Anterior Cruciate Ligament Reconstruction Surgery Research Articles

Characteristics of early complications in isolated primary anterior cruciate ligament reconstruction surgery.

The early complications of isolated anterior cruciate ligament reconstruction surgery (ACLR) have not been well characterized using large databases. This study aims to characterize incidence, impact, and risk factors for short-term operative complications following elective, isolated ACLR surgery. We hypothesize that demographic and perioperative factors may predict 30-day complications after isolated ACLR. This case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (2005-2017) used Current Procedural Terminology codes to identify elective, isolated ACLR patients. Patients undergoing concomitant procedures were excluded. Complications were analyzed using bivariate analysis against demographic variables. Multiple stepwise logistic regression was used to identify independent risk factors for morbidity after ACLR. A total 12,790 patients (37.0% female, p = 0.674) were included with a mean age of 32.2years old (SD 10.7years, p < 0.001). Mean BMI was 27.8kg/m2 (6.5) where 28.9% of patients had a BMI > 30 (p = 0.064). The most common complications were wound-related (0.57%). In cases with complications, there were higher rates of (1.3% vs 0.8%, p = 0.004) prolonged operation (> 1.5h), higher rate (2.9% vs 1.8%, p = 0.004) of extended length of stay (≥ 1day), unplanned reoperation (15.8% vs 0.3%, p < 0.001), and unplanned readmission (17.5% vs 0.3%, p < 0.001). Multivariate analysis showed prolonged operative time (p = 0.001), dyspnea (p = 0.008), and non-ambulatory surgery (p = 0.034) to be predictive of any complication. Dependent functional status (p = 0.091), mFI-5 > 0.2 (= 0.173), female sex (p = 0.191), obesity (p = 0.101), and smoking (p = 0.113) were not risk factors for complications. ACLR is associated with low rates of morbidity and readmissions. The most common comorbidities, complications, and predictors of morbidities were identified to aid surgeons in further reducing adverse outcomes of ACLR. Operative time > 1.5h, dyspnea, and non-ambulatory surgery are predictive of complications.

How Does Physical and Psychological Recovery Vary Among Competitive and Recreational Athletes After Anterior Cruciate Ligament Reconstruction?

The recovery and rehabilitation journey after anterior cruciate ligament reconstruction (ACLR) surgery can be different for competitive and recreational athletes as their motivation and goals toward sports are different. Competitive athletes would present with better patient-reported outcomes and higher muscle strength compared with recreational athletes postsurgery. Second, competitive athletes would recover better (patient-reported outcome [PRO] measures and muscle strength) compared with recreational athletes at later stages. Cross-sectional laboratory-based study. Level 2. A total of 245 patients with unilateral ACLR were categorized as competitive or recreational athletes and grouped into early (4-6.9 months) or late (7-10 months) stages of recovery. PRO were collected for psychological response (Tampa Scale Kinesiophobia; Anterior Cruciate Ligament-Return to Sport after Injury), perceived knee function (International Knee Documentation Committee subjective form [IKDC]), and quality of life (Knee injury and Osteoarthritis Outcome Score; Veteran Rand-12). Isokinetic, concentric knee extension strength was measured bilaterally with a multimodal dynamometer (System 4, Biodex Medical Systems) at a speed of 90° and 180°/s. Competitive athletes had significantly higher scores for IKDC (P = 0.03), and quadriceps peak torque at 90°/s (P = 0.01) and 180°/s (P < 0.01) compared with recreational athletes. Competitive athletes had higher quadriceps strength at 90°/s (P < 0.01) and 180°/s (P = 0.02) in the late group. Recreational athletes displayed higher sports participation in the late group. Outcomes of ACLR may differ based on preinjury athletic level. Whereas competitive athletes had higher knee and muscle function than recreational athletes, psychological measures were not different among groups. There is a need for more individualized care for patients with ACLR since there is variability among patient goals postsurgery. This information might help set realistic expectations for competitive and recreational athletes after surgery.

Return-to-Sport Testing in Young Athletes After Anterior Cruciate Ligament Reconstruction

Implementing return-to-sport (RTS) testing should be an integral component of rehabilitation for young athletes who have undergone anterior cruciate ligament (ACL) reconstruction, but there are no universally accepted standards for such testing. In this article, we highlight our institution’s use of a structured and evidence-based approach to guide RTS decision-making for athletes, coaches, surgeons, therapists, and parents, with an emphasis on reducing the likelihood of reinjury after ACL reconstruction surgery.

Tibiofemoral bone configuration is not associated with hamstring muscle strength in male and female patients with ACL reconstruction.

Previous evidence indicated that the tibiofemoral bone configuration might elevate the risk of an anterior cruciate ligament (ACL) injury. Furthermore, a low hamstring-to-quadriceps muscle ratio predisposes especially females to unfavourable knee kinematics. The primary objective of the present study was to investigate sex-specific associations between tibiofemoral bone geometry and isokinetic knee flexion torque in patients with primary ACL injury followed by ACL reconstruction. N = 100 patients (72 = male, 28 = female, age = 31.3 ± 10.2, body mass index = 25.3 ± 3.6) with primary ACL rupture with isokinetic knee flexion torque assessments before and 6 months after ACL reconstruction surgery were analysed. Magnetic resonance imaging scans were analysed for medial posterior tibial slope (MPTS) and lateral posterior tibial slope, notch width index (NWI) and lateral femoral condyle index (LFCI). Additionally, isokinetic knee flexion torque (60°/s) and hamstring-quadriceps ratios were evaluated. Subsequently, functional parameters were correlated with imaging data for gender subgroups. The findings showed that presurgical isokinetic knee flexion torque was not associated with any marker of femoral or tibial bone geometry. Further, while significant differences were observed between female (0.883 ± 0.31 Nm/kg) and male (1.18 ± 0.35 Nm/kg) patients regarding preoperative normalized knee flexion torque (p < 0.001), no significant sex differences were found for percentage increases in normalized knee flexion torque from presurgery to postsurgery. Generally, female patients demonstrated significantly higher MPTS magnitudes (p < 0.05) and lower LFCI values (p < 0.05) compared to men. The present results demonstrated no association between tibial or femoral bone geometry and muscle strength of the hamstrings in patients with ACL reconstruction, indicating an important mismatch of muscular compensation to deviations in bone geometry. There were no sex-specific differences in tibiofemoral bone parameters. Level III.

‘It’s just my knee’: a qualitative study investigating the process of reframing and young athletes’ perceived quality of life between anterior cruciate ligament injury and surgery

ObjectivesTo understand the factors influencing young athletes’ perceptions of quality of life (QOL) following an anterior cruciate ligament (ACL) rupture, prior to reconstructive surgery.DesignQualitative descriptive study using semi-structured interviews and...

Effect of alendronate and platelet-rich plasma in tendon-bones integration in sheep anterior cruciate ligament surgery

Context: Anterior cruciate ligament (ACL) reconstruction often faces challenges due to poor integration of the tendon with bone. Aims: To evaluate the potential benefits of alendronate and platelet-rich plasma (PRP) in enhancing tendon-to-bone osteointegration in ACL surgery. Methods: This was a post-test only control group experimental study with Ovis aries Linnaeus sheep as experimental animals. The sample was divided into four groups: the control group ACL reconstruction with calcaneal tendons given NaCl, the group given PRP, alendronate, and PRP and alendronate. Bone healing biomarkers (NF-B, TNF-α, MMP-9, TGF-β1, and COL1A1) were examined through immunohistochemical analysis and histological studies to assess osteoblast counts and inflammatory tissue. Results: There was a statistically significant (p&lt;0.05) increase in MMP-9 and osteoblast count after alendronate and PRP administration. Administration of alendronate and PRP also increased other variables, namely TNF-α, COL1A1, and the level of inflammation, although not statistically significant (p&gt;0.05). The intervention did not affect NF-B and TGF-β1 (p&gt; 0.05). Conclusions: These results show that the administration of alendronate and PRP improves the healing of tendon-calcaneal ACL reconstruction surgery in sheep.

ANALYSIS OF CAUSES AND POSTOPERATIVE RECOVERY OF ANTERIOR CRUCIATE LIGAMENT INJURY CAUSED BY AEROBICS IN KNEE JOINTS

Background: During the process of aerobic exercise, there are a lot of jumping and split movements, which can easily cause anterior cruciate ligament (ACL) injury in the knee joint. After undergoing ACL reconstruction (ACLR) surgery, postoperative recovery is crucial. Currently, many methods have been applied, but research on water exercise is still limited. Purpose: This paper aims to understand the role of water exercise in the recovery of athletic ability after ACLR and provide guidance for athletes’ postoperative rehabilitation. Methods: Forty athletes with ACL injuries caused by aerobics practice or competition and undergoing surgery were randomly assigned to either group A or group B. The former received six weeks of a conventional postoperative recovery program, and the latter received six weeks of a water exercise postoperative recovery program. Knee joint range of motion (ROM), swelling value, visual analog scale (VAS) score, knee joint function score, and passive angle reproduction (PAR) were measured before and after the experiment. Results: After six weeks of recovery, the knee ROM was [Formula: see text], the swelling value was [Formula: see text][Formula: see text]cm, the VAS score was [Formula: see text], the Lysholm score was [Formula: see text], and the International Knee Documentation Committee (IKDC) score was [Formula: see text] in group B, which were significantly lower than those before recovery and those in group A ([Formula: see text]). After recovery, the PAR of the affected side was still different from that of the healthy side in the two groups ([Formula: see text]), but the PAR of group B was better than that of group A ([Formula: see text]). Conclusion: Compared to the conventional program, the water exercise-based postoperative recovery program demonstrates better performance in improving knee joint ROM, functionality, and proprioception, and can be used for practical post-ACLR rehabilitation.

Evaluation of anterolateral ligament healing in patients with anterior cruciate ligament injury without anterior cruciate ligament reconstruction and its relationship with clinical examination tests.

This study radiologically investigated the potential of preoperative recovery of the anterolateral ligament (ALL) in patients who did not undergo anterior cruciate ligament reconstruction (ACLR) surgery in the early stages despite surgical indication. The secondary aim was to investigate the relationship between ALL injuries in magnetic resonance imaging (MRI) and the results of Lachman and pivot shift tests performed preoperatively and postoperatively under anaesthesia amongpatients who underwent ACLR in acute and chronic stages. The study examined 100 patients aged 19-51 years who underwent anatomic single bundle ACLR using hamstring autografts for the ACL. Based on the time between the injury and ACLR, they were divided into acute (≤6 months) and chronic (>6 months) groups. The chronic group had three subgroups of ACLR times: 7-12, 13-24and >24 months. Complete recovery was defined as a change from grade B or C upon injury to grade A before surgery according to the Muramatsu MRI classification. The relationship between preoperative and postoperative Lachman grades and pivot shifting test results and the degree of ALL injury was evaluated. In the chronic group, 19/61 patients (31.1%) had preoperative grade A, and 4/61 patients (6.5%) had grade A at the time of injury. In the acute group, 22/29 patients with grades B and C (76%) had grade 3 preoperative pivot shifting. In the acute group, grades 1 and 2 were more common in patients with grades B and C (10/29, 35%) than grade A (0/10, 0.0%). The improvement rate was 24.6% amongpatients who did not receive ACLR in the acute phase and underwent ACLR in the chronic phase. In the acute group, the degree of ALL damage was related to the pivot shift results. However, the results in the chronic phase were not associated with the degree of injury. Level IV.

Association between passing return-to-sport testing and re-injury risk in patients after anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis.

Inconsistent results have been obtained regarding the association between return-to-sport (RTS) testing and the risk of subsequent re-injury following anterior cruciate ligament reconstruction (ACLR). We therefore conducted a systematic review and meta-analysis to assess the potential association between passing of RTS and the risk of re-injury for patients after ACLR. This meta-analysis was registered in INPLASY with the registration number INPLASY202360027. The electronic databases MedLine, EmBase, and the Cochrane library were systematically searched to identify eligible studies from their inception up to September 2023. The investigated outcomes included knee injury, secondary ACL, contralateral ACL injury, and graft rupture. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the random-effects model. A total number of nine studies involving 1410 individuals were selected for the final quantitative analysis. We noted that passing RTS test was not associated with the risk of subsequent knee injury (OR: 0.95; 95% CI: 0.28-3.21; P = 0.929), secondary ACL injury (OR: 0.98; 95% CI: 0.55-1.75; P = 0.945), and contralateral ACL injury (OR: 1.53; 95% CI: 0.63-3.71; P = 0.347). However, the risk of graft rupture was significantly reduced (OR: 0.49; 95% CI: 0.33-0.75; P = 0.001). This study found that passing RTS test was not associated with the risk of subsequent knee injury, secondary ACL injury, and contralateral ACL injury, while it was associated with a lower risk of graft rupture. Thus, it is recommended that patients after ACLR pass an RTS test in clinical settings.

Infection after Anterior Cruciate Ligament Reconstruction: A Narrative Review of the Literature.

Infection is an uncommon side effect of arthroscopic surgery, and this percentage is higher in anterior cruciate ligament reconstruction (ACLR) surgery, where graft and fixation devices are used. Infections can not only lead to high re-admission rates and poor functional recovery of the knee but can also have a significant negative impact on the patient's psychological and economic health, especially in athletes, as it can affect their sports career. It is important to be aware of the many risk factors, especially the manifestation of symptoms. These may sometimes be non-specific to the infectious pathology and common to other situations, such as the presence of a significant intra-articular hematoma. Septic arthritis after ACLR can occur at any time after surgery but typically presents acutely, while late manifestation is relatively rare. Diagnosis of infection is based on patient history, physical examination, laboratory parameters, and analysis of synovial fluid after joint aspiration, which is the gold standard for diagnosing post-operative infection. Once symptoms appear and the diagnosis seems certain, it is necessary to intervene quickly with arthroscopic debridement and long-term antibiotic treatment to try to save the graft and resolve the infectious situation to avoid graft failure and arthrofibrotic sequelae. The aim of this paper is to provide an overview of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic evaluation, and current treatment guidelines of septic arthritis after ACLR surgery by analyzing recent literature, in particular meta-analyses and systematic reviews.

Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report.

Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR. Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented. Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively. We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.

Delaying anterior cruciate ligament reconstruction for more than 3 or 6 months results in lower risk of revision surgery

BackgroundThe objective of this study is to investigate the risk of revision surgery when delaying anterior cruciate ligament reconstruction (ACLR) past 3 months or 6 months after injury.Materials and methodsA total of 30,280 patients with isolated ACLR were identified in the Danish Knee Ligament Reconstruction Registry and divided into four groups; ACLR < 3 months, > 3 months, < 6 months, or > 6 months after injury. Primary outcome was revision surgery and secondary outcome were objective and subjective clinical outcome. The 2 year relative risk, crude, and adjusted hazard ratio (HR) were calculated.ResultsComparing ACLR < 3 months to ACLR > 3 months of injury the 2 year relative risk of revision surgery was found to be 1.81 (95% CI 1.46–2.23; P < 0.001) with an adjusted hazard ratio (HR) of 1.27 (95% CI 1.12–1.44; P < 0.001). Comparing ACLR < 6 months to ACLR > 6 months of injury the 2 year relative risk of revision surgery was found to be 1.61 (95% CI 1.34–1.92; P < 0.001) with an adjusted HR of 1.27 (95% CI 1.15–1.40; P < 0.001).ConclusionThe risk of revision ACLR surgery was found to be increased when ACLR was performed within 3 months or 6 months of injury compared with later surgery. The 1 year postoperative objective knee laxity and the subjective patient-related outcome was found to be without a clinically significant difference; however, those with early ACLR (< 3 months or < 6 months) were found to have a higher activity level 1 year postoperatively. The information about increased risk of revision when having early surgery should be informed to patients when deciding timing of ACLR treatment.Level of evidence: II.

Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature.

Background Anterior cruciate ligament reconstruction (ACLR) is a common operative procedure and many options regarding the type of the selected graft and fixation technique have been described to date. Although many studies have addressed the issue of the optimal femoral fixation device during ACLR with a hamstring tendon (HT) autograft, no clear evidence to indicate one technique over another has been found. Objective The purpose of this study was to compare the long-term postoperative outcomes and complication rates between transfemoral Cross-pin (CP) and Endobutton-Cortical Button (CB) fixation techniques in patients undergoing ACLR with an HT autograft. Methods One hundred and seven consecutive patients underwent ACLR by using a quadruple HT autograft that was stabilized with either a CP (CP Group: 52 patients) or a CB (CB Group: 55 patients) fixation technique. The Lachman test (LT), the Pivot-shift test (PST), the side-to-side difference in anterior translation of the tibia, the International Knee Documentation Committee (IKDC), and the Lysholm knee scoring systems were evaluated before surgery and during long-term follow up. Thefemoral and tibial tunnel diameter was measured in the anteroposterior (AP) and lateral radiographsafter surgery and at the final follow-up. Areview of the literature was also carried out to identify any differences between both techniques. Results Study groups were comparable in terms of patient demographics. The mean follow-up was 10.4 ± 1.3 and 10.6 ± 1.3 years in the CP and CB Groups, respectively (p = 0.47). In the CP Group, improvements after surgery in LT and PST from grade 2 (n=34) or 3 (n=18) to grade 0 (n = 41) or 1 (n = 11) and from grade 2 (n=36) or 3 (n = 16) to grade 0 (n = 44) or 1 (n = 8), respectively, were observed. In the CB Group, similar improvements in LT and PST scores from grade 2 (n = 40) or 3 (n = 15) to grade 0 (n = 46) or 1 (n = 9) and from grade 2 (n = 41) or 3 (n = 14) to grade 0 (n = 47) or 1 (n = 8), respectively, were observed. However, no differences between the groups (p = 0.53 for LT and p = 0.90 for PST) were noted. The mean Lysholm scores were 89.7 ± 6.8 and 90.2 ± 7.2 in the CP and CB groups, respectively (p = 0.59). Side-to-side difference improved from 9.1 ± 2.8 to 1.7 ± 1.5 mm and from 8.6 ± 2.5 to 1.6 ± 1.4 mm in the CP and CB groups, respectively (p = 0.89 between groups). According to IKDC grades, 92.1% and 91.4% of knees in the CP and CB groups, respectively were reported to be Grade A (Normal) or B (Nearly Normal) with a p = 0.7. Femoral and tibial tunnel widening was found in the last follow-up in both groups. However, there was no difference in the degree of tunnel widening among the two techniques.With respect to LT, PST, anterior drawer test, and IKDC score, none of the 15 published comparative studies demonstrated any significant differences between the two techniques and only one study detected a difference regarding the Lysholm score in favor of CP fixation. Conclusion In the long term, both CB and CP femoral stabilization techniques were shown to be associated with similar functional outcomes and low complication rates. Further large multicenter random clinical trials are still required to identify the most effective method of femoral fixation for HT autograft during ACLR surgery.

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review

Background Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. Questions/purposes In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries? Methods On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. Results There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. Conclusion Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. Level of Evidence Level III, therapeutic study

Anterior Cruciate Ligament Reconstruction Surgery Outcomes: A Comparison Between Patients Who Underwent the Procedure During the COVID-19 Pandemic and a Cohort Treated Prior to the Pandemic.

Background and objective During the coronavirus disease 2019 (COVID-19) pandemic, many elective orthopedic surgeries, including anterior cruciate ligament reconstruction(ACLR), were temporarily postponed. The purpose of this study was to compare the outcomes of ACLR in patients who underwent surgery during the COVID-19pandemic with those in a cohort treated before the pandemic. Materials and methods This retrospective review compared patients who underwent primary ACLR during two periods: March to June 2020 (the pandemic group) and January to December 2018 (the pre-pandemic group). Matched cohorts (1:1) were created using propensity matching. Time from injury-to-first visit, injury-to-surgery, and first visit-to-surgery were calculated. Subjective and objective outcomes, minimal clinically important difference (MCID) achievement, and complication rates were recorded for up to two years postoperatively. Statistical analysis included 𝛘2 or Fisher's exact tests for categorical data, and t- or Wilcoxon signed-rank tests for continuous data with significance set at P< 0.05. Results The pandemic and pre-pandemic groups consisted of 33 and 217 patients, respectively.Matched cohorts consisted of 33 patients each. The time from injury-to-surgery and the first visit-to-surgery was prolonged in the pandemic group. When unmatched, visual analog scale (VAS) scores at three months postoperatively and Patient-Reported Outcomes Measurement Information System (PROMIS)-pain interference (PI) at six months postoperatively and at the final follow-up were higher in the pandemic group. When matched, PROMIS-PI at six months postoperatively was higher in the pandemic group, and VAS scores at one year postoperatively were higher in the pre-pandemic group. MCID achievement and complication rates did not significantly differ between the groups. Conclusions ACLR procedures were significantly delayed in the early months of the COVID-19 pandemic. While patients treated before and during the pandemic experienced varying pain levels during recovery, their functional outcomes, MCID achievement, and complication rates did not differ significantly.

Influence of female sex and double-quadruple semitendinosus-gracilis graft on the incidence of postoperative symptomatic cyclops lesions after ACL reconstruction.

Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR. This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model. In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014). This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions. Level III.

Strontium-Doped Hydroxyapatite Coating Improves Osteo/Angiogenesis for Ameliorative Graft-Bone Integration via the Macrophage-Derived Cytokines-Mediated Integrin Signal Pathway.

Polyethylene terephthalate (PET) artificial ligaments, renowned for their superior mechanical properties, have been extensively adopted in anterior cruciate ligament (ACL) reconstruction surgeries. However, the inherent bio-inertness of PET introduces formidable barriers to graft-bone integration, a critical aspect of rehabilitation. Previous interventions, ranging from surface roughening to chemical modifications, have aimed to address this challenge; however, consistently effective techniques for inducing graft-bone integration remain scarce. Our study employed advanced surface-coating methodologies to introduce strontium-doped hydroxyapatite (SrHA) onto PET ligaments. Detailed scanning electron microscopy (SEM) examinations revealed a uniform and integrative coating of SrHA on PET fibers. Furthermore, spectroscopic analysis confirmed the steady release of strontium ions from the coated surface under physiological conditions. In-depth cellular studies proved that extracellular strontium emanating from SrHA-coated PET (PET@SrHA) ligaments actively steers the M2 macrophage polarization. Additionally, macrophages (Mφs) manifested a heightened secretion of prohealing cytokines when exposed to PET@SrHA. Subsequent investigations showed that these cytokines acted as mediators, activating integrin signaling pathways among macrophages, vascular endothelial cells, and osteoblasts. As a direct consequence, an increased rate of angiogenesis and osteogenic differentiation was observed, vital for graft-bone integration following ACL reconstruction with PET@SrHA ligaments. From a biochemical standpoint, our results pinpoint strontium ions as influential immunomodulators, sculpting the graft-bone interface's immune environment. This insight presents the SrHA-coating technique as a viable therapeutic strategy, holding sound promise for improving angiogenesis and osseointegration outcomes during ACL reconstruction using PET-based grafts.

High flexion femoral side remnant preservation positioning technique: a new method for positioning the femoral tunnel in anterior cruciate ligament reconstruction.

The aim of this study is to find a new method for femoral side preservation positioning in anterior cruciate ligament (ACL) reconstruction and test the accuracy and precision of this method. Fifty patients with isolated ACL rupture (42 males and 8 females) who underwent single-bundle ACL reconstruction in our hospital between July 2022 and July 2023 were included. The lowest point of the cartilage margin of the lateral wall of the intercontinental fossa and the tibial plateau plumb line at 120° of knee flexion were used as the anatomical landmarks for positioning of the femoral tunnel for ACL reconstruction surgery. Femoral side remnant preservation was performed in all cases. Three-dimensional CT was performed 3days postoperatively to collect the data, which were analyzed using Mimics 21.0 software. We measured the posterior cortical distance of the femoral condyle at 90° of knee flexion and the vertical distance from the center of the bone tunnel to the cortical extension line behind the femur. All femoral tunnel positions were marked on a 4 × 4 grid and visualized using the quadrant method. Using the new positioning method in 50 knees, the average distance of x was 25.26 ± 2.76% of t and the average distance of y was 23.69 ± 6.19% of h. This is close to the results of previous studies, where x was 24.2 ± 4.0% of t and the average distance of y was 21.6 ± 5.2% of h. Most femoral tunnel positions were located in the same area. The D values were distributed as follows: 60% in the range of 0 to 2mm, 24% in the range of 2 to 4mm, and 16% more than 4mm. The E values were distributed as follows: 80% in the range of 0 to 4mm and 20% more than 4mm. In arthroscopic ACL reconstruction, the knee was flexed at 120° and the lowest point of the cartilage edge of the lateral wall of the intercondylar fossa and the tibial plateau plumb line were used as anatomical landmarks for the positioning of the femoral bone tunnel, which resulted in more accurate femoral bone tunnel positioning, better reproducibility, and better preservation of the femoral stump compared to traditional positioning methods.

Platelet-rich plasma augmentation in anterior cruciate ligament reconstruction: Evidence is still too scattered. A scoping review of randomised controlled trials.

Platelet-rich plasma (PRP) augmentation has been proposed to improve the results of anterior cruciate ligament reconstruction (ACLR). The present study aims to quantify the available evidence to support the use of PRP as biological augmentation in ACLR surgery. A systematic literature search was conducted on the PubMed, Cochrane, Web of Scienceand Embase databases on 10 March2023. Inclusion criteria were randomised controlled trials (RCTs), written in English, addressing PRP augmentation in ACLR surgery, with no time limitation. A scoping review was performed to map the body of literature by examining the evidence related to specific aspects of patients' treatment and evaluation. Risk of bias evaluation was performed with the Cochrane risk-of-bias tool for randomised trials Version 2 (RoB 2), while the quality assessment was performed with the use of the Coleman Score. Out of 983 articles retrieved, 23 RCTs on 943 knees were included in this scoping review. PRP was administered in a liquid form in ninestudies and clotted in 11 studies, while in three studies both liquid and clotted PRP were used. Hamstring auto/allografts were used in 14 studies, patellar tendon auto/allografts were used in eight studiesand one study described ACLR with peroneus longus allografts. The map of the evidence documented high heterogeneity also in terms of surgical technique, objective and subjective outcome measuresand radiological assessment, as well as follow-up times ranging from 1 day to 2 years, with virtually no overlapping data among studies neither in terms of treatments nor evaluations. Risk of bias evaluation showed an overall low quality of the included studies. The available literature addressing PRP augmentation in ACLR is largely scattered. PRP was produced and applied following different procedures, and high variability was detected across the included studies for every aspect of ACLR surgery and evaluation. Currently, a meaningful comparison of the available studies is not possible as the quantification of the literature results is biased by their heterogeneity. Future studies should provide more standardisation to investigate the benefits of biological augmentation in ACL surgery and confirm the promising yet weak evidence of PRP potential as well as the most suitable application modality, before routine use in clinical practice. Levels I and II, scoping review.

Sensitivity analysis of paediatric knee kinematics to the graft surgical parameters during anterior cruciate ligament reconstruction: A sequentially linked neuromusculoskeletal-finite element analysis

Background and objectiveIncidence of paediatric anterior cruciate ligament (ACL) rupture has increased substantially over recent decades. Following ACL rupture, ACL reconstruction (ACLR) surgery is typically performed to restore passive knee stability. This surgery involves replacing the failed ACL with a graft, however, surgeons must select from range of surgical parameters (e.g., type, size, insertion, and pre-tension) with no robust evidence guiding these decisions. This study presents a systemmatic computational approach to study effects of surgical parameter variation on kinematics of paediatric knees. MethodsThis study used sequentially-linked neuromusculoskeletal (NMSK) finite element (FE) models of three paediatric knees to estimate the: (i) sensitivity of post-operative knee kinematics to four surgical parameters (type, size, insertion, and pre-tension) through multi-input multi-output sensitivity analysis; (ii) influence of motion and loading conditions throughout stance phase of walking gait on sensitivity indices; and (iii) influence of subject-specific anatomy (i.e., knee size) on sensitivivty indices. A previously validated FE model of the intact knee for each subject served as a reference against which ACLR knee kinematics were compared. ResultsSensitivity analyses revealed significant influences of surgical parameters on ACLR knee kinematics, albeit without discernible trend favouring any one parameter. Graft size and pre-tension were primary drivers of variation in knee translations and rotations, however, their effects fluctuated across stance indicating motion and loading conditions affect system sensitivity to surgical parameters. Importantly, the sensitivity of knee kinematics to surgical parameter varied across subjects, indicating geometry (i.e., knee size) influenced system sensitivity. Notably, alterations in graft parameters yielded substantial effects on kinematics (normalized root-mean-square-error > 10 %) compared to intact knee models, indicating surgical parameters vary post-operative knee kinematics. ConclusionsOverall, this initial study highlights the importance of surgical parameter selection on post-operative kinematics in the paediatric ACLR knee, and provides evidence of the need for personalized surgical planning to ultimately enhance patient outcomes.