Objective: Lateral collateral ligament (LCL) injuries can occur in isolation or as part of more extensive posterolateral corner (PLC) injury. Injuries can range from pure varus laxity, due to isolated LCL lesions, to pure posterolateral rotatory laxity from isolated popliteus complex (including popliteo-fibular ligament) lesions, but most injuries occur in combination. Although excess laxity due to PLC injury is usually considered an absolute indication for repair or reconstruction, non-operative management of isolated LCL injuries is also possible. The purpose of the present study is primarily to evaluate the outcome of non-operative treatment in a consecutive series of isolated LCL injuries in elite athletes as reflected by successful return to play, performance level, and rates of continued play at two- and five-years post injury. Furthermore, we hypothesised that the clinical and radiological grading of LCL injuries do not correlate. Methods: A consecutive series of elite athletes with posterolateral corner (PLC) injuries of the knee treated by two sports knee surgeons between January 2015 and June 2021 was identified. Only those with isolated LCL injuries were included. Data pertaining to clinical examination findings, radiological findings, treatment, return to play times, performance levels, and subsequent career longevity were collected. Results: Fifty-five professional athletes (44 soccer players), with a mean age of 24.3 years +/- 26 4.5 years, with MRI-confirmed isolated LCL injuries were included in final analysis. Clinical examination findings were notable for grade 0 laxity in 7/55 (12.7%) athletes, grade 1 in 42/55 (76.4%), grade 2 in 6/55 (10.9%), and grade 3 in 1/55 (1.8%). All patients were treated with restricted activities and rehabilitation. MRI grading and clinical grading showed low correlation (r =0.37, p = 0.01). Return to play (RTP) was 100% at a mean of 96.8 (±75.6) days. At 2 years, 51 athletes (92.7%) were still playing elite sport. At 5 years participation in elite sport reduced to 84.4% (27 of 32 players). All athletes returned to their pre-injury level of play. No athletes stopped elite sport secondary to their LCL injury. Discussion: The current data suggests that non-operative management of isolated LCL injuries, including high grade 2-3 MRI grading, is associated with high return to pre-injury level of sport (100%), reasonable recovery times (median 76 days), and no significant residual varus instability. There is low correlation of MRI grade of isolated LCL injury with clinical examination findings. The authors recommend these lesions be treated without surgery in nearly all cases.

Background:Lateral collateral ligament (LCL) injuries can occur in isolation or as part of more extensive posterolateral corner (PLC) injury. Although excess laxity due to PLC injury is usually considered an absolute indication for repair or reconstruction, nonoperative management of isolated LCL injuries is also possible. Purpose/Hypothesis:The purpose of the present study is primarily to evaluate the outcome of nonoperative treatment in a consecutive series of isolated LCL injuries in elite athletes as reflected by successful return to play (RTP), performance level, and rates of continued play at 2 and 5 years after injury. Furthermore, it was hypothesized that the clinical and radiological grading of LCL injuries do not correlate. Study Design:Case series; Level of evidence, 4. Methods:A consecutive series of elite athletes with PLC injury of the knee treated by 2 sports knee surgeons between January 2015 and June 2021 was identified. Only those with isolated LCL injuries as identified on magnetic resonance imaging (MRI) and by a lack of any abnormal rotatory laxity were included. Data pertaining to clinical examination findings, radiological findings, treatment, RTP times, performance levels, and subsequent career longevity were collected. Results:A total of 55 professional athletes (44 soccer players), with a mean ± SD age of 24.3 ± 4.5 years, with MRI-confirmed isolated LCL injuries were included in final analysis. Of the total cohort, clinical examination findings were notable for grade 0 laxity in 7 (12.7%) athletes, grade 1 in 42 (76.4%), grade 2 in 6 (10.9%), and grade 3 in 1 (1.8%). All patients were treated with restricted activities and rehabilitation. MRI grading and clinical grading showed low correlation (r = 0.37; P = .01). RTP was 100% at a mean of 103 (0-422) days (median of 76 days [2.5 months]). At 2 years, 51 athletes (92.7%) were still playing elite sport. At 5 years, participation among the 32 athletes still playing in elite sport reduced to 84.4% (n = 27 players). All athletes returned to their preinjury level of play. No athletes stopped elite sport secondary to their LCL injury. Conclusion:The current data suggest that nonoperative management of isolated clinically diagnosed grades 1 and 2 LCL injury is associated with high return to preinjury level of sport (100%), reasonable recovery times (median of 76 days), and no significant residual varus laxity. There was low correlation of MRI grade of isolated LCL injury with clinical examination findings. The authors recommend these lesions be treated without surgery.

Abstract Background Understanding common MRI findings may allow clinicians to appreciate the sport-specific effects on the lumbar spine, and to discern clinically significant pathology. Prevalence data regarding radiological abnormalities seen during the surveillance of asymptomatic elite footballers is, therefore, important to help understand injury mechanisms and to prevent associated injuries. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) findings in the lumbar spines of asymptomatic elite male adolescent footballers. Methods A prospective cross-sectional study design was used. MRI was performed using a 3T Siemens Prisma scanner including a 3D VIBE sequence in 18 asymptomatic male elite adolescent footballers recruited from a professional academy in England (mean age 17.8, range 16.9–18.6 years). The images were independently reported by two consultant musculoskeletal radiologists to achieve consensus opinion. Standardised classification criteria were used to assess and report abnormalities descriptively Results Fifteen players (15/18, 83.3%) showed ≥1 abnormalities, included facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury. One player (1/18, 5.56%) had mild (Grade 1) facet joint arthropathy at L4/L5 and 3/18 (16.7%) showing evidence of bilateral facet joint effusions. Three synovial cysts were identified in 2/18 players, 4/18 players presented asymptomatic pars injuries, with 4 showing a grade 2 subtotal stress fracture and 1 player a grade 4 chronic stress fracture seen on 3D VIBE sequencing. Disc degeneration at one or more levels was demonstrated in 7/18 players. Disc herniation was present in 5/18 players. Conclusions A range of unsuspected findings on MRI of the lumbar spine are common in elite adolescent footballers. MRI 3D VIBE may be useful to diagnose and assess healing of pars injuries in elite footballers and could negate the need to expose players to ionising radiation (e.g., computed tomography).

Background Understanding common MRI findings may allow clinicians to appreciate the sport-specific effects on the lumbar spine, and to discern clinically significant pathology. Prevalence data regarding radiological abnormalities seen during the surveillance of asymptomatic elite footballers is, therefore, important to help understand injury mechanisms and to prevent associated injuries. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) findings in the lumbar spines of asymptomatic elite male adolescent footballers. Methods A prospective case-series study was carried out. MRI was performed using a 3T Siemens Prisma scanner including a 3D VIBE sequence in 18 asymptomatic male elite adolescent footballers recruited from a professional academy in England (mean age 17.8, range 16.9–18.6 years). The images were independently reported by two consultant musculoskeletal radiologists to achieve consensus opinion. Standardised classification criteria were used to assess and report abnormalities descriptively. Results Fifteen players (15/18, 83%) showed ≥1 abnormalities, included facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury. One player (1/18, 6%) had mild (Grade 1) facet joint arthropathy at L4/L5 and 3/18 (16.7%) showing evidence of bilateral facet joint effusions. Three synovial cysts were identified in 2/18 players (11%), 4/18 players (22%) presented asymptomatic pars injuries, with 4 showing a grade 2 subtotal stress fracture and 1 player a grade 4 chronic stress fracture seen on 3D VIBE sequencing. Disc degeneration at one or more levels was demonstrated in 7/18 players (38%). Disc herniation was present in 5/18 players (27%). Conclusion A range of unsuspected findings on MRI of the lumbar spine are common in elite adolescent footballers.

Medial menisco-capsular separations (ramp lesions) are typically found in association with anterior cruciate ligament (ACL) deficiency. They are frequently missed preoperatively due to low MRI sensitivity. The purpose of this article was to describe demographic and anatomical risk factors for ramp lesions, and to identify concomitant lesions and define their characteristics to improve diagnosis of ramp lesions on MRI. Patients who underwent anterior cruciate ligament (ACL) reconstruction between September 2015 and April 2019 were included in this study. The presence/absence of ramp lesions was recorded in preoperative MRIs and at surgery. Patients’ characteristics and clinical findings, concomitant injuries on MRI and the posterior tibial slope were evaluated. One hundred patients (80 male, 20 female) with a mean age of 22.3 ± 4.9 years met the inclusion criteria. The incidence of ramp lesions diagnosed at surgery was 16%. Ramp lesions were strongly associated with injuries to the deep MCL (dMCL, p < 0.01), the superficial medial collateral ligament (sMCL, p < 0.01), and a small medial–lateral tibial slope asymmetry (p < 0.05). There was also good correlation between ramp lesions and bone oedema in the posterior medial tibia plateau (MTP, p < 0.05) and medial femoral condyle (MFC, p < 0.05). A dMCL injury, a smaller differential medial–lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. MRI sensitivity was 62.5% and the specificity was 84.5%. The presence on MRI of sMCL and/or dMCL lesions, bone oedema in the posterior MTP and MFC, and a smaller differential medial–lateral tibial slope than usual are highly associated with ramp lesions visible on MRI. Additionally, a dMCL injury, a flatter lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. Knowledge of the risk factors and secondary injury signs associated with ramp lesions facilitate the diagnosis of a ramp lesion preoperatively and should raise surgeons’ suspicion of this important lesion. Diagnostic study, Level III.

Address correspondence to Andy Williams (email: andy.williams @fortiusclinic.com). Submitted May 3, 2021; accepted May 4, 2021. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically ‘isolated’ ACL ruptures. Patients who underwent ACL reconstruction for complete ‘presumed isolated’ ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient’s characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus ‘ramp’ lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. III.

PURPOSE:The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures.METHODS:Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded.RESULTS:Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus).CONCLUSION:There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Background: Subcircumferential periosteal edema above the ankle joint is frequently present on magnetic resonance imaging (MRI) with syndesmosis injuries but has not been previously reported. Fluid height within the interosseous membrane also has not previously been shown to be associated with syndesmosis injury severity.Purpose: To investigate whether a new sign on MRI and measurement of the length of fluid within the interosseous membrane above the ankle may be used to enable identification of a syndesmosis injury and allow differentiation from lateral ligament injury.Study Design: Cohort study (diagnosis); Level of evidence, 3.Methods: Three groups of patients (those with an isolated syndesmosis injury [SI group], isolated lateral ligament injury [LLI group], and no injury [NI group]) who had an ankle MRI for another reason were identified from a patient notes database and the MRI scans retrieved. The scans were anonymized and independently assessed by 8 clinicians (surgeons and radiologists) who were blinded to the diagnosis. The maximum length of fluid above the ankle within the intraosseous membrane was measured for each patient. The presence or absence of distal anterior, lateral, and posterior tibial periosteal edema was recorded (broken ring of fire).Results: Measurement of the length of fluid above the ankle had excellent intraobserver reliability (intraclass correlation coefficient, 0.97; 95% CI, 0.93-0.99) but poor interobserver reliability. Fluid extended higher in both the LLI group (P = .0043) and SI group (P = .0058) than the NI group, but there was no significant difference between the LLI and SI groups (P = .3735), indicating that this measurement cannot differentiate between the injuries. The presence of the broken ring of fire around the distal tibia was significantly more frequent in the SI group when compared with both LLI and NI groups (P < .00001). The sensitivity of this sign is 49%, but when present, this sign has a 98% specificity for syndesmosis injury.Conclusion: The presence of tibial subcircumferential periosteal edema 4 to 6 cm above the ankle joint (the ring of fire) is highly suggestive of a syndesmosis injury. This new radiological sign can assist with early identification of such injuries. The measurement of height of fluid above the ankle within the interosseous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

BackgroundThe treatment of osteochondral lesions, especially those with a cystic component or those that have failed the standard arthroscopic procedures can be challenging. Synthetic grafts have several potential advantages over other second line treatments including the fact that only one operation is required and no other joint is violated.MethodWe report the results of the first series of synthetic grafts used in the treatment of osteochondral lesions of the ankle with a minimum of one year follow up.ResultsThere was significant improvement in the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot and Ankle Osteoarthritis Scale (AOS) scores and all patients were satisfied with the results of surgery. Magnetic Resonance Imaging (MRI) scans at one year have demonstrated resolution of the bony cysts and surrounding bone marrow oedema but, worryingly, continued to show high signal on the T2 weighted images within the plugs themselves. Qualitative T2 mapping has suggested a fibrous rather than hyaline appearance of the cartilage portions of the plugs.ConclusionsThe clinical results have been encouraging but more patients and longer follow up are required before firm conclusions can be drawn.

Level of Evidence: V, Expert Opinion