Contralateral Anterior Cruciate Ligament Tear Research Articles

Anterior Cruciate Ligament Reconstruction in Young Female Athletes: Patellar Versus Hamstring Tendon Autografts

Background: Female athletes are 2 to 8 times more prone to anterior cruciate ligament (ACL) rupture than males. Furthermore, reinjury to the ipsilateral or contralateral knee can occur in >20% of athletes. Female sex and younger age are known risk factors for graft failure. The optimal graft choice for young females remains unknown and poorly studied. Purpose/Hypothesis: The authors aimed to compare clinical outcomes in young females who underwent ACL reconstruction (ACLR) with bone–patellar tendon–bone (BTB) and quadrupled hamstring (HS) autografts. It was hypothesized that no significant differences in outcomes exist between graft choices. Study Design: Cohort study; Level of evidence, 3. Methods: Female patients aged 15 to 25 years who underwent primary ACLR with BTB or HS autograft were included for review. Patients were subdivided into 2 age groups: 15 to 20 years and 21 to 25 years. The occurrence of chondral, meniscal, or ligamentous injury to either knee was recorded for comparison. Results: A total of 256 females were included (BTB, n = 175; HS, n = 81). The majority of patients were between the ages of 15 and 20 years (BTB, 80%; HS, 77.8%). Overall, graft rupture occurred in 23 patients (9%) and contralateral ACL tear occurred in 18 (7%). Subgroup analysis showed that 75% of BTB and 100% of HS graft retears occurred in females aged 15 to 20 years. Within this age group, there was a significantly lower rate of graft ruptures in the BTB group (6.4%) as compared with the HS group (17.5%, P = .02). Allograft augmentation was used in 4 of the 11 HS grafts that retore. When allograft-augmented grafts were excluded, there was no significant difference in graft failure rate between graft choices. Fifteen patients in the BTB group (12%) as opposed to 1 in the HS group (2%) reported extreme difficulty or the inability to kneel on the front of the knee (P = .04). Conclusion: In females aged 15 to 20 years undergoing ACLR, BTB autograft may lead to fewer graft ruptures than HS autograft. While this difference was not observed in females aged 21 to 25 years, a larger sample may be required to accept the null hypothesis in this age group. BTB autograft significantly increased the risk of kneeling pain as compared with HS regardless of age.

Allograft Augmentation of Hamstring Anterior Cruciate Ligament Autografts Is Associated With Increased Graft Failure in Children and Adolescents

Background: Anterior cruciate ligament (ACL) reconstruction in adolescents is commonly performed with hamstring tendon autografts. Small graft diameter is one risk factor for graft failure and options to upsize the autologous hamstring graft include allograft augmentation and tripling one or both of the hamstring tendons. Purpose: To evaluate the association of upsized hamstring graft constructs and graft rupture after ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed of patients 19 years of age and younger who underwent hamstring autograft ACL reconstruction with or without soft tissue allograft augmentation from 2012 to 2016. All patients were skeletally mature or had less than 2 years of growth remaining. Graft constructs included 4-strand doubled semitendinosus and gracilis autograft (4-STG), 5-strand tripled semitendinosus and doubled gracilis autograft (5-STG), and 6-strand doubled gracilis and semitendinosus autograft augmented with a soft tissue allograft (6-STGAllo). The primary outcome measure was graft rupture. Results: A total of 354 patients with a mean age of 15.3 years (range, 10-19 years) were included. Graft constructs included 4-STG (198 knees), 5-STG (91 knees), and 6-STGAllo (65 knees). The average diameter of the graft constructs was 8.3 mm for 4-STG, 8.9 mm for 5-STG, and 9.2 mm for 6-STGAllo (P < .001). The mean follow-up was 26 months (range, 6-56 months). There were 50 (14%) graft ruptures and 24 (7%) contralateral ACL tears. The graft failure rates were 14% for 4-STG, 12% for 5-STG, and 20% for 6-STGAllo (P = .51). The average time to graft failure was 16 months (range, 2-40 months). After adjusting for age and graft size, patients who had allograft-augmented grafts (6-STGAllo) had 2.6 (95% CI, 1.02, 6.50) times the odds of graft rupture compared with 4-STG. There was no significant difference in failure rate between patients who had 5-STG grafts compared with 4-STG (OR, 1.2; 95% CI, 0.5, 2.7). Conclusion: ACL reconstruction with hamstring tendon autografts augmented with allografts has a significantly increased risk of graft rupture compared with comparably sized hamstring tendon autografts. In situations where the surgeon harvests an inadequately sized 4-strand autograft, we recommend obtaining a larger graft diameter by tripling the semitendinosus rather than augmenting with an allograft.

Eight-year results of transtibial nonanatomic single-bundle versus double-bundle anterior cruciate ligament reconstruction: Clinical, radiologic outcomes and survivorship.

To compare the long term outcomes of transtibial nonanatomic single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. Between January 2008 and September 2010, we retrospectively evaluated 377 patients who underwent primary ACL reconstruction and who were available at 8 years of follow-up. Patients who received transtibial nonanatomic SB ACL reconstruction ( n = 263) were assigned to group SB and DB ACL reconstruction ( n = 114) to group DB. The patients were assessed with the International Knee Documentation Committee (IKDC), the Lysholm scores, Tegner activity score, knee joint stability tests, and patellofemoral osteoarthritis (OA) findings using the Kellgren-Lawrence (K-L) classification. Contralateral ACL (CACL) injury was also evaluated. Thirteen patients underwent revision ACL surgery during the follow-up. Ultimately, 256 patients in group SB and 108 patients in group DB were available at the 8-year follow-up. At final follow-up, the IKDC subjective score ( p = 0.04) and Lysholm score ( p = 0.02) showed significantly superior results in group DB compared to group SB. However, there was no significant difference of Tegner activity score ( p = 0.30), range of motion ( p = 0.81), and knee joint stability tests. There was significant progression of patellofemoral OA between preoperative and final follow-up in ipsilateral knee of both groups but not significant progression in contralateral knee. However, there was no significant difference between the two groups at the follow-up. There were 2.7% ipsilateral ACL graft failure in group SB, compared with 5.2% in group DB ( p = 0.12) and 6.4% CACL tear in group SB, compared with 5.2% in group DB ( p = 0.65). The mean survivorship of ACL graft was 9.47 ± 0.05 years (95% confidence interval (CI), 9.36-9.58) in group SB and 9.87 ± 0.16 years (95% CI, 9.54-10.20) in group DB, and there was no significant difference ( p = 0.25). DB ACL reconstruction resulted in significantly better clinical IKDC subjective scores and Lysholm scores. However, most of the differences in clinical scores were small, and the clinical relevance of this difference is unknown. In addition, there was no significant difference in Tegner activity score, knee joint stability tests, patellofemoral OA, and survivor rate of the ACL graft and CACL after reconstruction after a minimum of 8-year follow-up. Level of Evidence: Cohort study; level of evidence, 3.

Which Children Are at Risk for Contralateral Anterior Cruciate Ligament Injury After Ipsilateral Reconstruction?

Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction. After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival. A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01). After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years. Level III-prognostic study.

PARTIAL TRANSPHYSEAL ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: CLINICAL, FUNCTIONAL, AND RADIOGRAPHIC OUTCOMES

BACKGROUND Partial transphyseal anterior cruciate ligament (ACL) reconstruction is a technique utilized in the skeletally immature population. The femoral tunnel is placed in the distal femoral epiphysis whereas the tibial tunnel is placed in a transphyseal fashion medial to the tibial tubercle. This technique was introduced in an effort to lessen insult to the distal femoral physis of skeletally immature adolescents while also avoiding the technical difficulty of placing an intra-epiphyseal tunnel in the proximal tibia which at times can be non-anatomic. There is limited literature examining this technique. In this study we analyzed the concurrent surgical procedures, re-operation and graft failure rates, and radiographic outcomes in adolescents undergoing partial transphyseal ACL reconstruction. METHODS Consecutive patients undergoing partial transphyseal ACL reconstruction by the two senior authors (NP and CA) were retrospectively reviewed. Inclusion criteria consisted of patients with symptomatic ACL rupture with open distal femoral physes and at least two years of growth remaining by chronologic and physiologic age as determined by growth and pubertal history. All patients received hamstring autograft. Femoral tunnels were drilled in an intra-epiphyseal location utilizing small angle guides under fluoroscopic guidance. Transphyseal tibial tunnels were drilled in standard fashion with a tip-aiming guide while minimizing thermal damage from slow reaming, avoiding horizontal tunnel placement, and using extraphyseal graft fixation to lessen insult to the proximal tibial physis. Radiographic outcomes including bilateral limb length (LL) and alignment as judged by mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA) were measured on long standing anterior-to-posterior (AP) view radiographs. Growth disturbance was defined as = 1 cm leg length discrepancy, = 1 cm difference in MAD, or 5-degree difference in mLDFA or MPTA as compared to the non-operative side and MAD/mLDFA/MPTA outside of established range of normal values. Clinical outcomes including graft failure and need for repeat operation were recorded at each follow-up visit. Operative extremity alignment measurements were compared to non-operative extremity measurements utilizing a paired students t-test. RESULTS Twenty-four patients with average follow up of 31.5 ± 17.1 months met inclusion criteria for this study. Five female and 19 male patients were enrolled consisting of 13 left and 11 right knees. Average age at time of surgery was 12.3 ± 0.9 years (10.1-13.8 years). The average ACL graft size was 7.8 mm ± 0.5 mm (6-9 mm). Ten patients (41.7%) had concurrent meniscal surgery, with seven (29.2%) undergoing partial lateral meniscectomy, two (8.3%) lateral meniscus repairs, and one patient (4.2%) with medial and lateral meniscal repairs. Six patients (25.0%) required re-operation at an average of 29.2 ± 17.3 months (1.5-49.5 months) for removal of hardware (n=3), revision ACL reconstruction (n=2), and meniscus surgery (n=1). Two patients had ACL graft failure (8.3%) during sporting activity and underwent revision ACL reconstruction at 19.7 months and 49.5 months post-operatively. There were no contralateral ACL tears. As shown in Table 1, comparison of the mean alignment and limb length measurements between all patients’ operative to nonoperative extremity revealed no significant difference in femur length, MAD, MLDFA, or MPTA. There was a small but statistically significant difference in operative versus non-operative tibia length (390.2 cm versus 392.4 cm, p=0.0004) and limb length (880.9 cm versus 884.0 cm, p=0.02). In analyzing individual patients’ limb length or alignment differences, five patients (20.8%) were identified with a growth disturbance. One patient had isolated shortening of the operative extremity, two with significant lateral deviation of the MAD, and two with both shortening and lateral MAD translation. No patients had significant side-to-side difference in mLDFA or MPTA. Femoral shortening accounted for the majority of the limb length discrepancy in two of the three patients with significant limb length discrepancy. All patients returned to sport. CONCLUSIONS / SIGNIFICANCE Partial transphyseal ACL reconstruction has a 25.0% re-operation rate, most often for hardware removal, and an 8.3% graft failure rate. Overall, approximately 20% of patients undergoing partial transphyseal ACL reconstruction had a growth disturbance but none required surgical intervention for these disturbances. While the partial transphyseal technique spares the distal femoral physis, femur-dominant limb length discrepancy can still occur. Drilling and graft placement across the tibial physis appears to be safe. Further studies are needed to directly compare the radiographic, functional, and clinical outcomes of partial transphyseal ACL reconstruction with transphyseal and all-epiphyseal techniques in the pediatric population. [Table: see text]

How Does Obesity Impact Pediatric Anterior Cruciate Ligament Reconstruction?

To assess the relationship of elevated body mass index (BMI) on postoperative outcomes, including graft rupture, contralateral anterior cruciate ligament (ACL) tear, new meniscus injuries, isokinetic strength testing, and range of motion (ROM) in a large group of pediatric patients. We also sought to calculate the risk of graft rupture in overweight patients with small femoral or tibial tunnels. The secondary objective was to evaluate the association between BMI and concurrent meniscus tears and the need for meniscectomy at the time of primary ACL reconstruction. We retrospectively reviewed all pediatric patients undergoing primary ACL reconstruction at our institution. BMI percentile for age was used to categorize children as having normal BMI or being overweight or obese per Centers for Disease Control and Prevention guidelines. Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral ACL tear, and meniscus injuries), ROM, and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, logistic regression to control for confounders. Of the 1,056 patients included, 535 (50.7%) were male and 521 were (49.3%) female, with a mean age of 15.1 ± 2.4years. The average BMI was 23.1 ± 4.7. There were 675 (63.9%) children with normal BMI, 228 (21.6%) who were overweight, and 153 (14.5%) who were obese. In multivariate analysis, children with elevated BMI had a higher rate of concurrent meniscus tears compared with those with normal BMI (76.3% vs 70.2%; P= .02) and 1.6 times higher odds of requiring a meniscectomy (95% confidence interval, 1.2-2.2; P < .01). The 723 patients included in the analysis of postoperative complications had a mean follow-up duration of 26.2 ± 3.3months Postoperatively, BMI did not impact the rate of graft rupture, contralateral ACL injury, or new meniscus tears. There was no increased risk of graft failure in overweight children with smaller graft size (≤8mm). There was no clinically relevant difference in postoperative ROM or isokinetic strength testing. After ACL rupture, overweight and obese children sustained more overall meniscus tears and more irreparable meniscus tears than those with normal BMI. Graft size did not impact the risk of early graft failure in overweight patients. With an appropriate rehabilitation protocol, there was no increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in early follow-up. Level III, retrospective comparative study.

Are athletes able to resume sport at six-month mean follow-up after anterior cruciate ligament reconstruction? Prospective functional and psychological assessment from the French Anterior Cruciate Ligament Study (FAST) cohort

BackgroundThe decision to return to sport following anterior cruciate ligament (ACL) reconstruction should not only be based on time since surgery. This study aimed to assess, using isokinetic and neuromuscular (hops) testing in a large group, postoperative objective functional recovery of the knee. The secondary objective was to determine the relationship between psychological, functional scores, and these postoperative tests. MethodsThis prospective study included athletes who underwent surgery between 2013 and 2016 for an isolated full-thickness ACL tear. They received a complete evaluation of functional performance of the knee by isokinetic tests performed on a dynamometer to measure quadriceps and hamstring strength, and neuromuscular assessment based on single-leg hop tests. The main judgment criterion was satisfactory functional recovery (yes/no) defined as a difference of ≤10% both in the quadriceps 60°/s and the single hop at a minimum of four months of follow-up. ResultsA total of 234 athletes were analyzed. The mean age was 28.4 ± 8.6 years. At 6.5 ± 1.7 months mean follow-up, 44 (18.5%) patients had satisfactory functional recovery of the knee. The correlations between isokinetic/hop tests and the different scores were variable. During follow-up, two patients presented with a graft tear and two with a contralateral ACL tear, all in the group with unsatisfactory functional recovery. ConclusionAt a mean of six months after ACL reconstruction, objective functional recovery of the knee was generally unsatisfactory and this seemed to be a risk factor for recurrent tears. Level of evidenceIV; case series.

Clinical and Functional Outcomes of Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years Using Adjustable Suspensory Fixation in Both the Femur and Tibia: A Prospective Study.

Background:The success of anterior cruciate ligament (ACL) reconstruction requires reliable and rigid graft fixation. Cortical suspensory fixation (CSF) devices have become an acceptable alternative to interference screws for soft tissue ACL grafts. However, CSF devices have been reported to be associated with tunnel widening and increased postoperative anterior laxity compared with interference screw fixation. Adjustable CSF devices were introduced to avoid these problems but have been associated with graft lengthening and inconsistent outcomes.Purpose:To (1) report the side-to-side difference (SSD) in anterior laxity at 150 N, clinical scores, and failure rates 2 years after ACL reconstruction with 4-strand semitendinosus autografts using an adjustable CSF device and (2) determine the preoperative factors associated with clinical outcomes.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 131 patients who had undergone primary ACL reconstruction, performed with 4-strand semitendinosus grafts that were secured using Pullup adjustable-length CSF devices with femoral and tibial fixation techniques, were prospectively enrolled in this study; 34 patients were excluded because of contralateral instability or ipsilateral knee injuries that required additional surgery. This left a cohort of 97 patients who were evaluated preoperatively and at 6, 12, and 24 months. The evaluation consisted of measuring the SSD in anterior laxity and patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Lysholm scores). Regression analyses were performed to determine associations between these outcomes and 9 preoperative variables.Results:Only 2 patients could not be reached, 2 could not be evaluated because of contralateral ACL tears, and 2 had graft failure. At 2-year follow-up, the remaining 91 patients had a mean SSD in anterior laxity of 0.8 ± 1.8 mm (range, –4.2 to 5.3 mm), mean IKDC score of 87.6 ± 10.6 (range, 43.7-100.0), and mean Lysholm score of 90.8 ± 9.3 (range, 56.0-100.0). At final follow-up, compared with knees with partial ruptures, those with complete ruptures had equivalent laxity (P = .266) and Lysholm scores (P = .352) but lower IKDC scores (P = .009). Multivariable regression revealed that the IKDC score decreased with increased preoperative laxity (β = –1.35 [95% CI, –2.48 to –0.23]; P = .019).Conclusion:The novel adjustable-length CSF device produced satisfactory anterior laxity and clinical outcomes, with a failure rate of 2.1%, which compare favorably with those reported for nonadjustable CSF devices.

Use of a Modified All-Epiphyseal Technique for Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient.

Background:Multiple surgical approaches have been described for the management of anterior cruciate ligament (ACL) tears in skeletally immature patients.Purpose:To provide a detailed description of a modified all-epiphyseal ACL reconstruction and report early outcomes and complications with this new technique.Study Design:Case series; Level of evidence, 4.Methods:A retrospective review of all skeletally immature patients undergoing ACL reconstruction via a modified all-epiphyseal technique prior to July 2015 was performed. Skeletally immature male patients with a bone age of 8 to 15 years and female patients with a bone age of 8 to 12 years were selectively indicated for this procedure. The surgical technique involved an all-epiphyseal femoral tunnel drilled parallel and distal to the physis as well as an all-epiphyseal tibial tunnel. Both tunnels were placed in the anatomic footprint of the ACL. Tibial fixation was achieved first with a suspensory cortical fixation device followed by fixation on the femur with an interference screw.Results:During the study period, 30 patients with a mean bone age of 11.8 years underwent ACL reconstruction with this physeal-sparing technique; 26 patients (87%) achieved a minimum follow-up of 2 years. At final follow-up, the mean Lysholm score, Single Assessment Numeric Evaluation score, patient satisfaction, return-to-sport rate, and Tegner activity score were 93, 89, 9.2, 94%, and 7.6, respectively. Four graft failures (15%) and 3 (12%) contralateral ACL tears were identified. One patient was noted to have a 12-mm leg-length discrepancy at final follow-up, which required no additional treatment. No other leg-length discrepancies or angular deformities were identified.Conclusion:The modified all-epiphyseal ACL reconstruction technique achieved good functional outcomes, a high rate of return to sport, low failure rates, and low physeal injury rates at a mean follow-up of 3.2 years. Skeletally immature patients with an ACL tear requiring reconstruction pose a unique challenge for sports medicine clinicians. While several previous approaches have been described for this patient population, the proposed benefits of this new technique are that it is anatomic, it is physeal sparing, it uses osseous tunnels, and it provides good initial graft fixation strength.

Pediatric ACL Reconstruction and Return to the Operating Room: Revision Is Less Than Half of the Story.

Although there are several causes of unplanned return to the operating room (RTOR) following pediatric anterior cruciate ligament (ACL) reconstruction (ACLR), prior outcomes studies focus primarily on the risk of graft failure. We sought to comprehensively describe indications for RTOR in pediatric primary ACLR patients, estimate associated rates of RTOR, and assess the impact of concomitant meniscal procedures on these rates. This retrospective cohort study considered patients who underwent primary ACLR at an urban, pediatric tertiary care hospital between 2013 and 2015. Cohorts were defined based on the presence or absence of a concomitant surgical meniscal procedure with the index ACLR. The primary outcome was RTOR for an indication pertaining to ACLR or a potential predilection for knee injury. Cases of RTOR were cataloged and classified according to indication. Survival analyses were performed using the Kaplan-Meier estimation and competing-risks regression. Comparisons of any-cause RTOR rates were done using log-rank tests. After exclusion criteria were applied, 419 subjects were analyzed. RTOR indications were organized into 5 categories. The overall rate for any RTOR by 3 years after surgery was 16.5%. Graft failure and contralateral ACL tear were the most common indications for RTOR, with predicted rates of 10.3% and 7.1%, respectively. ACL graft failure accounted for less than half of RTOR cases cataloged. Patients who had a concomitant meniscus procedure had lower rates of RTOR. Approximately 1 in 6 pediatric ACLR patients underwent ≥1 repeat surgery within 3 postoperative years for indications ranging from wound breakdown to contralateral ACL rupture. While previous studies revealed high rates of complication after pediatric ACLR due primarily to graft failure, we found that re-tear is responsible for less than half of the 3-year RTOR risk. As almost half of re-tears in our sample occurred before clearance to return to full activities, we suspect that the high rate of complication is largely attributable to pediatric patients' high activity levels and difficulties adhering to postoperative restrictions. Early treatment of meniscus pathology may reduce rates of RTOR. Level III-therapeutic.

Predictors of Subsequent Injury After Anterior Cruciate Ligament Reconstruction in Children and Adolescents

Objectives:Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children/adolescents than adults. These re-injuries result in significant time lost from sport, and may contribute to worse long-term outcomes and post-traumatic osteoarthritis. The reasons for higher subsequent injury rates in this unique population are incompletely understood.Methods:We analyzed a single center continuous cohort of patients under the age of eighteen years. Subjects underwent primary ACL reconstruction between 2006 and 2014 with minimum 2-year follow up. Age, sex, graft type, duration of physical therapy, time to return to sport, and length of follow-up were evaluated using multivariable logistic regression modeling to assess their contribution to the risk of subsequent ACL injury.Results:A total of 109 subjects met all study inclusion/exclusion criteria. Eighty-two subjects (75%) had follow-up data and were included in the final analysis. Mean age was 14 +/- 1.9 years (range 8 - 17 years). Mean follow-up was 47.7 +/- 15.6 months (range 28 - 91 months). Seventeen patients (20.7%) sustained an ACL graft rupture, eleven patients (13.4%) sustained a contralateral ACL tear, and one patient (1.2%) sustained both. The combined subsequent injury incidence was 35.4% (29 of 82 subjects). The odds of subsequent ACL injury decreased by 0.29 for every yearly increase in age (OR 0.71, 95% CI 0.53 - 0.92, p = 0.008), and decreased by 0.16 for every monthly increase in time to return to sport (OR 0.84, 95% CI 0.69 - 0.99, p = 0.048). Sex, graft type, duration of physical therapy, sport, and length of follow up did not have a statistically significant impact on the rate of subsequent ACL injury (p > 0.05).Conclusion:Subsequent ACL injuries (ipsilateral or contralateral) are common after primary ACL reconstruction in children and adolescents (combined incidence 35%). Within this high-risk population, younger age and an earlier return to sport portend a higher risk of a second injury.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury.

Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients' preoperative and postoperative sports involvement (primary and secondary sports, number of sports). A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Outcomes in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Patellar Tendon Versus Hamstring Autografts.

Background:Much controversy still exists surrounding graft choice in anterior cruciate ligament (ACL) reconstruction. Over the past decade, an increase in comparative studies with longer follow-up has enhanced our understanding of current graft options and outcomes.Purpose:To describe the long-term comparative outcomes of ACL reconstruction with autograft bone–patellar tendon–bone (BPTB) versus autograft hamstring (HS) ACL reconstruction with regard to clinical and radiographic outcomes.Study Design:Systematic review; Level of evidence, 2.Methods:A search of the PubMed, MEDLINE, Cochrane, and Scopus databases was performed to identify studies in the English language with outcome data comparing ACL reconstruction utilizing autograft BPTB and autograft HS; only studies with a minimum 5-year follow-up were included. Outcome data included failure and complications, manual and instrumented laxity, patient-reported outcomes, and radiographic risk of osteoarthritis.Results:Twelve studies with a total of 953 patients met the inclusion criteria. Of these studies, 8 were level 1 evidence and 2 were level 2. Mean follow-up was 8.96 years (range, 5-15.3 years). No differences in graft failure or manual or instrumented laxity were seen in any studies. Lower clinical outcomes scores and greater motion loss were seen in BPTB patients in 1 and 2 studies, respectively. Two of 4 studies reporting on anterior knee pain, and 3 of 7 that recorded kneeling pain found it more frequently among BPTB patients. One study found significantly increased reoperation rates in HS patients, while another found a similar result in BPTB, and 1 study reported a significant increase in contralateral ACL tears in BPTB patients. Three of 5 studies reporting on radiographic evidence of osteoarthritis noted significantly increased rates in BPTB patients.Conclusion:This systematic review comparing long-term outcomes after ACL reconstruction with either autograft BPTB or autograft HS suggests no significant differences in manual/instrumented laxity and graft failures between graft types. An increase in long-term anterior knee pain, kneeling pain, and higher rates of osteoarthritis were noted with BPTB graft use.

Outcomes and Complications After All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients.

Background:The safest and most effective technique for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients is currently unknown.Purpose:To evaluate the functional and patient-reported outcomes of a specific all-epiphyseal ACL reconstruction technique in which the graft, bone tunnels, and fixation do not cross the knee growth plates.Study Design:Case series; Level of evidence, 4.Methods:Twenty-seven patients (23 boys, 4 girls; mean age, 11 years; range, 8-15 years) underwent an all-epiphyseal ACL reconstruction with a single femoral transverse epiphyseal tunnel and primarily split tibial epiphyseal tunnels. Outcomes were evaluated in terms of the manual Lachman test, range of motion, pain, return to activity, angular or leg-length deformity on imaging, and International Knee Documentation Committee (IKDC) or Pedi-IKDC score an average of 3.8 years postoperatively, with a minimum 2-year follow-up.Results:The mean IKDC score was 94 ± 11. There were no growth arrests, but 3 patients had knee overgrowth, and 2 required a subsequent guided growth procedure. The ACL graft failed in 4 patients (15%), and 2 patients had contralateral ACL tears (7%). There were 5 subsequent ipsilateral meniscal tears, 4 of which were retears of a repaired meniscus. Ipsilateral knee reinjury significantly correlated with the number of associated injuries at the time of index surgery (P = .040) and the number of sports played (P = .029).Conclusion:All-epiphyseal ACL reconstruction resulted in excellent long-term functional outcomes, despite a high rate of complications (48%) and secondary procedures (37%) in this highly active cohort. The incidence of graft failure was similar to other standard ACL reconstruction techniques for patients younger than 20 years.

Double-layer versus single-layer bone-patellar tendon-bone anterior cruciate ligament reconstruction: a prospective randomized study with 3-year follow-up.

To evaluate the clinical results of a randomized controlled trial of single-layer versus double-layer bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Fifty-eight subjects who underwent primary ACL reconstruction with a BPTB allograft were prospectively randomized into two groups: single-layer reconstruction (n=31) and double-layer reconstruction (n=27). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery. Forty-eight subjects (24 in single-layer group and 24 in double-layer group) who were followed up for 3years were evaluated. Preoperatively, there were no differences between the groups. At 3-year follow-up, the Lachman and pivot-shift test results were better in the double-layer group (P=0.019 and P<0.0001, respectively). KT measurements were better in the double-layer group (mean 2.9 versus 1.5mm; P=0.0025). The Tegner score was also better in the double-layer group (P=0.024). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear. In ACL reconstruction, double-layer BPTB reconstruction was significantly better than single-layer reconstruction regarding anterior and rotational stability at 3-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the double-layer group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the double-layer group; however, there were no differences in the other subjective findings.

Are Female Soccer Players at an Increased Risk of Second Anterior Cruciate Ligament Injury Compared With Their Athletic Peers?

Background: Female soccer players have a well-known risk for anterior cruciate ligament (ACL) injury, but few studies have reported on second ACL injuries in this population. Purpose: To (1) report the rates of subsequent ACL injury (ipsilateral graft rupture or contralateral tear) in competitive female soccer players, (2) compare these rates with those of other female athletes of similar competitive level, (3) determine risk factors for second ACL injury, and (4) report clinical outcome scores in this population. Study Design: Cohort study; Level of evidence, 3. Methods: The medical records at a single institution were reviewed for female patients who were injured during a competitive athletic event and treated with primary ACL reconstruction (ACLR) between 1998 and 2013. Patients were followed for a mean of 68.8 months postoperatively (range, 24-115.2 months). Clinical outcome was obtained via Lysholm and International Knee Documentation Committee (IKDC) scores. Soccer players were matched 1:1 to non-soccer athletes for age, activity level, and graft type. Results: A total of 180 female ACLR patients with a mean ± SD age of 19.6 ± 6.9 years met the study inclusion and exclusion criteria (90 soccer players and 90 non-soccer players). Soccer players sustained more second ACL injuries, including both graft failures (11% vs 1%; P < .01) and contralateral ACL tears (17% vs 4%; P < .01), compared with non-soccer players. Of the 67 patients who returned to soccer after ACLR (mean age, 17.5 years; range, 13-27 years), significantly more had graft tears compared with those who did not return to soccer (15% vs 0%, respectively; P = .04); however, the difference in contralateral ACL tears (19% for returning players vs 9% for those who did not return; P = .34) was not significant. Relatively older age (odds ratio, 1.5 per year; P = .03) was a significant risk factor for ACL graft tear but not for contralateral ACL injury. Both groups had similar mean Lysholm (96 vs 95) and IKDC scores (95 vs 96) at final follow-up. Conclusion: Twenty-eight percent of all female soccer players and 34% of those players who returned to soccer had a second ACL tear. Soccer players had an increased rate of both graft tear and contralateral ACL injury compared with similar non-soccer athletes. Older age and return to soccer were significant risk factors for graft rupture.

Increased Risk of Second Anterior Cruciate Ligament Injury for Female Soccer Players

Objectives:Female athletes are an at-risk population for anterior cruciate ligament (ACL) injury, with rates of injury significantly higher than the general population. Few studies have reported on a second ACL injury for female athletes. The purpose of this study was to (1) report the rate of subsequent ACL injury (ACL graft rupture or contralateral ACL tear) in competitive female soccer players, (2) compare these rates to those of other female athletes of similar competitive level, and (3) determine risk factors for second ACL injury in this athletic population.Methods:The medical record at our institution was reviewed for patients treated with primary ACL reconstruction between 1998 and 2013. Female patients injured during a competitive athletic event were included for further review, and followed for an average of 7.1 years postoperatively (range 1.0 - 17.7 years). Chi-square analysis was used to compare rate of graft rupture and contralateral ACL injury based on pre-operative Tegner score, graft type, and injury side for soccer players vs. other female athletes. Wilcoxon rank-sum test was used to compare rate of subsequent ACL injury to patient age.Results:337 patients met our inclusion/exclusion criteria (90 soccer players; 247 non-soccer playing athletes) with a mean age of 24.0 years. Of the 337 athletes, 6 were injured during professional competition, 43 were injured during collegiate athletics, 184 during high school play, and 136 during recreational athletics. No patient demographical differences were found at baseline between the soccer group and non-soccer group, including Tegner scores. Overall, 21 soccer players (23.3%) sustained a second ACL injury compared to 21 (8.5%) non-soccer athletes (P < 0.001). Soccer players had significantly more graft ruptures (10.0% vs. 2.0%, P = 0.003) and more contralateral ACL tears (13.3% vs. 6.5%, P = 0.04). Risk factors for ACL graft tear included young age (mean 16.0 vs 24.3 years; P < 0.0001) and higher Tegner Activity Level scores (mean 8.1 vs. 7.4, P = 0.049), but were not risk factors for contralateral ACL injury. Graft selection and injury side showed no statistical significance on graft rupture or contralateral injury.Conclusion:Female soccer players treated with ACL reconstruction had an increased rate of second ACL injury, including graft tear and contralateral ACL injury, compared to a similar group of non-soccer female athletes (23.3% vs. 8.5%, P < 0.001). In addition, young age and higher activity level were risk factors for graft rupture in this population.

Comparison of Three-Dimensional Motion During Side-Step Cutting in Pediatric Athletes with Recent ACL Reconstruction and those with No ACL Surgical History

Objectives:This study assessed differences between pediatric athletes’ anterior cruciate ligament (ACL) reconstructed limb and non-reconstructed limb compared to limbs with no lower extremity surgical history during a side-step cut.Methods:28 limbs with an ACL reconstruction within the 12 months prior to testing (operative limbs), 28 contralateral limbs (non-operative limbs) and 56 limbs with no lower extremity surgical history (control limbs; 28 individuals) were included. Lower extremity kinematic and kinetic 3-dimensional data was recorded during the deceleration phase of a side-step cut. Outcomes were evaluated at initial foot contact and between initial foot contact and maximum knee flexion of the cutting limb. Differences between operative and non-operative limbs and control limbs were assessed using analysis of variance with Bonferroni post-hoc tests.Results:Operative limbs had higher peak hip adduction (-0.14° ± 7.3 vs. -6.1° ± 5.0, =0.01) and higher average external knee valgus moments (0.16 Nm/kg ± 0.50 vs. -0.21Nm/kg ± 0.58, p=0.02) compared to control limbs. In terms of shock absorption, operative limbs had lower peak ground reaction forces (23.2 N/kg ± 4.7 vs. 28.3 N/kg ± 5.8, p<0.0001) and peak ankle dorsiflexion (14.5° ± 7.5 vs. 20.0° ± 6.4, p=0.002) compared to control limbs with lower peak external knee flexor moments (1.4 Nm/kg ± 0.61 vs. 2.0 Nm/kg ± 0.63, p<0.0001) and less power absorption at the knee (0.38 Ws/kg ± 0.31 vs. 0.55Ws/kg ± 0.34, p=0.05) and ankle (0.43 Ws/kg ± 0.21 vs. 0.65 Ws/kg ± 0.41, p=0.01). Though non-operative limbs had less knee valgus (-1.0° ± 3.5 vs. 1.1° ± 3.3, p=0.04) at initial contact, they had higher peak knee valgus (3.6° ± 5.7 vs. 0.58° ± 4.1, p=0.04) and higher average external knee valgus moments (0.09 Nm/kg ±0.59 vs. -0.21Nm/kg ±0.58, p=0.06) compared to control limbs. Non-operative limbs also had less pelvic obliquity compared to control limbs (10.4° ± 5.8 vs. 14.6° ± 7.7, p=0.04). Lower peak ground reaction forces (24.5 N/kg ± 4.5 vs. 28.3 N/kg ± 5.8, p=0.005), increased power absorption at the hip (0.43 Ws/kg ± 0.48 vs. 0.15 Ws/kg ± 0.23, p=0.005), and decreased power absorption at the ankle (0.49 Ws/kg ± 0.23 vs. 0.65 Ws/kg ± 0.41, p=0.09) were seen in non-operative compared to control limbs.Conclusion:Limbs with ACL reconstruction exhibited poorer hip stability compared to control limbs. ACL reconstructed limbs also had less energy absorption at the knee and lower peak vertical ground reaction forces, likely reflecting an avoidance strategy when performing a cut using an ACL reconstructed limb. The uninjured, contralateral limbs of ACL reconstructed patients also demonstrated reduced ground reaction forces and altered neuromuscular control. These changes may reflect overall tentativeness in performing a cut but also suggest baseline suboptimal neuromuscular control that possibly lends insight into the increased risk of contralateral ACL tear seen in patients who have sustained an index ACL tear. It is also possible that the biomechanical strategies present on the operative side could be putting the non-operative limb at risk for injury. These findings support the need for ongoing research into rehabilitation protocols and return to sport timing and also support to existing injury prevention programs.

Case series: Revision anterior cruciate ligament reconstructions using patellar tendon autografts

BackgroundUsing intra-operative findings and clinical results, including return to play (RTP) at the pre-injury level, this study investigated the causes of primary graft failure after revision anterior cruciate ligament (ACL) reconstruction with bone–patellar-tendon–bone (BPTB) autografts. MethodsA total of 54 patients were followed for a mean of 38.2±10.2months post-surgery. Subjective and objective results were evaluated using single assessment numeric evaluation (SANE) scores, Lachman tests, KT-2000 arthrometer results, and pivot-shift tests. The change in each patient's Tegner activity scale and RTP at the pre-injury level were also evaluated. ResultsInappropriate positioning of the tunnels was the most important reason (54%) for primary graft failure. After revision surgery, anterior knee stability was significantly improved (1.2 (mean)±1.2 (SD)mm vs 4.5(mean) ±1.9 (SD)mm; P<0.01). Two (4%) patients sustained revision graft ruptures while two (4%) sustained contralateral knee ACL tears. The rate of RTP at the pre-injury level was 67% (36 patients), and mean SANE scores at the time of RTP were higher than before surgery (74.8±13.8 points vs 24.1±16.4; P<0.001). The average time from primary graft failure to revision surgery was shorter (12.2 (mean)±4.0 (SD) vs 37.6 (mean)±8.8 (SD)months; P<0.01) and the ratio of major cartilage injury was lower (39% vs 83%; P<0.05) in the RTP group than that in the non-RTP group. ConclusionsThe time from primary graft failure to revision surgery and the extent of the cartilage injury are major factors in RTP after revision ACL reconstructions.

Side-step Cutting In Pediatric Athletes With Recent Acl Reconstruction Compared To Those With No Acl Surgical History

PURPOSE: This study assessed differences between pediatric athletes’ anterior cruciate ligament (ACL) reconstructed limb and non-reconstructed limb compared to limbs with no lower extremity surgical history during a side-step cut. METHODS: 28 limbs with an ACL reconstruction within the 12 months prior to testing (operative limbs), 28 contralateral limbs (non-operative limbs) and 56 limbs with no lower extremity surgical history (control limbs; 28 individuals) were evaluated. Kinematic and kinetic data was recorded during the deceleration phase of a cut. Outcomes were evaluated at initial foot contact and between initial foot contact and maximum knee flexion of the cutting limb. Differences were assessed using analysis of variance. RESULTS: Operative limbs had higher peak hip adduction (p=0.01) and average external knee valgus moments (p=0.02) compared to control limbs. In terms of shock absorption, operative limbs had lower peak ground reaction forces (p<0.0001) and peak ankle dorsiflexion (p=0.002) compared to control limbs with lower peak external knee flexor moments (p<0.0001) and less power absorption at the knee (p=0.05) and ankle (p=0.01). Though non-operative limbs had lower knee valgus (p=0.04) at initial contact, they had higher peak knee valgus (p=0.04) and average external knee valgus moments compared to control limbs. Non-operative limbs also had less pelvic obliquity compared to control limbs (p=0.04). Lower peak ground reaction forces (p=0.005), increased power absorption at the hip (p=0.005), and decreased power absorption at the ankle (p=0.09) were seen in non-operative compared to control limbs. CONCLUSIONS: Limbs with ACL reconstruction exhibited poorer hip stability compared to control limbs. ACL reconstructed limbs also had less energy absorption at the knee and lower peak vertical ground reaction forces, likely reflecting an avoidance strategy when performing a cut. The uninjured, contralateral limbs of ACL reconstructed patients also demonstrated reduced ground reaction forces and altered neuromuscular control. These changes may reflect overall tentativeness in performing a cut but also suggest suboptimal neuromuscular control that possibly lends insight into the increased risk of contralateral ACL tear in patients who have sustained an index ACL tear. These findings support the need for ongoing research into rehabilitation protocols and return to sport timing.