMPRT, which is frequently challenging to diagnose preoperatively. LEVEL OF EVIDENCE: Level III.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction.

PURPOSE: To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage. METHODS: A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles. RESULTS: A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01). CONCLUSIONS: The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients. LEVEL OF EVIDENCE: Level III.

The posterior cruciate ligament-posterior femoral cortex angle: a reliable and accurate MRI method to quantify the buckling phenomenon of the PCL in ACL-deficient knees.

PURPOSE: The aim was to validate a new MRI method to measure the buckling phenomenon of the PCL, representative of anterior tibial translation, by comparing its reliability and accuracy to identify anterior cruciate ligament (ACL)-deficient knees with existing methods. METHODS: Patients were selected retrospectively and separated into a group of primary ACL injuries and ACL-intact knees. Exclusion criteria were: skeletal immaturity, PCL or a concomitant collateral ligament injury, signs of osteoarthritis (> 1 Kellgren and Lawrence score), tibial plateau fracture, previous ACL reconstruction or displaced meniscal bucket handle tear. The assessment of the curvature of the anterolateral bundle of the PCL was performed on T2 sagittal MRI slices according to 3 methods: (1) the PCL angle (PCLA), (2) the PCL inclination angle (PCLIA) and (3) a new method: the PCL-posterior cortex angle (PCL-PCA), representing the angle between the vertical part of the PCL-ALB and the posterior diaphyseal cortex of the femur. For each method, the inter- and intra-observer reliability was measured. The ability to discriminate both ACL-deficient and ACL-intact knees was evaluated using ROC curves. RESULTS: Twenty-four patients were included in each group. Intra-observer reliability was excellent for all 3 methods (ICCs > 0.90). Inter-observer reliability was excellent for the PCL-PCA (ICC > 0.90) and good for the PCLA and the PCLIA (ICCs between 0.75 and 0.90). The PCL-PCA had the highest precision (lowest standard error of measurement: 2.7°). It yielded an excellent discrimination between the ACL and CTL groups (AUC 0.80 [0.67-0.93]) with the highest sensitivity (71% [52.8-89.2]) and specificity (88% [75-100]) for a positive threshold when the angle was ≤ 22.7°. The PCLA and PCLIA methods led to acceptable discrimination and lower sensitivities and specificities (PCLA: AUC 0.71, sensitivity 63%, specificity 79%, threshold ≤ 117.9°; PCLIA: AUC 0.62, sensitivity 50%, specificity 83%, threshold ≤ 21.4°). CONCLUSION: In comparison with previously described methods, the PCL-PCA was the most reliable and accurate method to measure the PCL buckling phenomenon on MRI in anterior cruciate ligament (ACL)-deficient knees. It offers an easy and objective method for the follow-up of ACL-injured patients and can therefore be recommended for routine use. LEVEL OF EVIDENCE: IV.

The SFA datalake platform and anterior cruciate ligament tear registry of the French Society of Arthroscopy (SFA): Rationale, statutes and plans.

SFA Datalake is the registry platform of the French Society of Arthroscopy (SFA). It was designed to collect and store data on arthroscopic orthopedic surgery and joint-sparing surgery in French-speaking countries. The anterior cruciate ligament (ACL) tear registry is the first registry to be set up based on SFA Datalake. Registries are intended to enable systematic standardized data collection, and provide information for surgeons to improve clinical practice and results. The ACL tear registry was designed in the light of guidelines, the literature and existing registries. Data are collected prospectively on a secure on-line application accessible via a computer or smartphone. Data collection is organized according to clinical examination results, preoperative findings, and follow-up data based on patient-administered subjective quality of life questionnaires. The pilot committee consists of 5 SFA board members, appointed for 2 years. LEVEL OF EVIDENCE: IV.

Consensus statement on data to be entered in the ACL tear registry: SFA-DataLake.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction is a frequent procedure, with room for improvement by rehabilitation measures and associated peripheral and meniscal surgeries that are currently under assessment, requiring follow-up. Outside France, there have been ACL registries for 20 years now. The French Arthroscopy Society (SFA) decided to set up an ACL tear registry within its SFA DataLake registry platform. MATERIAL AND METHOD: This article presents the methodology underlying the ACL Tear Registry: i.e., identification, definition and coding of essential and relevant data. A test phase comprised an initial assessment to improve data quality and overall coherence, to optimize data-entry time for patients and practitioners, who are the guarantors of the registry's use and efficacy. RESULTS: The SFA DataLake ACL Tear Registry was made available to SFA members in December 2021. It aims to enable a review of practices for surgeons, early detection of failure of procedures and implants, with rates of failure and abnormal complications, and identification of prognostic factors for outcome, especially regarding original items that do not figure in previous registries. CONCLUSION: SFA DataLake strikes a balance between "indispensable" and "original" items. The choice of contents and data quality is founded on a robust methodology with overall coherence, enabling analysis of large cohorts and comparisons with the literature and other registries. However, it remains to assess rates of data entry and item relevance as the Registry progresses. LEVEL OF EVIDENCE: IV.

Anatomic reconstruction of lateral ankle ligaments: is there an optimal graft option?

PURPOSE: Different graft options are available for the reconstruction of lateral ankle ligaments to treat chronic ankle instability (CAI), which fall in two categories: allografts and autografts. This study aims to provide an updated comparison of the clinical outcomes after stabilisation procedures using allografts and autografts, to correctly advise the clinician during the choice of the best material to be used for the reconstruction of the lateral ligamentous complex of the ankle. METHODS: A systematic review was performed to analyse the use of autografts and allografts for anatomic reconstruction of the lateral ligamentous complex of the ankle in CAI patients. The presence of a postoperative assessment through outcome measures with proofs of validation in the CAI population or patient's subjective evaluation on the treatment were necessary for inclusion. The quality of the included studies was assessed through the modified Coleman Methodology Score (mCMS). Relevant clinical outcome data were pooled to provide a synthetic description of the results in different groups or after different procedures. RESULTS: Twenty-nine studies (autograft: 19; allograft: 9; both procedures: 1) accounting for 930 procedures (autograft: 616; allograft: 314) were included. The average mCMS was 55.9 ± 10.5 points. The Karlsson-Peterson scale was the most frequently reported outcome scale, showing a cumulative average post- to preoperative difference of 31.9 points in the autograft group (n = 379, 33.8 months follow-up) and of 35.7 points in the allograft group (n = 227, 25.8 months follow-up). Patient satisfaction was good or excellent in 92.8% of autograft (n = 333, 65.2 months follow-up) and in 92.3% of allograft procedures (n = 153, 25.0 months follow-up). Return to activity after surgery and recurrence of instability were variably reported across the studies with no clear differences between allograft and autograft highlighted by these outcomes. CONCLUSIONS: The systematic analysis of validated CAI outcome measures and the patient's subjective satisfaction does not support a specific choice between autograft and allograft for the reconstruction of the ankle lateral ligamentous complex in CAI patients. Both types of grafts were associated to a postoperative Karlsson-Peterson score superior to 80 points and to a similar rate of patient's subjective satisfaction. LEVEL OF EVIDENCE: Level IV.

Failure of primary ACL repair with dynamic intraligamentary stabilization may result in a high risk of two-stage ACL reconstruction: a case series of ten patients.

PURPOSE: Dynamic Intraligamentary Stabilization (DIS) is a technique for the repair of acute anterior cruciate ligament (ACL) injuries. The purpose of this study was to investigate the potential challenges of ACL reconstruction (ACLR) following failure of DIS. METHODS: A retrospective analysis of patients with failure of primary ACL repair performed with DIS was undertaken. Failure was defined as abnormal knee laxity (positive Lachman and/or pivot shift) and/or severely restricted range of motion. Medical and surgical records were reviewed and preoperative standard anteroposterior and lateral X-rays were assessed. RESULTS: Between July 2015 and May 2022, 10 patients (3 males, 7 females, median age 28 years, range 18-52 years) with failure of DIS were referred to and surgically treated at a single centre. In four patients, single-stage ACLR was performed following the removal of the tibial monoblock. In six patients, arthrofibrosis and excessive tibial tunnel enlargement following the removal of the monoblock prevented single-stage ACLR. These patients underwent arthroscopic arthrolysis and tibial tunnel bone grafting as a first-stage revision procedure. CONCLUSION: In the present case series, single-stage ACLR was performed in only four (40%) of ten patients following failure of ACL repair with DIS. Arthrofibrosis and excessive tibial tunnel enlargement following the removal of the monoblock prevented single-stage ACLR in six (60%) patients. It is important for clinicians to inform patients that, in the event of failure of ACL repair with DIS, they may run a high risk of undergoing two-stage ACLR. LEVEL OF EVIDENCE: Level IV, Case Series.

Side-to-side anterior tibial translation on monopodal weightbearing radiographs as a sign of knee decompensation in ACL-deficient knees.

PURPOSE: To evaluate the influence of time from injury and meniscus tears on the side-to-side difference in anterior tibial translation (SSD-ATT) as measured on lateral monopodal weightbearing radiographs in both primary and secondary ACL deficiencies. METHODS: Data from 69 patients (43 males/26 females, median age 27-percentile 25-75: 20-37), were retrospectively extracted from their medical records. All had a primary or secondary ACL deficiency as confirmed by MRI and clinical examination, with a bilateral weightbearing radiograph of the knees at 15°-20° flexion available. Meniscal status was assessed on MRI images by a radiologist and an independent orthopaedic surgeon. ATT and posterior tibial slope (PTS) were measured on the lateral monopodal weightbearing radiographs for both the affected and the contralateral healthy side. A paired t-test was used to compare affected/healthy knees. Independent t-tests were used to compare primary/secondary ACL deficiencies, time from injury (TFI) (≤ 4 years/ > 4 years) and meniscal versus no meniscal tear. RESULTS: ATT of the affected side was significantly greater than the contralateral side (6.2 ± 4.4 mm vs 3.5 ± 2.8 mm; p < 0.01). There was moderate correlation between ATT and PTS in both the affected and healthy knees (r = 0.43, p < 0.01 and r = 0.41, p < 0.01). SSD-ATT was greater in secondary ACL deficiencies (4.7 ± 3.8 vs 1.9 ± 3.2 mm; p < 0.01), patients with a TFI greater than 4 years (4.2 ± 3.8 vs 2.0 ± 3.0 mm; p < 0.01) and with at least one meniscal tear (3.9 ± 3.8 vs 0.7 ± 2.2 mm; p < 0.01). Linear regression showed that, in primary ACL deficiencies, SSD-ATT was expected to increase (+ 2.7 mm) only if both a meniscal tear and a TFI > 4 years were present. In secondary ACL deficiencies, SSD-ATT was mainly influenced by the presence of meniscal tears regardless of the TFI. CONCLUSION: SSD-ATT was significantly greater in secondary ACL deficiencies, patients with a TFI greater than 4 years and with at least one meniscal tear. These results confirm that SSD-ATT is a time- and meniscal-dependent parameter, supporting the concept of gradual sagittal decompensation in ACL-deficient knees, and point out the importance of the menisci as secondary restraints of the anterior knee laxity. Monopodal weightbearing radiographs may offer an easy and objective method for the follow-up of ACL-injured patients to identify early signs of soft tissue decompensation under loading conditions. LEVEL OF EVIDENCE: Level III.

Ramp lesions are six times more likely to be observed in the presence of a posterior medial tibial bone bruise in ACL-injured patients.

PURPOSE: The aim of this study was to determine whether posterior tibial slope (PTS), meniscal slope (MS), and bone bruise pattern (BBP), as observed on magnetic resonance imaging (MRI), differed between patients with or without medial meniscus ramp lesions at the time of anterior cruciate ligament reconstruction (ACLR). The hypothesis was that patients with a ramp lesion had a higher PTS and MS, with a different BBP than patients without a ramp lesion. METHODS: Fifty-six patients undergoing ACLR were selected from an in-house registry and separated into 2 groups: (1) the RAMP group included patients with a primary ACLR and a medial meniscus ramp lesion diagnosed intraoperatively; (2) the CONTROL group included patients with a primary ACLR without ramp lesion after arthroscopic exploration of the posteromedial knee area. The two groups were matched for age, sex and type of concomitant meniscal lesions. The medial/lateral-PTS/MS and BBP were subjected to blinded evaluation on the preoperative MRI of the reconstructed knee. RESULTS: Twenty eight patients (21 males; 7 females) were included in each group. No significant difference could be observed between groups in terms of demographical characteristics, PTS, and MS. A posteromedial tibial plateau (PMTP) bone bruise was more often observed in the RAMP group (n = 23/28) compared to the CONTROL group (n = 12/28) (p < 0.01). The RAMP group was 6.1 (95%CI [1.8; 20.8]) times more likely to present a PMTP bone bruise. The likelihood of having a bone bruise in both the medial and lateral compartments was 4.5 (95%CI [1.2; 16.5]) times higher in the RAMP group. However, a BBP only involving the lateral tibiofemoral compartment was more likely to be observed in the CONTROL group (n = 10/28) compared to the RAMP group (n = 3/28, p < 0.05 - odds ratio 4.6 (95%CI [1.1; 19.2]). CONCLUSION: Ramp lesions were 6.1 and 4.5 times more likely to be observed in the presence of a posteromedial tibia plateau bone bruise or a combined bone bruise respectively in both the medial and lateral tibiofemoral compartment in patients undergoing ACLR. The tibial and meniscal slopes did not differ between patients with or without ramp lesions undergoing ACLR. LEVEL OF EVIDENCE: Level III.