ACL-Return To Sport After Injury Research Articles

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up

Background: Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking. Purpose: To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non–graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score. Results: After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups. Conclusion: ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents. Registration: NCT02511158 (ClinicalTrials.gov identifier).

The Influence of Strength and Sport Exposure on Psychological Readiness After ACL Reconstruction.

Among young athletes returning to sport after anterior cruciate ligament reconstruction (ACLR), the extent to which psychological readiness is influenced by factors beyond the psychological domain is largely unknown. Young athletes with recent sport exposure and higher quadriceps strength will demonstrate higher psychological readiness within 8 weeks of medical clearance to return to sport (RTS) after ACLR. Cross-sectional study. Level 3. A total of 38 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. All participants completed isometric knee extension strength testing, in addition to the ACL Return to Sport after Injury (ACL-RSI) questionnaire. Athletes who participated in sport between time of medical clearance to RTS and date of study enrollment were categorized as SPORT-YES. Those who had not yet participated in sports were categorized as SPORT-NO. Multiple linear regression analyses were used to determine differences in ACL-RSI scores based on quadriceps strength and sport exposure status, while adjusting for age and sex. Of the 38 participants, 20 (52.6%) were categorized as SPORT-YES. The regression model estimating overall ACL-RSI score (P < 0.01, adjusted R2 = 0.389) included significant independent contributions from age, sex, and sport exposure variables (age: P = 0.01, β [95% CI] = -2.01 [-3.54, -0.48]; sex (male): P = 0.02, β [95% CI] = 12.50 [2.36, 22.64]; strength: P = 0.51, β [95% CI] = -2.47 [-10.07,5.13]; sport exposure: P < 0.01, β [95% CI] = 12.89 [3.58, 22.19]). In partial accordance with our hypothesis, recent sport exposure was significantly associated with higher ACL-RSI scores among young athletes in the weeks after medical clearance to RTS after ACLR, while quadriceps strength was not. Future prospective work is needed to determine the existence and direction of causal relationships between exposure to sport environment and psychological readiness among young athletes after ACLR.

Psychological Readiness to Return to Sport and Return to Sport Rates Are Similar in Patients After Either Bilateral or Unilateral Anterior Cruciate Ligament Reconstruction

To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR. The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts. In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years (P= .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P= .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P= .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P= .21), or time to return (41.2± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P= .31) between the 2 cohorts. Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return. Level III, retrospective cohort study.

Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift.

Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR). The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR. Cohort study; Level of evidence, 3. Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively. The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C. Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.

Short-term outcomes of anterior cruciate ligament reconstruction with or without lateral tenodesis or anterolateral ligament reconstruction: a retrospective cohort

PurposeThis study aimed to compare the short-term outcomes of ACL reconstruction (ACLR) alone, ACLR with lateral tenodesis, and ACL and ALL reconstruction.MethodsA retrospective cohort of prospectively collected data on all ACL procedures was performed at Aspetar Specialized Orthopaedic and Sports Medicine Hospital between January 2020 and January 2021. Patients were treated with ACLR alone, ACLR with lateral tenodesis, or ACLR with ALL reconstruction. The primary outcome was the subjective International Knee Documentation Committee (sIKDC) score. The secondary outcomes were the ACL Return to Sport after Injury (ACL-RSI) scores, pivot shift grade, subjective knee stability, and subjective pain on activity.ResultsA total of 100 cases were included. The most common technique was ACLR with lateral tenodesis (42%), followed by ACLR alone (38%) and ACL with ALL reconstruction (20%). The mean age was 28.15 years (15–60), and 94% of the patients were males. Meniscal procedures were more frequent in the ACLR alone group (65.8%). There was no association between subjective stability, sIKDC, ACL-RSI, and pivot shift grade and the three ACLR techniques while adjusting for age, sex, and concomitant meniscus procedures at six weeks, 12 weeks, six months, and nine months. However, there was a significant decrease in postoperative flexion in the ACL and ALL reconstruction group by a mean of 22° (95% CI − 40.7 − 3.4; P = 0.02) at 6 weeks compared to ACLR alone, which was not evident on later follow-ups.ConclusionACLR with/without lateral augmentation procedures yields similar subjective IKDC, ACL-RSI, pivot shift grade, and subjective knee instability at short-term follow-up. Therefore, lateral extra-articular augmentation procedures are safe to be performed.

Poster 277: Return to Sport after Multi-Ligament Knee Injury in Young Athletes

Objectives: While return to sport (RTS) has been well studied in young athletes after anterior cruciate ligament (ACL) reconstruction, there is a paucity of literature on RTS following reconstructive surgery for multi-ligament knee injury (MLKI). The purpose of this study is to assess level of RTS following MLKI in athletes 23 years old or younger at the time of injury and evaluate the factors associated with RTS. Methods: This was a retrospective study. We identified 116 patients at our Level 1 referral center who sustained MLKI at an age of 23 years old or younger. All 116 patients underwent operative reconstruction. Patients were contacted via mail and then completed surveys by telephone if willing to participate. Our primary outcome variable was self-reported ability to return to sport at their preoperative level or higher following surgery. Secondary variables included 2000 International Knee Documentation Committee Subjective Form (2000 IKDC-SF), ACL Return to Sport After Injury (ACL-RSI), and Short-Form 12 (SF-12) physical and mental health scales. Dependent variables included age, participation in cutting sports, number of and specific ligaments injured, and any concurrent mental health diagnoses. Results: A total of 30 (25.9%) patients completed surveys at an average follow-up of 7.8 years postoperatively (24 male, 6 female, 18.1±2.5 years old at time of injury). Of this cohort, 90% of patients returned to sport at some level, while 43.3% returned to their preoperative level or higher. Participation in cutting sports was associated with significantly lower rate of RTS at the same level or higher (p=0.017). Higher 2000 IKDC-SF and ACL-RSI scores were associated with significantly higher rate of RTS at the same level or higher (p=0.001 and 0.002, respectively). Patients who participated in higher level of sport preoperatively demonstrated a higher odds ratio (OR) of returning to their same athletic level or higher following MLKI (OR=3.516 [1.034-11.955]; p=0.044). Number of ligaments injured, age at time of injury, concurrent mental health diagnosis, and SF-12 scores were not associated with a statistically significant change in RTS at the same level or higher. Patients with concurrent ACL and MCL injuries trended toward higher rate of RTS at the same level or higher than two- or three-ligament injuries involving the ACL and PCL and/or LCL, but this was not statistically significant (50% vs. 25%, p=0.225). Conclusions: While a high percentage of young athletes return to some level of sport following MLKI, less than half return to their previous level. Those participating in cutting sports were significantly less likely to return to their pre-injury level of sport following MLKI. Participation in higher level of sport preoperatively was associated with a higher OR of return to sport at the same level or higher. Those who returned to the same level or higher reported significantly higher scores on the ACL-RSI and the 2000 IKDC-SF. There was no significant difference in those returning to sport at their previous level or higher based on SF-12 physical or mental scores, number of ligaments injured, presence of a mental health diagnosis, or age at injury. Future studies will focus on larger cohorts and any modifiable variables to obtain a functional return to sport. [Table: see text][Table: see text][Table: see text][Table: see text]

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction.

Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process. To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores. Prospective cohort study; Level of evidence, 2. Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex. A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001). This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

Return to Sport After Multiligament Knee Injury in Young Athletes.

While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI). To assess the level of and factors associated with RTS after MLKI in young athletes. Case series; Level of evidence, 4. We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL-Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries. A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels. Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.

Comparison of Psychological Readiness to Return to Sport After Primary Versus Revision Anterior Cruciate Ligament Reconstruction.

Rates of return to preinjury level of play after anterior cruciate ligament (ACL) reconstruction (ACLR) remain unsatisfactory, particularly for patients who undergo revision surgery. Psychological readiness is associated with successful return to sport (RTS) and self-perceived preinjury sport performance. To compare psychological readiness at RTS between patients who underwent revision ACL autograft reconstruction and matched controls who underwent primary ACL autograft reconstruction. Cohort study; Level of evidence, 3. Data were gathered using a single orthopaedic surgeon database of patients who underwent ACLR between 2015 and 2018. Patients who underwent revision ACLR and met the study criteria (N = 92) were matched by age, sex, graft type, and rehabilitation protocol to a control group of patients who underwent primary ACLR (n = 92). Functional assessment at release to play was examined using passive knee range of motion, single-leg squat, and single-leg hop testing. Self-reported outcomes included the International Knee Documentation Committee subjective function survey and the ACL-Return to Sport after Injury (ACL-RSI) psychological readiness scale. Time to release to play was recorded as the number of months needed to reach a ≥90% limb symmetry index from the date of the index ACLR. Data were assessed for normality using the Shapiro-Wilk test, and univariate general linear models were utilized with an alpha level of .05. The overall mean patient age was 29.9 ± 10 years, and 40% of patients were women. No significant differences between groups were noted in any of the baseline patient characteristics or surgical findings. At RTS, the mean ACL-RSI score was significantly lower in the revision surgery group (77.4 ± 19.4 vs 85.3 ± 17.4; P = .011). In addition, the revision surgery group returned to play significantly later than the primary surgery group (9.4 ± 2 vs 8.1 ± 1.3 months, respectively; P < .001). When compared with primary ACL autograft reconstruction, revision reconstruction patients exhibited lower psychological readiness scores and a longer time to meet the objective criteria for RTS. NCT03704376 (ClinicalTrials.gov identifier).

Association of COVID-19 Lockdown With Increased Rate of Cyclops Syndrome in Patients With Unexpected Home-Based Self-Guided Rehabilitation After ACL Reconstruction.

The risk of cyclops syndrome increases significantly after anterior cruciate ligament (ACL) reconstruction (ACLR) if complete extension is not recovered before the sixth postoperative week. The lockdown in France due to the COVID-19 pandemic led to an absence of supervised rehabilitation, requiring unexpected self-rehabilitation in patients who underwent ACLR just before lockdown. To determine the rate of cyclops syndrome after ACLR in patients who underwent self-rehabilitation during lockdown. Cohort study; Level of evidence, 3. A total of 75 patients receiving a hamstring graft for ACLR during the COVID-19 pandemic between February 10, 2022, and March 16, 2020, carried out self-rehabilitation during part of their first 6 postoperative weeks using exercise videos on a dedicated website. Clinical examination was performed at a minimum 1-year follow-up with International Knee Documentation Committee (IKDC), Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI) scores. This group was compared with a matched-pair control group of 72 patients who underwent surgery in 2019 and completed postoperative supervised rehabilitation with a physical therapist. Rates and reasons for second surgery (arthrolysis, meniscal procedure) were also recorded. In the COVID group (n = 72; 3 patients were lost to follow-up), the mean follow-up was 14.5 ± 2.1 months (range, 13-21) and rate of reoperation for clinical cyclops syndrome was 11.1% (n = 8). The rate of cyclops syndrome was significantly lower (1.4%) in the control group (P = .01). In the COVID group, 8 patients underwent anterior arthrolysis at a mean of 8.6 months after the primary surgery, and 4 patients underwent another surgical intervention (meniscal procedure [n = 3], device removal [n = 1]). In the COVID group, mean Lysholm was 86.6 ± 14.1 (range, 38-100), Tegner was 5.6 ± 2.3 (range, 1-10), subjective IKDC was 80.3 ± 14.7 (range, 32-100) and ACL-RSI score was 77.3 ± 19.7 (range, 33-100). The rate of cyclops syndrome after ACLR was significantly greater in the COVID group versus the matched controls. The dedicated website was not effective at supporting self-guided rehabilitation and could benefit from interactive improvements so it is at least as effective as supervised rehabilitation.

Relationship Between Bone Bruise Volume and Patient Outcomes After ACL Reconstruction.

Subchondral bone injuries, or bone bruises, are commonly observed on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury. The current relationship between bone bruise volume and postsurgical outcomes remains poorly understood. To examine the influence of bone bruise volume on self-reported and objective functional outcomes at the time of return to play and 2 years following ACL reconstruction. Cohort study; Level of evidence, 3. Clinical, surgical, and demographic data were obtained for a sample of convenience utilizing a single-surgeon ACL database (n = 1396). For 60 participants, femoral and tibial bone bruise volumes were estimated from preoperative MRI. Data obtained at the time of return to play included International Knee Documentation Committee (IKDC-2000) score, ACL-Return to Sport after Injury (ACL-RSI) score, and performance on an objective functional performance battery. Two-year follow-up data included graft reinjury rate, level of return to sport/activity, and self-reported knee function using the Single Assessment Numeric Evaluation (SANE). The forward stepwise linear regression was used to determine the relationship between bone bruise volume and patient function. The distribution of bone bruise injuries was as follows: lateral femoral condyle (76.7%), lateral tibial plateau (88.3%), medial femoral condyle (21.7%), and medial tibial plateau (26.7%). Mean total bone bruise volume of all compartments was 7065.7 ± 6226.6 mm3. At the 2-year follow up, there were no significant associations between total bone bruise volume and time of return to play (P = .832), IKDC-2000 score (P = .200), ACL-RSI score (P = .370), or SANE score (P = .179). The lateral tibial plateau was the most frequent site to sustain bone bruise injury. Preoperative bone bruise volume was not associated with delayed time to return to sport or self-reported outcomes at time of return to play or at 2 years postoperatively. NCT03704376 (ClinicalTrials.gov identifier).

Bilateral changes in knee joint laxity during the first year after non-surgically treated anterior cruciate ligament injury

ObjectivesAnalyse changes in knee laxity between 3, 6, 12 and 24 months after non-surgically treated ACL injury and to analyse associations between knee laxity and knee function, self-reported knee stability, ACL-Return to Sport after Injury (ACL-RSI), fear and confidence at different timepoints during recovery. DesignProspective cohort study. Participants125 patients (67 males, mean age 25.0 ± 7.0 years) with acute ACL injury. Main outcomeLaxity was measured using KT-1000 arthrometer. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Confidence and fear were assessed with questions from the ACL-RSI scale. Subjectively knee stability was assessed using SANE. ResultsKnee laxity increased bilaterally from 3 to 12 months, and in the non-involved knee from 3 to 24 months (p˂0.05), although mean change was below 1 mm. Side-to-side difference in knee laxity was correlated with IKDC-SKF (r = −0.283) and knee stability in rehabilitation/sport activities (r = −0.315) at 6 months, but not with confidence/fear. ConclusionKnee laxity increased bilaterally during the first year after non-surgically treated ACL injury, though, the mean change in knee laxity was below 1 mm and the clinical significance is unknown. Knee laxity was weakly associated with knee function and perceived knee stability. Level of evidenceLevel II Trial registrationNCT02931084

The Association Between Physical Competence and Psychological Response Among Young Athletes Following ACL Reconstruction

Background:The traditional index of return to sport (RTS) readiness following anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical for successful RTS among young athletes.Hypothesis/Purpose:The purpose of this study was to test the hypothesis that young athletes with higher actual and perceived physical competence will demonstrate a more positive psychological response at time of RTS after ACLR.Methods:Thirty-eight athletes (median age=16.9 years [IQR: 16.1, 18.8]) following primary ACLR completed testing within 8 weeks of medical clearance to RTS. All participants completed isokinetic knee extension strength (180°/s) and single-limb crossover hop for distance, in addition to the Knee injury and Osteoarthritis Outcome Score (KOOS), Self-Perception Profile Athletic Competence, and ACL Return to Sport after Injury (ACL-RSI) questionnaires. Criteria for the achievement of actual (APC) and perceived physical competence (PPC) were operationally defined based on established age- and activity-relevant cutoff scores (Table 1). Psychological response was assessed with ACL-RSI overall score, in addition to each ACL-RSI subscale score (Emotions, Confidence, Risk Appraisal). Multiple linear regression analyses were used to determine differences in ACL-RSI scores based on achievement of APC and PPC, while adjusting for age and sex.Results:Of the 38 participants, 9 (23.7%) were able to meet all criteria for High APC, while 29 (76.3%) participants were categorized as Low APC. Twenty-one (55.3%) of the 38 participants were categorized as Very Good PPC, and 17 (44.7%) were categorized as Somewhat Good PPC. The regression model for overall ACL-RSI score was significant (F (4,33) = 5.224, p=0.002, adj. R2 = 0.313), with age explaining 26.4% of the total variance (p=0.001). In evaluating the ACL-RSI subscales, the regression model for the ACL-RSI Emotions score was significant (F(4,33) = 7.760, p<0.001, adj. R2 = 0.422), with age, sex, and PPC explaining 33.9% (p<0.001), 7.0% (p=0.04), and 7.7% (p=0.03) of the total variance, respectively. Lastly, the regression model for ACL-RSI Risk Appraisal score (F(4,33) = 3.416, p=0.019, adj. R2 = 0.207) was significant, with age and PPC explaining 10.5% (p=0.034) and 12.9% (p=0.02) of the total variance, respectively (Table 2).Conclusion:In partial accordance with our hypothesis, higher PPC, but not APC, was significantly associated with a more positive psychological response among young athletes after ACLR. Interventions to improve self-perceptions of competence may optimize psychological readiness to RTS.Table 1.Actual and Perceived Physical Competence CriteriaTable 2.Results of Standard Multiple Regression of Competence on ACL-RSI Scores

Psychological Readiness to Return to Sport at 6 Months is Higher After Bridge-Enhanced ACL Repair than Autograft ACL Reconstruction

Background:Prior clinical studies have shown that psychological factors have a significant effect on an athlete’s readiness to return to sport following ACL reconstruction (ACLR).Hypothesis/Purpose:We hypothesized that patients who underwent Bridge-Enhanced ACL Repair (BEAR) would have higher levels of psychological readiness for return to sport compared to ACLR, and baseline characteristics and 6-month outcomes would predict psychological readiness at 6 months following an ACL surgical procedure.Methods:100 patients (median age 17 years; median pre-operative Marx Activity Score 16) with complete mid-substance ACL injuries were randomized to either the BEAR procedure (n=65) or autograft ACLR (n=35) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL-Return to Sport after Injury (ACL-RSI) scale, were assessed at 6 months, 12 months, and 24 months.Results:Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared to those that underwent an ACLR (71.1 vs 58.2, p=.008), and scores were similar at 12 months and 24 months. Baseline factors independently predictive of higher ACL-RSI scores at 6 months were having a BEAR procedure and participating in Level 1 sports prior to injury, which explained 15% of the variability in ACL-RSI scores. Regression analysis of baseline and 6-month outcomes as predictors indicated that the IKDC score at 6 months explained 45% of the 6-month ACL-RSI variance. Subsequent analysis, with IKDC excluded from the model, indicated that decreased pain, increased hamstring and quadriceps strength in the surgical limb, and decreased side-to-side difference in AP knee laxity were significant predictors of a higher ACL-RSI score at 6 months, explaining 34% of the variability in ACL-RSI scores. Higher ACL-RSI scores at 6 months were associated with earlier clearance to return to sports.Conclusion:Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months after surgery. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months. Lower pain levels, better muscle recovery, and less knee laxity at 6-months post-surgery were also associated with improved ACL-RSI scores at that time point.

Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial

Background:Previous clinical studies have shown that psychological factors have significant effects on an athlete’s readiness to return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR).Hypothesis:We hypothesized that patients who underwent bridge-enhanced ACL restoration (BEAR) would have higher levels of psychological readiness to return to sport compared with patients who underwent ACLR.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:A total of 100 patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were randomized to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33 hamstring and 2 bone--patellar tendon—bone]) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL--Return to Sport after Injury (ACL-RSI) scale, were assessed at 6, 12, and 24 months postoperatively.Results:Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2; P = .008); scores were similar at 12 and 24 months. Baseline factors independently predictive of higher ACL-RSI scores at 6 months were having a BEAR procedure and participating in level 1 sports prior to injury, explaining 15% of the variability in the scores. Regression analysis of baseline and 6-month outcomes as predictors indicated that the International Knee Documentation Committee (IKDC) score at 6 months explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC excluded from the model indicated that decreased pain, increased hamstring and quadriceps strength in the surgical limb, and decreased side-to-side difference in anteroposterior knee laxity were significant predictors of a higher ACL-RSI score at 6 months, explaining 34% of the variability in scores. Higher ACL-RSI score at 6 months was associated with earlier clearance to return to sports.Conclusion:Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months postoperatively. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months and were also associated with lower pain levels, better muscle recovery, and less knee laxity at 6 months.Registration:NCT02664545 (ClinicalTrials.gov identifier).

Psychological Patient-reported outcome measure after anterior cruciate ligament reconstruction: Evaluation of subcategory in ACL-Return to Sport after Injury (ACL-RSI) scale

BackgroundIt has been recognized that psychological factors influence the return to sports after anterior cruciate ligament reconstruction (ACLR). The ACL-return to sports after injury (RSI) scale was developed based on subcategories of emotions, confidence in physical performance and risk appraisal. However, it has not been clarified describing which is the most influential psychological factor of the ACL-RSI scale. HypothesisRisk appraisal is the most influent for return to sports in the subcategories of the ACL-RSI scale. Patients and methodsA total of 85 competitive patients who had undergone ACLR were evaluated at 6, 12 and 24 months after surgery. They were classified the return to sports (RTS) group and non-return to sports (NRTS) group. Evaluations were several clinical and functional scores including Cincinnati knee rating system, Knee Osteoarthritis Outcome Score (KOOS), Lysholm score, limitation in activities of daily living (ADL) and sports which estimated by Visual Analog Scale (VAS) score, Isokinetic Muscle Strength (quadriceps and hamstrings), single hop test and anterior laxity. They were investigated their relationship with the ACL-RSI scale including each subcategory. ResultsThe total ACL-RSI scale significantly improved at each point. Of the subcategories, only risk appraisal was not significantly different at each point (p=0.21 and p=0.13). There was a significant difference at 24 months after ACLR between the RTS group and NRTS group. In terms of risk appraisal, compared with emotion and performance confidence, the difference in the mean value was the most divergent (RTS group: 55.9±22.7 and NRTS group: 23.8±19.3) and took time to improve through 24 months. Among various clinical and functional scores, there were significant differences in the VAS score for sports, KOOS-symptoms, sports and QOL, Cincinnati Knee Rating System-cut, and single hop test values between two groups. Of these, the KOOS-QOL and VAS score for sports showed particularly strong correlations with ACL-RSI risk appraisal (r=0.75 and -0.68, respectively). ConclusionOf the ACL-RSI scale, risk appraisal took the longest time to improve and strongly affected the return to sports. The KOOS-QOL and VAS score for sports were most strongly correlated with the ACL-RSI risk appraisal. It seems that it is important to reduce the psychological risk as soon as possible after ACL injury in ACLR patients. Level of evidenceII.

Outcomes of Meniscal Repair versus Meniscectomy in Patients with Concomitant ACL and Bucket Handle Meniscus Tears (200)

Objectives:Bucket handle meniscus tears often present concurrently with tears of the anterior cruciate ligament (ACL). However, little is known regarding the influence of demographic factors on surgical decision-making, or on outcomes following treatment of bucket handle meniscus tears in ACL-deficient patients. Furthermore, no study has compared outcomes in this population between patients undergoing meniscectomy versus repair. The purpose of this study was therefore to determine if there is a difference in outcomes between patients presenting with concomitant ACL and bucket handle meniscus tears treated with meniscal repair versus meniscectomy. A secondary aim of this study was to discover if there is an association between the decision to perform a meniscus repair or meniscectomy based on demographic factors.Methods:In this institutional review board-approved retrospective study, we evaluated 62 patients presenting with ACL tear who were found to have a bucket handle meniscus tear preoperatively or at the time of ACL reconstruction. Of those, 30 patients underwent partial meniscectomy, while 32 underwent meniscal repair. Primary outcome measures included ACL and meniscal retear rates, as well as patient-reported outcome measures (PROMs). Documented PROMs included the International Knee Documentation Committee (IKDC), Single Assessment Numeric Evaluation (SANE), and ACL-Return to Sport after Injury (ACL-RSI) scores. Demographic and patient-specific factors evaluated included age, body mass index (BMI), smoking status, and location of meniscus tear.Results:Of 62 patients presenting for ACL reconstruction with concomitant bucket handle meniscus tear, a total of 34 patients with greater than one year (mean 22.4 month) follow-up were included. 14 patients underwent repair, and 20 underwent meniscectomy. No significant differences were noted in IKDC (p = 0.36), delta IKDC (p = 0.18), SANE (p = 0.61), or ACL-RSI (p = 0.67) scores between the repair and meniscectomy groups at final follow-up. No significant differences were found in ACL (p = 1.00) or meniscus (p = 0.49) retear rates between the two groups. Younger age, lower BMI, and tear location (red-red zone) were significantly associated with the decision to perform meniscal repair over meniscectomy (p < 0.05).Conclusions:Among patients presenting with concomitant ACL and bucket handle meniscus tears, we found no difference in patient-reported outcomes or retear rates in patients undergoing meniscal repair versus meniscectomy. Demographic and patient-specific factors including age, BMI, and tear location may influence surgical decision-making when determining the optimal treatment of bucket handle meniscus tears in this population.

EARLY OUTCOMES AFTER SUTURE TAPE REINFORCEMENT OF QUADRICEPS TENDON AUTOGRAFT ACL RECONSTRUCTION IN ADOLESCENT ATHLETES

Background:Recently, anterior cruciate ligament reconstruction (ACLR) with suture-tape reinforcement has been popularized for protection of the graft during the revascularization and remodeling phase of incorporation. To date, there are limited short-term data regarding the outcomes of suture tape reinforcement to ACLR. Furthermore, its use with quadriceps tendon autograft (QT) ACLR is limited.Purpose:The purpose of this study was to review the early, preliminary results of ACLR in adolescent patients using QT autograft with suture tape reinforcement (QT-SR).Methods:A retrospective review was performed of skeletally mature adolescent patients who underwent primary ACLR with all-soft tissue QT-SR since 2018. Surgeries were performed by a single surgeon using an all-inside technique. All patients followed the same standardized rehabilitation protocol. Twelve-month patient-reported outcome measures (PROMs) and complications were analyzed. PROMs included the Pediatric International knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, and the Tegner activity level scale. Psychological readiness was assessed with the ACL-Return to Sport after Injury (ACL-RSI) scale.Results:39 patients (24 girls, 15 boys) were identified. The mean age at the time of surgery was 15.7 ± 1.3 years (range, 13-18 years). 82% of patients were high school athletes. Soccer was the primary sport for 48.7% of patients. The mean graft diameter was 9.5 ± 0.4 mm. 51.3% of patients had concomitant meniscus repairs. The mean time to return-to-sport clearance was 10.1 ± 1.4 months. At 12 months, the mean postoperative Pedi-IKDC was 95.6 ± 4.0, the mean Lysholm score was 97.6 ± 3.9, and the mean Tegner score was 8.8 ± 0.9. All PROMs improved significantly compared to the preoperative scores (Pedi-IKDC: p = 0.003, Lysholm: p = 0.006, Tegner: p = 0.003). The mean ACL-RSI was 93.4 ± 4.7. Complications included return to surgery due to postoperative stiffness in two patients. There were no cases of postoperative instability, graft rupture, or contralateral ACL injury.Conclusion:QT-SR ACLR results in excellent clinical and patient-reported outcomes in adolescent athletes at 12 months follow-up. The long-term effect of QT-SR remains to be investigated.

Psychosocial factors 3-months after anterior cruciate ligament reconstruction predict 6-month subjective and objective knee outcomes.

The objective of the study was to determine if psychological readiness for sport and knee self-efficacy assessed early (3 months) after anterior cruciate ligament reconstruction (ACLR) are predictive of self-reported functional outcomes, quadriceps strength, and knee mechanics while running at the time of return to sport training (6 months). Thirty athletes with unilateral ACLR completed the ACL Return to Sport after Injury (ACL-RSI) and Knee Self-Efficacy Scale (K-SES) 3 months after ACLR and completed self-reported functional outcomes, isometric quadriceps strength testing, and three-dimensional running gait analysis 6 months after ACLR. The 3-month ACL-RSI significantly correlated with the 6-month International Knee Documentation Committee (IKDC; r = 0.565, p = 0.001), Knee Injury and Osteoarthritis Outcome Score (KOOS) sport/recreational activities (KOOSSport ; r = 0.548, p = 0.002) and quality of life (KOOSQoL ; r = 0.431, p = 0.017), and quadriceps strength (r = 0.528, p = 0.003). The 3-month K-SES significantly correlated with the 6-month IKDC (r = 0.528, p = 0.003), KOOSSport (r = 0.430, p = 0.018), KOOSQoL (r = 0.411, p = 0.024), quadriceps strength (r = 0.465, p = 0.010), and knee flexion excursion (r = 0.472, p = 0.008). With multivariate modeling, both the ACL-RSI and K-SES were predictive of the IKDC (R2 = 0.411; p = 0.001). Only the ACL-RSI was predictive of the KOOSSport (R2 = 0.300; p = 0.002), KOOSQoL (R2 = 0.186; p = 0.017), and quadriceps strength (R2 = 0.279; p = 0.003), whereas only the K-SES was predictive of knee flexion excursion (R2 = 0.173; p = 0.022). Athletes with greater psychological readiness for sport and knee self-efficacy at 3 months demonstrated higher scores on self-reported functional outcomes, greater quadriceps strength, and greater knee flexion excursion at 6 months after ACLR. This study indicates that psychosocial measures may be important to include into early post-surgical evaluations to help guide and facilitate interventions to restore subjective and objective knee function.

Knee extensor strength, hop performance, patient-reported outcome and inter-test correlation in patients 9–12 months after anterior cruciate ligament reconstruction

BackgroundHop performance and isokinetic knee extensor strength (IKES) asymmetry are associated with re-injury after anterior cruciate ligament reconstruction (ACLR). This study investigated deficits after ACLR, and which hop tests are most correlated with IKES and patient-reported outcome measures (PROMs). Methods50 patients were assessed 9–12 months after ACLR using the International Knee Documentation Committee (IKDC) and ACL Return to Sport after Injury (ACL-RSI) scores. Peak IKES and eight hop tests were assessed: single (SHD), triple (THD) and triple crossover (TCHD) hop for distance, 6 m timed hop (6MTH), single medial (MHD) and single lateral (LHD) hop for distance, single countermovement jump (SLCMJ) and timed speedy hop (SHT). The percentage of patients with limb symmetry indices (LSIs) < 90% was reported. Pearson’s correlations investigated the correlation between PROMs, IKES and hop LSIs. ResultsThe majority (80%) of patients had IKES LSIs < 90%. While 12–14% of patients demonstrated LSIs < 90% for the SHD, 6MTH, THD and TCHD, 52–80% demonstrated LSIs < 90% for the other hop tests. The IKES LSI was significantly different (p < 0.05) from all hop LSIs, besides the SLCMJ (p = 0.638). Large correlations were only observed between the IKES LSI and the SLCMJ (r = 0.82), MHD (r = 0.71) and LHD (r = 0.53). The SLCMJ, MHD and IKES LSIs demonstrated the largest significant correlations with the IKDC (r = 0.51–0.53) and ACL-RSI (r = 0.38–0.40). ConclusionsHop tests such as the MHD and SLCMJ may present a more practical alternative to quantifying peak IKES, especially in the absence of more sophisticated testing equipment. While not surrogates as such, these selective hop measures may better inform the clinician as to whether significant underlying quadriceps deficits are still present throughout the post-operative rehabilitation period.