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BACKGROUND: There has been an increase in interest in the use of biological therapies in orthopaedic conditions such as knee osteoarthritis. Platelet-rich plasma (PRP) is one of these therapies, but it still lacks consistent results. PURPOSE: To evaluate the effects (benefits and harms) of PRP intra-articular injection compared with other nonsurgical methods for the treatment of knee osteoarthritis. STUDY DESIGN: Systematic review and meta-analysis of randomized and quasi-randomized controlled trials; Level of evidence, 2. METHODS: Three electronic databases were searched to identify relevant studies published before January 2021. The primary outcomes were pain, function, and failure of treatment. Risks of bias of all trials were assessed using a Cochrane risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation System was used to assess the quality of evidence of included studies. RESULTS: A total of 40 studies with 3035 participants were included. Analysis of this review focused on comparing PRP with hyaluronic acid, corticosteroid, and saline, as we believe they are the most relevant comparisons with the most studies available. At 6-month follow-up, PRP was as effective as and in some studies more effective than other therapies regarding pain, function, and stiffness. However, current evidence is of low or very low quality and is based on trials with high risk of bias and great heterogeneity among them. No significant difference among treatments was found concerning major adverse events and treatment failure. CONCLUSION: Although studies suggest that PRP may be more effective than or at least as effective as other modalities of nonsurgical treatment for knee osteoarthritis in terms of pain, function, and adverse events, serious limitations and methodological flaws are considerable in the current literature. Therefore, the authors are not able to make recommendations for clinical practice regarding PRP for knee osteoarthritis.

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Nonabsorbable suture augmentation of ligament reconstruction has seen an increase in use over the past several years with the goal of protecting the newly reconstructed ligament while allowing early rehabilitation for a potential earlier return to activity and sport. By spanning the joint with a durable nonabsorbable suture, this construct shares the stress and load seen by the reconstructed ligament, thereby protecting it from forces that could result in an early failure during the early ligamentization phase of the tendon graft. However, stress shielding of the ligament via nonabsorbable suture augmentation is also a double-edged sword, as a reduction in the stress and load seen by the ligament during this healing phase may ultimately have an impact on the final strength and composition of the reconstructed ligament. Although the long-term effects of this stress shielding have yet to be studied or reported in human subjects, multiple biomechanical and animal studies have demonstrated overall changes in architecture, tensile strength, and mechanical properties of a stress-shielded autograft ligament reconstruction.

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BACKGROUND: Anterior drawer test, Lachman test including evaluation of the endpoint, and pivot shift test have been commonly applied clinically in diagnosing anterior cruciate ligament (ACL) injury but how they function in the appraisal of partial ACL tears is less known. The aims of this study were to examine the diagnostic values of the commonly used knee function tests on patients in detecting ACL injury including partial injury patterns, to assess each of the test's predictive values on the specific ACL injury pattern, and to assess if using multiple tests collectively for the diagnosis of the injury could improve diagnostic accuracy. METHODS: We evaluated 36 consecutive patients who underwent ACL single bundle augmentation surgery. Those patients were matched by gender and age to 36 patients with a complete rupture of the ACL. Data was obtained from the patients' records. The rupture pattern was confirmed by arthroscopy. An examination under anesthesia was routinely performed by two surgeons who were blinded to the rupture pattern prior to surgery. RESULTS: Collectively using both Lachman test and pivot shift test increases ability to distinguish between partial tears and complete ruptures. When comparing partial PL tears and complete ruptures the pivot shift test is more important than the Lachman test. In diagnosing a complete rupture, the evaluation of the endpoint during the Lachman test is more sensitive than the evaluation of the anterior tibial translation during the Lachman test. CONCLUSION: Based on the findings of this study, a diagnostic algorithm has been implemented and is presented in this manuscript.

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The anterolateral structures of the knee have recently garnered considerable interest regarding their role in rotatory knee instability related to anterior cruciate ligament tears. Isolated anterior cruciate ligament reconstruction may not always restore rotatory stability of the knee. In these patients, additional procedures, such as lateral reconstruction or tenodesis, may be indicated. The anatomy of the anterolateral structures of the knee has been well described. Histologic and anatomic studies have reported conflicting findings regarding the presence of a discrete ligament. The biomechanical role of the anterolateral capsule in restraining internal tibial rotation has been described as negligible. The existing body of research on the anterolateral knee structures provides insight into the composition of the anterolateral complex of the knee.

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The anterior cruciate ligament (ACL) is one of the more studied structures in the knee joint. It is not a tubular structure, but is much narrower in its midsubstance and broader at its ends, producing an hourglass shape. The ACL is composed of 2 functional bundles, the anteromedial and posterolateral bundles, that are named for their location of insertion on the anterior surface of the tibial plateau. Although the relative contribution in terms of total cross-sectional area of the ACL has been noted to be equal in regards to each bundle, dynamically these bundles demonstrate different properties for knee function.

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PURPOSE: To conduct a systematic review to identify and summarize the various techniques that have been used to simulate the pivot-shift test in vitro. METHODS: Medline, Embase, and the Cochrane Library were screened for studies involving the simulated pivot-shift test in human cadaveric knees published between 1946 and May 2014. Study parameters including sample size, study location, simulated pivot-shift technique, loads applied, knee flexion angles at which simulated pivot shift was tested, and kinematic evaluation tools were extracted and analyzed. RESULTS: Forty-eight studies reporting simulated pivot-shift testing on 627 cadaveric knees fulfilled the criteria. Reviewer inter-rater agreement for study selection showed a κ score of 0.960 (full-text review). Twenty-seven studies described the use of internal rotation torque, with a mean of 5.3 Nm (range, 1 to 18 Nm). Forty-seven studies described the use of valgus torque, with a mean of 8.8 Nm (range, 1 to 25 Nm). Four studies described the use of iliotibial tract tension, ranging from 10 to 88 N. Regarding static simulated pivot-shift test techniques, 100% of the studies performed testing at 30° of knee flexion, and the most tested range of motion in the continuous tests was 0° to 90°. Anterior tibial translation was the most analyzed parameter during the simulated pivot-shift test, being used in 45 studies. In 22% of the studies, a robotic system was used to simulate the pivot-shift test. Robotic systems were shown to have better control of the loading system and higher tracking system accuracy. CONCLUSIONS: This study provides a reference for investigators who desire to apply simulated pivot shift in their in vitro studies. It is recommended to simulate the pivot-shift test using a 10-Nm valgus torque and 5-Nm internal rotation torque. Knee flexion of 30° is mandatory for testing. LEVEL OF EVIDENCE: Level IV, systematic review of basic science studies.

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PURPOSE: To identify and describe reliable landmarks for tibial tunnel placement in anatomical ACL reconstruction. METHODS: Eight non-paired cadaveric knees were used. After dissection, the tibial plateaus, menisci and ACL insertions were grossly observed to identify anatomical landmarks and relate them to the ACL insertion site. The specimens were scanned with a laser scanner, and 3-Dimensional images were obtained. Measurements of the ACL tibial insertion were taken. The center of the ACL and its bundles was measured regarding the distance from the medial tibial eminence and intermeniscal ligament. RESULTS: The medial tibial eminence demonstrated a constant relationship with the ACL tibial insertion site center and its bundles, as well as the intermeniscal ligament. The anterior root of the lateral meniscus had a variable relationship with the ACL tibial insertion. The length of the ACL tibial insertion was 18.1 ± 2.8 mm and the width was 10.7 ± 1.9 mm. The width of the AM bundle was 11.1 ± 2.1 mm and the PL 7.9 ± 2.0 mm. The ACL center was 9.1 ± 1.5 mm posterior to the intermeniscal ligament and 5.7 ± 1.1 mm anterior to a projected line from the apex of the medial tibial eminence. The center of the AM bundle was at 4.6 ± 0.7 mm posterior to the intermeniscal ligament. The center of the PL bundle was 1.4 ± 0.7 mm anterior to the medial tibial eminence. CONCLUSION: The medial tibial eminence and the intermeniscal ligament may be used as landmarks to guide the correct tunnel placement in an anatomical ACL reconstruction.

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Um interesse cada vez maior na reconstrução dupla banda do LCA tem estimulado um grande avanço nesta área de pesquisa e levado a um aumento no nosso conhecimento de anatomia, cinemática e função do joelho. Estudos recentes têm melhor definido o tamanho e orientação das inserções femorais e tibiais das bandas ântero-medial e póstero-lateral do LCA. O objetivo da reconstrução anatômica do LCA é utilizar esses novos conceitos para melhorar a técnica cirúrgica e mimetizar a anatomia original do LCA. Acreditamos que a reconstrução anatômica do LCA irá resultar em uma melhora na biomecânica e, consequentemente, uma melhora no quadro funcional de cada paciente.

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