Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes. Cite this article: Bone Jt Open 2024;5(2):94–100

Introduction. Anterior Cruciate Ligament (ACL) injury prevention programs can reduce injury risk in various sports. The perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. The purpose of the study was to determine (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers and potential facilitators to implementing a sustainable ACL injury prevention program in netball. Methods. This cross-sectional observational study was undertaken using the CHERRIES checklist. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to participate in this web-based study between 1st May – 31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained. Results. Twenty-eight players (77.8%) and 29 coaches (13.2%) completed the questionnaire. Seventeen (60.7%) players and 15 (51.7%) coaches reported female athletes were at greater risk for sustaining ACL injuries. Over 90% of respondents identified netball as high-risk, whilst 89% of players and 76% of coaches reported these injuries to be preventable. Only two (7.1%) players and 6 (20.7%) coaches utilised an ACL injury prevention program with lack of time and engagement from coaches and players identified. Majority of respondents indicated that their club has neither promoted, advocated the use nor demonstrated exercises for ACL injury prevention. Over 90% of respondents would utilise an ACL injury prevention program if it minimised players risk with appropriate information and demonstration of exercises. Conclusion. This study highlights limited knowledge of female athletes' increased susceptibility of ACL injuries amongst players and coaches with lack of communication and education of ACL injury prevention programs between sporting associations, coaches, and players. However, the results demonstrate willingness amongst both players and coaches to implement an ACL injury prevention program in netball

Introduction. Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Methodology. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained. Results. Twenty-eight players (77.8%) and 29 coaches (13.2%) completed the questionnaire. Seventeen (60.7%) players and 15 (51.7%) coaches reported female athletes were at greater risk for sustaining ACL injuries. Over 90% of respondents identified netball as high-risk, whilst 89% of players and 76% of coaches reported these injuries to be preventable. Two (7.1%) players and 6 (20.7%) coaches utilised ACL injury prevention programs with lack of time and engagement from coaches and players identified. Majority of respondents indicated that their club has neither promoted, advocated nor demonstrated exercises for ACL injury prevention. Over 90% of respondents would utilise such programs if it minimised players risk with appropriate training and information. Conclusion. Study highlights limited knowledge of female athletes’ increased susceptibility of ACL injuries with lack of communication and education of ACL injury prevention programs between sporting associations, coaches and players. Results demonstrate willingness of players and coaches to implement ACL injury prevention programs in Welsh netball

Abstract. Introduction. Perception of ACL injury prevention programs amongst professional netball players and coaches has not been studied. We investigated (1) level of awareness and experience of ACL injury prevention programs; (2) use of ACL injury prevention programs; and (3) barriers to implementing ACL injury prevention program in netball. Methodology. Female netball players representing Welsh senior and under-21 teams and elite and amateur coaches were invited electronically to this web-based study between 1st May–31st July 2021. Information on ACL injury susceptibility and seriousness, knowledge, experience, and implementation of ACL injury prevention programs were ascertained. Results. Twenty-eight players (77.8%) and 29 coaches (13.2%) completed the questionnaire. Seventeen (60.7%) players and 15 (51.7%) coaches reported female athletes were at greater risk for sustaining ACL injuries. Over 90% of respondents identified netball as high-risk, whilst 89% of players and 76% of coaches reported these injuries to be preventable. Two (7.1%) players and 6 (20.7%) coaches utilised ACL injury prevention programs with lack of time and engagement from coaches and players identified. Majority of respondents indicated that their club has neither promoted, advocated nor demonstrated exercises for ACL injury prevention. Over 90% of respondents would utilise such programs if it minimised players risk with appropriate training and information. Conclusion. Study highlights limited knowledge of female athletes’ increased susceptibility of ACL injuries with lack of communication and education of ACL injury prevention programs between sporting associations, coaches and players. Results demonstrate willingness of players and coaches to implement ACL injury prevention programs in Welsh netball

Background: Anterior cruciate ligament (ACL) injury and re-injury rates are high and continue to rise in adolescents. After surgical reconstruction, less than 50% of patients return to their pre-injury level of physical activity. Clearance for return-to-play and rehabilitation progression typically requires assessment of performance during functional tests. Pain may impact this performance. However, the patient's level of pain is often overlooked during these assessments. Purpose: To investigate the level of pain during functional tests in adolescents with ACL injury. Fifty-nine adolescents with ACL injury (ACLi; female n=43; 15 ± 1 yrs; 167.6 ± 8.4 cm; 67.8 ± 19.9 kg) and sixty-nine uninjured (CON; female n=38; 14 ± 2 yrs; 165.0 ± 10.8 cm; 54.2 ± 11.5 kg) performed a series of functional tests. These tests included: maximum voluntary isometric contraction (MVIC) and isokinetic knee flexion-extension strength tests, single-limb hop tests, double-limb squats, countermovement jumps (CMJ), lunges, drop-vertical jumps (DVJ), and side-cuts. Pain was reported on a 5-point Likert scale, with 1 indicating no pain and 5 indicating extreme pain for the injured limb of the ACLi group and non-dominant limb for the CON group, after completion of each test. Chi-Square test was used to compare groups for the level of pain in each test. Analysis of the level of pain within and between groups was performed using descriptive statistics. The distribution of the level of pain was different between groups for all functional tests (p≤0.008), except for ankle plantar flexion and hip abduction MVICs (Table 1). The percentage of participants reporting pain was higher in the ACLi group in all tests compared to the CON group (Figure 1). Participants most often reported pain during the strength tests involving the knee joint, followed by the hop tests and dynamic tasks, respectively. More specifically, the knee extension MVIC was the test most frequently reported as painful (70% of the ACLi group), followed by the isokinetic knee flexion-extension test, with 65% of ACLi group. In addition, among all hop tests, pain was most often reported during the timed 6m hop (53% of ACLi), and, among all dynamic tasks, during the side-cut (40% of ACLi) test (Figure 1). Furthermore, the tests that led to the higher levels of pain (severe or extreme) were the cross-hop (9.8% of ACLi), CMJ (7.1% of ACLi), and the isokinetic knee flexion-extension test (11.5% of ACLi) (Table 1). Adolescents with and without ACL injury reported different levels of pain for all functional tasks, except for ankle and hip MVICs. The isokinetic knee flexion-extension test resulted in greater rates of severe or extreme pain and was also the test most frequently reported as painful. Functional tests that frequently cause pain or severe level of pain (e.g., timed 6m and cross hops, side-cut, knee flexion/extension MVICs and isokinetic tests) might not be the first test choices to assess function in patients after ACL injury/reconstruction. Reported pain during functional tests should be considered by clinicians and rehabilitation team members when evaluating a patient's readiness to return-to-play. For any figures or tables, please contact the authors directly

Anterior cruciate ligament (ACL) ruptures are debilitating injuries, often managed via ACL reconstruction (ACLR). Reduced range of motion (ROM), particularly loss of extension (LOE), is the most significant contributor to post-operative patient dissatisfaction. LOE may preclude return to sport, increase re-rupture rates and precipitate osteoarthritis. Passive LOE rates following ACLR have been reported at 15%. However, LOE incidence during active tasks are poorly characterised. Our review sought to determine knee extension angles for active tasks following an ACL injury or ACLR. We hypothesised greater incidences of active LOE following ACL injury or ACLR, compared to uninjured contralateral limbs or controls. We systematically searched MEDLINE, Embase, Cochrane Library, Scopus, SPORTDiscus, and relevant trials databases for English articles. Included were cohort, cross-sectional, case-controlled or randomised controlled trials analysing adults with ACL injury treated surgically or otherwise, with at least 12-weeks follow-up and reporting either active knee extension angle, active LOE angles or incidence of active knee LOE during functional tasks. The protocol was registered on PROSPERO (CRD42018092295). Subsequent meta-analysis was performed. After screening, 71 eligible articles were included. Studies were heterogenous in design and quality. Included tasks were overground walking (n=44), running (n=3), hopping/jumping/cutting (n=11) single-leg landing (n=7), and stair climbing (n=6). LOE incidence varied depending on functional activities (33.95-92.74%). LOE incidence did not vary depending on ACL status (67.26% vs. 65.90% vs. 62.57% for ACL intact, ACLD and ACLR, respectively). We observed no difference in active LOE incidence according to ACL status. Importantly, the observed incidence for active LOE was reliably higher than previously reported rates for passive measures. Given the discrepancy between active and passive LOE incidence, clinicians may advisably prioritise active ROM during ACL rehabilitation

Limb symmetry on a battery of functional tests is becoming more common as a clinical rehabilitation tool serving as a proxy assessment for readiness to return to sport following anterior cruciate ligament reconstruction (ACLR). The predictive capability of each included test for determining the likelihood of a second ACL injury is not well known. This study combines 14 established functional tests into a comprehensive return-to-sport assessment (RTSA). Study purpose: to determine if any of the functional tests were independently related to a second ACL injury occurring after the patient was cleared for return to sport. The RTSA was administered to 226 individuals after primary, unilateral ACLR who were followed for at least 24 months (51% female; mean ± SD age, 18.9 ± 4.0 years at RTSA, 9.4 ± 2.4 months post-surgery). The RTSA included 14 tests that involved calculation of Limb Symmetry Indices (LSI): leg press [LP], eccentric hamstring strength [HS], hip adductor strength [HA], Y Balance Test (anterior [YANT], posteromedial [YPM], posterolateral [YPL]), single hop [SH], triple hop [TH], crossover hop [CH], 6 meter timed hop [TiH], lateral hop [LH], medial hop [MH], vertical jump [VJ], single leg squat [SLS]. LSI averaged values of three trials for each leg for LP, HS, HA, SH, TH, CH, TiH, LH, MH, VJ, and SLS. The lowest bilateral difference across three trials was used for YANT, YPM, and YPL. Logistic regression using backward elimination was used to predict the odds of a second non-contact ACL injury using the RTSA, sex, age, and months post-surgery at RTSA as the independent variables. Twenty-five (11%) patients returned to have a subsequent ACL surgery. Twenty of the 25 experienced a second non-contact ACL injury (70% female; 10 ipsilateral, 10 contralateral). Of the 14 female athletes, there were eight contralateral and six ipsilateral tears. In males, there were two contralateral and four ipsilateral tears. The mean time from surgery to injury was 20.5 ± 9.8 months. Age (OR; 95%CI: 0.75; 0.58, 0.92), LP (0.97; 0.93, 0.99), YANT (1.21; 1.02, 1.43), and TiH (1.10; 1.01, 1.20) were found to be significantly associated with the odds of re-injury. Age, YANT, and the LSI of LP and TiH have a statistically significant impact on the odds of a second ACL injury after ACL reconstruction. YANT has an OR of 1.21, indicating that a 1cm increase in asymmetry will increase the likelihood of re-injury by 21%, holding all else constant. A 1% increase in the TiH LSI results in a 10% increase in the odds of re-injury. The risk of re-injury decreases as age increases. The OR for LP symmetry was near 1.0 and therefore may not have a clinically relevant effect on re-injury risk. Although LSI is a straightforward, quantitative measure, clinicians should not solely rely on it as a proxy for recovery of knee function. Many tests are available for clinical assessments, but this study found only a few of the tests to have significant associations with a subsequent ACL injury following return to play after ACL reconstruction

A quick, portable and reliable tool for predicting ACL injury could be an invaluable instrument for athletes, coaches, and clinicians. The gold standard, Vicon motion analysis, despite having a high sensitivity and risk specificity, is not practical for coaches or clinicians to use on a routine basis for assessing athletes. The present study validated the Kinect device to the currently used method of chart review in predicting athletes at high risk. A total of 114 participants were recruited from both the men and women McGill Varsity Sports Program. 69 males and 45 female athletes were evaluated to assess the specificity and sensitivity of the Kinect device in predicting athletes at high risk of injury. Each athlete performed three-drop vertical jumps off of a 31cm box and the data was recorded and risk score was generated. Generation of this data is done by our uniquely programmed software that measures landing angles at different time frames and compares live results to previously known data of injured athletes. A chart review was then performed by a clinician, blinded to these risk scores, to risk stratify the same athletes as high or low risk of ACL injury based on their medical charts. Data reviewed incorporated pre-season physical exams along with documented known risk factors for ACL injury, including previous knee injuries, family history of ACL injury, gender, sport, and BMI. Positive risk factors were assigned one point while negative risk factors assigned zero points. The Kinect device, powered by our software, identified 40 athletes as having a high-risk score (> 55%), and subsequently, five (4.39%) sustained an ACL injury by the end of their respective sport seasons. Two male and two female basketball players along with one male soccer player sustained non-contact ACL injuries. Given that all five of the injured athletes were in the cohort of 40 identified as high risk by the Kinect, this yielded a sensitivity of 100% for the device. As for the specificity, the Kinect computed 35 false positives, yielding a specificity of 68% for the duration of the study. The medical chart review identified 36 athletes as high risk and 60 as being low risk of ACL injury. Four of the athletes that sustained an ACL injury were in the group of 36 identified as high risk by the clinician. However, one of the five participants who sustained an ACL injury was not captured by the medical chart assessment, yielding a sensitivity of 80% and a specificity of 65% for the clinician. When it comes to injury prediction, it is preferred to have a high sensitivity even if the specificity is slightly lower as this ensures that all athletes who are at risk will be captured. Our data demonstrated that the chart analysis provided one false negative and led to missing one high-risk athlete who ended up sustaining an ACL injury. Based on the comparison of sensitivity and specificity, the Kinect system provides a slightly better predictive analysis for predicting ACL injury compared to chart review

Aims. The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness. Methods. A total of 316 patients were recruited and randomly assigned to either surgical reconstruction or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment). Healthcare resource use and health-related quality of life data (EuroQol five-dimension five-level health questionnaire) were collected in the trial at six, 12, and 18 months using self-reported questionnaires and medical records. Using intention-to-treat analysis, differences in costs, and quality-adjusted life years (QALYs) between treatment arms were estimated adjusting for baseline differences and following multiple imputation of missing data. The incremental cost-effectiveness ratio (ICER) was estimated as the difference in costs divided by the difference in QALYs between reconstruction and rehabilitation. Results. At 18 months, patients in the surgical reconstruction arm reported higher QALYs (0.052 (95% confidence interval (CI) -0.012 to 0.117); p = 0.177) and higher NHS costs (£1,017 (95% CI 557 to 1,476); p < 0.001) compared to rehabilitation. This resulted in an ICER of £19,346 per QALY with the probability of surgical reconstruction being cost-effective of 51% and 72% at a willingness-to-pay threshold of £20,000 and £30,000 per QALY, respectively. Conclusion. Surgical reconstruction as a management strategy for patients with long-standing ACL injury is more effective, but more expensive, at 18 months compared to rehabilitation management. In the UK setting, surgical reconstruction is cost-effective. Cite this article: Bone Joint J 2024;106-B(1):38–45

Background. Non-contact anterior cruciate ligament (ACL) injuries occurs with a higher incidence in female athletes compared with males after the onset of puberty. One anatomical factor with clinically observable differences between males and females is lower extremity alignment. The knee joint valgus in the coronal plane, which is associated with ACL injury risk, is composed of rotation of the tibia around the stationary femur and hip rotation combined with knee flexion. The purpose of this study was to prove the difference of hip rotation between female and male handball players with or without history of ACL injury. Methods. Elite collegiate athletes on the varsity handball team (17 females and 24 males) were recruited. Whereas 8 females and 1 male had a history of ACL injury, there were 9 females and 23 males with no history of ACL injury. The 6 measures of hip joint motion [flexion, extension, abduction, adduction, external rotation (ER), and internal rotation (IR)] and the 2 measures of knee joint motion (flexion and extension) were measured with the standard procedure using a goniometer. Results. The range of ER in ACL-injured females (37±7.5) was smaller than in uninjured females (49±8.2). The range of IR in ACL-injured female players (55±9.6) was greater than in uninjured females (41±13). There was no difference in ER+IR between ACL-injured and uninjured females. In the ACL-injured male handball player, ER was dominant to IR. Compared with the uninjured males, the ACL-injured female players showed smaller range of ER, greater ranges of IR and greater ER+IR. Conclusions. ACL-injured female handball players had greater hip IR with smaller hip ER, compared with uninjured counterpart. Hip rotation may be a crucial risk factor for ACL injury in female athletes. Level of evidence. 2b

Anterior cruciate ligament (ACL) injuries are frequent among athletes and a leading cause of time away from competition. Stability of the knee involves the ACL for limiting anterior tibial translation and the ALL (anterolateral ligament) to restrain internal rotation of the tibia. Present indications for treatment with a combined ACL-ALL reconstruction remain unclear and mostly subjective. We mathematically modeled the tibial plateau geometry to try and identify patients at risk of ACL injury, and develop an objective trigger point for the decision to proceed with additional surgery to optimize rotational stability in these higher risk patients. We hypothesized that an increased convexity and steepness of the posterior aspect of the lateral plateau would subject knees to higher rotational torques leading to potentially a higher risk of ACL injury. The study design was a case-control study involving ACL reconstruction cases (n=68) and matched controls (n=68) between 2008–2015 at our institution. We used a two-dimensional approach, evaluating sagittal MRI images of the knee to model the posterior convexity of the lateral tibial plateau. Points were selected along the articular surface, and a least-squares regression was used to curve-fit a power function (y = a xn). In the equation, larger coefficient a and n represented steeper slopes. The cases and controls were compared using a Mann-Whitney-U test, and the statistical significance was set at α < 0.05. A subgroup analysis for females and males was also performed for the curve-fit coefficients. We observed a significant difference in the tibial surface geometry between our ACL reconstruction cases and matched controls (Figure 1). The modeled power equation for our ACL cases had larger coefficients compared to controls for all groups. For all pooled subjects, coefficient a (ACL recon cases = 0.90 vs controls = 0.68, p < 0.0001) and coefficient n (ACL recon cases = 0.34 vs controls = 0.30, p = 0.07) (Table 1). For the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for the statistically significant coefficient a, we found it had a sensitivity of 78.9% and specificity of 77.5% for predicting injury, using a cut off coefficient of a = 0.78. The odds ratio was 12.6 [5.5 – 29]. The posterolateral cartilaginous slope of the tibial plateau was mathematically modeled in patients with ACL injury. Patients with ACL injury demonstrated abnormally steep and fast slopes compared to controls that may play predispose to ACL injury by increasing anterior translation forces and internal rotation torques sustained by their knee joint. A steeper slope may also explain high-grade pivot shifts on physical exam that are thought to be a relative indication for adding an associated ALL reconstruction. Our findings are promising for adding more objectivity to surgical decision-making, especially with identifying high-risk patients that may be candidates for combined ACL-ALL reconstructions. For any figures or tables, please contact the authors directly

Purpose: The aim of the study was to evaluate whether the recognition rates of ACL injuries had improved in the decade following the original paper published by the senior author. Methods: Prospective data collection using a standard questionnaire on all patients presenting to a dedicated soft tissue knee injury clinic. There were 103 patients with a median age of 31. Results: 94 out of the 103 patients gave a typical history of an ACL injury. The mean time to referral to this specialist clinic was 92 weeks. The commonest mechanism of ACL injuries was sports (88/103), with soccer making up the vast majority. The correct diagnosis was made by 13% of A& E staff, 30% of GPs and 57% of Orthopaedic surgeons. Of the 11 patients who had an arthroscopy, 4 were told that they had an ACL injury. None of the 15 who had an MRI scan were told that they had an ACL injury. Conclusion: Despite the increasing incidence and changes in management, there appears to have been very little improvement in the detection of the ACL injured knee in the last 10 years

This study set out to determine the incidence of avulsion of the posterior horn of the lateral meniscus in isolated Anterior cruciate ligament injuries. Anterior cruciate injuries are often associated with meniscal injuries and a number of different patterns of injuries are described. Although avulsion of the posterior horn of the lateral meniscus has been reported in combined ACL/MCL injuries this has not been reported in isolated ACL injuries. We examined 25 consecutive patients who had ACL ruptures and recorded the presence or absence of an avulsed posterior horn of the lateral meniscus. The mechanism of injury was also recorded. We found 6 patients (24%) with avulsion of the posterior horn of the lateral meniscus from its tibial attachment. All these patients had an external rotation injury rather than a valgus type injury. Avulsion of the posterior horn of the lateral meniscus is a relatively common finding in ACL injury. If this injury occurs the normal load sharing function of the meniscus may not be present and this may be part of the explanation for the development of degenerative change in the ACL injured knee

Background. Return to sports after anterior cruciate ligament reconstruction (ACLR) is multifactorial and rotational stability is one of the main concerns. Anterolateral ligament reconstruction (ALLR) has been recommended to enhance rotational stability. Purpose. To assess the effect of ALLR on return to sports. Study Design. Retrospective comparative cohort study;. Level of evidence: III. Methods. A total of 68 patients who underwent ACLR after acute ACL injury between 2015 and 2018 with a follow-up of at least 24 months were enrolled in the study. Patients with isolated ACLR (group ALL(-), n=41) were compared to patients with ACLR+ALLR (group ALL(+), n=27) in regard to subjective knee assessment via Tegner activity scale, Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale, Knee Documentation Committee (IKDC) form and Lysholm score. All tests were performed before the surgery, at 6 months and 24 months postoperatively. Results. Mean follow-up was 29.7±2.9 months for group ALL(-) and 31.6±3.0 for ALL(+) (p=0.587). Tegner, ACL-RSI and IKDC scores at last follow-up were significantly better in ALL(+) compared to ALL(-). There were no significant differences in isokinetic extensor strength and single-leg hop test results between the groups. 40 (97.6%) patients in ALL(-) and 27 (100%) in ALL(+) had a grade 2 or 3 pivot shift (p=0.812) preoperatively. Postoperatively, 28 (68.3%) patients in ALL(-) and 25 (92.6%) patients in ALL(+) had a negative pivot shift (p<0.001). 2 (5.9%) patients in ALL(-) and 1 (3.7%) patient in ALL(+) needed ACLR revision due to traumatic re-injury (p=0.165). There was no significant difference in the rate of return to any sports activity (87.8% in ALL(-) vs 88.9% in ALL(+); p=0.532), but ALL(+) showed a higher rate of return to the same level of sports activity (55.6%) than group ALL(-) (31.7%) (p=0.012). Conclusion. ACLR combined with ALLR provided a significantly higher rate of return to the same level sports activity than ACLR alone, probably due to enhanced rotational stability

We aim to identify any changes in the demographics of ACL injured patients over the last decade. Over a twelve month period, the demographic data from 117 consecutive new patients with ACL injuries attending one consultant’s clinic in 1994 was prospectively recorded. This was then compared with data from a similar cohort of 103 consecutive new ACL injured patients attending the same clinic some twelve years later. Since 1994, the proportion of women seen with ACL injury doubled from 12% to 25%. The proportion of skiing related injuries trebled from 9% to 28%. The average age at presentation rose by 6.5 years from 26.5 to 33. In 2006, the average age of the skiers was 40 and 72.4% of them were female compared to only 8% of non-skiers. The population of patients with new ACL injuries has changed significantly over the last twelve years. The average age, proportion of women and number of skiing related injuries have all increased significantly. We speculate that the most likely cause of these changes is the skiing population, which has enlarged and, due to retention of participants, has aged over the period of this study (1). Most skiing injuries are sustained abroad and the vast majority of skiers buy holiday insurance to cover themselves against injury. Yet it is the NHS that ends up footing the bill for any reconstructive surgery and rehabilitation. We propose that if the insurance companies maintained responsibility for their clients’ injuries until a full recovery had been made, the NHS would save millions of pounds

Aims: To identify any changes in the demographics of ACL injured patients over the last decade. Methods: Over a twelve month period, the demographic data from 117 consecutive new patients with ACL injuries attending one consultant’s clinic in 1994 was prospectively recorded. This was then compared with data from a similar cohort of 103 consecutive new ACL injured patients attending the same clinic some twelve years later. Results:. Since 1994, the proportion of women seen with ACL injury doubled from 12% to 25%. The proportion of skiing related injuries trebled from 9% to 28%. The average age at presentation rose by 6.5 years from 26.5 to 33. The average age of the skiers is 41 and 90% of them are female. Conclusion: The population of patients with new ACL injuries has changed significantly over the last twelve years. The average age, proportion of women and number of skiing related injuries have all increased significantly. We speculate that the most likely cause of these changes is the skiing population, which has enlarged and, due to retention of participants, has aged over the period of this study (. 1. ). Most skiing injuries are sustained abroad and the vast majority of skiers buy holiday insurance to cover themselves against injury. Yet it is the NHS that ends up footing the bill for any reconstructive surgery and rehabilitation. We propose that if the insurance companies maintained responsibility for their clients’ injuries until a full recovery had been made, the NHS would save millions of pounds

The purpose of the present study is to determine a correlation between articular cartilage changes and underlying bone contusions in ACL-deficient knees. Analysis of surgical and MRI findings in thirty-seven knees shows that medial femoral condyle and medial tibial plateau bone contusions, present in 30% of ACL injuries, correlate strongly with articular cartilage damage, irrespective of meniscal status. Although lateral compartment bone contusions are more commonly seen following injury, we have not found this to be associated with the status of the overlying cartilage. Degenerative changes in the ACL-deficient knee are multifactorial, but medial compartment bone contusions may be an important contributor that warrants further investigation. Despite successful reconstruction of the anterior cruciate ligament, many patients eventually develop osteoarthritis, suggesting that something in addition to mechanical instability may contribute. The purpose of the present study is to determine a correlation between articular cartilage changes and underlying bone contusions in ACL-deficient knees. Between January 2002 and March 2003, sixty-eight knees consecutively underwent ACL reconstruction at our institution. Presence and location of bone contusions on MRI were noted, and correlated to presence of articular cartilage changes and meniscal pathology witnessed during surgery. Of the sixty-eight knees operated, thirty-one were excluded because of either: pre-existing arthritis, previous surgery, presence of multiple ligament injury, or absence of bone contusions on MRI. In the analysis of the thirty-seven remaining knees, bone contusions were present on the medial tibial plateau and medial femoral condyle in 30%, on the lateral tibial plateau in 84%, and on the lateral femoral condyle in 73%. Articular cartilage damage is most commonly seen on the medial femoral condyle, irrespective of meniscal status. Analysis using Fisher’s Exact test shows that medial femoral condyle (p=0.026) and medial tibial plateau articular cartilage damage (p= 0.011) is strongly correlated with presence of underlying bone contusions. No association was found between lateral compartment articular cartilage status and presence of bone contusions. Although lateral compartment bone contusions are common following ACL injuries, we have not found an association with cartilage damage. Degenerative changes in the ACL-deficient knee are multifactorial, but medial compartment bone contusions may be an important contributor

Introduction Late degeneration of the ACL injured knee may be in part due to repeat injury, but also due to aberrant kinematics altering the wear pattern at the chondral surface. The aim of this study was to use tibio-femoral contact mapping by MRI to examine kinematic changes due to chronic ACL deficiency. Methods Twenty-three subjects with a history of chronic ACL deficiency (mean 18 years since injury) performed a closed chain leg press, relaxed and against a 15 kilogram weight. MRI recorded the tibio-femoral contact position at 15° intervals from 0° to 90° of knee flexion. Intra-articular pathology was assessed for all subjects by MRI, and at arthroscopy for 10 subjects. Results The tibio-femoral contact pattern of the ACL injured knee differed from the healthy contralateral knee (p=0.003). This difference was greatest in the medial compartment, particularly at 0° and 15° of knee flexion (p< 0.01), with the femur two millimetres (mean, SD 3.2 mm) posterior on the tibial plateau. Damage to the chondral surface was seen in the medial compartment in 16 subjects and lateral compartment in 12; medial meniscus damage was present in 16 subjects and lateral meniscus in 15. Chondral surface damage correlated with the difference in the tibio-femoral contact pattern between the healthy and injured knee in the medial compartment of the knee. Joint damage was not related significantly to time since injury, or Cincinnati knee score. Joint damage was related to level of sports participation, but probably indicates that as the joint failed, subjects curtailed their activity. Conclusions The kinematic consequences of chronic ACL injury may in part be responsible for the pattern of degenerative change, especially in the medial compartment of the knee. In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source

Introduction and Aims: Late degeneration of the ACL injured knee may be in part due to repeat injury, but also due to aberrant kinematics altering the wear pattern at the chondral surface. The aim of this study was to use tibio-femoral contact mapping by MRI to examine kinematic changes due to chronic ACL deficiency. Method: Twenty subjects with a recent unilateral ACL deficiency (mean 13 months since injury) and 23 subjects with a chronic ACL deficiency (mean 18 years since injury) were recruited. Passive ligament laxity was quantified using a KT1000® device. Subjects performed a closed-chain leg press, relaxed and against a 15 kg weight. MRI recorded the tibio-femoral contact position at 15-degree intervals from zero to 90 degrees of knee flexion. Tibio-femoral contact points were measured at each position. Damage to the knee was recorded for all subjects by MRI, and at arthroscopy. Results: The tibio-femoral contact pattern of the ACL injured knee was different from the healthy contralateral knee (p = 0.001). The contact pattern of the recently injured knees was different to the chronic ACL deficient knees (p = 0.034). In the recently injured knees the lateral compartment of the knee showed a posterior pattern of femoral contact, and in the chronic ACL deficient knees the medial compartment showed a posterior femoral contact pattern, particularly at zero and 15 degrees of knee flexion (p < 0.01), with the femur two millimetres (mean, SD 3.2mm) posterior on the tibial plateau. There was no difference in passive laxity between the recent and chronic injured knees (side-to-side difference: 5.8mm±2.4 for the recently injured knees, and 4.6±2.8mm for the chronic ACL-deficient knees). Nine of 20 recently injured knees had associated joint damage: three medial and three lateral meniscal tears, two with medial femoral condyle and two with patello-femoral damage. Eleven of 23 chronic ACL deficient subjects had associated joint damage: 15 medial and 16 lateral meniscus tears, 16 with medial and 12 with lateral compartment chondral damage. Greater kinematic changes in the chronic ACL deficient knees were associated with more severe chondral damage in the medial compartment. Conclusion: ACL injury shifts the axis of rotation of the knee medially. In chronic ACL deficiency the tibio-femoral contact pattern is altered in the medial compartment, where it is associated with joint damage. These findings describe the relationship between aberrant kinematics and wear in the ACL deficient knee