The effect of post-operative patella tilt on functional outcomes after total knee arthroplasty remains unclear. Our study aimed to analyze the relationship of post-operative patellar tilt with functional outcome scores after total knee arthroplasty. Patient data were retrieved from our institution’s prospectively maintained total knee arthroplasty. Three hundred three patients who underwent unilateral TKA from Jan 2012 to March 2017 were included in the study. After excluding patients with incomplete and lost follow-up data, 213 patients were analyzed. Radiographs of pre-operative and post-operative skyline views were used for patella tilt and patella displacement measurement at pre-op, post-op 1 year, and post-op 2 years. Three functional outcome scoring systems, SF-36, KSS, and WOMAC, were applied for function evaluation at different post-operative time points. Patients were divided into three subgroups according to the patella tilt, which includes less than 5°, 5.1–10°, and more than 10°. Statistical analysis was done to identify the relationship between patella tilt and functional outcomes. Mean post-operative patella tilt was significantly lower than the mean pre-operative patella tilt (3.35 ± 3.91 vs. 5.65 ± 4.41, p < 0.001). There was no significant difference in patella displacement among pre- and post-operative status. KSS functional score was significantly poor at post-op 1 year and KSS objective score at post-op 2 years in patients with more than 10° patella tilt. SF-36 and WOMAC were not significantly different among the groups. There was no significant difference in post-operative function between non-resurfaced and resurfaced patella patients evaluated with three scoring systems. We have found significantly less post-operative patella tilt after TKA than pre-operative patella tilt with or without patella resurfacing. Increased post-operative patella tilt of more than 10° can affect specific functional outcomes. Patella resurfacing does not affect the post-operative functional outcome compared to non-resurfacing of the patella post-op 2 years. III.

OBJECTIVE:Despite evidence supporting the efficacy of sport injury prevention programmes (SIPPs) in adolescents, implementation of SIPPs in community settings is low. This review aims to synthesise and integrate evidence on the efficacy of exercise-based SIPPs in reducing injury rates in adolescents with implementation strategies for such programmes in the community.DESIGN:A systematic review with meta-analysis, narrative synthesis and meta-aggregation was conducted, followed by a convergent segregated approach to integrate the findings. Sensitivity and subgroup analyses were conducted. Study appraisal was performed using Joanna Briggs Institute Critical Appraisal Checklists and Mixed Methods Appraisal Tool.DATA SOURCES:Literature search of nine databases was carried out to identify studies in English from January 2012 to December 2022.ELIGIBILITY CRITERIA:Included were randomised controlled trials (RCTs), qualitative or mixed-methods studies. Population included adolescents (10-19 years). Interventions included SIPPs. Outcomes were injury rate and rate ratio (IRR). Phenomena of interest were facilitators and barriers to the implementation of SIPPs.RESULTS:23 studies were included for analysis. Meta-analysis for 16 RCTs showed a protective effect of SIPP (IRR 0.63, 95% CI 0.53 to 0.74, p<0.00001) in adolescents. Meta-aggregation of seven qualitative/mixed-method studies revealed four sets of synthesised findings that impact implementation namely players' perceptions and beliefs, coaches as key facilitators, organisational support and characteristics of the SIPP.CONCLUSION:Implementation of SIPPs provides a 37% risk reduction in adolescents but requires targeting key stakeholders through a top-down multifaceted approach for its efficacy to be translated. Future research should investigate the effectiveness of SIPPs and implementation strategies in adolescents in community settings.

This study aims to compare the rate of meniscal tears after anterior cruciate ligament (ACL) reconstruction in patients who have undergone concomitant meniscal repair during the index procedure with that in patients who have not undergone such surgery. It also evaluates other risk factors, such as age, gender, race, body mass index (BMI), site of concomitant meniscal surgery, and ACL graft failure. This is a retrospective study conducted at a large tertiary public hospital. Patients who underwent primary anterior cruciate ligament reconstruction (ACLR) surgery with or without concomitant meniscal repair from 2011 to 2016 were identified. Patients with old meniscal tears and previous meniscal surgeries were excluded. The aforementioned demographical, injury, and surgical details were obtained and analyzed using univariate and multivariate logistic regression analysis. Our study cohort included 754 patients. Primary ACLR surgery was performed with meniscal repair in 172 (22.8%) of the patients, with meniscectomy in 202 (26.8%) of the patients, and without concomitant meniscal surgery in 380 (50.4%) of the patients. A total of 81 (10.7%) patients developed meniscal tears after the index procedure. Such tears occurred in 12.2% (21 of 172) of the patients who had undergone concomitant meniscal repair during the index ACLR, and in 10.3% (60 of 582) of the patients who had not undergone concomitant meniscal repair (p = 0.30). On multivariate analysis, only ACL graft failure was significantly associated with new meniscal tears (p < 0.001, odds ratio 18.69, 95% confidence interval 9.18-38.05). ACL graft failure is the only independent risk factor for meniscal tears after ACLR surgery in our large cohort of patients. Concomitant meniscal repair was not an associated risk factor.

Abstract Introduction The effect of post-operative patella tracking on functional outcomes after total knee arthroplasty (TKA) remains unclear. Our study aimed to analyze the relationship of post-operative patellar tilt with functional outcome scores at 2 years after total knee arthroplasty. Methods Patient's data were retrieved from our institutions prospectively maintained TKA registry. 303 patients who underwent unilateral TKA from Jan 2012 to March 2017 were included in the study. After excluding patients with incomplete data and lost to follow up data for 231 patients were analyzed. Information was collected from pre-operative as well as post-operative skyline views and three functional outcome scores including SF-36, KSS, and WOMAC at pre-op, post-op 1 year, and post-op 2 years. Patella tilt (PT), patella displacement was calculated from radiology software in PACS. Patients were divided according to PT into 3 subgroups (PT < = 5 degrees, 5.1–10, > 10 degrees). Statistical analysis was done to identify the relationship of patella tilt and 3 functional. Results There was a significant improvement in post-operative patella tilt as compared to pre-operative patella tilt (3.35+-3.91vs5.65+-4.41, p-value = 0.0000). There was no significant difference in patella displacement in the postoperative period as compared to the pre-operative period. KSS functional score was significantly poor at 1 year and KSS objective score at 2 years in patients with PT more than 10 degrees. SF-36 and WOMAC were not significantly different in three subgroups based on PT. Conclusion Poor functional after TKA can be associated with an increase in patella tilt at 2 years follow up. Level of evidence: II

Background: Metabolic disruption commonly follows Anterior Cruciate Ligament Reconstruction (ACLR) surgery. Brief exposure to low amplitude and frequency pulsed electromagnetic fields (PEMFs) has been shown to promote in vitro and in vivo murine myogeneses via the activation of a calcium & ndash;mitochondrial axis conferring systemic metabolic adaptations. This randomized-controlled pilot trial sought to detect local changes in muscle structure and function using MRI, and systemic changes in metabolism using plasma biomarker analyses resulting from ACLR, with or without accompanying PEMF therapy. Methods: 20 patients requiring ACLR were randomized into two groups either undergoing PEMF or sham exposure for 16 weeks following surgery. The operated thighs of 10 patients were exposed weekly to PEMFs (1 mT for 10 min) for 4 months following surgery. Another 10 patients were subjected to sham exposure and served as controls to allow assessment of the metabolic repercussions of ACLR and PEMF therapy. Blood samples were collected prior to surgery and at 16 weeks for plasma analyses. Magnetic resonance data were acquired at 1 and 16 weeks post-surgery using a Siemens 3T Tim Trio system. Phosphorus (31P) Magnetic Resonance Spectroscopy (MRS) was & nbsp;utilized to monitor changes in high-energy phosphate metabolism (inorganic phosphate (Pi), adenosine triphos-phate (ATP) and phosphocreatine (PCr)) as well as markers of membrane synthesis and breakdown (phospho-monoesters (PME) and phosphodiester (PDE)). Quantitative Magnetization Transfer (qMT) imaging was used to elucidate changes in the underlying tissue structure, with T1-weighted and 2-point Dixon imaging used to calculate muscle volumes and muscle fat content. Results: Improvements in markers of high-energy phosphate metabolism including reductions in delta Pi/ATP, Pi/PCr and (Pi & thorn; PCr)/ATP, and membrane kinetics, including reductions in PDE/ATP were detected in the PEMF-treated cohort relative to the control cohort at study termination. These were associated with reductions in the plasma levels of certain ceramides and lysophosphatidylcholine species. The plasma levels of biomarkers predictive of muscle regeneration and degeneration, including osteopontin and TNNT1, respectively, were improved, whilst changes in follistatin failed to achieve statistical significance. Liquid chromatography with tandem mass spec-trometry revealed reductions in small molecule biomarkers of metabolic disruption, including cysteine, homo-cysteine, and methionine in the PEMF-treated cohort relative to the control cohort at study termination. Differences in measurements of force, muscle and fat volumes did not achieve statistical significance between the cohorts after 16 weeks post-ACLR. Conclusion: The detected changes suggest improvements in systemic metabolism in the post-surgical PEMF-treated cohort that accords with previous preclinical murine studies. PEMF-based therapies may potentially serve as a manner to ameliorate post-surgery metabolic disruptions and warrant future examination in more adequately powered clinical trials. The Translational Potential of this Article: Some degree of physical immobilisation must inevitably follow ortho-paedic surgical intervention. The clinical paradox of such a scenario is that the regenerative potential of the muscle mitochondrial pool is silenced. The unmet need was hence a manner to maintain mitochondrial activation when movement is restricted and without producing potentially damaging mechanical stress. PEMF-based ther-apies may satisfy the requirement of non-invasively activating the requisite mitochondrial respiration when mobility is restricted for improved metabolic and regenerative recovery.

The aim of the study is to compare the tear rates of ipsilateral anterior cruciate ligament (ACL) grafts and the contralateral native ACL as well as to investigate the correlation of gender, age at time of surgery, and body mass index (BMI) with the occurrence of these injuries. The medical records of 751 patients who underwent ACL reconstruction surgery with follow-up periods of 2 to 7 years were retrospectively analyzed. Survival analyses of ipsilateral ACL grafts and contralateral native ACL were performed. Univariate and multivariate logistic regression analyses were performed to identify risk factors that were associated with these injuries. The tear rates of the ipsilateral ACL graft and contralateral ACL were 5.86 and 6.66%, respectively with no significant difference between groups (p = 0.998). The mean time of tears of the ipsilateral ACL and contralateral ACL was also similar (p = 0.977) at 2.64 and 2.78 years, respectively after surgery. Both the odds of sustaining an ipsilateral ACL graft and contralateral ACL tear were also significantly decreased by 0.10 (p = 0.003) and 0.14 (p = 0.000), respectively, for every 1-year increase in age at which the reconstruction was performed. However, graft type, gender, and BMI were not associated with an increased risk of these injuries. There was no difference between tear rates of ipsilateral ACL graft and contralateral ACL following ACL reconstruction. Patients who undergo ACL reconstruction at a young age are at an increased risk of both ipsilateral graft and contralateral ACL rupture after an ACL reconstruction. Patients who are young and more likely to return to competitive sports should be counselled of the risks and advised to not neglect the rehabilitation of the contralateral knee during the immediate and back to sports period of recovery. This is a Level III, retrospective cohort study.

The aim of this study was to evaluate the oxidative status in crossbred cows with subclinical mastitis and concurrent metabolic and infectious diseases. The crossbred cows were groped asGp-C (n=6) as controls,Gp-M (n=6) with clinical mastitis ,Gp-TS consists cows affected withstenosis of teat,Gp-RA with ruminal acidosis,Gp-ND with diarrhea along with dehydration and loss of appetite, Gp-RTIwith coughing, fever, decreased appetite, varying degrees of dyspnea, GpRB with a history of failure to conceive after at least two successive inseminations. oxidative stress parameters likecatalase, SOD, GPx, GSH and malondialdehyde were estimated spectrophotometrically. The antioxidant enzymes like catalase, super oxide dismutase (SOD), Glutathione Peroxidase (GPx) levels were significantly declined and the non enzymatic parameters reduced glutathione (GSH) and malondialdehyde (MDA) are significantly elevated in affected animals than in healthy animals. The results of the oxidative stress parameters indicate imbalance of antioxidant profile and oxidative stress in the animals with various disorders and previous illness along with subclinical mastitis.

Background: Infectious diseases and metabolic disorders are common in crossbred cows and adversely affect optimum production as well as quality of milk. The quality of milk plays a significant role in the production of high-quality dairy products. High somatic cell count (SCC) in the milk significantly decreases the potential of such milk for the production of high quality dairy products. In this study, it is hypothesized that the extra-mammary infections and metabolic disorders increase probability of intra-mammary infections thereby increasing somatic cell count in the milk making it unsuitable for dairy industry.Methods: Cows were grouped based on the diseases or disorders like Teat Stenosis (Gp SCM-TS), Ruminal Acidosis (Gp SCM-RA), Nonspecific Diarrhea (Gp SCM-ND), Respiratory Tract Infections (Gp SCM-RTI) and Repeat Breeder Syndrome (Gp SCM-RD). Diagnosis of subclinical mastitis was made on the basis of California Mastitis Test (CMT) scores and by Somatic Cell Count (SCC) by automatic somatic cell counter. Biochemical parameters analyzed in automatic biochemical analyzer using commercially available kits.Result: The mean SCC values significantly higher in cows with sublinical mastitis and with concurrent infectious and metabolic diseases. Similarly, the concentrations of serum alkaline phosphatase (ALP), aspartate amino transferase (AST), and alanine amino transferase (ALT) were higher in affected cows. Concentrations of serum total proteins (TP) and blood urea nitrogen (BUN) in all the groups of affected animals were higher. The changes in the calcium (Ca) and phosphorus (P) levels were not observed in cows with subclinical mastitis and with other diseases under study. The SCC values did not correlate with the values of ALP, AST, ALT, TP, BUN, Ca and P among the studied groups. It can be concluded that animals with concurrent infections and metabolic disorders increase the SCC and influence the alteration in the biochemical parameters of subclinical mastitic animals.

Objective: Medical image datasets with pixel-level labels tend to have a limited number of organ or tissue label classes annotated, even when the images have wide anatomical coverage. With supervised learning, multiple classifiers are usually needed given these partially annotated datasets. In this work, we propose a set of strategies to train one single classifier in segmenting all label classes that are heterogeneously annotated across multiple datasets without moving into semi-supervised learning. Methods: Masks were first created from each label image through a process we termed presence masking. Three presence masking modes were evaluated, differing mainly in weightage assigned to the annotated and unannotated classes. These masks were then applied to the loss function during training to remove the influence of unannotated classes. Results: Evaluation against publicly available CT datasets shows that presence masking is a viable method for training class-generic classifiers. Our class-generic classifier can perform as well as multiple class-specific classifiers combined, while the training duration is similar to that required for one class-specific classifier. Furthermore, the class-generic classifier can outperform the class-specific classifiers when trained on smaller datasets. Finally, consistent results are observed from evaluations against human thigh and calf MRI datasets collected in-house. Conclusion: The evaluation outcomes show that presence masking is capable of significantly improving both training and inference efficiency across imaging modalities and anatomical regions. Improved performance may even be observed on small datasets. Significance: Presence masking strategies can reduce the computational resources and costs involved in manual medical image annotations. All codes are publicly available at https://github.com/wong-ck/DeepSegment.

PURPOSE:To compare the clinical outcomes of the routine use of 5-strand hamstring grafts (where possible) with those of 4-strand grafts in primary anterior cruciate ligament (ACL) reconstruction. METHODS:A total of 64 patients were enrolled in a prospective randomized controlled study comparing the use of 5-strand and 4-strand semitendinosus-gracilis autografts in single bundle ACL reconstruction (n = 32 in each group). Four participants in each group were lost to follow-up and were excluded from the outcome analysis. The outcomes of 28 patients in the 5-strand group and 28 patients in the 4-strand group were analyzed. The diameters of all grafts were measured intraoperatively. Patients were assessed postoperatively at 2 years with objective assessments (anterior knee laxity using the KT-2000 arthrometer, Lachman test, pivot-shift test, hop test) and patient-reported outcome scores (Lysholm knee score, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee subjective knee score, SF-36 physical and mental components, Tegner activity scale). Postoperative graft ruptures were also noted. RESULTS:There were improvements in all outcome measures postoperatively regardless of the number of graft strands. When we compared the study and control groups, there were no significant differences in all subjective and objective outcome measures except the Knee Injury and Osteoarthritis Outcome Score symptoms score (5-strand group 93.3 ± 9.2 vs 4-strand group 86.2 ± 14.7, P = .04). The KT-2000 side-to-side difference was 2.79 ± 2.11 mm in the 5-strand group and 2.54 ± 1.75 mm in the 4-strand group (P = .63). The 5-strand study group had 2 graft ruptures at 1 year, whereas the 4-strand control group had one partial graft rupture at 6 months. CONCLUSIONS:At 2-year follow-up, the routine use of the 5-strand hamstring tendon autograft was not superior to that of the quadrupled or 4-strand graft in primary ACL reconstruction. LEVEL OF EVIDENCE:Level I, prospective randomized controlled trial.

PurposeIn this framework, the three dimensional (3D) flow of hydromagnetic Carreau nanofluid transport over a stretching sheet has been addressed by considering the impacts of nonlinear thermal radiation and convective conditions.Design/methodology/approachInfinite shear rate viscosity impacts are invoiced in the modeling. The heat and mass transport characteristics are explored by employing the effects of a magnetic field, thermal nonlinear radiation and buoyancy effects. Rudimentary governing partial differential equations (PDEs) are represented and are transformed into ordinary differential equations by the use of similarity transformation. The nonlinear ordinary differential equations (ODEs), along with the boundary conditions, are resolved with the aid of a Runge-Kutta-Fehlberg scheme (RKFS) based on the shooting technique.FindingsThe impact of sundry parameters like the viscosity ratio parameter (β*), nonlinear convection parameters due to temperature and concentration (βT, βC), mixed convection parameter (α), Hartmann number (M2), Weissenberg number (We), nonlinear radiation parameter (NR), and the Prandtl number (Pr) on the velocity, temperature and the concentration distributions are examined. Furthermore, the impacts of important variables on the skin friction, Nusselt number and the Sherwood number have been scrutinized through tables and graphical plots.Originality/valueThe velocity distribution is suppressed by greater values of the Hartmann number. The velocity components in the tangential and axial directions of the fluid are raised with the viscosity ratio parameter and the tangential slip parameter, but these components are reduced with concentration to thermal buoyancy forces ratio and stretching sheet ratio.

Importance Septic arthritis of the native knee joint is the most common bacterial joint infection. The management involves prompt surgical debridement and joint irrigation by arthroscopy or arthrotomy. This is the first systematic review and meta-analysis to compare arthroscopic debridement with arthrotomy for septic arthritis of native knee joint. Objective The purpose of this systematic review and meta-analysis is to compare re-operation rates, length of inpatient hospital stay (LOS) and functional outcome between arthroscopy and arthrotomy in the treatment of acute septic arthritis of the native knee joint. Evidence review This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched from database inception to 31 May 2019. All original studies that compared re-operation rates and LOS between arthroscopy and arthrotomy for septic arthritis of knee were included. The research question and eligibility criteria were established a priori. Pertinent data were extracted and random-effects model was used to pool the data where possible. Findings A total of seven studies with 1089 knees were included, of which 723 underwent arthroscopic surgery and 366 knees underwent arthrotomy. The relative risk of re-operation was significantly lower in the arthroscopy group with a pooled relative risk of 0.69 (95% CI 0.56 to 0.86; p=0.0006). All studies reported shorter LOS and one study reported better functional outcomes in the arthroscopy group as compared with arthrotomy. However, the data could not be quantitatively synthesised due to variation in reporting among the studies included. Conclusions and relevance Based on the available evidence, we conclude that arthroscopy for the treatment of septic arthritis of the knee results in a lower re-operation rate than arthrotomy. It cannot be concluded whether arthroscopic treatment results in shorter LOS or better functional outcome as compared with arthrotomy. Level of evidence IV

PurposeThe purpose of this prospective, randomized, double-blinded, placebo-controlled study was to determine if pregabalin, when given perioperatively in addition to patient-controlled analgesia morphine, paracetamol and etoricoxib, is effective in reducing morphine requirements and moderating pain scores after primary total knee arthroplasty. We hypothesize that there would be no difference in postoperative opioid requirements, postoperative pain scores, and functional scores with the use of perioperative pregabalin.MethodsEighty-seven patients who underwent primary total knee arthroplasty were randomised and allocated to two groups. One group received capsules containing pregabalin 75mg, and the other a placebo-one capsule before surgery and one capsule once per night up till postoperative day 2. Multimodal analgesia provided for all patients in this study included femoral nerve block, intravenous patient-controlled analgesia (morphine), paracetamol and etoricoxib. The primary outcome of patient's pain control was based on the measurement of cumulative morphine consumption during the first 72h postoperatively.ResultsPregabalin did not reduce the cumulative or effective morphine consumption at 48h and 72h post-operation. There were also no significant differences noted in pain scores at 48h and 72h after surgery, functional range of motion of the operated knee at 72h post-op, or outcomes recorded on the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 36-Item Short Form Survey (SF-36) questionnaires at 3 and 6months post-op. None of the patients demonstrated common adverse reactions to pregabalin.ConclusionThis study showed no reduction in postoperative opioid requirements, or improvement in early postoperative pain scores or functional outcomes at 6months, with perioperative use of pregabalin. Orthopaedic surgeons may consider this when selecting an analgesic regimen for their patients.Level of evidenceII.

Dear Editor, Osteoarthritis (OA) of the knee is a common condition and increases in occurrence and severity with advancing age.1 Total knee arthroplasty (TKA) can significantly improve patient function and quality of life in cases of severe disease.2-4 However, preoperative and postoperative patient-reported outcomes may be influenced by physical characteristics—a well known example being body mass index (BMI).5 In addition, ethnic differences in knee OA have been suggested in some large studies showing that African Americans in the general population had poorer preoperative functional scores, greater prevalence of valgus malalignment and greater severity of radiographic knee OA compared to Caucasians.6-9 Joshy et al revealed that Indian and Pakistani patients had poorer preoperative Knee Society Scores compared to Caucasians in Birmingham, United Kingdom10 while Gandhi et al found that Asians in Toronto, Canada had poorer preoperative function than their Caucasian counterparts.5 Differences between different Asian ethnicities have not been well established. Singapore has a multiracial community of Chinese (74.2%), Indians (9.5%) and Malays (13.3%)11 and is therefore a suitable location to study differences among these Asian ethnic groups. In this study, we evaluated differences among Chinese, Indians and Malays undergoing TKA in our institution, in terms of preoperative scores and postoperative outcomes at the end of 1and 2-years.

Background: Quadrupled (4-strand) hamstring tendon autografts are commonly used in anterior cruciate ligament (ACL) reconstruction, but there is significant variability in their diameter. The 5-strand hamstring autograft has been used as a means of increasing the graft diameter in patients with undersized hamstring grafts. Purpose: To report the outcomes of primary ACL reconstruction using 5-strand hamstring autografts in patients in whom the 4-strand configuration produced a graft diameter of <8 mm and to compare these outcomes with those of ACL reconstruction using 4-strand semitendinosus-gracilis autografts with a graft diameter of ≥8 mm. Study Design: Cohort study; Level of evidence, 2. Methods: The primary study group comprised 25 patients who underwent ACL reconstruction using a 5-strand hamstring autograft. The comparison group comprised 20 patients who underwent ACL reconstruction using a 4-strand hamstring autograft with a graft diameter of ≥8 mm. Interference screw fixation was used at the tibial and femoral ends for both groups of patients. Subjective questionnaires, including the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score, and the Physical Component Summary and Mental Component Summary of the Short Form–36 (SF-36), were administered preoperatively as well as at 1- and 2-year follow-up visits. Results: There were no significant differences in the patient demographics and preoperative scores between the 2 groups. The mean graft diameter was 9.06 ± 0.60 mm in the 5-strand group and 8.13 ± 0.32 mm in the 4-strand group ( P < .05). There was no statistically significant difference between groups on postoperative Lysholm, KOOS Pain, KOOS Symptoms, KOOS Activities of Daily Living, KOOS Sports, KOOS Quality of Life, and SF-36 Physical Component Summary scores. Conclusion: In primary ACL reconstruction, the 5-strand hamstring autograft achieves clinical outcomes that are comparable to those of the 4-strand hamstring autograft with a graft diameter of ≥8 mm. The 5-strand graft technique is therefore a useful means of increasing the graft diameter when faced with an undersized hamstring graft.

PurposeTo verify the correlation of time to surgery with the prevalence of concomitant intra-articular injuries detected on arthroscopy during anterior cruciate ligament (ACL) reconstruction.MethodsThe medical records of 653 patients who underwent ACL reconstruction surgery were retrospectively analyzed. Univariate and multivariate logistic regression analysis was performed to identify factors that were associated with the presence of at least one intra-articular injury, medial meniscus tears, lateral meniscus tears and chondral injuries at the time of surgery. Further univariate analysis was conducted to determine the earliest time-point for surgery, after which the rate of concomitant injuries was significantly higher.ResultsLonger time to surgery (OR 1.019 95% CI 1.010, 1.028, p=0.000), male sex (OR 1.695 95% CI 1.074, 2.675 p=0.023), and higher BMI (OR 1.050 95% CI 1.006, 1.097 p=0.025) were correlated with a higher prevalence of medial meniscus tears. There was an increased prevalence of medial meniscus tears when surgery was carried out more than 12months after the index injury (OR 2.274 95% CI 1.469, 3.522, p=0.000). The correlation between longer time to surgery and chondral injuries approached statistical significance (OR 1.006 95% CI 0.999, 1.012, p=0.073). However, a longer time to surgery was not associated with an increased prevalence of lateral meniscus tears (OR 1.003 95% CI 0.998, 1.009, p=n.s.).ConclusionsLonger time to surgery is associated with an increased prevalence of medial meniscus tears in ACL reconstruction. Surgery performed within 12months of the index injury reduces the prevalence of medial meniscus tears. Prioritizing males and overweight patients for counselling and early intervention can be considered.Level of evidenceTherapeutic level III retrospective cohort study.

The current review aims to compare the outcomes of anterior cruciate ligament (ACL) reconstruction in the female population after patellar-tendon-bone and hamstring grafts. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All original randomized controlled trials and prospective cohort studies that compared clinical outcomes after female ACL reconstruction using hamstring versus patellar-tendon-bone grafts were included. All clinical outcomes reported by three or more studies were included. Fifteen publications, with 948 female patients, were included. Most outcomes were reported to have no significant graft differences by all studies that reported the outcome. These included all the outcomes for objective knee scores (International Knee Documentation Committee [IKDC] objective knee score), neuromuscular testing (quadriceps strength, hamstring strength, and single hop test), graft rupture or failure, and subjective knee scores (Lysholm score and IKDC subjective knee score). The pivot shift test, flexion deficit, and presence of crepitus were also reported to have no significant graft differences by all studies. Some studies reported a significant difference in anteroposterior laxity (Lachman's test and instrumented laxity), range of motion deficits (extension deficit), and sports and activity level (Tegner score). However, these statistically significant differences were noted to be clinically insignificant due to the normal population variation or standard error of measurement of these tools of evaluation. Patients reconstructed with patellar-tendon-bone grafts have a higher risk of kneeling pain. There was no significant difference in the incidence of crepitus. Most of the outcomes following female ACL reconstructions showed no clinically and statistically significant difference when either patellar-tendon-bone or hamstring autograft was used. These included outcomes for anteroposterior laxity, objective knee scores, neuromuscular testing, graft rupture or failure, subjective knee scores, sports and activity level, and crepitus. This a level II study.

The purpose of this study was to describe our surgical technique of using five-strand hamstring autograft with interference screw fixation in primary anterior cruciate ligament (ACL) reconstruction and to report the early postoperative outcomes of this technique. Patients who underwent primary ACL reconstruction using five-strand hamstring autografts with interference screw fixation between December 2014 and June 2016 were included in this study. The five-strand configuration was used in these patients because the four-strand configuration produced a graft diameter of less than 8 mm. Subjective questionnaires, including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm Score, were administered preoperatively, as well as at 1- and 2-year follow-ups. Paired t-test was used to compare the pre- and postoperative outcome scores. The study group comprised 25 patients. There were no intraoperative complications. The mean follow-up period was 17.8 months (12-24). There were 19 males and 6 females. The median age was 24 years (16-41), and median body mass index was 23.9 (18.5-30.2). The median diameter of the five-strand graft was 9 mm (8-10 mm), with a mean of 9.06 +/- 0.60 mm. This was associated with a median graft length of 90 mm (80-100 mm). The postoperative Lysholm, KOOS symptoms, KOOS Pain, KOOS daily function, KOOS sports function, KOOS quality of life, and Short Form-36 Physical Component Summary scores improved significantly compared with the preoperative scores. The use of the five-strand hamstring graft with interference screw fixation in primary ACL reconstruction is associated with significant improvements in patient-reported outcomes in the early postoperative period. The five-strand graft technique is a useful means of increasing graft diameter when faced with an undersized hamstring graft.

BACKGROUND:Anterior cruciate ligament (ACL) injuries are frequently associated with bone bruises, and their presence may be associated with concomitant intra- and extra-articular injuries. PURPOSE:To investigate the prevalence and pattern of distribution of bone bruises in patients with acute ACL tears from noncontact sports trauma and their association with specific intra- and extra-articular injuries. STUDY DESIGN:Cross-sectional study; Level of evidence, 3. METHODS:A total of 168 patients underwent magnetic resonance imaging (MRI) within 6 weeks of sustaining an ACL tear. Information regarding their demographics as well as MRI evidence of bone bruise patterns and associated injuries was carefully documented. Univariate and multivariate logistic regression analyses were performed to determine the association between bone bruises and concomitant intra- and extra-articular injuries seen on MRI. RESULTS:Bone bruises were observed in 155 (92.3%) of 168 patients. The prevalence of bone bruises was 83.9%, 78.6%, 56.5%, and 29.8% on the lateral tibial plateau, lateral femoral condyle, medial tibial plateau, and medial femoral condyle, respectively. A total of 110 (65.5%) patients had bone bruises in both the medial and lateral compartments of the knee, 41 (24.4%) had isolated lateral compartment bone bruises, 4 (2.4%) had isolated medial compartment bone bruises, and 13 (7.7%) did not have any bone bruises. None of the demographic factors were significantly associated with the presence or absence of bone bruises. The presence of bone bruises was significantly associated with lateral meniscal injuries (P = .05). Lateral compartment bone bruises were significantly associated with lateral meniscal injuries (P = .034), while bone bruises affecting both the lateral and medial compartments were significantly associated with medial collateral ligament (MCL) injuries (P = .044) and lateral collateral ligament (LCL) injuries (P = .038) in addition to lateral meniscal injuries (P = .022). CONCLUSION:Bone bruises are common in patients with acute ACL tears after noncontact sports injuries. The compartmental distribution of bone bruises is associated with concomitant intra- and extra-articular injuries. Bone bruises involving the lateral compartment of the knee are associated with lateral meniscal injuries, while bone bruises involving both the lateral and medial compartments of the knee are associated with MCL and LCL injuries in addition to lateral meniscal injuries.

PurposeIncreased knee pain at the time of anterior cruciate ligament (ACL) reconstruction may predict increased pain post-operatively, a prolonged recovery and a more difficult rehabilitation. The main objective of our study was to identify preoperative factors, such as concomitant intra-articular injuries and bone bruises, that may be associated with increased knee pain and symptoms in patients undergoing ACL reconstruction.MethodsPatient data was queried from our institution's prospectively maintained ACL reconstruction registry. Two-hundred and seventy patients who underwent primary ACL reconstruction within 3 months of injury were included in the study. Predictors such as demographic characteristics (age, body mass index and gender) and injury characteristics (mechanism of injury, meniscal injury, chondral injury and bone bruise) were recorded. The association between the pre-operative knee injury and Osteoarthritis Outcome Score (KOOS) pain and symptom subscales and the Short Form-36 (SF-36) bodily pain subscale, and the predictors were assessed using logistic regression for categorical variables and linear regression for continuous variables.ResultsThe mean age of our patient group was 25.4years with 211 out of 270 (78%) being males. Bone bruise was present in 243 patients (90%), meniscal injury in 165 (61%) patients and chondral injury in 40 (15%) patients. The presence of bone bruise, meniscal injury or chondral injury was not significantly associated with worse preoperative KOOS pain and symptom and SF-36 bodily pain scores. Other factors that were not associated were demographic characteristics (age, BMI and gender) and mechanism of injury.ConclusionThe presence of bone bruise and concomitant intra-articular injuries does not affect pre-operative knee pain and symptoms in patients undergoing ACL reconstruction within 3 months of injury. This knowledge would aid the surgeon in pre-operative counselling, and prognostication of post-operative pain and rehabilitation after ACL reconstruction.