Associations Between Body Mass Index, Gait Biomechanics, and In Vivo Cartilage Function After Exercise in Those With Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Both high body mass index (BMI) and anterior cruciate ligament reconstruction (ACLR) independently influence knee osteoarthritis risk. Preliminary evidence shows the combination of these risk factors leads to poorer recovery and altered biomechanical outcomes after ACLR, but few studies have directly evaluated early changes in cartilage health between normal-BMI and high-BMI groups in this population. PURPOSE: To evaluate ultrasound-based measures of cartilage strain and compositional changes (via echo-intensity [EI]) in response to an incline walking stress test between normal-BMI and high-BMI individuals with ACLR. A secondary evaluation was conducted of associations between habitual walking biomechanics (ie, ground-reaction forces, sagittal knee kinetics and kinematics) and cartilage strain and EI outcomes. STUDY DESIGN: Controlled laboratory study. METHODS: Gait biomechanics and femoral trochlear ultrasound analyses were evaluated in 64 participants with ACLR who had normal BMI (BMI < 27.0; n = 40) and high BMI (BMI ≥ 27.0; n = 24). Ultrasound images were collected bilaterally before and after an incline treadmill walk, and medial and lateral trochlear strain and EI changes pre-post exercise were used to compare BMI groups and limbs. Gait outcomes included ground-reaction forces, peak sagittal plane knee moments, angles, and excursions and were used to determine associations with cartilage outcomes in the entire cohort. RESULTS: High-BMI individuals with ACLR exhibited greater medial trochlear cartilage strain in the ACLR limb compared with normal-BMI individuals (approximately 6%; P < .01). In those with high BMI, the ACLR limb exhibited greater medial trochlear strain relative to non-ACLR limbs (approximately 4%; P < .05), but between-limb differences were not observed in the normal-BMI group (P > .05). Medial trochlear EI changes were greater bilaterally in those with high BMI compared with normal-BMI ACLR counterparts (approximately 10%; P < .01). Last, individuals who walked with greater peak knee flexion angles exhibited less medial cartilage strain (ΔR2 = 0.06; P = .025). CONCLUSION: The data suggested that high BMI affects cartilage functional properties after ACLR, whereas smaller knee flexion angles were associated with larger medial cartilage strain. CLINICAL RELEVANCE: High-BMI individuals with ACLR may represent a subset of patients exhibiting earlier declines in cartilage functional integrity in response to loading, necessitating additional or more targeted interventions to mitigate disease development.

Evaluation of the peroneus longus tendon as an autologous graft in knee surgery.

Our hypothesis is that the peroneus longus (PL) is a great option for ligament reconstruction in the knee, and therefore the objective of the study is to determine if the use of this graft is safe and does not cause secondary damage to the harvested area. A prospective study was conducted between April 2019 and September 2022. Patients who underwent any type of knee ligament reconstruction using the PL or just the anterior half (AHPL) as grafts were followed up. These patients were evaluated according to the Tegner-Lysholm score and the International Knee Documentation Committee (IKDC) guidelines for functional evaluation of the knee and the American Orthopedic Foot and Ankle Score (AOFAS) and the Foot and Ankle Disability Index (FADI) for the functional evaluation of the ankle. Most patients had an increase in the IKDC score, Tegner-Lysholm score, AOFAS and FADI regardless of the graft used in the surgical procedure, with mean values at the 24-month follow-up of, respectively, 99.02± 0.02, 98.69± 0.08, 99.92± 0.07, and 99.92± 0.07 for those with PL grafts and 99.31± 0.54, 98.88± 0.95, 100± 0.00, and 100± 0.00 for those with AHPL grafts. The differences in the scores between the two graft groups during each of the follow-up periods were significant (P = 0.001). The use of the peroneus longus tendon as a graft in knee surgeries was shown to be adequate for achieving good knee functional results.

Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society.

Background: Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers. Purpose: To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume. Study Design: Cross-sectional study. Methods: A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses. Results: Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01). Conclusion: The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.

The Child Opportunity Index and Outcomes After Pediatric Anterior Cruciate Ligament Reconstruction.

Background: Research at the intersection between social determinants of health (SDOH) and orthopaedics remains an area of active exploration, with recent literature demonstrating significant disparities in a wide array of orthopaedic outcomes in patients with different SDOH. Purpose/Hypothesis: The purpose of this study was to use a validated composite measure of SDOH mapped to census tracts (Child Opportunity Index [COI]) to explore disparities in functional outcomes after anterior cruciate ligament (ACL) reconstruction. It was hypothesized that patients with a lower COI score would have delayed surgical care and worse functional outcomes after ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Demographic, surgical, and functional outcomes data were extracted for all patients aged ≤18 years who underwent primary ACL reconstruction at our institution between 2009 and 2019. Strength deficits were calculated, and COI quintile scores were obtained. One-way analysis of variance, the chi-square test, and the Fisher exact test were used to compare variables of interest between the lower 2 quintiles (low group) and the upper 2 quintiles (high group). Results: Of the 1027 patients, 226 (22.0%) were in the low group, while 801 (78.0%) were in the high group. There was a significantly greater time from injury to surgery in the low group than in the high group (98.15 ± 102.65 vs 71.79 ± 101.88 days, respectively; P < .001). The low group had a significantly lower extension-flexion range of motion at 1- and 3-month follow-up (P = .03 and P = .02, respectively) but no difference at 6-month follow-up (P = .27). The low group attended fewer physical therapy visits than the high group (24.82 ± 10.55 vs 37.81 ± 18.07, respectively; P < .001). The low group had significant deficits in quadriceps strength at 3, 6, and 9 months at 180 deg/s (P = .03, P < .001, and P = .01, respectively) and at 6 months at 300 deg/s (P = .002). Conclusion: In this study, we found that the COI was associated with disparities in key clinical outcomes including time to surgery, postoperative range of motion, and postoperative strength.

A systematic review on how to diagnose deltoid ligament injuries-are we missing a uniform standard?

BACKGROUND: Up to now, there is no convincing evidence, that surgical treatment of deltoid ligament injuries, especially in the setting of ankle fractures, does result in improved outcome. One reason could be a missing diagnostic standard. The aim of the current systematic review was to analyze the applied diagnostic strategies for acute deltoid ligament injuries in outcome studies. METHODS: MEDLINE, Scopus, Central, and EMBASE were searched through February 2022 for any original studies addressing diagnostics of acute deltoid injuries. The study was conducted per the PRISMA guidelines. The inclusion criteria were formed according to the PICOS criteria. The data assessed were study type, level of evidence, included fractures, time point and method of diagnosing deltoid ligament layers, differentiation between layers and syndesmotic injuries. RESULTS: 31 studies were included in the final analysis. Most studies (n = 28) based their decision to treat the deltoid ligament injury on radiologic findings only, with stressed radiographs (n = 18) being the most common. The radiographs were applied at one or more time points (preoperative, before ORIF, after ORIF, after ORIF and syndesmotic repair). The most frequently assessed parameter was the Medial Clear Space (MCS, n = 27) with cut-off-values considered pathological ranging between MCS > 1 mm and MCS > 6 mm. CONCLUSION: Comparing the 31 studies shows that a standardized method to diagnose deltoid ligament injuries is missing. Further research is needed to establish evidence-based guidelines on how to diagnose acute deltoid ligament injuries. TRIAL REGISTRATION: Prospero ID: CRD42022307112. CLINICAL TRIAL NUMBER: not applicable.

Graft Failure and Contralateral ACL Injuries After Primary ACL Reconstruction: An Analysis of Risk Factors Using Interpretable Machine Learning.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. Purpose: To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. Results: A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Conclusion: Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.

Factors Associated With a Successful Return to Performance After Anterior Cruciate Ligament Reconstruction: A Multiparametric Evaluation in Soccer Players.

Background: Anterior cruciate ligament reconstruction (ACLR) is highly recommended in patients with ACL deficiency who must perform at a high physical level. A combination of functional and psychological outcome measures is necessary to provide a comprehensive evaluation of functional status after successful return to sport after ACLR. Purpose: To identify factors associated with higher functional outcomes among soccer players who had returned to full sports participation after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 168 out of 231 patients who underwent primary unilateral arthroscopic anatomic single-bundle ACLR were available at follow-up. Postoperatively, knee function, generic health outcomes, and psychological impact were assessed using the International Knee Documentation Committee (IKDC), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm Knee Scoring Scale, the 12-item Short Form Health Survey (SF-12), and the ACL-Return to Sport after Injury scale. Results: After a mean follow-up of 35.5 ± 22.6 months, 85% of soccer players returned to performance. Midfielder position was associated with a better SF-12 Physical Component Summary (PCS) score (P = .013), IKDC (P = .003), total KOOS (P < .001), KOOS Symptoms (P = .004), KOOS Pain (P = .029), KOOS Activities of Daily Living (ADL) (P = .044), KOOS Sport and Recreation (Sport/Rec) (P = .001), KOOS Quality of Life (QoL) (P < .001), and Lysholm score (P = .008). Playing only on natural grass was associated with lower SF-12 PCS scores (P = .003), total KOOS (P = .001), and KOOS Sport/Rec (P = .011). Playing only on artificial turf was associated with lower Lysholm score (P = .018) and total KOOS (P = .014). The contact mechanism was associated with higher IKDC (P = .044) and KOOS QoL (P = .048), and injury affecting the dominant limb was associated with lower SF-12 Mental Component Summary scores (P = .012). Playing at a nonprofessional level was associated with lower total KOOS (P = .028), KOOS Symptoms (P = .002), KOOS ADL (P = .033), and KOOS Sport/Rec (P = .016). Conclusion: Professional soccer players and the midfielder position are associated with better functional scores upon returning to the sport. A history of noncontact ACL injury and playing on a single type of surface are associated with lower functional outcomes upon returning to the sport. Lower mental health scores can be expected after injury of the dominant limb.

The Use of Cone-Beam Computed Tomography (CBCT) Arthrography for Wrist Ligamentous Injuries - A Diagnostic Test Accuracy Meta-analysis.

Background: Diagnosis of ligamentous wrist injuries can be challenging with the absence of dynamic instability on radiographs. Our aim was to evaluate the accuracy of cone-beam computed tomography (CBCT) arthrography in diagnosing scapholunate ligament (SLL), lunotriquetral ligament (LTL) and triangular fibrocartilage complex (TFCC) injuries. Methods: A systematic review and literature search were conducted in compliance with Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) and registered at the International Prospective Register of Systematic Reviews, PROSPERO (CRD42024517655). A mixed-effects logistic regression bivariate model was used to estimate summary sensitivity and specificity, and hierarchical summary receiver operating characteristic (HSROC) curves were constructed to determine diagnostic accuracy of CBCT arthrography. Results: We identified five studies assessing the accuracy of CBCT arthrography against wrist arthrography or intraoperative findings as reference standard. The pooled estimates for sensitivity and specificity of CBCT arthrography was 93% (95% CI 40-100) and 91% (95% CI 81-96) for SLL injuries, 83% (95% CI 37-98) and 64% (95% CI 42-81) for LTL injuries and 78% (95% CI 57-91) and 80% (95% CI 54-93) for TFCC injuries. The area under the curve was 0.91 (95% CI 0.89-0.94), showing an excellent diagnostic accuracy of CBCT arthrography in SLL injuries. CBCT arthrography had an estimated mean effective dose of 3.2 mSv (2.0-4.8). Conclusions: Our study confirms that CBCT arthrography has an excellent diagnostic accuracy for wrist ligamentous injuries with comparably high sensitivity to conventional arthrography and a better specificity. While further studies with more robust methodology are required to support its implementation in clinical practice, our analysis shows that it is a reliable option and has a promising future. Level of Evidence: Level III (Diagnostic).

The Incidence of Injuries to Ramp Semimembranosus Complex Lesions After ACL Injury: An MRI Study.

Background: Medial meniscal ramp lesions have recently been an area of interest because of their recognized prevalence in association with anterior cruciate ligament (ACL) ruptures. Anatomically, the medial meniscal ramp is composed of the meniscocapsular ligament in continuity with the semimembranosus muscle and the meniscotibial ligament. Diagnosis of ramp semimembranosus complex (RSC) injuries remains challenging, and their prevalence is likely to be underestimated in comparison with ramp lesions. Purpose: To determine the prevalence of RSC lesions after a complete ACL rupture. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective database analysis was performed. The cohort consisted of the first 100 patients with complete ACL rupture confirmed by magnetic resonance imaging (MRI) who underwent knee arthroscopy for ACL reconstruction in 2019. The semimembranosus lesions were identified using MRI by 2 independent radiologists specializing in musculoskeletal imaging. The ramp lesions were initially diagnosed using MRI and then confirmed during arthroscopy by an experienced knee surgeon. The magnitude of rotatory instability was recorded using the pivot-shift test. A multivariate analysis was used to determine the lesions associated with the semimembranosus complex. Results: Of 100 patients, 53 showed lesions of the RSC; among them, 30 ramp lesions were confirmed after arthroscopic evaluation, and 40 semimembranosus lesions (23 without ramp lesion and 17 with ramp lesion) were found using MRI. A positive pivot shift was present in 57% of patients with combined RSC injury (P = .04) compared with 36% in patients without an RSC lesion. Conclusion: Lesions of the RSC were found in more than half of ACL ruptures in this retrospective cohort. Rotational instability could be associated with combined ACL and RSC injury.

Rate and Timing of Revision and Contralateral Anterior Cruciate Ligament Reconstruction Relative to Index Surgery.

Background: After anterior cruciate ligament (ACL) reconstruction (ACLR), ipsilateral ACL graft reinjury or contralateral ACL injury has been reported. The rate and predictors of such subsequent ACL injuries have not been reported in recent years and in large patient cohorts. Purpose: The current study utilized a large, national, multi-insurance, administrative database to assess subsequent ACLR and factors associated with its occurrence. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Using the PearlDiver M151 database, patients who underwent ACLR within the United States between 2015 and 2021 were abstracted. All included patients had ≥3 years of evaluation after initial ACLR. Patients who underwent a subsequent reconstruction (ipsilateral or contralateral) within 3 years were determined and the timing assessed. Using univariable and multivariable logistic regression, the factors associated with having a subsequent ACLR and the factors associated with returning for ipsilateral versus contralateral ACLR were examined. Results: In total, 40,151 patients who underwent initial ACLR during the study period were identified. Of these, subsequent ACLR was performed for 1689 patients (4.2%). These included ipsilateral revision for 1018 (60.3%) and contralateral reconstruction for 671 (39.7%) patients. Patients returning for ipsilateral reconstruction did so sooner than patients needing a contralateral reconstruction. On multivariable analysis, the only factor independently associated with subsequent ACLR was younger age (odds ratio [OR] = 4.17 for 10-14 years relative to 25-29 years; P < .0001). Factors associated with returning for an ipsilateral revision ACLR as opposed to contralateral ACLR were earlier revision (OR = 1.49 within 1.5 years relative to after 1.5 years; P = .0001) and female sex (OR = 0.62 relative to male sex; P < .0001). Conclusion: The overall rate of requiring a subsequent ACLR was found to be 4.2%, with 60.3% of these being to the ipsilateral ACL. This information may be helpful for evolving injury-prevention programs and patient counseling.

Simulation of osteotomy in total knee arthroplasty with femoral extra-articular deformity assisted by artificial intelligence: a study based on three-dimensional models.

BACKGROUND: The impact of extra-articular deformities (EADs) on lower limb alignment and collateral ligament integrity during total knee arthroplasty (TKA) poses significant challenges, increasing surgical complexity. Our study aims to evaluate the influence of EADs on mechanical axis alignment and the risk of collateral ligament injury during TKA using an AI-assisted surgical planning system, with the goal of minimizing ligament damage through precise and scientific planning. METHODS: A healthy volunteer underwent CT and MRI scans of the lower limbs. The scan images were imported into Mimics 20.0 software, and the reconstructed models were spatially aligned using 3-maticResearch 11.0 software. Using Unigraphics NX9.0 software, 50 three-dimensional models of femoral lateral joint deformities with varying positions and angles were created. Finally, TKA was simulated using the AI JOINT preoperative planning system. RESULTS: The larger the deformity angle and the closer it is to the knee joint, the more pronounced the deviation of the mechanical axis. During MA-aligned osteotomy, nine types of deformities can damage the collateral ligaments. After adjusting the varus/valgus of the prosthesis within a safe range of 3° and leaving a residual 3° varus/valgus in the lower limb alignment, only the 25° varus and 25° valgus deformities located at 90% of the femoral anatomical axis remain uncorrected. CONCLUSION: For patients with osteoarthritis and concurrent EAD undergoing TKA, using reconstructed 3D models of the collateral ligaments for preoperative planning helps visually assess collateral ligament damage, providing a practical solution. Minimizing intra-articular osteotomies within a safe range and allowing some residual alignment deviation can reduce the risk of collateral ligament injury.

Acromioclavicular joint biomechanics: a systematic review.

Background: The aim of this systematic review was to investigate the available literature on the biomechanical characteristics of the acromioclavicular (AC) joint to identify trends in translational parameters and contributions of the various ligamentous structures supporting the joint. Methods: A comprehensive literature search was conducted in the Web of Science, Scopus, and PubMed databases until October 2023 to identify articles reporting on the biomechanical characteristics of the AC joint. Non cadaveric or projects involving reconstruction were excluded. Consistent parameters evaluated were anterior, posterior, superior, and inferior translation. The data were extracted from the included articles and summarized. Results: 11 biomechanical papers were reviewed from six different countries - United States (n = 6), France (n = 1), Austria (n = 1), Thailand (n = 1), United Kingdom (n = 1), and Japan (n = 1). The total number of specimens included across the reviewed papers was 141. All 11 papers reported the data on an intact model (coracoclavicular and AC ligaments intact). Seven papers assessed the translational results of the AC sectioned condition, finding a greater increase in anterior-posterior (AP) laxity relative to SI. 3 papers evaluated coracoclavicular ligament sectioning, finding increased superior-inferior laxity relative to AP. Only one study involved ligament sectioning isolating the anterior-inferior bundle of the AC joint. Conclusion: This review highlights the key AP and superior-inferior constraints of both the intact and ligament sectioned AC joint. The inconsistency of AC joint testing parameters and the lack of thorough translation studies indicate a necessity for increased attention in the overall assessment of shoulder stability to close the gap in the foundational biomechanical research.

Static Stability of Elbow Interposition Arthroplasty Stabilized With Novel Ligament Reconstruction.

BACKGROUND: Outcomes of interposition arthroplasty for treatment of elbow arthritis are highly dependent on elbow stability. The purpose of this study was to determine whether interposition arthroplasty with a novel bidirectional ligament reconstruction technique could adequately restore the static stability of the native elbow. METHODS: Static varus and valgus elbow stability was tested in 7 cadaver elbows with intact ligaments and capsule at 5 flexion angles (0°, 30°, 60°, 90°, and 120°). At each angle, the distance between fixed reference points across the elbow was measured both medially and laterally. The elbows were then destabilized and an interposition arthroplasty with ligament reconstruction was performed. Static elbow stability was reassessed by comparing postoperative deflection measurements with those of the native state. Graft slippage or loosening was visually assessed following testing. RESULTS: Interposition arthroplasty was performed in 7 cadaver specimens. Following ligament reconstruction, specimens reproduced the flexion angle-dependent static stability of native elbows to both varus and valgus stress. The greatest deflection changes between native elbows and elbows after interposition arthroplasty were 2.7% (P = .13) medially and 2.3% (P = .42) laterally, which were not significant. There was no loosening or slippage of either the interposition graft or the ligament reconstruction grafts. CONCLUSIONS: Cadaveric elbow specimens underwent interposition arthroplasty with a novel technique for bidirectional ligament reconstruction. Static stability was maintained at varying degrees of elbow flexion, comparable to that of the native elbow. Interposition and ligament reconstruction grafts maintained secure fixation following static biomechanical testing.

[Histopathological diagnostics for assessment questions of tendo-, ligamento-, and meniscus pathologies]. / Histopathologische Diagnostik bei Begutachtungsfragen von Tendo­, Ligamento- und Meniskuspathologien.

This review article presents the possibilities and limitations of histopathological diagnostics on the issues of joint diseases, including in the context of the medical insurance inquiries, which consider the important articular, non-osseous compartments, especially of the tendons, ligaments, and meniscus. Essential for expert assessments is the causal clarification of whether the continuity disruption has been induced exogenously by trauma or endogenously based on tissue that is functionally impaired and thus degeneratively altered. The degree of degeneration/texture disorder is determined by means of the degeneration-score, which is set in a semiquantitative, three-stage grading. Grades 1 and 2 are summed up as low-grade degeneration and compared to grade 3, high-grade degeneration. Age determination of continuity disruption is based on the assessment of the morphology of discontinuity and on the assessment of hemosiderin deposits. The tasks of histopathological diagnostics thus consist of the detection and grading of textural disorder (degeneration), the determination of the histopathologic age of existing continuity disruptions, and particularly the diagnosis of clinically/radiologically undiagnosed diseases, which may be relevant for pathogenesis. In the case of contradictory diagnoses from different diagnostic disciplines and in the case of imprecise and potentially even contradictory patient information, purely legal, judicial decisions may be necessary. In this case the legally binding assessment within the framework of legal evidence evaluation then arises.

A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique.

Background: Long-term follow-up for anterior cruciate ligament reconstruction (ACLR) is limited due to heterogeneity in the number of techniques utilized, the number of surgeons included, and attrition bias. Purpose: To analyze a single surgeon's 35-year experience with ACLR using the transtibial technique, with an emphasis on temporal trends in graft selection and subanalyses on rates of revision surgery, contralateral ACLR, and nonrevision reoperation among different demographic cohorts of patients. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent arthroscopically assisted single-bundle ACLR between 1986 and 2021 were identified from a prospectively maintained single-surgeon registry. Outcomes of interest included revision, reoperation, and contralateral rupture rates. Results: A total of 2915 ACLRs were performed during the senior surgeon's career. The mean age for primary ACLR was 29.4 ± 14.8 years. During primary ACLR, 98.4% of patients received a central-third bone-patellar tendon-bone (BPTB) graft. Increasing patient age was associated with increasing allograft usage (P < .01), with a significant temporal increase in allograft usage over the senior surgeon's career (P < .01). There was a higher revision rate among younger patients (P < .01), female patients aged 21 to 25 years (P = .01), and patients who received an allograft during the primary procedure (P = .04). The contralateral rupture rate showed no difference between sexes (P = .34); however, patients who underwent ACLR with autograft had a greater rate of contralateral injury compared with those with allograft (P < .01). The contralateral rupture rate was greater than the revision rate (P < .01). The most common causes of nonrevision reoperation were failed meniscal repair, new meniscal tears, arthrofibrosis, and painful hardware removal. Conclusion: The findings of this single-surgeon registry reveal temporal trends in ACLR over a 35-year career. There was a trend toward increasing BPTB allograft use in ACLR, especially in older patients and revision cases. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery. Contralateral ACLR was more common than revision surgery.

Safety and Efficacy of an Injectable Solution Enriched With Sodium Hyaluronate, Amino Acids, and Peptides in Relation to Superficial Facial Connective Tissues (Dermis and Retinacular Cutis).

BACKGROUND: Skin aging research often focuses on the dermis, overlooking the significance of the retinacular cutis (RC) in aging. This study aimed to investigate the efficacy, safety, and effect of an injectable solution containing hyaluronic acid, amino acids, and peptides, on facial sagging and laxity by targeting the RC. METHODS: This single-center observational study recruited 28 female volunteers aged 25-65 years. The participants received four monthly injections of the studied solution. Objective measures included skin hydration, elasticity, color, thickness, collagen density evaluated via DermaLab Combo and high-resolution ultrasound imaging. Subjective measures included participant satisfaction evaluated using the Global Aesthetic Improvement Scale (GAIS). Adverse effects were monitored throughout the study period. RESULTS: Significant improvements were observed in skin hydration, elasticity, and collagen density after treatment. Hydration increased by 25.9% at T1 (30 days after last session), sustaining a 15.9% increase at T2 (120 days after last session). Elasticity improved by 29.2% at T1 and 20.7% at T2. Collagen density increased by 20.27% at T1 and 16.71% at T2. Self-reported GAIS scores showed consistent increases. Adverse effects were minimal and included only transient ecchymosis and mild pain. CONCLUSION: Injections of the solution had a substantial hydrating effect, enhanced elasticity, and increased collagen density in the RC and dermis. Results persisted at the 120-day follow-up, indicating sustained benefits. Hence, this injectable solution may offer a safe and effective non-invasive treatment option for improving skin laxity and sagging, targeting the RC and other deep connective tissue such as retaining ligaments.

New complex cell junctions in and around the intervertebral discs discovered using autoantibodies from patients affected by endemic pemphigus foliaceus in El Bagre, Colombia, South America.

BACKGROUND: Traditionally, the intervertebral disks' (IVD) nucleus pulposus (NP) and annulus fibrosus (AF) are considered to have few cellular components and cell junctions. Patients affected by a new variant of endemic pemphigus foliaceus in El Bagre, Colombia, experience back pain in the spinal areas of the lower and upper back. Here, we investigate the reactivity of the patient's autoantibodies to structures in and around the IVDs at the cellular level. METHODS: We first administered a questionnaire and performed a medical examination. We then tested for autoreactivity against IVDs by indirect immunofluorescence, confocal microscopy, and reflectance confocal microscopy using bovine and human tissues as antigen sources. We tested 45 sera from patients affected by the disease and 45 control sera from the endemic area matched by age, gender, demographics, and work activity. RESULTS: Most of the patient sera revealed polyclonal antibodies against newly discovered cell junctions in the NP and AF, including their translamellar cross-bridges. Additional reactivities were detected against cell junctions in the spinal cord neurons, paraspinal nerves, blood vessels, anterior and posterior longitudinal ligaments, and paraspinal skeletal muscles. The reactivities of the patient's autoantibodies co-localized with those of commercially available antibodies to desmoplakins I-II, armadillo repeat gene deleted in velo-cardio-facial syndrome, plakophilin-4, and myocardium-enriched zonula occludens-1-associated protein (p < 0.001). CONCLUSIONS: We discovered novel complex cell junctions in the IVDs using patients' autoantibodies. These discoveries open a new chapter in the knowledge of IVD, representing a breakthrough pertinent to many diseases.

Multiaxial 3D MRI of the Ankle: Advanced High-Resolution Visualization of Ligaments, Tendons, and Articular Cartilage.

MRI is a valuable tool for diagnosing a broad spectrum of acute and chronic ankle disorders, including ligament tears, tendinopathy, and osteochondral lesions. Traditional two-dimensional (2D) MRI provides a high image signal and contrast of anatomic structures for accurately characterizing articular cartilage, bone marrow, synovium, ligaments, tendons, and nerves. However, 2D MRI limitations are thick slices and fixed slice orientations. In clinical practice, 2D MRI is limited to 2 to 3 mm slice thickness, which can cause blurred contours of oblique structures due to volume averaging effects within the image slice. In addition, image plane orientations are fixated and cannot be changed after the scan, resulting in 2D MRI lacking multiplanar and multiaxial reformation abilities for individualized image plane orientations along oblique and curved anatomic structures, such as ankle ligaments and tendons. In contrast, three-dimensional (3D) MRI is a newer, clinically available MRI technique capable of acquiring high-resolution ankle MRI data sets with isotropic voxel size. The inherently high spatial resolution of 3D MRI permits up to five times thinner (0.5 mm) image slices. In addition, 3D MRI can be acquired image voxel with the same edge length in all three space dimensions (isotropism), permitting unrestricted multiplanar and multiaxial image reformation and postprocessing after the MRI scan. Clinical 3D MRI of the ankle with 0.5 to 0.7 mm isotropic voxel size resolves the smallest anatomic ankle structures and abnormalities of ligament and tendon fibers, osteochondral lesions, and nerves. After acquiring the images, operators can align image planes individually along any anatomic structure of interest, such as ligaments and tendons segments. In addition, curved multiplanar image reformations can unfold the entire course of multiaxially curved structures, such as perimalleolar tendons, into one image plane. We recommend adding 3D MRI pulse sequences to traditional 2D MRI protocols to visualize small and curved ankle structures to better advantage. This article provides an overview of the clinical application of 3D MRI of the ankle, compares diagnostic performances of 2D and 3D MRI for diagnosing ankle abnormalities, and illustrates clinical 3D ankle MRI applications.

Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation.

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

Douglas Pouch Fluid Improves the Accuracy of Transvaginal Ultrasound in the Diagnosis of Uterosacral Ligaments Deep Infiltration Endometriosis: A Prospective Study.

OBJECTIVES: To compare the accuracy of transvaginal ultrasound (TVUS) with laparoscopy in detecting and characterizing uterosacral ligament (USL) nodules of deep infiltrative endometriosis (DIE) between patients with and without pouch of Douglas (POD) fluid. METHODS: This prospective study was conducted between June 2021 and July 2023. We included patients from the Second People's Hospital of Shenzhen with two TVUS tests: no POD fluid on the first TVUS test and POD fluid on the second TVUS test. POD fluid was obtained in two ways: naturally occurring fluid during the luteal phase of the menstrual cycle and SonoPODography. Laparoscopic results are the gold standard. To compare the diagnostic performance of TVUS in the diagnosis of DIE on USLs with and without POD fluid. RESULTS: We included 42 patients with a mean age of 36.4 ± 5.4 years. The maximum length diameter for DIE nodules on USLs with and without POD fluid was 13.3 ± 3.3 mm and 10.2 ± 2.5 mm (P < .001), respectively, while the depth of infiltration was 8.1 ± 2.4 mm and 6.1 ± 1.4 mm (P < .001), respectively. When compared to laparoscopic findings, TVUS findings with and without POD fluid resulted in a sensitivity, specificity, accuracy, positive predictive value, negative predictive value area under the curve, and Cohen kappa of 92.3%, 93.8%, 92.9%, 96.0%, 88.2%, 0.930, and 0.850 and 61.5%, 93.8%, 73.8%, 94.1%, 50.0%, 0.766, and 0.499, respectively. Laparoscopy showed USL involvement in up to 59.5% of patients. With or without fluid, the most common ultrasound features of DIE lesions were USL thickening, irregular morphology, clear boundaries, low echo, and no blood flow signal. CONCLUSIONS: For patients with clinical suspicion of DIE, TVUS with POD fluid has a higher accuracy for diagnosing USL DIE than TVUS without POD fluid.