Cases Of Anterior Cruciate Ligament Reconstruction Research Articles

Patient and Operative Risk Factors for Osteoarthritis After Primary Anterior Cruciate Ligament Reconstruction: A Cohort Study of 41,976 Patients

Background: The reported incidence of posttraumatic knee osteoarthritis (PTOA) after primary anterior cruciate ligament reconstruction (ACLR) varies considerably. Further, there are gaps in identifying which patients are at risk for PTOA after ACLR and whether there are modifiable factors. Purpose: To (1) determine the incidence of PTOA in a primary ACLR cohort and (2) identify patient and perioperative factors associated with the development of PTOA after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Kaiser Permanente ACLR Registry were used to conduct a cohort study. Patients who had undergone primary ACLR without a previous diagnosis of osteoarthritis were identified (2009-2020). The crude incidence of PTOA was calculated using the Aalen-Johansen estimator with a multistate model. The association of patient and operative factors with the development of PTOA after primary ACLR was modeled as a time to event using multistate Cox proportional hazards regression. Models stratified by age (<22 and ≥22 years) were also conducted because of the effect modification of age. Results: The study sample included 41,976 cases of primary ACLR. The incidence of PTOA was 1.7%, 5.1%, and 13.6% at 2, 5, and 10 year follow-ups, respectively. Risk factors for PTOA that were consistently identified in the overall cohort and age-stratified groups included a body mass index ≥30 versus <30 and an allograft or quadriceps tendon autograft versus a hamstring tendon autograft. Patients presenting with knee pain after ACLR were further identified when considering postoperative factors. Other risk factors for PTOA in the overall cohort included age ≥22 versus <22 years, bone–patellar tendon–bone autograft versus hamstring tendon autograft, hypertension, cartilage injury, meniscal injury, revision after primary ACLR with concomitant meniscal/cartilage surgery, multiligament injury, other activity at the time of injury compared with sport, and tibial tunnel drilling technique rather than the anteromedial portal. Conclusion: Knee pain after ACLR may be an early sign of PTOA. Surgeons should consider the adverse associations of a higher body mass index and an allograft or quadriceps tendon autograft with the development of PTOA, as these were factors identified with a higher risk, regardless of a patient’s age at the time of primary ACLR.

Adolescent anterior cruciate ligament reconstruction: a decade of rising surgical cost.

The number of anterior cruciate ligament reconstruction (ACL-R) surgeries for adolescent patients has been increasing, and so are the costs for medical care services and the general cost of living. We proposed a novel economic model assessing the cost associated with adolescent ACL-R over time and how this compared with price measures in the US economy. Economic analysis. ACL-R surgeries performed from 2010 to 2022 in a single Level I trauma center were included. The trend of the total charge, charge of anesthesia, and operating room (OR) charge were normalized to 2010 (base year) and compared with the inflation in hospital services, medical care services, and the US economy measured by the Consumer Price Index (CPI). The actual reimbursements-to-charges percentage from the payers was analyzed. Comparing growth rates rather than dollar values circumvented any problematic direct-dollar comparisons across measures. Analyzing 459 qualified ACL-R cases in patients whose ages ranged from 12 to 18 years, the overall total median charge increased 70%, whereas the General CPI, Medical CPI, and Hospital CPI increased 35%, 41%, and 64%, respectively. The anesthesia and OR charges increased 52% and 92%, respectively. The annual reimbursements-to-charges percentage hovered steadily beneath 50%. All inflation measures rose sharply after 2019. The rising cost of adolescent ACL-R has been outpacing the inflation in the cost of medical services and the general economy in the US. The COVID-19 pandemic and market rigidity in medical services may have impacted these trends. Optimizing OR time usage may mitigate the rising cost.

Physiotherapy Rehabilitation for Accelerating the Recovery of Patient with Anterior Cruciate Ligament Total Reconstruction and Meniscal Repair: A Case Report

Background: The Anterior Cruciate Ligament (ACL) is a ligament that functions to limit the movement of the tibia toward the anterior and excessive rotation, while the meniscus serves as shock absorption, load transmission, and the stabilizer of the knee joint. About 22% to 86% meniscal tear incidences occurring along with ACL injuries is. The study aims to determine the role of physiotherapists in the postoperative rehabilitation process of patients of ACL Reconstruction (ACLR) and meniscal repair in preventing postoperative complications and functional abilities of patients. Case Report: The patient was a 35-year-old adult male who suffered a complete tear in the ACL and meniscus of the left knee. The patient underwent ACLR and meniscal repair with arthroscopic surgery 2 years after injury with Bone-Pattelar tendon-bone autograph. 2 weeks post-surgery the patient visited the physiotherapy polyclinic with medical conditions of difficulty in bending and straightening the knee, still feeling pain and thick in the knee area. Results: The physiotherapist program was conducted three times and it was a home program-based exercise. The physiotherapist program and outcomes used in the first phase focused on exercises to improve ROM (Goniometer), oedema management (Medline), pain reduction (Numerical Rating Scale), activation exercises, and surrounding muscle strength (Sphygmomanometer), and improve functional ability (Tegner Lysholm Knee Scale) as well as the provision of home programs Performed by regular monitoring of exercise intensity using isometric, isotonic, and isokinetic exercises, which were given according to the concept of progressive loading. Conclusion: This case study shows that surgery combined with a comprehensive physiotherapy program plan in ACLR and meniscal repair cases, as well as adding home-based exercise programs with intense monitoring, generate more effective results. Keywords: physiotherapy rehabilitation, anterior cruciate ligament total, meniscal repair Correspondence: Suryo Saputra Perdana. Physiotherapist Profession Education Department, Faculty of Health Sciences, Universitas Muhammadiyah Surakarta, Sukoharjo, Central Java, Indonesia. Email: suryo.saputra@ums.ac.id. Mobile: +6281298563988.

Low-Volume Surgeons Use Allograft in Younger Patients and Show Greater Rates of Revision Following Primary Allograft Anterior Cruciate Ligament Reconstruction Compared With High-Volume Surgeons

To determine whether surgeon volume affects revision rate following primary anterior cruciate ligament reconstruction (ACLR) with allograft and to determine whether surgeon volume impacts allograft tissue type used. All patients aged 14 years or older who underwent primary allograft ACLR at a large hospital system between January 2015 to December 2019 with minimum 2-year follow-up were included. Patients with double-bundle ACLR, multiligament reconstruction, and absent allograft type data were excluded. Surgeon volume was categorized as 35 or more ACLR/year for high-volume surgeons and less than 35 ACLR/year for low-volume surgeons. Revision was defined as subsequent ipsilateral ACLR. Patient characteristics, operative details, allograft type, and revision ACLR rates were retrospectively collected. Revision rate and allograft type were analyzed based on surgeon volume. A total of 457 primary allograft ACLR cases (mean age: 38.8 ± 12.3 years) were included. Low-volume surgeons experienced greater revision rates (10% vs 5%, P= .04) and used allograft in a younger population (37.6 vs 40.0 years old, P= .03) than high-volume surgeons. Subgroup analysis of the total cohort identified a significantly increased failure rate in patients <25 years old compared with ≥25 years old (30% vs 4%, P < .001). Allograft type selection varied significantly between surgeon volume groups, with low-volume surgeons using more bone-patellar tendon-bone (P < .001) and less semitendinosus allograft (P= .01) than high-volume surgeons. No differences in revision rate were observed based on allograft type (P= .71). There was a greater revision rate following primary allograft ACLR among low-volume surgeons compared with high-volume surgeons. Low-volume surgeons also used allograft in a younger population than did high-volume surgeons. Level III, retrospective comparative prognostic trial.

Rates of Septic Arthritis After ACL Reconstruction: A Single-Center Analysis Highlighting Quadriceps Tendon Grafts

Background: Although the infection rates for bone–patellar tendon–bone autograft (BTB), hamstring tendon autograft (HT), and allograft have been reported previously, there are limited data available for a large cohort of individuals undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) using quadriceps tendon autograft (QT). Purpose: The aims of this study are (1) to compare rates of septic arthritis after primary and revision ACLR with QT, BTB, HT, and allograft and (2) to evaluate the association between an infection after ACLR and potential risk factors in a large single-system analysis. Study Design: Cohort study; Level of evidence, 3. Methods: All ACLR cases performed by 10 high-volume sports medicine fellowship–trained ACL surgeons between January 2000 and January 2022 were retrospectively analyzed. Minimum follow-up was 90 days after ACLR, and all multiligament reconstructions were excluded. Demographic information, surgical variables, infection characteristics, and rate of ACL graft retention were collected for all included patients. Independent samples t test, chi-square test, or Fisher exact tests with adjusted Benjamini-Hochberg post hoc procedure were used for group comparisons. Results: In total, 6652 patients were included in this study. The most commonly used graft was allograft (n = 2491; 37.4%), followed by HT (n = 1743; 26.2%), BTB (n = 1478; 22.2%), and QT (n = 940; 14.1%). The overall postoperative rate of septic arthritis was 0.34% (n = 23). Septic arthritis rates based on graft type were 0.74% (n = 13) for HT, 0.24% (n = 6) for allograft, 0.20% (n = 3) for BTB, and 0.10% (n = 1) for QT. While a statistically significant difference with regard to graft type (P = .01) was observed, no significant relationships were found between postoperative septic arthritis and age, sex, revision ACLR, ACLR surgical technique, and accompanying intra-articular procedures for all septic arthritis patients (P > .05). The average time from the onset of the symptoms of infection to surgical irrigation and debridement (I&D) was 2 days (minimum, 0; maximum, 6). ACL grafts were retained during I&D procedures in all patients with postoperative septic arthritis. Conclusion: The postoperative rate of septic arthritis was 0.1% after use of the QT autograft. While graft choice may affect rates of septic arthritis after ACLR, patient characteristics, ACLR technique, revision ACLR, and accompanying intra-articular procedures during ACLR were not associated with postoperative septic arthritis with the numbers available for analysis.

Pattern of Anterior Cruciate Ligament Reconstruction (ACLR) among Athletes in Malaysia between 2015 and 2020

Background. Individual involvement in sports activity is rising and thus increases the risk of knee injury. Anterior Cruciate Ligament (ACL) rupture is the most common knee injury requiring ACL reconstruction (ACLR). However, limited evidence is available to date on ACLR characteristics in Malaysia for comparison with Western countries. This study aims to describe the epidemiological characteristic of ACLR surgery and the trend of pre-operative physiotherapy (pre-habilitation).&#x0D; Materials and methods. ACLR cases recorded in a tertiary hospital database between January 2015 and December 2020 were extracted and reviewed. This retrospective study was approved by the hospital’s Research Ethics Committee (UKMPPI/111/8/JEP-2020-500). All ACLR cases involving sports injuries were included with the exclusion of non-sports related injuries. Yearly ACLR cases were retrieved using an Injury Information form containing variables namely age, gender, type of ACL tear, accompanying meniscus injury, duration from injury to surgery and pre-habilitation details. Descriptive statistics were used to summarize the sample data.&#x0D; Results. A total of 131 ACLR cases were reported between 2015 and2020 (Male, n =122; Female, n = 25). The number of ACLR cases fluctuated during the observed years, with a maximum of 30 cases reported in a year and 98% of the cases were represented by the youth age group (15 – 47 years old). The average age at time of surgery was 27.1 (± 7.79). On an average, 80% of athletes stated no history of previous knee injury. The most common type of ACL injury was a complete tear (88%), followed by partial tear (9%), and re-rupture (3%). A meniscus injury was noted in 61% of cases. The time from injury to surgery was 15 weeks. The study found low percentage of the ACLR patients who received pre-habilitation prior to surgery (&lt;20%).&#x0D; Conclusions. ACLR cases are showing a fluctuating trend every year. Despite the majority of the ACL cases being a complete tear, the participants waited more than four months to undergo ACLR, with only a quarter of them had pre-habilitation prior to surgery. The reasons for these situations require investigation. Future research inclusive of a larger database is also desirable to develop a better insight into ACL injury pattern.

Machine Learning Can Accurately Predict Overnight Stay, Readmission, and 30-Day Complications Following Anterior Cruciate Ligament Reconstruction

This study aimed to develop machine learning (ML) models to predict hospital admission (overnight stay) as well as short-term complications and readmission rates following anterior cruciate ligament reconstruction (ACLR). Furthermore, we sought to compare the ML models with logistic regression models in predicting ACLR outcomes. The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent elective ACLR from 2012 to 2018. Artificial neural network ML and logistic regression models were developed to predict overnight stay, 30-day postoperative complications, and ACL-related readmission, and model performance was compared using the area under the receiver operating characteristic curve. Regression analyses were used to identify variables that were significantly associated with the predicted outcomes. A total of 21,636 elective ACLR cases met inclusion criteria. Variables associated with hospital admission included White race, obesity, hypertension, and American Society of Anesthesiologists classification 3 and greater, anesthesia other than general, prolonged operative time, and inpatient setting. The incidence of hospital admission (overnight stay) was 10.2%, 30-day complications was 1.3%, and 30-day readmission for ACLR-related causes was 0.9%. Compared with logistic regression models, artificial neural network models reported superior area under the receiver operating characteristic curve values in predicting overnight stay (0.835 vs 0.589), 30-day complications (0.742 vs 0.590), reoperation (0.842 vs 0.601), ACLR-related readmission (0.872 vs 0.606), deep-vein thrombosis (0.804 vs 0.608), and surgical-site infection (0.818 vs 0.596). The ML models developed in this study demonstrate an application of ML in which data from a national surgical patient registry was used to predict hospital admission and 30-day postoperative complications after elective ACLR. ML models developed performed well, outperforming regression models in predicting hospital admission and short-term complications following elective ACLR. ML models performed best when predicting ACLR-related readmissions and reoperations, followed by overnight stay. IV, retrospective comparative prognostic trial.

Factors Associated with Stiffness Following Pediatric and Adolescent ACL Reconstruction: Early Results from Score: A Multi-Center Quality Improvement Registry

Background:Anterior Cruciate Ligament reconstruction (ACLr) is commonly performed in pediatric and adolescent patients. The most common early complication associated with ACLr is stiffness, including motion loss and arthrofibrosis. There is minimal literature regarding risk factors for stiffness following ACLr in this age group.Hypothesis/Purpose:To evaluate the incidence and risk factors associated with stiffness following ACLr using a multi-center quality improvement registry.Methods:A multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of ACLr was reviewed. Audit processes using CPT codes were designed to insure that all consecutive cases were prospectively entered on patients <19 years old into a HIPAA-compliant electronic platform. Stiffness was defined as motion loss that prompted any deviation from the normal post-operative course (Clavien Dindo grade II or greater), including additional clinical or physical therapy (PT) visits, serial/dynamic splinting, or secondary surgery for stiffness (Clavien Dindo grade III). Each case of stiffness and associated complication form was secondarily reviewed to insure consistency of identification and grading. Demographic and peri-operative data were reviewed. Chi-Square or Fisher’s exact tests were used for categorical comparisons and a Kruskal-Wallis test for continuous comparisons.Results:2,839 ACLr cases (mean age 15.1, 6-19; female 46.9%) were identified, with stiffness reported in 4.2% of patients (including isolated flexion or extension and combined stiffness) and secondary surgery for stiffness (manipulation under anesthesia and/or lysis of adhesions) performed in 1.1% of patients. Loss of extension occurred in 3.8% of patients (59.3% females), while loss of flexion occurred in 3.1% of patients (49.4% females). Overall stiffness occurred with longer tourniquet times (93.0 min vs. 78.8 min, p<0.001) when used. Anterior displacement of medial or lateral meniscus tear were associated with nearly twice the incidence of extension loss (7.1%) and three times the incidence of surgery for stiffness (3.7%).Conclusion:Post-operative stiffness following ACLr is rare but may be associated with certain demographic and perioperative factors, such as female sex, prolonged tourniquet time, and certain concomitant injuries such as anteriorly displaced meniscus tears. The degree to which altered practices and/or additional monitoring/vigilance in the setting of such factors warrants additional study.

Effect of Tunnel Drilling Portal on Femoral Tunnel Entry Aperture’s Location in Arthroscopic Anterior Cruciate Ligament Reconstruction

IntroductionTransportal techniques for femoral tunnel drilling have the advantage of anatomical anterior cruciate ligament reconstruction, which was earlier difficult to achieve through transtibial femoral tunnels. However, the medial arthroscopic portal used for femoral tunnel drilling in single-bundle anterior cruciate ligament reconstruction (ACLR) has not been uniformly placed in different studies. Therefore, we performed a computed tomography-based analysis to compare the femoral tunnel entry aperture of the ACLR cases that used the standard AM portal and those using a far medial portal for femoral tunnel drilling.MethodsWe retrospectively reviewed computed tomography images of patients who underwent isolated single-bundle ACLR in our institute with either standard anteromedial portal or the far medial portal used for the femoral tunnel drilling. The femoral tunnel aperture's depth and height, measured using the quadrant method, were compared between the two portal methods.ResultsA total of forty-two case records were reviewed, sixteen belonging to standard anteromedial portal technique and twenty-six belonging to far medial portal technique. The tunnels created through the far AM portal were significantly shallower (more anterior) and inferior than the standard AM portal-created femoral tunnels.ConclusionThe choice of drilling portals can influence transportal femoral tunnel drilling. A tendency towards anterior and inferior positioning of the femoral tunnel entry aperture has been observed when a far medial arthroscopic portal is used for femoral tunnel drilling. Therefore, care must be taken to ensure that the drilling guide pin position does not change when the reamer is passed over it.

Superior Outcome of Early ACL Reconstruction versus Initial Non-reconstructive Treatment With Late Crossover to Surgery: A Study From the Swedish National Knee Ligament Registry

Background: Although comparable clinical and functional outcomes have been reported after nonsurgical and surgical anterior cruciate ligament (ACL) treatment, few studies have investigated the effects of early versus late ACL reconstruction with initial rehabilitation. Purpose: To determine patient-reported knee function in patients who initially undergo nonreconstructive treatment after an ACL injury but who later choose to undergo ACL reconstruction as compared with (1) patients undergoing ACL reconstruction close to the index injury and (2) patients treated nonreconstructively at 1 to 10 years of follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Results from the Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted from the Swedish National Knee Ligament Registry for patients treated with nonreconstruction, early ACL reconstruction, and initial nonreconstruction but subsequent ACL reconstruction (crossover group). The KOOS4 (a mean of 4 KOOS subscales) was analyzed cross-sectionally at baseline and at the 1-, 2-, 5-, and 10-year follow-ups. Additionally, the Patient Acceptable Symptom State (PASS) was applied to all KOOS subscales from baseline to the 10-year follow-up. Results: A total of 1,074 crossover, 484 nonreconstruction, and 20,352 early ACL reconstruction cases were included. The crossover group reported lower KOOS4 values than the group undergoing early ACL reconstruction at baseline and at all follow-ups (mean difference [95% CI]): baseline, −6.5 (−8.0 to −5.0); 1 year, −9.3 (−10.9 to −7.7); 2 years, −4.8 (−6.3 to −3.2); 5 years, −6.1 (−8.8 to −3.4); and 10 years, −10.9 (−16.3 to −5.2). Additionally, a smaller proportion of the crossover cohort achieved a PASS on KOOS subscales at baseline and through the 1-, 2-, 5-, and 10-year follow-ups as compared with the early ACL reconstruction cohort. No differences were observed between crossover and nonreconstruction cases on either the KOOS4 or the PASS at any follow-up. Conclusion: A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction.

Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft.

The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test. Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). This was a level 3 retrospective study. Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

HOW MANY PAIN PILLS DO WE PRESCRIBE: A SURVEY OF PARTICIPANTS IN SCORE: A QUALITY IMPROVEMENT INITIATIVE (204)

Objectives:The public health opioid abuse epidemic has led to nationwide interest in judicious use and close monitoring of opioid pain medication. Knee arthroscopy(KA) and anterior cruciate ligament reconstruction(ACLR) are common procedures in adolescent patients for which narcotics have been historically utilized for post-operative pain management. The purpose of this study is to investigate pain management strategies following basic KA or ACLR by pediatric sports surgeons who contribute to a multi-center quality improvement initiative(SCORE).Methods:Surgeon participants in SCORE represent fifteen U.S. institutions from primarily academic teaching hospitals who specialize in pediatric sports medicine. Surgeons contribute all ACLR and other KA-related cases. A RedCap survey was distributed to all SCORE surgeon participants in December 2019. A KA (defined as a knee arthroscopy that does not include a ligament reconstruction or a cartilage procedure other than chondroplasty) represented a less invasive procedure, while the ACLR represented a more invasive procedure. Survey results were collected and analyzed for both practice patterns of regional anesthesia utilization and post-operative narcotic prescribing volumes.Results:Twenty-eight SCORE surgeon participants completed the survey, a 100% response rate. A planned prescription of a mean of 16.4 pain pills (range 0-40 pills) were reported for pain management following a KA, only 32.1% of surgeons reported adjunctive regional anesthesia techniques for this procedure in addition to general anesthesia. Following an ACLR, surgeons reported a planned prescription of a mean 23.8 pain pills (range 0-40 pills) and most (92.3%) reported utilization of regional anesthesia for their peri-operative analgesia strategy. Of those using adjunctive regional anesthesia, significant variability was reported: 30.7% reported indwelling catheter placement for peripheral nerve block following ACLR as opposed to a single shot injection method, and several block locations were reported to be utilized of which adductor canal (67.9%) block was the most common (see Figure 1). For both procedure types, variability in multi-modal pain management was noted, with incomplete adoption of the use of additional non-narcotic medication (acetaminophen, 64.2%; and NSAIDS, 75%). Cryotherapy devices were applied/prescribed in 75.0% of knee arthroscopy procedures and 92.8% of ACLR.Conclusions:Despite evidence for effective adjunctive pain management strategies, incomplete adoption of multi-modal techniques and reliance on narcotic medication remains a significant component of pediatric sports surgical practice; with on average > 15 pills prescribed following these procedures. Opportunities for reducing practice variability, adoption of multi-modal analgesia strategies, and decreasing post-operative narcotic use following common adolescent knee procedures exist for this subset of pediatric sports medicine specialists

Anterior Cruciate Ligament Reconstruction Graft Technique Reliably Yields Grafts With 8.0-mm Diameter or Larger

The significance of graft diameter in anterior cruciate ligament reconstruction (ACLR) with soft tissue grafts is well established, with a minimum graft diameter of 8.0 mm associated with lower rates of revision surgery. Consistently achieving grafts that meet or exceed the ideal diameter of 8.0 mm is still a concern with traditional tibial screw fixation, even with quadrupled hamstring autografts. The authors hypothesized that following a simple intraoperative algorithm selectively incorporating the gracilis tendon in an 8-stranded construct for all-inside ACLR with suspensory fixation on both ends of the graft would consistently achieve graft diameters of 8.0 mm or larger by allowing more of the graft material to contribute to increased diameter instead of increased length for screw fixation, with no allograft tissue required. A total of 113 eligible cases were identified, including 70 male patients and 43 female patients (mean±SD age, 25.92±6.47 years; range, 14-49 years). All 113 grafts (100%) were at least 8.0 mm in diameter. There were 8 grafts that were 8.0 mm. Overall mean±SD graft diameter was 9.32±0.71 mm (median, 9.5 mm; range, 8.0-11.0 mm). There were no cases in which allograft tissue was needed to increase graft size. An analysis of 113 cases of all-inside hamstring autograft ACLR with dual suspensory fixation showed that a graft diameter of at least 8.0 mm was achieved in every case, without the use of allograft tissue. These results suggest that this technique for ACLR is reliable in producing grafts that meet or exceed the recommended minimum diameter of 8.0 mm. [Orthopedics. 2021;44(4):e539-e545.].

Peroneus longus tendon graft for anterior cruciate ligament reconstruction: A case report and review of literature.

IntroductionThe anterior cruciate ligament (ACL) is one of the most frequently injured structures of the knee joint. Anterior cruciate ligament reconstruction (ACLR) provides surgical restoration of the injured ACL using the placement of graft material. The choice of graft is principal in providing optimal knee stability after surgery. Peroneus longus tendon (PLT) is an autograft modality that offers unique benefits for ACL reconstruction cases.Presentation of caseWe present a case of ACL reconstruction surgery using PLT graft in a patient with a confirmed ACL rupture. Assessment of post-surgical pain, knee stability, and ankle function were performed to determine functional outcome and donor site morbidity. The follow-up results revealed favorable recovery and improvement in all objective parameters.DiscussionPost-operative biomechanical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and the American Orthopedic Foot and Ankle Score (AOFAS) score. The use of PLT in ACL reconstruction established an excellent potential for its satisfactory result and comparable to other graft modalities in widely used evidence-based findings.ConclusionPeroneus longus tendon may be considered the first-option graft in ACL reconstruction as it indicated the absence of significant post-operative morbidity.

Positioning of the Tibial Tunnel After Single-Bundle ACL Primary Reconstruction on 3D CT scans: A New Method

PurposeTo assess intra-articular tunnel aperture positioning after primary anterior cruciate ligament (ACL) reconstruction with either the reference standard method or the intercondylar area method in a single center using 3-dimensional (3D) computed tomography (CT) scans and to evaluate the intra-articular position of the tibial tunnel relative to the ACL footprint.Methods3D CT scans were performed after 120 single-bundle primary ACL reconstruction cases. The center of the tibial tunnel aperture and the center of the ACL footprint were referenced on axial views of the tibial plateau in the anteroposterior (AP) and mediolateral (ML) planes according to a centimetric grid system including the whole plateau (reference standard). This was compared with a grid system based on intercondylar area bony anatomy. The posterior aspect of intertubercular fossa, anterior aspect of the tibial plateau, medial intercondylar ridge, and crossing point between lateral intercondylar ridge and posterior margin were used as landmarks to define the grid.ResultsAccording to the reference standard method, the center of the tibial tunnel aperture was positioned 0.57 ± 2.62 mm more posterior and 0.67 ± 1.55 mm more medial than the center of the footprint. According to the intercondylar area method, the center of the tibial tunnel aperture was positioned 1.32 ± 2.74 mm more posterior and 0.66 ± 1.56 mm more medial than the center of the footprint. The position difference between the center of the tunnel aperture and the center of the footprint were statistically correlated for both grids, with r = –0.887, P < .001 for AP positioning and r = 0.615, P < .001 for ML positioning.ConclusionThis intercondylar area method using arthroscopic landmarks can be used to assess tunnel placement on 3D CT scans after ACL reconstruction.Level of EvidenceIII, retrospective comparative study.

Outcome of anterior cruciate ligament reconstruction in children and adolescents: A retrospective study

BackgroundIndications and outcomes of anterior cruciate ligament (ACL) reconstruction in children and adolescents is still controversial. It was the aim of this study to analyze outcomes of anterior cruciate ligament reconstruction in this special age group. MethodsRetrospectively, we analyzed 62 consecutive cases of ACL reconstruction using a physis crossing technique in six to 16-year-old patients with a mean follow-up of 69 months. ResultsCases operated later than six weeks after trauma had significantly more meniscal lesions than patients operated within six weeks of trauma. At last follow-up, we found good or very good subjective and objective results in 71% of the patients. ConclusionIn active and healthy children with anterior knee instability after ACL tear, ligament reconstruction is a safe and successful procedure and should be considered within six weeks of trauma because instability seems to promote secondary meniscal lesions.

AMBULATORY SURGERY TRENDS IN PEDIATRIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: WHERE’S IT HAPPENING AND HOW MUCH CAN WE SAVE?

Background:Benefits of ambulatory surgery include more efficient operations, lower cost, and patient preference. The national frequency of anterior cruciate ligament (ACL) reconstruction in children has increased three-fold compared other pediatric orthopaedic procedures, a trend that is likely attributable to an increased rate of ACL tears associated with year-round training and competition in young athletes.Hypothesis/Purpose:The goal of this study was to utilize the Pediatric Health Information System (PHIS) to analyze the national trends towards ambulatory surgery for ACL reconstruction procedures and quantify the cost savings associated with the trend.Methods:The PHIS database was queried using Common Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and 10) codes for ACL reconstruction from 2009-2017. Patient information including gender, age at surgery, region (Northeast, South, Midwest, West) and hospital cost data for each procedure was collected. Cases were classified as ambulatory or non-ambulatory (inpatient or observation). Annual rates of ambulatory surgery were calculated for each procedure regionally for hospitals with cases included in each year of the query. The Consumer Price Index (CPI) was used to adjust procedural costs for inflation. Ambulatory and non-ambulatory costs were analyzed with the Wilcoxon Signed-Rank test. Trends in rates of ambulatory surgery were compared using joinpoint regression and annual percent change (APC).Results:A total of 21,582 cases of ACL Reconstruction were identified from 33 different children’s hospitals from 2009-2017. More than half (50.3%) of the patients were female, and the average age at surgery was 15.4 years (± 2.1 years). The overall rate of ambulatory pediatric ACL reconstructions across the United States increased by 14.7% (APC 1.6%, 95% C.I. 0.8-2.4, p<0.01) from 2009 to 2017. Overall, this trend was most significant in the West (APC 2.0%, 95% C.I. 1.2-2.7, p<0.01), however in more recent years (2012-2017), there has been a similar significant increase in ambulatory pediatric ACL reconstruction in the South (APC 3.0%, 95% C.I. 1.7-4.3, p<0.01). The mean difference in median procedural cost between ambulatory and non-ambulatory ACL reconstructions was $3,145 ($13,866 vs. $10,721, p<0.01). This corresponds to national annual savings of 4.1% associated with the shift towards ambulatory surgery.Conclusions:From 2009-2017, there was a national trend towards performing pediatric ACL reconstruction in the ambulatory setting, which was accompanied by an annual 4.1% procedural cost savings. The feasibility of ambulatory surgery for other common pediatric orthopaedic surgeries should be explored in order to reduce healthcare costs.Figure 1.Comparison of National Ambulatory Pediatric ACL Reconstruction Rates and Procedural Costs over Time

Bone Bruise Distribution Patterns After Acute Anterior Cruciate Ligament Ruptures: Implications for the Injury Mechanism.

Background:Bone bruises observed on magnetic resonance imaging (MRI) after an anterior cruciate ligament (ACL) injury could provide significant information about ACL injury mechanisms.Purpose/Hypothesis:The purpose of this study was to investigate common bone bruise patterns after an ACL injury. It was hypothesized that the most common bone bruise distribution pattern would be only the lateral side of both the femur and tibia.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Knee MRI scans of patients who underwent acute ACL reconstruction from August 2016 to August 2018 at our institution were selected. Imaging sequences in the sagittal and coronal planes were used for determining the bone bruise location in the lateral-medial and anterior-posterior directions, respectively. The presence, location, and intensity of bone bruises within specific compartments of the tibia and femur were documented. The relative bone bruise patterns of the tibia and femur were classified and analyzed.Results:A total of 207 patients (165 men, 42 women) met the inclusion criteria from a total of 4209 ACL reconstruction cases. The most common relative bone bruise pattern was located on only the lateral side of both the femur and the tibia (44.4%), followed by the lateral and medial sides of both the femur and tibia (29.0%). For the pattern found on the lateral and medial sides of both the femur and tibia, the bone bruises on only the lateral side of both the tibia and femur were more severe (P < .001 and P < .001, respectively) and more anterior (P < .001 and P < .001, respectively) than those on only the medial side.Conclusion:The most common relative bone bruise pattern observed was on only the lateral side of both the tibia and femur. Bone bruises on the lateral side were more severe than those on the medial side in patients with bone bruises on the lateral and medial sides of both the femur and tibia. Anterior translation of the tibia relative to the femur occurred during an ACL injury based on the location of bone bruises in the anterior-posterior direction.

The mechanical characteristics and early-stage clinical effects of double bundle anterior cruciate ligament reconstruction with femoral direct fiber insertion

Objective To investigate the finite element analysis and early-stage clinical effects of double bundle anterior cruciate ligament (ACL) reconstruction with femoral direct fiber insertion. Methods From June 2016 to June 2017, a total of 26 cases of ACL reconstruction were analyzed retrospectively, including 15 males and 11 females, mean age 30.5±4.6 years. All the patients underwent ACL reconstruction by the same operator. The early-stage clinical effects were evaluated by the finite element analysis, pivot shift test, Lachman test, preoperative and postoperative IKDC score, Lyshlom score, KT-2000, 3D-CT and MRI. Results The finite element analysis confirmed theoretically that the double bundle ACL reconstruction with femoral direct fiber insertion could restore the stability and biomechanics of knee effectively. The results of pivot shift test were negative, and the Lachman test were negative except one first-stage positive after operation. 3D-CT showed that the bone tunnel was located in the direct fiber area. MRI showed clearly the ACL of double bundle after operation. Lysholm score increased from 56.5±3.6 pre-operation to 61.9±3.2 at three months after operation, and up to 88.5±2.0 two years after operation with statistically significant difference (F=824.72, P<0.001). IKDC score increased from 48.3±2.8 before operation to 58.0±2.0 at three months after operation, and to 92.5±2.6 at two years after operation with statistically significant difference (F=2 256.66, P<0.001). KT-2000 side-side difference decreased from 5.6±0.7 mm to 1.6±0.5 mm at three months after operation, and to 1.5±0.6 mm at two years after operation with statistically significant difference (F=389.14, P<0.001). Conclusion The double bundle ACL reconstruction with femoral direct fiber insertion can effectively restore the stability and the biomechanical environment of knee joint with satisfied early-stage clinical effects. Key words: Anterior cruciate ligament; Reconstructive surgical procedures; Finite element analysis

Anterior cruciate ligament (ACL) reconstruction and meniscal repair rates have both increased in the past 20 years in England: hospital statistics from 1997 to 2017

ObjectivesWe investigated the temporal trend and the geographical variation in the rate of an anterior cruciate ligament (ACL) reconstruction and meniscal repair (MR) performed in England during a 20-year window.MethodsAll...