Magnetic Resonance Imaging of Anterior Cruciate Ligament Injury.

The Anterior Cruciate Ligament (ACL) is considered the most commonly injured ligament of the knee. Magnetic Resonance Imaging (MRI) has become an indispensable imaging tool and modality of choice for assessing and managing knee conditions. This article outlines an effective MRI imaging technique that improves the diagnostic accuracy of ACL injuries of the knee, covering the appropriate pulse sequences and optimal imaging planes. Furthermore, the article provides a comprehensive review of the appearance of complete and partial ACL tears on MRI in the acute and chronic phases. In addition, it identifies and illustrates the primary MRI signs (signs related to the absence or abnormal visualization of the ACL fibers) and secondary MRI signs (signs related to the mechanism of injury or associated knee injuries) of ACL injury.

Posterior Cruciate Buckling Angle Variations Are Associated with Different Patterns of Medial Meniscus Tears in Anterior-Cruciate-Deficient Knees: Results of a Prospective Comparative Magnetic Imaging Resonance Study.

BACKGROUND: The diagnosis of anterior cruciate ligament (ACL) tear relies on clinical evaluation and magnetic resonance imaging (MRI). Direct and indirect signs of ACL tear have been described with MRI evaluation. Posterior cruciate ligament (PCL) buckling has been described as an indirect radiographic sign of an ACL tear. PURPOSE: The aim of the present study was to assess the variations in PCL buckling angles in patients with ACL tears and in patients with isolated lesions in the posterior horn of the medial meniscus. In addition, the influence of different patterns of medial meniscus tears in ACL-deficient knees was investigated. Finally, the influences of risk factors such as tibial slope, delay from injury to surgery, absence of medial meniscus tear, degree of Lachman and pivot shift testing were also assessed. STUDY DESIGN: This was a cohort study. METHODS: A total of 154 patients (78 in the group with ACL tear and 76 in the control group) were assessed with MRI and lateral weight-bearing X-ray to assess PCL buckling angle and tibial slope by two independent observers. The presence of a medial meniscus bucket handle or ramp lesion of the medial meniscus was assessed and recorded at the time of surgery. RESULTS: PCL buckling angle measurement was highly reliable, with an ICC of 0.866 and 0.894, respectively, in the study group and the control group for interobserver reliability. The intrarater reliability was found to be high in PCL buckling angle for the study group [ICC = 0.955] and the control group [ICC = 0.943]. The mean angle in patients with ACL tear was 110.7 ± 15.2° and 115.3 ± 16.2° (for the two examiners) and 111.4 ± 12° and 114 ± 14.5° (for the two examiners) in patients with an intact, healthy ACL. An association emerged between bucket handle tears of the medial meniscus (p = 0.010) and a decreased PCL buckling angle and between ramp lesions of the medial meniscus and increased PCL buckling angle both (p = 0.024). CONCLUSIONS: Good inter- and intraobserver reliability for the measurement of the PCL buckling angle was observed. Increased PCL buckling angle values were observed in patients with concomitant ACL and bucket handle tears of the medial meniscus, while decreased angle values were observed in those who had ACL tear and ramp lesion of the medial meniscus. No statistically significant difference in the PCL buckling angle emerged between patients with ACL tears and those who had a healthy, intact ACL.

Medial meniscal and bony slopes are higher in knees with failed ACL reconstruction than in patients with successful ACL reconstruction.

BACKGROUND: We aimed to compare tibial soft tissue and bony slopes in patients with failed and non-failed ACL reconstructions (ACLR). We hypothesized that patients with failed ACLR have increased slopes compared to non-failed ACLR, and unexplained failures have higher slopes than failures with clear technical errors and failed synthetic ligaments. METHODS: Between 2015 and 2022, 130 patients with failed ACLR were retrospectively identified; 79 knees with adequate MRI scans were analyzed. These were compared to 57 non-failed ACLRs. MRI measurements included lateral and medial tibial bony slope (LBS, MBS) and lateral and medial meniscal slope (LMS, MMS). Subgroup analysis assessed for failures with technical errors and failed synthetic ligaments. RESULTS: In all patients, the LMS and MMS reduced the bony slope towards the horizontal without reaching statistical significance. Failed ACLR had significantly higher MBS (7.1° ± 2.9 vs. 4.6° ± 2.5, p < 0.001) and MMS (5.6° ± 3.5 vs. 3.4° ± 2.8, p < 0.001). The area under the curve for MBS was 0.721 (CI: 0.628-0.813). The Youden optimal threshold value of MBS ≥ 5.1° (sensitivity 80 %, specificity 56.1 %) yielded an odd's ratio for failure of 5.1 (CI:2.3-11.6; p < 0.001). Revisions with technical errors had slopes that were not significantly different to non-failed ACLR. Revisions with synthetic grafts had MBS (7.3° ± 3.2 vs. 4.6° ± 2.5; p = 0.007) and MMS (6° ± 3.8 vs. 3.4° ± 2.8; p = 0.021) that were significantly higher to non-failed ACLR. CONCLUSION: Medial bony and meniscal slopes are higher in patients with unexplained failed ACLRs and revisions with synthetic grafts, but ACLR with technical errors failed with slopes similar to non-failed ACLRs. Increased medial slope values are a risk factor for surgical failure. LEVEL OF EVIDENCE: III.

Peroneus Longus Tendon Autografts have Better Graft Diameter, Less Morbidity, and Enhanced Muscle Recuperation than Hamstring Tendon in ACL Reconstruction.

Background: Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity. Methods: Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores. Results: At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52 mm) was larger compared with the HT group (7.43 ± 0.50 mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69). Conclusion: ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

Diagnostic Accuracy of Non-invasive Tests Versus Arthroscopy in Anterior Cruciate Ligament (ACL) Injuries.

BACKGROUND: The knee joint assessment to detect anterior cruciate ligament (ACL) injury after trauma involves clinical examination and radiography. The gold standard method is doing arthroscopy. We did this study seeking to evaluate the effectiveness of other non-invasive diagnostic methods, including the Anterior Drawer test, Lachman test and magnetic resonance imaging (MRI) in detecting ACL tears after trauma, compared to the reference standard method (the arthroscopy). METHODOLOGY: This descriptive cross-sectional study was conducted in the Orthopaedic Department of the Khyber Teaching Hospital, Peshawar, for six months. A total of 86 participants with knee injuries fulfilling the inclusion criteria were recruited for the study. Mechanism of injury, side of injury and body weight were recorded. The Anterior Drawer test and Lachman test for ACL injury were performed by orthopaedic surgeons with at least five years of post-fellowship experience in orthopaedic surgery. Sensitivities, specificities and accuracy of the clinical tests and MRI were calculated. RESULTS: The statistical analysis revealed that the mean age of participants was 35.73 (SD 12.7) years, with a range from 18 to 55 years. Among the participants, 67 (77.91%) were male and 19 (22.09%) were female. The side of injury was predominantly right in 50 (58.14%) and left in 36 (41.86%) participants. Road traffic accidents (RTAs) were the leading cause of knee injury, accounting for 63.95% (55) of cases, followed by sports injuries at 23.26% (20). Regarding diagnostic accuracy, MRI showed a sensitivity of 98.57%, specificity of 87.50% and diagnostic accuracy of 96.51% in detecting ACL tears. The Lachman test demonstrated a sensitivity of 90%, specificity of 87.5% and diagnostic accuracy of 89.53% compared to arthroscopy. Similarly, the anterior Drawer test exhibited a sensitivity of 88.57%, specificity of 87.50% and diagnostic accuracy of 88.37% against the gold standard of arthroscopy. These findings underscore the effectiveness of these diagnostic modalities in identifying ACL injuries. CONCLUSIONS: All three tests (MRI, Lachman test and anterior Drawer test) can be used for the diagnosis of anterior cruciate ligament injury with optimal results.

Clinico-Radiological Correlation Between Anterior Cruciate Ligament Deficiency and Hyperextension of the Knee Joint: A Prospective Study.

INTRODUCTION: The anterior cruciate ligament (ACL) primarily restricts anterior sliding of the tibia over the fixed femur, thereby also postulating to prevent hyperextension of the knee joint. The main objective of our study was to identify the role of the ACL in the prevention of knee hyperextension and to quantify the amount of hyperextension caused by an ACL tear, apart from its well-established role in the prevention of anterior tibial translation on the fixed femur. METHODS:  This prospective study was conducted in a tertiary care hospital. Eighty patients with unilateral ACL tears were assessed clinico-radiologically in the preoperative period to quantify the knee hyperextension, which was then compared with the uninjured contralateral knee of the same patient. Posterior tibial slope and notch width index were also assessed to rule out bias in our study. RESULTS: The mean age of patients in our study was 27.3 years. Out of 80 patients, 70 were male and 10 were female. The Pearson coefficient for clinically and radiologically assessed hyperextension was 0.919 (p-value 0.001) and 0.910 (p-value 0.001), respectively. Posterior tibial slope and notch width index assessment showed Pearson coefficients of -0.018 (p-value 0.887) and -0.068 (p-value 0.547), respectively. CONCLUSION: Anterior cruciate ligament complete tear or deficiency produces knee hyperextension, which varies from patient to patient. Though the amount of hyperextension produced is mild (less than five degrees in most patients), it can cause a significant amount of knee instability. Hence, correction of knee hyperextension is crucial while performing ACL reconstruction.

A Comparative Analysis of Quadriceps Tendon, Patellar Tendon Bone Allograft, and Cadaver Graft in Anterior Cruciate Ligament (ACL) Repair and Reconstructive Surgery.

Anterior cruciate ligament (ACL) injuries are a common occurrence among athletes and active individuals, often necessitating surgical intervention for optimal recovery. The choice of graft material for ACL reconstruction remains a topic of debate, with various options available, including quadriceps tendon (QT), patellar tendon bone allograft (PTBA), and cadaver graft (CG). This paper aims to provide an extensive review and comparison of the efficacy, outcomes, and complications associated with these graft types based on recent research. A systematic literature search following PRISMA guidelines was conducted to identify relevant studies published in the past six years. The findings suggest that while each graft type has its advantages and limitations, there is no definitive superior choice. Factors such as patient age, activity level, comorbidities, and surgeon preference should be considered when selecting the most appropriate graft for ACL repair surgery. QT grafts are associated with lower donor-site morbidity compared to patellar tendon grafts. However, QT grafts may have a higher risk of graft rupture and decreased knee flexion strength. PTBA grafts, compared to QT grafts, have a higher risk of donor-site morbidity but a lower risk of graft rupture and improved knee stability. CG grafts have lower donor-site morbidity compared to PTBA grafts but may have a higher risk of graft rupture and decreased knee flexion strength compared to PTBA grafts. In conclusion, the choice of graft material for ACL reconstruction is a complex decision that requires careful consideration of various factors, including patient age, activity level, comorbidities, and surgeon preference. While each graft type has its advantages and limitations, there is no definitive superior choice. Therefore, it is essential to carefully weigh the risks and benefits of each graft type to ensure optimal outcomes for patients undergoing ACL repair surgery.

Anterior Cruciate Ligament Repair Leads to Improved Patient-Reported Outcomes Compared to Anterior Cruciate Ligament Reconstruction.

Introduction Anterior cruciate ligament (ACL) tears occur frequently in young athletes, and ligament repair and reconstruction are surgical treatments. Although there are suggested benefits for both approaches, there is a lack of direct comparisons between ACL repair and reconstruction.This study aims to compare the mid-term functional outcomes and quality of life measures between patients that have undergone ACL repair versus reconstruction. Methods A retrospective review was conducted for demographic and operative report data of patients who underwent an ACL repair or reconstruction between 2012 and 2018. Patients were contacted over the phone and underwent a Patient-Reported Outcomes Measurement Information System (PROMIS) survey evaluating pain interference, mobility, and function. Patients were excluded from the study if there was an incomplete operative note, missing contact information, or failure to answer phone calls. Results A total of 74 eligible patients were included, with n = 54 in the ACL reconstruction group (73.0%) and n = 20 in the ACL repair group (27.0%). Reconstruction patients had a PROMIS (median (IQR)) physical function score of 22.50 (16.00-59.00), as compared to repair patients' physical function score of 60.00 (21.50-60.00). There was a significant difference favoring repair (p = 0.040). In addition, ACL reconstruction patients had a significantly higher rate of additional procedures, with 63.0% of reconstruction patients receiving an additional operation as compared to 30.0% of repair patients (p = 0.017). The surgery type did not show a significant effect on physical function scores, while additional procedures remained significant in the linear regression analysis. Conclusion Although ACL repair is associated with improved physical function scores as compared to reconstruction in the univariate analysis, surgery type did not show significance when controlling for other variables. Further studies are necessary to compare patients with similar injuries to account for differences in additional procedures, but the results remain promising in assisting with patient-driven treatment decisions.

Deep learning-based automated detection and segmentation of bone and traumatic bone marrow lesions from MRI following an acute ACL tear.

INTRODUCTION: Traumatic bone marrow lesions (BML) are frequently identified on knee MRI scans in patients following an acute full-thickness, complete ACL tear. BMLs coincide with regions of elevated localized bone loss, and studies suggest these may act as a precursor to the development of post-traumatic osteoarthritis. This study addresses the labour-intensive manual assessment of BMLs by using a 3D U-Net for automated identification and segmentation from MRI scans. METHODS: A multi-task learning approach was used to segment both bone and BML from T2 fat-suppressed (FS) fast spin echo (FSE) MRI sequences for BML assessment. Training and testing utilized datasets from individuals with complete ACL tears, employing a five-fold cross-validation approach and pre-processing involved image intensity normalization and data augmentation. A post-processing algorithm was developed to improve segmentation and remove outliers. Training and testing datasets were acquired from different studies with similar imaging protocol to assess the model's performance robustness across different populations and acquisition conditions. RESULTS: The 3D U-Net model exhibited effectiveness in semantic segmentation, while post-processing enhanced segmentation accuracy and precision through morphological operations. The trained model with post-processing achieved a Dice similarity coefficient (DSC) of 0.75 ± 0.08 (mean ± std) and a precision of 0.87 ± 0.07 for BML segmentation on testing data. Additionally, the trained model with post-processing achieved a DSC of 0.93 ± 0.02 and a precision of 0.92 ± 0.02 for bone segmentation on testing data. This demonstrates the approach's high accuracy for capturing true positives and effectively minimizing false positives in the identification and segmentation of bone structures. CONCLUSION: Automated segmentation methods are a valuable tool for clinicians and researchers, streamlining the assessment of BMLs and allowing for longitudinal assessments. This study presents a model with promising clinical efficacy and provides a quantitative approach for bone-related pathology research and diagnostics.

Outcomes of Primary Anterior Cruciate Ligament (ACL) Repair for Proximal Tears: A Systematic Review and Meta-Analysis.

The purpose of this study is to compare failure rates among different techniques of primary anterior cruciate ligament (ACL) repair for the treatment of proximal ACL ruptures. Meta-analysis and systematic review were completed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Studies from Embase, Cochrane, and PubMed published between June 2011 and June 2022 reporting outcomes of primary ACL repair on proximal tears with a minimum two-year follow-up were included. Primary ACL repair was divided into dynamic, static, and non-augmented repair. The primary outcome was failure rates, and the secondary outcomes included patient-reported outcomes (PROs) and anterior tibial stability (ATT). Eighteen studies on primary ACL repair were included, with a total of 614 patients (ages ranging from 6 to 65, 60% male). Only two studies were level 1 randomized controlled clinical trials. The static repair had a failure rate of 33 out of 261 (12.6%), non-augmented was 17 out of 179 (9.4%), and dynamic repair was 31 out of 174 (17.8%); no statistically significant difference was found comparing the failure rates (p = 0.090). PROs using the International Knee Documentation Committee (IKDC) and Lysholm scores had weighted averages of 91.7 (95% confidence interval (CI): 89.6-93.8) and 94.7 (95% CI: 92.7-96.7), respectively. ATT had a weighted average of 1.668 mm (95% CI: 1.002-2.334). The primary findings of this paper include a 12.6% combined failure rate for primary proximal ACL repair with no significant difference in failure rate or PROs when accounting for the methodology of repair at a minimum two-year follow-up. It is important to note the lack of high-quality randomized controlled trials, the heterogeneity of included studies, and the lack of long-term data. Despite these limitations, the findings of the current analysis suggest that primary repair may be a useful treatment option for indicated candidates with proximal ACL ruptures. Further long-term and higher-quality comparative studies on ACL reconstruction are warranted.

A Comprehensive Case Study of a Hyperlaxity Dilemma: An Injury-Prone Young Athlete.

A prevalent condition that is frequently linked to joint trauma is joint hyper-laxity. The knee joint is one of the most complex and injury-prone joints in sports. The most commonly injured is the anterior cruciate ligament (ACL). The case presented below is of a 24-year-old athlete with a past history of many sports-related injuries who is now presented with a complete tear of the ACL with hyper-laxity as a risk factor. The patient has a Beighton score of six out of nine without any other symptoms, which is suggestive of benign hyper-laxity of the joints and not hyper-laxity syndrome. Here, we emphasize that medical professionals must know the fundamental connection between hyper-laxity and musculoskeletal injuries and their proper management and rehabilitation for future prevention.

Functional outcomes in single stage bilateral ACL reconstruction with a maximum follow up of 10 years.

Background: Bilateral ACL injuries are a rarity and there is no particular consensus on whether this rare problem has to be tackled in stages or in a single stage. There are a few studies and case reports in the literature about the outcomes in single staged bilateral Anterior cruciate ligament reconstruction (ACLR). This study is focused on functional outcomes after a single staged bilateral ACLR, as well as impact of simultaneity of the injury, meniscal tears, notch stenosis and hyperlaxity. Materials and methods: A retrospective study was conducted from 2013 to 2021. Patients with bilateral ACL injury either simultaneous or non simultaneous, with or without meniscal tears were included in this study. Pre operative diagnosis was made both clinically and by MR imaging. All patients underwent a single staged bilateral ACL reconstruction. Pre operative functional scores (IKDC and Lysholm) were taken at admission and patients were examined at regular follow ups. Final functional scores were collected in a phone interview. Results: 33 patients underwent bilateral ACLR in a single stage during the study period but one patient had revision ACLR in one knee and so was excluded. Of the 32 patients, 25 (78%) had non simultaneous injury and 7 (22%) had a simultaneous injury, meniscus tear was noted in 27 (84.4%), notch stenosis in 19 (59.3%) and hyperlaxity in 12 (37.5%). IKDC and Lysholm scores have improved postoperatively. No statistically significant difference was found with or without simultaneous injury or meniscus tears. Conclusion: Single stage bilateral ACL reconstruction is a safe, reproducible approach to bilateral ACL injuries whether they were simultaneous or non simultaneous or with or without meniscal tears.

Evaluation of Bony Femoral Morphological Parameters in Anterior Cruciate Ligament Injury Using Magnetic Resonance Imaging: A Retrospective Unmatched Case-Control Study.

Background Over time, there has been a noticeable increase in anterior cruciate ligament (ACL) injuries. The current imperative is to anticipate predisposing factors and proactively prevent ACL injuries. The occurrence of ACL injuries has been linked to diverse factors associated with the morphology of the distal femur. Objectives Through this study, we aim to compare the anatomic variables of distal femur morphology such as notch width (NW), bicondylar width (BW), notch entrance width (NEW), and notch width index (NWI) between patients with ACL injuries and non-injured patients using MRI. We also aim to make a comparison of these factors between male and female genders to assess the gender variability. Material and methods A retrospective case-control study was conducted amongst patients who underwent MRI Knee scan for clinical suspicion of internal derangement during the study period. We selected the first 125 individuals who were found to have ACL injury in the MRI scans and selected another 125 individuals who had an intact ACL in the scans, to serve as controls in the study. Demographic information was retrieved from the hospital's electronic records, and the assessment of NW, NWI, BW, and NEW was conducted through a review of MRI sequences. They were then compared between the cases and control groups, as well as between male and female genders. Results The ACL-injured group exhibited statistically significant reductions in NW and NWI. While 17.39 mm was the mean NW among cases, 17.86 was the mean value among controls. Similarly, the mean NWI was 0.25 among patients with ACL injuries and 0.27 among controls. Gender-based comparisons also revealed statistically significant differences in NW and NWI measurements, where females were reported to have comparatively lower measurements. The mean NW for males and females in the injured group were 18.26 mm and 15.40 mm, respectively, while it was 18.71 mm and 16.90 mm, respectively, in the control group. In the case of NEW, males in the injured group had a slightly higher value (21.33 mm) than the controls (20.65). Females on the other hand exhibited a lower mean value of NEW in ACL-injured group (18.51 mm) in comparison to the non-injured (18.79 mm). BW did not seem to show a significant difference between the two groups. Conclusions In the studied population, ACL injuries demonstrated a higher occurrence in individuals with a narrow femoral intercondylar NWI. If any of these characteristics are identified in an MRI, it may be helpful to identify individuals who are at a higher risk of developing ACL injuries and may thereby help in planning preventative strategies.

Effect of Age and Body Mass Index on Time to Advanced Imaging and Surgery in Young Athletes With Anterior Cruciate Ligament Injury.

Background: In young athletes with anterior cruciate ligament (ACL) injury, increased times from injury to magnetic resonance imaging (MRI) and injury to surgery can lead to the accrual of new injuries over time. Purpose: To determine the patient characteristics associated with differences in timing between injury, MRI, and surgery in young athletes with ACL tears. Study Design: Case-control study; Level of evidence, 3. Methods: We reviewed the electronic medical records of patients aged 13 to 25 years who underwent isolated primary ACL reconstruction between January 2017 and June 2020 at a single orthopaedic surgery department. The times from injury to MRI, MRI to surgery, and injury to surgery were documented. Patient demographic data (age, sex, body mass index [BMI], race and ethnicity, and insurance type) were recorded. Multivariable analysis was used to determine if any patient characteristic had a significant association with increased time to MRI or surgery. Results: A total of 369 patients (mean age, 18.0 years; 56% female) were included. Both age and BMI were found to be significantly associated with timing of care while holding all other predictors constant. For every 1-year increase in patient age, time from injury to MRI increased by 9.6 days (95% CI, 1.8-17.4 days; P = .02), time from MRI to surgery increased by 7.4 days (95% CI, 4.4-10.5 days; P < .001), and time from injury to surgery increased by 17.0 days (95% CI, 8.4-25.6 days; P < .001). Compared with patients with normal BMI, overweight patients (BMI range, 25-29.9 kg/m2) had an MRI-to-surgery time that was on average 37.2 days (95% CI, 11.7-62.7 days; P < .004) longer and an injury to surgery time that was on average 71.8 days (95% CI, 0.5-143.0 days; P = .048) longer. Obese patients (BMI ≥30 kg/m2) did not demonstrate a significant relationship with the studied time intervals. Conclusion: Increasing age and elevated BMI were found to be associated with increased time to MRI and surgical care in young athletes with ACL injuries.

[Imaging of the anterior cruciate ligament and anterolateral rotational instability of the knee joint]. / Bildgebung des vorderen Kreuzbands und der anterolateralen Rotationsinstabilität des Kniegelenks.

The anterior cruciate ligament (ACL) is essential for the stability of the knee joint and ACL tears are one of the most common sports injuries with a high incidence, especially in sports that require rotational movements and abrupt changes in direction. Injuries of the ACL are rarely isolated and are often accompanied by meniscal and other internal knee injuries, which increase the risk of osteoarthritis. The spectrum of ACL injuries includes strains, partial tears and complete tears. Magnetic resonance imaging (MRI) plays a pivotal role in the diagnostics as it can accurately depict not only the ACL but also accompanying injuries. Proton density and T2-weighted sequences are particularly suitable for evaluating the ACL, which is usually well visible and assessable in all planes. In addition to depicting fiber disruption as a direct sign and central diagnostic indicator of an ACL tear, there are numerous other direct and indirect signs of an ACL injury in MRI. These include abnormal fiber orientations, signal increases and an anterior subluxation of the tibia relative to the femur. The bone marrow edema patterns often associated with ACL tears are indicative of the underlying injury mechanism. The treatment of ACL tears can be conservative or surgical depending on various factors, such as the patient's activity level and the presence of accompanying injuries. The precise and comprehensive description of ACL injuries by radiology is crucial for optimal treatment planning. Anterolateral rotational instability (ALRI) of the knee joint characterizes a condition of excessive lateral and rotational mobility of the tibia in relation to the femur in the anterolateral knee region. This instability is primarily caused by a rupture of the ACL, with the anterolateral ligament (ALL) that was rediscovered about 10 years ago, also being attributed a role in stabilizing the knee. Although ALRI is primarily diagnosed through clinical examinations, MRI is indispensable for detecting injuries to the ACL, ALL, and other internal knee structures, which is essential for developing an optimal treatment strategy.

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

CONTEXT: While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport. OBJECTIVE: To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS. DATA SOURCES: A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021. STUDY SELECTION: Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria. STUDY DESIGN: Systematic review and meta-analysis. LEVEL OF EVIDENCE: Level 2 to 4. DATA EXTRACTION: The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return. RESULTS: The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%). CONCLUSION: This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

Segond fracture: an indicator for increased risk of lateral meniscus injury in patients with acute anterior cruciate ligament ruptures.

PURPOSE: The purpose of this study was to investigate the incidence and anatomic distribution of meniscus injury in patients who have sustained acute ACL injuries with and without concomitant Segond fracture. We hypothesized that patients who have sustained a torn ACL with a concomitant Segond fracture would have a higher incidence of lateral meniscal injuries than patients with an isolated ACL injury. METHODS: Patients who underwent ACL reconstruction from 2012 to 2022 were retrospectively reviewed. Segond fractures were identified on knee radiographs. Inclusion criteria were age 18-40, injury during sports activity, and reconstruction within 90 days of injury. Sports activity, anatomic location of meniscus injury, and meniscus treatment were documented. Multivariable regression was used to identify predictors of meniscus injury/treatment. RESULTS: There were 25 of 603 (4.1%) patients who had an ACL tear with concomitant Segond fracture. The incidence of lateral meniscus injury in the Segond group (72%) was significantly higher than in the non-Segond cohort (49%; p = 0.024). A significantly smaller proportion of medial meniscus injuries among patients with Segond fractures were repaired (23.1%) compared to the non-Segond group (54.2%; p = 0.043). Multivariate analysis found patients with Segond fractures to have increased odds of lateral meniscus injury (OR 2.68; [1.09, 6.60], p = 0.032) and were less likely to have medial meniscus injuries repaired (OR 0.35; [0.15, 0.81], p = 0.014). Additionally, males had increased odds of lateral meniscus injury (OR 1.54; [1.08 - 2.91], p = 0.017), which were more likely to require repair (OR 1.48; [1.02, 2.14], p = 0.038). CONCLUSIONS: Among acute ACL injuries, the incidence of lateral meniscus injury is greater among patients with Segond fractures. Patients with Segond fracture were less likely to undergo repair of medial meniscal injuries.

Enhancing Muscle Strength Post Anterior Cruciate Ligament Reconstruction: A Case Report Assessing the Effectiveness of Russian Current.

The effectiveness of Russian electrical stimulation in enhancing muscular strength after anterior cruciate ligament (ACL) restoration is examined in this case study. In addition to traditional physiotherapy, a 29-year-old male athlete having ACL repair took part in a Russian contemporary rehabilitation regimen. Subjective evaluations of pain and functional tests all showed a substantial increase in muscular strength following the intervention. The Russian current's distinct waveform and high-frequency bursts appeared to improve neuromuscular control and quicken the activation of skeletal muscle in the excitation-contraction phase. The evaluation conducted after the intervention revealed notable enhancements in muscular strength and scores on the lower extremity functional scale. The initial score of 32, indicating a moderate functional limitation, improved to 64, indicating a minimal functional limitation. Additionally, the use of Russian electrical stimulation in ACL rehabilitation programs resulted in a reduction in pain levels from 9/10 to 3/10, as measured by the visual analog scale. These findings suggest that the implementation of Russian electrical stimulation shows promise in ACL rehabilitation. However, to validate and further explore these results, it is necessary to conduct larger-scale research studies and randomized controlled trials.

Intra- and interobserver reliability of two classification systems for posterolateral tibial plateau fractures in the setting of an ACL rupture.

Background: Posterolateral tibial plateau impaction fractures occur frequently associated with anterior cruciate ligament (ACL) tears. Some authors advocate operative treatment of high-grade impaction fractures, which has led to the development of classification systems. Our study aims (1) to describe and compare the intra- and interobserver reliability of the two most used classifications and (2) to assess correlations between the grade of bony posterolateral tibial injury, patient characteristics and short-to mid-term revision rate after ACL reconstruction. Materials and methods: In a retrospective series of 163 patients who underwent ACL reconstruction, two reviewers independently evaluated the preoperative MRI scans. Conform the Menzdorf and Bernholt classification the presence and grade of an associated posterolateral impaction fracture were assessed. Statistical analyses were performed to test for both study hypotheses. Results: 171 primary ACL cases were evaluated. Mean follow-up time was 41 months (range 12-154, SD = 17.1). Mean age was 32 years (range 13-59, SD = 12). Posterolateral impaction fractures were present in 111 (64.9 %) and 120 (70.0 %) cases, according to the Menzdorf and Bernholt classification. A Segond fracture was present in 19 (11.1 %) cases. Kappa value was 0.47 for intra- and 0.52 for the interobserver reliability for the Menzdorf classification (moderate reliability). For the Bernholt classification kappa values were 0.66 and 0.61, respectively (good reliability). A Segond fracture correlated significantly with the presence of a posterolateral impaction fracture (p < 0.05). A significant association was present between patients necessitating ACL revision surgery and patients for whom operative intervention for the posterolateral impression was advised following the Menzdorf classification (p < 0.001). Conclusion: Inter- and intraobserver reliability testing for classifying posterolateral tibial fractures resulted in moderate to good reliability. High-grade posterolateral tibial fractures should be identified, selective treatment should be considered as they are associated with higher revision rates after ACL reconstruction if left untreated.

A comparison of continuous cold flow and compression device and traditional icing regimen and no icing following anterior cruciate ligament reconstruction: A pilot study.

The aim of this study was to investigate the effectiveness of continuous cold flow and compression device as against traditional icing regimen and without icing after anterior cruciate ligament (ACL) reconstruction. All patients undergoing ACL reconstruction from June 2021 to August 2021 were enrolled in this study. Patients were randomly allocated to three groups: A control group (n=10) with no ice regimen post-operatively, a second control group (n=10) with ice bag, and a third group (n=10) with continuous cold flow and compression device (physiolab). All patients who had isolated ACL tear evident on magnetic resonance imaging were included. Pain intensity, limb girth, Oxford Knee Score, and 12-item survey form were measured pre- and post-operatively. Significant difference was noted between pain scores in all groups at two- and six-week follow-ups with p-value of 0.004 and 0.01. The test for "between subject effects" showed significant difference (p=0.007) in limb girth between the two groups. Cold and compression device can be used to reduce swelling immediately after ACL reconstruction.