Age and chronic ACL injury are associated with reduced ramp-region vascularity during ACL reconstruction.

Investigating internal and external focus of attention strategies during return-to-sport tests post- anterior cruciate ligament reconstruction (ACLR).

Isolated lateral release or lateral lengthening for non-instability indications: A systematic review.

Association between sensorimotor function and lower limb biomechanics during a single-leg forward hop in athletes after ACL reconstruction.

Athletes adopted a more cautious, informed, and prevention-focused approach during their second ACLR rehabilitation, drawing on lessons from their first injury. Integrating psychological readiness with physical recovery, promoting communication between athletes, physiotherapists, and coaches, and emphazising injury prevention may enhance RTS outcomes after a second ACLR.

Anterior cruciate ligament (ACL) ruptures are prevalent, particularly among young athletes. Although ligament reconstruction is the gold standard treatment, the rehabilitation process is extensive and has high reinjury rates. Recovery is often hindered by muscle inhibition and psychological factors like kinesiophobia and associated fear of reinjury. Emerging evidence suggests that motor imagery and action observation could enhance rehabilitation outcomes. Immersive virtual reality (VR) offers a novel way to integrate these techniques, potentially accelerating recovery. In this parallel randomized controlled trial, patients undergoing ACL reconstruction were randomly assigned to receive either conventional rehabilitation alone or conventional rehabilitation plus VR training. Our VR content incorporated several novel elements, including embodiment in a virtual body, first-person perspective, and the performance of virtual exercises guided by a virtual physiotherapist. Another innovative feature was that patients conducted the daily VR training independently at home using a standalone head-mounted display. The VR group performed a 20-min daily VR rehabilitation program for 4 weeks post-surgery, visualizing, planning, and executing movements using an embodied virtual avatar. Self-reported disability (International Knee Documentation Committee score, IKDC), quadriceps strength limb symmetry, active knee extension range of motion (ROM) limb symmetry, and kinesiophobia (Tampa Scale of Kinesiophobia-short form, TSK-11) were measured at baseline, 4, 12, and 36 weeks. Forty-seven participants were randomized, with 44 completing treatment. IKDC scores were not statistically significantly different between groups, despite moderate effect sizes at 4 and 36 weeks (Cohen's d = 0.559, and d = 0.722, respectively). The VR intervention group showed significantly lower kinesiophobia at 4 weeks post-surgery compared to controls (27.00 ± 6.58 vs. 33.35 ± 5.07, Cohen's d = - 0.971, p = 0.045). Both groups demonstrated significant improvements in all outcomes over time (p < 0.001). No significant differences were found for range of motion or quadriceps strength limb symmetry. No adverse events were reported related to the intervention. Reducing kinesiophobia is crucial for timely and effective rehabilitation and return to sport, and for reducing reinjury risk. To our knowledge, this is the first clinical study to investigate the independent use of therapeutic VR at home during post-orthopedic surgery rehabilitation. Future research should explore different VR interventions, including more active exercises and personalized programs, to enhance adherence and optimize recovery. The study was pre-registered with the National Library of Medicine (NCT05080894; first registered 09/20/2021).

Psychological health effects after anterior cruciate ligament (ACL) reconstruction is of interest, with perceived poor health thought to negatively impact recovery. Understanding the relationship between perceived health at mid-rehabilitation and objective outcomes at return to sport will help clinicians ensure that rehabilitation meets the specific needs of patients. A retrospective chart review. A chart review of 44 adolescent patients (n = 22 males, 50%) who presented for ACL reconstruction from March 2020 to March 2022 was conducted. Patients completed the ACL-Return to Sport Index Short Form and Pediatric International Knee Documentation Committee form during mid-rehabilitation evaluation (average 5.7 [0.73]mo postsurgery) and performed strength and functional testing during the return to sport evaluation (average 9.1 [1.6]mo postsurgery). Outcome variables included absolute and relative bodyweight peak torque knee extension and peak torque knee flexion, limb symmetry index, single-leg hop for distance, and 30-second side hop. Higher Pediatric International Knee Documentation Committee scores at mid-rehabilitation were correlated with higher peak torque (r = .369, P < .05) and higher peak torque/BW (r = .527, P < .05) during knee extension on the operative leg and better knee extension limb symmetry index (r = .381, P < .05) at return to sport testing. Higher Pediatric International Knee Documentation Committee scores mid-rehabilitation were correlated with a lower hamstring-to-quadriceps ratio on the operative leg (r = -.373, P < .05) at return to sport testing. Higher ACL-Return to Sport Index Short Form scores mid-rehabilitation were correlated with lower 30-second side-hop repetitions on the operative (r = -.480, P < .05) and nonoperative (r = .456, P < .05) legs. These correlations suggest that patient-reported outcomes during mid-rehabilitation may correlate to strength and functional outcomes at return to sport. In addition, biases may exist between patient-reported outcomes, patient sex, and strength and functional measures. The unexpected finding that readiness to return to sport correlated with lower repetitive jumping performance requires further study.

Response to fatigue protocol on running ground reaction forces in individuals with anterior cruciate ligament reconstruction and pronated feet: a cross-sectional observational study.

Editorial Commentary: Look Out for Internal Rotational Tibial Subluxation on Magnetic Resonance Imaging as an Indicator of High-Grade Rotatory Instability in Anterior Cruciate Ligament-Deficient Knees.

Understanding drivers of supply and labor cost variation in orthopaedic surgery is crucial to provide value-based care. Time-driven activity-based costing (TDABC) is a more accurate methodology for capturing costs of care than traditional methods. Anterior cruciate ligament reconstruction (ACLR) is one of the most performed outpatient procedures within orthopaedic surgery. The purpose of this study was to characterize the cost composition of ACLR and identify factors that drive cost variation. Cost data for supplies and time-based personnel usage were extracted from electronic health records and were used to calculate costs using TDABC. TDABC methodology was applied to calculate the cost of personnel usage by multiplying the duration and associated cost per minute. Descriptive statistics and mixed-effects modeling were used to determine cost drivers. This study included 861 patients who underwent ACLR at 8 hospitals. The mean patient age (and standard deviation) was 31.1 ± 11.6 years. Of the 861 patients, 350 were male and 511 were female; 85.6% of patients were White, 8.1% were Asian, and 3.4% were Black. There was 3.2-fold variation in supply costs ($2,950) and 1.6-fold variation in labor costs ($940) between the 10th and 90th percentiles. Overall, supply costs accounted for 58.2% of total costs, whereas labor costs comprised the remaining 41.8%. The intraoperative phase was the greatest generator of total cost (89.7%). After adjusting for surgeon and hospital variability, variation in total cost was most effectively explained by graft type, primary surgery status, and meniscal repair (conditional R2 = 0.84; marginal R2 = 0.27). On subanalysis, patients undergoing allograft ACLR had significantly higher total costs, implant costs, and age compared with those undergoing ACLR with any autograft type (all p < 0.01). The most notable drivers of labor and supply cost variation were graft type, surgeon, surgery center, primary surgery status, and concomitant meniscal repair. Understanding modifiable cost drivers may aid health systems in designing value-based pathways, implant formularies, and surgeon education programs. Future studies may integrate cost with outcome measures for a more holistic view of value. Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior cruciate ligament reconstruction remains the standard treatment for symptomatic anterior cruciate ligament deficiency in active patients, and graft selection continues to influence postoperative stability, donor-site morbidity, and return-to-sport outcomes. This review summarized the anatomy and function of the anterior cruciate ligament, the epidemiology, diagnosis, and treatment principles of anterior cruciate ligament rupture, and the current role of superficial quadriceps tendon graft in reconstruction. The available literature showed that superficial quadriceps tendon graft provided a large cross-sectional area, predictable graft diameter, and favorable biomechanical properties with lower anterior knee pain and less donor-site morbidity than bone-patellar tendon-bone grafts. When compared with hamstring grafts, quadriceps-based grafts achieved similar or better stability while preserving hamstring strength. Compared with allografts, synthetic grafts, and xenografts, superficial quadriceps tendon autograft generally showed more reliable biologic incorporation and lower failure risk in young or high-demand patients. Overall, superficial quadriceps tendon graft appeared to be a strong and safe option for primary anterior cruciate ligament reconstruction, although further long-term studies and standardized harvesting techniques are still needed. Keywords: anterior cruciate ligament, ACL reconstruction, superficial quadriceps tendon, quadriceps tendon graft, autograft

Five-year ACL-RSI scores are associated with patient-reported outcomes after ACL reconstruction.

Background and Aims: Lateral extra-articular tenodesis (LET) is increasingly used as an adjunct to anterior cruciate ligament reconstruction (ACLR) to reduce graft failure, particularly in high-risk patients. Multiple femoral fixation techniques for LET have been described; however, their relative effectiveness in improving graft survivorship and associated complications remains unclear. Materials and Methods: A systematic review and meta-analysis were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were searched for studies comparing ACLR with and without LET using the modified Lemaire technique. Subgroup analyses were conducted based on femoral fixation method, graft type, reconstruction setting (primary vs. revision), and level of evidence. The primary outcome was anterior cruciate ligament (ACL) graft failure. Pooled odd ratios (ORs) were calculated using a random-effects model. Results: Eleven studies encompassing 2208 knees were included. Overall, ACLR augmented with LET significantly reduced graft failure compared with isolated ACLR (OR, 0.45; 95% confidence interval [CI], 0.30–0.68; P = 0.0002). Subgroup analysis demonstrated a significant reduction in failure rates with anchor fixation (OR, 0.31; 95% CI, 0.13–0.75) and staple fixation (OR, 0.43; 95% CI, 0.23–0.79). Screw, button, and suture fixation did not demonstrate statistically significant reductions in graft failure. No significant heterogeneity was observed across analyses. Conclusion: LET augmentation significantly improves ACL graft survivorship compared with ACLR alone. Anchor and staple femoral fixation methods demonstrate the greatest clinical benefit; however, overlapping confidence intervals preclude definitive superiority of one technique.

Introduction Persistent neuromuscular deficits following anterior cruciate ligament reconstruction (ACLR) impair dynamic stability and sport-specific performance in volleyball athletes who rely on repetitive jumping and single-leg control. Reactive neuromuscular training (RNT) using TheraBand-mediated perturbations may enhance sensorimotor integration, yet evidence in male volleyball players during late-stage rehabilitation (6–12 months post-ACLR) remains limited. This study evaluated the effects of an eight-week TheraBand-based RNT program on dynamic balance and functional performance. Methods A quasi-experimental pre-test/post-test design was used with 30 male volleyball players (18–30 years) allocated to an experimental group ( n = 15) or control group ( n = 15). The experimental group completed 16 supervised RNT sessions (two 40-minute sessions per week) incorporating progressive TheraBand perturbations during squats, lunges, and single-leg landings. The control group maintained routine activity. Outcomes, assessed on the reconstructed limb, included Y Balance Test composite score (%), triple hop distance (cm), single-leg hop time for 6 m (s), and countermovement vertical jump height (cm). Within-group changes were analyzed with paired-samples t -tests; between-group differences were examined using ANCOVA with baseline adjustment (α = 0.05). Results The experimental group demonstrated significant improvements in dynamic balance ( p &amp;lt; 0.001), triple hop distance ( p = 0.022), single-leg hop time ( p = 0.015), and vertical jump height ( p = 0.014), whereas no significant changes occurred in the control group (all p &amp;gt; 0.05). ANCOVA revealed significant group effects favoring RNT for all outcomes ( F (1,27) = 5.67–8.66, p = 0.007–0.024, ηp 2 = 0.174–0.243). Discussion An eight-week TheraBand-based RNT program produced clinically meaningful short-term gains in balance and functional performance. These findings support integration of perturbation-based training into late-stage ACLR rehabilitation in male volleyball players, although longer-term studies are required to confirm retention and return-to-sport benefits.

Background and Aims: Anterior cruciate ligament reconstruction (ACLR) is commonly performed using autografts. Hamstring tendon (HT) grafts are traditionally favored, and in recent times, quadriceps tendon (QT) grafts are gaining popularity. This systematic review and meta-analysis aimed to compare patient-reported outcomes, graft failure rates, adverse events, and donor site morbidity between QT and HT autografts in primary ACLR. Materials and Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Multiple databases were searched to identify randomized controlled trials (RCTs) comparing QT and HT autografts in primary ACLR. Outcomes included International Knee Documentation Committee (IKDC) scores, Lysholm Knee Questionnaire, Tegner Activity Scale, graft failure rates, adverse events, and donor site morbidity. Meta-analysis was performed using standardized mean differences and odds ratios with assessment of heterogeneity. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Results: Six RCTs comprising 426 patients were included. Meta-analysis demonstrated no significant differences between QT and HT autografts in IKDC scores, Lysholm scores, or Tegner activity levels at final follow-up. Graft failure rates and overall adverse event rates were also comparable between groups. However, QT autografts were associated with significantly lower donor site morbidity scores at 24 months. The overall quality of evidence ranged from low to moderate, with generally low heterogeneity across pooled outcomes. Conclusion: QT autografts provide clinical outcomes, graft survival, and safety profiles comparable to HT autografts in primary ACLR, with the added advantage of reduced donor site morbidity. These findings support that QT autografts are a safe and effective alternative to HT autografts.

Posterior tibial slope (PTS) is a well-established anatomic risk factor for anterior cruciate ligament (ACL) graft failure. Lateral extra-articular tenodesis (LET) is increasingly used as an adjunctive procedure in high-risk patients to reduce rerupture rates; however, how its protective effect varies across the continuum of slope values remains insufficiently characterized. To determine how PTS modifies the protective effect of LET in high-risk patients and to evaluate the influence of PTS on graft failure across different risk profiles. Cohort study; Level of evidence, 3. A retrospective cohort of 585 patients who underwent primary ACL reconstruction (ACLR) with hamstring tendon autografts between 2014 and 2017 was analyzed at a minimum follow-up of 6 years. Patients were nonrandomly allocated according to predefined clinical risk criteria into a low-risk group (isolated ACLR) and a high-risk group (ACLR + LET). A graft rerupture was defined clinically and confirmed by imaging. Multivariable logistic regression was used to assess the association between PTS and graft failure. Restricted cubic spline regression was also used to explore nonlinear relationships and identify slope ranges associated with low and high failure probabilities. PTS independently predicted a graft rerupture in both groups, with a stronger effect in the high-risk group (adjusted odds ratio, 1.63; P = .005) compared with the low-risk group (adjusted odds ratio, 1.21; P = .029). The relationship between PTS and graft failure was nonlinear. In the high-risk group, the lowest failure probabilities were observed within a PTS range of 5° to 9°, below which the risk of failure plateaued. In contrast, PTS values exceeding 11° to 12° were associated with high failure probabilities in both groups. PTS was independently associated with graft failure in both groups. Although LET was associated with lower failure probabilities within a moderate slope range, increasing PTS values were linked to a progressively higher risk of reruptures in both groups. The association between a steeper slope and failure observed in the ACLR with LET group suggests that an elevated PTS may attenuate the relative protective effect of LET.

Serial Changes in Graft Diameter Following Anterior Cruciate Ligament Reconstruction Using Allograft.

The existing body of evidence referring to the return-to-sport (RTS) outcomes and psychological readiness to return to sport after revision compared to the primary anterior cruciate ligament (ACL) reconstruction has not yet been comprehensively synthesized. To examine RTS outcomes and psychological readiness to return to sport after revision compared to the primary ACL reconstruction. A comprehensive search of Web of Science, EMBASE, and PubMed was carried out up to November 15, 2024. Observational studies that compared revision and primary ACL reconstruction regarding RTS outcomes and psychological readiness to return to sport were considered adequate for inclusion. The Methodological Index for Non-Randomized Studies and Grading of Recommendations Assessment, Development, and Evaluation were used to assess methodological quality as well as the overall strength and quality of evidence of involved studies, respectively. A total of 19 studies fulfilled the eligibility criteria and were included in the quantitative analysis. There were 3209 athletes with a history of revision and primary ACL reconstruction (mean age: 26.0 ± 6.5 years; 78% males). The main findings indicated that individuals who were subjected to revision ACL reconstruction had slightly lower odds of RTS (-6%; odds ratio (OR) = 0.66 [95% confidence interval (CI) 0.49 to 0.89]), slightly lower odds of RTS at the preinjury level of competition (-5%; OR = 0.52 [95% CI 0.36 to 0.76]), slightly prolonged RTS time (1.2 months; standardized mean differences (SMD) = 0.38 [95% CI 0.12 to -0.63]), and moderately lower psychological readiness to return to sport (-14.2 points; SMD = -0.75 [95% CI -1.14 to -0.36]) relative to their counterparts who were subjected to the primary ACL surgery. Athletes who underwent the revision ACL surgery had a 6% reduced rate of RTS, 5% lower rates of RTS at the preinjury level of competition, 1.2 months extended RTS time, and 14.2 points decreased psychological readiness to return to sport relative to the respondents with a history of the primary ACL reconstruction. PROSPERO registration number CRD42024600347.

Higher posterior tibial slope (PTS) is associated with a greater rate of failure in meniscus root tears and anterior cruciate ligament reconstruction. To analyze the correlation of PTS with patient-reported outcomes (PROs) and rates of reoperation and failure in meniscal allograft transplantation (MAT). Cohort study (prognostic); Level of evidence, 3. A retrospective review of a prospectively maintained database was performed to assess outcomes after MAT in patients between 2003 and 2021 with minimum 2-year follow-up. PTS was measured on lateral knee radiographs, with medial PTS (MPTS) and lateral PTS (LPTS) measured on magnetic resonance imaging (MRI). PROs were collected preoperatively and at minimum 2-year follow-up. MAT failure was defined as revision MAT or conversion to arthroplasty. Multivariable regression was used to correlate PTS with PROs and rates of reoperation and failure. Failure and reoperation were further analyzed separately in medial and lateral MATs for MPTS and LPTS. In total, 175 knees (174 patients) met inclusion criteria with a mean ± SD age of 27.4 ± 9.1 years and follow-up of 8.3 ± 3.8 years. By radiograph, the mean PTS was 8.8°± 3.2°; by MRI, the mean MPTS and LPTS were 5.1°± 2.7° and 5.8°± 3.3°, respectively. MRI measurements significantly underestimated radiographic measurements by 3.3°± 2.9°. Correlation coefficients demonstrated weak to moderate correlations between radiograph and MRI measurements, while intraclass correlation coefficients ranged from 0.920 to 0.931 for intrarater reliability and 0.855 to 0.952 for interrater reliability within MRI or radiographic measurements. There was no association between PTS and postoperative PROs. Sixty cases (34.3%) resulted in reoperation at a mean 2.5 ± 2.8 years, and 8 cases (4.6%) experienced failure at 8.9 ± 2.9 years. Higher radiographic PTS and MPTS were associated with greater odds of reoperation (odds ratio [OR], 1.126 [P = .024]; OR, 1.166 [P = .013]) and failure (OR, 1.654 [P = .001]; OR, 1.712 [P < .001]). Higher LPTS was associated with greater odds of failure (OR, 1.279; P = .018). In medial MAT, MPTS was associated with higher odds of reoperation and failure. Increased PTS, as measured by radiographs and MRI, is correlated with greater risk of reoperation and failure after MAT, with increased MPTS on MRI significantly associated with medial MAT reoperation and failure. There is good to excellent inter- and intrarater reliability for radiographic and MRI PTS measurements, although MRI underestimates radiographic PTS on average 3.3°.

Restoring muscle strength in the injured knee is a primary rehabilitation goal following anterior cruciate ligament reconstruction (ACLR). However, even when standard rehabilitation criteria, such as muscle strength and hop distance, are achieved, many patients still exhibit landing mechanical asymmetries, suggesting that the conventional limb symmetry index (LSI), although reflective of strength recovery in the involved limb, fails to capture neuromuscular control deficits during functional tasks. Currently, the relationship between knee muscle strength symmetry and landing mechanics symmetry remains unclear. The purpose of this study is to evaluate lower limb mechanic asymmetry during single-leg drop-landing, and to determine the relationship between symmetry in isokinetic knee strength and landing mechanic asymmetry upon return to sport (RTS) following ACLR. The cross-sectional study entailed a total of 40 participants at the time of RTS following ACLR (Graft type: hamstring tendon; time since surgery: 9.7 ± 3.4 months) and 20 control participants. Isokinetic concentric contractions of the knee flexors and extensors were performed at an angular velocity of 60°/s on each leg. The LSI [LSI = (involved/uninvolved)[Formula: see text]100%] was calculated for isokinetic quadriceps and hamstring strength, which was then used to divide the ACLR participants into high-symmetry (ACLR-HS, LSI ≥ 85% for both the quadriceps and hamstring) and lower-symmetry (ACLR-LS, LSI < 85% for either the quadriceps or hamstring) subgroups. Three-dimensional kinematic data and ground reaction force (GRF) data were collected for the bilateral lower limbs of all participants during the single-leg drop-landing task. Group differences were compared by use of one-way ANOVA, and Pearson correlations were performed to examine the associations between muscle strength symmetry and landing mechanic asymmetry of the measured variables in three groups. Both the ACLR-HS [peak knee extension moments: p = 0.007; peak vertical ground reaction force (PVGRF): p < 0.001)] and ACLR-LS (peak knee extension moments: p = 0.001; PVGRF: p < 0.001) groups demonstrated lower peak knee extension moments and PVGRF in the involved limb during landing compared with the control group's dominant limb. Compared with the control group, the ACLR-LS group also demonstrated greater asymmetry during landing in knee extension moment (p = 0.001) and knee valgus moment (p = 0.007). No significant correlations were found between quadriceps and hamstring strength symmetry and landing mechanics asymmetry across all variables at RTS among three groups. Restoring strength symmetry alone does not guarantee comprehensive functional recovery. To optimize outcomes, clinical decision-making should systematically integrate multidimensional indicators to promote comprehensive functional recovery and ensure a safe RTS following ACLR.