Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

© The Author(s) 2020. Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

© 2020, The Author(s). Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results: In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of evidence: V

Fractures of the Lower Extremity after E-Bike, Bicycle, and Motorcycle Accidents: A Retrospective Cohort Study of 624 Patients

Electric bicycles (e-bikes) have gained enormous popularity in recent years, and as a result, they have successively become more involved in traffic accidents. The aim of the present study was to assess differences in severity and localization of injuries to the lower extremities after accidents with e-bikes, conventional bicycles, and motorcycles. A retrospective cohort-analysis of patients who sustained traumatic accidents with two-wheeled vehicles transferred to a level 1 trauma center in Switzerland was performed. We assessed patient demographics, injury pattern, and trauma severity (ISS), with a subgroup analysis of outcomes stratified by vehicle. In total, 624 patients (71% male) with injuries to the lower extremities after bicycle (n = 279), electric bike (n = 19), and motorcycle (n = 326) accident were included. The mean age of all assessed patients was 42.4 years (SD 15.8), with a significantly higher age in the e-bike cohort (p = 0.0001). High-velocity injuries were found significantly more often in the motorcycle and e-bike group. The motorcycle group had a significantly higher mean ISS (17.6) than the other groups (p = 0.0001). E-bike accidents produce a different injury profile to the lower extremities compared to motorcycle or bicycle accidents. Higher age, higher velocity, and different protective equipment seem to have an impact on these fracture patterns

Fractures of the Lower Extremity after E-Bike, Bicycle, and Motorcycle Accidents: A Retrospective Cohort Study of 624 Patients

Electric bicycles (e-bikes) have gained enormous popularity in recent years, and as a result, they have successively become more involved in traffic accidents. The aim of the present study was to assess differences in severity and localization of injuries to the lower extremities after accidents with e-bikes, conventional bicycles, and motorcycles. A retrospective cohort-analysis of patients who sustained traumatic accidents with two-wheeled vehicles transferred to a level 1 trauma center in Switzerland was performed. We assessed patient demographics, injury pattern, and trauma severity (ISS), with a subgroup analysis of outcomes stratified by vehicle. In total, 624 patients (71% male) with injuries to the lower extremities after bicycle (n = 279), electric bike (n = 19), and motorcycle (n = 326) accident were included. The mean age of all assessed patients was 42.4 years (SD 15.8), with a significantly higher age in the e-bike cohort (p = 0.0001). High-velocity injuries were found significantly more often in the motorcycle and e-bike group. The motorcycle group had a significantly higher mean ISS (17.6) than the other groups (p = 0.0001). E-bike accidents produce a different injury profile to the lower extremities compared to motorcycle or bicycle accidents. Higher age, higher velocity, and different protective equipment seem to have an impact on these fracture patterns

Clinical outcomes after anterior cruciate ligament injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group

Purpose A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. Methods To establish a standardised assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA, USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific patient-reported outcomes and Health-Related Quality of Life questionnaires. In the mid-term to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. Level of Evidence Level V

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

PURPOSE: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed. METHODS: To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. RESULTS: In general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. CONCLUSION: This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment. LEVEL OF EVIDENCE: V

The structure and function of the anterolateral ligament of the knee: A systematic review

© 2015 Arthroscopy Association of North America. Purpose The purpose of this systematic review was to evaluate the anatomic structure and function of the anterolateral ligament (ALL) of the knee. Methods The Medline, Embase, and Cochrane databases were screened for all studies related to the ALL of the knee. Two reviewers independently reviewed all eligible articles and the references of these articles. Inclusion and exclusion criteria were applied to all searched studies. Quality assessment was completed for the included studies. Results Nineteen studies were identified for final analysis. Pooled analysis identified the ALL in 430 of 449 knees (96%) examined. The ligament was found to originate from the region of the lateral femoral epicondyle and insert on the proximal tibia midway between the Gerdy tubercle and the fibular head. The ALL was found to be 34.1 to 41.5 mm in length, 5.1 to 8.3 mm in width above the lateral meniscus, and 8.9 to 11.2 mm in width below the lateral meniscus. By use of magnetic resonance imaging, the ALL was identified in 93% of knees examined (clinical, 64 of 70; cadaveric, 16 of 16). In one case study the ligament was clearly visualized by ultrasound examination. Histologic analysis across 3 studies showed characteristics consistent with ligamentous tissue. Though not shown in biomechanical studies, it is hypothesized that the ALL provides anterolateral stability to the knee, preventing anterolateral subluxation of the proximal tibia on the femur. One study identified a network of peripheral nerves, suggesting a proprioceptive function of the ALL. Conclusions This systematic review shows the ALL to be a distinct structure with a consistent origin and insertion sites. The ALL is an extra-articular structure with a clear course from the lateral femoral epicondyle region, running anteroinferiorly, to the proximal tibia at a site midway between the Gerdy tubercle and the head of the fibula. The function of this ligament is theorized to provide anterolateral knee stability. Level of Evidence Level IV, systematic review of cadaveric and imaging studies

The Anterolateral Capsule Is Infrequently Damaged As Evaluated Arthroscopically in Patients Undergoing Anatomic ACL Reconstruction

OBJECTIVES Concomitant anterolateral complex (ALC) injury may contribute to persistent rotatory knee instability following anterior cruciate ligament (ACL) reconstruction. There is no consensus on how to best identify concomitant ALC injury preoperatively, nor how well ALC injury identified on imaging modalities correlates with clinical examination of knee instability. The purpose of this retrospective study was to determine the incidence of concomitant ALC injury in ACL-injured knees, as determined by arthroscopy, and in comparison to, preoperative radiography, ultrasound, and MRI. METHODS 117 patients with unilateral primary ACL injury who underwent individualized anatomic ACLR between June 2016 and May 2019 were enrolled. Preoperative imaging modalities including x-ray, ultrasound, and MRI, were evaluated for concomitant ALC injury. Clinical examination under anesthesia, including the anterior drawer, Lachman, and pivot shift tests were performed. Anterolateral capsule injury, as defined by hemorrhage and/or capsular tearing on diagnostic arthroscopy, was also determined. Correlative analyses of ALC injury incidence and severity were performed across imaging modalities and against clinical examination grades. RESULTS ALC injury incidence across imaging modalities was as follows: x-ray (3%), arthroscopy (19%), MRI (53%), and US (63%). The ALC injury rate on arthroscopy was significantly less than MRI (p<0.001) or ultrasound (p<0.001). ALC injury incidence and severity were significantly correlated between MRI and US grading scales (p=0.02) but no correlations among other imaging modalities were found. Similarly, no imaging modality meaningfully correlated with physical examination maneuvers. CONCLUSION The incidence of ALC injury varies across imaging modalities, with lower injury rates found on arthroscopy (19%) compared to MRI (53%) and US (63%). Increasing ALC injury severity grades on imaging does not predict increasing anterolateral knee laxity on clinical examination. LEVEL OF EVIDENCE V, retrospective case series