Rogério Pereira

Notch morphology is a risk factor for ACL injury: a systematic review and meta-analysis

Importance Several bone morphological parameters have been identified in the scientific literature as risk factors for sustaining an anterior cruciate ligament (ACL) injury; however, a clear consensus on which are the most predisposing factors is still missing. Aim This systematic review and meta-analysis aims to investigate the association between bone morphological parameters and the risk of sustaining an ACL injury. Evidence review We conducted a comprehensive search using PubMed, Cochrane Library, Scopus, CINAHL and SPORTDiscus databases from 2005 until 2015. Two authors independently searched for relevant studies that assessed the association between bone morphology and ACL injury. Other search sources were used for hand-searching additional potential studies and the reference list of recent studies was screened. The methodological quality of the included studies was assessed through an adapted scale for radiological studies. A fixed-effects or random-effects model was used accordingly to estimate the mean differences with 95% CIs regarding the association of ACL injury with intercondylar notch (ICN) width, notch width index (NWI) and tibial slopes. Findings 23 studies were included for analysis comprising a total of 3452 participants, 1681 with an ACL injury and 1763 with an intact ACL. The ACL-injured individuals had narrower ICN width (p<0.001), smaller NWI (p=0.005) and steeper tibial slope (p<0.001). Conclusions On the basis of the current scientific literature, narrower ICN widths, smaller NWI and increased tibial slopes put the individual at higher risk of injuring the ACL. Future research should focus on developing indexes for different parameters rather than absolute measurements.

Patellofemoral Evaluation: Do We Need an Objective Kinematic Approach?

In the scope of patellofemoral research, there have been several efforts to understand the complexity of motion and forces involved. Nevertheless, several issues remain waiting for resolution. On the evaluation of symptomatic patellofemoral cases, one can realize that several limitations subside in the road from understanding etiology to clinical diagnosis. If in one hand it faces ambiguous and discrepant definitions due to its multifactorial origin, on the other hand, the assessment methods applied are inaccurate and nonobjective and present limited reliability and reproducibility. The present approach aims to contribute with an innovative solution, enabling objective anatomical and kinematic patellofemoral assessment.

ACL injuries identifiable for pre-participation imagiological analysis: Risk factors

Identification of pre-participation risk factors for noncontact anterior cruciate ligament (ACL) injuries has been attracting a great deal of interest in the sports medicine and traumatology communities. Appropriate methods that enable predicting which patients could benefit from preventive strategies are most welcome. This would enable athlete-specific training and conditioning or tailored equipment in order to develop appropriate strategies to reduce incidence of injury. In order to accomplish these goals, the ideal system should be able to assess both anatomic and functional features. Complementarily, the screening method must be cost-effective and suited for widespread application. Anatomic study protocol requiring only standard X rays could answer some of such demands. Dynamic MRI/CT evaluation and electronically assisted pivot-shift evaluation can be powerful tools providing complementary information. These upcoming insights, when validated and properly combined, envision changing pre-participation knee examination in the near future. Herein different methods (validated or under research) aiming to improve the capacity to identify persons/athletes with higher risk for ACL injury are overviewed.

Systematic Approach from Porto School

The high prevalence of anterior cruciate ligament (ACL) reconstruction [1–3] reinforces the importance of developing strategies aiming at prevention, diagnosis, and treatment of possible complications and/or failure of such procedures. Revision of ACL reconstruction always presents a challenge in orthopedic practice. However, in present time it must enter in the “routine” of any knee reconstruction surgeon [4–19]. Revision of ACL repair, regardless of the inherent cause, must be considered a demanding and delicate clinical procedure. Its results have been considered as predictably less satisfactory than those of the primary operation [20]. Somewhat inferior patient-reported outcome scores comparing to previously published results of primary ACL reconstruction have been shown, but clinical relevance of these findings remains to be clarified [21]. Furthermore, higher remaining laxity, higher graft failure rate, and meniscal or cartilage degeneration have also been described [1, 22]. Despite several reports of favorable results and return to sports at the same level after AC revision, clinical failure rates up to 25 % have been reported [17].

MRI-Based Laxity Measurement for Return to Play

The objective measurement of knee sagittal and rotation laxity upon the anterior cruciate ligament (ACL) lesion has an essential role in the knee stability assessment. These measurements can further be evaluated through magnetic resonance imaging (MRI), which in combination with instrumented assessment and physical examination can correlate both the “anatomy” and “function” of the ligament. The Porto-Knee Testing Device (PKTD) is a knee laxity testing device compatible with MRI that is capable of measuring the posterior-anterior tibial translation and tibial internal and external rotation. In this sense, the PKTD is a useful tool for the assessment of knee sagittal and rotatory laxity in the follow-up of football players that underwent ACL reconstruction. Hence, this tool may allow to identify individuals presenting residual knee laxity with increased risk of sustaining secondary ACL injuries and assist in the planning of secondary prevention programs.

Clinical Management in Early OA

Knee osteoarthritis affects an important percentage of the population throughout their life. Several factors seem to be related to the development of knee osteoarthritis including genetic predisposition, gender, age, meniscal deficiency, lower limb malalignments, joint instability, cartilage defects, and increasing sports participation. The latter has contributed to a higher prevalence of early onset of knee osteoarthritis at younger ages with this active population demanding more consistent and durable outcomes. The diagnosis is complex and the common signs and symptoms are often cloaked at these early stages. Classification systems have been developed and are based on the presence of knee pain and radiographic findings coupled with magnetic resonance or arthroscopic evidence of early joint degeneration. Nonsurgical treatment is often the first-line option and is mainly based on daily life adaptations, weight loss, and exercise, with pharmacological agents having only a symptomatic role. Surgical treatment shows positive results in relieving the joint symptomatology, increasing the knee function and delaying the development to further degenerative stages. Biologic therapies are an emerging field showing early promising results; however, further high-level research is required.

Management of Cartilage Injuries in Handball

Articular cartilage lesions of the knee are complex injuries, posing a serious threat to the handball player competitive career. Returning to competition at the pre-injury sports activity level as early and as safe as possible is the ultimate goal to be achieved. There is no consensus on the best surgical technique, and clinical algorithms have been proposed to manage the different articular cartilage defects. The chapter will also overview and summarize the available conservative and surgical management options and stepwise criteria-based rehabilitation strategy and return to play considerations in handball players with focal cartilage defects and osteochondral lesions.

Return to Play Following Cartilage Injuries

Articular cartilage lesions are serious injuries, particularly in the football player, once these may endanger the athlete’s competitive career. Returning to competition at the preinjury sports activity level as fast and as safe as possible is the ultimate goal to be achieved. Although there is no consensus on the best surgical technique, clinical algorithms have been proposed to manage the different articular cartilage defects. Herein, we summarize the available clinical treatment possibilities for addressing focal cartilage defects and osteochondral lesions. We also overview the three rehabilitation phases and the progression of the patient within these plans shall follow objective criteria. The considerations to return to play are also briefly discussed herein.

MRI laxity assessment

Knee laxity, by definition, is a dynamic and multifactorial condition. MRI evaluation, due to its known capacity in achieving high soft tissue contrast (e.g., meniscus, synovia, ligaments, cartilage) and multiplanar joint assessment without ionizing radiation, has contributed to its popularity in the last decades. However, “traditional” MRI studies provide static evaluation, thus requiring careful correlation to clinical findings, particularly when dealing with functional ligament stability. This work aims to describe the most important features of current MRI studies when dealing with anterior cruciate ligaments injuries, while also presenting the evolving possibilities of dynamic and objective MRI assessment of knee instability.

Basics on Knee (dys)Function

The athlete’s body is in constant adaptation, i.e., the mechanotransduction phenomenon in stricto sensu and all the genotype-environment interactions in lato sensu occur in a continuum, delivering structural and functional effects which have their implications for recovering, maintenance, and development. Upon injuries and/or demanding for safe and greater performance, it is possible to set goals such as motor and physical improvements. This is possible through specific exercise aiming kinetics balance and motor learning. This has particular importance in the lower limb injuries since epidemiological studies clearly report the high incidence and severity in this body segment.