Background
The use of kneeling stress radiography in evaluating posterior knee laxity is a simple and reproducible method with high intra/inter-observer reliability. Knee size and flexion angle can affect accurate measurement of tibial translation but a simple modification of the kneeling device has resolved this. We have compared two accepted methods for measuring posterior tibial translation (PTT).

Objectives
To compare the reliability of stress-radiography methods calculating posterior knee laxity

Study Design & Methods
A bespoke kneeling x-ray device was built using a Plexiglass frame and a high-density foam and leather platform. In order to account for the difference in thigh size and muscle bulk, we incorporated 10mm adjustments into the frame. Bilateral knee lateral radiographs were taken to calculate a side-to-side difference in PTT.

Results
A total of 19 patients with PCL deficient knees and those who had undergone PCL reconstructions were evaluated using stress radiography with lateral kneeling x-rays under bodyweight load. The radiographs were interpreted by 2 clinicians using 2 separate methods to calculate a side-to-side difference in posterior laxity (LaPrade and Schulz). Both methods proved reliable in assessing posterior knee laxity with high inter and intra-observer correlation. There was no significant difference in accuracy between the two methods of measurement (P=0.97).
Conclusions
The kneeling device allowed accurate measurement of posterior displacement of the tibia using validated methods. Raters found the Schulz method more intuitive and easier to use. Moreover, the LaPrade method was not possible in cases where implanted metalwork obscured the posterior point of Blumensaat’s line.

Introduction: Obesity, smoking status, and older age have been shown to predict poorer general postoperative outcomes. The purpose of this study is to evaluate the risk that these comorbidities have on 30-day postoperative outcomes in patients undergoing arthroscopic posterior cruciate ligament (PCL) reconstruction. Methods: The National Surgical Quality Improvement Program was queried to identify PCL reconstruction patients between 2008 and 2016. Subjects undergoing simultaneous ligamentous knee repair were excluded. Patients were stratified by BMI, age (≤30 vs. >30), and smoking status. Patient demographics, operative details, and postoperative outcomes were assessed. Binary logistic regression determined the impact of BMI, age, and smoking on adverse effects. Results: 444 arthroscopic PCL reconstructions were identified. 21.2% were smokers. 16.2% were normal weight, 38.1% were overweight, 22.5% were obese, 13.5 were obese class-2, and 8.3% were obese class-3. 40% were aged >30. The rates of any complication, reoperations, and readmissions were 2.5%, 0.5%, and 0.5%, respectively. BMI status and age grouping posed no significant influence on complication occurrence, reoperation, or readmission (all, p>0.05). Smokers were significantly more likely to have a reoperation (2.6% vs 0%, p=0.043), readmission (2.7% vs 0%, p=0.043), and wound dehiscence (2.1% vs 0%, p=0.044). Conclusion: In this study, despite patients of varying ages and BMI experience comparable postoperative outcomes within 30 days following PCL reconstruction surgery, smokers were more likely to be readmitted, have a reoperation, and experience wound dehiscence.

Background
The all-inside PCL reconstruction is a recognised technique for symptomatic PCL injuries and offers several advantages including easy graft passage and adjustable fixation. We present the first objective radiological and clinical evaluation of a consecutive series of patients who have undergone all-inside PCL reconstructions.

Objectives
To clinically and radiologically assess patients who have had All-inside PCL reconstructions in the context of isolated and multi-ligamentous injuries.

Methods
IKDC, KOOS, Tegner and Lysholm scores were used to evaluate 18 consecutive all-inside PCL reconstruction cases between June’15 and October’18. Kneeling stress x-rays were obtained after a minimum 6-months post-operative period to compare side-to-side difference (SSD) in posterior-tibial-translation.

Results
We completed follow-up for 4 isolated and 14 multi-ligamentous injury patients. Average age was 35 with a M:F ratio of 11:7. Median follow-up was 22 months (Range 12 to 43). Median injury-to-surgery time was 12.4 months (Range 0.5 to 197). Combined scores(median) for all patients were as follows: IKDC:54, Lysholm:68, Tegner:4, and Combined KOOS:55.

Kneeling stress x-rays were performed and showed a median SSD of 5.4mm(Range 2.5 to 7.2mm). 2 patients had failed grafts. In patients with isolated PCL injury the median SSD was 2.7mm(Range 1 to 4.5mm) and scores as follows: IKDC:91, Lysholm:95, Tegner:7, Combined KOOS:96.

Conclusions
All-inside PCL reconstruction is a safe and reliable technique for improving knee function in selected cases. According to objective stress-radiographic evaluation, posterior laxity is not completely eliminated but restored to within one grade of laxity. Isolated PCL injuries revealed superior outcomes compared to multi-ligament injuries.

Background: Combined Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) injuries continues to be a challenge for the operating surgeon, with the dearth of high quality studies relating to graft considerations and functional outcomes and lack of clear consensus on what the optimal management should be. Methods: The retrospective evaluation of 33 patients with combined ACL and PCL reconstruction was performed according to the inclusion criteria. Patients were divided into three groups: - Group 1: ACL reconstruction with hamstring graft with preserved insertion (STGPI) and PCL reconstruction with free hamstring graft (STGF); Group 2: ACL with STGF and PCL with BPTB graft and Group 3: ACL with BPTB graft and PCL with STGPI. Patients were assessed for functional outcome scores including Lysholm score, International Knee Documentation Committee (IKDC) and Tegner activity score at a minimum follow-up of 2 years. Results: The mean follow-up of patients in group 1, 2 and 3 were 103.09±10.32, 74.36±10.24 and 44.6±1.32 months respectively. All the 3 groups were found to be comparable in terms of age, gender, duration of injury and surgery, pre-injury Tegner score, post-surgical Lysholm, IKDC and Tegner scores. Mean BPTB bone plug for group 2 patients were 7 mm and for group 3 patients were 10 mm. The average tourniquet time in group 1, 2 and 3 were 54.34±20.40, 72.24±14.42, and 60.08±21.89 minutes respectively (p=0.04). Conclusions: No differences were observed in functional outcome scores in combined ACL and PCL reconstructed patients, when different types of grafts were used.

Introduction- Fibular collateral ligament (FCL) injuries can occur alone or combination with ACL.PCL( posterior cruciate ligament ) or MCL ( medial collateral ligament). Varus instability due to (FCL) is also reported to increase forces on the cruciate ligaments, which can lead to overload and failure of these reconstructions in cases of nonrecognized combined injuries.Material and methods- we present 30 cases ( Sports person / athletes) of ACL tear with varus instabilty(with the knee flexed at 20°, a side-to-side lateral gapping difference of 2.7 to 4.0 mm in varus stress radiographs and normal PLC in MRI),treated with ACL reconstruction using semi tendinous and FCL using gracilis graft using bioabsorble interference screw. Results –Evaluated at 2 years of follow up mean knee range of flexion unaffected and affected side was 129.5+5.3 and 109+9.1,Preoperative VAS score( 8.2+1.2)reduced to (4.3+1.6) post operatively, Preoperative lysholm score was (22.3+7.4) improved to (56.43+11.76) post operatively.Preoperative IKDC score was (22.6+4.08) improved to (68.72+5.03) . the mean post operative rollimeter was (3.06+1.04 )SD anatomical FCL reconstruction using gracilis graft at an average 2-year follow-up resulted in improved patient outcomes and near-normal lateral compartment stability. Conclusion- Arthroscopy assisted FCL reconstruction using Gracillis tendon autograft provides stable knee, reduced post operative morbidity, It allows the patients to return to there preinjury level of physical activity without difficulty.Degeneration of articular surfaces rarely occurs and reoperation rate are minimal.

Indications: Posterolateral rotational instabilities of the knee. Combined lesions of the PCL and the posterolateral corner. Purpose: A minimally invasive Laprade modified technique procedure with arthroscopic assistance for anatomical popliteus tendon (PLT) reconstruction was developed. Methods: In 8 cadaver knees, an arthroscopic reconstruction of the PLT was performed. Two arthroscopic portals are necessary; the tibial tunnel guide is placed under arthroscopic vision. One minimally invasive posterolateral approach (10mm) is performed to allow passage of the graft through the proximal lateral posterior portion of the tibia. The positioning of the femoral tunnel -by placement of the guide wire- is performed under arthroscopic vision. Results: The femoral drill tunnel is located with a high degree of precision in the centre of the femoral footprint of the popliteus tendon. On the tibial side, the drill tunnel is located in the distal third of the sulcus popliteus. Conclusions: The presented arthroscopic technique for popliteus tendon reconstruction is standardized, reproducible, with high precision for the placement of the tibial and femoral tunnel. The technique could be clinically relevant for future arthroscopic posterolateral corner reconstructions.

Introduction:
Arthroscopic surgery is the gold standard for cruciate ligament reconstruction in multi-ligament knee injuries. However, hospitals in limited-resource settings often lack arthroscopic-trained surgeons or equipment. Open approaches for treating knee dislocations can overcome many of these limitations.

Methodology:
This study aims to describe techniques for open approaches in a supine patient to address the cruciate ligaments in multi-ligament knee injuries and to review associated complications and clinical outcomes in a retrospective case series.

Results:
Ten patients with multi-ligament knee injuries who had undergone open cruciate ligament reconstruction between July 2016 and November 2018 were retrospectively identified. Open approaches were performed owing to the extravasation of arthroscopy fluid into the posterior compartment (3) or a large traumatic arthrotomy (7). Complications and patient-reported outcomes were analysed. Eight of the 10 patients were followed up at 10 months postoperatively (range, 5–23 months). None had iatrogenic neurovascular damage. Median outcomes scores were: visual analogue scale, 45 (range, 0–100); Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, 81.4 (range, 75–100); Lysholm, 85 (range, 67–92).

Discussion:
Open approaches were safe and useful in treating cruciate ligaments and should be considered in arthroscopy fluid extraversion and large traumatic arthrotomies.

Objective: evaluate musculoskeletal function and knee joint quality in amateur half-marathon street runners. Methodology: Analytical observational cross-sectional study, with male street runners, who participated at least one half marathon race in the city of Curitiba-PR between 2017 and 2018. Evaluate a musculoskeletal function: handgrip strength (FPM) (34.47 - 79.83 kgf), position of first resistance detected (34-43º), elevation of the rectified leg (TEPR) (D-dominant:> 85º; ND (non-dominant- ND:> 87º), knee flexion fleximetry (0-140º), flexibility of the iliotibial band (adducted limb), adducted weight (WBLT) (46-50º) and knee radiography for Ahlback classification. Parameters were deviated using SPSS software (25.0) Results: 52 runners participated, mean age of 36.2 ± 6.8 years, using the first resistance position test detected (D: 36.4 ± 15.6º , E: 38.3 ± 14.7º), shortening of hamstring muscles by TEPR (D: 55.7 ± 8.8 º; ND: 55.6 ± 9.3º); Decreased knee flexion ROM (D: 132.3 ± 7.2 °; E: 137 ± 7.8º), adequate iliotibial band flexibility (adducted limb) and reduced dorsiflexion ROM by WBLT (42.4 ± 6, 8th). As for Ahlback's classification, 43.3% (n = 13) did not show alteration on the x-ray, 46.7% (n = 14) alteration grade I (reduction of joint space) and 10% (n = 6) grade II alteration (obliteration of the joint space). Conclusion: Street runners with altered musculoskeletal function due to decreased ROM and muscle length, which can be considered a risk factor for the changes in knee radiography found and, consequently, for musculoskeletal associations of lower lower limbs resulting from sport.

Background: Arthroscopic simulation has rapidly evolved recently with the introduction of higher-fidelity simulation models, such as virtual reality simulators, which provide trainees an environment to practice skills without causing undue harm to patients. Simulation training also offers a uniform approach to learn surgical skills with immediate feedback. The aim of this article is to review the recent research investigating the use of arthroscopic simulators in training and the teaching of surgical skills. Study Design & Methods: A systematic review of the Embase, MEDLINE, and Cochrane Library databases for English-language articles published before December 2019 was conducted. The search terms included arthroscopy or arthroscopic in combination with simulation or simulator. Results: We identified a total of 44 relevant studies involving benchtop or virtually simulated ankle, knee, shoulder, and hip arthroscopy environments. The majority of these studies demonstrated construct and transfer validity; considerably fewer studies demonstrated content and face validity. Conclusions: Our review indicates that there is a considerable evidence base regarding the use of arthroscopic simulators for training purposes. Further work should focus on the development of a more uniform simulator training course that can be compared with current intraoperative training in large-scale trials with long-term follow-up at tertiary centers.

Introduction.
Femoro-acetabular impingement (FAI) is a dynamic phenomenon. Its management is guided by MRI scan findings. We aimed to evaluate how informed MRI-based pre-operative planning is, and the value of anterior acetabular sector angle (AASA) as a measure of anterior acetabular coverage.

Materials.
We performed a review of patients that underwent hip arthroscopy for FAI. Pre-operative MRI findings were correlated with examination under anaesthetic (EUA) and intra-operative arthroscopic findings (benchmark). We analysed alpha-angles (>50 degrees) versus CAM, precise nature of labral lesions, pincer versus AASA (>65 degrees).

Results.
150 patients (78–females) underwent 150 arthroscopies. Average age–38years (53-18). Intra-operatively, pincer was present in 20% of patients, CAM in 26%, mixed impingement in 54%. MRI scans correctly identified the presence of pincer in 36% of cases, CAM in 44%, precise labral abnormalities in 80%. Although there was a statistically significant difference in AASA values between pure CAM-type and pincer/mixed impingements (57o vs 63o,p<0.05); no statistical difference between pure pincer and mixed impingement (62o vs 63o,p=0.62). Pre-operative EUA accurately identified CAM lesions in 89% and pincer-type lesions in 77%.

Conclusions.
Ability to precisely establish pathology enables thorough pre-operative planning. MRI scans, even when reported by experienced MSK radiologists, frequently fail to identify the impingement pattern. Pathological threshold of AASA >65 degrees in MRI-based axial-plane evaluation of pincer-type pathomorphology was shown to be unreliable. We advocate pre-operative EUA to enhance the understanding of pathology, treatment planning and hip arthroscopy success.

Introduction
Femoroacetabular impingement (FAI) has been extensively investigated and is strongly associated with athletic participation. The aim of this systematic review was to assess the prevalence of cam-type FAI across various sports, whether kinematic variation between sports and performance level, duration and frequency of participation influenced hip morphology in a sporting population.

Materials and Methods
A systematic search of Embase, PubMed and the Cochrane Library was undertaken following PRISMA guidelines. The study was registered on the PROSPERO database (CRD4202018001). Prospective and retrospective case series, case reports and review articles published after 1999 were screened and inclusion criteria was decided a priori.

Results
The literature search identified 58 relevant articles involving 5 683 participants for final analysis highest alpha angle was identified at the 1 o’clock position (n=9/9) in football, skiing, golf, ice
hockey and basketball. Maximal alpha angle was found to be located in a more lateral position in goalkeepers versus positional players in ice hockey (1 o’clock vs 1.45 o’clock). A positive correlation was also identified between the alpha angle and both age and activity level (n=5/8 and n=2/3, respectively) and also between prevalence of FAI and both age and activity level (n=2/2 and n=4/5), respectively.

Conclusions/Discussion
Hip-heavy sports show an increased prevalence of FAI, with specific sporting activities influencing hip morphology. Both a longer duration and increased level of training also resulted in an increased prevalence of FAI.

Background: Athletic pubalgia often occurs in the setting of other hip and pelvic pathology. Femoroacetabular impingement (FAI) reportedly occurs in a very high percentage of athletes examined for chronic groin and/or hip pain. This suggests that the presence of FAI may be a predisposing factor for developing groin-related sports injuries.

Objectives: The purpose of this study is to evaluate the influence of FAI in groin-related sports injuries

Study Design & Methods: A search in the Pubmed database was performed to identify articles relating to this topic. We reviewed the results to evaluate the prevalence of FAI in case of athletic pubalgia and examine treatment outcomes and evidence for a common underlying pathogenic mechanism between sports hernia and FAI.

Results: FAI has been reported in 12-94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain. Currently, it is assumed that chronic groin injuries result from increased loading and mechanical stress on the pubic symphysis and surrounding structures caused by reduced hip range of motion. It was postulated that the improved hip range of motion and function after FAI correction reduces the stress on extra-articular pelvic structures, thus alleviating the symptoms. Multiple studies have shown that the arthoscopic treatment of FAI, leads to much better results and higher levels of return to sports.

Conclusions: FAI surgery should also be considered if assumed as a contributing issue to the athletic pubalgia. For patients with FAI and sports hernia, surgical treatment of both pathologies appears to be the best option.