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Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. The UK National Institute for Health Research Health Technology Assessment Programme.

AbstractObjectiveTo assess whether a clinically relevant difference exists in patients’ perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens.DesignOpen labelled, multicentre, parallel randomised controlled trial (COMPARE).SettingSix hospitals in the Netherlands, between May 2011 and April 2016.ParticipantsPatients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months.Interventions85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment).Main outcomesPatients’ perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months.ResultsBetween May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups −9.3, −14.6 to −4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group.ConclusionsIn patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction.Trial registrationNetherlands Trial Register NL 2618.

Introduction A decrease in proprioceptive sensation occurs after anterior cruciate ligament reconstruction (ACLR). However, there is relatively little research on proprioceptive rehabilitation, compared with studies on muscle strength and range of motion (ROM). The purpose of this study was to assess the effect of supplementing a traditional rehabilitation program with proprioceptive training in ACLR patients to improve knee function, psychological readiness, pain and dynamic balance in the early postoperative period. Methods This was a randomized, parallel-group, controlled trial in which 48 patients were enrolled in either proprioceptive group ( n  = 24) or control group ( n  = 24) from the first week up to 12 th weeks of the operation. Participants in the control group received a traditional ACLR rehabilitation program, while the proprioceptive group received additional proprioceptive training in addition to the traditional ACLR rehabilitation program. The outcome measures included the International Knee Documentation Committee (IKDC), the ACL Return to Sport After Injury scale (ACL-RSI), the visual analog scale (VAS), and the Y-Balance Test before and after surgery. Results We found that, at 12 weeks post—surgery, patients in the proprioceptive group had significantly higher IKDC scores compared to those in the control group (74.8 ± 4.3 vs 71.6 ± 5.2, P = 0.04). At the 12 th week, the ACL-RSI score of patients in the proprioceptive group was greater than that of the control group (68.2 ± 9.2 vs 62.8 ± 8.2, P = 0.04). The Y balance comprehensive index (YBCI) in the proprioceptive group of patients was greater than that in the control group (94.5% ± 3.3% vs 91.5% ± 4.1%, P  = 0.01) at 12 weeks after surgery. No statistically significant differences in the VAS score were found between the two groups. Conclusions Proprioceptive training is superior to conventional training in terms of knee function, psychological readiness and dynamic balance 12 weeks after ACL reconstruction surgery, but has no statistically significant effect on pain. Trial registration (Chinese Clinical Trial Registry ( https://www.chictr.org.cn ), No. ChiCTR2400087631, 7/31/2024).

Purpose To define the bony attachments of the medial ligaments relative to anatomical and radiographic bony landmarks, providing information for medial collateral ligament (MCL) surgery. Method The femoral and tibial attachments of the superficial MCL (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL), plus the medial epicondyle (ME) were defined by radiopaque staples in 22 knees. These were measured radiographically and optically; the precision was calculated and data normalised to the sizes of the condyles. Femoral locations were referenced to the ME and to Blumensaat’s line and the posterior cortex. Results The femoral sMCL attachment enveloped the ME, centred 1 mm proximal to it, at 37 ± 2 mm (normalised at 53 ± 2%) posterior to the most-anterior condyle border. The femoral dMCL attachment was 6 mm (8%) distal and 5 mm (7%) posterior to the ME. The femoral POL attachment was 4 mm (5%) proximal and 11 mm (15%) posterior to the ME. The tibial sMCL attachment spread from 42 to 71 mm (81–137% of A-P plateau width) below the tibial plateau. The dMCL fanned out anterodistally to a wide tibial attachment 8 mm below the plateau and between 17 and 39 mm (33–76%) A-P. The POL attached 5 mm below the plateau, posterior to the dMCL. The 95% CI intra-observer was ± 0.6 mm, inter-observer ± 1.3 mm for digitisation. The inter-observer ICC for radiographs was 0.922. Conclusion The bone attachments of the medial knee ligaments are located in relation to knee dimensions and osseous landmarks. These data facilitate repairs and reconstructions that can restore physiological laxity and stability patterns across the arc of knee flexion.

Background The FIFA 11+ injury prevention program has been shown to decrease the risk of soccer injuries in men and women. The program has also been shown to decrease time loss resulting from injury. However, previous studies have not specifically investigated how the program might impact the rate of anterior cruciate ligament (ACL) injury in male soccer players. Questions/purposes The purpose of this study was to examine if the FIFA 11+ injury prevention program can (1) reduce the overall number of ACL injuries in men who play competitive college soccer and whether any potential reduction in rate of ACL injuries differed based on (2) game versus practice setting; (3) player position; (4) level of play (Division I or II); or (5) field type. Methods This study was a prospective cluster randomized controlled trial, which was conducted in 61 Division I and Division II National Collegiate Athletic Association men’s soccer teams over the course of one competitive soccer season. The FIFA 11+ is a 15- to 20-minute on-the-field dynamic warm-up program used before training and games and was utilized as the intervention throughout the entire competitive season. Sixty-five teams were randomized: 34 to the control group (850 players) and 31 to the intervention group (675 players). Four intervention teams did not complete the study and did not submit their data, noting insufficient time to complete the program, reducing the number for per-protocol analysis to 61. Compliance to the FIFA 11+ program, athletic exposures, specific injuries, ACL injuries, and time loss resulting from injury were collected and recorded using a secure Internet-based system. At the end of the season, the data in the injury surveillance system were crosshatched with each individual institution’s internal database. At that time, the certified athletic trainer signed off on the injury collection data to confirm their accuracy and completeness. Results A lower proportion of athletes in the intervention group experienced knee injuries (25% [34 of 136]) compared with the control group (75% [102 of 136]; relative risk [RR], 0.42; 95% confidence interval [CI], 0.29-0.61; p < 0.001). When the data were stratified for ACL injury, fewer ACL injuries were reported in the intervention group (16% [three of 19]) compared with the control group (84% [16 of 19]), accounting for a 4.25-fold reduction in the likelihood of incurring ACL injury (RR, 0.236; 95% CI, 0.193–0.93; number needed to treat = 70; p < 0.001). With the numbers available, there was no difference between the ACL injury rate within the FIFA 11+ group and the control group with respect to game and practice sessions (games—intervention: 1.055% [three of 15] versus control: 1.80% [12 of 15]; RR, 0.31; 95% CI, 0.09–1.11; p = 0.073 and practices—intervention: 0% [zero of four] versus control: 0.60% [four of four]; RR, 0.14; 95% CI, 0.01–2.59; p = 0.186). With the data that were available, there were no differences in incidence rate (IR) or injury by player position for forwards (IR control = 0.339 versus IR intervention = 0), midfielders (IR control = 0.54 versus IR intervention = 0.227), defenders (IR control = 0.339 versus IR intervention = 0.085), and goalkeepers (IR control = 0.0 versus IR intervention = 0.0) (p = 0.327). There were no differences in the number of ACL injuries for the Division I intervention group (0.70% [two of nine]) compared with the control group (1.05% [seven of nine]; RR, 0.30; CI, 0.06–1.45; p = 0.136). However, there were fewer ACL injuries incurred in the Division II intervention group (0.35% [one of 10]) compared with the control group (1.35% [nine of 10]; RR, 0.12; CI, 0.02–0.93; p = 0.042). There was no difference between the number of ACL injuries in the control group versus in the intervention group that occurred on grass versus turf (Wald chi square [ 1 ] = 0.473, b = 0.147, SE = 0.21, p = 0.492). However, there were more ACL injuries that occurred on artificial turf identified in the control group (1.35% [nine of 10]) versus the intervention group (0.35% [one of 10]; RR, 0.14; 95% CI, 0.02–1.10; p = 0.049). Conclusions This program, if implemented correctly, has the potential to decrease the rate of ACL injury in competitive soccer players. In addition, this may also enhance the development and dissemination of injury prevention protocols and may mitigate risk to athletes who utilize the program consistently. Further studies are necessary to analyze the cost-effectiveness of the program implementation and to analyze the efficacy of the FIFA 11+ in the female collegiate soccer cohort. Level of Evidence Level I, therapeutic study.

Category: Arthroscopy; Hindfoot Keywords: Spring ligament; FDL; Posterior Tibial Tendon Dysfunction Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a complex deformity that is predisposed to by failure of the spring ligament, resulting in peritalar subluxation. A medializing calcaneal osteotomy and flexor digitorum longus (FDL) tendon transfer are standard surgical procedures for a symptomatic flexible deformity. Endoscopic-assisted FDL transfer and a minimally invasive medializing calcaneal osteotomy (MIMCO), allow a fully MIS approach to address flat foot reconstruction. Concerns remain regarding low correction potential, without surgically addressing the attenuated spring ligament. Spring ligament augmentation with an internal brace provides benefits of high resistance to forefoot lateralization, reliably improved radiographic parameters, and patient-reported outcomes. We describe a tendoscopic-assisted FDL tendon transfer and a spring ligament synthetic suture tape reconstruction technique, used in conjunction with a MIMCO. Methods: Commence with MIMCO. Once complete, position the patient into a supine position. Mark and place portals at the sustentaculum tali and 0.5cm under the navicular. View via proximal and work via distal portal. Identify FDL and divide its sheath distally until the knot of Henry is identified. Tack the FDL tendon with fiberwire using labral Scorpion suture passer. Secure the stitch, deliver the tendon outside the distal portal and cut it long. Whipstitch the FDL and pull it outside the proximal portal. Under fluoroscopy guidance introduce fibertape loaded 3.5 siwvelock into the sustentaculum tali. Establisch navicular tunnel 0.5mm larger than a measured tendon diameter. Pass FDL and the tape into the distal portal, feed to the Guide pin and pass through the navicular bone tunnel. Tighten the strands in inversion and secure with a SwiveLock, 0.25 - 0.5mm smaller than a drilled tunnel. Perform percutaneous triple hemisection of the Achilles tendon. Results: This technique has proven itself to be safe in the cadaveric lab exercise and subsequent dissection demonstrating no damage to neurovascular structures in 5 specimens. It has been performed by a lead author in flexible PCFD with preserved clinical correction, radiographic parameters at 3 months follow up. Conclusion: Tendoscopy-Assisted Flexor Digitorum Longus Transfer and Spring Ligament Synthetic Suture Tape Reconstruction for Flexible Progressing Collapsing Foot Deformity is a technically demanding procedure for advanced foot and ankle surgeons, which allows a completely minimally invasive approach to flexible progressive collapsing foot deformity reconstruction, with increased resistance to forefoot lateralization and the potential to more reliably improve and preserve radiographic parameters. The results of the larger sample size series are to be reported in the future.

Objectives: To evaluate the clinical and radiological outcomes of open anatomical reconstruction of both the coracoclavicular and acromioclavicular ligaments using semitendinosus autograft augmented with a cortical button construct in acute high-grade acromioclavicular joint dislocation. Methods: This retrospective consecutive case series included patients treated for acute Rockwood type III–V acromioclavicular joint dislocation between 2018 and 2023. All patients underwent open anatomical ligament reconstruction using semitendinosus autograft with cortical button augmentation. Clinical outcomes were assessed using the Constant– Murley, Quick Disabilities of the Arm, Shoulder and Hand, and Simple Shoulder Test scores. Radiological evaluation included coracoclavicular distance measurements preoperatively and at final follow-up. Complications and loss of reduction were recorded. Results: Thirteen patients (mean age 35.4±8.7 years) were included, with a mean follow-up of 28.6±4.3 months. All functional scores significantly improved (p<0.001). The coracoclavicular distance decreased from 17.3 mm to 8.5 mm. Loss of reduction occurred in two patients (15%) but remained asymptomatic. Twelve patients (92%) returned to previous activities. No major complications or revision surgeries were observed. Conclusion: Combined anatomical coracoclavicular and acromioclavicular ligament reconstruction with semitendinosus autograft and cortical button augmentation provides reliable functional recovery, satisfactory radiological stability, and a low complication rate in acute high-grade injuries.