Anterior Cruciate Ligament Procedures Research Articles

Comparative transcriptomic analysis of articular cartilage of post-traumatic osteoarthritis models.

Animal models of post-traumatic osteoarthritis (PTOA) recapitulate the pathological changes observed in human PTOA. Here, skeletally mature C57Bl6 mice were subjected to either rapid-onset non-surgical mechanical rupture of the anterior cruciate ligament (ACL) or to surgical destabilisation of the medial meniscus (DMM). Transcriptome profiling of micro-dissected cartilage at day7 or day42 following ACL or DMM procedure, respectively, showed that the two models were comparable and highly correlative. Gene ontology (GO) enrichment analysis identified similarly enriched pathways that were overrepresented by anabolic terms. To address the transcriptome changes more completely in the ACL model, we also performed small RNA sequencing, describing the first microRNA profile of this model. miR-199-5p was amongst the most abundant, yet differentially expressed, microRNAs, and its inhibition in primary human chondrocytes led to a transcriptome response that was comparable to that observed in both human 'OA damaged vs intact cartilage' and murine DMM cartilage datasets. We also experimentally verified CELSR1, GIT1, ECE1 and SOS2 as novel miR-199-5p targets. Together, these data support the use of the ACL rupture model as a non-invasive companion to the DMM model.

Dimensions of the anterior cruciate ligament and thickness of the distal femoral growth plate in children: a MRI-based study.

When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height. We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty. We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18years (mean age: 14.9 ± 2.6years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured. Mean ACL length increased linearly up to the age of 12years in females and 14years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13years (38.18mm) in females and at 15 to < 16years (39.38mm) in males. Mean ACL width increased up to the age of 12years in girls and 13years in boys. After the age of 12years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12years in girls and 14years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12years and 12 to < 13years in girls and between the age intervals of 13 to < 14years and 14 to < 15years in boys. ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures. III-retrospective cohort study.

Patient-Reported Outcome Measures Following Surgical Intervention for Pediatric Sports-Related Injuries to the Knee: a Systematic Review.

Increased sports participation and early specialization has contributed to an increase in surgically managed musculoskeletal injuries to the knee in youth athletes. Established patient-reported outcome (PRO) measures have been extensively reported in adult patients to assess outcomes following sports-related knee surgery. However, current PRO measures for pediatric patients undergoing surgery for sports-related injuries have not been well-described. Strong emphasis has been placed on patient-reported outcomes in recent years, and surgeons have identified many different scoring systems that could be used for sports-related knee injuries in children and adolescents. Recent research has shown that substantial variability exists in the reporting of PRO measures assessing outcomes following surgical management of sports-related knee injuries in pediatric patients. With a paucity of studies using PRO measures in surgically managed pediatric knee injuries, only procedures involving the anterior cruciate ligament (ACL) and medial patellofemoral ligament (MPFL) showed preference for particular systems. Pediatric ACL procedures predominantly use the International Knee Documentation Committee (IKDC) scoring system, while MPFL procedures predominantly use the Kujala scoring system. Further studies are necessary to determine preferred and appropriate patient-reported outcome measures for specific sports-related knee procedures in pediatric patients.

Meniscal Preservation is More Likely When Performed with Acute Anterior Cruciate Ligament Repair Rather Than with Anterior Cruciate Ligament Reconstruction.

Rupture of the anterior cruciate ligament (ACL) often occurs in conjunction with meniscal tears. In this study, we investigate the rates and outcomes of meniscal repair surgery performed with ACL reconstruction compared with acute ACL repair surgery. Data was collected for all patients undergoing surgery for ACL ruptures between 2012 and 2018, including ACL reconstruction with hamstring autograft and primary ACL repair augmented with suture tape. Patients undergoing multi-ligament surgery were excluded. Meniscal injury was evaluated intraoperatively and the treatment was determined by type of tear, reducibility, and quality of meniscal tissue. If possible, tears were repaired using all-inside anchors and all others were resected. There were 272 ACL reconstructions and 134 ACL repairs, and mean age was 28 (±9) and 35 (±14) years, respectively (p <0.01). The mean Tegner activity score was 6.6 in both groups. The mean interval from injury to surgery was longer in the reconstruction group (26.2 vs. 1.3 months, p <0.01). Fifty-five percent of reconstructions and 43% of ACL repairs required meniscal surgery at the time of their ACL procedure. In the reconstruction group, 123 (70%) were meniscectomies and 53 (30%) were meniscal repairs, compared to 31 (50%) of each in the ACL repair group. Meniscal repair was more likely to be possible when carried out as part of acute ACL repair surgery, c2(1, n=238)=7.94, p <0.01. The success rate of meniscal repair was 97% in both groups. The rate of meniscal repair is 67% higher when performed early with ACL repair. When ACL reconstruction is performed, meniscal resection was more likely. Rates of post-traumatic osteoarthritis are high after ACL reconstruction when performed with meniscal resection. Furthermore, the success rate of meniscal repair in conjunction with ACL surgery is high (97%). Therefore, meniscal repair should be encouraged whenever possible to improve long-term outcomes.

RISK FACTORS FOR FAILURE FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN A PEDIATRIC POPULATION: A NOVEL PREDICTION ALGORITHM

Background:Pediatric anterior cruciate ligament (ACL) reconstruction is becoming increasingly common, however, there is limited literature on the risk factors for failure in this demographic.Hypothesis/Purpose:In the present study we sought to: 1. To determine the rate of pediatric ACL reconstruction (ACLR) failure requiring revision surgery in a nationally representative sample. 2. To determine the associated patient/injury-specific risk factors for ACLR failure. 3. To examine the differences in the rate and risks of failure between pediatric and adult patients.Methods:Patient records were drawn from Humana individual health plans and Medicare medical records. Adult and pediatric patients who underwent primary ACLR and subsequent reoperation for either ACL revision surgery or a revision meniscal procedure between 2011-2016 were identified. Multivariate regression was used to determine the significant risk factors for ACL revision and overall reoperation rates in pediatric and adult patients. A risk algorithm was developed to predict the risk of ACL revision following pediatric ACL reconstruction.Results:Pediatric patients were significantly more likely to require ACL revision within one year (OR=1.97, 95%CI 1.57-2.45, p<0.0001) and five years (OR=3.22, 95%CI 2.77-3.72, p<0.0001) following their index ACLR compared to adults. Survivorship of the index ACL procedure was significantly decreased in pediatric patients (log-rank test p<0.0001) (Figure 1). Pediatric patients were also at higher risk of sustaining a contralateral ACL tear compared to adults (5.9% vs. 1.4%, respectively, p<0.0001). Meniscus injury was a risk factor for overall re-operation (OR=2.18, 95%CI 1.67-2.89 p<0.0001) as well as ACL revision (OR=2.28, 95%CI=1.66-3.21, p<0.0001) in the pediatric cohort. This increased risk was sustained despite the type of meniscal tear intervention, with patients undergoing concurrent meniscal repair (OR=1.84, 95%CI 1.43-2.38, p<0.0001) or meniscectomy (OR=2.20, 95%CI 1.72-2.82, p<0.0001) having a higher likelihood of requiring a revision ACLR. Concomitant MCL injury but not LCL injury was a risk factor for ACL revision in this cohort (OR=1.70, 95%CI 1.31-2.19, p<0.0001). Male sex and (OR=0.78, 95%CI 0.63-0.96, p=0.0204) and being >14 years old (OR=0.62, 95%CI 0.45-0.86, p=0.0035) was associated with a decreased risk of overall reoperation. The risk algorithm demonstrated the highest probability for ACLR failure in females, less than 15 years of age, with concomitant meniscus and MCL injury, demonstrating a 36% risk of failure (Table 1).Conclusion:Compared to adults, pediatric patients have an increased likelihood of ACL revision surgery, contralateral ACL tears, and meniscal reoperation within 5 years of an index ACLR.Figure 1.

Timing of Anterior Cruciate Ligament Reconstruction and Relationship With Meniscal Tears: A Systematic Review and Meta-analysis

Background: Anterior cruciate ligament (ACL) ruptures are common, but the ideal timing for ACL reconstruction after injury is unclear with regard to meniscal insult. Purpose: To determine whether there is a relationship between timing from ACL rupture to ACL reconstruction and development of meniscal tears within this period. Study Design: Systematic review and meta-analysis. Methods: A systematic literature search was undertaken independently by 2 reviewers using the Cochrane method for systematic reviews in 5 online databases. The reviewers performed independent data extraction and assessment of risk of bias and study quality. The search included any comparative study, including randomized controlled trials (RCTs), prospective and retrospective cohort studies, and case-control studies of an adult population, that assessed the relationship between timing of ACL reconstruction surgery and rates of meniscal tears. Results: After screening, 12 studies (No. of participants = 3042) out of 3390 records were included for analysis: 3 RCTs (n = 272), 2 prospective cohort studies (n = 307), and 7 retrospective cohort studies (n = 2463). In analysis of these studies, rates of reported meniscal tears were compared for ACL procedures performed at 3 and 6 months after injury. Meta-analysis of 5 studies (n = 2012) showed that ACL reconstruction performed >3 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 3 months of injury (estimated OR, 2.235; 95% CI, 1.183-4.223; P = .013) but not with a higher rate of lateral meniscal tears. Similarly, meta-analysis of 4 studies (n = 990) showed that ACL reconstruction performed >6 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 6 months of injury (estimated OR, 2.487; 95% CI, 1.241-4.984; P = .01) but not with a higher rate of lateral meniscal tears. Conclusion: Our results suggest that delay of ACL reconstruction surgery >3 months after injury is associated with a higher rate of medial meniscal tears within this prereconstruction time frame. Further high-quality prospective studies may help determine whether this is a causal effect. However, based on current evidence, in those patients for whom ACL reconstruction is indicated, ACL reconstruction within 3 months of injury may be recommended. Registration: CRD42016032846 (PROSPERO)

O’Donoghue Sports Injury Award: Bridge-Enhanced ACL Repair is Non-Inferior to Autograft ACL Reconstruction at 2-Years: Results of a Prospective Randomized Clinical Trial

Objectives:Preclinical studies and an early clinical cohort study have suggested that for complete midsubstance ACL injuries, the technique of suture repair of the anterior cruciate ligament (ACL) augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair) may be a viable alternative to ACL reconstruction. We hypothesized that patients treated with bridge-enhanced ACL repair would have non-inferior patient reported outcomes and anteroposterior (AP) laxity, and superior hamstring strength at 2 years after surgery when compared with subjects who had ACL reconstruction with autograft.Study Design:Prospective Randomized Control Trial (NCT02664545).Methods:One hundred patients, ages 13 to 35, with complete mid-substance ACL injuries, were enrolled and underwent surgery within 45 days of injury. Sixty-five patients were randomized to receive a bridge-enhanced ACL repair (BEAR group) and 35 were randomized to receive autograft ACL reconstruction (ACLR group). Outcomes, including the International Knee Documentation Committee (IKDC) Subjective score, instrumented AP laxity and muscle strength were assessed at 2 years post-operatively. Both patients and assessors were blinded as to surgical assignment until after the 2-year assessment.Results:Ninety-six percent of the subjects returned for follow-up at 2 years. The median age of the subjects in both groups at enrollment was 17 years and the median pre-operative Marx score in both groups was 16 points. Non-inferiority criteria were met for both the IKDC subjective score and AP laxity. The BEAR group had significantly better recovery of hamstring strength than the ACLR group (p<0.001). The number of subjects who were reinjured and required a second ACL surgery was not statistically different between the two groups. Subjects who converted from BEAR to ACLR in the study period had outcomes at the 2-year point that were similar to those for subjects who had only a single ipsiateral ACL procedure (BEAR or ACLR).Conclusion:Bridge-enhanced ACL repair using a specific protein-based implant led to non-inferior outcomes to that of ACL reconstruction for patient reported and instrumented knee laxity measures at 2 years after surgery in a young and active cohort of patients with acute mid-substance ACL tears.

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

ACL reconstruction with lateral extra-articular tenodesis using a continuous graft: 10-year outcomes of 50 cases

BackgroundPersistence of pivot shift is the main problem after isolated intra-articular anterior cruciate ligament (ACL) reconstruction. Adding lateral extra-articular tenodesis (LET) to the ACL procedure increases the knee's stability by controlling rotational laxity. The aim of this study was to evaluate the long-term clinical and radiological outcomes of combined ACL reconstruction with LET using a continuous hamstring graft as a first-line procedure. Material and methodsFifty patients were reviewed at 10 years postoperative. Subjective outcome scores –IKDC, Lysholm, KOOS and Tegner– were collected. A clinical and radiological assessment was done. The knees’ anteroposterior laxity was measured with a rollimeter. ResultsThe mean IKDC subjective score was 85.5, the mean Lysholm score was 90.2 and 80% of patients had a score graded as good or very good. No pivot shift was present in 94% of patients and there was a firm endpoint in the Lachman test in 86% of patients. There was a flexion deficit>5° in 5 patients and an extension deficit of 10° in one patient. Most patients (56%) had resumed their physical activities at the same level as before the surgery. Signs of osteoarthritis were found in 26% of patients (16% were Ahlback stage 1 and 10% were stage 2). There was only one graft failure. These good outcomes are consistent with other published studies on combined ACL-LET. There was neither significant stiffness, nor a higher rate of secondary osteoarthritis relative to ACL reconstruction only, particularly in the lateral tibiofemoral compartment. ConclusionAdding primary LET to ACL reconstruction improves control of rotational laxity over time without increasing the complication rate. Level of evidenceIV, retrospective study without control group.

Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial

Background: Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR). Hypothesis: We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, –11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone–patellar tendon–bone]). Outcomes—including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength—were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit. Results: In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, –1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, –0.15 mm [95% CI, –1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure (P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure. Conclusion: BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified. Registration: NCT02664545 (ClinicalTrials.gov identifier)

Terminal Sterilization of Anterior Cruciate Ligament (ACL) Allografts: A Systematic Review of Outcomes

Anterior cruciate ligament (ACL) injuries are common and reconstruction can be completed with either autograft or allograft tissue. However, there is concern about an increased failure rate with allograft tissue. The purpose of this study was to systematically review the available evidence to determine the effect of irradiation and level of dose on the failure rates of allograft in ACL reconstruction. A literature search was performed using PubMed, Scopus, and Web of Science from January 2000 to September 2013. Inclusion criteria consisted of the following: (1) primary, unilateral, single-bundle allograft ACL procedure, (2) studies with data documenting graft type and terminal sterilization technique, (3) subjective assessments of outcome, and (4) objective assessments of outcome. Studies without reported subjective and objective outcomes and those pertaining to revision ACL reconstruction were excluded. Failures were defined and compared between irradiated and non-irradiated grafts, as well as between grafts irradiated with 1.2 - 1.8 Mrad and those with 2.0 - 2.5 Mrad. Of the 242 articles identified via initial search, 17 studies met the final inclusion criteria. A total of 1,090 patients were evaluated in this study, all having undergone unilateral primary ACL reconstruction with allograft tissue with 155 failures. The failure rate between non-irradiated (98/687, 14.7%) and irradiated (57/408, 14.0%) was not statistically significant (p = 0.86). Grafts in the high-dose irradiation group (27/135, 20.0%) had a statistically significant higher (p < 0.001) rate of failure than those in the low-dose irradiation group (30/273, 10.6%). The irradiation of an allograft increases the risk of failure after an ACL reconstruction but the use of lower doses of radiation decreases that risk.

Trends in Concomitant Meniscal Surgery Among Pediatric Patients Undergoing ACL Reconstruction: An Analysis of ABOS Part II Candidates From 2000 to 2016.

Background:Rates of anterior cruciate ligament (ACL) reconstruction among pediatric and adolescent patients are increasing. Limited knowledge exists about population-level rates of concomitant meniscal surgery in this age group.Purpose/Hypothesis:This study sought to examine trends in concomitant meniscal procedures and describe short-term complications in pediatric and adolescent patients undergoing ACL reconstruction. We hypothesized that overall meniscal surgery rates are increasing and that the likelihood of performing meniscal repair or meniscectomy is associated with patient- and surgeon-specific factors.Study Design:Cross-sectional study.Methods:We queried ACL procedures in patients younger than 19 years reported by American Board of Orthopaedic Surgery (ABOS) part II examination candidates from 2000 to 2016. Regression models examined associations between patient and surgeon characteristics, year of surgery, follow-up time, meniscal procedure type, and number and type of complications.Results:A total of 9766 cases were identified. Females represented 46% (n = 4468) of included cases. Mean patient age was 16.1 years (SD, 1.62 years; range, 0-18 years). The rate of concomitant ACL-meniscal procedures increased from the years 2000 to 2016 (49%-60%; P = .005). Surgeons with sports medicine (+7.0%) or pediatric orthopaedic fellowship (+6.6%) training had a higher likelihood of reporting a concomitant ACL-meniscal procedure (P = .003 and .006, respectively). Sports medicine–trained surgeons were more likely to perform meniscal repair compared with meniscectomy (+3.0%; P = .016). Younger patient age was associated with increased likelihood of undergoing meniscal repair compared with meniscectomy. Overall reported complication rate was 12.8%. Notable reported complications included infection (1.61%), arthrofibrosis (1.14%), and deep venous thrombosis or pulmonary embolism (0.11%). Sports medicine and pediatric orthopaedic fellowship training was associated with higher rates of reporting postoperative stiffness and/or arthrofibrosis.Conclusion:Among ABOS part II candidates, concomitant ACL-meniscal surgery has become more common than isolated ACL procedures. Procedures involving sports medicine fellowship–trained surgeons and younger patients were associated with increased rates of meniscal repair compared with meniscectomy. Pediatric orthopaedic and sports medicine training was associated with a greater likelihood of being involved in a concomitant ACL-meniscal procedure of any kind, and surgeons with such training also reported a higher incidence of postoperative stiffness and/or arthrofibrosis in patients.

High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis

Background: Lateral extra-articular tenodesis (LET) is being increasingly added to primary and revision anterior cruciate ligament (ACL) reconstruction to address residual anterolateral rotatory instability. However, currently there is a lack of knowledge on how close the femoral tunnels are when combining these procedures. Purpose/Hypotheses: To assess the risk of tunnel convergence in combined ACL and LET procedures using 2 different surgical techniques (Lemaire and MacIntosh). It was hypothesized that the risk of tunnel convergence would be greater when using the more distally located Lemaire position. The authors further hypothesized that tunnel proximity would be influenced by knee size. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric knees were used for this study. In each specimen, an anatomic ACL femoral tunnel and 2 LET tunnels were drilled using the Lemaire and MacIntosh positions, respectively. After knee dissection, minimal distances between each ACL and LET tunnel were directly measured on the lateral femoral cortex. Furthermore, computed tomography scans were obtained to measure intertunnel convergence and lateral femoral condyle (LFC) width. On the basis of the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence. Results: Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while intertunnel (intramedullary) conflicts were not observed. Collisions emerged in both small (n = 4) and large (n = 3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh positions was 3.1 ± 4.6 mm and 9.8 ± 5.4 mm, respectively. Conclusion: Tunnel convergence was more frequently observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction was not associated with tunnel collision. Clinical Relevance: These findings help to raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures. Surgeons may contemplate adjustments on the ACL femoral tunnel drilling technique or fixation device when applying an additional Lemaire procedure. However, in the absence of clinical outcome studies comparing different LET techniques, it remains unclear which technique is superior in a clinical setting.

POSTOPERATIVE AND POST-DISCHARGE PAIN OUTCOMES AND OPIOID REQUIREMENTS IN PEDIATRIC ARTHROSCOPIC ACL RECONSTRUCTION AND/OR MENISCUS PROCEDURES MANAGED WITH PERIPHERAL NERVE BLOCKADE

Background: Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia strategy for managing pain after knee arthroscopy and supports goals of improved opioid stewardship given the national crisis. However, the impact of PNB on short-term recovery in pediatric patients undergoing knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and meniscus surgery (repair or resection) has not been well characterized. This prospective study presents patient outcomes following discharge home in pediatric patients undergoing arthroscopic ACL and/or meniscus procedures managed with PNB. Methods: This is a single-center, single-surgeon prospective observational study conducted over a three year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to affected limb, analgesic use (NSAID’s and opioids), readmission rate, and activities of daily living via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using SPSS v24. Results: We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (n=18) or meniscus surgery only (n=29). The mean ages for each group were 16.0 ± 1.4 years and 15.7 ± 1.4 years, with 13/18 and 18/29 females, respectively. At 72 hours post-surgery, there were no readmissions or complications related to pain. PACU pain scores and follow up data from the post discharge survey is presented in Table 1. Median and interquartile ranges (IQR) of maximum PACU pain ratings were 0 (0.0-3.5) for the ACL group and 0 (0.0-2.5) for the meniscus-only group. Median (IQR) for pain score at 72 hours post-surgery was 2.5 (1.0-5.0) and 5 (3.0-6.0) for the ACL and meniscus-only groups only. For the meniscus-only group, maximum PACU pain scores correlated with 72-hour pain score (r=0.431, p=0.025) but not for the ACL group (r=0.418, 0.084). PACU pain scores and follow up data from the post discharge survey is presented in Table 2. A majority of patients continued to require opioids (45/47) and NSAIDs (46/47) at 72 hours post-surgery, but the number of daily opioid doses taken decreased each day postoperatively. Over 93% of patients could ambulate and shower at 72 hours post-surgery and sensation to affected limbs returned most commonly on postoperative day 1 in both groups. Conclusions / Significance: Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort and all patients showing clinically minor levels of pain post-discharge. Future prospective investigation is needed to characterize long-term pain outcomes and opioid use in this surgical population in direct comparison to patients not receiving PNB. [Table: see text]

Short-term Outcomes in Pediatric Patients Managed with Peripheral Nerve Blockade for Arthroscopic Anterior Cruciate Ligament Reconstruction and/or Meniscus Surgeries.

IntroductionPeripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia approach in managing pain after knee arthroscopy. However, the impact of PNB and short-term recovery in pediatric patients, particularly adolescents, who underwent knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and/or meniscus surgery (repair or resection) has not been well characterized. This prospective study presents observational data on short-term patient outcomes and side effects for 72 hours following discharging home of pediatric patients who underwent arthroscopic ACL and/or meniscus procedures with PNB.MethodsThis is a single-center, single-surgeon prospective observational study conducted over a three-year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to the affected limb, analgesic use [nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids], readmission rate, and activities of daily living (ADL) via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using the SPSS version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY, USA).ResultsWe collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (18/47, 38.3%) or meniscus surgery only (29/47, 61.7%). At 72 hours postsurgery, there were no readmissions or complications related to pain. Median-reported pain scores were 2.5 and 5.0 for the ACL and meniscus groups, respectively. A majority of patients continued to require opioids (45/47, 95.7%) and NSAIDs (46/47, 97.9%) at 72 hours postsurgery, but the number of daily opioid doses taken decreased with each day postoperatively. Over 93% of the patients could ambulate and shower at 72 hours postsurgery.ConclusionsRegional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort. Future prospective investigation is needed to characterize long-term pain outcomes in this surgical population.

Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction

Background: Despite numerous technical descriptions of anterolateral procedures, knowledge is limited regarding the effect of knee flexion angle during graft fixation. Purpose: To determine the effect of knee flexion angle during graft fixation on tibiofemoral joint kinematics for a modified Lemaire tenodesis or an anterolateral ligament (ALL) complex reconstruction combined with anterior cruciate ligament (ACL) reconstruction. Study Design: Controlled laboratory study. Methods: Twelve cadaveric knees were mounted in a test rig with kinematics recorded from 0° to 90° flexion. Loads applied to the tibia were 90-N anterior translation, 5-N·m internal tibial rotation, and combined 90-N anterior force and 5-N·m internal rotation. Intact, ACL-deficient, and combined ACL plus anterolateral-deficient states were tested, and then ACL reconstruction was performed and testing was repeated. Thereafter, modified Lemaire tenodeses and ALL procedures with graft fixation at 0°, 30°, and 60° of knee flexion and 20-N graft tension were performed combined with the ACL reconstruction, and repeat testing was performed throughout. Repeated-measures analysis of variance and Bonferroni-adjusted t tests were used for statistical analysis. Results: In combined ACL and anterolateral deficiency, isolated ACL reconstruction left residual laxity for both anterior translation and internal rotation. Anterior translation was restored for all combinations of ACL and anterolateral procedures. The combined ACL reconstruction and ALL procedure restored intact knee kinematics when the graft was fixed in full extension, but when the graft was fixed in 30° and 60°, the combined procedure left residual laxity in internal rotation (P = .043). The combined ACL reconstruction and modified Lemaire procedure restored internal rotation regardless of knee flexion angle at graft fixation. When the combined ACL reconstruction and lateral procedure states were compared with the ACL-only reconstructed state, a significant reduction in internal rotation laxity was seen with the modified Lemaire tenodesis but not with the ALL procedure. Conclusion: In a knee with combined ACL and anterolateral ligament injuries, the modified Lemaire tenodesis combined with ACL reconstruction restored normal laxities at all angles of flexion for graft fixation (0°, 30°, or 60°), with 20 N of tension. The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension. Clinical Relevance: In combined anterolateral procedure plus intra-articular ACL reconstruction, the knee flexion angle is important when fixing the graft. A modified Lemaire procedure restored intact knee laxities when fixation was performed at 0°, 30°, or 60° of flexion. The ALL procedure restored normal laxities only when fixation occurred in full extension.

A New Reconstructive Technique of the Anterolateral Ligament with Iliotibial Band-Strip.

Background:Anterior cruciate ligament (ACL) reconstruction is a well-established surgical procedure for the correction of ACL ruptures. However, the incidence of instability following ACL reconstruction is substantial. Recent studies have led to greater insight into the anatomy and the radiographic characteristics of the native anterolateral ligament (ALL), along with its possible role in residual instability after ACL reconstruction.Method:The current paper describes a lateral extra-articular tenodesis to reconstruct the ALL during ACL procedures, using a short iliotibial band strip. The distal insertion of this strip is left intact on the anterolateral side of the proximal tibia, and the proximal part is fixed at the anatomic femoral insertion of the ALL.Results:Our technique avoids the sacrifice of one of the hamstring tendons for the ALL reconstruction. Additionally, there is no interference with the anatomical location or function of the LCL.Conclusion:Our technique offers a minimally invasive and nearly complete anatomical reconstruction of the ALL with minimal additional operative time.

Feasibility of establishing an Australian ACL registry: a pilot study by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

Rupture of the anterior cruciate ligament (ACL) is a common and debilitating injury that impacts significantly on knee function and risks the development of degenerative arthritis. The outcome of ACL surgery is not monitored in Australia. The optimal treatment is unknown. Consequently, the identification of best practice in treating ACL is crucial to the development of improved outcomes. The Australian Knee Society (AKS) asked the Australian Orthopaedic Association (AOA) to consider establishing a national ACL registry. As a first step, a pilot study was undertaken by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to test the hypothesis that collecting the required information in the Australian setting was possible. Surgeons completed an operative form which provided comprehensive information on the surgery undertaken. Patients provided pre- and post-operative questionnaires including the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Marx Activity Scale (MA Scale). The number of ACL procedures undertaken at each hospital during the recruitment period was compared against State Government Health Department separation data. A total of 802 patients were recruited from October 2011 to January 2013. The overall capture rate for surgeon-derived data was 99%, and the capture rate for the pre-operative patient questionnaire was 97.9%. At 6months, patient-reported outcomes were obtained from 55% of patients, and 58.5% of patients at 12months. When checked against State Government Health Department separation data, 31.3% of procedures undertaken at each study hospital were captured in the study. It is possible to collect surgeon-derived and pre-operative patient-reported data, following ACL reconstruction in Australia. The need to gain patient consent was a limiting factor to participation. When patients did consent to participate in the study, we were able to capture nearly 100% of surgical procedures. Patient consent would not be an issue in for a national registry where inclusion is automatic unless the patient wishes to opt out. The collection of post-operative patient-reported outcome measures (PROMs) is more problematic, due to an insufficient proportion of individuals providing patient-reported outcomes. Alternative outcome measures are required for an ACL registry in Australia to be successfully implemented. Diagnostic, Level III.

Anterior cruciate ligament reconstruction tunnel size: causes of tunnel enlargement and implications for single versus two-stage revision reconstruction.

Anterior cruciate ligament (ACL) reconstructions have increased over the past 25years. The increased incidence of ACL reconstructions has translated into a larger number of graft failures and revision ACL procedures. It is important to understand the causes of graft failure when evaluating for a revision ACL reconstruction and to appreciate changes in tunnel anatomy over time prior to planning revision surgery. In this manuscript, tunnel size for ACL reconstruction and implications for single-stage versus two-stage revision ACL reconstruction will be discussed, as well as causes of tunnel enlargement, including mechanical and biological factors.

Hamstring graft bacterial contamination during anterior cruciate ligament reconstruction: clinical and microbiological study.

Autograft preparation for anterior cruciate ligament (ACL) reconstruction has a potential for graft contamination. The purpose of this study was to evaluate the possibility of bacterial contamination of hamstring autograft during preparation and when dropped onto the operating room floor and methods of graft decontamination. Sixty hamstring tendon autograft specimens were used as the test group. Excess tendon not used in the ACL procedure was divided into five segments. One segment, at the completion of preparation, was sent for culture as a control; the remaining four segments were dropped onto the floor adjacent to the surgical field for 15seconds. One segment was cultured without undergoing any further treatment. Cultures were taken from each segment after immersion in 10% povidone-iodine solution, 4% chlorhexidine and bacitracin, respectively, for three minutes. Cultures of a skin swab and floor swab were taken at the same time and place that the ACL was dropped. Cultures of control graft tissue from ten patients (16.7%) were positive for bacteria. No patient developed post-operative infection. Ninety organisms were identified, with Staphylococcus epidermidis being the most common isolate. Grafts rinsed in either bacitracin or 4% chlorhexidine solutions were less likely to be culture positive. A high rate of contamination can be expected during autograft preparation for ACL reconstruction. Soaking the hamstring autograft in either bacitracin or 4% chlorhexidine solution is effective for decontamination, particulary if graft is dropped on the floor.