The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.     

Incidence and diagnosis of anterior cruciate injuries in the accident and emergency department

A total of 220 consecutive young adults with a traumatic effusion of the knee joint, seen initially in the accident and emergency department, have been reviewed in a weekly orthopaedic acute knee clinic. Of the patients, 80 per cent were seen within 3 days of the injury, and all patients were seen within 8 days of the injury. There were 62 patients (28 per cent) with damage to the anterior cruciate ligament (ACL), of whom 37 patients (17 per cent) had acute complete ACL tears. There were 92 haemarthroses in this series, in which there was a high incidence of ACL damage. The Lachman test was used in this study and identified 73 per cent of the acute complete ACL tears preoperatively and all the chronic ACL injuries. Acute ACL injuries can be diagnose early provided adequate resources are available to provide clinic and theatre facilities. Early diagnosis enables the patients to be given clear advice on future job and sports prospects and allows selection of patients most likely to benefit from augmented repair of the ligament. Associated meniscal lesions can also be identified and treated at an early stage.     

Traumatic hemarthrosis in stable knees

A thorough arthroscopic examination was performed in 90 consecutive patients with sprained knee injuries with hemarthrosis, but without signs of instability or fracture. The source of bleeding was found in all but five joints. Thirty-nine injuries were tears of the cruciate ligament, only three of which were complete tears. Fourteen injuries were (osteo)chondral fractures and six were meniscal lesions. The remainder bled from the synovium or meniscal attachments. The arthroscopic examination resulted in an altered course of treatment in few, if any, of these patients.     

Traumatic hemarthrosis in stable knees

A thorough arthroscopic examination was performed in 90 consecutive patients with sprained knee injuries with hemarthrosis, but without signs of instability or fracture. The source of bleeding was found in all but five joints. Thirty-nine injuries were tears of the cruciate ligament, only three of which were complete tears. Fourteen injuries were (osteo)chondral fractures and six were meniscal lesions. The remainder bled from the synovium or meniscal attachments. The arthroscopic examination resulted in an altered course of treatment in few, if any, of these patients.     

Acute hemarthrosis of the knee: indications for diagnostic arthroscopy

The objective of this study was to define the role of early diagnostic knee arthroscopy for patients with an acute knee injury and hemarthrosis. Forty-five patients with an acute knee injury followed by a posttraumatic hemarthrosis during a 1-year period were prospectively reviewed. All patients were evaluated preoperatively followed by examination under anesthesia and arthroscopy of the knee. The majority of patients, 32 (71%), had an anterior cruciate ligament tear. Meniscal tears occurred in 21 patients (47%). Meniscal tears requiring surgery occurred in only 10 of 25 meniscal tears (40%). Seven patients (16%) had medial collateral ligament and/or posteromedial capsular sprain. Eight patients (18%) had an osteochondral fracture or patellar dislocation associated with an osteochondral fracture. The majority of knees with a torn meniscus or osteochondral fracture had an anterior cruciate ligament tear. Clinically, 18 of 21 knees (86%) with an acute complete anterior cruciate ligament tear were diagnosed preoperatively with the Lachman test. The Lachman test conducted with patients under anesthesia was positive for 19 of 21 knees (90%) with an acute complete anterior cruciate ligament tear. The preoperative examination correctly identified six of seven knees (86%) with a medial collateral ligament sprain. The preoperative Lachman test was positive in only two of five knees (40%) with a partial anterior cruciate ligament tear. The Lachman test with patients under anesthesia was positive for four of five knees (80%) with an acute partial anterior cruciate ligament tear. Preoperative examination yielded the correct diagnosis in only 9 of 21 knees (43%) with a meniscal tear and 1 of 6 knees (17%) with an osteochondral fracture.(ABSTRACT TRUNCATED AT 250 WORDS)     

Post-traumatic hemarthrosis of the knee joint--an indication for arthroscopy

Diagnostic arthroscopy including the use of a probe should be performed if the cause for a haemarthrosis of the knee cannot be established by radiological means. The clinical examination of the recently injured knee must be considered to be unreliable due to pain. In approximately one-third of knee injuries an incorrect or incomplete diagnosis is made. Even if ligamentous injuries can be established, arthroscopy is mandatory, because this is the only sure way in which acute and degenerative meniscal or cartilaginous lesions can be diagnosed. Arthroscopy should be performed under general or spinal anaesthesia to allow the use of a tourniquet and the immediate repair of ligaments if deemed necessary. The experienced arthroscopist needs only a few minutes to obtain information that could influence the approach to the injury and its longterm prognosis. In a series of 1238 arthroscopies 252 (20.3%) were done for haemarthrosis of unknown origin. In 68% of these cases diagnosis could only have been established by arthroscopy. In this series of 252 cases 23% had an isolated complete anterior cruciate ligament (ACL) injury, 28% had anterior-medical instability, 8% had partial ACL lesions, 5% posterior cruciate ligament injuries, 15% medial collateral ligament injuries, 11% had only synovial tears or contusions. 5% of cases had chronic ACL instability, 4% had osteochondral fragments which could not be diagnosed radiologically. A recent traumatic patellar dislocation with a tear of the retinaculum was found in 1.6% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears

A prospective and retrospective study was undertaken to compare the accuracy of magnetic resonance imaging (MRI) with clinical examination in diagnosing meniscal and anterior cruciate ligament (ACL) tears. Pathological findings were then confirmed during arthroscopy. One hundred fifty-four patients clinically diagnosed with a meniscal or ACL tear who ultimately had arthroscopic knee surgery were evaluated; 100 patients underwent clinical examination followed by MRI, and 54 underwent clinical examination alone. The presence or absence of meniscal and ACL tears was confirmed during arthroscopy. The accuracies of clinical examination and MRI were compared for the 100 patients who underwent both clinical examination and MRI. The accuracy of MRI was 75% for medial meniscal tears, 69% for lateral meniscal tears and 98% for ACL tears. The accuracy of clinical examination was 82% for medial meniscal tears, 76% for lateral meniscal tears and 99% for complete tears of the ACL. Furthermore, the accuracy of clinical examination for the 54 patients who underwent clinical examination alone was not significantly different from the accuracy of clinical examination in the 100 patients who also underwent MRI. There was no significant difference between the accuracy of clinical examination and MRI in the diagnosis of meniscal and ACL tears and, overall, MRI contributed to treatment in only 16 of 100 cases. Based on these findings, we feel that MRI, except in certain circumstances, is an expensive and unnecessary diagnostic test in patients with suspected meniscal and ACL pathology.     

Acute traumatic knee effusions in children and adolescents

A prospective analysis was completed during a 6-month period to identify all patients, age 18 years or younger, who presented for evaluation of their knee effusion. There were 44 injured knees in 44 patients. There were a total of 55 diagnoses: 16 (29%) anterior cruciate ligament (ACL) injuries, 16 (29%) meniscal tears, 14 (25%) patellofemoral subluxations or dislocations, 3 (5%) medial collateral ligament sprains, 2 (4%) patellar osteochondral fractures, 2 (4%) retinacular injuries, 1 (2%) posterior cruciate ligament rupture, and 1 (2%) tibial eminence fracture. Girls had 11 of the 14 patellofemoral injuries; 58% of the girls had effusions secondary to patellofemoral pathology compared with 12% of the boys. Boys had 10 of the 16 meniscal tears and 13 of the 16 ACL tears. Fifty-two percent of boys had an injury to the ACL and 44% had an injury to a meniscus. In contrast, 16% of girls had an ACL injury and 32% had meniscal tears. ACL injuries, meniscal tears, and patellofemoral pathology accounted for 87% (48/55) of the diagnoses. Girls were more likely to have patellofemoral pathology; boys were more likely to have ACL and meniscal tears.     

Editorial Commentary: Arthroscopy Is the Gold Standard for Diagnosis of Meniscal Ramp Lesions: Magnetic Resonance Imaging Also May Be Helpful

Identifying and treating medial meniscal ramp lesions in conjunction with ligament reconstruction restores critical stability in knees with ligament injuries. This must begin with obtaining high-quality magnetic resonance imaging (MRI) and critical evaluation of the MRI and include a subsequent thorough arthroscopic examination of these knees. As evident in previous studies, most surgeons associate medial meniscal ramp lesions with anterior cruciate ligament (ACL) tears. Biomechanical studies have reported that a ramp lesion produces significant anterior tibial translation and external rotational instability in ACL-deficient knees that is not reestablished with an isolated ACL reconstruction. In addition, recent research identified ramp lesions in one-third of multiligament knee injuries with an intact ACL and two-thirds of patients with posteromedial tibial plateau bone bruises on MRI. Restoring knee stability and biomechanics is necessary in treating all knee ligament injuries. Don’t miss the meniscal ramp lesion. Have a high index of suspicion, obtain a high-quality MRI,and arthroscopically evaluate the meniscocapsular junction of the medial meniscus, especially if there is a bone bruise seen on MRI.     

The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury?

OBJECTIVES: To map by magnetic resonance imaging (MRI) and quantitative MRI (qMRI) concomitant fractures and meniscal injuries, and location and volume of traumatic bone marrow lesions (BMLs) in the acutely anterior cruciate ligament (ACL) injured knee. To relate BML location and volume to cortical depression fractures, meniscal injuries and patient characteristics. METHODS: One hundred and twenty-one subjects (26% women, mean age 26 years) with an ACL rupture to a previously un-injured knee were studied using a 1.5T MR imager within 3 weeks from trauma. Meniscal injuries and fractures were classified by type, size and location. BML location and volume were quantified using a multi-spectral image data set analyzed by computer software, edited by an expert radiologist. RESULTS: Fractures were found in 73 (60%) knees. In 67 (92%) of these knees at least one cortical depression fracture was found. Uni-compartmental meniscal tears were found in 44 (36%) subjects and bi-compartmental in 24 (20%). One hundred and nineteen (98%) knees had at least one BML, all but four (97%) located in the lateral compartment. Knees with a cortical depression fracture had larger BML volumes (P<0.001) than knees without a cortical depression fracture, but no associations were found between meniscal tears and BML volume or fractures. Older age at injury was associated with smaller BML volumes (P<0.01). CONCLUSION: A majority of the ACL injured knees had a cortical depression fracture, which was associated with larger BML volumes. This indicates strong compressive forces to the articular surface and cartilage at the time of injury, which may constitute an additional risk factor for later knee osteoarthritis development.     

The relationship between intra-articular meniscal,chondral, and ACL lesions: finding from 1,774 knee arthroscopy patients and evaluation by gender

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.     

Accuracy of nonorthogonal magnetic resonance imaging in acute disruption of the anterior cruciate ligament

A controlled, prospective study of 30 patients with suspected acute internal derangement of the knee was undertaken to evaluate the sensitivity, specificity, predictive value, and accuracy of nonorthogonal (oblique) sagittal magnetic resonance imaging (MRI) in the assessment of anterior cruciate ligament (ACL) injuries. Thirty patients with acute hemarthroses underwent MRI within 12 days of injury, followed by arthroscopy within 24 h of the MRI. A control population of 30 chondromalacia patients underwent similar evaluation. In the acute hemarthrosis patient population, the incidence at arthroscopy of acute complete ACL tears was 60% (18/30); of partial ACL tears, 13.3% (4/30); and of chronic tears, 10% (3/30). A normal ACL was found in 16.6% (5/30) of patients. In the MRI evaluation of patients with suspected ACL injury the following results were obtained for both acute and chronic complete disruption on orthogonal (sagittal) and nonorthogonal (oblique sagittal) imaging, respectively: sensitivity, 61 (16/26) versus 100%; specificity, 70 (21/34) versus 100%; positive predictive value, 61 (16/26) versus 100%; negative predictive value 70 (24/34) versus 100%; and accuracy, 66 (40/60) versus 100%. In the evaluation of partial ACL injury, four partial tears were correctly diagnosed on nonorthogonal MRI, with one false-positive diagnosis. Orthogonal imaging failed to correctly identify any of the partial ACL injuries. Two patients in the control population demonstrated evidence of chronic ACL tears. We believe that we have demonstrated the superiority of T2-weighted nonorthogonal sagittal over conventional orthogonal sagittal ACL MRI in the evaluation of ACL injury.     

A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases

A retrospective study was conducted to survey the extent of intracapsular damage associated with ACL insufficient knees in both the acute and chronic situation. Previously unoperated knees were studied to assess the effect that reinjury had on the knee joint. One hundred patients with confirmed anterior cruciate ligament damage, both clinically and under general anesthesia, were examined arthroscopically and the findings recorded on video tape. Both anterolateral and posteromedial approaches were used to well visualize the entire intra-articular structures of the knee joint. The incidence of meniscal tears increased from 77% in the acute injury to 91% in the chronically reinjured knee (p less than .06). Furthermore, articular surface disease increased from 23% in the acute injury to 54% in the chronically ACL lax knee (p less than .002). The majority of meniscal tears were medial and amenable to peripheral suture repair (63%). Irrespective of how one approaches ACL insufficiency of the knee acutely, one cannot ignore the likelihood of finding these significant associated lesions. Reinjury to the knee will likely enhance the incidence of meniscal tears and articular changes.     

The accuracy of joint line tenderness by physical examination in the diagnosis of meniscal tears

Purpose: The purpose of this study was to document the accuracy of joint line tenderness in the diagnosis of meniscal tears. Type of Study: Prospective cohort study. Methods: There were 104 male recruits (age range, 18 to 20 years; mean, 19.2 years) with suspected meniscal lesions who underwent arthroscopy. A thorough history and physical examination was performed on each patient by a physician with 4 years’ experience on arthroscopic knee surgery. Twenty-six (25%) patients sustained injuries while in the Turkish Army, and 78 patients (75%) sustained injuries before they came to the army. On physical examination, assessment of joint line tenderness at the lateral and medial joint lines was performed with the patient’s knee flexed 90°. The accuracy, sensitivity, specificity, and positive and negative predictive values of joint line tenderness for medial and lateral sides were calculated based on arthroscopic findings. Results: In 104 knees, the diagnosis was correct in 71 (68%) and incorrect in 33 (32%) knees. A total of 37 medial meniscal tears and 27 lateral meniscal tears were identified at arthroscopy. Other pathology included 11 anterior cruciate ligament (ACL) tears, 5 medial femoral chondral lesions, 4 chondromalacia patellae, and 1 medial plica. No discernable abnormalities were seen in 21 knees. A preoperative diagnosis of a medial meniscal tear was made in 54 knees and 32 were confirmed at arthroscopy. A lateral meniscus tear was suspected in 27 knees and confirmed in 25. Five medial meniscus and 2 lateral meniscus tears were seen at arthroscopy. These had not been suspected with tenderness over the joint line. The accuracy of the test was lower with the presence of ACL lesions and condromalacia patella. Conclusions: I concluded that joint line tenderness as a test for lateral meniscal tears is accurate (96%), sensitive (89%), and specific (97%). However, for medial meniscal tears, rates are lower.     

Clinical,MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries

The aim of this prospective study was to compare and correlate clinical, magnetic resonance imaging (MRI), and arthroscopic findings in cases of meniscal tear and anterior cruciate ligament (ACL) injuries. MRI scan results and clinical diagnosis are compared against the arthroscopic confirmation of the diagnosis. One hundred and thirty-one patients had suspected traumatic meniscal or anterior cruciate ligament (ACL) injury. Clinical examination had better sensitivity (0.86 vs. 0.76), specificity (0.73 vs. 0.52), predictive values, and diagnostic accuracy in comparison to MRI scan in diagnosis for medial meniscal tears. These parameters showed only marginal difference in lateral meniscal and anterior cruciate ligament injuries. We conclude that carefully performed clinical examination can give equal or better diagnosis of meniscal and ACL injuries in comparison to MRI scan. MRI may be used to rule out such injuries rather than to diagnose them.     

The efficacy of magnetic resonance imaging in acute multi-ligament injuries

This study compares MRI with examination under anaesthesia to surgical findings in evaluating soft tissue injuries in acute multi-ligament knee trauma. Pre-operative MRI was done for 44 patients who underwent surgery for grade III ACL and grade III medial collateral ligament (MCL) injury. In 21 cases both ACL and MCL were treated surgically, but in 23 only ACL. Intra-operative and MRI findings were compared. Accuracy of MRI for medial meniscal tears was 88.6%, sensitivity 80%, and specificity 91.2%; accuracy for lateral meniscal tears was 72.7%, sensitivity 55% and specificity 87.5%. Accuracy and sensitivity for severity of ACL tear was 93.2% and of MCL tear 86.4%. In 88.6% of the knees, bone bruises were visible, with anterolateral femoral and posterolateral tibial bone bruise being the most common. MRI revealed no chondral lesion, but arthroscopy revealed 11. In combined ACL–MCL ruptures, the incidence of concomitant injuries is high and the injuries are best detected with MRI.     

Early arthroscopic evaluation of acute repair of the anterior cruciate ligament

Follow-up arthroscopy was performed in 71 patients who had undergone primary repair of an acute rupture of the anterior cruciate ligament (ACL) after 6-19 months. An augmented repair was done on 61 patients and 10 patients had a nonaugmented repair. Based on the arthroscopic findings, the ACL repair was classified into three categories. Four years after the injury a clinical reexamination, including a laxity test using instrumentation and a standard knee-function test, was done on 66 patients. Arthroscopy revealed that 64 of the 71 patients (90%) had a defined ACL repair, although the repair was elongated in 37 patients. Seven patients with a nonfunctioning ACL repair had inferior knee function after 4 years. Arthroscopy also showed superficial cartilage lesions in 24 patients and meniscal pathology in 6 patients. Two patients with more advanced chondral lesions had inferior knee function. Treatment of meniscal injuries did not affect the long-term results.     

Longitudinal Effects of Acute Anterior Cruciate Ligament Tears on Peri‐Articular Bone in Human Knees Within the First Year of Injury

Anterior cruciate ligament (ACL) tears are common sports‐related knee injuries that increase the risk of developing post‐traumatic osteoarthritis. ACL tears are rarely an isolated injury but are often associated with traumatic bone marrow lesions (BMLs). While early loss of bone mass following the ACL injury has been previously described, to date, microarchitectural information has not been reported due to the limited resolution of clinical imaging systems. In this study, we provide the first evidence of detailed bone mass and microarchitectural changes in the first 10 months following an acute ACL tear, and localized to traumatic BMLs. Fifteen participants with an acute unilateral ACL tear were assessed at four‐time points using dual‐energy X‐ray absorptiometry and high‐resolution peripheral quantitative computed tomography, and traumatic BMLs were identified with magnetic resonance imaging. Loss of bone mass was localized to the injured knee (?4.6% to ?15.8%, depending on bone and depth) and was accelerated immediately following the injury before suggesting a recovery phase. This loss of bone was accelerated even greater in traumatic BMLs (?18.2% to ?20.6%, depending on bone). Bone loss was accompanied by microstructural degeneration of trabecular bone. For example, in the lateral femur of the injured knee, the subchondral bone plate decreased in thickness (?9.0%). This study confirmed loss of bone mass in the months following ACL tears and described the underlying bone microstructural changes. The presented bone changes were accelerated in regions of traumatic BMLs. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2325–2336, 2019     

Post-traumatic hemarthrosis of the knee and arthroscopy. Review of 161 cases

In a prospective study, 161 traumatic hemarthrosis of the knee had clinical, radiological and arthroscopic examination. The anatomical lesions were diagnosed clinically and radiologically in 78%, but was incomplete every other time. Arthroscopy allowed us to confirm, to complete or to do the exact diagnosis in 98%. Anatomical lesions were never benign: ligaments ruptures (65%), patella dislocations (20.5%), chondral lesions (41%), meniscal lesions (31%). The main interest of arthroscopy is to precise associated lesions and thus, to use these data for a rational treatment program. Most often, the treatment has been performed by arthroscopic techniques, avoiding arthrotomy and shortening post operative rehabilitation. No complication due to arthroscopy has been noted. This study confirms: (1) that a traumatic hemarthrosis indicates a serious knee injury, and (2) the important contribution of arthroscopy for diagnosis and treatment of these traumatic knees.