Novel Insights into Anterior Cruciate Ligament Injury

Anterior cruciate ligament (ACL) injury is one of the most common sports injuries of the knee. ACL reconstruction has become, standard orthopaedic practice worldwide with an estimated 175,000 reconstructions per year in the United States.6 The ACL remains the most frequently studied ligament in orthopaedic research. Hundreds of papers are published each year related to the ACL. However, the treatment options and techniques are still developing and increasing, indicating the difficulties in the treatment of this central knee ligament

Knee arthrodesis for a congenital luxation with Larsen syndrome

A 31-year-old woman with known Larsen syndrome presented with congenital chronic luxation of her right knee with increasing instability symptoms, which limited her daily activities. We refrained from a constrained knee arthroplasty due to her relatively young age and decided to perform a knee arthrodesis. Knee arthrodesis is a viable lifelong-lasting operative treatment alternative for specific instability-related knee disease. The knee arthrodesis was performed by double plating with an additional fixation of the patella. At 1-yearfollow-up, she was able to walk without

Failure load of patellar tendon grafts at the femoral side: 10- versus 20-mm-bone blocks

The aim of the study was to investigate whether use of short bone blocks is safe in anterior cruciate ligament (ACL) reconstruction. Our hypothesis was that the smaller 10-mm-length bone blocks will fail at lower loads than 20-mm-bone blocks. Ten paired human cadaver knees were randomly assigned to the 10- or 20-mm group (group 1 and 2) and underwent bone-patellar tendon-bone femoral fixation with interference screw. Tensile tests were performed using a tensile testing machine (Instron). Stiffness, failure load and failure mode were recorded. Median stiffness was 72 N/mm (16-103) for 10-mm-bone blocks and 91 N/mm (40-130) for 20-mm-bone blocks. Median failure loads were 402 N (87-546) for 10-mm-long bone block and 456 N (163-636) for 20-mm-bone blocks. There was no statistically significant difference between groups (P = 0.35). All bone-patellar tendon-bone grafts were pulled out of the femoral tunnel with interference screw, due to slippage. We concluded that a 10-mm-long bone block was not significantly weaker than a 20-mm-long bone block. Failure loads of a 10-mm-bone block exceeded loading values at passive and active extension of the knee under normal conditions. Ten millimetre bone blocks offered sufficient fixation strength in ACL reconstruction

Extracorporeal Shock Wave Treatment for Delayed Union and Nonunion Fractures: A Systematic Review

Objectives: Nonunions after bone fractures are usually treated surgically with risk of infections and failure of osteosynthesis. A noninvasive alternative is extracorporeal shock wave treatment (ESWT), which potentially stimulates bone regeneration. Therefore this review investigates whether ESWT is an effective and safe treatment for delayed unions and nonunions. Data Sources: Embase.com, MEDLINE ovid, Cochrane, Web of Science, PubMed publisher, and Google Scholar were systematically searched. Study Selection: Inclusion criteria included studies with patients with delayed union or nonunion treated with ESWT; inclusion of $10 patients; and follow-up period$6 weeks. Data Extraction: Assessment for risk of bias was conducted by 2 authors using the Cochrane tool. Union rates and adverse events were extracted from the studies. Data Synthesis: Two RCTs and 28 nonrandomized studies were included. One RCT was assessed at medium risk of bias and reported similar union rates between ESWT-treated patients (71%) and surgery-treated patients (74%). The remaining 29 studies were at high risk of bias due to poor description of randomization (n = 1), nonrandomized allocation to control groups (n = 2), or absence of control groups (n = 26). The average union rate after ESWT in delayed unions was 86%, in nonunions 73%, and in nonunions after surgery 81%. Only minor adverse events were reported after ESWT. Conclusions: ESWT seems to be effective for the treatment of delayed unions and nonunions. However, the quality of most studies is poor. Therefore, we strongly encourage conducting well-designed RCTs to prove the effectiveness of ESWT and potentially improve the treatment of nonunions because ESWT might be as effective as surgery but safer. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidenc

Is Training Load Associated with Symptoms of Overuse Injury in Dancers? A Prospective Observational Study

Overuse injuries in dance are extremely common and often difficult to treat. High training load and dancing with pain are frequently regarded as risk factors for musculoskeletal injuries in professional dancers. The aims of this study were to assess for: 1. any association between training load (TL) and symptoms of overuse injury in professional dancers, and 2. any difference between the number of "time-loss" injuries and injuries causing significant symptoms not leading to decreased performance time. Twenty-one dancers from a professional contemporary dance company were followed for 7 weeks. They completed the dance-specific Self-Estimated Functional Inability because of Pain (SEFIP) questionnaire on a weekly basis to quantify musculoskeletal pain. Their TL was calculated by multiplying the Ratings of Perceived Exertion scale (RPE Borg CR10) by the daily training time. Associations between TL and SEFIP scores, recorded on a weekly basis, were evaluated using a mixed linear model with repeated measurements. No significant association was found between TL and severity of musculoskeletal pain. However, the TL of the dancers with no symptoms of overuse-injury, SEFIP = 0, was significantly lower compared to the dancers with symptoms, SEFIP > 0; p = 0.02. No time loss because of injury was reported during the study period. There were 251 symptoms of overuse injury reported, and 67% of the recorded time was danced with pain. It is concluded that dancers without musculoskeletal pain had lower TLs. While no time-loss injuries were found, two-third of the participants danced with pain during this 7-week period

Genetic Variants and Anterior Cruciate Ligament Rupture: A Systematic Review

_Background:_ Studies have shown a familial predisposition for anterior cruciate ligament (ACL) rupture and have been followed by genetic-association studies on polymorphisms in candidate genes in recent years. To date, no systematic review with a best-evidence synthesis has evaluated the influence of genetics on this devastating knee injury. _Objective:_ Our objective was to evaluate the association between genetic variants and ACL rupture. _Methods:_ We performed an extensive search in Embase, MEDLINE, Web of Science, Scopus, PubMed Publisher, Cochrane Register of Clinical Trials, and Google scholar up to 24 August 2015. Studies were eligible if they met the following inclusion criteria: (1) design was a case–control study, retrospective or prospective follow-up study, or a randomized controlled trial (RCT); (2) the study examined the association between a genetic variant and ACL rupture in both an ACL and a control group. We determined the risk of bias for all included studies. _Results:_ We included a total of 16 studies (eight at high risk of bias and eight with an unclear risk) that examined 33 different DNA variants. Conflicting evidence was found for the COL1A1 rs1800012 and COL3A1 rs1800255 variants, whereas limited evidence was found for no association of the COL5A1 rs12722 and rs13946 and COL12A1 rs970547 variants (all encoding collagen). Evidence was insufficient to draw conclusions as to whether any other genetic variant identified in this review had any association with ACL rupture. _Conclusions:_ More research is needed to support a clear association between ACL rupture and genetic variants. Genome-wide studies are recommended for exploring more potential genetic variants. Moreover, large prospective studies are needed to draw robust conclusions

Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes

Background: An anterior cruciate ligament (ACL) rupture has major consequences at midterm follow-up, with an increasing chance of developing an old knee in a young patient. The long-term (≥20 years) effects of the operative and nonoperative treatment of ACL ruptures are still unclear. Purpose: To compare the long-term treatment outcomes of operative versus nonoperative treatment of ACL ruptures in high-level athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Fifty patients with an ACL rupture were eligible for participation, and they were treated either nonoperatively (n = 25) in 1992, consisting of structured rehabilitation and lifestyle adjustments, or operatively (n = 25) between 1994 and 1996 with an arthroscopic transtibial bone–patellar tendon–bone technique. The patients in the nonoperative group were drawn from those who responded well to 3 months of nonoperative treatment, whereas the patients in the operative group were drawn from those who had persistent instability after 3 months of nonoperative treatment. Both groups were pair-matched and assessed at 10- and 20-year follow-up regarding radiological knee osteoarthritis, functional outcomes (Lysholm, International Knee Documentation Committee [IKDC], Tegner, Knee injury and Osteoarthritis Outcome Score), meniscal status, and knee stability (KT-1000 arthrometer, pivot-shift test, Lachman test, 1-legged hop test). Results: All 50 patients (100%) were included in the current study for follow-up. After 20 years, we found knee osteoarthritis in 80% of the operative group compared with 68% of the nonoperative group (P =.508). There was no difference between groups regarding functional outcomes and meniscectomy performed. The median IKDC subjective score was 81.6 (interquartile range [IQR], 59.8-89.1) for the operative group and 78.2 (IQR, 61.5-92.0) for the nonoperative group (P =.679). Regarding the IKDC objective score, 21 patients (84%) in the operative group had a normal or near normal score (A and B) compared with 5 patients (20%) in the nonoperative group (P <.001). The pivot-shift test finding was negative in 17 patients (68%) versus 3 patients (13%) for the operative and nonoperative groups, respectively (P <.001), and the Lachman test finding was negative in 12 patients (48%) versus 1 patient (4%), respectively (P =.002). Conclusion: In this retrospective pair-matched follow-up study, we found that after 20-year follow-up, there was no difference in knee osteoarthritis between operative versus nonoperative treatment when treatment was allocated on the basis of a patient’s response to 3 months of nonoperative treatment. Although knee stability was better in the operative group, it did not result in better subjective and objective functional outcomes

Can we predict the clinical outcome of arthroscopic partial meniscectomy? A systematic review

NHS-Prospero registration number 42016048592 Objective In order to make a more evidence-based selection of patients who would benefit the most from arthroscopic partial meniscectomy (APM), knowledge of prognostic factors is essential. We conducted a systematic review of predictors for the clinical outcome following APM. Design Systematic review Data sources Medline, Embase, Cochrane Central Register, Web of Science, SPORTDiscus, PubMed Publisher, Google Scholar Inclusion criteria Report an association between factor(s) and clinical outcome; validated questionnaire; follow-up >1 year. Exclusion criteria 1 year) are associated with worse clinical outcome following APM. In addition, resecting >50% of meniscal tissue and leaving a non-intact meniscal rim after meniscectomy are intra-articular predictive factors for worse clinical outcome. Moderate evidence was found that sex, onset of symptoms (acute or chronic), tear type or preoperative sport level are not predictors for clinical outcome. Conflicting evidence was found for the prognostic value of age, perioperative chondral damage, body mass index and leg alignment. Summary/conclusion Long duration of symptoms (>1 year), radiological knee osteoarthritis and resecting >50% of meniscus are associated with a worse clinical outcome following APM. These prognostic factors should be considered in clinical decision making for patients with meniscal tears

Four-strand hamstring graft is stiffer than a tripled semitendinosus graft in anterior cruciate ligament reconstruction: a cadaveric study

Purpose: The aim of this study was to compare the biomechanics of a four-strand hamstring graft with a tripled semitendinosus graft, with and without adjustable extra-cortical button fixation, in a cadaveric model. Methods: Four groups of 10 cadaveric hamstrings were tested: In group A, a tripled semitendinosus graft fixated with two adjustable extra-cortical buttons; in Group B, a four-strand semitendinosus and gracilis graft fixated with an adjustable extra-cortical button and a clamp; in group C, a tripled semitendinosus graft fixated to a steel hook and a clamp; in group D, a four-strand semitendinosus and gracilis graft fixated to a steel hook and a cla

High knee loading in male adolescent pre-professional football players: Effects of a targeted training programme

Objective: To assess whether targeted neuromuscular exercises can decrease knee loading of adolescent pre-professional footballers with high knee loading as identified with the field-based Drop Vertical Jump Test (DVJT). Design: Prospective controlled trial, conducted between August and November 2016 at Erasmus Medical Centre, The Netherlands. Methods: Pre-professional football players (aged 14–21 years) were evaluated at baseline and after 12 weeks follow-up with the field-based DVJT. The field-based DVJT is a standardised test in which a player drops from a box and jumps up immediately after landing; knee load is calculated based on five parameters. Players with high knee load (probability ≥ 0.75) from one club performed regular training(control group), and players with high knee load from another other club performed targeted neuromuscular exercises for 12 weeks (intervention group). The difference of change in knee load between both groups after 12 weeks was the primary outcome measure. Results: Of 107 eligible players, 75 had a high knee loading. Knee loading decreased in both groups after 12 weeks of training, but change in probability of high knee load was not significantly different between both groups (95% Confidence Interval [−0.012–0.082], p = 0.139). Conclusion: Targeted neuromuscular exercises had no additional effect in decreasing knee loading of adolescent male pre-professional football players compared to regular training. Trial registration number: The Netherlands Trial Register (ID number: 6044)