Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

11-01-2023 | Cruciate Ligament Injury | KNEE

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction

Authors: Romain Seil, Charles Pioger, Renaud Siboni, Annunziato Amendola, Caroline Mouton

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 7/2023

Abstract

Purpose

To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage.

Methods

A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles.

Results

A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01).

Conclusions

The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients.

Level of evidence

Level III.

Prentice HA, Lind M, Mouton C et al (2018) Patient demographic and surgical characteristics in anterior cruciate ligament reconstruction: a description of registries from six countries. Br J Sports Med 52:716–722PubMedCrossRef

Claes S, Hermie L, Verdonk R et al (2013) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc 21:1967–1976PubMedCrossRef

Curado J, Hulet C, Hardy P et al (2020) Very long-term osteoarthritis rate after anterior cruciate ligament reconstruction: 182 cases with 22-year’ follow-up. Orthop Traumatol Surg Res 106:459–463PubMedCrossRef

Keays SL, Newcombe PA, Bullock-Saxton JE et al (2010) Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med 38:455–463PubMedCrossRef

Parkinson B, Robb C, Thomas M et al (2017) Factors that predict failure in anatomic single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 45:1529–1536PubMedCrossRef

Pioger C, Claes S, Haidar I et al (2022) Prevalence and incidence of chondral and meniscal lesions in patients undergoing primary and subsequent revision anterior cruciate ligament reconstruction: an analysis of 213 patients from the SANTI group. Am J Sports Med 50:1798–1804PubMedCrossRef

Verdonk R, Madry H, Shabshin N et al (2016) The role of meniscal tissue in joint protection in early osteoarthritis. Knee Surg Sports Traumatol Arthrosc 24:1763–1774PubMedCrossRef

Magosch A, Jacquet C, Nuhrenborger C et al (2022) Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears. Knee Surg Sports Traumatol Arthrosc 30:1611–1619PubMedCrossRef

Gracia G, Cavaignac M, Marot V et al (2022) Epidemiology of combined injuries of the secondary stabilizers in ACL-deficient knees: medial meniscal ramp lesion, lateral meniscus root tear, and all tear: a prospective case series of 602 patients with ACL tears from the SANTI study group. Am J Sports Med 50:1843–1849PubMedCrossRef

10.

Magosch A, Mouton C, Nuhrenborger C et al (2021) Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 29:3059–3067PubMedCrossRef

11.

Willinger L, Balendra G, Pai V et al (2022) High incidence of superficial and deep medial collateral ligament injuries in “isolated” anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 30:167–175PubMedCrossRef

12.

Filardo G, Andriolo L, di Laura FG et al (2019) Bone bruise in anterior cruciate ligament rupture entails a more severe joint damage affecting joint degenerative progression. Knee Surg Sports Traumatol Arthrosc 27:44–59PubMedCrossRef

13.

Zhang L, Hacke JD, Garrett WE et al (2019) Bone bruises associated with anterior cruciate ligament injury as indicators of injury mechanism: a systematic review. Sports Med 49:453–462PubMedCrossRef

14.

Beel W, Mouton C, Tradati D et al (2022) Ramp lesions are six times more likely to be observed in the presence of a posterior medial tibial bone bruise in ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 30:184–191PubMedCrossRef

15.

Schenck R (2003) Classification of knee dislocations. Operative Tech Sport Med 11:193–198CrossRef

16.

Grindem H, Eitzen I, Engebretsen L et al (2014) Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL cohort study. J Bone Joint Surg Am 96:1233–1241PubMedPubMedCentralCrossRef

17.

Rasenberg EI, Lemmens JA, van Kampen A et al (1995) Grading medial collateral ligament injury: comparison of MR imaging and instrumented valgus-varus laxity test-device. A prospective double-blind patient study. Eur J Radiol 21:18–24PubMedCrossRef

18.

Mink JH, Deutsch AL (1989) Occult cartilage and bone injuries of the knee: detection, classification, and assessment with MR imaging. Radiology 170:823–829PubMedCrossRef

19.

Shaikh H, Herbst E, Rahnemai-Azar AA et al (2017) The Segond fracture is an avulsion of the anterolateral complex. Am J Sports Med 45:2247–2252PubMedCrossRef

20.

Bernholt DL, DePhillipo NN, Crawford MD et al (2020) Incidence of displaced posterolateral tibial plateau and lateral femoral condyle impaction fractures in the setting of primary anterior cruciate ligament tear. Am J Sports Med 48:545–553PubMedCrossRef

21.

Lucidi GA, Grassi A, Di Paolo S et al (2021) The lateral femoral notch sign is correlated with increased rotatory laxity after anterior cruciate ligament injury: pivot shift quantification with a surgical navigation system. Am J Sports Med 49:649–655PubMedCrossRef

22.

Warren RF, Kaplan N, Bach BR (1988) The lateral notch sign of anterior cruciate ligament insufficiency. Am J Knee Surg 1:119–124

23.

Sonnery-Cottet B, Conteduca J, Thaunat M et al (2014) Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med 42:921–926PubMedCrossRef

24.

LaPrade CM, James EW, Cram TR et al (2015) Meniscal root tears: a classification system based on tear morphology. Am J Sports Med 43:363–369PubMedCrossRef

25.

Jacquet C, Mouton C, Magosch A et al (2022) The aspiration test reveals an instability of the posterior horn of the lateral meniscus in almost one-third of ACL-injured patients. Knee Surg Sports Traumatol Arthrosc 30:2329–2335PubMedCrossRef

26.

Cooper DE, Arnoczky SP, Warren RF (1990) Arthroscopic meniscal repair. Clin Sports Med 9:589–607PubMedCrossRef

27.

Jacquet C, Magosch A, Mouton C et al (2021) The aspiration test: an arthroscopic sign of lateral meniscus posterior horn instability. J Exp Orthop 8:17PubMedPubMedCentralCrossRef

28.

Cameron ML, Briggs KK, Steadman JR (2003) Reproducibility and reliability of the outerbridge classification for grading chondral lesions of the knee arthroscopically. Am J Sports Med 31:83–86PubMedCrossRef

29.

Noyes FR, Stabler CL (1989) A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med 17:505–513PubMedCrossRef

30.

McHorney CA, Tarlov AR (1995) Individual-patient monitoring in clinical practice: are available health status surveys adequate? Qual Life Res 4:293–307PubMedCrossRef

31.

Tomczak M, Tomczak E (2014) The need to report effect size estimates revisited. An overview of some recommended measures of effect size. Trends sport sci 1:19–25

32.

Kopf S, Beaufils P, Hirschmann MT et al (2020) Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc 28:1177–1194PubMedPubMedCentralCrossRef

33.

Bisson LJ, Kluczynski MA, Hagstrom LS et al (2013) A prospective study of the association between bone contusion and intra-articular injuries associated with acute anterior cruciate ligament tear. Am J Sports Med 41:1801–1807PubMedCrossRef

34.

Mandalia V, Henson JH (2008) Traumatic bone bruising–a review article. Eur J Radiol 67:54–61PubMedCrossRef

35.

Grassi A, Tosarelli F, Agostinone P et al (2020) Rapid posterior tibial reduction after noncontact anterior cruciate ligament rupture: mechanism description from a video analysis. Sports Health 12:462–469PubMedPubMedCentralCrossRef

36.

Calvo-Gurry M, Hurley ET, Withers D et al (2019) Posterior tibial bone bruising associated with posterior-medial meniscal tear in patients with acute anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 27:3633–3637PubMedCrossRef

37.

Owusu-Akyaw KA, Kim SY, Spritzer CE et al (2018) Determination of the position of the knee at the time of an anterior cruciate ligament rupture for male versus female patients by an analysis of bone bruises. Am J Sports Med 46:1559–1565PubMedPubMedCentralCrossRef

38.

Patel SA, Hageman J, Quatman CE et al (2014) Prevalence and location of bone bruises associated with anterior cruciate ligament injury and implications for mechanism of injury: a systematic review. Sports Med 44:281–293PubMedPubMedCentralCrossRef

39.

Viskontas DG, Giuffre BM, Duggal N et al (2008) Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med 36:927–933PubMedCrossRef

40.

Andrade R, Rebelo-Marques A, Bastos R et al (2019) Identification of normal and injured anterolateral ligaments of the knee: a systematic review of magnetic resonance imaging studies. Arthroscopy 35:1594–1613PubMedCrossRef

41.

Batty L, Murgier J, O’Sullivan R et al (2019) The Kaplan fibers of the iliotibial band can be identified on routine knee magnetic resonance imaging. Am J Sports Med 47:2895–2903PubMedCrossRef

42.

Devitt BM, O’Sullivan R, Feller JA et al (2017) MRI is not reliable in diagnosing of concomitant anterolateral ligament and anterior cruciate ligament injuries of the knee. Knee Surg Sports Traumatol Arthrosc 25:1345–1351PubMedCrossRef

43.

Lynch TB, Bernot JM, Oettel DJ et al (2022) Magnetic resonance imaging does not reliably detect Kaplan fiber injury in the setting of anterior cruciate ligament tear. Knee Surg Sports Traumatol Arthrosc 30:1769–1775PubMedCrossRef

44.

Cavaignac E, Laumond G, Reina N et al (2018) How to test the anterolateral ligament with ultrasound. Arthrosc Tech 7:e29–e31PubMedCrossRef

45.

Cavaignac E, Wytrykowski K, Reina N et al (2016) Ultrasonographic identification of the anterolateral ligament of the knee. Arthroscopy 32:120–126PubMedCrossRef

46.

Batty LM, Murgier J, Feller JA et al (2020) Radiological identification of injury to the kaplan fibers of the iliotibial band in association with anterior cruciate ligament injury. Am J Sports Med 48:2213–2220PubMedCrossRef

47.

Helito PVP, Bartholomeeusen S, Claes S et al (2020) Magnetic resonance imaging evaluation of the anterolateral ligament and the iliotibial band in acute anterior cruciate ligament injuries associated with Segond fractures. Arthroscopy 36:1679–1686PubMedCrossRef

48.

Wissman RD, England E, Mehta K et al (2014) Patellotibial contusions in anterior cruciate ligament tears. Skeletal Radiol 43:247–250PubMedCrossRef

49.

Goncalves H, Steltzlen C, Boisrenoult P et al (2017) High failure rate of anterior cruciate ligament reconstruction with bimeniscal repair: a case-control study. Orthop Traumatol Surg Res 103:943–946PubMedCrossRef

50.

Svantesson E, Hamrin Senorski E, Alentorn-Geli E et al (2019) Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc 27:2450–2459PubMedCrossRef

51.

Sukopp M, Schall F, Hacker SP et al (2021) Influence of Menisci on Tibiofemoral Contact Mechanics in Human Knees: A Systematic Review. Front Bioeng Biotechnol 9:765596PubMedPubMedCentralCrossRef

52.

Yeo DYT, Suhaimi F, Parker DA (2019) Factors predicting failure rates and patient-reported outcome measures after arthroscopic meniscal repair. Arthroscopy 35:3146–3164PubMedCrossRef

53.

Duchman KR, Westermann RW, Spindler KP et al (2015) The fate of meniscus tears left in situ at the time of anterior cruciate ligament reconstruction: a 6-year follow-up study from the moon cohort. Am J Sports Med 43:2688–2695PubMedPubMedCentralCrossRef

54.

Kurzweil PR, Lynch NM, Coleman S et al (2014) Repair of horizontal meniscus tears: a systematic review. Arthroscopy 30:1513–1519PubMedCrossRef

55.

Bedi A, Kelly N, Baad M et al (2012) Dynamic contact mechanics of radial tears of the lateral meniscus: implications for treatment. Arthroscopy 28:372–381PubMedCrossRef

56.

Koo B, Lee SH, Yun SJ et al (2020) Diagnostic performance of magnetic resonance imaging for detecting meniscal ramp lesions in patients with anterior cruciate ligament tears: a systematic review and meta-analysis. Am J Sports Med 48:2051–2059PubMedCrossRef

57.

Song GY, Zhang H, Liu X et al (2017) Complete posterolateral meniscal root tear is associated with high-grade pivot-shift phenomenon in noncontact anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 25:1030–1037PubMedCrossRef

58.

Shi H, Ding L, Jiang Y et al (2020) Bone bruise distribution patterns after acute anterior cruciate ligament ruptures: implications for the injury mechanism. Orthop J Sports Med 8:2325967120911162PubMedPubMedCentralCrossRef

59.

Ward P, Chang P, Radtke L et al (2022) Clinical implications of bone bruise patterns accompanying anterior cruciate ligament tears. Sports Health 14:585–591PubMedCrossRef

60.

Dimitriou D, Reimond M, Foesel A et al (2021) The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury. Knee Surg Sports Traumatol Arthrosc 29:1968–1976PubMedCrossRef

61.

Frobell RB, Roos HP, Roos EM et al (2008) The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury? Osteoarthritis Cartilage 16:829–836PubMedCrossRef

62.

Marinetti A, Tessarolo F, Ventura L et al (2020) Morphological MRI of knee cartilage: repeatability and reproducibility of damage evaluation and correlation with gross pathology examination. Eur Radiol 30:3226–3235PubMedCrossRef

63.

Potter HG, Jain SK, Ma Y et al (2012) Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up. Am J Sports Med 40:276–285PubMedCrossRef

64.

Borchers JR, Kaeding CC, Pedroza AD et al (2011) Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med 39:1889–1893PubMedPubMedCentralCrossRef

Title: The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction
Authors: Romain Seil
Charles Pioger
Renaud Siboni
Annunziato Amendola
Caroline Mouton
Publication date: 11-01-2023
Publisher: Springer Berlin Heidelberg
Keywords: Cruciate Ligament Injury
Segond Fracture
Magnetic Resonance Imaging
Magnetic Resonance Imaging
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 7/2023
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-023-07311-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Level of evidence

Please log in to get access to this content

Other articles of this Issue 7/2023

Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review

Particulate cartilage and platelet-rich plasma treatment for knee chondral defects in sheep

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis

Harvesting a second graft from the extensor mechanism for revision ACL reconstruction does not delay return of quadriceps function

Posterior tibial plateau impaction fractures are not associated with increased knee instability: a quantitative pivot shift analysis

Bone–patellar tendon–bone autograft and female sex are associated with the presence of cyclops lesions and syndrome after anterior cruciate ligament reconstruction