Mucoid degeneration of the anterior cruciate ligament (ACL) is a rare, little-known, underdiagnosed pathology and asymptomatic in most patients. We report an unusual case of a symptomatic mucoid degeneration of the ACL that was treated with good result. A 68-year-old female patient presented with progressive posterior knee pain and restriction of flexion without history of a major trauma. Clinical tests for cruciate ligaments were negative and for meniscal injuries were positive for lateral meniscus. The magnetic resonance imaging (MRI) showed an increased signal in the substance of the ACL in the T2-weighted images with a mass-like configuration that was reported as a partial tear of the ACL, besides degenerative tear of the anterior horn of the lateral meniscus. At arthroscopy, the ACL was homogeneous, hypertrophied, and taut with a yellowish degenerative substance within its fibers and the lateral meniscal injury was confirmed. An arthroscopic partial excision of posterior areas of the ACL and lateral partial meniscectomy was performed. Postoperatively she recovered pain-free range-of-motion and had no signs of instability. ACL mucoid degeneration is characterized by infiltration of glycosaminoglycan deposits between the collagen fibers causing ACL hypertrophy, knee pain, and limited range-of-motion. Its pathogenesis remains controversial. Synovial, traumatic or degenerative theories have been proposed. Awareness and a high index of suspicion are required to diagnose. Excellent results have been reported following arthroscopic partial excision with complete resolution of symptoms as in this case. Further clinical research is required with cooperation between surgeons, radiologist and pathologists to raise knowledge of this entity.

Introduction: Multi-ligament knee injuries (MLKIs) are among the most detrimental injuries, which can cause significant compromise of joint stability and function. Our aim was to investigate the functional outcomes of non-sport induced MLKIs who presented late after injury and underwent delayed arthroscopic reconstruction. Method: In a retrospective cohort of 18 MLKI patients (19 knees, January 2012-2018) who had undergone arthroscopic reconstruction, we assessed the knee ROM, return to work/sport, IKDC, KOOS, WOMAC, Lysholm, and Tegner scores. The preoperative scores were retrieved from the patients’ registry database. We reviewed their surgical notes, and extracted the operation data, including the damaged ligaments, stages of the surgery, and associated meniscal injury. Result: There were 14 males and four females with a mean age of 30.57±10.31 years. The mean time from injury to surgery was 17.31±11.98 months. The most common injury was ACL/PCL (31.6%). The mechanisms of injury were motor-vehicle accidents (72.2%), falls (22.2%), and sports (5.6%). The reconstruction was either single- (61.2%) or multiple-stage (38.8%). The pre- and postoperative scores were 45.31±7.30 vs. 79.16±11.86 IKDC, 3.84±1.26 vs. 8.37±1.16 Tegner, and 60.42±7.68 vs. 89.42±8.81 Lysholm, respectively. All the scores showed significant improvement at mean follow-up of 24.05±9.55 months (P<0.001). In conclusion, delayed arthroscopic reconstruction of MLKIs significantly improved the functional outcomes and return to work in patients presenting late to the orthopedic clinic. Conclusion: There was no relationship between the demographic variables, mechanism of injury, number of injured ligaments, and the stages of surgery and the functional outcomes in this group of patients.

Background: In Saudi Arabia, the rate of knee Anterior Cruciate Ligament (ACL) injury has increased tremendously in the last two decades through active male group especially military personnel. In the past, many studies have examined the possible risk factors of ACL surgical reconstruction failure. This study primarily focuses on the Posterior Tibial Slope (PTS), the width of the Femoral Intercondylar Notch (FIN) and the Alpha Angle and their relationship with the failure rate of primary ACL reconstruction failure. Methods: From 2015 to 2021, 325 patients with a symptomatic ACL deficient knee underwent primary arthroscopic ACL reconstruction using hamstring soft tissue auto graft. All failed ACL reconstruction patients (35 (10.76%)) in the last six years were followed up and examined. Lateral radiographs of all patient’s knees were reviewed, and the PTS was measured using a standardized technique. The Alpha Angle and the FIN width were measured via Magnetic Resonance Imaging (MRI). Results: Overall, with high significance, there were 27 patients (77.14%) with PTS angle >17.5 degrees (mean 20.3 degrees). There were 13 patients (37.1%) with FIN width < 15 mm (mean 13.7mm). There were 15 patients (42.85%) with Alpha Angle > 60 degrees (mean 64 degrees). Another risk factor identified with great significance was early return to work, as 30 patients (85.7%) had returned to work in 12 weeks or less. Conclusion: Failure of ACL reconstruction was most strongly associated with increased Posterior Tibial Slope, increased Alpha Angle width, increased Intercondylar Femoral Notch width, and early return to work.

Objectives: In pair skating and ice dance, a high prevalence of acute and overuse injuries was observed. We hypothesised increasing age, numbers of total points, and more complex jumps of the best elite couples at international championships in recent years. Method: Retrospective study. Age, total points and the numbers of single, double, triple and quadruple jumps were assessed via the results databases of the European and World Championships, as well as the Winter Olympics since 2005. Regression statistics were conducted and significance was assessed via one-way ANOVAs. Results: There were no significant changes of age. Increases in total points were found in both disciplines (World and European Championships both P < 0.001 for both disciplines, Olympics pair skating P = 0.003, ice dance n/a). Significant increases were found in the number of double and triple twist jumps at the European Championships (Double P = 0.046, triple P = 0.041), but not at the World Championships or the Olympics. At the World Championships, single solo jumps decreased (P = 0.031) in favour of triple jumps, which increased (P = 0.020), without a similar effect at the European Championships or Olympics.
Conclusions: The present paper is the first to analyse trends in age and performance in elite pair skating and ice dance. The study findings of rising total points and in some instances more complex jumps indicate that further attention should be given to possible increases in the incidence of acute and overuse injuries after recent changes in regulations.

This is a single-center observational cross-sectional study that analyzed the anatomy of the normal posterior cruciate ligament (PCL) from magnetic resonance images (MRI) of the knee. The aim of this study is to measure the length and thickness of PCL from the MRI and its width at femoral and tibial attachment. 240 MRIs from patients suspected to have knee ligamentous injury from sports injuries were analyzed. 196 images were from male patients and 44 from female patients. The age ranges from 17 to 45 with a mean age of 26.7 years. The MRIs were done within 5 years of the initial injury and the mean time interval between injury and the MRI study was 13 months. The measurements were performed using INFINITT/PACS software using sagittal T2 weighted images. All the parameters measured showed greater value in males compared to females. There was no significant difference when compared between young and middle age groups within the same gender. In conclusion, there is a significant difference in several measurements of the anatomical variants of the PCL footprints between genders among the Malaysian population.

Introduction: Isolated PCL injuries are quoted to be uncommon. PCL tears are more commonly associated with high-energy, multiligamentous knee injuries involving the ACL, MCL or posterolateral corner. Although studies have quoted that the MCL is the most commonly injured ligament alongside PCL tears, the literature on this is sparse. We aim to present the patient-reported outcome measures (PROMs) of a series of patients with these injuries.

Methods: A retrospective audit identified nine patients with concomitant PCL and MCL injuries between September 2015 to April 2022. All patients were initially managed conservatively, with three patients subsequently undergoing concurrent PCL and MCL reconstruction for persistent instability. Baseline demographics, mechanism of injury, comorbidities and type of reconstruction were recorded. The Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Tegner-Lysholm (TL) score were recorded for all patients.

Results: Our patient cohort was predominantly male, with a mean age of 47.1 years. Minimum follow-up for PROM data was 6 months from injury. PCL and MCL reconstructions were performed using LARS synthetic graft. Mean KOOS, IKDC and TL scores were similar in both conservative and operative groups (81.05, 74.33, 75.17 versus 80.56, 72.43, 73.67). The authors suspect that the PROM values in the operative group were negatively affected by an outlier who developed arthrofibrosis post-operatively.

Conclusion: Although small, our study presents PROMs on an uncommonly-reported disease entity. There may be a trend towards better knee function following PCL and MCL reconstruction. Further studies are required to formulate a definite conclusion.

Introduction-Posterior cruciate ligament (PCL) tears are uncommon injuries, and PCL avulsion fractures are an extremely rare variant of this injury. Despite the low incidence of PCL injuries, resulting instability and early degenerative changes can be debilitating to patients, which are mostly young males. With this study, we evaluated role of operative and conservative management of PCL avulsion injury .Material and method-10 patients of displaced PCL avulsion were retrospectively reviewed. Group A ( 5 patients) were managed conservatively with 3 week immobilization followed by early controlled activities and early weight bearing. Group B ( 5 patients) were operated through modified posteromedial approach and fixed with lag screw. Postoperatively, endorsement of foot-flat weight-bearing and allowed for passive range of motion immediately under the supervision of physical therapy. Active hamstring activation is minimized for the first 3 weeks after surgery, and full weight-bearing was started at 6 weeks . Results-There were significant differences between the intergroup comparison of post-treatment lysholm score of Group A (60.1+20.2) Vs Group B (84.0.+14.1) (P<0.05). Post-treatment IKDC score of Group A (73.4+8.3) vs Group B (94.0+6.2).(P<0.05) The most common complication was arthrofibrosis seen in Group A Conclusion Hence we recommend that in case of PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate with operative treatment

Background:Multi-ligament knee injury is a rare but severe injury.Treatment strategies are challenging for most orthopedic surgeons & optimal treatment remains controversial.The purpose of our study was to assess clinico-radiological and functional outcomes after surgical management of multi-ligament knee injuries & to determine factors that could predict outcome of surgery. Materials And Method:It is a prospective observational study of 30 consecutive patients of Multi-ligament knee injury conducted between 2018 to 2020.All patients were treated surgically with single-stage reconstruction of all injured ligaments and followed a standardized postoperative rehabilitation protocol.All patients were evaluated for Clinical(VAS score,laxity stress test,muscle-strength,range of motion),Radiological(stress radiographs) &Functional(Lysholm score) outcomes three times-preoperatively,post-operative 3 months & 12 months.Results:At final follow up mean VAS score was 0.86±0.77.The anteroposterior and valgus-varus stress test showed ligament laxity >10mm(Grade D) in 93.3% patient which improved to<3mm(normal,Grade A) in 90% patients. Most patients(83.3%) had preoperative range<100° and muscle strength of MRC Grade 3 which improved to >120° and muscle strength of MRC grade 5 at final followup.Lysholm score was poor (<64) in all patients preoperatively and improved to good(85-94) in 73.3%, excellent(>95) in 20% & fair(65-84) in 6.6% patients. The stress radiographs showed stable results for anterior/posterior &varus/valgus stress. All patients returned to their previous work. Factors that could predict outcomes of surgery are age, timing of surgery, type of surgery &associated injury. Conclusion:Early complete single stage reconstruction can achieve good functional results with overall restoration of sports and working capacity.Positive predictive factors for good outcome are younger age, early surgery and appropriate rehabilitation.

Abstract
Introduction: Rectus abdominis tear following blunt skiing injuries are extremely rare. An extensive pubmed search using key words rectus abdominis tear did not reveal any reports of closed isolated bilateral tears without associated injuries, till date.
Case: We present a case of 49 years old athletically active male with isolated closed bilateral rectus abdominis tear following a skiing injury. He was treated with an open surgical repair along with prolene mesh re-enforcement. There were no post-operative complications. Furthermore, he was able to return back to his sporting activities in 3 months. A 12 month follow up showed an excellent healing of the repair.
Conclusion: Our case highlights the need for high degree of suspicion, appropriate investigation and necessary surgical intervention of Rectus Abdominis tear following blunt injury of abdomen to avoid future complications. Rectus Abdominis tear can be a rare differential for an acute abdomen.
Keywords: Bilateral Rectus Abdominis tear, Skiing injury, Blunt abdominal injury

Introduction:To examine the significance of serum levels pf alkaline phosphatase (sALP) measurement during growth and its relationship with height increase.Method：Fifty-five male football players who joined Iwaki FC Academy under 15(U15) and under 18 (U18) in 2019 and 2020 were included. Their mean age were 151.4 months in U15 and 192.0 in U18. The levels of sALP at the initiation of the season and increase of height during six months were observed. Statistical analysis was conducted using SPSS ver.28 with a significance level of 5%.Results:The levels of sALP was 1053.9±304.6IU/l in U15 and 706.1±257.9IU/I in U18, the height increase during six months was 4.1cm in U15 and 1.3cm in U18. Both sALP and height increase was higher in U15 (p<0.01, t-test). There was correlation between sALP and height increase only in U18 players (Spearman's rank correlation coefficient r=0.88, p<0.01), but not in U15. The ROC curve analysis of sALP levels to determine the cut off age when the height increase was less than 1cm/six months, which reflects the end of peak growth, revealed a cutoff value of sALP was 600IU/l(sensitivity 0.85, specificity 0.3). Conclusion:sALP values in U15 were higher than those in U18, and sALP correlate with height increase only in U18. It is suggested that sALP less than 600IU/l in Japanese U18 football players could be an indicator of the end of peak growth. This cutoff value would help physicians as well as coaches to manage the adolescent players.

Isolated subscapularis tears are rare, with a 4.9% incidence of rotator cuff tendon tears. While open repair is widely described and considered successful, it has many drawbacks and can be prone to several complications. However, the arthroscopic repair of isolated subscapularis tears and its results remain poorly described in the literature. This is a retrospective study reporting eight cases of isolated subscapularis tears repaired arthroscopically out of a series of 95 cases of rotator cuff tears. The patient's age was between 20 and 55 years. The clinical evaluation and the Constant score were assessed pre- and postoperatively. All our patients benefited from an MRI and the average duration evolution was 3 months. The arthroscopy was carried out with a 30° optic. Seven patients benefited from a suture by a Mason-Allen stitch against only one by a simple stitch. Acromioplasty was associated in three cases. All patients benefited from an immobilization and rehabilitation. Arthroscopic analysis of the lesions found an isolated rupture of the subscapularis in all of our patients. Five classified Lafosse III and three classified Lafosse II. Post-operative clinical evaluation showed a marked improvement in pain and disappearance of the anterior instability sensation, thus the Constant score was very good in seven patients and good in only one. Arthroscopic repair represents a reliable and validated technique for the treatment of rotator cuff lesions and allows an easy and safer management.

Purpose: The purpose was to investigate tendon tissue after ACLr using 7T MRI T2* mapping as a possible marker for follow-up of tissue maturation
Methods: Twelve patients after ACLr have been examined at prea-op and 3, 6 and 12 months post-op (mean age 29.2 ± 7.7 years, 7 male / 5 female). T2* maps and gagCEST maps were acquired at 7T Magnetom scanner (Siemens, Healthcare, Germany) using a 28-channel knee array coil. The vTE technique was acquired for acquisition of T2* maps, which are known to be collagen sensitive. The gagCEST technique was acquired to quantify the proteoglycans. T2* maps and gagCEST maps were calculated and regions of interest (ROIs) were drawn always at tibial, central and femoral part of the ACLr tissue. The Student’s t-test was used to determine the differences in T2* values in various time points in the post-op period.
Results: We observed decreasing trend of tibial T2* values and increasing trend of T2* values in central and femoral ACLr in the early post-op period. In terms of gagCEST values, the increasing trend was observed in tibial ACLr, however the gagCEST of central and femoral ACLr show increasing trend. The T2* changes as well as gagCEST changes were not statistically significant.
Conclusion: This study showed that the collagen network re-organization after the ACL reconstruction surgery can be monitored in the follow-up period using T2* mapping by vTE. Similarly the proteoglycan content could be followed-up by quantitative MRI using gagCEST technique at 7T MRI.

Background: Orthopaedic training in Southern Africa is largely focused on trauma, although elective procedures, such as knee arthroscopy are increasing. This is especially true in the private sector where most trainees will practice. The primary aim of this study was to assess the arthroscopic competency of orthopaedic trainees in a setting of limited resources. Methods: A prospective observational cohort study was carried out. Orthopaedic trainees of a Southern African university hospital performed basic arthroscopy on a knee model. Their surgical competency was assessed by two surgeons proficient in arthroscopy using the modified Basic Knee Arthroscopy Skill Scoring System (mBAKSSS). Results: A total of 16 trainees (12 male) were included (6 junior and 10 senior trainees). The median age of participants was 36 (IQR 2.25). There was no difference in mean score between junior trainees (26.56, range 20.5 - 42.5) and senior trainees 27.31 (12.0 to 38.0, p=0.1). The overall interrater reliability of the surgeons rating the trainees was excellent with Cronbach’s Alpha of 0.91 and interclass correlation of 0.914 (95% CI=0.97). Conclusions: Knee arthroscopy skills of our trainees are comparable to those of international training programs, but no progression of arthroscopy skills was seen when comparing surgeons in their early years of training to colleagues in their final years. This calls for improved arthroscopy training and skills transfer, exposure to procedures and ongoing assessment.