Higher sensitivity with the lever sign test for diagnosis of anterior cruciate ligament rupture in the emergency department.

INTRODUCTION: The objective of this study was to assess the diagnostic value of the "lever sign test" to diagnose ACL rupture and to compare this test to the two most commonly used, the Lachman and anterior drawer test. METHOD: This prospective study was performed in the ED of the Cliniques Universitaires Saint-Luc (Brussels, Belgium) from March 2017 to May 2019. 52 patients were included undergoing knee trauma, within 8 days, with an initial radiograph excluding a fracture (except Segond fracture or tibial spine fracture). On clinical investigation, patients showed a positive lever sign test and/or a positive Lachman test and/or a positive anterior drawer test. Exclusion criteria were a complete rupture of the knee extensor mechanism and patellar dislocation. All the physicians involved in this study were residents in training. An MRI was performed within 3 weeks for all included patients after the clinical examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were investigated for all three tests with MRI used as our reference standard. RESULTS: Forty out of 52 patients suffered an ACL rupture (77%) and 12 did not (23%). The sensitivity, specificity, PPV and NPV of the lever sign test were respectively 92.5%, 25% 82% and 50%. Those of the Lachman test were 54%, 54.5%, 81% and 25%, and those of the anterior drawer test were 56%, 82%, 90.5% and 37.5%. Twelve out of 40 ACL ruptures (30%) were diagnosed exclusively with a positive lever sign test. CONCLUSION: When investigating acute ACL ruptures (< 8 days) in the ED, the lever sign test offers a sensitivity of 92.5%, far superior to that of other well-known clinical tests. The lever sign test is relatively pain-free, easy to perform and its visual interpretation requires less experience. Positive lever sign test at the ED should lead to an MRI to combine high clinical sensitivity with high MRI specificity.

The evaluation of Rolimeter, KLT, KiRA and KT-1000 arthrometer in healthy individuals shows acceptable intra-rater but poor inter-rater reliability in the measurement of anterior tibial knee translation.

PURPOSE: To assess measurement equivalence, inter- and intra-rater reliability, standard error of measurements (SEM) and false positive measurements (FPM) of four different knee arthrometers (KLT,Karl Storz; KiRA, I + ; KT-1000 MEDmetric Corp; Rolimeter, Aircast) in healthy patients. METHODS: Four different investigators (two advanced (AR) and two beginners (BR)) examined 12 participants with healthy knees at two time points with regards to anterior tibial translation (ATT) and side-to-side difference (SSD). Test equivalence was assessed using the TOST (two-one-sided t test) procedure with ± 1 mm equivalence boundaries. Intraclass correlation coefficients (ICCs) were calculated using two-way mixed effects models. Furthermore, false positive-(SSD > 3 mm) and SEMs were assessed. RESULTS: A total of 2304 Lachman Tests were performed. Between-rater SSDs were equivalent between AR and BR raters for the Rolimeter only. Inter-rater ICC values (SSD, ATT) were graded as "poor" to "moderate" for all devices. Equivalent test-retest results were observed for all raters using the Rolimeter, KLT and KT-1000, whereas measurement consistency with KiRA was given in the advanced examiners group only. Intra-rater ICC values (Range: SSD, ATT) were graded as "poor" to "moderate" for SSD values and "moderate" to "good" for ATT. SEMs were lowest for the Rolimeter and highest for KiRA. FPM were never obtained with the Rolimeter (0%), twice (2.1%) with the KT-1000, three times (3.1%) with the KLT and 33 times (34.4%) using KiRA. CONCLUSION: There is acceptable intra-rater but poor inter-rater reliability with all tested arthrometers. Measures of knee laxity are comparable between Rolimeter, KLT and KT-1000 but higher for KiRA. Clinically, the present study shows that repeated arthrometry measurements should always be performed by the same investigators.

The "Lever Sign": a new clinical test for the diagnosis of anterior cruciate ligament rupture.

PURPOSE: A new clinical test for the diagnosis of ACL rupture is described: the so-called "Lever Sign". This prospective study on four groups of patients divided subjects on the basis of MRI findings (complete or partial ACL lesion) and the clinical phase of the injury (acute or chronic). The hypothesis was that this manual test would be diagnostic for both partial and complete tears of the ACL regardless of the elapsed time from injury. METHODS: A total of 400 patients were evaluated and divided into four, equal-sized groups based on time elapsed from injury and MRI findings: Group A (acute phase with positive MRI for complete ACL rupture), Group B (chronic phase with positive MRI for complete ACL rupture), Group C (acute phase with positive MRI for partial ACL rupture), and Group D (chronic phase with positive MRI for partial ACL rupture). Clinical assessment was performed with the Lachman test, the Anterior Drawer test, the Pivot Shift test, and the Lever Sign test. The Lever Sign test involves placing a fulcrum under the supine patient's calf and applying a downward force to the quadriceps. Depending on whether the ACL is intact or not, the patient's heel will either rise off of the examination table or remain down. Additionally, the Lever Sign test was performed on the un-injured leg of all 400 patients as a control. RESULTS: All tests were nearly 100 % sensitive for patients with chronic, complete tears of the ACL. However, for patients with acute, partial tears, the sensitivity was much lower for the Lachman test (0.42), Anterior Drawer test (0.29), and Pivot Shift test (0.11), but not the Lever Sign test (1.00). CONCLUSION: In general, chronic, complete tears were most successfully diagnosed but acute, partial tears were least successfully diagnosed. The Lever Sign test is more sensitive to correctly diagnosing both acute and partial tears of the ACL compared with other common manual tests. The clinical relevance is that some ACL ruptures may be more accurately diagnosed.

Postoperative Knee Joint Stability Following Anterior Cruciate Ligament Reconstruction Using the Ligament Advanced Reinforcement System.

BACKGROUND: One of the goals of the synthetic materials used in knee joint reconstruction of the anterior cruciate ligament (ACL) is to improve the strength and stability of the graft immediately after the reconstruction. One of the synthetic grafts is a non-absorbable synthetic ligament device made of terephthalic polyethylene polyester fibers, the Ligament Advanced Reinforcement System (LARS). OBJECTIVES: The aim of the study was to assess postoperative knee joint stability in patients who had undergone ACL reconstruction using the LARS graft. MATERIAL AND METHODS: The study group was comprised of 20 males who had undergone primary unilateral intraarticular ACL reconstruction using LARS. The patients were evaluated one day before the reconstruction and an average of six weeks postoperatively. Knee stability was evaluated manually using the Lachman test, anterior drawer test and pivot-shift test. Knee active range of motion (ROM) was measured. RESULTS: Preoperatively, the Lachman test indicated abnormal/2+ results in the vast majority of the patients. The postoperative results in most of the patients were normal/0. The anterior drawer test results were also abnormal/2+ preoperatively and normal/0 postoperatively. The pivot-shift test was positive in all of the patients before the ACL reconstruction and negative after the surgery. In general, no differences were found in the ROM between the involved and uninvolved limbs and in the between-measurement comparison. CONCLUSIONS: The evaluation demonstrated significant progress from the preoperative to postoperative results in reducing anterior translation and anterolateral rotational instability of the tibia in patients who had undergone ACL reconstruction using the synthetic LARS graft. In the short-term follow-up assessments, restoration of anterior and anterolateral rotational stability of the operated knee joints was observed.

Predictive Refined Computational Modeling of ACL Tear Injury Patterns.

Anterior cruciate ligament (ACL) ruptures are prevalent knee injuries, with approximately 200,000 ruptures annually, and treatment costs exceed USD two billion in the United States alone. Typically, the initial detection of ACL tears and anterior tibial laxity (ATL) involves manual assessments like the Lachman test, which examines anterior knee laxity. Partial ACL tears can go unnoticed if they minimally affect knee laxity; however, they will progress to a complete ACL tear requiring surgical treatment. In this study, a computational finite element model (FEM) of the knee joint was generated to investigate the effect of partial ACL tears under the Lachman test (GNRB® testing system) boundary conditions. The ACL was modeled as a hyperelastic composite structure with a refined representation of collagen bundles. Five different tear types (I-V), classified by location and size, were modeled to predict the relationship between tear size, location, and anterior tibial translation (ATT). The results demonstrated different levels of ATT that could not be manually detected. Type I tears demonstrated an almost linear increase in ATT, with the growth in tear size ranging from 3.7 mm to 4.2 mm, from 25% to 85%, respectively. Type II partial tears showed a less linear incline in ATT (3.85, 4.1, and 4.75 mm for 25%, 55%, and 85% partial tears, respectively). Types III, IV, and V maintained a nonlinear trend, with ATTs of 3.85 mm, 4.2 mm, and 4.95 mm for Type III, 3.85 mm, 4.25 mm, and 5.1 mm for Type IV, and 3.6 mm, 4.25 mm, and 5.3 mm for Type V, for 25%, 55%, and 85% partial tears, respectively. Therefore, for small tears (25%), knee stability was most affected when the tears were located around the center of the ligament. For moderate tears (55%), the effect on knee stability was the greatest for tears at the proximal half of the ACL. However, severe tears (85%) demonstrated considerable growth in knee instability from the distal to the proximal ends of the tissue, with a substantial increase in knee instability around the insertion sites. The proposed model can enhance the characterization of partial ACL tears, leading to more accurate preliminary diagnoses. It can aid in developing new techniques for repairing partially torn ACLs, potentially preventing more severe injuries.

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.

GNRB® Knee Arthrometer: Inter- and Intra-observer Reliability and Learning Curve.

Background Diagnosing anterior cruciate ligament rupture is challenging, particularly due to the subjective nature of clinical laxity assessments. Objective evaluation methods are necessary for consistency and publication in clinical research. This study aims to assess the reproducibility of the GNRB® knee arthrometer (GeNouRoB, Laval, France) across different examiners and to examine the associated learning curve for a junior examiner. Methods Anterior translation measurements were conducted on 20 healthy knees using the GNRB arthrometer. Two examiners, a senior and a junior, performed the measurements independently and were blinded to each other's results. Measurements were taken at two different push forces (134 N and 200 N). The study evaluated inter- and intra-observer reproducibility using Cohen's kappa coefficient and the intraclass correlation coefficient (ICC). The junior examiner also performed a third series of measurements to assess the learning curve. Results The senior examiner demonstrated excellent reproducibility with an ICC greater than 0.75 for all measurements. The junior examiner's reproducibility varied from fair to good, with an ICC ranging from 0.45 to 0.75. Inter-observer reproducibility between the senior and junior examiners was excellent (ICC >0.75). Notably, the junior examiner's reproducibility improved to an excellent level (ICC >0.75) during the second series of measurements. Conclusion The GNRB system provides a reproducible method for evaluating anterior knee laxity across different examiners. A learning curve of approximately 20 knees is sufficient for a junior examiner to achieve statistically excellent reproducibility.

Diagnostic accuracy of lever sign test in acute and chronic ACL injuries.

Introduction: The anterior cruciate ligament (ACL) is a commonly affected knee ligament prone to frequent injuries. Henceforth, we aimed to determine the diagnostic accuracy of lever sign test in Acute and chronic ACL injuries. Method: At the institution's initial outpatient visit, 150 consecutive patients (92 males and 58 females) were evaluated. Total 108 patients had injury in their right leg, whereas 42 had injury in their left leg. Based on time since injury, the patients were divided into Acute and chronic groups. Clinical examinations (lachman's test and lelli's test) of all patients were confirmed with arthroscopic findings and compared between the two groups. Results: In the acute ACL injury, the lever test had a kappa value 0.704. The accuracy and sensitivity of the Lachman, anterior drawer, pivot shift, and lever tests were calculated. We found that the lever test had the highest accuracy and sensitivity (85.48 %, 91.18 %) than the rest. In the chronic ACL injury, the kappa value for the results of the Lachman test evaluation was 0.723. The chronic ACL injuries accuracy and sensitivity values for the Lachman (86.36 %, 91.67 %), anterior drawer (76.14 %, 81.25 %), pivot shift (55.68 %, 58.49 %), and lever tests were determined. Conclusion: The lever sign test is more accurate and reliable in the acute ACL injuries, while the Lachman test is more accurate and reliable in the chronic ACL injuries.

Investigating the effect of autograft diameter for quadriceps and patellar tendons use in anterior cruciate ligament reconstruction: a biomechanical analysis using a simulated Lachman test.

Introduction: Current clinical practice suggests using patellar and quadriceps tendon autografts with a 10 mm diameter for ACL reconstruction. This can be problematic for patients with smaller body frames. Our study objective was to determine the minimum diameter required for these grafts. We hypothesize that given the strength and stiffness of these respective tissues, they can withstand a significant decrease in diameter before demonstrating mechanical strength unviable for recreating the knee's stability. Methods: We created a finite element model of the human knee with boundary conditions characteristic of the Lachman test, a passive accessory movement test of the knee performed to identify the integrity of the anterior cruciate ligament (ACL). The Mechanical properties of the model's grafts were directly obtained from cadaveric testing and the literature. Our model estimated the forces required to displace the tibia from the femur with varying graft diameters. Results: The 7 mm diameter patellar and quadriceps tendon grafts could withstand 55-60 N of force before induced tibial displacement. However, grafts of 5.34- and 3.76-mm diameters could only withstand upwards of 47 N and 40 N, respectively. Additionally, at a graft diameter of 3.76 mm, the patellar tendon experienced 234% greater stiffness than the quadriceps tendon, with similar excesses of stiffness demonstrated for the 5.34- and 7-mm diameter grafts. Conclusions: The patellar tendon provided a stronger graft for knee reconstruction at all diameter sizes. Additionally, it experienced higher maximum stress, meaning it dissociates force better across the graft than the quadriceps tendon. Significantly lower amounts of force were required to displace the tibia for the patellar and quadriceps tendon grafts at 3.76- and 5.34-mm graft diameters. Based on this point, we conclude that grafts below the 7 mm diameter have a higher chance of failure regardless of graft selection.

Clinical and Patient-Reported Functional Outcome of Semitendinosus Autograft Anterior Cruciate Ligament Reconstruction With FiberTape® InternalBrace™ All-Inside Technique: A Prospective Study.

AIM: The purpose of this study is to report the early one-year clinical and patient-reported functional outcomes of semitendinosus autograft anterior cruciate ligament reconstruction with the FiberTape® InternalBrace™ all-inside technique. MATERIALS AND METHODS: The patient-reported functional outcomes and clinical outcomes were analyzed prospectively following the treatment of 324 unilateral ACL rupture cases with the FiberTape® InternalBrace™ Technique. Patient-reported outcome measures (KOOS scores, WOMAC scores, VAS score, and IKDC score) and clinical examinations like pre-operative and post-operative pivot shift, Lachman test, and range of motion (ROM) were conducted. These tests and examinations were recorded for each patient before surgery and at 3, 6, and 12 months after surgery. Secondary outcomes like re-rupture, infection, synovitis, or limited range of motion were noted. The mean follow-up period was 18±4.5 months (range: 12-24 months). RESULTS: Out of a total of 324 cases, 37 cases (11.4%) could not be followed up. 158 patients (55.1%) were male and 129 were female (44.9%). Preoperative mean KOOS pain value, KOOS symptoms, KOOS ADLs, KOOS sport and recreation, and KOOS quality of life were 77.05, 78.69, 84, 21, 89.7, and 57, respectively. All KOOS subsections increased significantly at one-year to 98.37, 99.09, 98.95, 99.02, and 99.30 (p<0.0001), respectively. Mean preoperative WOMAC pain, WOMAC stiffness, and WOMAC function were 76.4, 65.2, and 74.1 and increased significantly at one-year to 94.5, 89.6, and 98.2 (p<0.0001), respectively. There was a significant decrease in VAS for pain from 2.93 before surgery to 0.12 (p<0.0001) at one year. The IKDC score significantly changed from a pre-treatment value of 50.9 to 96.2 (94.5-97.8) at a follow-up of one year. The Lysholm score at 12-months was significant at 95 (93.1-96.9), p<0.05. Post-operative Lachman test values decreased significantly, which meant decreased laxity, from 1.98 (1.89-2.07) pre-operative to 1.60 (1.57-1.62) p<0.05 at one-year post-operative. At one-year follow-up, 276 patients (96%) had fully recovered. CONCLUSION: It was concluded that the FiberTape® InternalBrace™ technique for ACL reconstruction provides orthopedic surgeons with an effective alternative technique to conventional methods of surgery and also reduces the overall time to recovery for patients, thereby allowing them to return to sports faster. LEVEL OF EVIDENCE: Level 4.

Knee positioning systems for X-ray environment: a literature review.

The knee is one of the most stressed joints of the human body, being susceptible to ligament injuries and degenerative diseases. Due to the rising incidence of knee pathologies, the number of knee X-rays acquired is also increasing. Such X-rays are obtained for the diagnosis of knee injuries, the evaluation of the knee before and after surgery, and the monitoring of the knee joint's stability. These types of diagnosis and monitoring of the knee usually involve radiography under physical stress. This widely used medical tool provides a more objective analysis of the measurement of the knee laxity than a physical examination does, involving knee stress tests, such as valgus, varus, and Lachman. Despite being an improvement to physical examination regarding the physician's bias, stress radiography is still performed manually in a lot of healthcare facilities. To avoid exposing the physician to radiation and to decrease the number of X-ray images rejected due to inadequate positioning of the patient or the presence of artefacts, positioning systems for stress radiography of the knee have been developed. This review analyses knee positioning systems for X-ray environment, concluding that they have improved the objectivity and reproducibility during stress radiographs, but have failed to either be radiolucent or versatile with a simple ergonomic set-up.

3D assessment of graft malposition after ACL reconstruction: Comparison of native and 11o'clock ligament orientations.

BACKGROUND: Femoral tunnel malposition makes up the majority of technical failures for ACL reconstructive surgery. The goal of this study was to develop adolescent knee models that accurately predict anterior tibial translation when undergoing a Lachman and pivot shift test with the ACL in the 11o'clock femoral malposition (Level of Evidence: IV). METHODS: FEBio was used to build 22 subject-specific tibiofemoral joint finite element representations. To simulate the two clinical tests, the models were subject to loading and boundary conditions established in the literature. Clinical, historical control data were used to validate the predicted anterior tibial translations. RESULTS: A 95% confidence interval showed that with the ACL in the 11o'clock malposition, the simulated Lachman and pivot shift tests produced anterior tibial translations that were not statistically different from the in vivo data. The 11o'clock finite element knee models resulted in greater anterior displacement than those with the native (approximately 10o'clock) ACL position. The difference in anterior tibial translation between the native and 11o'clock ACL orientations was statistically significant. CONCLUSION: Clinically, by understanding the impact that ACL orientation has in anterior tibial displacement biomechanics, surgical interventions can be improved to prevent technical errors from occurring. The integration of this methodology into surgical practice not only allows for anatomical visualization prior to surgery, but also creates the opportunity to optimize graft placement, thus improving post-surgical outcomes.

Lever-Test Accuracy in Detecting Anterior Cruciate Ligament (ACL) Tears: A Single Institution Experience.

Background One of the most often damaged ligaments in the knee is the anterior cruciate ligament (ACL). With the increased occurrence of ACL injuries, there is a greater need for clinical diagnostics to rule in or rule out a suspected rupture. The Lever Test, a novel clinical tool for diagnosing ACL rupture, has been presented, with preliminary trials indicating encouraging results. Methods This is a prospective, blinded, diagnostic accuracy study. The aim of this study was to evaluate the accuracy of the Lever Test and other common clinical tests (Anterior Drawer Test, Lachman Test, Pivot Shift Test) for diagnosing ACL injuries. The study enrolled 23 patients who had knee pain, instability, and locking symptoms. The clinical tests were performed on the patients in supine position before, during, and after anesthesia. The results of the clinical tests were compared with MRI findings to determine the sensitivity of each test. Results The patients consisted of 17 men and six women, with a mean age of 30.4±9.95 years. 18 patients had complete tears, four had partial tears, and one had intact ACL damage. 10 (44%) complained in the right knee, 13 (56%) in the left knee, and two (9%) had a generalized ligamentous laxity. 21 (91%) complained of giving away, 22 (96%) complained of knee pain, and 10 (43%) complained of locking of the knee. On the ipsilateral leg examination, pre-operative positivity of Lever Sign was 44%, Lachman 83%, and Anterior Drawer 67%. After being given anesthesia, test positivity rates were 44% for Lever Sign and 56% for Pivot Shift. Post-operative positivity of Lever Sign was 17%, Lachman 39%, and Anterior Drawer 35%. Mcnemar test p values were significant for the difference of positivity anterior drawer test (p=0.002) and were not significant on Lever Sign (p=0.7) and Lachman tests (p=0.13). Correlation analysis showed a weak but not statistically significant interrater reliability between MRI findings and Lever Sign (p=0.846) (Kappa= 0.2). On the contralateral leg examination, the pre-operative positivity of Lever Sign was 9%, Lachman 17%, and Anterior Drawer 22% Conclusion The study suggests that the Lever Test has lower accuracy than other clinical tests when comparing the results of tests with MRI findings. As a result, Lever Test should be used in combination with other clinical tests to accurately rule out suspected ACL injuries.

Validity of the lever sign test for the clinical diagnosis of anterior cruciate ligament tears: Assessments in ski resorts.

INTRODUCTION: The clinical diagnosis of an anterior cruciate ligament (ACL) tear is based on 3 tests: anterior drawer, pivot shift and Lachman. The latter is the most commonly used test. The "lever sign" is a new clinical test that was first described by Lelli et al. in 2014. The primary objective of this study was to determine the sensitivity of the lever sign test for the clinical diagnosis of ACL tears, in the primary care setting of patients with acute knee injuries. Primary care being the first point of contact between patients and the healthcare system (general practitioners in this study). The secondary objective was to calculate the positive predictive value (PPV) of the lever sign test, by comparing it to the PPV of the Lachman test and its sensitivity. The working hypothesis was that the sensitivity of the lever sign test was equal to or greater than 80%. METHODS: This prospective cohort study included patients with ski-related knee injuries which occurred in French ski resorts between December 1, 2019, and March 15, 2020. The Lachman test and the lever sign test were performed by 36 mountain physicians and were compared to the magnetic resonance imaging (MRI) findings. The lever sign test involved placing a closed fist under the patient's calf in the supine position and applying downward pressure over the quadriceps. Depending on whether the ACL was intact or not, the patient's heel would either rise off the examination table or remain still. This study included 258 patients: 190 women and 68 men. RESULTS: The MRIs found 219 ACL tears and 36 intact ACLs. Three MRIs were deemed uninterpretable. The sensitivity of the lever sign test was 61.2% and the PPV was 83.8%. The sensitivity of the Lachman test was 99.1% and the PPV was 86.5%. CONCLUSION: This study determined the sensitivity of the lever sign test for the clinical diagnosis of ACL tears during real-life situations encountered by mountain physicians. This sensitivity was lower than expected. The Lachman test, on the other hand, showed a very high sensitivity. It remains the test of choice for the clinical diagnosis of ACL tears in patients with knee injuries. Therefore, the lever sign test can complement the Lachman test but is not a substitute for it. LEVEL OF EVIDENCE: II.

Pivot shift and Lachman test simulation-based exploration in juvenile populations for accurately predicting anterior tibial translation.

Advancements in technology and finite element software have made it possible to develop simulation-based exploration of subject-specific tibiofemoral joint kinematics. In this study, the goal was to develop baseline knee models that accurately predict anterior tibial displacement when undergoing a Lachman and pivot shift test. A total of 22 subject-specific adolescent tibiofemoral joint finite element representations were developed using FEBio. The models were subject to loading conditions established in the literature to simulate the two clinical tests. Anterior tibial translations that were measured through clinical, historical controls were used to validate the proposed models. A 95% confidence interval showed that the simulated Lachman and pivot shift tests of the juvenile knee models were not statistically different from the historical controls and were in accordance with the anterior tibial translations that were measured experimentally. Clinically, simulations are important in advancing the field of knee finite element modeling, particularly in pediatric applications where the surgeon must balance restoring full function in a patient who is skeletally immature and where the growth plate is vulnerable. The methodologies created in developing these foundational models can be utilized to build more anatomically complex finite element representations that can both predict ligament stresses in response to dynamic activities and analyze the effects of different insertion sites.

Prospective Comparison of Functional and Radiological Outcomes of Arthroscopic Anterior Cruciate Ligament Reconstruction by Hamstring Graft Alone and Platelet-Rich Plasma Added to the Hamstring Graft.

AIMS AND OBJECTIVES: To measure the additional effect of platelet-rich plasma (PRP) on functional outcome of anterior cruciate ligament tear managed by augmenting anterior cruciate ligament (ACL) reconstruction with PRP. METHODS: The present study was conducted on patients with ACL tear admitted in the department of orthopaedics, King George's Medical University, Lucknow wherein a total of 70 subjects were assigned into two groups of 35 patients each randomly, viz Group 1 in which the patients were treated by quadruple hamstring graft alone and Group 2 in which the patients were treated with augmented hamstring graft with PRP. The standardized anterior drawer test, Lachman's test, Lysholm knee score were quantified both preoperatively and postoperatively at different follow-ups and also tibial tunnel widening was measured postoperatively at different follow-ups. RESULT: The present study had 70 patients with ACL tears. The mean age of patients in non-PRP groups was 29.71 ±2.99 years while that in the PRP group was 28.34±4.32 years. On comparing the improvement in grades at pre-op, immediate postop, 6 weeks, and 3 months follow-ups, there was no statistically significant difference between the two groups. The tibial tunnel widening also showed no significant difference between the two groups. CONCLUSION: In our study, it was found that both the groups showed improvements in grades of anterior drawer test and Lachman's test postoperatively but the difference between both the groups was not significant. Similarly, while comparing the improvements in Lysholm knee score and tibial tunnel widening among both the groups, the difference was not significant. Follow up of 3 months was a limiting factor in our study. This technique needs further clinical evaluation to assess the long-term results.

Effect of native ligament versus graft reconstruction on sensitivity of clinical tests used to diagnose anterior cruciate ligament tears.

PURPOSE: Although there have been multiple clinical studies evaluating the accuracy of physical examination tests used to diagnose anterior cruciate ligament (ACL) injury, there are no data to date evaluating the accuracy of these tests in diagnosing re-injury after prior ACL reconstruction. We compared the sensitivity of three clinical tests - Lachman, anterior drawer, and pivot shift - in diagnosing initial ACL tears versus graft re-tears following a prior ACL reconstruction. METHODS: Twenty consecutive adult patients who had undergone primary ACL reconstruction and 20 consecutive adult patients who had undergone revision ACL reconstruction by a single surgeon at a tertiary care center from November 2011 to December 2017 were included in this study. RESULTS: The sensitivity of the Lachman test was 95.0% in diagnosing ACL tears in patients with native ACL versus 85.0% in patients with prior ACL reconstruction with allograft or autograft. The sensitivity of the anterior drawer test was 80.0% in patients with native ACL compared to 77.8% in patients with prior ACL reconstructions. The sensitivity of the pivot shift test could not be accurately assessed because pain and swelling prevented the physician from performing this test in most patients on their initial presentation to the clinic. CONCLUSIONS: This study suggests that a clinician may need to have a lower threshold to perform advanced imaging or diagnostic arthroscopic evaluation in a patient with prior ACL reconstruction with a suspected re-injury even if the physical examination tests are not immediately positive.

Developing a Technique for the Imaging-Based Measurement of ACL Elongation: A Proof of Principle.

Towards the goal of obtaining non-invasive biomarkers reflecting the anterior cruciate ligament's (ACL) loading capacity, this project aimed to develop a magnetic resonance imaging (MRI)-based method facilitating the measurement of ACL elongations during the execution of knee stress tests. An MRI-compatible, computer-controlled, and pneumatically driven knee loading device was designed to perform Lachman-like tests and induce ACL strain. A human cadaveric leg was used for test purposes. During the execution of the stress tests, a triggered real-time cine MRI sequence with a temporal resolution of 10 Hz was acquired in a parasagittal plane to capture the resultant ACL elongations. To test the accuracy of these measurements, the results were compared to in situ data of ACL elongation that were acquired by measuring the length changes of a surgical wire directly sutured to the ACL's anteromedial bundle. The MRI-based ACL elongations ranged between 0.7 and 1.7 mm and agreed very well with in situ data (root mean square errors, RMSEs ≤ 0.25 mm), although peak elongation rates were underestimated by the MRI (RMSEs 0.19-0.36 mm/s). The high accuracy of elongation measurements underlines the potential of the technique to yield an imaging-based biomarker of the ACL's loading capacity.

A modified anterior drawer test for anterior cruciate ligament ruptures.

OBJECTIVE: This study was aimed to utilize a modified anterior drawer test (MADT) to detect the anterior cruciate ligament (ACL) ruptures and investigate its accuracy compares with three traditional tests. METHODS: Four hundred patients were prospectively enrolled between January 2015 and September 2017 preoperatively to undergo knee arthroscopic surgeries. The MADT, anterior drawer test, Lachman test, and pivot shift test were used in the outpatient clinical setting and were compared statistically for their accuracy in terms of ACL ruptures, with arthroscopic findings as the gold standard. RESULTS: The prevalence of ACL ruptures in this study was 37.0%. The MADT demonstrated the highest sensitivity (0.89) and accuracy (0.92) among the four tests and had comparable specificity (0.94) and a positive predictive value (0.90) compared with the anterior drawer test, Lachman test, and pivot shift test. The diagnostic odds ratio (DOR) of MADT was 122.92, with other test values of no more than 55.45. The area under the receiver operating characteristic curve (AUC) for the MADT was 0.92 ± 0.01, with a significant difference compared with that for the anterior drawer test (z = 17.00, p < 0.001), Lachman test (z = 9.66, p = 0.002), and pivot shift test (z = 16.39, p < 0.001). The interobserver reproducibility of the MADT was good, with a kappa coefficient of 0.86. When diagnosing partial tears of ACL, the MADT was significantly more sensitive than the anterior drawer test (p < 0.001), Lachman test (p = 0.026), and pivot shift test (p = 0.013). The MADT showed similar sensitivity in detecting anteromedial and posterolateral bundle tears (p = 0.113) and no difference in diagnosing acute and chronic ACL ruptures (χ2 = 1.682, p = 0.195). CONCLUSIONS: The MADT is also an alternative diagnostic test to detect ACL tear, which is equally superior to the anterior drawer test, Lachman test, and pivot shifting test. It could improve the diagnosis of ACL ruptures combined with other clinical information including injury history, clinical examination, and radiological findings. LEVELS OF EVIDENCE: Level II/observational diagnostic studies TRIAL REGISTRATION: Chinese Clinical Trial Registry. ChiCTR1900022945 /retrospectively registered.

Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: A meta-analysis.

PURPOSE: To systematically analyze the effectiveness between combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) and isolated anterior cruciate ligament reconstruction (ACLR) for treatment of patients with injured ACL. METHODS: We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wanfang Data for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. RESULTS: A total of six articles with 460 study subjects were included, with 193 patients in ACL+ALL reconstruction group and 267 patients in ACL reconstruction group. The results of the meta-analysis showed that the ACL+ALL reconstruction group had significantly lower KT measured value (P < 0.00001), Lachman test positive-rate (P = 0.02), Pivot-shift test positive-rate (P < 0.00001) and graft rupture rate (P = 0.02) compared with the ACL reconstruction group. Higher IKDC score (P < 0.00001) and Lysholm score (P < 0.00001) were measured in ACL+ALL reconstruction group, while infection rate (P = 0.86) and other complications rate (P = 0.29) showed no significant differences between the two groups. CONCLUSIONS: Anatomic reconstruction of the ACL of the knee with reconstruction of the ALL indicates better postoperative knee function and clinical outcomes compared with isolated ACL reconstruction. The infection rate and other complications rate showed no significant difference between two groups.