Search Results (31)

Background and Objectives: This study aimed to evaluate the influence of the angle and position of the tibial tunnel in the coronal and sagittal planes on short-term postoperative clinical outcomes following arthroscopic anterior cruciate ligament reconstruction (ACLR). Materials and Methods: This retrospective study included 40 patients who underwent anatomical ACLR between 1 January 2023 and 31 December 2023 and had a follow-up period of at least 4 months. The angle of the tibial tunnel on the AP radiograph and both the angle and anteroposterior position on the lateral radiograph were measured. Clinical evaluations were conducted using the Visual Analogue Scale (VAS), the International Knee Documentation Committee (IKDC) score, and the Lysholm Knee Score, along with measurements of knee flexion and extension, to assess short-term outcomes at 1, 2, and 4 months postoperatively. Results: In patients whose tibial tunnels were positioned at 40–50° in the coronal plane, Lysholm scores were significantly higher at the 2nd and 4th months compared to other angles. In the sagittal plane, a tunnel angle between 30° and 40° was associated with significantly increased IKDC scores at both the 2nd and 4th months. Additionally, tunnels with an anterior–posterior ratio of 0.4–0.6 in the sagittal plane were associated with limitations in flexion and extension at the 4th month. There was no significant difference in VAS scores between the groups. Conclusions: Our findings suggest that optimizing the tibial tunnel angle in both the coronal and sagittal planes may play a crucial role in early postoperative knee function. Specifically, tibial tunnels placed between 40° and 50° in the coronal plane and 30° and 40° in the sagittal plane were associated with higher functional scores. However, tunnels positioned with an anterior–posterior ratio of 0.4 to 0.6 were linked to greater joint motion limitation. These findings indicate that angular and positional optimization of the tibial tunnel may have contributed to improved functional recovery following ACL reconstruction. Full article

Machine learning-based tools are becoming increasingly popular in clinical practice. They offer new possibilities but are also limited in their reliability and accuracy. The present systematic review updates and discusses the existing literature regarding machine learning algorithm-based identification of cruciate ligament injury on radiographic images. PubMed was searched for articles containing machine learning algorithms related to cruciate ligament injury recognition. No additional filters or time constraints were used. All eligible studies were accessed by hand. From the 115 articles initially retrieved, 29 articles were finally included. Only one study included the posterior cruciate ligament (PCL). Deep learning algorithms in the form of convolutional neural networks (CNNs) were most frequently used. Many studies presented CNNs that identified binary decision classes of regular and torn anterior cruciate ligaments (ACLs) with a best sensitivity of 0.98, a specificity of 0.99, and an AUC ROC of 1.0. Other studies expanded the decision classes to partially torn ACLs or reconstructed ACLs, usually at the cost of sensitivity and specificity. Deep learning algorithms are excellent for identifying ACL injuries, tears, or postoperative status after reconstruction on MRI images. They are much faster but only sometimes better than the human reviewer. While the technology seems ready, barriers to ethical and legal issues and clinicians’ refusals must be overcome to some extent. It can be firmly assumed that artificial intelligence will have a future contribution in the diagnosis of cruciate ligament injuries. Full article

Background/Objectives: Chronic ruptures of the quadriceps and Achilles tendons present significant reconstructive challenges due to factors such as tendon retraction, scar tissue formation, and compromised tissue quality. Traditional repair methods, including V–Y tendinoplasty, autografts, and synthetic scaffolds, often prove inadequate for large or neglected defects. Achilles tendon bone–tendon allografts have emerged as a promising alternative, offering strong fixation, biological incorporation, and sufficient length for bridging extensive gaps. This study aims to document the clinical, radiographic, and MRI outcomes of two challenging cases treated with Achilles tendon bone–tendon allografts and to synthesize these findings within the context of the existing literature to evaluate the broader viability of this reconstructive approach. Methods: An observational analysis was conducted at the Orthopedic and Traumatology Clinic of “Victor Popescu” Military Emergency Hospital in Timișoara, encompassing two patients with chronic, iterative tendon ruptures—one quadriceps tendon rupture and one Achilles tendon rupture. Both patients had previously failed primary repairs, resulting in significant tendon retraction and tissue deficits. Reconstruction was performed using Achilles tendon bone–tendon allografts, involving specific osteotomy techniques for patellar and calcaneal fixation. Postoperative protocols included immobilization followed by structured physiotherapy. Clinical assessments and MRI evaluations were conducted at 8, 12, and 24 weeks postoperatively. Additionally, a comprehensive literature review was performed to compare our findings with existing studies on Achilles bone–tendon allograft utilization in chronic tendon reconstructions. Results: Both patients exhibited substantial improvements in their range of motion and reported low pain levels at the 8- and 12-week follow-ups. MRI assessments indicated well-aligned graft fibers, early bone block integration, and the absence of complications such as re-rupture or infection in the long term. Functional recovery was achieved with complete bone block union and return to normal activities by 24 weeks. The literature review corroborated these outcomes, demonstrating that Achilles tendon bone–tendon allografts provide robust fixation and facilitate biological integration, particularly in cases with large defects and poor tissue quality. Comparative studies highlighted similar functional improvements and graft stability, reinforcing the efficacy of bone–tendon allograft constructs over traditional repair methods in chronic tendon ruptures. Conclusions: Achilles tendon bone–tendon allografts are effective in reconstructing chronic quadriceps and Achilles tendon ruptures, offering robust fixation and facilitating biological integration. These findings, supported by the existing literature, suggest that Achilles bone–tendon allografts are a viable alternative to traditional repair strategies, especially in patients with extensive tendon defects and compromised tissue quality. Further comparative studies are warranted to establish the superiority of bone–tendon allograft constructs over conventional methods. Full article

Objectives: The aim of this study is to evaluate the literature for comparing clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with concomitant anterolateral ligament reconstruction (ALLR) versus isolated ACLR, with a primary focus on analyzing differences in outcomes based on the type of graft used for ALLR. Methods: We identified comparative studies involving primary ACLR performed in conjunction with ALLR. Graft failure rates, residual pivot shift, residual anterior–posterior (AP) laxity at follow-up, and patient-reported outcome measures were determined. Variables associated with isolated ACLR and ACLR combined with ALLR were compared based on the type of graft used for ALLR. Results: This systematic review included nine studies involving 2740 patients. Combined ACLR with ALLR using hamstring tendon (HT) autografts or tibialis allografts showed lower graft failure rates than isolated ACLR (HT autograft: rate, 0–5.9%, odds ratio [OR], 2.16–12.91; tibialis allograft: rate, 0%, OR, 2.00–5.27). Similarly, the combined procedure showed reduced residual pivot shift rates (HT autograft: rate, 0–9.1%, OR, 2.00–12.16; tibialis allograft: rate, 0%, OR, 7.65–15.33) compared to isolated ACLR. Residual AP laxity and patient-reported outcomes were similar or more favorable for the combined procedure; however, the results were heterogeneous. Complications related to the type of graft used for ALLR or the presence of ALLR itself were not reported. Conclusions: Regardless of the graft type used for ALLR, the combination of ACLR with ALLR showed better clinical outcomes, including reduced graft failure rates and superior residual rotational stability compared to isolated ACLR. However, the high heterogeneity observed across studies suggests that these findings should be interpreted with caution, and further research is needed to draw more definitive conclusions. Full article

Background: Posterior cruciate ligament (PCL) injuries are relatively rare, with limited consensus on the optimal treatment for isolated acute cases. Conservative management and surgical reconstruction each offer potential benefits, but their comparative efficacy remains unclear. Methods: A scoping review was conducted following the Joanna Briggs Institute (JBI) framework and PRISMA-ScR guidelines. A systematic search of MEDLINE, Cochrane CENTRAL, Scopus, PEDro, and Web of Science was completed on 23 December 2024. Studies comparing conservative treatment and surgical reconstruction for isolated acute PCL injuries were included. Outcomes such as functional recovery, stability, and long-term complications were extracted and synthesized qualitatively. Results: Six studies were included, comprising case series, prospective, retrospective, and review designs. Conservative treatment demonstrated significant improvements in functional recovery (IKDC scores: 67–90.3/100) but showed limited improvement in stability (STSD reduction: 0–3 mm). Surgical reconstruction yielded superior stability (STSD reduction: 8.2 to 2.7 mm) and lower rates of degenerative changes but was associated with a higher risk of complications. Functional outcomes were comparable between approaches in some studies, although surgical patients showed slightly better long-term stability. Conclusions: Both conservative and surgical treatments achieve satisfactory outcomes for isolated acute PCL injuries. Treatment selection should be tailored to patient-specific factors, considering functional demands and injury severity. Full article

This cross-sectional laboratory-based study investigates the stress characteristics of the anterior cruciate ligament (ACL) during side-cutting using a knee finite element (FE) model and identifies biomechanical factors influencing ACL stress. Kinematics and ground reaction forces (GRF) were collected from eight participants (age: 30.3 ± 5.3 years; BMI: 25.6 ± 2.4 kg/m²; time since surgery: 12.8 ± 1.2 months) one year post–ACL reconstruction during side-cutting tasks. A knee FE model incorporating time-varying knee angles, knee forces, and femoral translation was developed to simulate the knee biomechanics. The relationships between ACL stress and lower limb biomechanics were analyzed. The results indicated the highest stress concentrations at the femoral attachment during the early landing phase. Posterior femoral displacement relative to the tibia was significantly correlated with peak ACL equivalent stress (r = 0.89, p = 0.003) and peak ACL shear stress (r = 0.82, p = 0.023). Peak ACL equivalent stress also showed positive correlations with posterior GRF (r = 0.77, p = 0.025) and knee extension moments (r = 0.71, p = 0.049). In contrast, peak ACL shear stress exhibited a significant negative correlation with hip extension moment (r = −0.80, p = 0.032). This study identified key biomechanical factors affecting ACL stress, highlighting the roles of femoral displacement, knee extension moments, and ground reaction forces, while demonstrating a negative relationship with hip extension moments. Full article

Background/Objectives: Cruciate ligament injuries, particularly those involving the anterior cruciate ligament and posterior cruciate ligament, are common among active individuals and often require surgical reconstruction followed by intensive rehabilitation to restore knee stability, movement, and strength. Virtual reality exposure therapy has emerged as a potentially beneficial adjunct to traditional rehabilitation, offering immersive, interactive environments that may aid in pain relief, balance, proprioception, and functional recovery. This meta-analysis aimed to evaluate the efficacy of VRET compared to conventional rehabilitation for postoperative cruciate ligament reconstruction, focusing on outcomes in pain, balance, proprioception, and the knee flexion range of motion. Methods: A systematic review and meta-analysis were conducted following the PRISMA guidelines and registered in PROSPERO (CRD42024604706). A comprehensive search across databases including MEDLINE (PubMed), SPORTDiscus, ScienceDirect, Web of Science (WOS), Cochrane Library, Scopus, and EBSCOhost included studies from inception until the date of search, using terms such as “cruciate ligament”, “virtual reality”, “rehabilitation”, “pain”, and “balance”, combined with Booleans “AND” and “OR”. Methodological quality, risk of bias, and recommendation strength were assessed using PEDro Scale, Cochrane Risk of Bias Tool (RoB 2.0), and GRADE, respectively. Results: Eleven studies (n = 387) met the inclusion criteria, involving patients who had undergone ACL or PCL reconstruction. Virtual reality exposure therapy showed significant benefits in reducing pain intensity [SMD = −2.33, 95% CI: −4.24 to −0.42, Z = 2.40, p = 0.02], improving proprioception, and enhancing the knee flexion range of motion. However, the results for static balance [SMD = −0.37, 95% CI: −1.62 to 0.88, Z = 0.58, p = 0.56] and dynamic balance [SMD = −0.37, 95% CI: −1.83 to 1.09, Z = 0.50, p = 0.62] were mixed and not statistically significant. Conclusions: Virtual reality exposure therapy is an effective adjunct therapy to postoperative rehabilitation for cruciate ligament reconstruction, particularly in reducing pain and enhancing proprioception. However, the small sample sizes and variability across studies underscore the need for further research with larger cohorts to validate these benefits in diverse patient populations. Full article

Purpose: Multi-ligament reconstruction in adolescent patients affected by congenital femoral deficiency is an extremely rare and delicate surgical procedure. There are very few reported cases of complete anterior and posterior cruciate ligament agenesis in these patients. Methods: We present a complex case of a 16-year-old girl affected by congenital femoral deficiency and ipsilateral tibial hypoplasia who was treated successfully for a complete agenesis of the anterior (ACL) and posterior (PCL) cruciate ligament with single-sitting ACL and PCL reconstruction. Results: The adolescent patient was successfully reconstructed with excellent clinical results. Conclusions: Knee MRI (Magnetic Resonance Imaging) should be requested in all patients affected by congenital femoral deficiency to exclude ligamentous agenesis. Where present, these should be reconstructed at an early stage as soon as limb-lengthening procedures are completed. If still skeletally immature, physeal-sparing surgical techniques should be implemented. Full article

Background/Objectives: Lateral extraarticular tenodesis (LET) has been advocated in revision anterior cruciate ligament reconstruction (ACLR) to improve knee stability and furthermore, decrease failure rates. The aim of this study was to compare clinical outcomes, knee laxity, and failure rates after revision ACLR with LET (ACLR + LET) versus without LET. It was hypothesized that ACLR + LET improves clinical outcomes and reduces the failure rate. Methods: A retrospective analysis of prospectively collected data was conducted to examine patients who underwent revision ACLR with and without LET between 2017 and 2021 with a minimum follow-up of 24 months. Patients with coronal malalignment (>5°), posterior tibial slope >12°, and concomitant injuries to collateral ligaments were excluded. Patient reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) subjective knee score, the Lysholm score, and the Tegner activity scale (TAS). Anterior knee laxity was measured with a Rolimeter and side-to-side difference (SSD) was determined. Revision ACLR failure was defined as ACL revision surgery and SSD > 5 mm. Group comparisons were performed using chi-square-, independent-samples students t-test or Mann–Whitney–U tests. Results: Of 56 eligible patients, 45 (80%, follow up, 23 isolated rACLR vs. 22 rACLR + LET) were included with a mean follow-up of 45.6 ± 15.8 months. Postoperative PROMs were not statistically different between rACLR and rACLR + LET groups (IKDC: 73.0 ± 18.9 vs. 68.7 ± 16.6, n.s.; Lysholm: 84.8 ± 12.3 vs. 77.7 ± 16.2, n.s.). Both groups showed similar TAS (rACLR vs. rACLR +LET (5; range 4–6 vs. 4; range 3–5; n.s.). Anterior knee laxity SSD was 2.4 ± 1.3 mm in the rACLR group and 1.8 ± 1.8 mm in the rACLR + LET group (n.s.). The failure rate was 13% in the rACLR group compared to 4.5% in the rACLR + LET group (n.s.). Conclusions: Isolated revision ACLR showed comparable postoperative patient-reported outcome measures and anterior knee laxity compared to ACLR + LET at mid-term follow up. The addition of a LET demonstrated a lower, though non-significant, failure rate after revision surgery. However, future studies with a prospective, randomized design and an increased number of patients are needed to clearly identify the exact indication for the use of additional LET. Full article

Background: Excessive posterior tibial slope (PTS) has been associated with a higher risk of graft failure after anterior cruciate ligament reconstruction (ACLR). Although anterior closing wedge osteotomy (ACWO) can reduce the PTS, it may also change the coronal alignment and patellar height. Purpose: To elucidate the radiological outcomes after infratubercle ACWO, specifically to evaluate its influence on perioperative changes in patellar height. Methods: Patients who underwent infratubercle ACWO with combined ACLR with a minimum follow-up of 3 months were included. Surgery was indicated when the PTS was greater than 12°. Radiological evaluation included measurements of the hip–knee–ankle angle (HKA), PTS, femoral patellar height index (FPHI), and Caton–Deschamps index (CDI) preoperatively and 3 months postoperatively. Patellar height was classified as patella baja, normal, or alta based on CDI values. Knee recurvatum was measured preoperatively and at final follow-up. Results: A total of 21 patients with a mean age of 21.6 ± 3.0 years were included. Although HKA did not significantly change, significant corrections were achieved in the PTS from 14.5° ± 1.6° to 5.7° ± 1.0° (p < 0.001). No significant change in FPHI was found (preoperative: 1.33 ± 0.11 vs postoperative: 1.30 ± 0.09). Patellar height categories showed no significant differences pre- and postoperatively, while three patients (14.3%) changed their patellar height category (all moved up one category). Knee recurvatum increased significantly from 4.9° ± 2.9° preoperatively to 7.8° ± 3.1° at the final follow-up (p < 0.001). Conclusions: Precise sagittal correction was achieved after infratubercle ACWO without altering the coronal alignment and patella height. Level of Evidence: IV, Case series. Full article

Background/Objective: The effects of concomitant meniscal tears and their associated treatment on strength, lower extremity balance, and functional status after anterior cruciate ligament reconstruction (ACLR) have not been widely investigated. This study aimed to compare the functional outcomes in patients who underwent ACLR with concomitant treatment of the medial meniscus repair versus meniscectomy when returning to unrestricted physical activity. Methods: A total of 85 patients who underwent primary ACLR with combined meniscal repair (MREP; n = 39) or meniscectomy (MRES; n = 46) were assessed. The dataset included the Functional Movement Screen^TM (FMS) outcomes and single-leg balance test (SLBT) with anterior–posterior, medial–lateral, and overall stability indexes. Isokinetic knee extension and flexion strengths were tested at velocities of 60 deg·s⁻¹ and 180 deg·s⁻¹. The peak torque-to-body weight ratio (PT/BW) and limb symmetry index (LSI) were calculated. Results: In the functional assessment, there was no significant inter-group difference in the composite score of the FMS (MREP: 15.08 pts vs. MRES: 15.13 pts; p > 0.05). The SLBT outcomes in inter-group and inter-extremity comparisons were irrelevant (p > 0.05), too. Significant differences emerged in the inter-group comparison of the knee extension strength in the non-operated extremity at both 60 deg·s⁻¹ and 180 deg·s⁻¹ (p = 0.02). Inter-extremity differences were significant in both the MREP and MRES groups for knee extension and flexion at both angular velocities (all p values < 0.05). For knee extension, the LSI values ranged from 82% to 87%, and for flexion, from 77% to 84%, with no significant inter-group differences. Conclusions: Patients undergoing ACLR with concomitant meniscal repair or resection did not exhibit differences in isokinetic muscle strength, lower extremity balance, and functional tests upon returning to activity. However, participants in both groups demonstrated significant differences between the operated and non-operated extremities as far as the knee joint extensor and flexor strengths are concerned. Therefore, rehabilitation protocols should prioritize equalizing inter-extremity strength differences after the ACLR with additional treatment procedures addressing the menisci. Full article

There is currently no consensus on the optimal placement of the tibial tunnel for double-bundle posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare the clinical and radiologic outcomes of double-bundle PCL reconstruction utilizing anatomic versus low tibial tunnels. We conducted a retrospective cohort study involving patients who underwent double-bundle PCL reconstruction between Jan 2019 and Jan 2022, with a minimum follow-up of 2 years (n = 36). Based on the tibial tunnel position on postoperative computed tomography, patients were categorized into two groups: anatomic placement (group A; n = 18) and low tunnel placement (group L; n = 18). We compared the range of motion, stability test, complications, and side-to-side differences in tibial posterior translation using kneeling stress radiography between the two groups. There were no significant differences between the groups regarding clinical outcomes or complication rates. No significant differences in the posterior drawer test and side-to-side difference on kneeling stress radiography (2.5 ± 1.2 mm in group A vs. 3.7 ± 2.0 mm in group L; p = 0.346). In conclusion, the main findings of this study indicate that both anatomic tunnel and low tibial tunnel placements in double-bundle PCL reconstruction demonstrated comparable and satisfactory clinical and radiologic outcomes, with similar overall complication rates at the 2-year follow-up. Full article

Background: Medial meniscus ramp tears are present in 22.9–40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman’s exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman’s exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman’s exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings. Full article

Background. Stair climbing is often performed by people in daily life and requires considerable energy and muscle effort. This task has been widely described in the literature, but the role of the knee joint ligaments has not been sufficiently investigated. This could be relevant for planning ligament reconstruction surgery, for providing suggestions to subjects with partial ligament injuries, and for identifying compensatory strategies for reducing ligament loads. Methods. A dynamic musculoskeletal model was used to analyse the relationship between ligament loads and muscle forces during stair climbing. Results. The most loaded ligaments were the posterior cruciate ligament and the deep fibres of the medial collateral ligament, particularly during the mid-swing phase, where the knee was maximally flexed and the hamstring muscles contracted. The anterior cruciate ligament was recruited during the stance phase to compensate for the anteriorly-directed force applied to the tibia by the vasti muscles; the collateral ligaments stabilized the knee joint during the swing phase. The tibiofemoral contact force, resulting from all external and internal forces applied to the knee, was in good agreement with data provided in the literature. Conclusions. This study represents a forward step in the knowledge of ligament loads during stair climbing, which could be useful for providing informed recommendations to subjects with ligament injuries. Full article

Background and Objectives: The aim of this study is to investigate the femoral tunnel geometry (femoral tunsnel location, femoral graft bending angle, and femoral tunnel length) on three-dimensional (3D) computed tomography (CT) and graft inclination on magnetic resonance imaging (MRI) after anatomic anterior cruciate ligament (ACL) reconstruction using a flexible reamer system. Materials and Methods: A total of 60 patients who underwent anatomical ACL reconstruction (ACLR) using a flexible reamer system were retrospectively reviewed. One day after the ACLR procedure was performed, all patients underwent three-dimensional computed tomography (3D-CT) and magnetic resonance imaging (MRI). The femoral tunnel location, femoral graft bending angle, femoral tunnel length, and graft inclination were assessed. Results: In the 3D-CTs, the femoral tunnel was located at 29.7 ± 4.4% in the posterior to anterior (deep to shallow) direction and at 24.1 ± 5.9% in the proximal to distal (high to low) direction. The mean femoral graft bending angle was 113.9 ± 5.7°, and the mean femoral tunnel length was 35.2 ± 3.1 mm. Posterior wall breakage was observed in five patients (8.3%). In the MRIs, the mean coronal graft inclination was 69.2 ± 4.7°, and the mean sagittal graft inclination was 52.4 ± 4.6°. The results of this study demonstrated that a comparable femoral graft bending angle and longer femoral tunnel length were observed compared with the reported outcomes from previous studies that used the rigid reamer system. Conclusions: ACLR using a flexible reamer system allowed for an anatomic femoral tunnel location and a comparable graft inclination to that of the native ACL. In addition, it achieved a tolerable femoral graft bending angle and femoral tunnel length. Full article