Management Of Anterior Cruciate Ligament Injuries Research Articles

Conservative vs Surgical Treatment of Anterior Cruciate Ligament Rupture: A Systematic Review.

Anterior cruciate ligament (ACL) injury is very common, especially in young athletic individuals who injure themselves during sports involving pivoting actions. Management options include conservative management, which involves progressive physical therapy, educating the patient on how to prevent instability, and the use of a hinged knee brace. Surgical management involves reconstruction of the torn ligament using an autograft or an allograft and ACL repair where the torn ligament is affixed back to the tibia or femur.The choice of management depends on the severity of the injury, other injuries in associated structures, the level of fitness, and the athletic goals of the patient. Many studies exist on the management choice of ACL injury, but no clear consensus prevails. This study will examine the effectiveness of conservative versus surgical management. A literature review will be performed to identify appropriate papers which compare and evaluate the two approaches. A literature search for randomized controlled trials (RCTs) and cohort studies comparing the conservative to surgical management of ACL injury was conducted on PubMed, Scopus, and Web of Science. Patient eligibility criteria included individuals older than 15 with an isolated, recent ACL injury diagnosis via an appropriate clinical test, MRI, or arthroscopy. Studies were eligible if they were using appropriate surgical or conservative methods, as mentioned previously, and measuring results via appropriate scores, tools, and methods that will be presented below. The follow-up timeline would be from presentation time until at least two years. Five papers were found to be eligible. Overall, these papers included 462 patients. Two studies measuring overall knee symptoms, function, and sports activities using the International Knee Documentation Committee Subjective Knee Form (IKDC) score found that the operated group had a significantly higher score. The other two studies measured overall knee function and health using the Tegner & Lysholm and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores. In both papers, no significant difference was found between the two groups. Regarding Tegner's activity score, only one paper had significant findings. A significantly longer period to return to sports activities was observed in the operative group. Stability was significantly higher in all papers in the operated group. Osteoarthritis was measured using different tools in each paper. Only one paper found a significantly higher risk in the operated group. Only one paper indicated significantly more complications in the operated group regarding side effects. Overall, very few differences were observed between the two treatment groups. The most significant differences observed were the higher stability and the longer recovery period in patients undergoing surgery. Large RCTs following patients for enough time are needed to prove if surgical treatment offers significant benefits over conservative treatment.

The Value of Ultrasound Diagnostic Imaging of Anterior Crucial Ligament Tears Verified Using Experimental and Arthroscopic Investigations

This study investigates the potential of the ultrasound imaging technique in the assessment of Anterior Cruciate Ligament (ACL) pathologies by standardizing the examination process. We focused on four key ultrasound parameters: the inclination of the ACL; swelling or scarring at the ACL’s proximal attachment to the lateral femoral condyle; swelling or scarring of the ACL/posterior cruciate ligament (PCL) compartment complex with accompanying morphological changes in the posterior joint capsule; and dynamic instability, categorized into three ranges—0–2 mm, 3–4 mm, and ≥5 mm. The study group consisted of 25 patients with an ACL injury and 25 controls. All four tested parameters were found more frequently in the study group compared to the control (p < 0.0001). Our findings suggest that this standardized approach significantly augments the diagnostic capabilities of ultrasound, complementing clinical evaluation and magnetic resonance imaging (MRI) findings. The meticulous assessment of these parameters proved crucial in identifying subtle ACL pathologies, which might otherwise be missed in conventional imaging modalities. Notably, the quantification of dynamic instability and the evaluation of morphological changes were instrumental in early detection of ACL injuries, thereby facilitating more precise and effective treatment planning. This study underscores the importance of a standardized ultrasound protocol in the accurate diagnosis and management of ACL injuries, proposing a more comprehensive diagnostic tool for clinicians in the field of sports medicine and orthopedics.

Navigating ACL Injuries Amid the COVID-19 Pandemic: A Retrospective Analysis.

Introduction In the United Kingdom, musculoskeletal injuries represent a substantial proportion of primary care appointments, and within this category, acute knee injuries are prominent in accident and emergency department cases. Notably, diagnosing anterior cruciate ligament (ACL) injuries is a recognized challenge, often leading to extended diagnostic delays. The COVID-19 pandemic has significantly affected the management of musculoskeletal disorders, driven by reduced surgical capacities, creating a backlog of patients awaiting necessary surgical interventions. Delayed ACL reconstruction poses risks of prolonged knee instability and secondary injuries. To address these concerns, this study evaluates the impact of COVID-19 on the timeline from ACL injury diagnosis to MRI and surgical intervention, with a specific focus on an internal acute knee clinic pathway designed to expedite the evaluation, diagnosis, and management of soft tissue knee injuries. Methods In this cross-sectional study, we retrospectively reviewed all the patients who underwent primary ACL reconstruction from January 2019 to November 2022 in a district general teaching hospital (DGH). Besides demographic data of the patients, we recorded the dates of injury, primary presentation, first knee specialist review, knee MRI, and ACL reconstruction surgery, as well as the injury-to-surgery, injury-to-MRI, and MRI-to-surgery periods. Patients were divided based on the date of operation to pre- and post-COVID, and outcomes were compared to see the possible effects of COVID-19. Data were analyzed using a quantitative and qualitative test with a P < 0.05 significance level. Results Our cohort included 97 patients, and the mean age of patients was 30.6 years (17-53 years). The median time of injury-to-MRI was 46.5 days during the pre-COVID period, which decreased to 44 days in the post-COVID period (P = 0.596). The median time of injury-to-surgery was 287.5 days during the pre-COVID period, which increased to 289 days in the post-COVID period (P = 0.019). The median MRI-to-surgery duration was 200 days during the pre-COVID period, which increased to 225 days in the post-COVID period (P = 0.006). Around 35% of patients had an MRI prior to getting evaluated by a specialist. Conclusion The COVID-19 pandemic had a significant impact on the management of ACL injuries, with delays in elective knee clinics and surgery potentially leading to delays in the diagnosis and management of such injuries. However, our study showed that the delay from ACL injury to subsequent surgery actually reduced post-pandemic due to hospital-based acute knee pathway, which is particularly important in the context of associated meniscal injury that can worsen while patients wait for surgery.

Ligament Healing After Anterior Cruciate Ligament Rupture: An Important New Patient Pathway?

Recent studies have shown satisfactory functional results after spontaneous healing of a ruptured anterior cruciate ligament (ACL). However, current literature on this topic may exclude important parting selection, outcome measures, and long-term results. Rehabilitation protocols applied in those studies, as well as objective assessments appear far from the usual gold standard after ACL reconstruction. Ideally, outcomes measures should be based on the same testing procedures that are recommended to clear an athlete to return to sport following ACL reconstruction. There is still a lot to understand in how an injured ACL may heal, and therefore ACL injury management should be individualized to each patient and carefully discussed.

Multiphasic bone-ligament-bone integrated scaffold enhances ligamentization and graft-bone integration after anterior cruciate ligament reconstruction

The escalating prevalence of anterior cruciate ligament (ACL) injuries in sports necessitates innovative strategies for ACL reconstruction. In this study, we propose a multiphasic bone-ligament-bone (BLB) integrated scaffold as a potential solution. The BLB scaffold comprised two polylactic acid (PLA)/deferoxamine (DFO)@mesoporous hydroxyapatite (MHA) thermally induced phase separation (TIPS) scaffolds bridged by silk fibroin (SF)/connective tissue growth factor (CTGF)@Poly(l-lactide-co-ε-caprolactone) (PLCL) nanofiber yarn braided scaffold. This combination mimics the native architecture of the ACL tissue. The mechanical properties of the BLB scaffolds were determined to be compatible with the human ACL. In vitro experiments demonstrated that CTGF induced the expression of ligament-related genes, while TIPS scaffolds loaded with MHA and DFO enhanced the osteogenic-related gene expression of bone marrow stem cells (BMSCs) and promoted the migration and tubular formation of human umbilical vein endothelial cells (HUVECs). In rabbit models, the BLB scaffold efficiently facilitated ligamentization and graft-bone integration processes by providing bioactive substances. The double delivery of DFO and calcium ions by the BLB scaffold synergistically promoted bone regeneration, while CTGF improved collagen formation and ligament healing. Collectively, the findings indicate that the BLB scaffold exhibits substantial promise for ACL reconstruction. Additional investigation and advancement of this scaffold may yield enhanced results in the management of ACL injuries.

Early Surgical Reconstruction Versus Rehabilitation for Patients With Anterior Cruciate Ligament Rupture: A Systematic Review and Meta-Analysis.

Anterior cruciate ligament (ACL) rupture is a common and debilitating knee injury that can significantly impair knee function and stability. The optimal management of ACL injuries remains a topic of ongoing debate, with two primary treatment approaches being surgical reconstruction and adequate rehabilitation. The aim of this study is to compare the knee function and stability outcomes between these two treatment modalities, shedding light on their respective effectiveness. We utilized Scopus, PubMed, Cochrane Database, MEDLINE, and Web of Science from inception until April 20, 2022. We utilized the Cochrane risk of bias tool for quality assessment. The following outcomes were assessed: Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) Subjective Knee score, Lysholm score, the occurrence of the knee giving way, Tegner score, KT1000, Lachman test, pivot shift test, SF-36 score to assess the quality of life, and incidence of reinjury and reoperation. We included a total of six trials with a population sample size of 691 patients, which were divided into surgical versus non-surgical groups, accounting for 348 and 343 patients, respectively. The pooled estimate demonstrated that the surgical reconstruction was associated with a significant increase in the IKDC score (MD = 7.49 [2.04, 12.94], (P = 0.007)), and KOOS score was significant in the reconstruction cohort (MD = 5.87 [1.64, 10.09], (P = 0.007)). The incidences of reoperation (RR = 0.43 [0.20, 0.91], (P = 0.03)), reinjury (RR = 0.49 [0.27, 0.88], (P = 0.02)), and occurrence of the knee giving way (RR = 0.19 [0.08, 0.49], (P = 0.005)) were significantly decreased in the surgical cohort. There is no significant difference between both cohorts regarding the Lysholm score (1.27 [-1.39, 3.93], (P = 0.35)). The findings of this comprehensive analysis indicate that early reconstruction does not demonstrate clear superiority over rehabilitation alone in terms of knee function, Lysholm score, and Tegner score among patients with ACL rupture. However, early reconstruction does exhibit a substantial reduction in the incidence of reinjury, reoperation, and knee giving way, suggesting potential benefits in terms of stability outcomes. These results underscore the importance of considering individual patient characteristics and preferences in treatment decision-making.

Functional outcome of arthroscopic anterior cruciate ligament reconstruction with hamstring graft

Introduction Incidence of anterior cruciate ligament (ACL) injuries is increasing owing to increased participation in sports. We are presenting our case series in which we have done ACL reconstruction (ACLR) with autologous hamstring graft. Basic idea for this project was to increase the awareness regarding timely management of ACL injury and good to excellent outcome of this minimal invasive technique. Materials and Methods In this retrospective study, we included 10 patients who underwent arthroscopic transportal single bundle ACLR using hamstring autograft, between January 2019 to December 2021 in Isra university hospital Hyderabad. Patients were followed routinely and outcome was recorded with the help of Lysholm knee scoring questionnaire at 6 months and 12 months post procedure. Results Mean age of the patients was 28.2 years (22 to 35 years) (Table-1). Average duration between injury to surgical intervention was 12.3 months (6 to 26 months). Final outcome was excellent in 3 patients (60%), good in 6 patients (30%) and fair in one patient (10%). Conclusion Injury to ACL is a critical event for any individual. Its timely management is important not only to return the patient back to pre-injury activity level but also to prevent delayed consequences of ACL tear. Our study and the literature review shows satisfactory results of arthroscopic ACLR. Finally, one should follow the basic principles of arthroscopic surgical technique of ACLR along with postoperative supervised physiotherapy rehabilitation protocol to get the desired results.

Clinical Outcomes After ACL Reconstruction in Soccer (Football, Futbol) Players: A Systematic Review and Meta-Analysis.

The risk factors for anterior cruciate ligament (ACL) tear for athletes participating in pivoting sports includes young age and female sex. A previous meta-analysis has reported a reinjury rate of 15% after ACL reconstruction (ACLR) for athletes across all sports. To the best of the authors' knowledge, this is the first systematic review and meta-analysis of available literature reporting outcomes after ACLR in soccer players. To review and aggregate soccer-specific outcomes data after ACLR found in current literature to help guide a more tailored discussion regarding expectations and prognosis for soccer players seeking operative management of ACL injuries. A comprehensive search of publications was performed using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and SPORTDiscus databases. Inclusion criteria consisted of original studies, level of evidence 1 to 4, studies reporting clinical and patient-reported outcomes (PROs) after primary ACLR in soccer players at all follow-up length. The primary outcomes of interest were graft failure/reoperation rates, ACL injury in contralateral knee, return to soccer time, and PROs. Level 4. Search of literature yielded 32 studies for inclusion that involved 3112 soccer players after ACLR. The overall graft failure/reoperation rate ranged between 3.0% and 24.8% (mean follow-up range, 2.3-10 years) and the combined ACL graft failure and contralateral ACL injury rate after initial ACLR was 1.0% to 16.7% (mean follow-up range, 3-10 years); a subgroup analysis for female and male players revealed a secondary ACL injury incidence rate of 27%, 95% CI (22%, 32%) and 10%, 95% CI (6%, 15%), respectively. Soccer players were able to return to play between 6.1 and 11.1 months and the majority of PROs showed favorable scores at medium-term follow-up. Soccer players experience high ACL injury rates after primary ACLR and demonstrated similar reinjury rates as found in previous literature of athletes who participate in high-demand pivoting sports.

Anterior Cruciate Ligament (ACL) Injury in Sports: Focusing Elite Athletes Knowledge, Attitude, and Reporting Behavior

The current study was conducted to determine the relationship among knowledge, attitude and reporting behavior of elite athletes, those who were injured of an ACL injury in their sporting career. A sample of n=332 (male=270 (81.30%); female=62 (18.70%)) was selected and participated in the cross-sectional survey. A self-made structured questionnaire was developed and used for the collection of the required information. The collected data was properly tabulated and analyzed with the help of appropriate statistical tests. The analyzed data revealed a moderate correlation of knowledge and attitude with reporting behaviours of elite athletes. Pertaining to attitude towards ACL injury, athletes reported statistically significantly more unsafe attitudes regarding the management of ACL injury during a practice session and competition. The analyzed data revealed that athletes prefer to use play with an ACL in jury a behavior embedded in competitive sports culture. These findings suggest an intentional education program that could the attitude of athletes towards ACL injury.

Health disparities in the management of ACL injuries: How socioeconomic status, insurance, and race influence care.

Health care disparities and racial health inequities significantly influence health care delivery and patient outcomes, including for people with injuries of the anterior cruciate ligament (ACL). This narrative review explores factors that may influence the management of ACL injuries. Studies that have discussed potential social barriers to treatment such as socioeconomic status (SES), insurance status, educational level, and cost of treatment were identified by searching databases such as EBSCO Host, PubMed, and Galileo for the index years from 2008 to 2020. The influence of health care inequities on ACL injury management was explored. Twelve studies met inclusion criteria and described a total of 219,708 participants. Barriers to surgical management of ACL injury were higher cost of surgery, greater time to evaluation and treatment, lower SES, lack of private insurance, and being identified as a racial minority. In addition, surgical environment, whether within a private or community-based health care system, and access to care affected post-surgical complication rates. Finally, risk of revision, lack of physical therapy access, and odds of additional injuries to include chondral and meniscal derangement were higher in racial minority, lower SES, and government insurance populations. These findings suggest health disparity and inequity exist in the care of ACL injury for patients with lower SES and without commercial insurance, and in minority populations. These patients appear to have a significantly reduced ability to access timely care, which can impact healing and ability to return to preferred activities of daily life or sport.

Management status of anterior cruciate ligament injury in children and adolescents

To summarize the current management of anterior cruciate ligament (ACL) injury in children and adolescents, in order to provide reference for the management of ACL injury in children and adolescents. The relevant literature at home and abroad in recent years was extensively accessed to summarize the management status of ACL injury in children and adolescent. The number of ACL injury in children and adolescents is increasing every year. The diagnosis of ACL mainly depends on symptoms and signs. Rehabilitation, physeal-sparing techniques, partial transphyseal techniques, all-epiphyseal techniques, and transphyseal techniques are used to treat ACL injury in children and adolescents. Dynamic monitoring of knee joint in children and adolescents should be strengthened. The best treatment for ACL injury in children and adolescents is selected according to the patients' actual age, bone age, Tanner stage, and physiological conditions such as menstruation, body growth speed, and other characteristics.

Ultrasound Imaging of the Anterior Cruciate Ligament: A Pictorial Essay and Narrative Review.

Ultrasound has been extensively applied to the diagnosis of and guided interventions for knee disorders. However, although it is commonly affected during sports injuries, the anterior cruciate ligament (ACL) is not usually incorporated in the majority of ultrasound scanning protocols. In the past, because of its oblique trajectory and deeper location, the ACL was considered to be a challenging structure for ultrasound imaging. Owing to advances in ultrasound technology and knowledge of knee sono-anatomy, an increasing number of studies are investigating the clinical value of ultrasound in the diagnosis and management of ACL injuries. In this regard, the present review aims to elaborate on the sono-anatomy of the ACL, to summarize the evidence for ultrasound imaging for ACL lesions and to investigate whether it is useful in the pre-operative preparation and post-operative follow-up of ACL reconstruction.

Single-Tunnel Double-Bundle-Like Effect With Footprint Enhancing Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) consists of an anteromedial bundle and a posterolateral bundle giving anteroposterior and rotational stability. It’s one of the most commonly injured ligaments and also one of the most commonly performed arthroscopic procedures. Management of ACL injuries is one of the most frequently studied subjects in the literature. Surgical management of ACL injuries varies from extraarticular tenodesis to arthroscopic transtibial reconstruction to double-bundle reconstruction to anatomic single-bundle reconstruction. Although double-bundle ACL reconstruction gives more rotational stability than anatomic single-bundle, functional outcome of both are the same, but the complication rates are much higher for double-bundle reconstruction. Hence, anatomic single-bundle ACL reconstruction has gained popularity. The femoral and tibial footprint of the ACL varies in shape and size; it can be oval, elliptical, rectangular, C-shape, and more. But all available ACL reconstruction techniques prepare a circular tunnel; hence, the footprint coverage of the native ACL is maximum after double-bundle reconstruction and less after anatomic single-bundle reconstruction. So, to have the benefit of double-bundle reconstruction with a single tunnel, we propose our technique of a single-tunnel double-bundle-like effect, with the footprint enhancing ACL reconstruction using our newly designed tunnel dilators.

Controversies in the management of anterior cruciate ligament injuries in skeletally immature patients: a literature review of current treatment options

Background: Despite an increasing incidence of injury, there continues to be a paucity of literature, when compared with adult cohorts, for anterior cruciate ligament (ACL) disruption in skeletally immature patients. The detrimental long-term effects of chondral or meniscal damage resulting from an ACL deficient and unstable knee, has led most contemporary orthopaedic surgeons to opt for surgical intervention rather than nonoperative management. However, high failure rates in the young and adolescent group after formal ACL reconstruction, along with the potential risks of physeal disturbance, have been highlighted as a cause for concern. The aim of this review was to provide the state of art management of ACL injuries in skeletally immature patients based on the current evidence. Methods: A literature review on the different management options of ACL injuries in skeletally immature patients was conducted. The authors searched PubMed entries from inception until April 2021. The search was performed with the search terms “ACL injuries” AND “skeletally immature”. Results: A comprehensive search related to the management of “ACL injuries” generated 13,157 results. Thus, search was narrowed to include the term “children” to focus our study on 570 papers. To further refine our search, we included the terms “ACL injuries” AND “skeletally immature,” which produced 327 results. Conclusion: This review highlights pros and cons of current treatment options, based on available evidence, including a detailed assessment of factors affecting the success of repairing the ACL. Overall, further Level 1 studies are necessary to improve the available evidence. Level of Evidence: Level I.

ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group

ObjectivesThe primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG).MethodsA survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more.ResultsThe survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6–8 months (44%) and 8–12 months (41%).ConclusionWe presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR.Level of evidenceLevel V, Expert Opinion.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V

Change in Posterior Tibial Slope in Skeletally Immature Patients With Anterior Cruciate Ligament Injury: A Case Series With a Mean 9 Years’ Follow-up

Background: Increased lateral posterior tibial slope (LPTS) is associated with increased rates of anterior cruciate ligament (ACL) injury and failure of ACL reconstruction. It is unknown if ACL deficiency influences the developing proximal tibial physis and slope in skeletally immature patients through anterior tibial subluxation and abnormal force transmission. Purpose: To assess the natural history of LPTS in skeletally immature patients with an ACL-injured knee. Study Design: Case series; Level of evidence, 4. Methods: A total of 38 participants from a previous study on nonoperative management of ACL injury in skeletally immature patients were included. During the initial study, bilateral knee magnetic resonance imaging (MRI) was performed within 1 year of enrollment and again at final follow-up. All patients were younger than 13 years at the time of enrollment, and final follow-up occurred a mean 10 years after the injury. MRI scans were retrospectively reviewed by 2 reviewers to determine bilateral LPTS for each patient and each time point. Linear mixed models were used to assess LPTS differences between knees, change over time, and association with operational status. Subgroup analyses were performed for patients who remained nonoperated throughout the study. Results: A total of 22 patients had ACL reconstruction before final follow-up and 16 remained nonoperated. In the entire study population, the mean LPTS was higher in the injured knee than in the contralateral knee at final follow-up by 2.0° (P < .001; 95% CI, 1.3°–2.6°). The mean LPTS increased significantly in the injured knee by 0.9° (P = .042; 95% CI, 0.03°–1.7°), while the mean LPTS decreased in the contralateral knee by 0.4° (P = .363; 95% CI, –0.8° to 0.4°). A significant difference in LPTS was also observed in the nonoperated subgroup. No significant association was observed between LPTS and operational status. Conclusion: Lateral posterior tibial slope increased more in the ACL-injured knee than in the contralateral uninjured knee in a group of skeletally immature patients. Lateral posterior tibial slope at baseline was not associated with the need for surgical reconstruction over the study period.

Physician Assistant Roles in Prevention and Management of Anterior Cruciate Ligament Injury

With incidence of anterior cruciate ligament (ACL) injuries on the rise and a predicted impending shortage of physicians in medical fields, including orthopaedics, demand could soon outweigh supply for optimal care of these injuries. Physician assistants (PAs) are uniquely suited to care for patients in the screening, prevention, and management of ACL injuries. PAs frequently practice in primary care and in this setting can screen for at-risk patients and promote preventative techniques such as neuromuscular training. Primary care PAs can perform patient education about preventative measures and provide resources on a variety of available prevention programs that exist which aim to decrease the likelihood of ACL injury. Primary care PAs frequently use standardized scales or questionnaires in clinic to screen for health risks in their patients such as the Patient Health Questionnaire-9 (PHQ-9) for depression; the creation of a similarly standardized screening tool which assesses for ACL injury risk factors may be beneficial to aid primary care PAs in performing such screenings moving forward. Recovery from an ACL injury, regardless of operative or conservative management, can be a lengthy and complex process that is defined by months of follow-up appointments, rehabilitation exercises, and psychological management. Psychological impairment is a vital component in ACL injury recovery and has been identified as a preeminent factor in prolonging or inhibiting return to sport. By using available psychological measurement tools such as the ACL-Return to Sport after injury, as well as the patient education and counseling skills emphasized in their training, PAs can incorporate a psychologically based approach in management to promote a patient’s safe and timely return to sport. Maximizing efficiency and effectiveness of ACL rupture recovery can occur with the utilization of PAs. PAs embody the training, skills, and scope of practice to prevent and manage ACL injury; therefore, it becomes imperative to promote PA involvement in this injury. Proposed methods to achieve this objective include enhancing orthopaedic training in PA programs and integrating the work of national orthopaedic and PA organizations. More investigation is needed on this topic because having a comprehensive understanding of the potential roles of PAs in ACL care could have a profound, far-reaching impact on this increasingly prevalent injury.

Does Graft type affect the Cost of Anterior Cruciate Ligament Reconstruction: A Time-Driven Activity-Based Costing Approach Comparing Hamstring and Bone Patella Bone Autograft

Objectives:Annually, an estimated 250,000 anterior cruciate ligament (ACL) reconstructions are performed. Operative management of ACL injuries has increased 22% between 2002 and 2014. With national healthcare expenditures rising at unsustainable rates, an improved understanding of healthcare costs is essential to identifying avenues of inefficiency and implement innovative solutions. This study is purposed to utilize time-driven activity-based costing (TDABC) to estimate the costs for the two-year care episode in the surgical reconstruction of ACL tears. Provided its high incidence, the operative reconstruction of ACL injuries serves as a prime setting for this study.Methods:This study follows 611 patients that underwent an ACL reconstruction for an acute ACL tear between 2009-2016 within a single outpatient orthopaedic surgery center (Figure 1). Patient demographics were collected via the electronic medical record (EMR) (Table 1). The total cost-of-care was determined using time-driven activity-based-costing (TDABC). This formula derives the cost of care as a function of the time spent for each activity and personnel cost contributions for all involved. This process was performed at all phases: surgical intervention, all clinical follow-ups, and physical therapy (PT) sessions.Results:A total of 611 patients were included for this investigation. The patient sample was primarily female (n=355, 58.1%) with an average age of 28.9 + 12.9 [27.9, 30.0], and average BMI of 25.5 + 4.5 [25.2, 25.9]. The majority of the patients identified with an Anesthesiologist Society of America (ASA) score of 1 (n=505, 83.9%). The average operative time was 107.1 + 31.5 minutes [104.6, 109.6]. The average TDABC cost-of-care was derived at $3364.95 + $958.99 [$3288.75, $3441.14]. Surgical costs occupied the greatest proportion of the overall cost-of-care, $1836.11 (53.2%), followed by costs relating to surgical implants, $911.61 (27.1%), physical therapy appointments, $342.00 (10.2%), and clinical follow-up appointments, $318.77 (9.5%) (Figure 1). A total of 459 (75.1%) patients were treated with an autograft, averaging a total cost-of-care of $2882.19, with the 90th percentile costing $3427.23 and 10th percentile costing $2343.08, reporting a 16.0% variability in costing. Of the 152 (24.9%) allografts, the average cost of care was $4884.10, with the 90th percentile costing $5321.50 and 10th percentile costing $4411.25, reporting a 9.0% variability. Hamstring autografts reported a significantly higher cost-of-care when compared to bone-patellar-bone (BTB) autografts (Hamstring: $3120.10 vs BTB: $2718.60; p<0.01).Conclusion:Given the increasing frequency of ACL procedures performed, an improved understanding of its costing components is critical for implementing change and strategizing solutions for increasing healthcare costs. Operative costs drive the total cost of care with implants, graft choice, and surgical resources constituting almost 80% for the two-year cost episode. With the growing focus of healthcare transitioning towards value-based healthcare delivery and cost reduction, identifying areas of costing inefficiency in surgical decision-making and implant-choice provides an avenue to reduce costs.Figure 1.Table 1.Population characteristics for study sample between 2009-2016 (N=611) n (% of N) or Mean SD (95% CI) GenderFemale: 355 (58.1%)Male: 256 (41.9%)Age28.912.9 (27.9, 30.0)BMI25.54.5 (25.2, 25.9)Anxiety105 (17.3%)Depression82 (13.5%)ASA1: 505 (83.9%)2: 92 (15.3%)3: 5 (0.8%)Operative Time (Minutes)107.131.5 (104.6, 109.6)Other Ligament TearLateral Collateral Ligament (LCL): 6 (1.0%)Medial Collateral Ligament (MCL): 30 (4.9%)Posterior Collateral Ligament (PCL): 3 (0.5%)Meniscus TearLateral: 213 (38.9%)Medial: 170 (31.1%)Meniscetomy188 (40.6%)Graft SourceAllograft: 151 (24.7%)Autograft: 460 (75.3%)Graft TypeBone-Patellar Tendon-Bone Graft (BTB): 400 (65.4%)Hamstring: 197 (32.2%)Posterior Tibialis: 9 (1.5%)Anterior Tibialis: 5 (0.8%)SANE @ BaselineSANE @ 1-YearSANE @ 2-Years63.423.3 (61.5, 65.4)88.412.7 (87.0, 89.9)85.622.4 (83.8, 87.5)SANE 1-Year24.122.8 (21.5, 26.7)SANE 2-Years22.929.3 (20.4, 25.4)KOOS @ BaselineKOOS @ 1-YearKOOS @ 2-Years65.315.9 (63.6, 66.9)79.712.7 (77.5, 81.9)83.213.5 (81.8, 84.6)KOOS 1-Year17.416.1 (14.6, 20.1)KOOS 2-Years17.916.8 (16.2, 19.7)Total Cost$3364.95958.99 ($3288.75, $3441.14)1-Year Value Coefficient ()0.550.53 (0.46, 0.64)2-Year Value Coefficient ()0.580.57 (0.52, 0.64)A Summary of the study populations’ characteristics

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.