Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 - March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using Chi-squared or Student's T-test was performed to identify associations between preoperative variables and two postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (P = 0.009, 0.005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (P = 0.021, 0.005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Cell internalization kinetics and surface charge accessibility of surface-modified PAMAM dendrimers.

Surface-modified PAMAM dendrimers have important applications in drug delivery, yet a gap remains about the role that surface functionalization plays on their cell internalization capacity. We examined the cell internalization kinetics of PAMAM dendrimers that were surface-modified with acetyl, folate and poly(ethylene glycol), as model functional groups differing in size, charge, and chemical functionality. Dendrimers with 25% functionalization were internalized by HEK cells, but with slower rates and lower maximum uptakes than the native dendrimer between 1-6 h of incubation. Dendrimers with 50% functionalization exhibited negligible internalization capacities at all incubation times. Molecular dynamics simulations revealed that the solvent accessibility of the cationic surface charges is a key factor affecting cell internalization, unlike the total charge, functionality or size of surface-modified PAMAM dendrimers. These findings provide valuable insights to assist the design of PAMAM-based systems for drug delivery applications.

Rational Discovery of Microtubule-Stabilizing Peptides.

Microtubule (MT) stabilization is an attractive pharmacological strategy to hamper the progress of neurodegenerative diseases. In this regard, seeking peptides with MT-stabilizing properties has awoken great interest. This work reports the rational discovery of two structurally related MT-stabilizing octapeptides using a combination of protein-peptide docking, conventional molecular dynamics, Gaussian accelerated molecular dynamics (GaMD), and tubulin polymerization assays. FASTA sequences for ∼1000 peptides were crafted from single and double mutants of davunetide (NAP) and docked against the Taxol (TX) site on an octameric MT model representing a portion of the MT wall. Docked peptides were rescored after MM minimization and binding free energy refinement through single-point MM/GBSA calculations. The 60 best-ranked peptides were subjected to 50 ns MD simulations on peptide-MT complexes at the terminal TX site in the octameric Tau-MT model resulting in 11 complexes with occupancies greater than 99% and peptide-protein binding free energies less than -40 kcal/mol. Selected peptides were then examined through 300 ns GaMD simulations in complexes containing two identical ligands at the terminal and intermediate TX sites in the Tau-MT model to account for the differential association of MT-binding peptides to different regions of the MT structure. Six candidates showed a favorable MT-binding potential based on the analysis of interaction frequencies and relative mobilities of the complex components, suggesting a pivotal role of Arg278, Gln281, and Arg369 residues for peptides recognition. Four candidates were predicted to preserve an adequate balance of longitudinal and lateral interactions between tubulin dimers in peptide-MT complexes such that MT-stabilizing effects could be expected. MT polymerization experiments confirmed that four peptides (HAPVSIHQ, NYPVSIHQ, NWPVSIWQ, HAPVSIIQ) exhibit MT-stabilizing activity in vitro with NWPVSIWQ (P43) and HAPVSIIQ (P52) being the most active. Tryptophan quenching assays verified that P43 and P52 bind to nonpolymeric tubulin, whereas viability experiments on HEK cells confirmed their safety to pursue future pharmacological studies. The results herein presented are valuable to making progress in the rational design of MT-stabilizing peptides.

Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee.

PURPOSE: Medial collateral ligament (MCL) injury is very common and surgical repair is sometimes necessary. Especially in the setting of simultaneous anterior cruciate ligament reconstruction (ACLR) as the ACL is the secondary restraint against valgus stress. The goal of this study was to evaluate knee biomechanics after suture repair of the MCL augmented with suture tape, as compared to MCL repair alone, in the setting of concomitant ACL reconstruction (ACLR). METHODS: Fifteen fresh-frozen human cadaveric knees were tested using a six-degrees-of-freedom robotic system under four loadings: (a) an 89.0 N anterior tibial load, (b) a 5.0 Nm internal and external rotation torque, (c) a 10.0 Nm valgus load, (d) a 7.0 Nm valgus load combined with 5.0 Nm internal rotation torque as a static simulated pivot-shift. The tested conditions were ACLR with the following states: (1) MCL intact, (2) MCL deficient, (3) MCL Repair, and (4) MCL repair augmented with suture tape (MCL Repair + ST). Under the different knee loadings, the tibial displacement, and the force in either the intact MCL, suture repaired MCL or repaired MCL-suture tape complex was measured. RESULTS: While neither the MCL Repair nor the MCL Repair + ST restored valgus rotation to the MCL intact state, displacement was significantly smaller after MCL Repair + ST (p < 0.05). The knee rotation under external rotation torque in MCL Repair + ST did not differ MCL intact (n.s.), while with MCL Repair the rotation was significantly greater (p < 0.05). MCL Repair + ST did not cause an over-constraint of the knee in any of the tested loading conditions. CONCLUSION: In a combined ACL-reconstruction-MCL-repair model, MCL Repair augmented with suture tape improved valgus and external rotation laxity when compared to MCL suture repair alone. Suture tape augmentation may provide this additional means of stabilization and can be added at the time of surgical repair of the MCL. Clinically this may result in lower failure rates and less residual laxity after MCL repair, as well as shorter immobilization times and faster return to play.

Notchplasty alters knee biomechanics after anatomic ACL reconstruction.

PURPOSE: The aims of this study were (1) to study the biomechanics of single-bundle anatomic ACL reconstructed knees with and without notchplasty using a robotic testing system and (2) to determine if there would be a difference between performing a small or large notchplasty. METHODS: Fifteen fresh-frozen specimens were used in this study. The ACL reconstruction (ACL-R) was performed using an anatomic single-bundle technique with the 8 mm soft tissue graft fixed at 30° with suspensory fixation on the femoral side and a screw and washer on the tibial side. The notchplasty was then created with a burr. The following knee states were compared: (1) ACL-R, (2) ACL-R with a small (3 mm) notchplasty, and (3) ACL-R with a large (6 mm) notchplasty. Four loading conditions were applied: (1) an anterior drawer with an 89 N anterior tibial load, (2) simulated pivot-shift loading, (3) a 5 Nm internal rotational moment, and (4) a 5 Nm external rotational moment. RESULTS: Under anterior tibial loading, anterior tibial translation increased, and graft force decreased significantly after ACL-R + 3 mm notchplasty and ACLR + 6 mm notchplasty compared to ACL-R alone at FE, 15° and 30° of knee flexion. There were no changes in either anterior tibial translation or graft force under simulated pivot-shift loading, internal rotational moment, or external rotational moment. CONCLUSION: When added to anatomic ACL reconstruction, notchplasty increased anterior tibial translation and decreased graft forces during low knee flexion angles. There was no difference between a small and large notchplasty. The findings of this study are clinically relevant as the purpose of anatomic ACL reconstruction is to restore normal knee laxity, and while notchplasty may be helpful in avoiding graft impingement and improving visualization, removing even 3 mm of bone leads to biomechanical changes.

Bioelectric Silver-Zinc Dressing Equally Effective to Chlorhexidine in Reducing Skin Bacterial Load in Healthy Volunteers.

PURPOSE: The aim of the present study was to evaluate and compare the effectiveness of the silver-zinc bioelectric dressing as compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in reducing the bacterial count on the knee. METHODS: Three groups consisting of 48 healthy volunteers were included. Age range was 23 to 54 years old and 60% of participants were male. Each subject had 1 knee serve as the test and the contralateral as the control. The test site was prepared with either 2% chlorhexidine, 4% chlorhexidine, or a silver-zinc bioelectric dressing and after 24 hours skin cultures were taken and examined for bacterial growth. RESULTS: In the 2% chlorhexidine group 23 of 48 unprepped knees had positive cultures, compared with 9 of 48 prepped knees (P = .003; risk reduction, 4.0 times). In the 4% chlorhexidine group 25 of 48 unprepped knees had positive cultures, compared with 14 of 48 prepped knees (P = .027; risk reduction, 2.6 times). In the silver-zinc bioelectric dressing group 29 of 48 unprepped knees had positive cultures, compared with 7 of 48 prepped knees (P < .001; risk reduction, 8.9 times). There was no difference in the positive skin culture rate between the 3 methods. CONCLUSIONS: Application of the silver-zinc bioelectric dressing was equally effective at reducing skin bacterial load when compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in healthy volunteers. LEVEL OF EVIDENCE: Basic Science - Microbiology. CLINICAL RELEVANCE: The findings of this study indicate that the use of a bioelectric dressing after knee surgery can match the standard of care of preparing the skin with an antiseptic before surgery.

Lack of level I evidence on how to prevent infection after elective shoulder surgery.

PURPOSE: Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery. METHODS: An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery. RESULTS: Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis. CONCLUSION: There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society. LEVEL OF EVIDENCE: IV systematic review of literature.

Suture Tape Augmentation of the Thumb Ulnar Collateral Ligament Repair: A Biomechanical Study.

PURPOSE: This study aimed to evaluate and compare the biomechanical strength of repair of the thumb ulnar collateral ligament (UCL) alone and repair augmented with suture tape. METHODS: Twelve fresh-frozen cadaveric specimens (6 matched pairs) had the UCL divided at its attachment on the base of the proximal phalanx and repaired with or without suture tape augmentation. A material testing machine was used to provide valgus stress at a rate of 0.1 mm/s until failure. The maximum load, load at clinical failure, and mode of failure were recorded. RESULTS: In the specimens with UCL repair augmented with suture tape, the maximum load (46.6 N [SD, 25.6 N]) and load at clinical failure (25.3 N [SD, 18.3 N]) were significantly higher than in the repair-only group (8.02 N [SD, 2.24 N]) and (6.00 N [SD, 2.39 N], respectively). CONCLUSIONS: In this model, thumb UCL repair with suture tape augmentation demonstrated greater maximum and clinical failure loads compared with nonaugmented repair at time 0, that is, without any biological healing. CLINICAL RELEVANCE: Suture tape augmentation of UCL repair may be valuable in the setting of acute tears by decreasing the time of postoperative cast immobilization and, therefore, allowing for earlier thumb metacarpophalangeal joint motion and overall faster clinical recovery.

Clinical outcomes of a single-tunnel technique for coracoclavicular and acromioclavicular ligament reconstruction.

BACKGROUND: A large number of surgical techniques have been described to treat acromioclavicular (AC) joint separations. Despite the high success rates with double-tunnel reconstruction, this method has been associated with the risk of coracoid and clavicle fractures. This study aimed to evaluate the outcomes of the first cohort of patients who underwent single-tunnel AC and coracoclavicular (CC) ligament reconstruction. It was hypothesized that this technique would result in maintenance of reduction and a minimal risk of fracture of the coracoid and clavicle. METHODS: All patients who underwent single-tunnel AC joint reconstruction between 2012 and 2015 via the technique with 2-year follow-up were included. Objective outcomes recorded were maintenance of reduction as measured by the CC distance on radiographs, shoulder range of motion, strength, return to sports, and complications. Subjective outcomes included maintenance of reduction on visual inspection and various patient-reported outcomes. RESULTS: Seventeen patients were included with a mean age of 41 ± 12 years. Separation types included types III, IV, and V. The mean follow-up period was 29 ± 9 months (range, 16-45 months). The CC distance improved from 37.4 to 30.0 mm on plain radiographs (P = .006), the American Shoulder and Elbow Surgeons score improved from 67.0 to 90.1 (P = .094), and the Single Assessment Numeric Evaluation score improved from 30.5 to 91.1 (P = .025). Reduction on visual inspection was maintained in 16 patients (94.1%). Regarding sports participation, 14 patients (82.4%) returned to their preinjury level. The most common complication was a prominent suture knot stack, occurring in 3 patients (17.6%), which was removed in all 3 in a second procedure. There were no clavicle or coracoid fractures. CONCLUSION: The described technique results in satisfactory objective and patient-reported outcomes and return to sports while avoiding coracoid and clavicle fractures.

Clinical outcomes of anconeus interposition arthroplasty after radial head resection in native and prosthetic radial heads.

BACKGROUND: Radiocapitellar pathology after traumatic injury to the elbow can be challenging to treat. The anconeus interposition arthroplasty has been proposed to treat radiocapitellar or proximal radioulnar joint dysfunction and pain, or both. This study evaluated whether radial head excision (native or prosthetic), followed by an anconeus interposition arthroplasty, relieves pain and improves subjective and objective elbow function in patients with post-traumatic radiocapitellar pathology. METHODS: A retrospective comparative case series was performed of 50 consecutive patients who underwent a native radial head excision or radial head implant excision, followed by an anconeus interposition arthroplasty. Clinical outcome scores, range of motion, and proximal radius migration were evaluated in patients with at least 2 years of follow-up. RESULTS: Included were 23 patients (11 native and 12 prosthetic radial heads) with a mean age of 41 years. Average follow-up was 38 months. Overall, significant improvement was obtained in the Disabilities of the Arm, Shoulder and Hand and visual analog scale scores. Range of motion significantly improved from preoperatively to postoperatively. Patients with a native radial head excision scored better on the Single Assessment Numeric Evaluation (76.8 vs. 56.3, P = .037) and obtained significantly more flexion postoperatively (141° vs. 123°, P = .016). Mild wrist pain developed in 3 patients, but no further intervention was required. The overall complication rate was 13%, and 5 patients required reoperation. CONCLUSIONS: Anconeus interposition arthroplasty performed after radial head resection in native and prosthetic groups is a viable adjunct in the operative treatment of patients with post-traumatic radiocapitellar pathology. However, whether anconeus interposition arthroplasty alone produced the favorable clinical results of this study was difficult to determine.

A novel MRI classification system for congenital functional lumbar spinal stenosis predicts the risk for tandem cervical spinal stenosis.

PURPOSE: The purpose of this study was to develop a simple and clinically useful morphological classification system for congenital lumbar spinal stenosis using sagittal MRI, allowing clinicians to recognize patterns of lumbar congenital stenosis quickly and be able to screen these patients for tandem cervical stenosis. METHODS: Forty-four subjects with an MRI of both the cervical and lumbar spine were included. On the lumbar spine MRI, the sagittal canal morphology was classified as one of three types: Type I normal, Type II partially narrow, Type III globally narrow. For the cervical spine, the Torg-Pavlov ratio on X-ray and the cervical spinal canal width on MRI were measured. Kruskal-Wallis analysis was done to determine if there was a relationship between the sagittal morphology of the lumbar spinal canal and the presence of cervical spinal stenosis. RESULTS: Subjects with a type III globally narrow lumbar spinal canal had a significantly lower cervical Torg-Pavlov ratio and smaller cervical spinal canal width than those with a type I normal lumbar spinal canal. CONCLUSION: A type III lumbar spinal canal is a globally narrow canal characterized by a lack of spinal fluid around the conus. This was defined as "functional lumbar spinal stenosis" and is associated with an increased incidence of tandem cervical spinal stenosis.

Can we predict the size of frequently used autografts in ACL reconstruction?

PURPOSE: This study presents a method to measure the size of quadriceps, patellar tendon and hamstring autografts using preoperative magnetic resonance imaging (MRI). METHODS: Sixty-two subjects with a mean age of 25 ± 10 years who underwent ACL surgery between 2011 and 2014 were included. Patient anthropometric data were recorded for all subjects. During surgery, the respective autograft was harvested and measured using commercially available graft sizers. MRI measurements were performed by two raters, who were blinded to the intra-operative measurements. RESULTS: The inter- and intra-rater reliability was ≥0.8 for all MRI measurements. The intra-class correlation coefficient between the MRI measurement of the graft and the actual size of the harvested graft was 0.639. There were significant correlations between quadriceps tendon thickness and height (r = 0.3, p < 0.03), weight (r = 0.3, p < 0.01), BMI (r = 0.3, p < 0.04) and gender (r = -0.4, p < 0.002) and patellar tendon thickness and height (r = 0.4, p < 0.01), weight (r = 0.3, p < 0.01) and gender (r = -0.4, p < 0.012). CONCLUSION: Preoperative MRI measurements of quadriceps, patellar tendon and hamstring graft size are highly reliable with moderate-to-good accuracy. Significant correlations between patient anthropometric data and the thicknesses of the quadriceps and patellar tendons were observed. Obtaining this information can be useful for preoperative planning and to help counsel patients on appropriate graft choices prior to surgery. LEVEL OF EVIDENCE: III.

Fibrin clot prevents bone tunnel enlargement after ACL reconstruction with allograft.

PURPOSE: Bone tunnel enlargement is a feared complication after ACL reconstruction. The aim of this study was to evaluate whether adding a fibrin clot to the allograft for anatomic single-bundle ACL reconstruction would reduce tunnel widening. METHODS: Fifty patients who underwent anatomic single-bundle ACL reconstruction were included. Twenty-five patients received an allograft alone, and 25 patients received an allograft with fibrin clot. All patients underwent standard plain anteroposterior and lateral radiographs of the operated knee immediately after surgery and at 1-year follow-up. The size of the tunnels was measured at both time points to calculate tunnel widening. Tunnel widening at 1 year was compared between the allograft and the allograft + fibrin clot group. RESULTS: There was significantly less tunnel widening in the allograft + fibrin clot group for the femoral tunnel width in the middle and distal portion of the tunnel and for the tibial tunnel width in the proximal and distal portions, as compared to the allograft only group. CONCLUSION: Adding a fibrin clot to the allograft in anatomic single-bundle ACL reconstruction reduces the amount of tunnel widening at 1-year follow-up. Reducing tunnel widening may positively affect outcomes after ACL surgery and may prevent inadequate bone stock during ACL revision procedures. LEVEL OF EVIDENCE: Case-control study, Level III.

A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist.

PURPOSE: The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic. METHODS: A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study. RESULTS: Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction. CONCLUSIONS: There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.

Surgical interventions for meniscal tears: a closer look at the evidence.

INTRODUCTION: The aim of the present study was to compare the outcomes of various surgical treatments for meniscal injuries including (1) total and partial meniscectomy; (2) meniscectomy and meniscal repair; (3) meniscectomy and meniscal transplantation; (4) open and arthroscopic meniscectomy and (5) various different repair techniques. MATERIALS AND METHODS: The Bone, Joint and Muscle Trauma Group Register, Cochrane Database, MEDLINE, EMBASE and CINAHL were searched for all (quasi) randomized controlled clinical trials comparing various surgical techniques for meniscal injuries. Primary outcomes of interest included patient-reported outcomes scores, return to pre-injury activity level, level of sports participation and persistence of pain using the visual analogue score. Where possible, data were pooled and a meta-analysis was performed. RESULTS: A total of nine studies were included, involving a combined 904 subjects, 330 patients underwent a meniscal repair, 402 meniscectomy and 160 a collagen meniscal implant. The only surgical treatments that were compared in homogeneous fashion across more than one study were the arrow and inside-out technique, which showed no difference for re-tear or complication rate. Strong evidence-based recommendations regarding the other surgical treatments that were compared could not be made. CONCLUSIONS: This meta-analysis illustrates the lack of level I evidence to guide the surgical management of meniscal tears. LEVEL OF EVIDENCE: Level I meta-analysis.

Anatomic anterior cruciate ligament reconstruction: a changing paradigm.

Injury to the anterior cruciate ligament (ACL) of the knee is potentially devastating for the patient and can result in both acute and long-term clinical problems. Consequently, the ACL has always been and continues to be of great interest to orthopaedic scientists and clinicians worldwide. Major advancements in ACL surgery have been made in the past few years. ACL reconstruction has shifted from an open to arthroscopic procedure, in which a two- and later one-incision technique was applied. Studies have found that traditional, transtibial arthroscopic single-bundle reconstruction does not fully restore rotational stability of the knee joint, and as such, a more anatomic approach to ACL reconstruction has emerged. The goal of anatomic ACL reconstruction is to replicate the knee's normal anatomy and restore its normal kinematics, all while protecting long-term knee health. This manuscript describes the research that has changed the paradigm of ACL reconstruction from traditional techniques to present day anatomic and individualized concepts.

Intercondylar notch dimensions and graft failure after single- and double-bundle anterior cruciate ligament reconstruction.

PURPOSE: The objective of this study was to evaluate the dimensions of the femoral intercondylar notch intraoperatively and to determine whether a small intercondylar notch increases the risk of graft failure after individualized anatomic single- or double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A retrospective review of prospectively collected data was performed. One hundred and thirty-seven primary single- or double-bundle ACL reconstructions with at least 2-year follow-up were included in this study. Of these, 116 subjects had intraoperative notch measurements recorded. All operations were performed anatomically using a three-portal technique by the senior author. Intraoperative notch measurements (width at the base, middle, and top and height) were taken using a standard, commercially available arthroscopic ruler. Graft failure was defined as patient report of instability, pathologic laxity on clinical exam, or an MRI or arthroscopic diagnosis of rupture or absence of the ACL graft. RESULTS: Graft failure at 2-year follow-up in the overall population was 13.9 % (19/137). Graft failure was reported to occur from contact or non-contact trauma, failure of the graft to incorporate, or hardware failure. The dimensions of the intercondylar notch and the graft type used did not influence the risk of graft failure. CONCLUSIONS: Smaller intercondylar notch dimensions do not appear to be a risk factor for higher rates of graft failure after anatomic and individualized ACL reconstruction. Based on these data, the use of notchplasty is not supported in conjunction with individualized anatomic single- or double-bundle ACL reconstruction.

Relationship between bone bruise volume and the presence of meniscal tears in acute anterior cruciate ligament rupture.

PURPOSE: To determine whether there is a relationship between the size of the bone bruise volume after an acute anterior cruciate ligament (ACL) rupture and the presence of meniscal tears in the medial and lateral compartment. METHODS: Following Institutional Review Board approval, 50 patients with an acute ACL rupture and MRI imaging within 30 days of injury were identified. Two musculoskeletal radiologists evaluated the lateral and medial menisci and graded them as one of the following: no meniscal tear, tear of one meniscus (medial or lateral) or tear of both menisci (medial and lateral). Sagittal T2 fat-suppressed images were used to calculate bone bruise volume. The relationship between bone bruise volume and the presence of a meniscus tear was calculated. RESULTS: Forty-three (86%) patients had a bone bruise, 16 (32%) patients had no tear, 7 (14%) patients had lateral meniscus tear, 13 (26%) patients had medial tear and 14 (28%) patients had medial and lateral tears. There was a statistically significant difference in femoral bone bruise volume when comparing no meniscal tear to medial and lateral tears as well as when comparing medial or lateral tears to medial and lateral tears. CONCLUSION: There is a statistically significant relationship between femoral bone bruise volume and the presence of meniscal tears in ACL injury, especially in the setting of medial and lateral pathology. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Graft size after anterior cruciate ligament reconstruction.

PURPOSE: The native anterior cruciate ligament (ACL) is composed of two distinct bundles, the anteromedial (AM) and posterolateral (PL), and both have been shown to be reliably measured on magnetic resonance imaging (MRI). The purpose of this study was to measure the size of the AM and PL bundles after ACL double-bundle reconstructions on MRI and compare this to the relative graft size at the time of surgery. METHODS: Between January 2007 and April 2010, 85 knees were identified after allograft double-bundle ACL reconstruction with post-operative MRI (1.5 T) and met inclusion criteria. On standard sagittal, coronal and oblique coronal MRIs, the AM and PL bundles were delineated and the midsubstance width of the ACL graft was measured. The images were independently measured in a blinded fashion by two observers. Linear and curvilinear regression analysis was used to analyse the relationship between graft size and time after reconstruction. RESULTS: The mean age of the patients was 24.6 years (SD 10.4). Mean time from surgery to post-operative MRI was 271.5 days (SD 183.4). The mean percentage of the original size of the AM bundle was 86.9% (SD 9.9) and of the PL bundle was 88.6% (SD 9.9). There was no correlation between the relative size of the AM graft and the time from surgery (r = 0.3, n.s.) and no significant relationship for the PL graft (r = 0.1, n.s). CONCLUSION: On average, there was no graft enlargement of the AM and PL grafts 275.1 days after allograft ACL double-bundle reconstruction, as the mean relative graft size was less than 100 % on MRI. This study suggests that surgeons, who use allografts, should measure the ACL and replace it with a similar size, as there is a low risk of hypertrophy of the graft within one year post-operative. LEVEL OF EVIDENCE: IV.

Knee morphology and risk factors for developing an anterior cruciate ligament rupture: an MRI comparison between ACL-ruptured and non-injured knees.

PURPOSE: The objective of this study was to evaluate multiple morphological features on MR images in patients with and without ACL rupture to evaluate whether there are certain variables that confer a higher risk for an ACL rupture. METHODS: MRI measurements were taken from 45 subjects with ACL injury and 43 subjects without ACL injury, by two independent observers. The morphometrics were compared between ACL-injured and non-injured subjects, between men and women and for male and female subjects separately. A factor analysis was performed to determine whether any variables were related in the injured, non-injured, male or female groups. RESULTS: There were no significant differences in the overall population between the ACL-injured and non-injured group. Significant differences were found in bicondylar (P ≤ 0.001), medial condyle (P ≤ 0.001) and lateral condyle widths (P = 0.001) between men and women. In the male group, there were no significant differences between ACL-injured and non-injured subjects. In the female group, there was a significant difference in bicondylar (P = 0.002) and lateral condyle width (P = 0.002) between ACL-injured and non-injured subjects. CONCLUSIONS: There were gender-related differences in bony morphology between ACL-injured and non-injured subjects. The morphological features that were different between ACL-injured and non-injured subjects varied between male and female subjects. LEVEL OF EVIDENCE: Case-Control study, Level III.