Anatomic Anterolateral Ligament Reconstruction with Iliotibial Band Graft and Concomitant Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) reconstruction (ACLR) attempts to restore native ACL function. Persistent anterolateral instability is a common symptom after ACLR that can lead to worse patient outcomes. Additional surgeries, like anterolateral ligament reconstruction (ALLR), can augment the ACL graft and help increase anterolateral rotational stability. Certain indications for ACLR with ALLR include high-grade pivot shift, increased posterior tibial slope (>12°), revision ACLR, and concomitant ligamentous or meniscal injuries. We describe an anatomic ALLR technique using an 8 cm long × 1 cm wide strip of the inferior aspect of the iliotibial band fixed at the native attachment sites of the ALL.

Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques.

Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.

Isolated, Proximal Tibiofibular Injuries in Athletic Patients: A Critical Analysis Review.

While infrequently reported, isolated injuries to the proximal tibiofibular (TF) joint primarily occur in young, athletic patients participating in sporting activities requiring explosive, high impact movements, increasing the risk for potential twisting injuries, especially across a hyperflexed knee. The proximal TF joint is stabilized by bony, muscular and ligamentous structures, including both the anterior and posterior proximal tibiofibular complexes, with the anterior complex providing more robust stability. Proximal TF injuries frequently involve anterior and lateral displacement of the proximal fibula relative to its native articulation with the tibia. Proper diagnosis is dependent on careful and meticulous history and physical examination, as missed injuries are common, leading to the potential for continued pain, weakness and disability, especially in athletic patients. While spontaneous joint reduction has been reported, injuries may require formal closed reduction, with irreducible and chronic injuries requiring open reduction and stabilization, with recent investigations reporting satisfactory outcomes following anatomic reconstruction of the proximal TF ligament.

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.

The Functional Integrity of the Anterior Cruciate Ligament Can Be Objectively Assessed With the Use of Stress Radiographs: A Systematic Review.

Background: Stress radiography is a viable imaging modality that can also be used to assess the integrity of the anterior cruciate ligament (ACL) after primary or secondary injury. Because conventional radiography is relatively easy, affordable, and available worldwide, the diagnostic efficacy of ACL standing, lateral decubitus, and supine stress radiography should be evaluated. Purpose: To examine the existing literature regarding the application of stress radiography in evaluating the integrity of the ACL. Study Design: Systematic review; Level of evidence, 3. Methods: Using the PubMed and MEDLINE databases for relevant articles published between 1980 and the present, a systematic review was conducted to identify evidence related to the radiographic diagnosis or assessment of ACL tears. The literature search was conducted in September 2022. Results: Of 495 studies, 16 (1823 patients) were included. Four studies examined standing stress radiography, and 12 investigated lateral decubitus or supine stress radiography. Significant heterogeneity in imaging technique and recorded anterior tibial translation was identified. Anterior tibial translation for ACL-injured knees ranged from 1.2 to 10.6 mm for standing stress radiographs and 2.7 to 11.2 mm for supine stress radiographs, with high sensitivities and specificities for both. Conclusion: Stress radiography was a dependable diagnostic method for identifying ACL rupture. Further research is necessary to determine the ideal anatomic landmarks, optimal patient positioning, and appropriate applied stresses to establish a standardized protocol for both assessing ACL tears and evaluating the postoperative integrity of ACL reconstruction using stress radiography.

Meniscal Radial Tears: A Classification System Based on Tear Morphology.

Appropriate management of radial meniscal tears is complex, with continued efforts focused on optimizing diagnostic methods for identification to help dictate treatment, especially as surgical indications for repair have expanded, coupled with improvements in surgical techniques and instrumentation. Currently, no standardized classification system for radial meniscal tears exists, limiting the ability to accurately characterize injury patterns and guide surgical decision-making.

Biomechanical Performance of Transtibial Pull-Out Posterior Horn Medial Meniscus Root Repair Is Improved With Knotless Adjustable Suture Anchor-Based Fixation.

Background: While posterior medial meniscus root (PMMR) techniques have evolved, there remains a need to both optimize repair strength and improve resistance to cyclic loading. Hypothesis: Adjustable tensioning would lead to higher initial repair strength and reduce displacement with cyclic loading compared with previously described transtibial pull-out repair (TPOR) fixation techniques. Study Design: Controlled laboratory study. Methods: A total of 56 porcine medial menisci were used. Eight intact specimens served as a control for the native meniscus. For the others, PMMR tears were created and repaired with 6 different TPOR techniques (8 in each group). Fixed PMMR repairs were executed using 4 different suture techniques (two No. 2 cinch sutures, two cinch tapes, two No. 2 simple sutures, and two No. 2 sutures in a Mason-Allen configuration) all tied over a cortical button. Adjustable PMMR repairs using Mason-Allen sutures were fixed with an adjustable soft tissue anchor fixation tensioned at either 80 N or 120 N. The initial force, stiffness, and relief displacement of the repairs were measured after fixation. Repair constructs were then cyclically loaded, with cyclic displacement and stiffness measured after 1000 cycles. Finally, the specimens were pulled to failure. Results: The PMMR repaired with the 2 cinch sutures fixed technique afforded the lowest (P < .001) initial repair load, stiffness, and relief displacement. The adjustable PMMR repairs achieved a higher initial repair load (P < .001) and relief displacement (P < .001) than all fixed repairs. The 2 cinch sutures fixed technique showed an overall higher cyclic displacement (P < .028) and was completely loose compared with the native meniscus functional zone. Repairs with adjustable intratunnel fixation showed displacement with cyclic loading similar to the native meniscus. With cyclic loading, the Mason-Allen adjustable repair with 120 N of tension showed less displacement (P < .016) than all fixed repairs and a stiffness comparable to the fixed Mason-Allen repair. The fixed Mason-Allen technique demonstrated a higher ultimate load (P < .007) than the adjustable Mason-Allen techniques. All repairs were less stiff, with lower ultimate failure loads, than the native meniscus root attachment (P < .0001). Conclusion: Adjustable TPOR led to considerably higher initial repair load and relief displacement than other conventional fixed repairs and restricted cyclic displacement to match the native meniscus function. However, the ultimate failure load of the adjustable devices was lower than that of a Mason-Allen construct tied over a cortical button. All repair techniques had a significantly lower load to failure than the native meniscus root. Clinical Relevance: Knotless adjustable PMMR repair based on soft anchor fixation results in higher tissue compression and less displacement, but the overall clinical significance on healing rates remains unclear.

Meniscal extrusion consensus statement: A collaborative survey within the Meniscus International Network (MenIN) Study Group.

PURPOSE: The purpose of the present study was to perform a survey administered to members of the Meniscus International Network (MenIN) Study Group, seeking to delineate the most contentious aspects of meniscal extrusion classification and provide a foundation for new, more comprehensive definitions and treatments for these pathologies. METHODS: MenIN Study Group is a group of international experts treating and performing research on meniscus pathology and treatment. All MenIN Study Group members were asked to complete a survey aimed at establishing criteria for the optimal classification system for meniscal extrusion. Data obtained from the completed questionnaires were transferred into a spreadsheet and then analysed. All responses are presented as counts, percentages or means. RESULTS: Forty-seven (85.5%) MenIN Study Group members completed the survey and were included in this analysis. Key aspects recommended for inclusion in a comprehensive classification system for meniscal extrusion included laterality (93.6%), anatomical location (76.6%), patient age (76.6%), body mass index (BMI) (68.1%) and aetiology (68.1%). For classifying meniscal extrusion, 53.2% considered the distance in millimetres from the tibial plateau's outer margin as the most reliable measurement technique on imaging. Preferences for imaging modalities varied, with 44.7% favouring weight-bearing magnetic resonance imaging (MRI) and 36.2% opting for weight-bearing ultrasound due to its greater availability. Respondents advocated for a classification system addressing stability or progression of meniscal extrusion (66%), reducibility (53.2%), potential progression of knee osteoarthritis (OA) (83%), influencing treatment approaches (83%), a gradation system (83%), consideration of dynamic factors (66%), association with clinical outcomes and prognosis (76.6%) and investigation around centralization procedures (57.4%). CONCLUSIONS: In conclusion, the findings of this survey shed light on the global perspectives regarding meniscal extrusion classification. It was generally felt that a new classification of extrusion measured on MRI scans at the mid-tibial plateau should be developed, which considers factors such as laterality, anatomical location, age, BMI and aetiology. Additionally, the results support the integration of dynamic factors and clinical outcomes in MRI-based classifications to inform treatment approaches. LEVEL OF EVIDENCE: Level IV.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations.

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Inflammatory synovial biomarkers and state of the tibiofemoral joint in the post-surgical settings: a narrative review.

Background and Objective: Knee surgery attempts to restore the native biomechanics of the knee, improve stability, and decrease the progression of osteoarthritis (OA). However, despite improvements in surgical techniques, tissue degradation and OA are common after knee surgery, occurring in higher rates in surgical knees compared to non-surgical knees. The aim of this study is to analyze previous literature to determine which synovial fluid biomarkers contribute to knee tissue degradation and decrease patient outcomes in the post-surgical setting of the knee. Methods: A narrative review of relevant literature was performed in July 2023. Studies reporting on synovial biomarkers associated with the post-surgical knee were included. Key Content and Findings: The literature reported that proinflammatory synovial biomarkers cause cartilage degradation and turnover which eventually leads to OA. The associated biomarkers are typically present prior to physical symptoms so understanding which one's correlate to OA is important for potential therapeutic treatments in the future. Studying the preoperative, early postoperative, and late postoperative synovial biomarkers will allow physicians to develop an improved understanding of how these biomarkers progress and correlate to knee tissue degradation and OA. This understanding could lead to further developments into potential treatment options. Research into inhibiting or reversing these inflammatory biomarkers to slow the progression of knee tissue degradation has already begun and has reported some promising results but is currently limited in scope. Conclusions: Synovial fluid biomarkers in the post-surgical knee setting may contribute to decreased patient outcomes and the progression of knee tissue degradation. There is no current consensus on which of these biomarkers are the most detrimental or associated with decreased patient outcomes. With an improved understanding of the individual biomarkers, potential personalized therapeutic treatment could be used by physicians in the future to improve patient outcomes after surgery.

The effect of nonsteroidal anti-inflammatory drug use on soft tissue and bone healing in the knee: a systematic review.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to mitigate pain and inflammation associated with musculoskeletal conditions; however, there is conflicting data on the adverse effects of these drugs on tissue and bone healing. The objective of this study was to investigate the effect of NSAIDs on the healing of knee, soft tissue, and bone. Methods: A systematic literature search was conducted across PubMed/MEDLINE, Excerpta Medical Database (Embase)/Ovid, and the Cochrane Central Register of Controlled Trials databases. Clinical, animal, and in vitro studies on the effect of NSAIDs on knee healing were included. Risk of bias assessment was performed using the Cochrane bias assessment tool and Methodological Index for Non-Randomized Studies scoring system for included clinical studies, and the Systematic Review Center for Laboratory Animal Experimentation assessment tool for all included animal studies. General study population characteristics, interventions used, NSAIDs utilized, outcome measures, and study results were analyzed using descriptive statistics. Results: Fifteen articles met the inclusion criteria. Of the 15 studies, there were three clinical, ten animal, and two in vitro studies. In clinical studies, nonselective cyclooxygenase (COX) inhibitors and selective COX-2 inhibitors did not cause a significant increase in failure of anterior cruciate ligament (ACL) reconstructions or meniscal repairs with NSAID administration pre-, peri-, or post-operatively in comparison to placebo or no NSAID administration. Among animal studies assessing COX-2 inhibitor effects on soft tissue, healing was impaired (2/4), delayed but unaffected (1/4), or unaffected (1/4). In animal studies assessing COX-1 inhibitors, ligament healing was either increased (1/4), unaffected (2/4), or impaired (1/4). Meanwhile, administration of non-selective COX inhibitors in animals did not affect soft tissue (3/3) and cartilage (1/1) healing. Two in vitro studies identified a negative outcome on patellar tendon and ACL cell proliferation or viability after non-selective COX inhibition and variable results after selective COX-2 inhibition. Conclusions: Animal studies on postoperative NSAID use after knee surgery suggest that administration of selective and nonselective COX-2 inhibitors may impair healing of soft tissue, bone and tendon-to-bone; however, further clinical studies are needed to better characterize dose and duration dependent risks of NSAIDs.

Effect of anti-inflammatory treatments on patient outcomes and concentrations of inflammatory modulators in the post-surgical and post-traumatic tibiofemoral joint setting: a narrative review.

Background and Objective: There are several anti-inflammatory therapeutic options that can be used in the context of post-surgical and post-traumatic knee settings. Each of these options carries with it certain benefits, as well as potential issues depending on the duration and administration of each therapy. An understanding of how these anti-inflammatory drugs modulate various biomarkers of inflammation is also necessary in understanding how they can affect patient and objective outcomes following acute knee injury or surgery. This review covers the many traditional therapeutic options that have been used in treating knee injuries, as well as some natural therapeutics that have shown anti-inflammatory properties. Methods: A current review of the literature was conducted and synthesized into this narrative review. Key Content and Findings: Many traditional anti-inflammatory therapeutics have been shown to be beneficial in both post-traumatic and post-surgical tibiofemoral joint settings at reducing inflammation and improving patient outcomes. However, many of these treatments have risks associated with them, which becomes problematic with prolonged, repeated administration. Natural anti-inflammatory compounds may also have some benefit as adjunctive treatment options in these settings. Conclusions: There are multiple different therapeutic options that can be used in acute knee settings, but the specific mechanism of injury or surgical context should be weighed when determining the best clinical approach.

Comparing Clinical Outcomes and Knee Stability in Remnant- Preserving ACL Reconstruction Versus Standard ACL Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed procedures in sports medicine, and undesirable outcomes still may range from 3-18%. One technique that has been explored to improve outcomes is preservation of the ACL remnant tibial stump, as opposed to stump debridement, at the time of reconstruction. PURPOSE: To review current high-level evidence and compare remnant-preserving anterior cruciate ligament reconstruction (ACLR) versus standard ACLR in terms of clinical outcomes and measures of knee stability. HYPOTHESIS: ACLR with remnant preservation would result in improved clinical outcomes and knee stability measures. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review of randomized controlled trials (RCTs) and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of 2 was performed. Extracted data were summarized as general information, surgical characteristics, postoperative clinical outcomes, knee stability, graft evaluation, tunnel assessment, and postoperative complications. When feasible, a meta-analysis was performed. RESULTS: Seven RCTs and 5 cohort studies met the inclusion criteria. In total, 518 patients underwent remnant-preserving ACLR and 604 patients underwent standard ACLR. Ten studies performed the reconstruction with hamstring tendon (HT) autografts, 1 study with HT and bone-patellar tendon-bone autografts, and 1 study with HT and tibialis anterior allografts. On meta-analysis, remnant-preserving ACLR provided comparable outcomes with respect to International Knee Documentation Committee grades or Tegner scores. Even though there was a significant improvement in Lysholm scores (mean difference, -1.9; 95% CI, -2.89 to -0.91; P = .0002) with the remnant-preserving technique, this did not exceed previously reported minimal clinically important difference values. Remnant-preserving ACLR demonstrated superior knee stability in terms of patients achieving negative pivot shift when compared with the control group (88.89% vs 79.92%; P = .006). Although there was a significant improvement in the side-to-side difference in anterior tibial translation favoring remnant preservation (P = .004), the mean difference was 0.51 mm. CONCLUSION: Remnant-preserving ACLR, primarily with HT autografts, results in comparable clinical outcome scores and significantly improved knee stability relative to standard ACLR without remnant preservation without increasing the complication rate. Further studies will help clarify if remnant-preserving ACLR also has benefits in terms of enhancing graft integration and maturation, improving proprioception, limiting tunnel enlargement, and reducing complications.

Hypermobile lateral meniscus: A systematic review of current treatment options.

PURPOSE: The reliable data on the incidence of hypermobile lateral meniscus (HLM) and its clinical manifestations, diagnostic methods and therapeutic approaches are limited. This systematic study aimed to review available treatment options for HLM and the outcomes of each approach. METHODS: A systematic search was performed in four electronic databases (PubMed, EMBASE, Scopus, Web of Science) to identify studies in which arthroscopically confirmed cases of HLM were treated surgically or nonsurgically, and the required data comprising study characteristics, patient data, treatment approaches and outcome measures were extracted from eligible studies. RESULTS: Twenty studies with a total of 212 patients (138 males and 74 females) and 219 knees were included. The most frequently reported symptoms were locking sensations, knee pain, giving way and snapping. Treatments used by the studies were: radiofrequency energy in two studies; arthroscopic partial meniscectomy in one study; open surgery in two studies; and arthroscopic meniscal repair in 17 studies. Eleven studies used an all-inside repair method and an inside-out meniscal repair was reported in eight studies. Three studies reported the usage of posterior arthroscopy for therapeutic or diagnostic approaches. Evaluation of symptom resolution was the main outcome measurement for which almost all of the studies stated relief of symptoms after intervention. CONCLUSION: Despite the lack of definite consensus about the most appropriate intervention for HLM, therapeutic preference was directed towards arthroscopic all-inside and inside-out repair techniques. Although the surgeon's decision remains the key factor in choosing the most suitable treatment option for each individual, posterior arthroscopic meniscal repair may be considered as a better option for HLM treatment according to the findings of this review. LEVEL OF EVIDENCE: Level IV.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021.

BACKGROUND: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR. PURPOSE/HYPOTHESIS: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44. RESULTS: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07). CONCLUSION: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation.

Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established surgical procedure, but it may not always restore complete rotational knee stability. Interest is increasing in anterolateral complex (ALC) procedures, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in association with ACLR to overcome this problem. The better ALC procedure, LET or ALLR, remains controversial to date. PURPOSE: To analyze the patient-reported outcome measures and ACL reinjury rate after ACLR with an ALC procedure compared with after isolated ACLR, as well as to analyze the clinical results and graft failure rate of the LET group versus the ALLR group. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 2. METHODS: A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart was used to conduct a comprehensive search of 5 databases: Scopus, MEDLINE, Embase, PubMed, and the Cochrane Database of Systematic Reviews. Only randomized controlled trials were included. Eligible articles were classified according to the levels of evidence of the Oxford Centre for Evidence-Based Medicine. A methodological quality assessment of randomized controlled trials was performed using the Risk of Bias 2 tool. The present systematic review and meta-analysis was registered on PROSPERO. RESULTS: A total of 14 clinical trials were included in the final analysis, with 1830 patients. Isolated ACLR or a combined procedure with LET or ALLR was performed, with several characteristics described, including the surgical technique, additional torn knee structures and their management, graft failure, complications, clinical outcomes, clinical and instrumental examinations to assess knee stability, and postoperative protocols. Regarding clinical outcomes, pivot-shift tests and reduced graft failure, a significant difference was found in the superiority of the combined ACLR associated with the ALC procedure compared with an isolated ACLR (P < .05). No statistically significant difference was found between the 2 ALC procedures. CONCLUSION: This systematic review and meta-analysis reported on the importance of combined ACLR and ALC procedures in patients with a high-grade rotational laxity, as both procedures, LET or ALLR, without superiority of one over the other, are associated with improved pivot-shift tests, patient-reported outcome measures, and reduced graft failure rates.

Do the Differences in the Epiligament of the Proximal and Distal Parts of the Anterior Cruciate Ligament Explain Their Different Healing Capacities? Quantitative and Immunohistochemical Analysis of CD34 and α-SMA Expression in Relation to the Epiligament Theory.

The aim of this study was to assess the epiligament theory by determining the normal epiligament morphology of the proximal and distal parts of the anterior cruciate ligament in humans and analyzing the differences between them and the midportion of the ligament in terms of cell numbers and expression of CD34 and α-SMA. Samples were obtained from the anterior cruciate ligaments of 12 fresh knee joints. Monoclonal antibodies against CD34 and α-SMA were used for immunohistochemistry. Photomicrographs were analyzed using ImageJ software, version 1.53f. The cell density was higher in the epiligament than in the ligament connective tissue. Cell counts were higher in the proximal and distal thirds than in the midsubstance of the epiligament. CD34 was expressed similarly in the proximal and distal thirds, although it seemed slightly more pronounced in the distal third. α-SMA expression was more robust in the proximal than the distal part. The results revealed that CD34 and α-SMA are expressed in the human epiligament. The differences between the numbers of cells in the proximal and distal parts of the epiligament and the expression of CD34 and α-SMA enhance epiligament theory. Future investigations into improving the quality of ligament healing should not overlook the epiligament theory.

The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies.

PURPOSE: To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees. METHODS: An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale. RESULTS: Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift. CONCLUSIONS: The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees. CLINICAL RELEVANCE: This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.

Gluteal Complex is important in External Snapping Hip: intraoperative identification of syndrome origin and endoscopic stepwise release-a case series.

PURPOSE: External snapping hip syndrome (ESHS) was historically attributed to isolated iliotibial band (ITB) contracture. However, the gluteus maximus complex (GMC) may also be involved. This study aimed to intraoperatively identify the ESHS origin and assess the outcomes of endoscopic treatment based on the identified aetiological type. METHODS: From 2008-2014, 30 consecutive patients (34 hips) with symptomatic ESHS cases refractory to conservative treatment underwent endoscopic stepwise "fan-like" release, gradually addressing all known reasons of ESHS: from the isolated ITB, through the fascial part of the GMC until a partial release of gluteus maximus femoral attachment occurred. Snapping was assessed intra-operatively after each surgical step and prospectively recorded. Functional outcomes were assessed via the MAHORN Hip Outcome Tool (MHOT-14). RESULTS: Twenty seven patients (31 hips) were available to follow-up at 24-56 months. In all cases, complete snapping resolution was achieved intra-operatively: in seven cases (22.6%) after isolated ITB release, in 22 cases (70.9%), after release of ITB + fascial part of the GMC, and in two cases (6.5%) after ITB + fascial GMC release + partial release of GM femoral insertion. At follow-up, there were no snapping recurrences and MHOT-14 score significantly increased from a pre-operative average of 46 to 93(p<0.001). CONCLUSION: Intraoperative identification and gradual addressing of all known causes of ESHS allows for maximum preservation of surrounding tissue during surgery while precisely targeting the directly involved structures. Endoscopic stepwise "fan-like" release of the ITB and GMC is an effective, tailor-made treatment option for ESHS regardless of the snapping origin in the patients with possibility to manually reproduce the snapping.