Proprioception After Primary Repair of the Anterior Cruciate Ligament.

BACKGROUND: Primary repair of the anterior cruciate ligament (ACL) has some potential advantages over the reconstruction technique, which include but are not limited to better knee sensation due to preservation of the natural ACL tissue in patients compared with tendon graft. Proprioception is impaired after ACL injuries and the sense of the joint position is lost. PURPOSE/HYPOTHESIS: The purpose of this study was to compare arthroscopic ACL primary repair and ACL reconstruction techniques clinically and functionally and analyze the differences in proprioception. It was hypothesized that primary repair would restore knee joint proprioception more successfully because the original tissue of the ACL is preserved. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 63 patients (34 underwent reconstruction and 29 underwent primary repair between 2017 and 2020) and 33 healthy controls, as well as the healthy knees of the operated groups, were evaluated between 24 and 48 months (mean, 29 months) postoperatively. Patients with proximal femoral avulsion tears and stump quality suitable for repair underwent primary repair, and those with tears outside these criteria underwent reconstruction using hamstring tendon autograft. Proprioception was evaluated using the active joint position sensation method during weightbearing, with a digital inclinometer used to measure differences between the target and achieved flexion angles of 15°, 30°, and 60°. RESULTS: At 15° of knee flexion, the deviation angles for the healthy knee of the reconstruction and primary repair groups were significantly smaller than those of the control group (P < .001), but there was no statistically significant difference between the groups in terms of deviation angle at 30° and 60° of flexion. The deviation angle of the operated knees was statistically significantly larger in the reconstruction group than in the primary repair group at all angles. The deviation angles at 15°, 30°, and 60° were 2.83°, 2.66°, and 2.66° in the reconstruction group and 1.00°, 1.00°, and 1.33° in the primary repair group, respectively (P < .001). There was no statistically significant difference between the reconstruction and primary repair groups in terms of clinical scores. CONCLUSION: Primary ACL repair can preserve proprioception in a well-selected patient group. In short-term follow-up, primary repair of the ACL in patients with proximal femoral avulsion tears and stump quality suitable for repair appears to be proprioceptively protective. Future studies are needed to clarify the long-term consequences of primary repair on proprioception in a larger population.

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.

The Relationship Between Calcaneofibular Ligament Injury and Ankle Osteoarthritis Progression: A Comprehensive Analysis of Stress Distribution and Osteophyte Formation in the Subtalar Joint.

BACKGROUND: Ankle osteoarthritis (OA) mainly arises from trauma, particularly lateral ligament injuries. Among lateral ligament injuries, ankles with calcaneofibular ligament (CFL) injuries exhibit increased instability and can be a risk factor ankle OA progression. However, the relationship between CFL injury and OA progression remains unclear. Therefore, this study aims to assess the relationship between CFL injuries and ankle OA by investigating stress changes and osteophyte formation in subtalar joint. METHODS: We retrospectively reviewed the magnetic resonance imaging (MRI) and plain radiographic evaluations of 100 ankles of 91 patients presenting with chronic ankle instability (CAI), ankle OA, or other ankle conditions. The association between CFL injuries on the oblique view of MRI and the severity of ankle OA (based on Takakura-Tanaka classification) was statistically evaluated. Additionally, 71 ankles were further subjected to CT evaluation to determine the association between the CFL injuries and the Hounsfield unit (HU) ratios of the subtalar joint and medial gutter, and the correlation between the subtalar HU ratios and osteophyte severity were statistically evaluated. RESULTS: CFL injury was observed in 35.9% (14/39) of patients with stage 0, 42.9% (9/21) with stage 1, 50.0% (10/20) with stage 2, 100% (9/9) with stage 3a, and 90.9% (10/11) with stage 3b. CFL-injured ankles exhibited higher HU ratios in the medial gutter and lower ratios in the medial posterior subtalar joint compared to uninjured ankles. A negative correlation was observed between medial osteophyte severity and the medial subtalar joint HU ratio. CONCLUSION: Our findings suggest that CFL injuries are common in severe ankle OA impairing the compensatory function of the subtalar joint through abnormal stress distribution and osteophyte formation. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Defining the imaging diagnostic criteria for adult chronic non-bacterial osteitis.

Osteitis of the sternocostoclavicular (SCC) region, referred to as sternocostoclavicular hyperostosis (SCCH), is the clinical expression of chronic non-bacterial osteitis (CNO) in adults with this rare chronic auto-inflammatory disorder of the axial skeleton. The diagnosis is based on distinctive computerized tomography (CT) features of sclerosis and hyperostosis of the SCC region, and local increases in osteoid formation visualized by high radiopharmacon uptake on skeletal scintigraphy but clear radiologic diagnostic criteria are lacking. In a cross-sectional study, CT scans and whole-body skeletal scintigraphy images obtained in 169 patients seen at the Center for Bone Quality of the Leiden University Medical Center between 2008 and 2018 with a suspected diagnosis of CNO of the SCC region were re-evaluated by 2 skeletal radiologists and 2 nuclear physicians. The diagnosis was confirmed in 118 (70%) predominantly female patients (n = 103, 89.2%); median age at first symptoms 45 years (range 20-73). The diagnosis was excluded in the remaining 51 "non-CNO" patients. Increased radiopharmacon uptake at the SCC region was observed in 82% CNO patients, with the manubrium sterni having the highest predictive ability to discriminate on both imaging modalities. The prevalence of sclerosis of the clavicles, manubrium and first ribs was significantly higher in CNO patients (P < 0.001). Hyperostosis was not observed in non-CNO patients. 46 CNO versus only 2 non-CNO patients had costoclavicular ligament calcification. Our findings identify CT scan features of sclerosis and hyperostosis of manubrium sterni, medial end of clavicles and first ribs, and calcification of costoclavicular ligaments, associated with increased tracer uptake on skeletal scintigraphy at the SCC region, specifically manubrium sterni, as well-defined imaging diagnostic criteria for adult CNO. Pitfalls encountered in the diagnosis of CNO are highlighted. These defined imaging diagnostic criteria for adult CNO should facilitate the diagnosis of this rare auto-inflammatory bone disease across the spectrum of its early to late stages.

A Novel Ligamentous Complex in the Anteromedial Region of the Knee: A Cadaveric Study.

Background: The medial knee structures have a primary role in stabilizing valgus and rotational stress, which makes them important in assessing the ligament-injured knee globally and choosing the most adequate treatment. Purpose: To conduct a layer-by-layer dissection of the knee's anteromedial side and provide a qualitative and quantitative description of the anatomy and histology of a ligament in the anteromedial region of the knee, which we have termed the anterior oblique ligament (AOL). Also, to describe the AOL relationship with what we have termed the medial cross-a ligament complex that stabilizes the medial pivot. Study Design: Descriptive laboratory study. Methods: A total of 35 fresh-frozen knees from transfemoral amputations that were exclusively performed for vascular reasons were dissected. Structures were identified after meticulous dissection, respecting the same protocol, measured with a digital caliper rule, and histologically studied for data. Results: The AOL was found in all dissected knees, with a mean length of 31.47 ± 5.06 mm. This structure presented a ligament histology with densely organized collagen fibrils. The medial cross was represented by the superficial medial collateral ligament, AOL (anterior region), and posterior oblique ligament. Conclusion: This study demonstrated the presence of a ligament in the anteromedial region of the knee, termed the AOL. This structure was in the anterior part of a ligament complex-the medial cross. Clinical Relevance: Studying and revisiting the medial compartment can provide important information for understanding joint instability and promoting better results in ligament reconstructions.

Thin-slice elbow MRI with deep learning reconstruction: Superior diagnostic performance of elbow ligament pathologies.

PURPOSE: With the slice thickness routinely used in elbow MRI, small or subtle lesions may be overlooked or misinterpreted as insignificant. To compare 1 mm slice thickness MRI (1 mm MRI) with deep learning reconstruction (DLR) to 3 mm slice thickness MRI (3 mm MRI) without/with DLR, and 1 mm MRI without DLR regarding image quality and diagnostic performance for elbow tendons and ligaments. METHODS: This retrospective study included 53 patients between February 2021 and January 2022, who underwent 3 T elbow MRI, including T2-weighted fat-saturated coronal 3 mm and 1 mm MRI without/with DLR. Two radiologists independently assessed four MRI scans for image quality and artefacts, and identified the pathologies of the five elbow tendons and ligaments. In 19 patients underwent elbow surgery after elbow MRI, diagnostic performance was evaluated using surgical records as a reference standard. RESULTS: For both readers, 3 mm MRI with DLR had significant higher image quality scores than 3 mm MRI without DLR and 1 mm MRI with DLR (all P < 0.01). For common extensor tendon and elbow ligament pathologies, 1 mm MRI with DLR showed the highest number of pathologies for both readers. The 1 mm MRI with DLR had the highest kappa values for all tendons and ligaments. For reader 1, 1 mm MRI with DLR showed superior diagnostic performance than 3 mm MRI without/with DLR. For reader 2, 1 mm MRI with DLR showed the highest diagnostic performance; however, there was no significant difference. CONCLUSIONS: One mm MRI with DLR showed the highest diagnostic performance for evaluating elbow tendon and ligament pathologies, with similar subjective image qualities and artefacts.

Outcomes of "Over the Top" Anterior Cruciate Ligament Reconstruction Associated with a Lateral Extra-Articular Tenodesis in Children.

(1) Purpose: The incidence of anterior cruciate ligament (ACL) ruptures in children and adolescents has considerably increased during the last decades due to higher levels of competitive athletic activity, and early sport specialization and professionalization. Contemporary ACL reconstruction techniques have recently been subject to renewed interest in this population. The objective of this study is to report the short- and mid-term results of our physis-sparing ACL reconstruction technique using an "over the top" technique associated with a modified Lemaire procedure. (2) Methods: A retrospective series of 12 junior soccer players who presented to our clinic with a torn ACL between January 2019 and September 2021 was reviewed. The inclusion criteria were patients under 15 years with open tibial and femoral physes, with a stable contralateral knee, a minimum follow-up of 6 months, and a time frame from injury to surgery of <3 months. Patients with previous knee surgery, structural concomitant injuries, muscular, neurological, or vascular abnormalities, or hypersensitivity to metal alloys were excluded. The functional evaluation was performed using the International Knee Documentation Committee (IKDC) rating, Lysholm score, and Tegner activity level. Moreover, clinical and radiological assessments were also performed, including KT-1000 and knee X-rays. (3) Results: We identified 1 female and 11 male patients with ACL tears, with a mean age of 13.17 ± 0.9 months. Concomitant injuries include isolated vertical and bucket-handle tears of the medial meniscus, lateral meniscus tears, bilateral tear of both menisci. The mean follow-up time was 26 ± 12.6 months. The average IKDC, Lysholm and Tegner scores were 93.29 ± 11.04, 95.08 ± 13.2 and 9 ± 0.0 points, respectively. The average KT-1000 score of the participants was 0.96 ± 1.6 points. None of the included patients reported post-surgical complications or required additional surgeries. (4) Conclusions: Our novel ACL reconstruction with LET technique is a safe procedure that resulted in good clinical outcomes, lower failure rate and return to sports in skeletally immature patients.

Clinical anatomy of pulmonary connections in young people.

OBJECTIVE: Aim: To study the clinical anatomy of the pulmonary ligaments of young people. PATIENTS AND METHODS: Materials and Methods: The study was carried out when performing 28 autopsies of young people aged 25 to 44 years. Methods of dissection of chest organocomplexes, macro-microscopy, morphometry and planimetry, and statistical processing were used. The shape and topography of the pulmonary ligaments was assessed, their area, the localization of lymph nodes was examined. RESULTS: Results: The pulmonary ligament is an anatomical formation, which is formed as a result of a combination of leaves of the mediastinal pleura, which, covering the surfaces of the roots of the lungs, descend towards the diaphragm and are located between the mediastinal organs and the lungs. Pulmonary connections on both sides have a few edges: the inner, outer and lower free. The pulmonary ligaments with lower free edges do not pass to the diaphragmatic surface of the pleura, but only with inner ones, which are located on the right along the esophagus, and on the left along the aorta. Pulmonary ligaments on both sides pass into the mediastinal part of the pleura, covering the pericardium. CONCLUSION: Conclusions: There are individual differences between the shape and size of the right and left pulmonary ligaments in males and females. There is no significant difference between the sizes of the right and left pulmonary ligaments, but such dimensions as: the width, the angle of inclination and the ratio of their lower free edge to the lower edge of the lungs are not found in all cases.

Full-field strain distribution in hierarchical electrospun nanofibrous poly-L(lactic) acid/collagen scaffolds for tendon and ligament regeneration: A multiscale study.

Regeneration of injured tendons and ligaments (T/L) is a worldwide need. In this study electrospun hierarchical scaffolds made of a poly-L (lactic) acid/collagen blend were developed reproducing all the multiscale levels of aggregation of these tissues. Scanning electron microscopy, microCT and tensile mechanical tests were carried out, including a multiscale digital volume correlation analysis to measure the full-field strain distribution of electrospun structures. The principal strains (εp1 and εp3) described the pattern of strains caused by the nanofibers rearrangement, while the deviatoric strains (εD) revealed the related internal sliding of nanofibers and bundles. The results of this study confirmed the biomimicry of such electrospun hierarchical scaffolds, paving the way to further tissue engineering and clinical applications.

A histology guide for performing human cadaveric studies: SQIP 2024 what to look for with light microscopy.

Histological observation under light microscopy has long been used in human cadaveric studies. However, it can distort the interpretations of findings if not used appropriately; there is no guide for its proper use. The aim of this article is to revisit and discuss the correct use of histology in human cadaveric studies, following discussions with experts in multiple fields of medicine, and to create the first guide for such usage. We reached a consensus with the experts, agreeing that when this principle (structure, quantification, interaction, position: SQIP) is applied to histological observations, the findings will be interpreted correctly. Appropriate use of this recommendation can make human cadaveric studies more accurate and informative. This is the first histology guide for human cadaveric studies.

A Histomorphometric and Computational Investigation of the Stabilizing Role of Pectinate Ligaments in the Aqueous Outflow Pathway.

Murine models are commonly used to study glaucoma, the leading cause of irreversible blindness. Glaucoma is associated with elevated intra-ocular pressure (IOP), which is regulated by the tissues of the aqueous outflow pathway. In particular, pectinate ligaments (PLs) connect the iris and trabecular meshwork (TM) at the anterior chamber angle, with an unknown role in maintenance of the biomechanical stability of the aqueous outflow pathway, thus motivating this study. We conducted histomorphometric analysis and optical coherence tomography-based finite element (FE) modeling on three cohorts of C57BL/6 mice: "young" (2-6 months), "middle-aged" (11-16 months), and "elderly" (25-32 months). We evaluated the age-specific morphology of the outflow pathway tissues. Further, because of the known pressure-dependent Schlemm's canal (SC) narrowing, we assessed the dependence of the SC lumen area on varying IOPs in age-specific FE models over a physiological range of TM/PL stiffness values. We found age-dependent changes in morphology of outflow tissues; notably, the PLs were more developed in older mice compared to younger ones. In addition, FE modeling demonstrated that murine SC patency is highly dependent on the presence of PLs and that increased IOP caused SC collapse only with sufficiently low TM/PL stiffness values. Moreover, the elderly model showed more susceptibility to SC collapse compared to the younger models. In conclusion, our study elucidated the previously unexplored role of PLs in the aqueous outflow pathway, indicating their function in supporting TM and SC under elevated IOP.

Rigid tape dynamic fixation in conservative treatment of acute anterior talofibular ligament tear: A retrospective cohort study.

Objectives: This study aims to compare results of rigid tape (RT) dynamic fixation and static fixation in conservative treatment of acute anterior talofibular ligament (ATFL) tear. Patients and methods: Between September 2021 and December 2021, a total of 91 patients (41 males, 50 females, mean age: 28.5±6.5 years, range, 18 to 40 years) who were diagnosed with ATFL tear and underwent rigid tape (RT) or cast/brace rehabilitation protocol were retrospectively analyzed. The patients were divided into two groups as the RT group (n=36) and the control group (n=55). Follow-up (FU) was performed at six months. Outcomes included pain (Numerical Rating Scale [NRS]), ankle function (American Orthopaedic Foot & Ankle Society [AOFAS] hindfoot score), deviation of center of gravity (DCG), and symptoms after returning to sports. Results: The difference at each time point of pain, AOFAS, DCG and SRS between the two groups was statistically significant (p<0.05 for all). Only one patient at Week 12 in the RT group had pain in the lateral side of the ankle, while 36 patients at Week 12 and 21 patients (18 in the medial side) at FU had pain in the control group. Conclusion: Our study results suggest that RT dynamic fixation can accurately lock the ATFL function and may prevent pseudo-stability, so as to quickly repair injury, restore function, and return to sports earlier.

Harnessing Mechanical Stress with Viscoelastic Biomaterials for Periodontal Ligament Regeneration.

The viscoelasticity of mechanically sensitive tissues such as periodontal ligaments (PDLs) is key in maintaining mechanical homeostasis. Unfortunately, PDLs easily lose viscoelasticity (e.g., stress relaxation) during periodontitis or dental trauma, which disrupt cell-extracellular matrix (ECM) interactions and accelerates tissue damage. Here, Pluronic F127 diacrylate (F127DA) hydrogels with PDL-matched stress relaxation rates and high elastic moduli are developed. The hydrogel viscoelasticity is modulated without chemical cross-linking by controlling precursor concentrations. Under cytomechanical loading, F127DA hydrogels with fast relaxation rates significantly improved the fibrogenic differentiation potential of PDL stem cells (PDLSCs), while cells cultured on F127DA hydrogels with various stress relaxation rates exhibited similar fibrogenic differentiation potentials with limited cell spreading and traction forces under static conditions. Mechanically, faster-relaxing F127DA hydrogels leveraged cytomechanical loading to activate PDLSC mechanotransduction by upregulating integrin-focal adhesion kinase pathway and thus cytoskeletal rearrangement, reinforcing cell-ECM interactions. In vivo experiments confirm that faster-relaxing F127DA hydrogels significantly promoted PDL repair and reduced abnormal healing (e.g., root resorption and ankyloses) in delayed replantation of avulsed teeth. This study firstly investigated how matrix nonlinear viscoelasticity influences the fibrogenesis of PDLSCs under mechanical stimuli, and it reveals the underlying mechanobiology, which suggests novel strategies for PDL regeneration.

ESR essentials: MRI of the knee-practice recommendations by ESSR.

Many studies and systematic reviews have been published about MRI of the knee and its structures, discussing detailed anatomy, imaging findings, and correlations between imaging and clinical findings. This paper includes evidence-based recommendations for a general radiologist regarding choice of imaging sequences and reporting basic MRI examinations of the knee. We recommend using clinicians' terminology when it is applicable to the imaging findings, for example, when reporting meniscal, ligament and tendon, or cartilage pathology. The intent is to standardise reporting language and to make reports less equivocal. The aim of the paper is to improve the usefulness of the MRI report by understanding the strengths and limitations of the MRI exam with regard to clinical correlation. We hope the implementation of these recommendations into radiological practice will increase diagnostic accuracy and consistency by avoiding pitfalls and reducing overcalling of pathology on MRI of the knee. CLINICAL RELEVANCE STATEMENT: The recommendations presented here are meant to aid general radiologists in planning and assessing studies to evaluate acute and chronic knee findings by advocating the use of unequivocal terminology and discussing the strengths and limitations of MRI examination of the knee. KEY POINTS: • On MRI, the knee should be examined and assessed in three orthogonal imaging planes. • The basic general protocol must yield T2-weighted fluid-sensitive and T1-weighted images. • The radiological assessment should include evaluation of ligamentous structures, cartilage, bony structures and bone marrow, soft tissues, bursae, alignment, and incidental findings.

Comparison of the Kinematics and Laxity of Total Knee Arthroplasty Bearing Designs Stabilized With Specimen-Specific Virtual Ligaments on a Joint Motion Simulator.

A variety of total knee arthroplasty (TKA) designs offer increased congruency bearing options, primarily to compensate for a loss of posterior cruciate ligament (PCL) function. However, their efficacy in providing sufficient stability under different circumstances requires further investigation. The preclinical testing of prosthesis components on joint motion simulators is useful for quantifying how design changes affect joint stability. However, this type of testing may not be clinically relevant because surrounding ligaments are either ignored or greatly simplified. This study aimed to assess the kinematics and stability of TKA joints during various motions using condylar-stabilized (CS) bearings without a PCL versus cruciate-retaining (CR) bearings with an intact PCL. TKA prosthetic components were tested on a joint motion simulator while being stabilized with five different sets of specimen-specific virtual ligament envelopes. In comparison to CR knees, CS knees without a PCL exhibited a greater amount of posterior tibial displacement laxity, with a mean increase of 2.7±2.1 mm (p = 0.03). Additionally, significant differences were observed in the anterior-posterior kinematics of the knee joint during activities of daily living (ADL) between the two designs. These results were consistent with previous cadaveric investigations, which indicated that CS knees without a PCL are less resistant to posterior tibial displacement than CR knees with one. This study employing virtual ligaments confirms previous findings that the raised anterior lip of some CS bearings may not completely compensate for the absence of the PCL; however, as both studies used reduced joint contact forces, the contributions of this design feature may be attenuated.

Acute clinical evaluation for the diagnosis of lateral ankle ligament injuries is useful: A comparison between the acute and delayed settings.

PURPOSE: To determine the diagnostic value of seven injury history variables, nine clinical tests (including the combination thereof) and overall clinical suspicion for complete discontinuity of the lateral ankle ligaments in the acute (0-2 days post-injury) and delayed setting (5-8 days post-injury). METHODS: All acute ankle injuries in adult athletes (≥18 years) presenting up to 2 days post-injury were assessed for eligibility. Athletes were excluded if imaging studies demonstrated a frank fracture or 3 T MRI could not be acquired within 10 days post-injury. Using standardized history variables and clinical tests, acute clinical evaluation was performed within 2 days post-injury. Delayed clinical evaluation was performed 5-8 days post-injury. Overall, clinical suspicion was recorded after clinical evaluation. MRI was used as the reference standard. RESULTS: Between February 2018 and February 2020, a total of 117 acute ankle injuries were screened for eligibility, of which 43 were included in this study. Complete discontinuity of lateral ankle ligaments was observed in 23 (53%) acute ankle injuries. In the acute setting, lateral swelling had 100% (95% confidence interval [CI]: 82-100) sensitivity, haematoma had 85% (95% CI: 61-96) specificity and the anterior drawer test had 100% (95% CI: 77-100) specificity. In the delayed setting, sensitivity for the presence of haematoma improved from 43% (95% CI: 24-65) to 91% (95% CI: 70-98; p < 0.01) and the sensitivity of the anterior drawer test improved from 21% (95% CI: 7-46) to 61% (95% CI: 39-80; p = 0.02). Clinical suspicion had a positive likelihood ratio (LR) of 4.35 (95% CI: 0.55-34.17) in the acute setting and a positive LR of 6.09 (95% CI: 1.57-23.60) in the delayed setting. CONCLUSIONS: In the acute setting, clinical evaluation can exclude complete discontinuity (e.g., absent lateral swelling) and identify athletes with a high probability of complete discontinuity (e.g., positive anterior drawer test) of the lateral ankle ligaments. In the delayed setting, the sensitivity of common clinical findings increases resulting in an improved diagnostic accuracy. In clinical practice, this study underlines the importance of meticulous clinical evaluation in the acute setting. LEVEL OF EVIDENCE: Level III.

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up.

BACKGROUND: Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking. PURPOSE: To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non-graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score. RESULTS: After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups. CONCLUSION: ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents. REGISTRATION: NCT02511158 (ClinicalTrials.gov identifier).

The Effect of Varying Sizes of Ramp Lesions in the ACL-Deficient and Reconstructed Knee: A Biomechanical Robotic Investigation.

BACKGROUND: Conflicting evidence has been reported regarding the biomechanical relevance of ramp lesions (RLs) on knee kinematics. Furthermore, the influence of the defect size of the RLs on anterior tibial translation (ATT) and external rotation (ER) is currently unknown. PURPOSE: To evaluate the influence of RL defect size on knee kinematics in anterior cruciate ligament (ACL) deficiency and after simulated ACL reconstruction (sACLR). STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric knee specimens were tested in a 6 degrees of freedom robotic test setup. Force-controlled clinical laxity tests were performed with 200 N of axial compression in 0°, 30°, 60°, and 90° of flexion: 5 N·m internal rotation (IR)/ER torque, 134 N ATT force, and an anteromedial drawer test consisting of 134 N ATT force under 5 N·m ER torque. After determining the native knee kinematics, the ACL was cut at the tibial insertion, followed by a transosseous refixation to simulate a surgical repair or reconstruction (simulated ACL reconstruction; sACLR). An RL was sequentially created with a length of 1, 2, and 3 cm. Each state of the RL was evaluated in the ACL-deficient state and after sACLR. RESULTS: In the ACL-deficient state, only an RL of 3 cm length resulted in a significant increase of ATT in 30° of flexion (mean difference 0.73 mm; 95% CI, 0.36-1.1 mm). After sACLR, an RL had no significant effect. When looking at ER, an RL significantly increased ER in full extension in the ACL-deficient state in 2 cm (mean difference 0.9°; 95% CI, 0.08°-1.74°) and 3 cm length (mean difference 1.9°; 95% CI, 0.57-3.25). Furthermore, a 3-cm RL significantly increased IR in 0° of flexion in the ACL-deficient state (mean difference 1.9°; 95% CI, 0.2°-3.6°). No effect of ramp lesions on rotation was found after sACLR. CONCLUSION: RLs result in a small increase in ATT, ER, and IR in ACL-deficient knees at early flexion angles, but not after sACLR. CLINICAL RELEVANCE: Small RLs did not change time-zero knee kinematics and may, therefore, be left untreated, especially when the ACL is reconstructed.

MRI characterization of pelvic floor ligaments in nulliparous women: Technique development and morphometry within the 3D pelvic inclination correction system (3D-PICS).

PURPOSE: The aim of the MRI-study was to evaluate the visibility of the pelvic floor ligaments and to analyze the ligament morphometry in 3D space. METHODS: Twenty-two nulliparous women underwent MRI with a ligament specific protocol. MR datasets were evaluated using the 3D Pelvic Inclination Correction System (3D-PICS). The round ligament (RL), sacrospinous ligament (SSL), sacrotuberous ligament (STL), urogenital diaphragm (UGD) and uterosacral ligament (USL) were analyzed. Qualitative and quantitative analysis was performed. 3D coordinates for origin and insertion points were determined relative to the symphysis; subsequently lengths and angles were calculated. Interrater reliability was calculated to validate the point determination method. RESULTS: Moderate to good visibility was reported for the RL, the SSL, the STL and the UGD. Standard deviation of the points analyzed in the different dimensions vary from 1.5 mm to 21.3 mm. Origin and insertion points of the ligaments are found within a mean standard distance of 10.7 mm. The highest variability was seen in insertion points of RL, with a standard distance of 25.4 mm. The interrater reliability was good to very good (range of intraclass correlation coefficients (ICC) from 0.58 to 0.96), except for the UGD ventral points (ICC from 0.27 to 0.55). CONCLUSIONS: This in-vivo MRI technique development study offers first exact data describing the pelvic floor ligaments in nulliparous women in 3D-PICS. Visibility, exact 3D coordinates of the origin and insertion points, lengths, angles and interrater reliability assessed for all parameters were evaluated morphometrically.