After Anterior Cruciate Ligament Tear Research Articles

Distinct patterns of cytokines, chemokines, and growth factors in synovial fluid after ACL injury in comparison to osteoarthritis.

This study analyzed knee synovial fluid after anterior cruciate ligament (ACL) tear and in osteoarthritis (OA) to test the hypotheses that concentrations of cytokines, chemokines, and growth factors differ (a) by diagnosis and (b) after ACL tear by time from injury and presence/absence of concomitant meniscus tear. Synovial fluid samples were collected from two groups, ACL tears (with or without meniscus tear) (N = 13) and Kellgren-Lawrence grade 3 and 4 OA (N = 16), undergoing clinically indicated aspiration of the knee joint. Multiple cytokines, chemokines, and growth factors were assessed using a multiplexed 45-protein panel. Comparisons were made for the concentrations of all molecules between ACL tear and OA patients, isolated versus combined ACL and meniscus tears, and categorized by time from injury: acute or early subacute (<15 days, N = 8) versus late subacute or chronic (>15 days and <3 months, N = 5). ACL tear patients have higher levels of six molecules (IL-4, IL-5, IL-13, PlGF-1, bNGF, TNF-α) in knee synovial fluid compared to OA patients. Isolated ACL tears express higher levels of IL-4, IL-13 and IFN-γ and lower levels of IL-7 than ACL tears with a concomitant meniscus tear. SDF-1α, PlGF-1, IL-1RA, HGF, bNGF, and BDNF levels are elevated immediately after injury and drop off significantly in the late subacute phase (after 15 days). Synovial fluid from knees with ACL tears have elevated metabolic activity compared to knees with OA. The cytokine profiles after ACL tears are influenced by the time from injury and the presence of meniscus tears. These findings offer valuable insights into the levels of cytokines, chemokines, and growth factors in the knee after ACL injury, information which may have important implications for the diagnosis, prognosis and treatment of this common pathology.

The Role of Artificial Intelligence in Anterior Cruciate Ligament Injuries: Current Concepts and Future Perspectives

The remarkable progress in data aggregation and deep learning algorithms has positioned artificial intelligence (AI) and machine learning (ML) to revolutionize the field of medicine. AI is becoming more and more prevalent in the healthcare sector, and its impact on orthopedic surgery is already evident in several fields. This review aims to examine the literature that explores the comprehensive clinical relevance of AI-based tools utilized before, during, and after anterior cruciate ligament (ACL) reconstruction. The review focuses on current clinical applications and future prospects in preoperative management, encompassing risk prediction and diagnostics; intraoperative tools, specifically navigation, identifying complex anatomic landmarks during surgery; and postoperative applications in terms of postoperative care and rehabilitation. Additionally, AI tools in educational and training settings are presented. Orthopedic surgeons are showing a growing interest in AI, as evidenced by the applications discussed in this review, particularly those related to ACL injury. The exponential increase in studies on AI tools applicable to the management of ACL tears promises a significant future impact in its clinical application, with growing attention from orthopedic surgeons.

The nature of gait biomechanics changes with walking speed increase in patients with anterior cruciate ligament injury.

This study on gait biomechanics is based on a functional test (FT) performed at free and fast walking speeds. We investigated the pattern of changes in gait biomechanical parameters and the knee function in patients after anterior cruciate ligament (ACL) injury or its reconstruction. The study included 51 patients (33 males, 18 females) with a confirmed recent or old history of ACL tear, before or after reconstruction (26 patients). Mocap data was obtained using an inertial system. All patients were divided into three groups: 41 patients with physiological response (compensation), 6 patients with signs of decompensation, and 4 non-assessable patients. Increase in gait speed was associated with decrease in the walking cycle duration, stance and double support phases. In the compensation group, the physiological response of the knee was manifested in increased amplitudes. In the decompensation group, the amplitudes remained unchanged or decreased. In the compensation group, there were increases in the symmetrical muscle activity. The decompensation group was characterized by electromyography asymmetry. The observed universal physiological mechanism limiting the load on the damaged joint can be used for accurate assessment of the knee functional state in various periods of rehabilitation.

Systematic Review of Clinical Outcomes After Proximal Tibia Anterior Closing-Wedge Osteotomy With ACL Reconstruction.

While increased posterior tibial slope (PTS) is an important risk factor for failure after anterior cruciate ligament (ACL) reconstruction, controversy exists regarding indications and outcomes of proximal tibia anterior closing-wedge osteotomy (ACWO) with concomitant ACL reconstruction in patients with ACL tears. To assess clinical outcomes after combined ACL reconstruction and proximal tibia ACWO. Systematic review; Level of evidence, 4. In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we performed a systematic review of the existing literature on ACWO and ACL reconstruction using PubMed (MEDLINE), Cochrane Library, Scopus, and Embase. The search phrases included "anterior closing wedge osteotomy,""anterior closing wedge tibial osteotomy,""anterior closing wedge proximal tibial osteotomy,""anterior cruciate ligament," and "revision anterior cruciate ligament." Non-English publications and single-patient case reports were excluded. Extracted data included study details, patient demographics, patient-reported outcomes (PROs), clinical outcomes, radiographic outcomes, complications, and return-to-sport (RTS) rates. A total of 6 studies with 110 patients (110 knees) were included. Two-stage ACWO and ACL reconstruction was reported in 2 studies of 78 patients (71%), while a single-stage technique was reported in 4 studies of 32 patients (29%). ACWO was performed in the setting of primary ACL tear in 23 patients (21%) and in recurrent ACL tear in 87 patients (79%). Patients demonstrated postoperative improvements in Lysholm, pivot-shift test, and side-to-side difference in anterior tibial translation. After ACWO, all studies reported mean postoperative PTS of <10° (range, 4.4°-9.2°). Of patients with available RTS data (n = 43), the same-level RTS rate ranged from 65% to 100%. A two-stage procedure reported in 1 study had a lower RTS rate (n = 13 of 20 [65%]) than that of 2 studies with single-stage procedure (n = 4 of 5 [80%] and n = 18 of 18 [100%]). The overall complication rate was 0.9% to 1.3%, and there were no reported ACL retears. The current evidence, which is constrained by the quantity and quality of studies, showed that ACWO with single- or two-stage ACL reconstruction in patients with ACL insufficiency and increased PTS was associated with significant improvements in PROs and high RTS rates.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts.

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

Poster 312: Graft harvest for ACL reconstruction from the contralateral knee does not increase patellofemoral arthritis rates versus a normal knee

Objectives: Previous outcome studies after anterior cruciate ligament (ACL) reconstruction have suggested a link between patella tendon (PT) graft harvest and increased incidence of patellofemoral (PF) degenerative changes. However, with the graft harvest on the same knee as the ACL reconstruction, it is difficult to specifically elucidate whether this association is directly from the graft harvest itself as opposed to other factors. Knowledge of the incidence of PF osteoarthritis (OA) after graft harvest from the contralateral knee may provide insight into this relationship. The purpose of this study was to compare PF OA rates between contralateral versus ipsilateral graft harvest for ACL reconstruction. Methods: A database of long-term follow up of ACL reconstruction patients done by a single surgeon was queried to find surgeries done between minimum 15 years and maximum 25 years ago. Patients were included if they had long term radiographs within this window for evaluation of PF OA. Exclusion criteria included revision ACL reconstruction, bilateral ACL involvement, subsequent graft retear, contralateral ACL tear, PF chondral wear seen at the time of surgery, preoperative or subsequent surgeries to either knee, or the presence of preoperative PF OA. Once patients met inclusion criteria, they were separated into groups based on ipsilateral or contralateral PT graft harvest. Standard Merchant’s radiographs were taken by the same technicians with the assistance of a Merchant’s board. Radiographs were graded by the physical therapist that saw the patient back for their long term research visit, each individually trained to grade the images based on the set criteria. Radiographs were graded as none, mild, moderate, or severe PF OA based on joint space narrowing of none, &lt;50%, &gt;50% but &lt;100%, and complete, respectively. Patellofemoral OA rates were then statistically compared utilizing chi-squared analysis or Fisher’s exact test. These criteria produced an ipsilateral group with 95 patients and a contralateral group with 98 patients. Mean ages at time of surgery, height, weight, and sex distribution were not statistically different between groups. The ipsilateral group had a slightly, but statistically significantly, longer mean follow up interval (20.0 vs. 17.4 years, p&lt;.001). Results: In the ipsilateral graft group, PF OA of any grade was present in 20.0% of the involved ACL reconstructed knees and 9.5% of the uninvolved normal knees, which was a statistically significant difference ( p=.041, OR 2.4). In the contralateral graft group, PF OA was present in 10.2% of the ACL reconstructed knees and 13.3% of the contralateral graft donor knees ( p=.506). Patellofemoral OA of any grade was present in 14.7% of all knees in the ipsilateral group and 11.7% of all knees in the contralateral group ( p=.348). When comparing the uninvolved normal knee from the ipsilateral group to the contralateral graft donor knee of the contralateral group, there was no statistical difference in PF OA rates of any grade (9.5% vs. 13.3% p=.407). The ACL reconstructed knee in the ipsilateral group exhibited PF OA in 20.0% and 10.2% in the contralateral group ( p=.057). With regard to moderate or severe PF OA in either knee, the rates were not statistically significant between the ipsilateral and contralateral groups. When comparing the ipsilateral group normal knee to the contralateral group donor knee, the rates of moderate or severe PF OA were 1.1% and 2.0% respectively, which was not statistically significantly different. Conclusions: Previous studies suggest that patella tendon grafts are associated with higher rates of PF OA after ACL reconstruction. Our study reveals that PF OA rates are not statistically increased when a patella tendon graft alone is taken from the knee, when compared to a normal control knee. However, when ACL reconstruction and PT graft are combined in the same knee, there is a statistically significant increase in PF OA versus the uninvolved normal knee, with the ACL reconstructed knee with ipsilateral graft being 2.4 times more likely to experience PF OA than the uninvolved knee. Furthermore, harvesting the ACL graft from the contralateral knee trends toward decreased PF OA rates in the ACL reconstructed knee, though this is not statistically significant. We conclude that the PT graft itself does not increase PF OA rates and that contralateral PT graft harvest may provide advantages to ipsilateral graft harvest with regard to PF OA.

Effect of Tibiofemoral Rotation Angle on Graft Failure After Anterior Cruciate Ligament Reconstruction

Background: Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament (ACL) reconstruction (ACLR). However, the effect of axial malalignment on graft survival after ACLR is yet to be determined. Purpose: To evaluate whether increased tibiofemoral rotational malalignment, namely, tibiofemoral rotation angle (TFA) and tibial tubercle–trochlear groove (TT-TG) distance, is associated with graft failure after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: In this retrospective matched control study of a single center’s database, 151 patients who underwent revision ACLR because of graft failure (ACLR failure group, defined as symptomatic patients with anterior knee instability and an ACL graft tear appreciated on magnetic resonance imaging [MRI] and confirmed during arthroscopic surgery) were compared with a matched control group of 151 patients who underwent primary ACLR with no evidence of failure after ≥2-year follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative MRI through the TFA and the TT-TG distance. Sagittal alignment was measured through the posterior tibial slope on MRI. The optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic curve. The Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of the TFA on ACLR longevity. Results: The mean age was 25.7 ± 10.4 years for the ACLR failure group and 25.9 ± 10.0 years for the intact ACLR group. Among all the included patients, 174 (57.6%) were male. In the ACLR failure group, the mean TFA was 5.8°± 4.5° (range, −5° to 16°), while it was 3.0°± 3.3° (range, −3° to 15°) in the intact ACLR group (P < .001). Neither the TT-TG distance nor the posterior tibial slope presented statistical differences between the groups. The receiver operating characteristic curve suggested an optimal TFA cutoff of 4.5° for graft failure (area under the curve = 0.71; P < .001; sensitivity, 68.2%; specificity, 75.5%). Considering this a threshold, patients who had a TFA ≥4.5° had 6.6 times higher odds of graft failure compared with patients with a TFA <4.5° (P < .001). Survival analysis demonstrated a 5-year survival rate of 81% in patients with a TFA <4.5°, while it was 44% in those with a TFA ≥4.5° (P < .001). Conclusion: An increased TFA was associated with increased odds of ACLR failure when the TFA was ≥4.5°. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration before ACLR for a successful outcome.

Poster 135: Posterior Capsular Release for Knee Extension Deficits After Anterior Cruciate Ligament Reconstruction in Athletes

Objectives: To describe outcomes of posterior capsular release to treat knee extension deficits after anterior cruciate ligament (ACL) reconstruction in athletes. Methods: A retrospective review was performed between January 2014 and December 2019 for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction. Patients were indicated for the procedure if they had greater than 10° of extension loss at least three months after ACL reconstruction that was refractory to physical therapy. Patients were included in the study if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least two years of follow up. Collected outcomes included preoperative and postoperative measurement of knee extension, international knee documentation committee (IKDC) score, Lysholm score, return to sport data, and complications. Results: Over the study period a total of 38 arthroscopic posterior capsular releases were performed. Of these, 20 were high school or college athletes. Two of these patients did not have 2-year follow up, leaving a total of 18 patients included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2-years follow up (pre- release extension deficit 15.1°, post-release extension deficit 1.3°, p &lt; 0.005). Improvements in the IKDC score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (p &lt; 0.001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (p &lt; 0.001). In total, 77.8% returned to sport at an average of 9.8 months from their primary surgery and 6.5 months following posterior capsular release surgery. Complications included one patient that required revision capsular release for persistent extension loss, one ACL tear of the ipsilateral knee, and two ACL tears of the contralateral knee. No infections or neurovascular injuries occurred. Conclusions: Knee extension loss after ligamentous repair surgery can have significant consequences including diminished patient satisfaction, reduced return to sport, and an increased risk of osteoarthritis development. Although arthroscopic posterior capsular release is a recognized treatment for knee extension loss, outcomes have not been reported in athletes. In our series, arthroscopic posterior capsular release resulted in significant improvement of knee extension and patient reported outcome scores at 6 month and 2 years postoperatively. Additionally, the procedure appears to be safe with few complications and only 5.6% of patients requiring repeat arthroscopy for knee extension loss. Posterior capsular release appears to be a reliable and safe treatment for athletes with persistent knee extension loss after ACL reconstruction.

Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up

Background: Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse. Purpose/Hypothesis: The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score–12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure. Results: A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63). Conclusion: ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).

Upregulation Of Vitamin D Pathways Is Inversely Associated With Quadriceps Fiber Atrophy Following ACL Tear.

Protracted quadriceps atrophy and weakness after Anterior Cruciate Ligament (ACL) injury results in poor knee mechanics and contributes significantly to the development of posttraumatic osteoarthritis. The cellular and molecular underpinnings of poor functional recovery are unknown, limiting the development of evidence-based therapies. Vitamin D is a fat-soluble vitamin with critical roles for bone and skeletal muscle health. PURPOSE: Our goal is to determine how participants’ skeletal muscle expression of vitamin D receptor (VDR), CYP24A1, and CYP27B1 is affected by anterior cruciate ligament (ACL) tear. METHODS: Fifteen participants (mean ± SD; age, 22.3 ± 5.4; BMI, 27 ± 5; 47% female) who sustained an ACL tear received muscle biopsies from the injured and noninjured vastus lateralis. Muscle biopsies were processed for western blotting and immunohistochemistry. The expression of VDR, CYP24A1, and CYP27B1 were assayed via western blot. Seven μm sections were cut on a cryostat and fiber cross-sectional area (CSA) was assessed with automated methods. Arbitrary densitometry units (AU) from western blotting and mean fiber CSA results were compared between limbs using paired t-tests. Pearson correlations were used to identify associations between VDR protein expression in the injured limb and pooled muscle fiber CSA. RESULTS: VDR expression was 57% higher in the injured limb when compared to the noninjured limb (0.11 ± 0.05 vs 0.07 ± 0.037 AU, p = 0.024). The expression of CYP24A1 were CYP27B1 were higher in the injured limb, but the differences did not reach statistical significance. Additionally, mean fiber CSA was lower in the injured limb (4259 ± 990 vs. 4976 ± 1115 μm2, p = 0.005). VDR expression in the injured limb and VDR percent difference between limbs was inversely associated with fiber atrophy (as assessed as CSA percent difference) (R = -0.575, p = 0.025; R = -0.545, p = 0.036). CONCLUSIONS: ACL injury increases VDR expression in quadriceps, and preliminary results suggest alterations in vitamin D activity and turnover. Our results support a role for vitamin D receptor expression to maintain quadriceps fiber size and highlight the need for further research into micronutrient metabolism to aid in the recovery from injury.

Participants With ACL Injury Have Poor Diet Quality And Lower Energy Intake After Reconstruction Surgery.

PURPOSE: High-quality diet and sufficient energy support optimal recovery following orthopedic injury. Our goal is to determine participants’ energy intake and diet quality before and after anterior cruciate ligament (ACL) reconstruction. METHODS: Thirty-six participants (mean ± SD; age, 21.5 ± 5.9; BMI, 25.1 ± 4.0; 53% female) who sustained an ACL tear volunteered for a physical therapy rehabilitation study. Concurrent with the parent trial, 3-day diet records were collected before and after ACL reconstruction. Participants recorded food and drink intake for two weekdays and one weekend day. A registered dietitian educated participants about keeping food records and estimating portion sizes. The dietitian prompted participants to complete records on assigned days and checked diet logs throughout the recording period for completeness. Energy consumption was analyzed through Nutrition Data System for Research (NDSR), and diet quality was measured using Healthy Eating Index 2015 (HEI-2015). Paired t-tests were used to compare pre-and post-surgery average energy intake (kcal), weight (kg), and protein (g/kg). One-sample tests were used to compare HEI-2015 to population averages for children and adults using NHANES 2015-2016 data. RESULTS: Average energy consumption decreased from pre-surgery to post-surgery (1797.3 ± 588.9 vs. 1587.8 ± 604.9, respectively; p = 0.029). Comparisons pre- and post-surgery for weight (74.9 kg ±18.0 vs. 74.5 ± 18.5), kcal/kg (24.8 ± 7.5 vs 22.3 ± 8.8), and protein g/kg (0.99 ± 0.35 vs. 0.97 ± 0.44) did not show differences. HEI-2015 was significantly lower in teenagers pre- and post-surgery compared to the US average of 53 for Americans age 2-19 (42.4 ± 8.5; p < .001; 42.7 ± 9.8; p < .001). Adult participants’ HEI was significantly lower than the US average of 59 only after ACL reconstruction (53.2 ± 13.3; p = 0.073; 50.5 ± 13.2; p = 0.011). Children had significantly lower HEI-2015 than adults before reconstruction (42.4 ± 8.5 vs 53.2 ± 13.3; p = 0.007) but not after (42.7 ± 9.8 vs 50.5 ± 13.2; p = 0.057). CONCLUSION: On average, energy intake decreases following ACL surgery in young participants. Future research should address links between diet quality, reduced energy intake and recovery following ACL surgery.

Paper 21: Blood Flow Restriction Therapy Improves Early Patient Reported Outcomes Following ACL Reconstruction

Objectives:To evaluate the affect of blood flow restriction (BFR) therapy conducted both before and after anterior cruciate ligament (ACL) reconstruction on early quadriceps strength and patient reported outcomes.Methods:A total of 43 patients (24 male, 19 female; age 27.6 ± 11.88 years) presenting with an ACL tear were randomized into two groups, BFR (N=22) and Control (N=21) at their initial clinic visit (ICV). Quadriceps strength was measured utilizing a handheld dynamometer in order to calculate peak force, average force and time to peak force during seated leg extension at the ICV. All patients were provided education on preoperative exercises to be performed 4-5 days per week for two weeks between the ICV and date of surgery. The BFR group was instructed to perform these exercises with a pneumatic cuff set to 80% of limb occlusion pressure placed over the proximal thigh. Following surgery, patients underwent physical therapy utilizing standard post-ACL reconstruction therapy protocols, with exercises performed with and without the use of BFR in each respective group. Patient Reported Outcome Measurement System Physical Function (PROMIS-PF), International Knee Documentation Committee (IKDC) scores, knee range of motion and quadriceps circumference were gathered at the ICV, the day of surgery, 2 weeks and 6 weeks after surgery. Quadriceps strength measurements were repeated the day of surgery and six weeks following ACL reconstruction.Results:No significant differences were noted between the BFR and control groups in peak quadriceps force generation (Figure 1), time to peak force or average force at any timepoints (P>0.05). At six weeks post-surgery, the BFR group had significantly higher PROMIS-PF (43.16 ± 5.29 versus 38.39 ± 5.39, p=0.02) and IKDC (58.22 ± 7.64 versus 47.05 ± 13.50, p=0.01, Figure 2) scores compared to the control group.Conclusions:Blood flow restriction therapy before and after ACL reconstruction results in improved patient reported outcomes scores without objective improvements in strength at six week follow up. Long term follow up is needed to determine if differences arise in quadriceps strength between groups.Figure 1.Peak quadriceps force of the injured leg measured in Newtons during the initial clinic visit (ICV), day of surgery (PreOp) and 6 weeks post ACL reconstructions. No statistically significant differences (p>0.05) Figure 2.International Knee Documentation Committee (IKDC) scores collected at initial clinicvisit (ICV), day of surgery (PreOp), 2 weeks and 6 weeks following ACL reconstruction. * Denotes statistically significant difference between groups (p<0.05)

Pour une amélioration de la prise en charge du diabète des résidents en EHPAD

Postoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step.Treatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension.A retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0 ± 11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0 ± 10.4 years. Patients were classified according to age of ACL tear, as acute (< 6 weeks), subacute (6 weeks to 6 months), or chronic (> 6 months).Risk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p = 0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7–97.2) and 97.1% (95% CI, 94.3–99.9) respectively (p = 0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p > 0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p = 0.421) or specifically in Group A (p = 0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months’ follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p = 0.128).The present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness.IV, retrospective exposure/non-exposure cohort study.

Significant risk of arthrolysis after simultaneous anterior cruciate ligament reconstruction and treatment of dislocated bucket-handle meniscal tear

IntroductionPostoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step. HypothesisTreatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension. Material and methodsA retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0±11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0±10.4 years. Patients were classified according to age of ACL tear, as acute (<6 weeks), subacute (6 weeks to 6 months), or chronic (>6 months). ResultsRisk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p=0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7–97.2) and 97.1% (95% CI, 94.3–99.9) respectively (p=0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p>0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p=0.421) or specifically in Group A (p=0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months’ follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p=0.128). ConclusionThe present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness. Level of evidenceIV, retrospective exposure/non-exposure cohort study.

A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation

Background:Some patients have a positive pivot-shift finding and rotational instability after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major pathologies known to affect the pivot-shift examination include ACL tear, anterolateral ligament injury, and loss of posterior lateral meniscus root function.Purpose:To describe a surgical algorithm determining indications for lateral extra-articular tenodesis (LET) based on intraoperative pivot-shift examination to prevent postoperative pivot shift and rotational instability and to evaluate the 2-year clinical and functional outcomes.Study Design:Case series; Level of evidence, 4.Methods:The study included 47 consecutive patients (39 men and 8 women) who underwent operative treatment for ACL injury between 2016 and 2017. Pivot-shift examination was performed under anesthesia, and the pivot shift was graded as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the surgical algorithm, single-bundle ACLR was performed in patients with grade 1 pivot shift. In patients with grade 2 with loss of posterior lateral meniscus root function, concurrent lateral meniscal repair was performed, and in patients with grade 2 with an intact lateral meniscus posterior root, concurrent extra-articular iliotibial band tenodesis was performed. Patients with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and radiographic evaluations were performed.Results:The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%) patients were evaluated as having pivot-shift grade 1; 16 (34%) patients, grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients underwent LET in addition to ACLR. Two of these patients had pivot-shift grade 2, and LET was performed since the lateral meniscus posterior root was intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption was detected, and lateral meniscal repair was performed. One patient was excluded from the further follow-up because of graft failure. At a mean postoperative follow-up of 29 months in 46 patients, the pivot-shift examination was negative in all patients. The mean Lysholm and International Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ± 9.36, respectively. Radiographic evidence of osteoarthritis was not detected.Conclusion:Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and anterolateral ligament surgery, it was possible to prevent positive pivot-shift findings postoperatively.

Incidence of anterior cruciate ligament graft tears in high-risk populations: An analysis of professional athlete and pediatric populations

BackgroundProfessional athletes are at increased risk of injury with high activity levels and additional pressure to return to sports quickly after anterior cruciate ligament (ACL) injury. The purpose of this study was to determine ACL graft re-tear rates in National Basketball Association (NBA), Major League Baseball (MLB), and National Hockey League (NHL) athletes using publicly available databases and to compare these to general populations, National Football League (NFL) athletes, and the pediatric population to establish a baseline for those partaking in high-risk sporting activity. MethodsA comprehensive online search was performed to identify athletes in the NBA, MLB, and NHL who had a reported ACL tear between 2007 and 2017. For each tear, the type of tear (initial or re-tear) and return to play data were documented. Comparisons of re-tear rates from these leagues to prior registry, meta-analyses, and epidemiologic studies were performed using Fisher's exact or Chi-squared tests. ResultsThe aggregate re-tear rate was 11.9%. ACL re-tear rates by league did not statistically differ. Return to play rate after index surgery was 95.8%, whereas after a revision procedure was 92.3%. There was a statistically significant difference between the studied ACL re-tear rates (NBA, MLB, NHL) and those of national registries (P < 0.01), and no difference when compared with the pediatric population or with the NFL. ConclusionsExposure to higher-risk sporting activity, common to pediatric patients and professional athletes, is a likely major influential factor in ACL re-tear.

Bone Bruise and Anterior Cruciate Ligament Tears: Presence, Distribution Pattern, and Associated Lesions in the Pediatric Population

Background: Bone bruise characteristics after anterior cruciate ligament (ACL) injury have been correlated with the level of joint derangement in adults. However, the literature lacks information about younger patients, whose higher ligamentous laxity may lead to different lesion patterns. Purpose: To investigate the prevalence, size, location, and role of bone bruise associated with ACL rupture in the pediatric population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Knee magnetic resonance imaging scans (MRIs) of patients aged 8 to 16 years with ACL tears from 2010 to 2018 were selected from the institution database. Inclusion criteria were open or partially open physes, less than 90 days between trauma and MRI, and no history of injury or surgery. Presence, localization, and size of bone bruise were analyzed by 2 blinded researchers and scored with the Whole-Organ Magnetic Resonance Imaging Score (WORMS) bone bruise subscale. Ligamentous, cartilaginous, meniscal, and other lesions were documented. Results: Of the 78 pediatric patients selected from the database, 54 (69%) had bone bruise. The mean area of bone bruise was larger in males than in females (femur, 3.8 ± 2.8 vs 2.2 ± 1.4 cm2, respectively, P = .006; tibia, 2.6 ± 1.6 vs 1.5 ± 0.8 cm2, respectively, P = .007). The subregions most affected by bone bruise were the lateral posterior tibia and the lateral central femur (in 83% and 80% of the knees affected, respectively). A low correlation was found between age and bone bruise area (biggest areas r = 0.30, P = .03, and sum of areas r = 0.27, P = .04), but no correlation was found between age and WORMS (femur, r = −0.03, P = .85; tibia, r = −0.04, P = .76). The injuries most associated with bone bruise were 23 meniscal lesions (43%), 10 lesions of other ligaments (19.0%), 2 cartilage lesions (3.7%), and 2 patellar fractures (3.7%). Conclusion: The prevalence of bone bruises in pediatric patients with ACL tears is high, although it seems slightly lower than the prevalence documented in adults but with similar localization. The area and the distribution pattern of bone bruises are similar among different ages. The pediatric patients had a lower presence of cartilage and meniscal lesions compared with that reported in adults, which suggests a different effect of this trauma on the knee of pediatric patients.

An interventional study on functional outcome of combined anterior cruciate ligament and anterolateral ligament reconstruction

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The anterolateral ligament (ALL) is an important structure for rotational stability of knee joint after anterior cruciate ligament (ACL) rupture. Outcome of combined ACL and ALL reconstruction will change view of high demanding ACL tear cases.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A hospital based prospective interventional study was done in Department of Orthopaedics, SMS Medical College, Jaipur to find the functional outcome of combined anterior cruciate ligament and anterolateral ligament reconstruction. A total of 45 patients underwent ACL and ALL reconstruction. Indications for a combined procedure were associated grade 3 pivot shifts, high level of sporting activity and pivoting sports. Patients were assessed pre- and post-operatively with objective and subjective International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity scale.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The mean follow up time was around 5 months. Two patients lost to follow up. Leaving 45 patients for final evaluation. At the last follow-up, all patients had full range of motion. The Lysholm, subjective IKDC, and objective IKDC scores were significantly improved (all p&amp;lt;0.0001). Pre-operatively, 38 patients had a grade 3 pivot shifts and 7 had a grade 2 according to the IKDC criteria. Post-operatively, 42 patients had a negative pivot shift (grade 0), and 3 patients were grade 1 (p&amp;lt;0.0001).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; This study demonstrates that a combined reconstruction can be an effective procedure without specific complications at a minimum follow-up of 6 months. Longer follow up is required to know any long term complications and functional outcome.&lt;/p&gt;

Predictors of Radiographic Osteoarthritis 2-3 Years after ACL Reconstruction: Data from MOON Onsite Nested Cohort

Objectives: Multiple studies have shown patients are susceptible to post-traumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) injury even with ACL reconstruction (ACLR). Prospective studies using multivariate analysis to identify risk factors for PTOA are lacking. This study aims to identify baseline predictors of radiographic PT OA after ACLR at an early time point and hypothesizes that meniscal injury and cartilage lesions will be associated with worse radiographic OA using the Osteoarthritis Research Society International (OARSI) atlas criteria. Methods: 421 patients who underwent ACLR returned onsite for standardized posteroanterior metatarsophalangeal radiographs a minimum of 2 years after surgery. At baseline, demographics, graft type, meniscal status/treatment, and cartilage status were collected. OARSI atlas criteria were used to grade all knee radiographs. Multivariable ordinal regression models identified baseline predictors of radiographic OARSI grades at follow-up. Results: The mean age was 19.8 years with 51.3% females. Higher age (odds ratio (OR) 1.06) and BMI (OR 1.05) were statistically significantly associated with higher OARSI grade in the medial compartment. Patients with a meniscal repair and a partial meniscectomy had statistically significantly higher OARSI grades in the medial compartment (meniscal repair OR 1.92 and meniscectomy OR 2.11) and in the lateral compartment (meniscal repair OR 1.96 and meniscectomy OR 2.97). Graft type, cartilage lesion, sex, and Marx activity scales had no significant association with OARSI grade. Conclusion: Older patients with a higher BMI who have an ACL tear with concurrent meniscal tear requiring partial meniscectomy or meniscal repair should be advised of their increased risk of developing radiographic OA. Alternatively, patients with an ACL tear with an articular cartilage lesion can be reassured that they are not at increased risk of developing radiographic knee OA at 2-3 years following ACLR.

Comparative Study of Hamstring Graft Healing Time after Anterior Cruciate Ligament Reconstruction with Augmentation of Platelet-Rich Plasma

Aim: To Compare hamstring graft healing time after anterior cruciate ligament (ACL) reconstruction with the use of augmentation of platelet-rich plasma. Methods: 30 patients between age group of 18 to 40 years with complete ACL tear were randomly divided into two groups the control group in which only ACL reconstruction was done and second group in which acl reconstruction was performed along with augmentation with Platelet rich plasma. For the PRP group, 3 ml of PRP was obtained in the operation room and was injected into femoral tunnel just before after portal suture. MRI was obtained post operatively 3 month, 6 month and 9th month for both the groups. Graft healing time was defined as the time taken for the graft to reach ligamentization phase when the graft became hyperintense or was visualised similar to PCL or the remnant which was preserved during reconstruction. Results: Patients in PRP augmented group achieved ligamentization phase significantly earlier as compared to those in the control group, with mean time of 3.4 months as compared to 8.1 months in the control group. Conclusion: PRP helps in faster healing of the Hamstring graft. However further studies are required to correlate graft healing time with return to previous activity.