Background: Arthrogenic muscle inhibition (AMI) is a process in which neural inhibition after injury or surgery to the knee results in quadriceps activation failure and knee extension deficit. A recent study showed that AMI occurs in over half of patients with acute ACL injuries.
Purposes: To (1) determine the incidence of AMI within the 6 weeks after an anterior cruciate ligament reconstruction (ACLR) and (2) identify the risk factors associated with AMI after an ACLR.
Study design: Case-control study; Level of evidence, 3.
Methods: Consecutive patients who sustained a primary ACLR between January and October 2023 were considered for study inclusion. Eligible patients underwent a standardized physical examination at 3 and 6 weeks postoperatively. This included an assessment of quadriceps inhibition, identification of any extension deficits, and grading of AMI and its clinical reversibility according to the Sonnery-Cottet classification.
Results: A total of 210 consecutive patients with a primary ACLR were prospectively enrolled in the study. Respectively, 48.6% of patients had AMI at 3 weeks and 24.3% at 6 weeks postoperatively. Among them, 79.4% and 72.5% demonstrated reversible types (grade 1A or 2A), respectively. Multivariate analysis revealed that patients who had a preoperative AMI (odds ratio [OR], 8.27 [95% CI, 4.177-17.138]; P < .001), experienced immediate postoperative pain exceeding 7 out of 10 on the visual analog scale (VAS) (OR, 4.689 [95% CI, 2.144-10.814]; P = .0002), or did not have preoperative physical therapy (OR, 2.303 [95% CI, 1.186- 4.530]; P = .0149) were associated with a significantly greater risk of AMI at 3 weeks postoperatively. No risk factors were found at 6 weeks postoperatively.
Conclusion: AMI occurs in 48.5% of patients at 3 weeks, and 24.2% at 6 weeks after an ACLR. Important risk factors identified for the presence of AMI at 3 weeks postoperatively included the presence of preoperative AMI, immediate postoperative VAS pain score of >7, and absence of preoperative physical therapy.
Background: Technical variations in elbow ulnar collateral ligament reconstruction (UCLR) include graft source, graft/tunnel configuration, and humeral and ulnar fixation. While the biomechanical performance of various constructs has been reported, these studies have small sample sizes and compare at most a few technical variations.
Purpose: To quantitatively synthesize the results of biomechanical investigations of UCLR and repair.
Study design: Systematic review.
Methods: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses); included articles were published between 1998 and 2020. Biomechanical metrics were utilized to compute effect sizes (standardized mean difference [SMD]) for quantitative analysis when 2 studies reported the same metric for the same comparison. After our initial search, 1293 studies were identified. Summary effects were estimated in random-effects models, and mixed-effects models were constructed to evaluate the fixed effects of technical variations through meta-regression.
Results: A total of 24 eligible studies were included, of which 19 were included in the quantitative analysis. Compared with the intact ligament, UCLR had significantly lower ultimate strength (SMD, -1.411; P < .0001) and stiffness (N/mm) (SMD, -3.259; P = .0268), and significantly greater valgus opening at 70° of flexion (SMD, 1.638; P < .0001). Stiffness (N·m/deg), valgus opening angle at 30° and 90° of flexion, and gapping at failure were not significantly different from the intact UCL (all P > .05). There was no significant difference in ultimate strength between docking and Jobe reconstructions (P = .2889). There were no significant differences between repair and reconstruction in ultimate strength, stiffness (N·m/deg), or yield torque (all P > .05).
Conclusion: Our study demonstrates that, at time zero, UCLR has inferior biomechanical properties compared with the native intact ligament. Biomechanical performance of UCLR was either inferior to the intact UCL (ultimate strength, stiffness [N/mm], and valgus opening at 70° flexion) or not significantly different from it (stiffness [N⋅m/deg], valgus opening at 30° and 90° of flexion, and gapping at failure). There is no difference in biomechanical outcome measurements between docking and Jobe reconstructions, or between UCL repair and reconstruction.
Background: Arthroscopic anterior cruciate ligament (ACL) primary repair (ACLPR) has reemerged as a treatment option for select proximal ACL tears. However, concerns persist regarding its ability to restore knee stability adequately to support meniscal healing after concurrent meniscal repair.
Purpose: To evaluate the clinical outcomes after medial and/or lateral meniscus repair in patients undergoing ACLPR, compared with isolated ACLPR (ACLPR-only) and ACLPR with partial meniscectomy (ACLPR-PME).
Study design: Cohort study; Level of evidence, 3.
Methods: Consecutive patients with complete, proximal modified Sherman type 1 and 2 ACL tears who underwent ACLPR between 2008 and 2021 with a minimum 2-year follow-up were included. Patients were categorized into 3 groups: ACLPR-only, ACLPR with meniscal repair (ACLPR-MR), and ACLPR-PME. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Form score. Secondary outcomes consisted of meniscal repair and ACLPR failure, overall reoperation rates, anterior tibial translation side-to-side difference (ATT SSD), clinical outcomes (Lachman test and pivot-shift test results), and patient-reported outcome measures (PROMs) including the Lysholm score, Forgotten Joint Score-12, Anterior Cruciate Ligament Return to Sport after Injury score, and Tegner activity scale score.
Results: A total of 276 patients (ACLPR-only: n = 131; ACLPR-MR: n = 76; ACLPR-PME: n = 69) with a mean age of 39.7 ± 10.7 years (50.4% female) and mean follow-up of 2.9 ± 1.0 years were included (7.4% lost to follow-up). The mean IKDC scores demonstrated no significant difference between groups (ACLPR-only: 89.4 ± 10.3 [95% CI, 87.2-91.6]; ACLPR-MR: 86.7 ± 12.9 [95% CI, 83.6-89.8]; ACLPR-PME: 89.2 ± 9.9 [95% CI, 86.6-91.9]; P = .27). Eight patients (10.5%) in the ACLPR-MR group experienced recurrent meniscal injury. ACLPR failure occurred in 28 patients (10.1%), with no significant difference between groups (P = .62). Younger age was a significant predictor of ACLPR failure (P < .01), but not meniscal repair failure (P = .77). No group differences were observed in ATT SSD (ACLPR-only: 0.8 ± 1.3 mm; ACLPR-MR: 1.1 ± 1.2 mm; ACLPR-PME: 1.2 ± 1.4 mm; P = .34), overall reoperations, Lachman test results, pivot-shift test results, and PROMs (all P > .05).
Conclusion: Meniscal repair with ACLPR is not associated with inferior clinical and patient-reported outcomes at the 2-year follow-up when compared with ACLPR-only and ACLPR-PME, with ACLPR-MR demonstrating a meniscal reinjury rate of 10.5%. These findings suggest that ACLPR provides sufficient knee stability to support clinically successful meniscal healing.
Background: Although the posterior tibial slope (PTS) has been identified as a key factor influencing anterior cruciate ligament (ACL) graft biomechanics and clinical outcomes, little is known regarding which plateau has the greater effect on mechanics of the ACL-reconstructed knee. There are differences in slopes of the medial and lateral tibial plateaus, but this difference has yet to be biomechanically investigated in an ACL-reconstructed setting.
Purpose: To investigate the individual effects of medial and lateral PTS differential modifications on ACL graft force, anterior tibial translation (ATT), and internal tibial rotation in a cadaveric model.
Study design: Controlled laboratory study.
Methods: Twelve fresh-frozen human cadaveric knees (mean age, 61.6 years) were tested. Native PTS was measured using computed tomography. ACL reconstruction was performed, followed by individual anterior closing-wedge osteotomies of the medial and lateral compartments to achieve a 0° slope. Each compartment was then adjusted in 5° increments with 3-dimensional printed wedges and secured with an external fixator. Biomechanical testing consisted of a 500-N axial load and a 1-N⋅m axial torque across 8 medial-lateral PTS states: native/native, 5°/10°, 5°/5°, 10°/5°, 10°/10°, 10°/15°, 15°/15°, and 15°/10°. ACL graft force, ATT, and internal tibial rotation at full extension were recorded. Linear mixed modeling was used to evaluate the effect of medial and lateral slopes on the outcome variables.
Results: The lateral tibial slope contribution had a greater effect on ACL graft force and ATT than the medial tibial slope contribution. Each 1° increase in lateral slope was associated with a 4.9-N (11.1%) increase in graft force and a 0.63-mm (25.2%) increase in ATT (P < .001). Each 1° increase in medial slope was associated with a 1.9-N (4.3%) increase in graft force and a 0.48-mm (19.2%) increase in ATT (P < .001). Internal tibial rotation was not significantly affected by either lateral or medial PTS.
Conclusion: Although both slopes significantly affected ACL graft force and ATT, lateral PTS had a greater effect on ACL graft force and ATT compared with the medial PTS and may warrant primary consideration for a slope-correcting osteotomy.
Clinical relevance: While correction of both medial and lateral slopes is important, the lateral PTS contributes more significantly to ACL graft forces and ATT.
Background: Mucoid degeneration of the anterior cruciate ligament (ACL) is an uncommon clinical condition with a reported prevalence of <0.5%. There is a paucity of histopathological descriptions in the literature, which limits our understanding of the underlying pathophysiology.
Purpose: To define the histopathology and gene expression patterns of ACL mucoid degeneration to guide future biological and surgical management options.
Study design: Case series; Level of evidence 4.
Methods: Ten patients with ACL mucoid degeneration between 2002 and 2023 were included. Plain radiograph and magnetic resonance imaging were reviewed to obtain multiple anatomic and morphometric measurements. Tissue samples were obtained from all patients during arthroscopic partial debridement of the ACL, and ACL tissue from 3 normal cadaveric knees was sampled for comparison. Formalin-fixed and paraffin-embedded tissues were prepared for histopathologic examination of microstructure and composition and for multiplex gene expression analysis using the NanoString nCounter Human Fibrosis V2 Panel.
Results: All 10 patients reported pain and limited knee flexion. Radiological evaluation exhibited a bulbous appearance, an increased posterior tibial slope, a narrow notch width index, and increased signal intensity of the ACL. Early degenerative changes were common in the medial compartment. Histopathological analysis revealed significant differences in tissue architecture compared with normal ACL controls, including a disorganized collagen matrix and increased glycosaminoglycan content. NanoString multiplex gene expression analysis revealed 155 differentially expressed genes (DEGs) between the mucoid degeneration and control groups. The 5 most upregulated DEGs identified were Fibronectin 1, COL5A1, COL6A3, COL3A1, and COL1A2. Significant differences were observed in the pathway scores for epithelial-to-mesenchymal transition, extracellular matrix degradation/synthesis, collagen biosynthesis, focal adhesion kinase, platelet-derived growth factor signaling, and PI3K-Akt.
Conclusion: Histological findings demonstrated distinct abnormalities in ACL structure and composition. We hypothesized that repetitive microtrauma of the ACL would lead to cumulative damage that ultimately would result in mucoid degeneration. Also, we hypothesized that increased PTS and a narrow notch width index would contribute to cumulative ligament loading and subsequent mucoid degeneration.
Background: Knee injuries are among the most common injuries in female basketball players. Despite the growing popularity of professional women's basketball, particularly the Women's National Basketball Association (WNBA), there are limited recent data evaluating the incidence of and risk factors for knee injuries in WNBA athletes.
Hypothesis: Older age, minutes played per game, number of games played, and player usage rate would be significantly associated with having a knee injury in WNBA players from the 2017 to 2022 seasons.
Study design: Descriptive epidemiology study.
Methods: Publicly available data on the injury history and player records of active WNBA players between the 2017 and 2022 seasons were reviewed to identify players with a knee injury resulting in ≥1 games missed. The primary outcome was the incidence of knee injuries reported per 1000 minutes-exposures (MEs). Player demographics, statistics, and injury characteristics were recorded. Secondary analysis was conducted using bivariate and multivariable logistic regression to investigate risk factors associated with having a knee injury.
Results: A total of 87 players (10.8% of all players) sustained a combined 104 knee injuries between the 2017 and 2022 seasons, indicating a rate of 6.03 knee injuries per 1000 MEs. Accounting for potential confounders, having a knee injury was significantly associated with older age (OR, 1.11; 95% CI, 1.05-1.18; P = .0002) and higher usage rate (OR, 1.06; 95% CI, 1.02-1.11; P = .02).
Conclusion: This study showed that knee injuries occurred in 10.8% of players, with an overall rate of 6.03 injuries per 1000 MEs. The most significant risk factors associated with having a knee injury in WNBA athletes were older age and higher player usage rate. Implementing targeted load management strategies for players with higher usage rates or advanced age may help reduce the incidence of knee injuries among female basketball athletes.
Background: Platelet-rich plasma (PRP) treatment for chronic lateral elbow tendinopathy (LET) has increased because of its potential for prolonged symptom relief and improved function. Limited studies have definitively documented long-term benefits.
Purpose: To assess the efficacy of a single intratendinous PRP injection compared to a corticosteroid injection for the treatment of LET.
Study design: Randomized controlled trial; Level of evidence, 1.
Methods: In total, 48 participants (n = 50 elbows), aged 18 to 65 years, were randomly assigned to ultrasound-guided PRP (n = 26) or corticosteroid (control, n = 24) injection. Patient-Rated Tennis Elbow Evaluation (PRTEE) and Quick version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) were compared at baseline and 4, 8, 12, 16, 26, and 52 weeks. Secondary outcomes were assessed via grip strength, visual analog scale (VAS) scores, and overall satisfaction with treatment. Wilcoxon rank-sum tests and longitudinal analysis of covariance models were used to assess outcomes over time.
Results: At 4 weeks, mean PRTEE scores were 47.6 ± 3.7 in the PRP group compared to 14.8 ± 3.9 in the CSI group (P < .001). At 8 weeks, PRTEE scores were 32.1 ± 3.7 for PRP and 15.2 ± 4.0 for CSI (P = .003). At 12 weeks, scores were 26.3 ± 3.9 for PRP versus 16.0 ± 4.1 for CSI (P = .07). By 26 weeks, mean scores favored PRP (17.7 ± 6.5 vs 35.3 ± 6.8; P = .07), and by 52 weeks, PRP scores remained lower (14.4 ± 6.3 vs 29.6 ± 6.3; P = .10). At 4 weeks, mean QuickDASH scores were 22.4 ± 1.1 in the PRP group versus 15.5 ± 1.1 in the CSI group (P < .001). At 8 weeks, PRP scores were 19.3 ± 1.1 compared to 15.8 ± 1.2 for CSI (P = .04). No significant differences were observed at 12 weeks (17.7 ± 1.1 vs 16.6 ± 1.2; P = .49) or 16 weeks (16.8 ± 1.1 vs 18.4 ± 1.2; P = .35). At 26 weeks, QuickDASH scores favored PRP (15.7 ± 1.6 vs 20.3 ± 1.7; P = .05), and this difference persisted at 52 weeks (14.0 ± 1.6 vs 18.6 ± 1.6; P = .05). However, VAS scores were on average 1.5 points lower in the PRP group across all time points.
Conclusion: Our study demonstrated that corticosteroids resulted in greater short-term improvement, while PRP demonstrated superior longer-term outcomes at 6 and 12 months. PRP was associated with lower average VAS scores over time.
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