Functional anterior cruciate ligament braces may have a role in select patient groups although there is presently limited evidence supporting or refuting their routine use: A scoping review of clinical practice guidelines and an updated bracing classification.

PURPOSE: The purpose of this study was to perform a scoping review of clinical practice guidelines (CPGs) concerning the use of functional anterior cruciate ligament (ACL) braces and to clarify the nomenclature for bracing relevant to ACL injury treatment in order to support prescribing clinicians. METHODS: A PubMed search for CPGs for the use of braces following ACL injury or reconstruction was performed. CPGs on the treatment of ACL injuries with sufficient attention to postoperative braces were included in this scoping review. The references used for supporting the specific CPG recommendations were reviewed. Specific indications for brace use including brace type, period of use following surgery and activities requiring brace use were collected. RESULTS: Six CPGs were identified and included this this review. Three randomised trials provided the evidence for recommendations on functional brace use following ACL reconstruction in the six CPGs. Functional ACL braces were the primary focus of the three randomised trials, although extension braces (postoperative knee immobilisers) were also discussed. A novel dynamic ACL brace category has been described, although included CPGs did not provide guidance on this brace type. CONCLUSIONS: Guidance on the use of functional ACL braces following ACL reconstruction is provided in six CPGs supported by three randomised trials. However, the brace protocols and patient compliance in the randomised trials render these CPGs inadequate for providing guidance on the use of functional ACL braces in the general and high-risk patient populations when returning to sport after ACL reconstruction. Functional ACL braces are commonly utilised during the course of ACL injury treatment although there is presently limited evidence supporting or refuting the routine use of these braces. Future studies are, therefore, necessary in order to provide guidance on the use of functional and dynamic ACL braces in high-risk patient populations. LEVEL OF EVIDENCE: Level II.

Diagnosis and treatment strategies of the multiligament injured knee: a scoping review.

OBJECTIVE: To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs). DESIGN: Scoping review. DATA SOURCES: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary. RESULTS: Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups. CONCLUSIONS: There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.

Repair of Quadriceps and Patellar Tendon Tears.

Tears of the quadriceps or patellar tendon usually occur after a sudden eabccentric contraction and are diagnosed by a palpable gap at the injury site combined with an inability to perform a straight leg raise. Bilateral knee radiographs may demonstrate patella alta with patellar tendon tears and patella baja with quadriceps tendon tears compared with the uninjured knee. Ultrasound and magnetic resonance imaging can be helpful when there is uncertainty in the diagnosis. Surgical treatment is indicated for complete tears and some high-grade, partial tears. Nonabsorbable high-strength sutures or suture tape are placed in running locking fashion along the injured tendon and secured to the patella with bone tunnels (i.e., transosseous) or suture anchors. The transosseous technique requires exposure of the length of the patella to drill 3 bone tunnels to shuttle the sutures and tie over either pole of the patella. The suture anchor technique allows for a smaller incision and less soft-tissue dissection and may use a knotted or knotless technique. Biomechanical testing with load to failure is not statistically different between the transosseous and anchor techniques, although anchors have been shown to have less gap formation at the repair site. Repair augmentation with a graft may be beneficial in mid-substance injuries, chronic tears, and in cases of compromised tissue quality. Rehabilitation usually can be initiated immediately with protected weight-bearing in an orthosis, safe-zone knee passive range of motion, and avoidance of active extension. After a period of 6 weeks, rehabilitation can progress with full range of motion and a concentric strengthening program.

Radiographic and Dynamic Assessment for Resection of Cam Lesions in Patients With Femoroacetabular Impingement.

Cam-type femoroacetabular impingement is characterized by a pathologic asphericity of the femoral head-neck junction, and arthroscopic femoral osteoplasty is indicated to correct the bony abnormality and restore normal hip mechanics when symptomatic. Residual femoroacetabular impingement deformity after arthroscopy is a leading cause of failure, and it is therefore critical to perform a thorough fluoroscopic and dynamic assessment when addressing cam deformities arthroscopically. The fluoroscopic assessment uses 6 anteroposterior views, including 3 in hip extension (30° internal rotation, neutral rotation, and 30° external rotation) and 3 in 50° flexion (neutral rotation, 40° external rotation, 60° of external rotation), performed before, during, and after the femoral resection. The dynamic assessment includes evaluation of impingement-free range of motion and "end feel" (a subjective description of the tactile feedback during assessment of hip motion), and should be performed before and after the femoral resection in 3 specific positions (extension/abduction, flexion/abduction, and flexion/internal rotation). Although the anterior aspect of the head-neck junction is readily accessed through standard arthroscopic portals with the hip in 30 to 50° of flexion, the posterolateral, posteromedial, and posterior extent of the femoral head-neck junction are challenging to address. The natural external rotation of the proximal femur during flexion and internal rotation during extension can be used to gain posterior lateral and medial access. Antero/posteromedial femoral access can be obtained with >50° of hip flexion with the burr in the anteromedial portal. Posterolateral femoral access is achieved with hip extension with the burr in the anterolateral portal, and further posterolateral access can be achieved with the addition of traction, allowing resection of posterolateral deformities extending beyond the lateral retinacular vessels while remaining proximal to the vessels. This comprehensive intraoperative fluoroscopic and dynamic assessment and surgical technique can lead to a predictable correction of most cam-type deformities.

Biomedical Research Infographics and Visual Abstracts Increase Social Media Attention and Article Citation.

Biomedical research Infographics, a short-form neologism for "information graphics," illustrate medical educational information in an engaging manner by enhancing concise text with figures, tables, and data visualizations in the form of charts and graphs. Visual Abstracts present a graphic summary of the information contained in a medical research abstract. In addition to improving retention, both Infographics and Visual Abstracts allow for dissemination of medical information on social media and increase the breadth of medical journal readership. In addition, these new methods of scientific communication increase citation rates, as well as social media attention as determined by Altmetrics (alternative metrics).

Combined Anterior Cruciate Ligament and Lateral Extra-Articular Reconstruction.

The anterolateral complex (ALC) of the knee has received renewed research interest because of the potential role of this anatomic region in anterior cruciate ligament (ACL) tear biomechanics and surgical treatment outcomes. The primary structures of the ALC include the iliotibial band deep (Kaplan) fibers, the anterolateral ligament (ALL), and the capsulo-osseous layer (COL) of the iliotibial band, although there remains disagreement on the precise anatomic locations and biomechanical relevance of these structures. Sectioning studies in the ACL-deficient knee have revealed a contribution of the ALC in restraining tibial internal rotation and anterior translation. Biomechanical studies have revealed a potential role for lateral extra-articular reconstruction as an augmentation to ACL reconstruction in knees with combined ACL and ALC sectioning. Clinical studies have reported a reduced ACL reconstruction failure rate with both ALL reconstruction and lateral extra-articular tenodesis procedures.

Combined Meniscus Repair and Anterior Cruciate Ligament Reconstruction.

Meniscal tear patterns associated with anterior cruciate ligament (ACL) tears, such as root tears and ramp lesions are common but less easily recognized on magnetic resonance imaging (MRI) compared with a complete radial tear or a locked bucket-handle tear. Timely treatment of these tears improves outcomes in the setting of ACL reconstruction. While physical examination does not enable a definitive diagnosis of meniscal root tears and ramp lesions, high-grade laxity, including a 3+ Lachman and 3+ pivot shift, should raise suspicions for these tear patterns. MRI allows visualization of both root tears and ramp lesions, although the gold standard for diagnosis is probing at the time of arthroscopy due to a high false-negative rate on MRI. Up to 17% of patients with an ACL tear have a lateral meniscal root tear; a contact mechanism and increased posterior slope are both associated with a greater incidence of lateral meniscal root tears and these are repaired with a tunnel technique. Meniscal ramp lesions occur in up to 41% of patients with ACL tears due to a contact mechanism, and we prefer repair with an inside-out technique. More than 60% of complete radial meniscal tears occur in the setting of ACL tears and are preferentially repaired with a hashtag technique for minimally separated tears and a 2-tunnel technique combined with an inside-out repair for more severe tears. Bucket-handle tears are more common in the setting of chronic ACL deficiency; concurrent with ACL reconstruction urgent meniscal repair with an inside-out technique is the gold standard, which allows for precise approximation of the tear with multiple points of fixation for improved biomechanical performance. It is critical to identify and treat these tears during ACL reconstruction because of their role as secondary stabilizers and for long-term chondral protection.

Editorial Commentary: Infographics Engage a Broader Audience Than Traditional Scientific Articles in the Medical Literature: The Latest Social Media Influencer?

Infographics are an evolving medium within the orthopaedic literature and support engagement of a broad audience than traditional scientific articles. Arthroscopy infographics have been published monthly since January 2019 on a range of topics relevant to the readership. Citation numbers have long been used as a metric for quality and relevance of a scientific article, although alternative metrics (altmetrics) are now available to quantify the online activity related to scholarly content. Altmetrics are defined as "metrics and qualitative data that are complementary to traditional, citation-based metrics," and the altmetric attention score depends on 3 main factors: volume (number of "mentions"), sources (e.g. newspaper, blog, tweet), and author (source of the "mention", e.g. physician vs journal). Recent research links altmetric scores to citation gains. Infographics are a tool for expanding, educating, and increasing the breadth of medical journal readership.

Editorial Commentary: Revision Hip Surgery After Arthroscopy-What Went Wrong? Are There Second Chances?

Hip arthroscopy allows minimally invasive treatment of femoroacetabular impingement (FAI) with labral tears. Over the last 2 decades, the indications and techniques for treatment of FAI have evolved, and complex pathology can now be treated arthroscopically. Short- and medium-term patient-reported outcomes demonstrate the reliability of hip arthroscopy for treatment of FAI, although a subset of patients fail to achieve desired results and require revision surgery. The indications for revision surgery after a primary hip arthroscopy are not well described in a large series, and most reviews focus on revision arthroscopy at the exclusion of open surgery (notably periacetabular osteotomy and total hip arthroplasty). Furthermore, patient-reported outcomes after these revision procedures have not been recently summarized.

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction: In Pursuit of Ideal Graft Fixation.

With evolution of techniques in orthopaedic surgery, incremental improvements can be anticipated. All-inside anterior cruciate ligament (ACL) reconstruction represents a revolution in treatment of ACL injuries, and further technical modifications may result in gradual improvements. This process of continual optimization of our techniques is important for providing the best possible surgical outcomes. Supplemental fixation of the inner graft limbs may lead to improved time-zero biomechanical performance when all-inside ACL reconstruction is performed. However, in ACL surgery, optimal graft selection and fixation are still debated.

The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting.

The structure and function of the anterolateral complex (ALC) of the knee has created much controversy since the 're-discovery' of the anterolateral ligament (ALL) and its proposed role in aiding control of anterolateral rotatory laxity in the anterior cruciate ligament (ACL) injured knee. A group of surgeons and researchers prominent in the field gathered to produce consensus as to the anatomy and biomechanical properties of the ALC. The evidence for and against utilisation of ALC reconstruction was also discussed, generating a number of consensus statements by following a modified Delphi process. Key points include that the ALC consists of the superficial and deep aspects of the iliotibial tract with its Kaplan fibre attachments on the distal femur, along with the ALL, a capsular structure within the anterolateral capsule. A number of structures attach to the area of the Segond fracture including the capsule-osseous layer of the iliotibial band, the ALL and the anterior arm of the short head of biceps, and hence it is not clear which is responsible for this lesion. The ALC functions to provide anterolateral rotatory stability as a secondary stabiliser to the ACL. Whilst biomechanical studies have shown that these structures play an important role in controlling stability at the time of ACL reconstruction, the optimal surgical procedure has not yet been defined clinically. Concern remains that these procedures may cause constraint of motion, yet no clinical studies have demonstrated an increased risk of osteoarthritis development. Furthermore, clinical evidence is currently lacking to support clear indications for lateral extra-articular procedures as an augmentation to ACL reconstruction. The resulting statements and scientific rationale aim to inform readers on the most current thinking and identify areas of needed basic science and clinical research to help improve patient outcomes following ACL injury and subsequent reconstruction.Level of evidence V.

Editorial Commentary: More Evidence That Anterior Cruciate Ligament Deficiency Contributes to Knee Arthritis-In Search of an Optimal Biomechanical Model.

Patients with anterior cruciate ligament (ACL) tears have a greater incidence of knee arthritis than the general population. Acute chondral injury, acute or delayed meniscal pathology, and altered contact mechanics have all been implicated in the development of arthritis. Dynamic models (i.e., testing during simulated knee motion) have shown the biomechanical influence of ACL tears on knee laxity, although most investigations of contact mechanics rely on static models (i.e., testing during no relative tibiofemoral motion) wherein pressure distribution is mapped by thin films loaded in compression. A model that quantifies the change in contact mechanics during simulated knee motion after ACL tears, including stress distribution and shear stress, is desirable.

An Overview of Clinically Relevant Biomechanics of the Anterolateral Structures of the Knee.

Residual anterolateral rotatory laxity following injury and reconstruction of the anterior cruciate ligament (ACL) has become a popular topic and has generated interest in characterizing the relative contribution from the anterolateral structures of the knee. Studies have reported on the anatomic and biomechanical features of the anterolateral ligament (ALL), revealing a role in restraining internal tibial rotation in both ACL-intact and ACL-deficient knees. The Kaplan fibers of the iliotibial band have also been reported to provide significant restraint to internal tibial rotation. The ACL is the primary restraint to anterior tibial translation, and both the proximal and distal bundles of the iliotibial band, with a divergent orientation, also provide significant static restraint against internal tibial rotation, and each bundle may have a distinct individual role. In the setting of ACL deficiency, subsequent sectioning of the ALL and Kaplan fibers led to further increases in anterior tibial translation. Residual rotatory laxity that may be seen clinically following ACL reconstruction may be attributable to an associated anterolateral structure injury even in the setting of an anatomic ACLR, leading to consideration for a concomitant anterolateral structure reconstruction. Studies evaluating the kinematic influence of anatomic ALL reconstruction or lateral extra-articular tenodesis have focused on internal rotation, axial plane translation, and anterior tibial translation, with variable results having been reported. Further, despite the long history of anterolateral structure reconstruction, most commonly with a lateral extra-articular tenodesis, the clinical use of these combined techniques is still in its relative infancy, and long-term patient outcomes have yet to be published for relative comparisons.

Ligamentous Reconstruction of the Knee: What Orthopaedic Surgeons Want Radiologists to Know.

Knee ligament injuries are common, and treatment methods are continually evolving. Accurate clinical diagnosis with imaging confirmation is critical to support appropriate treatment. Several imaging pearls allow for improved recognition of injuries. Stress radiographs may be obtained to quantify knee laxity. Magnetic resonance imaging allows assessment of the complex anatomy of the knee and has excellent sensitivity and specificity for many injuries.

Anterolateral Ligament Reconstruction Techniques, Biomechanics, and Clinical Outcomes: A Systematic Review.

PURPOSE: To perform a systematic review of the described anterolateral ligament (ALL) reconstruction techniques, biomechanical performance, and clinical outcomes of ALL reconstruction in the setting of concurrent anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was performed according to PRISMA guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase, from 1980 to present. Inclusion criteria were as follows: ALL reconstruction techniques, ALL reconstruction biomechanical studies, ALL surgical outcomes, English language, human studies with at least 2 years of follow-up, and cadaveric studies. Exclusion criteria were lateral extra-articular tenodesis, ALL anatomic studies, ALL radiographic studies, animal studies, clinical studies with <2 years of follow-up, editorial articles, and surveys. RESULTS: The systematic review identified 12 articles that met the inclusion criteria: 6 techniques, 5 biomechanical studies, and 1 outcome study were available. Five studies described ALL reconstruction in the setting of ACL reconstruction, whereas 1 study described isolated ALL reconstruction. Femoral tunnel location was most commonly placed posterior and proximal to the lateral epicondyle, whereas 2 studies reported a distal tunnel location. There was little variability in tibial tunnel location. The most common ALL reconstruction graft used was the gracilis tendon. Review of the biomechanical studies revealed internal rotation overconstraint with the posterior/proximal femoral tunnel position but not anterior/distal, although fixation angle and graft tension were inconsistent. Only 1 clinical study with 2 years' follow-up was available and reported improvement in the majority of cases. Complications occurred in 15 patients, including a residual pivot shift in 8% of patients at 2 years after a combined ACL and ALL reconstruction. CONCLUSIONS: There is inconsistency in the selection of ALL graft femoral attachment location as well as in the biomechanical performance of ALL reconstruction techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

The Heel Height Test: A Novel Tool for the Detection of Combined Anterior Cruciate Ligament and Fibular Collateral Ligament Tears.

PURPOSE: To determine the exact value of side-to-side difference (SSD) in heel height that was associated with combined anterior cruciate ligament (ACL) and fibular collateral ligament (FCL) tears (compared with an isolated ACL tear) and determine the clinical utility of heel height SSD in the assessment of this injury pattern. METHODS: Two patient groups were identified: (1) patients with isolated ACL tears and (2) patients with combined ACL-FCL tears but without additional collateral or cruciate ligament injuries. Determination of the amount of the heel height SSD was determined during the outpatient clinic visit. Receiver operator characteristic curves were used to evaluate the accuracy of diagnostic tests by plotting the true-positive (sensitivity) rate against the false-positive (1-specificity) rate at various thresholds. In addition, magnetic resonance imaging (MRI) reports were reviewed to calculate the sensitivity of MRI for the detection of FCL injury. MRI sensitivity was then compared with the sensitivity of the heel height examination. RESULTS: One hundred and fifty-eight patients (71 men, 87 women) in the isolated ACL tear patient group and 117 patients (60 men, 57 women) in the combined ACL-FCL tear patient group were reviewed. A 3-cm or greater SSD was found in 13 of the 158 (8.2%) isolated ACL tear patients and 84 of the 117 (72%) ACL-FCL tear patients. The sensitivity, specificity, positive predictive value, and negative predictive value of the heel height test were 72%, 92%, 86%, and 86%, respectively. The area under the receiver operator characteristic curve was found to be 0.876. After review of all preoperative MRI musculoskeletal radiology reports for patients in the ACL-FCL patient group, a sensitivity of 48% was found. CONCLUSIONS: The clinical heel height test resulted in high sensitivity and excellent specificity for the diagnosis of combined ACL-FCL tears compared with the sensitivity and specificity of the MRI detection of FCL injury. The information presented in the current study will improve diagnostic ability through a simple physical examination and avoid missed injuries that are known to compromise surgical outcomes. LEVEL OF EVIDENCE: Level III, cross-sectional.

Influence of lateral meniscal posterior root avulsions and the meniscofemoral ligaments on tibiofemoral contact mechanics.

PURPOSE: The purpose of this study was to investigate the effect of lateral meniscal posterior root avulsions combined with intact meniscofemoral ligaments (MFLs), deficient MFLs, anterior cruciate ligament (ACL) tears and reconstructions, and root repairs using an established tibiofemoral contact mechanics testing protocol. METHODS: Ten fresh-frozen cadaveric knees were tested with six knee conditions (1: intact; 2: lateral meniscal posterior root avulsion; 3: root avulsion and deficient MFLs; 4: condition 3 with ACL tear; 5: condition 4 with ACL reconstruction; 6: ACL reconstruction with root repair) at five flexion angles (0°, 30°, 45°, 60°, and 90°), under a 1000-N axial load. Contact area and pressure were measured with Tekscan sensors. RESULTS: Compared to the intact state, condition 2 did not significantly change lateral compartment contact area or pressure. Changes in contact mechanics were greater at increased flexion angles; for condition 3 at 0° and 90°, contact area decreased 37 and 52 % [95 % CI (21-53) and (39-66), respectively] and mean contact pressure increased 55 and 87 % [95 % CI (33-76) and (59-114), respectively]. Root repair with ACL reconstruction was not significantly different from the intact state. CONCLUSIONS: The MFLs protect the lateral compartment from changes in contact mechanics in the setting of a lateral meniscal posterior root avulsion, whereas a combination of lateral meniscal root avulsion and deficient MFLs leads to significant changes. Concurrent ACL reconstruction and lateral meniscal root repair restore mean contact pressure and area to the intact state and are recommended in this combined injury to prevent or slow the development of lateral compartment arthritis.

Partial Tears of the Distal Biceps Brachii Tendon: A Systematic Review of Surgical Outcomes.

PURPOSE: To systematically review the literature regarding surgical outcomes for treatment of partial tears of the distal biceps brachii tendon. METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A systematic review of the literature regarding treatment of partial tears of the distal biceps tendon was conducted using PubMed, Embase, and Cochrane. Inclusion criteria consisted of studies in the English language on the treatment of partial distal biceps tendon tears. Exclusion criteria consisted of (1) studies without outcome data, (2) studies that did not specify the degree of distal biceps tendon tear (ie, complete rupture vs partial tear), and (3) studies without partial tear subgroup data. Two investigators independently reviewed the abstracts from all identified articles. RESULTS: Only 5 patients who underwent successful nonsurgical treatment were identified; all were treated with different algorithms, and because of the small number, outcomes for nonsurgical treatment are not included in this review. Therefore, 19 studies involving 86 partial tears that underwent surgical treatment are reported; at least 65 of these received a trial of nonsurgical treatment before surgery. Surgery resulted in 94% satisfactory clinical outcomes. Of the 16 studies (n = 83) that specified the presence or absence of surgical complications, lateral antebrachial cutaneous nerve paresthesia (17%), posterior interosseous nerve palsy (6%), elbow discomfort (2%), surgical revision (2%), and asymptomatic heterotopic ossification (1%) were reported. CONCLUSIONS: Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity can yield satisfactory results and appears to provide predictable outcomes. Further research is necessary to better define the optimal regimen and duration of nonsurgical treatment, as well as the indications for surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.