Intraarticular injuries associated with anterior cruciate ligament tear: findings at ligament reconstruction in high school and recreational athletes. An analysis of sex-based differences

BACKGROUND: Despite research on the increased risk of anterior cruciate ligament tears in female athletes, few studies have addressed sex differences in the incidence of associated intraarticular injuries. HYPOTHESIS: When patients are stratified by sport and competition level, no sex differences exist in either the mechanism of injury or pattern of intraarticular injuries observed at anterior cruciate ligament reconstruction. STUDY DESIGN: Prospective cohort study. METHODS: Two hundred twenty-one athletes undergoing anterior cruciate ligament reconstruction met our inclusion criteria of anterior cruciate ligament tear as a singular event without reinjury or history of prior injury or surgery in either knee. Data were collected on competition level (high school, amateur), sport (basketball, soccer, skiing), mechanism of injury, articular cartilage injuries, and meniscal tears. Data were statistically analyzed by sex with the chi-square test and Student's t-test. RESULTS: High school athletes had no significant sex differences in mechanism of injury. Female soccer athletes had fewer medial meniscal tears than did male athletes, and female basketball players had fewer medial femoral condyle injuries. At the amateur level, female basketball players had more contact injuries, an earlier onset of swelling, and fewer lateral meniscal tears than did male players. CONCLUSION: At the high school level, male and female athletes shared a common mechanism of injury, and yet the female athletes had fewer intraarticular injuries in basketball and soccer. If such intraarticular injuries prove to be a significant risk factor for poor long-term outcome, women may enjoy a better prognosis after reconstruction.     

膝关节半月板及其损伤的MRI研究

目的　研究正常和损伤的膝关节半月板的MRI表现。方法　对经手术、关节镜或临床证实的 2 6例共 3 2个损伤的半月板与 15例正常的膝关节半月板进行回顾性MRI对比观察。结果　显示正常膝关节半月板在T1WI和T2 WI上均呈三角形低信号。 3 2个损伤的半月板 ,其中内侧损伤 15个 ,外侧损伤 11个 ,两侧半月板同时损伤 3例 6个 ,将 3 2个损伤的半月板按Stoller的 4级分法分类 ,其中 0级 0个 ,I级 6个 ,Ⅱ级 12个 ,Ⅲ级 14个。 18例出现并发症 ,其中合并半月板囊肿 6例 ,内侧副韧带损伤 10例 ,外侧副韧带损伤 9例 ,前交叉韧带损伤 7例 ,后交叉韧带损伤 6例 ,骨挫伤 8例 ,骨折 5例 ,关节囊积液 11例 ,膝关节周围软组织内瘀血 6例。结论　MRI能够清晰显示膝关节半月板的解剖结构 ,能准确诊断半月板的损伤并进行分级 ,还能发现多种并发症。     

Anterior medial meniscus detachment and anterior cruciate ligament tear

This paper reports on two cases of medial meniscus injury involving detachment of the anterior horn together with a coronary ligament tear. Both cases were associated with tearing of the anterior cruciate ligament. The meniscal injuries observed were similar to those reported in the literature prior to the development of arthroscopic surgery. Variant attachments of the anterior horn of the medial meniscus are thought to have contributed to this injury.     

Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. A long-term follow-up study.

From a total of 293 patients who had an acute, complete anterior cruciate ligament rupture, we selected all patients (N = 55) who had an anterior cruciate ligament rupture without associated meniscal or ligamentous injuries, and all patients (N = 52) who had an anterior cruciate ligament rupture combined with a rupture, and subsequent primary repair, of the medial collateral ligament. Initially, all patients were assigned to one of two groups: conservative treatment of the anterior cruciate ligament or augmented anterior cruciate ligament repair with the iliotibial band. In the 52 patients who had an anterior cruciate ligament rupture combined with a medial collateral ligament rupture, the associated injuries to the medial collateral ligament and sometimes the posterior oblique ligament, meniscus, and arcuate ligament complex were treated in a similar fashion, without regard to the treatment of the anterior cruciate ligament. Ninety-nine patients (93%) were reexamined 35 to 74 months after the injury, and knee function was evaluated with subjective and objective criteria, including functional tests. Patients who had been treated with augmented anterior cruciate ligament repair had superior stability with better subjective results and returned to strenuous activities more frequently than patients who had undergone conservative treatment. In those patients who had augmented repair, the prognosis did not differ between those who had isolated lesions and those who had combined lesions. Conservative treatment of the anterior cruciate ligament with repair of the medial collateral ligament and other associated injuries, when present, resulted in an almost equally unfavorable outcome for patients with combined and isolated anterior cruciate ligament lesions.     

Incidence and location of bone bruises after acute posterior cruciate ligament injury

BACKGROUND: In patients suffering from an anterior cruciate ligament injury, the incidence and location of bone bruises are well documented. This study reports data regarding bone bruises after acute posterior cruciate ligament injury. HYPOTHESIS: Bone bruises associated with posterior cruciate ligament injury are common, and their location differs from those seen with anterior cruciate ligament injury. STUDY DESIGN: Retrospective cohort study. METHODS: Thirty-five consecutive patients were identified as having a grade II or III posterior cruciate ligament tear, with an intact anterior cruciate ligament, in which a magnetic resonance imaging scan had been obtained within 20 days of injury. Magnetic resonance imaging scans were reviewed to document bone bruises, associated medial or lateral ligamentous injury, and meniscal and chondral abnormalities. RESULTS: Of the 35 patients, 29 (83%) had a bone bruise in at least one location. Bone bruises were found throughout the joint, more widely dispersed than is commonly seen with anterior cruciate ligament injury. Also, 29 patients had magnetic resonance imaging findings of associated ligamentous injury. Lateral bone bruises were associated with medial collateral ligament injury, whereas medial bone bruises correlated with posterolateral injury. CONCLUSIONS: The incidence of bone bruises associated with posterior cruciate ligament injury is similar to that seen with anterior cruciate ligament injury. Their location is more widely dispersed. The location of a bone bruise should lead to careful magnetic resonance imaging inspection and physical examination for ligamentous injury to the opposite side of the joint. Truly isolated posterior cruciate ligament injuries are rare, as most occur with osseous and some degree of associated ligamentous injury.     

The effect of anterior cruciate ligament reconstruction on the risk of knee reinjury

BACKGROUND: Although there is evidence that very active, young patients are better served with anterior cruciate ligament reconstruction, there is a lack of objective data demonstrating that future knee injury is prevented by these procedures. HYPOTHESIS: Anterior cruciate ligament reconstruction protects against reinjury of the knee that would require reoperation. STUDY DESIGN: Retrospective cohort study. METHODS: A cohort of 6576 active-duty army personnel who had been hospitalized for anterior cruciate ligament injury from 1990 to 1996 were identified. Using the Total Army Injury and Health Outcomes Database, the authors followed these individuals for up to 9 years and collected clinical, demographic, and occupational data. These data were evaluated with bivariate and multivariable analyses to determine the effect of anterior cruciate ligament reconstruction on the rate of knee reinjury that required operation. RESULTS: Of the 6576 study subjects, 3795 subjects (58%) underwent anterior cruciate ligament reconstruction and 2781 (42%) did not. The rate of reoperation was significantly lower among the anterior cruciate ligament reconstruction group (4.90/100 person-years) compared with those treated conservatively (13.86/100 person-years; P < .0001). Proportional hazard regression analyses adjusted for age, race, sex, marital status, education, and physical activity level confirmed that anterior cruciate ligament reconstruction was protective against meniscal and cartilage reinjury (P < .0001). Secondary medial meniscal injury was more common than secondary lateral meniscal injury (P < .003). Younger age was the strongest predictor of failure of conservative management leading to late anterior cruciate ligament reconstruction (P < .0001). CONCLUSIONS: Anterior cruciate ligament reconstruction protected against reoperation in this young, active population; younger subjects were more likely to require late anterior cruciate ligament reconstruction. CLINICAL RELEVANCE: Strong consideration should be given to anterior cruciate ligament reconstruction after anterior cruciate ligament injury in young, active individuals.     

Magnetic resonance diagnosis of meniscal tears in patients with acute anterior cruciate ligament tears

OBJECTIVE: To evaluate the accuracy of magnetic resonance imaging in the diagnosis of meniscal tear in patients with acute anterior cruciate ligament tears. METHODS: Magnetic resonance images obtained from 41 patients imaged within 6 weeks of injury who had acute anterior cruciate ligament tears identified at arthroscopy were retrospectively reviewed for meniscal tear. RESULTS: With MR imaging the sensitivity, specificity and accuracy for diagnosing meniscal tears in the presence of acute anterior cruciate ligament tears were 71%, 93%, and 88%; for the lateral meniscal tears were 57%, 100% and 85%; and for the medial meniscal tears were 100%, 88%, 90%. All false negative cases (n = 6) involved the posterior horn of the lateral meniscus. CONCLUSION: In the presence of acute anterior cruciate ligament tears, MRI imaging has relatively low sensitivity for detecting meniscal tears due to missed tears in the lateral meniscus.     

Fresh meniscal allograft transplantation and autologous ACL/PCL reconstruction in a patient with complex knee trauma following knee dislocation--a case report

Instability of the knee joint, particularly in combination with the loss of one meniscus, regularly leads to the early development of arthritis. This paper describes the case of a 19-year-old male with ruptures of the anterior (ACL) and posterior cruciate ligament (PCL) along with the loss of the medial meniscus due to knee dislocation. Combined, time-delayed reconstruction of both the ACL and PCL and the allogenic fresh meniscal transplantation of the medial meniscus without bone plugs were performed. The control arthroscopy performed 6 months post-transplantation revealed good vitality and integration of the grafts as assessed both macroscopically and histologically. A small portion of the posterior horn had to be refixated, and the anterior horn was atrophic. At 24 months after trauma and 13 months following meniscal transplantation, the patient achieved a Lysholm score of 88 points and clinical examination indicated a stable knee. Fresh meniscal allograft transplantation, in combination with autologous ACL and PCL reconstruction, constitutes--in specialized centers--an alternative treatment option for complex trauma of the knee joint with loss of a meniscus.     

前交叉韧带损伤与膝关节骨密度的关系研究

对在我所进行手术的膝关节内损伤３７例进行局部骨密度检测,其中单纯前交叉韧带断裂１０例,前交叉韧带断裂合并内外侧半月板损伤１９例,膝关节内其他损伤但无前交叉韧带损伤的８例。结果显示,全部患者均呈现伤侧骨密度下降,有前交叉韧带断裂的患膝骨密度显著低于膝关节内其他损伤但无前交叉韧带损伤的;前交叉韧带断裂合并半月板损伤的与单纯前交叉韧带断裂相比,骨密度的差异无显著性;前交叉韧带断裂病史在２个月内患膝骨密度显著高于病史长于２个月者。由此建议对前交叉韧带断裂应在伤后２个月内进行修补;此外,当患膝的骨密度低于健侧的７０％时,应在重建前交叉韧带时注意打孔和界面螺丝钉的技术操作,同时适当加强外固定,延长固定时间,以免术后移植骨脱落。     

Usefulness of 99Tcm-MDP knee SPET for pre-arthroscopic evaluation of patients with internal derangements of the knee

The aim of this study was to ascertain whether knee SPET can localize lesion sites in patients with internal derangements of the knee. We performed knee SPET as a pre-arthroscopic examination in 63 consecutive patients. SPET imaging was performed with a triple-headed SPET camera 4 h after the injection of 99Tcm-methylene diphosphonate. Arthroscopic diagnoses were as follows: 28 medial meniscus injuries, 24 lateral meniscus injuries, 31 anterior cruciate ligament (ACL) injuries, three posterior cruciate ligament injuries and one medial collateral ligament injury. Of 30 patients with crescent-shaped increased activity at the medial tibial plateau, 22 had medial meniscus injuries (positive predictive value: PPV 73%); of 17 patients with crescent-shaped activity at the lateral tibial plateau, 13 had lateral meniscus injuries (PPV 76%). Of 18 patients with increased activity at ACL attachment sites (primary sign), 17 had ACL injuries (PPV 94%). Of 27 patients with increased activity at bone impaction sites of ACL injury (secondary sign), 22 had ACL injuries (PPV 81%). Of 32 patients who had either a primary or secondary sign, 26 had ACL injuries (PPV 81%). We conclude that knee SPET is very useful in the management of internal derangements of the knee, particularly in determining the need for arthroscopy by localizing lesion sites.     

The O'Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears

We identified 60 consecutive patients with combined anterior cruciate and medial collateral ligament (ACL-MCL) disruptions that were incurred during athletic endeavors. Each underwent acute reconstruction of the ACL. The arthroscopic data obtained at the time of reconstructive surgery was reviewed in order to determine the incidence of O'Donoghue's triad (the "unhappy triad"), consisting of ACL, MCL, and medial meniscus tears. Patients were subdivided into two groups for analysis based upon the degree of MCL injury at time of presentation (Group I, 35 patients with a second-degree sprain; Group II, 25 patients with a complete, or third-degree injury). Medial meniscus tears were an uncommon finding. Lateral meniscus tears significantly out-numbered medial meniscus tears in both groups, occurring in 25 (71%) of Group I patients and 8 (32%) of those in Group II. Even chondral fractures of the lateral femoral condyle outnumbered medial meniscus tears [6 (17%) versus 4 (11%)] in patients with a second-degree MCL sprain. Furthermore, when present in Group I patients, tears of the medial meniscus were associated with a concomitant lateral meniscus injury. Group II patients were more likely (60%) than Group I not to have any meniscal abnormality at all. We conclude that the classic O'Donoghue triad is, in fact, an unusual clinical entity among athletes with knee injuries; it might be more accurately described as a triad consisting of ACL, MCL, and lateral meniscus tears. This injury combination appears to be more common when an incomplete, or second-degree, tear of the medial collateral has occurred.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers.

To determine if the incidence and patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers are different from those seen in individuals injured in nonskiing athletic activities, we reviewed the records of 150 patients with acute anterior cruciate ligament injuries. All patients had undergone arthroscopic evaluation within 21 days from the time of injury. There were 75 individuals who were injured while skiing and 75 individuals who sustained an injury in some other high-load athletic activity. Associated meniscal injury was documented at the time of arthroscopy and characterized by location, region, zone, depth, shape, size, and stability. Thirty-one of 75 skiers had an associated meniscal injury as compared to 47 of 75 of the nonskiers. This suggested a strong trend of decreased incidence of meniscal injury in the skier group, but the nonskiers had a higher incidence of major meniscal tears that required repair or partial meniscectomy. The location of the meniscal tear was also significantly different. The incidence of isolated lateral meniscal injury in skiers was higher than in nonskiers. There was a strong trend of increased incidence of medial meniscal involvement in the nonskiers than in the skiers. While there was no difference in the zone or region of tear between the two groups, the skier group was more likely to have a longitudinal tear of the posterior horn of the lateral meniscus. In both groups, lateral meniscal tears were more likely to require conservative treatment or partial meniscectomy while medial meniscal tears were more likely to be repaired than excised.     

T-Fix anchor sutures for arthroscopic meniscal repair

The results of arthroscopically repaired meniscal tears with the T-Fix system in a short-term follow-up of 6 months was assessed in a non-comparative, prospective study. The T-Fix device consists of a short, rigid Delrin T attached to a braided, non-absorbable, polyester suture which is preloaded inside and deployed through a delivery (spinal) needle. The T grabs inside the tissue and provides an anchor for the suture. Twenty menisci in 20 patients (mean age 29 years) were repaired. Sports-related injuries were documented in 18 patients. In 15 patients, meniscus tears were repaired 6 months or more after injury. Half of the patients had isolated meniscus injuries. Associated injuries included anterior cruciate ligament (ACL), medial or lateral collateral ligament ruptures. These were not treated at the time of meniscal surgery except for an ACL reconstruction. All tears were longitudinal and positioned mainly in the posterior horn of the medial meniscus. A total of 70 T-Fixes were used with an average of 3 per patient (range 2–7). Only 4 T-Fixes (6%) were unsuccessfully placed, and this occurred early on in the series in 4 patients. In 90% of the patients, the postoperative activity levels returned to preoperative levels, and the clinical symptoms had either resolved or were experienced at a higher level of activity. The T-Fix device was relatively easy to use and could be reliably placed in the meniscus. Postoperatively, there were no complications directly associated with the device. However, further studies are needed to confirmed these results in a long-term follow-up in a larger patient population.     

High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees

In a consecutive series, we treated 41 young patients who had anterior cruciate ligament deficiency, lower limb varus angulation, and varying amounts of posterolateral ligament deficiency. Seventy-three percent of the patients (N = 30) had lost the medial meniscus and 63% (N = 26) had marked articular cartilage damage in the medial compartment. All patients were treated with high tibial osteotomy and, in the majority (N = 34), anterior cruciate ligament reconstruction a mean of 8 months later. Posterolateral reconstructions were also required in 18 knees. A 100% follow-up was obtained at a mean of 4.5 years after osteotomy. Gait analysis testing was done in 17 knees before and after osteotomy. At follow-up, a reduction in pain was found in 71% (29 knees); elimination of giving way, in 85% (35 knees); and resumption of light recreational activities without symptoms, in 66% (27 knees). The patient rating of the knee condition was normal or very good in 37% (15 knees) and good in 34% (14 knees). The mean Cincinnati Knee Rating Score significantly improved from 63 to 82 points. The mean adduction moment, 35% higher than controls preoperatively, significantly decreased to below normal values postoperatively. Correction of varus alignment was maintained in 33 knees (80%). We recommend osteotomy in addition to ligament reconstructive procedures in these knees with complex injury patterns.     

Five-year results of anterior cruciate ligament reconstruction with the Stryker Dacron high-strength ligament

Forty-two consecutive patients (27 male and 15 female, with a mean age of 26 years) suffering from uniflateral chronic anterior cruciate ligament insufficiency underwent surgical reconstruction with a Dacron highstrength ligament (Stryker). In 32 patients the synthetic legament was used as a reinforcement in an iliotibial band intra-articular procedure and in 10 patients as an intra-articular prosthesis without biological reinforcement. There were 24 concomitant injuries such as meniscal tears, status post—meniscectomy or medial collateral ligament insufficiency at the time of reconstruction. The initial injury occurred during soccer in 23 patients and other pivoting sports in 16 patients. Two and 5 years after reconstruction, the patients underwent clinical examination, including the instrumented knee laxity test (OSI), and performed subjective evaluation. The anterior tibial translation was 6.3±2.6mm grater than in the healthy knee, the mean Lysholm score was 78 points, and the Tegner activity score was lower than its pre-injury level. Radiography revealed that 31 of 37 ligaments had ruptured and another 2 ligaments showed more than 5 mm side-to-side increased laxity. The Stryker Dacron high-strength ligament ruptured in more than 80% of the cases and patients could not return to their pre-injury physical performance activities.Supported by grants from the Karolinska Institute     

Successful anterior cruciate ligament reconstruction and meniscal repair in osteogenesis imperfecta

A case of anterior cruciate ligament (ACL) reconstruction with meniscal repair in an osteogenesis imperfecta patient is reported. A 24-year-old female with osteogenesis imperfecta type 1a suffered from a valgus extension injury resulting in tear of ACL and medial meniscus. She underwent an arthroscopic-assisted ACL reconstruction and medial meniscus repair. Meniscal tear at the menisco-capsular junction of the posterior horn of medial meniscus was repaired with three absorbable sutures via inside-out technique. ACL reconstruction was then performed with a bone-patellar tendon-bone allograft. The patient was followed up for 1 year with intact ACL grafts and healed medial meniscus. This case report showed that successful ACL reconstruction and meniscal repair is possible in an osteogenesis imperfecta patient.Level of evidence V.     

前交叉韧带损伤合并内侧半月板桶柄样撕裂的临床治疗

目的:回顾性评估前交叉韧带(ACL)损伤合并内侧半月板桶柄样撕裂(BHT)的关节镜下修补疗效。方法:2002年5月~2007年2月,67例前交叉韧带损伤合并内侧半月板桶柄样撕裂手术病例。入选条件为:红-红区及红-白区损伤、具备可复位性、半月板组织无复合撕裂及明显变性,进行过二次手术探查。手术技术:前交叉韧带关节镜下重建。内侧半月板修补采用关节镜下联合修补方法:后体部至前体部区域采用标准的自内向外缝合技术,后部区域采用经两个后内侧入路的全关节内缝合技术。结果:平均随访40.6个月(12个月~70个月)。二次手术探查结果:完全愈合57例(85%),部分愈合3例(4.5%),不愈合7例(10.4%)。总体成功率(包括完全愈合与部分愈合)为89.5%。临床评估包括交锁、积液、关节间隙压痛、McMurray试验,其中无症状者59例(88%),关节间隙压痛者5例(7.5%),交锁复发3例(4.5%)。膝关节活动度检查显示,3例伸膝受限大于10°,1例出现止血带麻痹。结论:对于ACL合并内侧半月板红-红区及红-白区BHT,在重建ACL的同时采用关节镜下联合修补技术对BHT的全长范围进行有效修补,在平均40个月的随访期内,可以获得89.5%的总体成功率,包括85%的完全愈合率及4.5%的部分愈合率,失效率为10.4%。     

MRI对急性膝关节骨挫伤的临床应用价值

目的：探讨MRI对急性膝关节骨挫伤的临床应用价值。方法：对117例X线平片显示阴性并行MRI检查的外伤性膝关节病例进行回顾性分析,MRI检查时间为外伤后2h．5天,重点观察股骨下端、胫腓骨上端及髌骨的骨质信号,前后交叉韧带、内外侧副韧带、内外侧半月板的完整性和信号情况。结果：急性外伤后骨挫伤的发生率为87．2％（102／117）,合并韧带损伤62例,半月板损伤49例,关节软骨损伤17例,隐性骨折21例。结论：急性膝关节外伤后骨挫伤的发生率较高,MRI能准确显示骨挫伤的部位、范围以及临近结构的损伤,对临床诊断、治疗具有重要意义。     

The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees.

In this study, follow-up data was obtained in 90 of 117 consecutive meniscal repairs. In Group I, there were 68 meniscal repairs in conjunction with anterior cruciate ligament reconstruction, and in Group II, 22 isolated repairs in anterior cruciate ligament stable knees. Meniscal healing was assessed using the criteria established by Henning, by either arthroscopy or arthrography, at a mean of 7 months for isolated repairs and a mean of 10 months for repairs done in conjunction with anterior cruciate ligament reconstruction. Average time from injury to surgery was 19 months in Group I patients, and 14 months in Group II patients. The overall rate of successful healing was 82%. Group I repairs were successful 93% of the time compared to a 50% success rate in Group II (P less than 0.00005). Lateral meniscal repairs fared better than medial repairs in both groups. Although a smaller rim width yielded better overall healing, there was no difference in the mean rim width of the two groups. Patients with anterior cruciate ligament reconstruction did better than those with isolated meniscal repair, regardless of tear length. Older patients had better healing than younger ones. Overall, acute repairs were more successful than repairs of chronic tears. Even so, the chronic Group I patients had a 91% successful healing rate.     

Changes in bone scans after anterior cruciate ligament reconstruction: a prospective study

BACKGROUND: Whether anterior cruciate ligament reconstruction retards the progression of osteoarthrosis is not established. Bone scintigraphy can be useful for monitoring the course of osteoarthrosis. Bone scan findings are abnormal in the majority of patients with anterior cruciate ligament deficiency. Three uptake patterns can be distinguished. HYPOTHESIS: Reconstruction corrects the three abnormal bone scan patterns seen in patients with anterior cruciate ligament deficiency. STUDY DESIGN: Prospective cohort study. METHODS: We performed bone scintigraphy in 80 patients, before and 2 years after anterior cruciate ligament reconstruction. RESULTS: Reconstruction consistently corrected type 2 bone scan pattern (meniscus scan) but not type 1 and 3 patterns (osteoarthrosis and cartilage ulcer scan). Correction of all three patterns decreased among patients who had longer duration of anterior cruciate ligament deficiency and was more reliable for the combined uptake of all three patterns among patients who had less than 6 months of deficiency. CONCLUSION: These findings indicate anterior cruciate ligament reconstruction protects the menisci. Reconstruction may be best performed within 6 months after injury.