Publications
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Runer, Armin; Bouguennec, Nicolas; Wierer, Guido; Robinson, James; Amis, Andrew & Herbst, Elmar
[Show all 25 contributors for this article]
(2026).
Current concepts in isolated and combined injuries of the medial collateral ligament complex, part II: The anteromedial knee instability classification.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
doi:
10.1002/ksa.70630.
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Tandberg, Alexander Nagel; Zegzdryn, Marek Walerian; Brattgjerd, Jan Egil; Moatshe, Gilbert & Aune, Arne Kristian
(2026).
Greater deformation and lower stiffness, but similar ultimate failure strength with fixed-loop cortical suspensory device compared to metal interference screw for femoral fixation of bone–patellar tendon–bone grafts in anterior cruciate ligament reconstruction.
Journal of Experimental Orthopaedics.
13(3).
doi:
10.1002/jeo2.70921.
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Cao, Mingde; Hoshino, Yuichi; Moatshe, Gilbert; Wang, Joon Ho; Issaragrisil, Pakapon & Mogos, Stefan
[Show all 24 contributors for this article]
(2026).
APKASS 2024 consensus statement on anterior cruciate ligament reconstruction, Part II: Management of anterior cruciate ligament revision in adults.
Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology.
45,
p. 74–81.
doi:
10.1016/j.asmart.2026.06.001.
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Trøan, Ingrid; Holm, Inger; Moatshe, Gilbert; LaPrade, Robert F.; Engebretsen, Lars & Bere, Tone
(2026).
Quadriceps and Hamstring Muscle Strength Recovery After a Multiligament Knee Injury: A Long-term Follow-up.
American Journal of Sports Medicine.
ISSN 0363-5465.
54(11),
p. 2722–2731.
doi:
10.1177/03635465261466381.
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Background: Multiligament knee injuries (MLKIs) are serious and heterogeneous injuries that often lead to long-term functional limitations. There is limited literature regarding objective muscle strength and functional recovery after surgical treatment of MLKIs. Purpose: To investigate long-term quadriceps and hamstring muscle strength and functional recovery after surgical treatment of MLKI and to compare postoperative outcomes between single cruciate MLKI and bicruciate MLKIs. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients surgically treated for an MLKI at a single level 1 trauma center between January 2013 and December 2020 were included. Isokinetic quadriceps and hamstring muscle strength were assessed using a Biodex dynamometer, and physical function was measured by single-leg hop, triple hop, crossover hop, and 6-m timed hop tests, with the limb symmetry index (LSI) calculated. Results: Of 124 eligible patients, 90 (72%) participated at a mean follow-up time of 7 years (SD, 2.1) since surgery to evaluation. The median age at the time of testing was 49 years (range, 21-72) and 59% were male. In total, 54% of the patients had not regained full quadriceps strength (LSI <90%), and 46% had persistent hamstring deficits for peak torque/body weight (PT/BW) at 60 deg/s. Across the entire cohort, there was a significant difference between the uninvolved and involved sides for quadriceps and hamstrings for PT/BW ( P = .01). The mean LSI for quadriceps PT/BW was 88% at 60 deg/s and 90% at 240 deg/s, while for the hamstrings, the mean LSI was 93% at 60 deg/s and 97% at 240 deg/s. Median LSIs for the hop tests ranged from 93% (range, 41%-187%) for single leg to 99% (42%-141%) for crossover; however, 44% of patients failed to reach the 90% threshold for the single-leg hop. The 6-m timed hop test and quadriceps muscle strength were significantly lower for patients with bicruciate injuries than those with single cruciate injuries ( P < .05). Conclusion: Persistent deficits in quadriceps and hamstring muscle strength were observed 7 years after MLKI surgery, with a substantial proportion of patients failing to regain full functional symmetry in muscle strength and hop test performance. Patients with bicruciate injuries demonstrated significantly more pronounced deficits in muscle strength and hop test scores as compared with those with single cruciate injuries.
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Gray, Mitchell T.; Danaher, Michael; Geeslin, Matthew G.; Moatshe, Gilbert & Geeslin, Andrew G.
(2026).
Surface Attachment Points for Lateral Extra-articular Procedures Are in Close Proximity to the Femoral and Tibial Physes in Skeletally Immature Patients.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
42(5),
p. 914–919.
doi:
10.1002/arj.70073.
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Wang, Ming; Hoshino, Yuichi; Moatshe, Gilbert; Wang, Joon Ho; Issaragrisil, Pakapon & Mogos, Stefan
[Show all 24 contributors for this article]
(2026).
APKASS 2024 consensus statement on anterior cruciate ligament reconstruction, Part I: Management of paediatric anterior cruciate ligament injury.
Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology.
45,
p. 26–32.
doi:
10.1016/j.asmart.2026.05.007.
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Liang, Zuru; Hoshino, Yuichi; Moatshe, Gilbert; Wang, Joon Ho; Issaragrisil, Pakapon & Mogos, Stefan
[Show all 24 contributors for this article]
(2026).
APKASS 2024 consensus statement on anterior cruciate ligament reconstruction, part Ⅲ: Return to play after anterior cruciate ligament reconstruction.
Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology.
45,
p. 1–7.
doi:
10.1016/j.asmart.2026.05.006.
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Morgan, Jacob T.; Nishioka, Tanner; Casanova, Felipe; Moatshe, Gilbert; LaPrade, Robert F. & Chahla, Jorge
(2026).
Evaluation and Management of Meniscal Tears.
Journal of Bone and Joint Surgery. American volume.
ISSN 0021-9355.
doi:
10.2106/JBJS.26.00230.
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Winkler, Philipp Wilhelm; Zsidai, Bálint; Narup, Eric; Runer, Armin; Lind, Martin & Moatshe, Gilbert
[Show all 9 contributors for this article]
(2026).
Inferior clinical outcomes and higher subjective treatment failure after revision compared to primary posterior cruciate ligament reconstruction: A propensity score-matched analysis.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
doi:
10.1002/ksa.70323.
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Dworsky-Fried, Joshua; Kotipalli, Satyavenkata; Vivekanantha, Prushoth; Alomari, Meshal; Tapasvi, Sachin & Moatshe, Gilbert
[Show all 8 contributors for this article]
(2025).
Rates of Return to Sport After Surgical Management of Multiligament Knee Injuries Are Higher Than Previously Described yet Highly Heterogeneous: A Systematic Review.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
41(11),
p. 4911–4927e.13.
doi:
10.1016/j.arthro.2025.06.006.
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LaPrade, Robert F.; Gerhold, Cameron; Kunze, Kyle N.; Geeslin, Andrew G.; Tollefson, Luke V. & Dave, Udit
[Show all 45 contributors for this article]
(2025).
A Contemporary International Expert Consensus Statement on the Evaluation, Diagnosis, Treatment, and Rehabilitation of Injuries to the Posterolateral Corner of the Knee.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
41(11),
p. 4630–4640.
doi:
10.1016/j.arthro.2025.04.055.
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Sonnery-Cottet, Bertrand; Carrozzo, Alessandro; Saithna, Adnan; Monaco, Edoardo; Vieira, Thais Dutra & Musahl, Volker
[Show all 56 contributors for this article]
(2025).
Surgical Treatment and Complications of Lateral Extra-articular Procedures in the Anterior Cruciate Ligament–Reconstructed Knee: Part II of an International Consensus Statement.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
41(9),
p. 3313–3321.
doi:
10.1016/j.arthro.2025.06.013.
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Chahla, Jorge; Garcia, Jose Rafael; Tollefson, Luke; Dzidzishvili, Lika; Allende, Felicitas & Gerhold, Cameron
[Show all 61 contributors for this article]
(2025).
International Delphi Consensus on Medial Meniscal Root Tears Shows High Agreement on Diagnosis, Treatment, and Rehabilitation but Lack of Agreement on Treatment of Asymptomatic Tears.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
41(11),
p. 4683–4698.
doi:
10.1016/j.arthro.2025.06.028.
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Purpose
To develop an expert consensus statement on the diagnosis, management, and rehabilitation of medial meniscal root tears (MMRTs) using a modified Delphi technique.
Methods
A working group developed statements on MMRT diagnosis, nonoperative management, surgical indications, surgical management, alignment, and rehabilitation using modified Delphi techniques. Fifty-six experts were surveyed over 3 rounds to reach consensus, with agreement measured on a 5-point Likert scale. Statements were included, revised, or excluded on the basis of predefined thresholds (≥75% agreement, <20% disagreement). Experts suggested revisions or new statements in the first 2 rounds, and final consensus statements were included.
Results
All 56 experts completed 3 survey rounds. Experts agreed that root tears may occur with no known history of trauma, typically in older patients, and that it should be diagnosed with an magnetic resonance imaging. In symptomatic patients with MMRTs without advanced osteoarthritis should be repaired using an anatomic transtibial pull-out technique (performing a pie-crusting technique can be helpful for visualization). Nonoperative management is advised for patients with advanced osteoarthritis. High tibial osteotomy may be considered for significant varus malalignment during MMRT repair. The only statement without consensus was the management of asymptomatic MMRTs with mild medial compartment cartilage wear, indicating ongoing debate.
Conclusions
Overall, 98% of statements reached consensus. There is agreement that magnetic resonance imaging is the gold standard for diagnosis. Symptomatic MMRTs without advanced osteoarthritis should be repaired early using an anatomic transtibial pull-out technique. End-stage knee osteoarthritis warrants nonoperative management of MMRTs, and a structured postoperative protocol with limited weightbearing and range of motion is essential after repair. No agreement was reached on managing asymptomatic MMRTs in patients without significant medial compartment degeneration. Meniscal centralization sutures may help in cases of substantial extrusion, but their routine use is debated.
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Zachovajevas, Vilius; Engebretsen, Lars; Moatshe, Gilbert; Zachovajevas, Pavelas & Røise, Olav
(2025).
Injuries in Mixed Martial Arts After Adoption of the Unified Rules of MMA: A Systematic Review.
Orthopaedic Journal of Sports Medicine (OJSM).
13(7).
doi:
10.1177/23259671251342578.
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Background:
The existing literature on injuries in mixed martial arts (MMA) is sparse and lacks a summarized review of injuries in the sport after the adoption of the new rule set in 2009.
Purpose:
To assess the injury characteristics in terms of injury rates and types in MMA after the adoption of the Unified Rules of MMA (URM) by the Association of Boxing Commissions and compare them with preadoption trends.
Study Design:
Systematic review; Level of evidence, 4.
Methods:
Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, primary literature in English examining injuries in MMA after URM adoption was scanned in Medline, Embase, and PubMed from the inception of these databases until December 27, 2023. Reports providing relevant information on injury rates and characteristics, with data solely on MMA athletes rather than in a combination of athletes from other combat sports, were reviewed and analyzed. In total, 191 reports were identified after the initial search. Descriptive statistics were employed to summarize injury rates, types, and locations, as well as variations across subgroups.
Results:
A total of 43 reports were included in the analysis. The reports varied widely in design, injury definitions, and data collection methods. Post-URM competition injury rates ranged from 23.6 to 54.5 injuries per 100 athlete-exposures (AEs), with soft tissue injuries (lacerations/abrasions/contusions) being the most common type of injury (20.7%-56.9% of all injuries). The most common location of injury was the head and neck area (29.5%-75.9% of all injuries). Concussion rates varied from 14.7 to 16.1 per 100 AEs, and heavier fighters experienced more knockouts and technical knockouts. There is some evidence suggesting higher injury rates among professional fighters.
Conclusion:
The review demonstrated that the most common injuries reported in MMA athletes are soft tissue injuries including lacerations, abrasions, and contusion mainly in the head and neck area. Professional athletes seem to have higher injury rates than amateur athletes, while heavier weight fighters sustain more knockouts and technical knockouts. Current injury rates and types seem to remain similar to those before the adoption of the URM. Analysis of current literature emphasizes a lack of standardized definitions, data on training injuries, and female injuries, which are required to fully evaluate injury characteristics in MMA and ensure the long-term well-being of those participating in the sport.
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Trøan, Ingrid; Bere, Tone Tufte; Holm, Inger; Løken, Sverre Bertrand; LaPrade, Robert F. & Engebretsen, Lars
[Show all 7 contributors for this article]
(2025).
Return to sport and work after multiligament knee injury.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
34(1),
p. 329–337.
doi:
10.1002/ksa.70175.
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Abstract Purpose Multiligament knee injuries (MLKIs) are complex and often associated with significant functional impairments. Data on return to sport (RTS) and return to work (RTW) remain limited, particularly for recreational athletes and the general population. The purpose of the study was to evaluate RTS, RTW and physical activity levels after surgical treatment of MLKIs. Methods Patients surgically treated for MLKI at a single Level 1 Trauma centre from 2013 to 2020 were included. Patient‐reported outcomes included the Tegner score and work status before and after injury. Physical activity was assessed using the activity questionnaire from the Nord‐Trøndelag Health Study (HUNT 1). Health‐related quality of life was measured with the EuroQol 5‐Dimension Questionnaire (EQ‐5D). Results Out of 191 eligible patients, 124 (65%) participated (mean age 37 ± 13.7 years, range 17–70). RTS: 77% ( n = 84) returned to some level of sport, 37% ( n = 31) returned to their pre‐injury sport at any level, and only seven of 28 (25%) resumed high‐level pivoting sports. The mean Tegner score declined from 5.2 to 3 ( p < 0.001). RTW: 90% ( n = 112) returned to work, but 15% required task modifications or became disabled. Work participation significantly declined (2.1–1.9, p < 0.04). Patients with single cruciate injuries had better outcomes, including higher Tegner (3.6 vs. 3, p = 0.043) and EQ‐5D scores (0.931 vs. 0.893, p = 0.012) than those with bicruciate injuries. Conclusion A significant number of patients with an MLKI were unable to return to their former sports activities, with only 37% returning to the same level as before the injury. Although most patients were able to return to their pre‐injury work levels, 15% had to adapt to less demanding tasks or became disabled due to the injury. Despite significant reductions in activity levels, most patients reported good health‐related quality of life. Level of Evidence Level IV, cross‐sectional cohort study.
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Trøan, Ingrid; Bere, Tone Tufte; Holm, Inger; LaPrade, Robert F.; Engebretsen, Lars & Moatshe, Gilbert
(2025).
Patient-Reported Outcomes of Bicruciate Multiligament Versus Single Cruciate Multiligament Knee Injuries.
American Journal of Sports Medicine.
ISSN 0363-5465.
53(1),
p. 138–146.
doi:
10.1177/03635465241293743.
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Tollefson, Luke V.; Shoemaker, Evan P.; Slette, Erik L.; Carlson, Mitchell; LaPrade, Robert F. & Engebretsen, Lars
[Show all 8 contributors for this article]
(2025).
Adequate Failure Loads for Modified Lemaire Lateral Extra-articular Tenodesis Are Achieved With an Interference Screw, Staple, and Suture Anchor: A Biomechanical Study of Structural Properties.
American Journal of Sports Medicine.
ISSN 0363-5465.
53(2),
p. 327–332.
doi:
10.1177/03635465241305739.
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Familiari, Filippo; Saithna, Adnan; Martinez-Cano, Juan Pablo; Chahla, Jorge; Castillo, Juan Miguel Del & DePhillipo, Nicholas
[Show all 11 contributors for this article]
(2025).
Exploring artificial intelligence in orthopaedics: A collaborative survey from the ISAKOS Young Professional Task Force.
Journal of Experimental Orthopaedics.
12.
doi:
10.1002/jeo2.70181.
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Purpose: Through an analysis of findings from a survey about the use ofartificial intelligence (AI) in orthopaedics, the aim of this study was to es-tablish a scholarly foundation for the discourse on AI in orthopaedics and toelucidate key patterns, challenges and potential future trajectories for AIapplications within the field.Methods: The International Society of Arthroscopy, Knee Surgery andOrthopaedic Sports Medicine (ISAKOS) Young Professionals Task Forcedeveloped a survey to collect feedback on issues related to the use of AI inthe orthopaedic field. The survey included 26 questions. Data obtained fromthe completed questionnaires were transferred to a spreadsheet and thenanalyzed.Results: Two hundred and eleven orthopaedic surgeons completed thesurvey. The survey encompassed responses from a diverse cohort oforthopaedic professionals, predominantly comprising males (92.9%). Therewas wide representation across all geographic regions. A notable proportion(52.1%) reported uncertainty or lack of differentiation among AI, machinelearning and deep learning (47.9%). Respondents identified imaging‐baseddiagnosis (60.2%) as the primary field of orthopaedics poised to benefit fromAI. A considerable proportion (25.1%) reported using AI in their practice,with primary reasons including referencing scientific literature/publications(40.3%). The vast majority expressed interest in leveraging AI technologies(95.3%), demonstrating an inclination towards incorporating AI into ortho-paedic practice. Respondents indicated specific areas of interest for furtherstudy, including prediction of patient outcomes after surgery (30.8%) andimage‐based diagnosis of osteoarthritis (28%).
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Mitchnik, Ilan Y.; Mimouni, Tomer; Haichin, Loren S.; Bayyouk, Suzana; Moatshe, Gilbert & Lindner, Dror
[Show all 9 contributors for this article]
(2025).
Disagreement Persists on Optimal Rehabilitation Goals and Timelines for Weight-Bearing Restriction, Knee Brace Use, and Return to Sports After Posterolateral Corner Reconstruction.
Arthroscopy, Sports Medicine, and Rehabilitation (ASMAR).
7(3).
doi:
10.1016/j.asmr.2025.101142.
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Purpose
To assess the variability of rehabilitation protocols for both isolated posterolateral corner (PLC) reconstructions and those with a concomitant anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) reconstruction, to construct uniform rehabilitative protocol recommendations, and to propose rehabilitative outcome measures for future PLC-related clinical studies.
Methods
A Google search was conducted for online PLC reconstruction rehabilitation protocols, categorizing them into isolated PLC reconstructions or PLC with concomitant ACL/PCL reconstructions. Rehabilitative goals and timelines were described and agreement rates among protocols were calculated. Comparisons were made between groups and before/after 2019, when a global consensus was published. Common rehabilitative goals with high agreement rates were used to form a recommended protocol.
Results
Thirty-seven protocols were analyzed (19 isolated PLC, 9 PLC + PCL, and 9 PLC + ACL). Overall, 31% of rehabilitative goals and timelines had good-to-excellent agreement rates. Post-2019 consensus, adherence to a stepwise rehabilitative approach significantly improved, especially for initiating strength exercises after muscular endurance exercises (P = .009) and initiating power exercises after strength exercises (P = . 031). However, there was no significant change in overall agreement rates (P = . 735). Most disagreements involved postoperative weight-bearing restrictions, with one half of protocols recommending non−weight-bearing and one half partial-weight-bearing; the period of time a knee brace is required after 6 weeks; and return to sports timing, which differed with concomitant ACL (later return) and PCL (earlier return) reconstructions.
Conclusions
There is disagreement about optimal rehabilitative goals and timelines for weight-bearing restriction, knee brace use, and return to sports after PLC reconstructions. Rehabilitative outcomes that warrant further research were identified, and a suggested rehabilitation protocol was constructed.
Clinical Relevance
Rehabilitation after PLC reconstruction lacks standardization, with significant variation in key milestones such as weight-bearing, knee bracing, and return-to-sport timelines. This study provides an analysis of current rehabilitation protocol inconsistencies and offers a structured recommendation that may assist clinicians and physiotherapists in patient counseling and protocol development.
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Robinson, James; Murray, Iain R.; Moatshe, Gilbert; Chahla, Jorge; Tollefson, Luke V. & Parker, David A.
[Show all 9 contributors for this article]
(2025).
Current practice of biologic augmentation techniques to enhance the healing of meniscal repairs: A collaborative survey within the Meniscus International Network (MenIN) Study Group.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
34,
p. 436–444.
doi:
10.1002/ksa.12685.
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Oeding, Jacob F.; Boos, Alexander M.; Kalk, Josh R.; Sorenson, Dane; Verhooven, F. Martijn & Moatshe, Gilbert
[Show all 7 contributors for this article]
(2024).
Pitch-Tracking Metrics as a Predictor of Future Shoulder and Elbow Injuries in Major League Baseball Pitchers: A Machine-Learning and Game-Theory Based Analysis.
Orthopaedic Journal of Sports Medicine (OJSM).
12(8).
doi:
10.1177/23259671241264260.
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Background: Understanding interactions between multiple risk factors for shoulder and elbow injuries in Major League Baseball (MLB) pitchers is important to identify potential avenues by which risk can be reduced while minimizing impact on player performance.
Purpose: To apply a novel game theory–based approach to develop a machine-learning model predictive of next-season shoulder and elbow injuries in MLB pitchers and use this model to understand interdependencies and interaction effects between the most important risk factors.
Study Design: Case-control study; Level of evidence, 3.
Methods: Pitcher demographics, workload measures, pitch-tracking metrics, and injury data between 2017 and 2022 were used to construct a database of MLB pitcher-years, where each item in the database corresponded to a pitcher's information and metrics for that year. An extreme gradient boosting machine-learning model was trained to predict next-season shoulder and elbow injuries utilizing Shapley additive explanation values to quantify feature importance as well as interdependencies and interaction effects between predictive variables.
Results: A total of 3808 pitcher-years were included in this analysis; 606 (15.9%) of these involved a shoulder or elbow injury resulting in placement on the MLB injured list. Of the >65 candidate features (including workload, demographic, and pitch-tracking metrics), the most important contributors to predicting shoulder/elbow injury were increased: pitch velocity (all pitch types), utilization of sliders (SLs), fastball (FB) spin rate, FB horizontal movement, and player age. The strongest game theory interaction effects were that higher FB velocity did not alter a younger pitcher's predicted risk of shoulder/elbow injury versus older pitchers, risk of shoulder/elbow injury increased with the number of high-velocity pitches thrown (regardless of pitch type and in an additive fashion), and FB velocity
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Nassar, Joseph E.; Sleem, Bshara; Tollefson, Luke V.; Shoemaker, Evan P.; LaPrade, Robert F. & Moatshe, Gilbert
(2024).
Strategies for Preventing Tunnel Convergence in Multiligament Knee Injury Reconstructions.
Indian Journal of Orthopaedics.
ISSN 0019-5413.
58,
p. 1528–1536.
doi:
10.1007/s43465-024-01267-4.
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Geeslin, Andrew G.; Moatshe, Gilbert; Engebretsen, Lars; Lind, Martin; Hansson, Frida & Stalman, Anders
[Show all 8 contributors for this article]
(2024).
Functional anterior cruciate ligament braces may have a role in select patient groups although there is presently limited evidence supporting or refuting their routine use: A scoping review of clinical practice guidelines and an updated bracing classification.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
doi:
10.1002/ksa.12203.
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Purpose The purpose of this study was to perform a scoping review of clinical practice guidelines (CPGs) concerning the use of functional anterior cruciate ligament (ACL) braces and to clarify the nomenclature for bracing relevant to ACL injury treatment in order to support prescribing clinicians. Methods A PubMed search for CPGs for the use of braces following ACL injury or reconstruction was performed. CPGs on the treatment of ACL injuries with sufficient attention to postoperative braces were included in this scoping review. The references used for supporting the specific CPG recommendations were reviewed. Specific indications for brace use including brace type, period of use following surgery and activities requiring brace use were collected. Results Six CPGs were identified and included this this review. Three randomised trials provided the evidence for recommendations on functional brace use following ACL reconstruction in the six CPGs. Functional ACL braces were the primary focus of the three randomised trials, although extension braces (postoperative knee immobilisers) were also discussed. A novel dynamic ACL brace category has been described, although included CPGs did not provide guidance on this brace type. Conclusions Guidance on the use of functional ACL braces following ACL reconstruction is provided in six CPGs supported by three randomised trials. However, the brace protocols and patient compliance in the randomised trials render these CPGs inadequate for providing guidance on the use of functional ACL braces in the general and high-risk patient populations when returning to sport after ACL reconstruction. Functional ACL braces are commonly utilised during the course of ACL injury treatment although there is presently limited evidence supporting or refuting the routine use of these braces. Future studies are, therefore, necessary in order to provide guidance on the use of functional and dynamic ACL braces in high-risk patient populations.
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Zegzdryn, Marek Walerian; Moatshe, Gilbert; Engebretsen, Lars; Drogset, Jon Olav; Lygre, Stein Håkon Låstad & Visnes, Håvard
[Show all 7 contributors for this article]
(2024).
Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
32(3),
p. 656–665.
doi:
10.1002/ksa.12081.
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Purpose: Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts.
Methods: Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan–Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recorded preoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories ‘Sport’ and ‘Quality of Life’ was measured for patients that were not revised and analysed with multiple linear regression.
Results: A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery
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Engebretsen, Lars; Møller, Merete; Kooy, Caroline; Yamaguchi, Tetsuo & Moatshe, Gilbert
(2024).
The gender and sex data gap in anterior cruciate ligament injuries in paediatric patients.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
32(10),
p. 2500–2504.
doi:
10.1002/ksa.12397.
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Anterior cruciate ligament (ACL) injury is a concerning problem in the paediatric population, impacting joint health and longevity. Moreover, ACL injury hampers physical activity, which is important for children's social network and general well-being. Recent data demonstrates a rise in paediatric ACL reconstructions, affecting both girls and boys. However, it is unclear whether this rise reflects a higher injury rate or a more proactive approach towards surgery, as information on nonoperated patients is lacking. Regarding gender differences, increasing evidence implies that girls engaged in pivoting sports experience a higher incidence of ACL injuries and reinjuries compared to boys. Furthermore, data suggest that girls have inferior outcomes and lower return-to-sport rates than boys. The social context in which girls compete in sports is likely a significant contributing factor to the risk of serious knee injuries. Lack of attention and insufficient data on gender-based differences in ACL injuries, outcomes and evidence-based treatment guidelines highlight the need for further research on this topic.
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Garcia, Jose Refael; Ayala, Salvador Gonzalez; Allende, Felicitas; Mameri, Enzo; Haynes, Monique & Familiari, Filippo
[Show all 12 contributors for this article]
(2024).
Diagnosis and Treatment Strategies of Meniscus Root Tears: A Scoping Review.
Orthopaedic Journal of Sports Medicine (OJSM).
12(11).
doi:
10.1177/23259671241283962.
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Background: Meniscus root tears comprise 10% to 21% of all meniscal tears. These tears alter knee biomechanics, elevating contact pressure, akin to a meniscectomy. Consequently, they are linked to advanced joint degeneration and cartilage damage in the affected compartment.
Purpose: To systematically evaluate and relate the current literature describing the diagnosis and treatment strategies for meniscus root tears.
Study Design: Scoping review; Level of evidence, 4.
Methods: This review was conducted following the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. Inclusion criteria encompassed English-language clinical and preclinical research, technical notes, and narrative reviews on meniscus root tears. Exclusion criteria were studies on patellar tendon rupture, studies on medial patellofemoral ligament rupture with additional knee joint ligament injuries, studies of patients \16 years old, and studies involving open fractures. The data were summarized using a descriptive analysis and a thematic analysis.
Results: After 1425 articles were identified, 461 studies were included; 17% (n = 78) were case reports or case series, 15% (n = 71) were technical notes, 9% (n = 41) addressed aspects of diagnosis, 7% (n = 32 ) were narrative reviews, and 5% (n = 21) were systematic reviews or meta-analyses. Studies presenting original data comprised 57% (n = 262) of all included studies, and 97% of the studies were of evidence levels 3 to 5. Contributions were mainly from the United States (n = 123; 27%), Republic of Korea (n = 102; 22%), and Japan (n = 99; 21%). Many studies (n = 216; 47%) focused on the treatment and outcomes of meniscus root tears. A significant chronological surge in the quantity of studies addressing the diagnosis and treatment of meniscus root tears was evident, particularly over the past 3 years. Consensus was found regarding the definition of meniscus root tears, the advantages of early repair, and postoperative rehabilitation protocols. The variations in surgical techniques and operative strategies
created the greatest amount of contention, along with clinical assessment and imaging modalities.
Conclusion: High-level evidence studies for diagnosing and managing meniscus root tears were scarce. A consensus has yet to be reached regarding the role of concomitant osteotomy, comparison of repair techniques, the use of a centralization stitch, patient factors affecting outcomes, and long-term outcomes of nonoperative management.
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Martin, Richard Kyle; Marmura, Hana; Wastvedt, Solvejg; Pareek, Ayoosh; Persson, Andreas & Moatshe, Gilbert
[Show all 10 contributors for this article]
(2024).
External validation of the Norwegian anterior cruciate ligament reconstruction revision prediction model using patients from the STABILITY 1 Trial.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
32(2),
p. 206–213.
doi:
10.1002/ksa.12031.
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Purpose: A machine learning-based anterior cruciate ligament (ACL) revision prediction model has been developed using Norwegian Knee Ligament Register (NKLR) data, but lacks external validation outside Scandinavia. This study aimed to assess the external validity of the NKLR model (https://swastvedt.shinyapps.io/calculator_rev/) using the STABILITY 1 randomized clinical trial (RCT) data set. The hypothesis was that model performance would be similar.
Methods: The NKLR Cox Lasso model was selected for external validation owing to its superior performance in the original study. STABILITY 1 patients with all five predictors required by the Cox Lasso model were included. The STABILITY 1 RCT was a prospective study which randomized patients to receive either a hamstring tendon autograft (HT) alone or HT plus a lateral extra-articular tenodesis (LET). Since all patients in the STABILITY 1 trial received HT ± LET, three configurations were tested: 1: all patients coded as HT, 2: HT + LET group coded as bone-patellar tendon-bone (BPTB) autograft, 3: HT + LET group coded as unknown/other graft choice. Model performance was assessed via concordance and calibration.
Results: In total, 591/618 (95.6%) STABILITY 1 patients were eligible for inclusion, with 39 undergoing revisions within 2 years (6.6%). Model performance was best when patients receiving HT + LET were coded as BPTB. Concordance was similar to the original NKLR prediction model for 1- and 2-year revision prediction (STABILITY: 0.71; NKLR: 0.68–0.69). Concordance 95% confidence interval (CI) ranged from 0.63 to 0.79. The model was well calibrated for 1-year prediction while the 2-year prediction demonstrated evidence of miscalibration.
Conclusion: When patients in STABILITY 1 who received HT + LET were coded as BPTB in the NKLR prediction model, concordance was similar to the index study. However, due to a wide 95% CI, the true performance of the prediction model with this Canadian and European cohort is unclear and a larger data set is required to definitively determine the external validity. Further, better calibration for 1-year predictions aligns with general prediction modelling challenges over longer periods. While not a large enough sample size to elicit the true accuracy and external validity of the prediction model when applied to North American patients, this analysis provides more support for the notion that HT plus LET performs similarly to BPTB reconstruction. In addition, despite the wide confidence interval, this study suggests optimism regarding the accuracy of the model when applied outside of Scandinavia.
Level of Evidence: Level 3, cohort study.
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Geeslin, Andrew G.; Tollefson, Luke V.; Slette, Erik L.; Shoemaker, Evan P.; Carlson, Mitchell & LaPrade, Robert F.
[Show all 8 contributors for this article]
(2024).
The Fibular Collateral Ligament Is a More Important Restraint to Varus Laxity Compared to the Anterolateral Complex in the Anterior Cruciate Ligament–Deficient Knee in a Cadaveric Biomechanical Study.
Arthroscopy: The Journal of Arthroscopy And Related.
ISSN 0749-8063.
doi:
10.1016/j.arthro.2024.09.025.
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Moatshe, Gilbert; LaPrade, Christopher M.; Fenstad, Anne Marie; Persson, Andreas; LaPrade, Matthew D. & Martin, Richard Kyle
[Show all 8 contributors for this article]
(2024).
Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021.
American Journal of Sports Medicine.
ISSN 0363-5465.
52(6),
p. 1491–1497.
doi:
10.1177/03635465241238461.
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Background: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR.
Purpose/Hypothesis: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR.
Study Design: Cohort study; Level of evidence, 3.
Methods: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score ﹤44.
Results: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score ﹤44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P ﹤ .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL ﹤44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07).
Conclusion: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.
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Oeding, Jacob F.; Jurgensmeier, Kevin; Boos, Alexander M.; Krych, Aaron J.; Okoroha, Kelechi R. & Moatshe, Gilbert
[Show all 7 contributors for this article]
(2024).
Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model–Based Analysis.
American Journal of Sports Medicine.
ISSN 0363-5465.
52(9),
p. 2319–2330.
doi:
10.1177/03635465241255147.
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Familiari, Filippo; Chahla, Jorge; Compagnoni, Riccardo; DePhillipo, Nicholas; Moatshe, Gilbert & LaPrade, Robert F.
(2024).
Meniscal extrusion consensus statement: A collaborative survey within the Meniscus International Network (MenIN) Study Group.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
32(6),
p. 1–9.
doi:
10.1002/ksa.12183.
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Purpose
The purpose of the present study was to perform a survey administered to members of the Meniscus International Network (MenIN) Study Group, seeking to delineate the most contentious aspects of meniscal extrusion classification and provide a foundation for new, more comprehensive definitions and treatments for these pathologies.
Methods
MenIN Study Group is a group of international experts treating and performing research on meniscus pathology and treatment. All MenIN Study Group members were asked to complete a survey aimed at establishing criteria for the optimal classification system for meniscal extrusion. Data obtained from the completed questionnaires were transferred into a spreadsheet and then analysed. All responses are presented as counts, percentages or means.
Results
Forty-seven (85.5%) MenIN Study Group members completed the survey and were included in this analysis. Key aspects recommended for inclusion in a comprehensive classification system for meniscal extrusion included laterality (93.6%), anatomical location (76.6%), patient age (76.6%), body mass index (BMI) (68.1%) and aetiology (68.1%). For classifying meniscal extrusion, 53.2% considered the distance in millimetres from the tibial plateau's outer margin as the most reliable measurement technique on imaging. Preferences for imaging modalities varied, with 44.7% favouring weight-bearing magnetic resonance imaging (MRI) and 36.2% opting for weight-bearing ultrasound due to its greater availability. Respondents advocated for a classification system addressing stability or progression of meniscal extrusion (66%), reducibility (53.2%), potential progression of knee osteoarthritis (OA) (83%), influencing treatment approaches (83%), a gradation system (83%), consideration of dynamic factors (66%), association with clinical outcomes and prognosis (76.6%) and investigation around centralization procedures (57.4%).
Conclusions
In conclusion, the findings of this survey shed light on the global perspectives regarding meniscal extrusion classification. It was generally felt that a new classification of extrusion measured on MRI scans at the mid-tibial plateau should be developed, which considers factors such as laterality, anatomical location, age, BMI and aetiology. Additionally, the results support the integration of dynamic factors and clinical outcomes in MRI-based classifications to inform treatment approaches.
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Murray, Iain Robert; Makaram, Navnit S.; Geeslin, Andrew G.; Chahla, Jorge; Moatshe, Gilbert & Crossley, Kay
[Show all 42 contributors for this article]
(2024).
Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation.
British Journal of Sports Medicine.
ISSN 0306-3674.
doi:
10.1136/bjsports-2024-108089.
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Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined ‘a priori’ if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.
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Barton, Kristen I.; Boldt, Kevin R.; Sogbein, Olawale A.; Steiner, Nicholas J.; Moatshe, Gilbert & Arendt, Elizabeth
[Show all 7 contributors for this article]
(2024).
Femoral internal torsion greater than twenty-five degrees and/or external tibial torsion greater than thirty degrees as measured by computed tomography are threshold values for axial alignment correction in patellofemoral instability.
Journal of ISAKOS: Joint Disorders & Orthapaedic Sports Medicine.
ISSN 2059-7754.
9(3),
p. 386–393.
doi:
10.1016/j.jisako.2024.02.002.
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Objectives: Patellofemoral instability (PFI) has multiple predisposing anatomic factors, including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea dysplasia, excessive lateral patellar tilt, and excessive lateral Q vector. Yet, few studies have analyzed surgical thresholds for performing axial alignment corrective osteotomies in the treatment of PFI and patella maltracking. The objective of this systematic literature review was to determine if there is a threshold for axial plane alignment that triggers surgical correction for the treatment of patellar instability in the published literature.
Methods: Using a predetermined search strategy, a systematic literature search of 10 major databases and gray literature resources was completed. Only studies reporting on patellar instability and outcomes were included. Radiologic indications, additional procedures, outcomes, and complications were reported. Titles and abstracts were screened, and full-text manuscripts were then selected and extracted. Variables related to radiographic and clinical parameters, patient demographics, surgery performed, surgical correction, complications, and reoperations were recorded preoperatively and postoperatively.
Results: A total of 1132 abstracts and titles were screened by two reviewers, yielding 15 eligible studies. The reported threshold identified in our study for axial plane alignment that triggers surgical correction in most of the published literature when discussing PFI was either tibial torsion greater than 30° and/or femoral anteversion greater than 25°. Following rotational osteotomy of one or both long bones, one study (7%) reported improvements in tubercle-sulcus angle, two studies (13%) reported improvements in femoral-tibial angle, and four studies (27%) reported decreases in tibial torsion. For patient-reported outcomes, seven studies (47%) reported improvement in the Kujala score, five studies (33%) reported postoperative improvement in Lysholm, and four studies (27%) reported improvement in the International Knee Documentation Committee (IKDC) score. Nine studies (60%) reported preoperative femoral anteversion; however, only two studies compared pre- and post-operative values (one study reported a decrease in anteversion and another study reported an increase in anteversion).
Conclusion: When treating PFI, the reported threshold for axial plane alignment that triggers surgical correction in most of the published literature was tibial torsion greater than 30° and/or femoral anteversion greater than 25° as measured by CT. However, there is no consensus on the axial alignment measurement technique.
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Banovetz, Mark T.; Kennedy, Nicholas I.; LaPrade, Robert F.; Engebretsen, Lars & Moatshe, Gilbert
(2023).
Biomechanical considerations for graft choice in anterior cruciate ligament reconstruction.
Annals of Joint.
8.
doi:
10.21037/aoj-22-50.
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Makaram, Navnit S.; Murray, Iain R.; Geeslin, Andrew G.; Chahla, Jorge; Moatshe, Gilbert & LaPrade, Robert F.
(2023).
Diagnosis and treatment strategies of the multiligament injured knee: a scoping review.
British Journal of Sports Medicine.
ISSN 0306-3674.
57(9),
p. 543–550.
doi:
10.1136/bjsports-2022-106425.
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Objective: To map the current literature evaluating the diagnosis and treatment of multiligament knee injuries (MLKIs).
Design: Scoping review.
Data sources: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O’Malley frameworks were followed. A three-step search strategy identified relevant published literature comprising studies reporting on at least one aspect in the diagnosis or treatment of MLKI in adults. Data were synthesised to form a descriptive analysis and thematic summary.
Results: Overall, 417 studies were included. There was a substantial chronological increase in the number of studies published per year, with 70% published in the last 12 years. Of included studies, 128 (31%) were narrative reviews, editorials or technical notes with no original data. The majority of studies (n=239, 57%) originated from the USA; only 4 studies (1%) were of level I evidence. Consistent themes of contention included clinical assessment, imaging, operative strategy, timing of surgery and rehabilitation. There was a lack of gender and ethnic diversity reported within patient groups.
Conclusions: There remains insufficient high-level evidence to support definitive management strategies for MLKI. There is considerable heterogeneity in outcome reporting in current MLKI literature, precluding robust comparison, interpretation and pooling of data. Further research priorities include the development of expert consensus relating to the investigation, surgical management and rehabilitation of MLKI. There is a need for minimum reporting standards for clinical studies evaluating MLKI.
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Familiari, Filippo; Madonna, Vincenzo; Mercurio, Michele; Cinque, Mark E.; Gasparini, Giorgio & Galasso, Olimpio
[Show all 7 contributors for this article]
(2023).
Outcomes and complications of inlay versus onlay patellofemoral arthroplasty: A systematic review.
Knee (Oxford).
ISSN 0968-0160.
41,
p. 124–136.
doi:
10.1016/j.knee.2023.01.001.
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Purpose:
The purpose of this systematic review was to evaluate outcomes and complications rates between inlay and onlay patellofemoral arthroplasty (PFA).
Methods:
According to the PRISMA statement, 42 studies with 2552 patients were included. Data considered for quantitative analysis consisted of the Knee Society Score (KSS), the range of motion (ROM), the visual analogue score (VAS), and the Western Ontario and McMaster Universities questionnaire (WOMAC). Complications and revision surgery were considered.
Results:
Data on postoperative KSS showed no differences between the groups. The ROM was evaluated in 8 studies for 70 and 331 inlay and onlay PFA, respectively. Onlay group was favorable in terms of postoperative ROM. Postoperative VAS was available for 64 inlay and 110 onlay and no differences were found. Data on postoperative WOMAC were available for 49 inlay and 527 onlay PFA and inlay group showed better scores. A statistically significant higher rate of instability, persistent pain, malposition, stiffness, deep infection, disease progression, and wear of the patellar component were noted in the inlay group. A higher rate of lateral release was noted in the onlay group. A higher number of manipulations under anesthesia was noted in the inlay group. The revision to total knee arthroplasty was reported more frequently in the inlay group.
Conclusion:
A higher rate of conversion to total knee arthroplasty and complication rates after inlay technique was found. The potential of achieving better WOMAC scores with the inlay technique should be weighed against the higher complication and revision rates compared to the onlay technique.
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Martin, R. Kyle; Wastvedt, Solvejg; Pareek, Ayoosh; Persson, Andreas; Visnes, Håvard & Fenstad, Anne Marie
[Show all 10 contributors for this article]
(2023).
Ceiling Effect of the Combined Norwegian and Danish Knee Ligament Registers Limits Anterior Cruciate Ligament Reconstruction Outcome Prediction.
American Journal of Sports Medicine.
ISSN 0363-5465.
51(9),
p. 2324–2332.
doi:
10.1177/03635465231177905.
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Background:
Clinical tools based on machine learning analysis now exist for outcome prediction after primary anterior cruciate ligament reconstruction (ACLR). Relying partly on data volume, the general principle is that more data may lead to improved model accuracy.
Purpose/Hypothesis:
The purpose was to apply machine learning to a combined data set from the Norwegian and Danish knee ligament registers (NKLR and DKRR, respectively), with the aim of producing an algorithm that can predict revision surgery with improved accuracy relative to a previously published model developed using only the NKLR. The hypothesis was that the additional patient data would result in an algorithm that is more accurate.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Machine learning analysis was performed on combined data from the NKLR and DKRR. The primary outcome was the probability of revision ACLR within 1, 2, and 5 years. Data were split randomly into training sets (75%) and test sets (25%). There were 4 machine learning models examined: Cox lasso, random survival forest, gradient boosting, and super learner. Concordance and calibration were calculated for all 4 models.
Results:
The data set included 62,955 patients in which 5% underwent a revision surgical procedure with a mean follow-up of 7.6 ± 4.5 years. The 3 nonparametric models (random survival forest, gradient boosting, and super learner) performed best, demonstrating moderate concordance (0.67 [95% CI, 0.64-0.70]), and were well calibrated at 1 and 2 years. Model performance was similar to that of the previously published model (NKLR-only model: concordance, 0.67-0.69; well calibrated).
Conclusion:
Machine learning analysis of the combined NKLR and DKRR enabled prediction of the revision ACLR risk with moderate accuracy. However, the resulting algorithms were less user-friendly and did not demonstrate superior accuracy in comparison with the previously developed model based on patients from the NKLR alone, despite the analysis of nearly 63,000 patients. This ceiling effect suggests that simply adding more patients to current national knee ligament registers is unlikely to improve predictive capability and may prompt future changes to increase variable inclusion.
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Corsi, Matthew P.; Thompson, Adam B.; Kennedy, Nicholas I.; LaPrade, Robert F. & Moatshe, Gilbert
(2023).
Multiligament knee injuries in winter sports athletes.
Journal of Cartilage & Joint Preservation (JCJP).
3(3).
doi:
10.1016/j.jcjp.2023.100143.
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Multiligament knee injuries (MLKIs) are severe injuries that involve complete or partial tear to multiple ligaments of the knee, such as the cruciate ligaments, collateral ligaments, as well as structures such as the posteromedial and posterolateral corners. These injuries often occur as a result of high-energy trauma in motor vehicle accidents, but can also occur during sports activities such as a fall or collision while skiing or snowboarding. Diagnosis of an MLKI can be challenging due to the multifaceted nature of these injuries, and a comprehensive evaluation, including a thorough history, physical examination, and imaging studies, is necessary. Imaging methods, such as plain and stress radiographs and magnetic resonance imaging, are often used to confirm the diagnosis and assist in the establishment of a treatment plan. Treatment of MLKIs commonly involves surgical repair or reconstruction of torn ligaments and capsular structures, followed by lengthy rehabilitation focused on mobility, strength, and improving knee function. Return to sport is a concern, especially for those with many ligaments torn and those involving both cruciate ligaments and/or those involving the posterolateral corner. Prevention of MLKIs in skiing and snowboarding is important, and proper technique, equipment, risk awareness, and strengthening exercises can help reduce the risk of injury. While much is known about knee injuries in skiers, further research is needed to better understand MLKIs in ski and snowboard athletes, including the incidence, optimal management, and return to sport rates.
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Engseth, Lars; Grønsund, Jørgen; Aunan, Eirik; Brattgjerd, Jan Egil; Schulz, Anselm & Moatshe, Gilbert
[Show all 7 contributors for this article]
(2023).
A novel instrument for ligament balancing: a biomechanical study in human cadaveric knees.
Journal of Experimental Orthopaedics.
10(1).
doi:
10.1186/s40634-023-00643-7.
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Purpose: Ligament balancing is a prerequisite for good function and survival in total knee arthroplasty (TKA). Various balancing techniques exist, but none have shown superior results. The pie-crusting technique by Bellemans of the medial collateral ligament is commonly utilized; however, it can be difficult to achieve repeatable ligament lengthening with this technique. Therefore, we invented a novel instrument to standardize the pie-crusting technique of the superficial and deep medial collateral ligament (hereafter MCL). The purpose was to examine if pie-crusting with the instrument could produce repeatable ligament lengthening.
Methods: The MCL was isolated in 16 human cadaveric knees, and subjected to axial tension. The instrument was composed of a specific grid of holes in rows, used to guide sequential pie-crusting puncturing of the MCL with a Ø1.6 mm end-cutting cannula. Ligament lengthening was measured after each row of punctures. Regression analysis was performed on the results.
Results: Mean lengthening ± SD in human cadaveric MCL for puncturing of row 1 in the instrument was 0.06 ± 0.09 mm, 0.06 ± 0.04 mm for row 2, 0.09 ± 0.08 mm for row 3, 0.06 ± 0.05 mm for row 4 and 0.06 ± 0.04 mm for row 5, giving a mean total lengthening of 0.33 ± 0.20 mm. Linear regression revealed that MCLs were repeatably lengthened by 0.07 mm per row when punctured using the instrument.
Conclusions: MCLs showed linear lengthening in human cadavers for subsequent use of the instrument. Our instrument shows promising results for repeatable ligament lengthening.
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Martinez-Cano, Juan Pablo; Familiari, Filippo; Vinagre, Gustavo; Moatshe, Gilbert; Gomez-Sierra, Maria Antonia & Fermín, Theodorakys Marín
(2023).
Instrument-based anterolateral rotatory laxity assessment of the knee has a high intra-observer and inter-observer reliability: a systematic review.
Journal of ISAKOS: Joint Disorders & Orthapaedic Sports Medicine.
ISSN 2059-7754.
doi:
10.1016/j.jisako.2023.07.007.
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Importance: A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients might need concurrent anterolateral augmentation procedures. Objective: The purpose of this study was to systematically review studies that assess the intra-observer and inter-observer reliability of instruments used to measure anterolateral rotatory laxity of the knee. Evidence review: A comprehensive literature review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, using PubMed, Embase, Scopus, and Google Scholar databases for original, English-language studies evaluating the reliability of objective or instrument-based anterolateral rotatory laxity of the knee until October 31, 2022. Reliability data were extracted from text, tables, and figures. Findings: Twelve studies, with patients between the ages of 14–63 years, were included. The instruments used to measure anterolateral rotatory knee laxity included inertial sensors (n = 9), magnetic resonance imaging (n = 1), and navigation systems (n = 2). The global intra-observer intraclass correlation coefficient for these devices was between 0.63 and 0.97, and the global inter-observer reliability was between 0.63 and 0.99. Conclusion and relevance: Instrument-based anterolateral rotatory knee laxity assessment has moderate to good intra- and inter-observer reliability. Evaluating anterolateral instability in ACL-deficient knees with these devices could help in decision-making when considering anterolateral augmentation. Level of Evidence: IV.
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Toyooka, Seikai; Moatshe, Gilbert; Persson, Andreas & Engebretsen, Lars
(2023).
Return to Pivoting Sports after Cartilage Repair Surgery of the Knee: A Scoping Review.
Cartilage.
ISSN 1947-6035.
14(1).
doi:
10.1177/19476035221141416.
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Objective. to perform a scoping literature review evaluating and reporting on outcomes and return to pivoting sports after cartilage procedures. For this review, the following cartilage procedures were evaluated: microfracture, osteochondral autograft transplantation (Oat), osteochondral allograft transplantation (OCa), and autologous chondrocyte implantation (aCi). Design. the scoping review incorporated articles identified using PubMed (MeDliNe), CiNaHl, and Cochrane Central register of Controlled trials. Screening of reference lists of included studies and forward citation tracking were performed to identify additional studies. reported on return to pivoting sports after cartilage surgery written in english language. Results. Sixteen studies fulfilled the inclusion criteria. the return to sports (rtS) rates after microfracture ranged from 44% to 83%, and to preinjury level from 25% to 75%. the rtS rates after Oat ranged from 87% to 100%, and to preinjury level from 67% to 93%. the rtS rates after OCa ranged from 77% to 80%, and to preinjury level 64%. the rtS rates after aCi ranged from 33% to 96%, and to preinjury level from 26% to 67%. Conclusions. there was a high heterogeneity and range in rates of rtS in athletes participating in pivoting sports. Most studies reported high rates of rtS; however, return to preinjury level was lower. these data may be important to clinicians in shared decision making on the type of procedure to be performed and counseling pivoting sports athletes on prognosis and expected rtS rates.
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Toyooka, Seikai; Persson, Andreas; LaPrade, Robert F.; Engebretsen, Lars & Moatshe, Gilbert
(2023).
Injury Patterns in Posterolateral Corner Knee Injury.
Orthopaedic Journal of Sports Medicine (OJSM).
11(8).
doi:
10.1177/23259671231184468.
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Background:
Posterolateral corner (PLC) knee injuries associated with different injury mechanisms are not well known.
Purpose/Hypothesis:
This study sought to assess the patterns of associated injuries in the setting of PLC injury. The hypothesis was that there are recognizable injury patterns in PLC injuries that may correlate with injury mechanism.
Study Design:
Cross-sectional study; Level of evidence, 3.
Methods:
Patients who sustained a multiligament knee injury were retrospectively reviewed. Patients who sustained an acute grade 3 PLC injury and underwent surgery were enrolled in this study. A description of the PLC injury (location of the injury of the fibular collateral ligament [FCL], popliteus tendon, and/or popliteofibular ligament) and reported concomitant injuries (biceps femoris tendon or meniscal tears, cartilage pathology and/or peroneal nerve palsy, or bone bruises) were collected and classified based on intraoperative and magnetic resonance imaging (MRI) findings.
Results:
Of 135 patients reviewed, 83 did not have PLC involvement and 13 were excluded due to insufficient MRI scans available. Thus, 39 patients were included in this study. For both the anterior cruciate ligament (ACL)–PLC and ACL–posterior cruciate ligament–PLC injury patterns, the most frequent injury pattern entailed a bone bruise of the anteromedial (AM) femur and tibia, an FCL tear from the fibular head, the popliteus tendon avulsed off the femur, a biceps femoris tendon torn off the fibular head, and a common peroneal nerve palsy. Conversely, when no bone bruise occurred on the AM femur and tibia, the FCL was injured on the femoral side and the popliteus tendon, biceps femoris, and peroneal nerve were not injured.
Conclusion:
AM bone bruise was associated with a peroneal nerve injury in almost half of the patients, and peroneal nerve injury was not seen if there was no AM bone bruise.
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Familiari, Filippo; Compagnoni, Riccardo; Bait, Corrado; Grassi, Alberto; Pieroni, Arianna & Moatshe, Gilbert
[Show all 8 contributors for this article]
(2022).
International cooperation needed to improve national anterior cruciate ligament registries.
Knee Surgery, Sports Traumatology, Arthroscopy.
ISSN 0942-2056.
31(1),
p. 235–247.
doi:
10.1007/s00167-022-07091-3.
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Purpose:
The aim of this study is to illustrate an overview of the registries currently operative in many countries to support the introduction of new prospective registries in other countries.
Methods:
The authors carried out a systematic web research in July 2021 to identify national ACL registries’ annual reports and scientific literature on national ACL registries. The latest annual public registry reports were collected and analyzed in this study.
Results:
There are currently established national ACL registries in Norway, Denmark, Sweden, Luxembourg, New Zealand, the United Kingdom (UK), and the Kaiser Permanente National Anterior Cruciate Ligament Reconstruction Registry in the United States (US). Some differences can be found among the various registries due to the local healthcare system structure, data management rules, and general national laws.
Conclusion:
It is possible to develop accessible, cost-effective and entirely web-based ACL registries—as demonstrated by the Danish and Swedish registries—respecting the national legislation of different countries. This study supports the introduction of new ACL prospective registries in other countries to obtain valuable information for implementing daily clinical practice.
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Persson, Andreas; Moatshe, Gilbert & Engebretsen, Lars
(2022).
The Evidence Regarding ACL Repair.
In Nakamura, Norimasa; Marx, Robert G.; Musahl, Volker; Getgood, Alan; Sherman, Seth L. & Verdonk, Peter (Ed.),
Advances in Knee Ligament and Knee Preservation Surgery.
Springer.
ISSN 9783030847470.
p. 61–69.
doi:
10.1007/978-3-030-84748-7_7.
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Uddin, Fares; Moatshe, Gilbert & Getgood, Alan
(2022).
Evidenced-Based Approach for Anterolateral Surgery for ACL
Reconstruction.
In Nakamura, Norimasa; Marx, Robert G.; Musahl, Volker; Getgood, Alan; Sherman, Seth L. & Verdonk, Peter (Ed.),
Advances in Knee Ligament and Knee Preservation Surgery.
Springer.
ISSN 9783030847470.
p. 43–56.
doi:
10.1007/978-3-030-84748-7_5.
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Tandberg, Alexander Nagel; Zegzdryn, Marek Walerian; Brattgjerd, Jan Egil; Moatshe, Gilbert & Aune, Arne Kristian
(2025).
Kortikal fiksasjon vs interferensskrue for fiksasjon av patellarsenegraft i femur ved ACLR. En biomekanisk kadaverstudie.
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Trøan, Ingrid; Bere, Tone Tufte; Holm, Inger; Moatshe, Gilbert; Engebretsen, Lars & LaPrade, Robert
(2025).
Quadriceps- og hamstringstyrke gjenvinnes ikke fullstendig etter en multiligamentskade i kneet - en langtidsoppfølging.
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Moatshe, Gilbert; Owesen, Christian; Løken, Sverre Bertrand; Trøan, Ingrid; Årøen, Asbjørn & Engebretsen, Lars
(2025).
Det er ingen forskjell i aktivitetsnivå 1 år etter bakre korsbåndskade, etter rehabilitering med eller uten PCL-ortose.
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Trøan, Ingrid; Moatshe, Gilbert; Bere, Tone Tufte; Holm, Inger & Engebretsen, Lars
(2025).
Return to sport and to work after mulitligament knee injury.
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Rodriguez, Ariel N.; Falaas, Kari; Moatshe, Gilbert & Engebretsen, Lars
(2024).
Posterior Oblique Ligament.
In Espregueira-Mendes, João; Karlsson, Jón; Musahl, Volker & Ayeni, Olufemi R. (Ed.),
Orthopaedic sports medicine: An encyclopedic review of diagnosis, prevention, and management.
Springer.
doi:
10.1007/978-3-030-65430-6_95-1.
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Knee dislocations have historically been severe and potentially limb-threatening injuries. Over the last several decades, the diagnosis, treatment, and rehabilitation for knee dislocations have improved, leading to improved patient outcomes and knee function. A thorough physical examination including assessment of neurovascular status and the integrity of all ligaments and soft tissue structures of the knee is necessary for a comprehensive treatment plan. The use of stress radiographs, in combination with magnetic resonance imaging, is recommended to assess the functional status of the cruciate and collateral ligaments of the knee. An anatomic-based reconstruction approach within the acute treatment period following injury is recommended. In order to allow early functional rehabilitation, Patients who undergo anatomic-based reconstructions, followed by early postoperative rehabilitation focusing on protected range of motion and quadriceps strengthening, have shown optimal outcomes. With these principles, improved knee function and activity level can be expected; however, return to preinjury activity level cannot be expected.
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Moatshe, Gilbert & Engebretsen, Lars
(2024).
Knee dislocations with vascular injuries – a review article.
Danish Medical Journal.
71(3).
doi:
10.61409/A08230529.
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Knee dislocations are complex and devastating injuries that are potentially limb threatening. A high level of suspicion is required to diagnose and treat these injuries properly and timely because some of the knee dislocations spontaneously reduce, and the seriousness of the injury might not be appreciated early. Early diagnosis of concomitant vascular injuries is imperative to avoid limb loss because the risk of amputation is high when diagnosis and timely intervention are delayed. It is recommended that serial ankle-brachial index (ABI) be performed in all patients with suspected knee dislocation. This is particularly important in fracture dislocations, high-energy trauma, morbidly obese patients, lateral sided injuries, concomitant peroneal nerve injuries and fracture in the ipsilateral limb because these were demonstrated to be associated with a high risk of concomitant vascular injuries in knee dislocations. In cases where serial ABI cannot be performed, in high-risk patients and ABI
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Braaten, Jacob; Rodriguez, Ariel; Engebretsen, Lars & Moatshe, Gilbert
(2024).
Posterior oblique ligament.
In Espregueira-Mendes, João; Karlsson, Jón; Musahl, Volker & Ayeni, Olufemi R. (Ed.),
Orthopaedic sports medicine: An encyclopedic review of diagnosis, prevention, and management.
Springer.
doi:
10.1007/978-3-030-65430-6_46-1.
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Toyooka, Seikai; Moatshe, Gilbert; Persson, Andreas & Engebretsen, Lars
(2023).
Return to pivoting sports after cartilage repair surgery of the knee - a scoping review.
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Uddin, Fares; Alfaraidy, Moaad; Moatshe, Gilbert & Getgood, Alan
(2023).
Outcomes and complications following medial patellofemoral ligament reconstruction utilizing a single converging patella tunnel technique with gracilis tendon autograft - minimum 2-year followup.
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Moatshe, Gilbert
(2023).
Optimizing knee dislocation treatment - single stage, anatomic reconstructions with early PT and ROM.
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Moatshe, Gilbert
(2023).
The posterior cruciate ligament rReconstruction - how do I get it tight and how do I get it right? My Way.
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Berge, Tea; Blich, Ingvild; Stølen, Ragnhild Øydna; Moatshe, Gilbert; Ludvigsen, Tom C & Bøe, Berte Marie Grimsmo
(2023).
Minimum five years follow-up after arthroscopic latarjet at Oslo University Hospital.
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Moatshe, Gilbert; Lind, Martin; Larson, Christopher; Hiemstra, Laurie; Harlem, Thomas & Tjong, Vehniah
(2023).
Panel debate - Acute ACL-MCL case.
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Rodriguez, Ariel N.; Falaas, Kari L.; Monson, Jill; Moatshe, Gilbert; Engebretsen, Lars & LaPrade, Robert F.
(2023).
Management of Posterolateral Corner Injury in the Multiligament Injured Knee.
In Sherman, Seth L.; Chahla, Jorge; Rodeo, Scott & LaPrade, Robert F. (Ed.),
Knee Arthroscopy and Knee Preservation Surgery.
Springer.
ISSN 9783030828691.
doi:
10.1007/978-3-030-82869-1_41-1.
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Persson, Andreas; Løken, Sverre Bertrand; Engebretsen, Lars & Moatshe, Gilbert
(2022).
Kneluksasjon - diagnostikk og initial behandling.
Kirurgen.
ISSN 1504-8888.
4,
p. 198–201.
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Løken, Sverre Bertrand; Persson, Andreas & Moatshe, Gilbert
(2022).
Kirurgiske behandlingsmetoder ved kneluksasjoner.
Kirurgen.
ISSN 1504-8888.
p. 206–209.
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Moatshe, Gilbert & Engebretsen, Lars
(2022).
Knee dislocations with vascular injuries.
Kirurgen.
ISSN 1504-8888.
p. 202–205.
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Grønsund, Jørgen; Aunan, Eirik; Brattgjerd, Jan Egil; Schulz, Anselm; Moatshe, Gilbert & Röhrl, Stephan Maximilian Herbert
(2022).
A novel instrument for ligament balancing in Total Knee Arthroplasty – a biomechanical study in porcine tissue.
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Aunan, Eirik; Schulz, Anselm; Moatshe, Gilbert; Brattgjerd, Jan Egil; Grønsund, Jørgen & Röhrl, Stephan Maximilian Herbert
(2022).
A novel instrument for ligament balancing in Total Knee Arthroplasty – a biomechanical study in porcine and human tissue.
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Published
Dec. 21, 2021 4:18 PM
- Last modified
Dec. 21, 2021 4:18 PM
