Early Anterior Cruciate Ligament Reconstruction Research Articles

Safety and Early Return to Sports for Early ACL Reconstruction in Young Athletes: A Retrospective Study.

Background and Objectives: Although previous reports have shown that early anterior cruciate ligament (ACL) reconstruction is associated with an increased risk of stiffness, recommendations for delayed surgery are based on outdated literature. The advent of arthroscopic surgery and accelerated rehabilitation protocols warrants a reexamination of the optimal surgical timing. The purpose of this study was to investigate complications during early ACL reconstruction after injury in young athletes. Materials and Methods: A total of 87 patients (27 males and 60 females) were included in this study. Patients who underwent anatomic ACL reconstruction using hamstring autografts were evaluated. Patients under 25 years of age with a Tegner activity score greater than 6 were included and classified into three groups according to the time from injury to surgical treatment: one week from injury to surgery (early group), three to six weeks from injury to surgery (normal group), and three to six months from injury to surgery (delayed group). We evaluated the rates of various complications such as graft rupture, contralateral injury, the need for manipulation for loss of ROM, infection, and fracture around the knee up to 2 years postoperatively. In addition, we investigated postoperative muscle strength, Lysholm score, Tegner activity score, and period of the return to sport from injury. Results: Patients in the delayed group were younger than those in the other groups (p = 0.009). Patients in the early group had a lower range of motion than those in the other groups preoperationly. However, the 1-month postoperative range of motion was comparable between groups. Patients in the early group had greater postoperative Tegner activity scores than those in the other groups. The period of return to sport from injury in the delayed group was longer than in the other groups. There were no statistically significant differences in the postoperative complication rate, muscle strength, or Lysholm score. Conclusions: ACL reconstruction performed 1 week from injury to surgery in young athletic patients indicated the rate of complications were not significantly different among the groups. Early ACL reconstruction with no postoperative complications may be related to early return to sports and a high level of sports.

Diameter of Quadrupled Semitendinosus Autograft in Primary Anterior Cruciate Ligament Reconstruction Did Not Impact Early Revision Rate or Functional Outcome in a Large Cohort of Patients

To determine whether the diameter of the quadrupled semitendinosus tendon (ST) graft in primary anterior cruciate ligament reconstruction (ACLR) is related to the risk of revision ACLR within 2 years of primary ACLR, postoperative knee laxity and patient reported knee outcome. Furthermore, to investigate whether smaller graft than estimated is related to revision ACLR. Patients who underwent primary ACLR with a quadrupled ST autograft at our institution, from January 2005 to December 2017 were identified. Data from the Swedish National Knee Ligament Registry (SNKLR) were collected up to two years or until revision surgery was registered within two years after primary ACLR. Knee laxity was assessed, pre-operatively and at 6-months follow up using the KT-1000 arthrometer (134 N anterior tibial load). The Knee injury and Osteoarthritis Outcome Score (KOOS) were collected preoperatively and at two years postoperatively from SNKLR. Based on anthropometric measurements (body height and weight) and sex the estimated quadrupled ST graft diameter was calculated. A total of 4,519 patients who underwent ACLR with a quadrupled ST autograft were included. The mean graft diameter was 8.3 mm± 0.7 mm; 8.0 mm± 0.6 mm for women and 8.6 mm ± 0.7 mm for men. The quadrupled ST graft diameter was not significantly correlated to revision ACLR. There was no significant difference in the ST graft diameter regarding post-operative knee laxity. The correlations between ST graft diameter and KOOS were weak, except for the "Sport and Recreation" subscale (P=.012). The quadrupled ST graft diameter was not significantly related to the need for early revision ACLR nor was related to postoperative knee laxity or patient reported outcome except for the KOOS "Sport and Recreation" subscale. Smaller ST graft than estimated was not a risk factor for revision ACLR. The outcome after ACLR is multifactorial and ST graft diameter is of no significant importance.

Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country

BackgroundThe ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia.MethodsA decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 — three times the Indonesian GDP per capita in 2021 — the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE).ResultsThe early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%.ConclusionsBased on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

Anterior Cruciate Ligament Repair With Suture Tape Augmentation of Proximal Tears and Early Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Result in Comparable Clinical Outcomes With Anterior Cruciate Ligament Reconstruction at 2-Year Follow-Up

To compare the postoperative side-to-side laxity and short-term clinical outcomes of patients who received primary anterior cruciate ligament (ACL) repair with suture tape augmentation, acute anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation performed within 8 weeks of injury (ACLRacute), or ACLR beyond 8 weeks of injury. After institutional review board approval was obtained, 100 patients were enrolled in this prospective trial: 34 primary ACL repair with suture tape augmentation, 33 ACLRs performed within 8 weeks of injury (ACLRacute), and 33 ACLRs. Patients were allocated to ACL repair if a proximal avulsion was present with good tissue quality (Sherman type 1), confirmed by intraoperative diagnostic arthroscopy. Preoperative side-to-side anteroposterior knee laxity was assessed with KT-1000 arthrometer, and patient-reported outcomes (PROs) including the visual analog scale, Marx activity scale, Veterans RAND 12-item health survey (VR-12 physical & mental), Single Assessment Numeric Evaluation, Knee Injury and Osteoarthritis Outcome Score survey subscales, and range of motion were collected. These objective and subjective measures were repeated at regular intervals postoperatively through 2 years. Minimal clinically important difference calculations were performed assessing postoperative PRO changes at 2 years compared with preoperative. The average time from injury to surgery was 5.03 ± 1.2 weeks for the ACL repair group, 5.09 ± 0.74 weeks for the ACLRacute, and 43.22 ± 33.5 weeks for the ACLR group. Postoperatively, the KT-1000 side-to-side laxity difference for 30 lbs was determined to be 0.1 ± 0.37 (95% confidence interval [CI] -0.7 to 0.8) for ACL repair versus ACLR (P < .0001), -0.8 ± 0.35 (95% CI -1.5 to -0.1) for ACLRacute versus ACLR (P < .0001), and 0.8 ± 0.40 (95% CI 0.0-1.6) for ACL repair versus ACLRacute (P < .0001). The data reveal ACL repair and ACLRacute are noninferior to ACLR at 2-year follow-up. The postoperative difference from baseline for all PROs demonstrated improvement for all PROs. Magnetic resonance imaging at 1 year revealed tissue healing for the 3 ACL injury treatment groups. Patients who underwent ACL repair of proximal tears with suture tape augmentation or ACL reconstruction within 8 weeks from injury resulted in noninferior side-to-side knee laxity, comparable PROs, and similar range of motion at 2-year follow-up compared with ACLR. Level II, prospective comparative study.

Steep medial posterior tibial slope angle and ramp lesion are independent risk factors for an increase in quantitatively measured pivot shift in patients with ACL-deficient knees.

Delayed anterior cruciate ligament (ACL) reconstruction often causes residual anterolateral rotatory instability (ALRI) and consequent knee osteoarthritis, warranting the recommendation of early ACL reconstruction within 6 months after injury. Nonetheless, some cases show notable instability, even shortly after injury. The purpose of this study was to identify risk factors for an increase in quantitatively measured pivot shift in patients with ACL-deficient knees within 6 months after injury. Patients with primary ACL reconstruction within 6 months after injury and quantitative triaxial accelerometer measurements of preoperative pivot shift were included. Descriptive statistics were calculated for 11 independent variables (age, gender, time from injury to surgery, KT-1000, knee extension angle, lateral and medial posterior tibial slope angle, medial and lateral meniscus tears, ramp lesion and Tegner active scale). A single regression analysis was performed on the 11 items and acceleration during the pivot shift, and a multiple regression analysis was performed for items with p value less than 0.1. Overall, 111 patients met the inclusion criteria. Single regression analysis showed that medial posterior tibial slope angle, medial meniscus tear and ramp lesion were significantly correlated with acceleration during the pivot shift (p < 0.001, p = 0.04 and p = 0.001). Multiple regression analysis identified medial posterior tibial slope angles and ramp lesions as independent factors for increased preoperative pivot shift (p = 0.005 and 0.01). A steep medial posterior tibial slope angle and ramp lesion were independent risk factors for increased quantitatively measured pivot shift in patients with ACL-deficient knees. Level IV, case series study.

Comparative analysis of five-year outcomes of anterior cruciate ligament tears repaired with different techniques

Introduction Primary repair of the anterior cruciate ligament (ACL) torn from the femur and the synovial membrane being intact can be an indication for two competing methods including dynamic intraligamentary stabilization (DIS) as the saving method and resection of the stump and primary autoplasty as a more traumatic option.The purpose was to evaluate the five-year results of DIS in comparison with early ACL reconstruction of the knee joint.Material and methods A review and statistical analysis of outcomes of 72 patients with ACL injuries (47 males and 25 females) were performed. The patients aged between 18 and 45 years (30.9 ± 8.5), with the length of time from injury ranging from 3 to 21 days (10.6 ± 5.0) and the Tegner activity score of 5 (1–9; 5.8 ± 0.9) prior to injury. DIS was performed for the first group of patients (n = 39) who arthroscopically were diagnosed with ACL torn off the femur with the synovial membrane preserved. Early ACL repair was performed for the controls (second group, n = 33).Results VAS scored 1.4 ± 0.8 in group I and 1.9 ± 0.8 in group II at 6 months, p = 0.004. Patient satisfaction scored 8.0 ± 0.8 in group I and 7.4 ± 0.8 in group II at 12 months, p = 0.003. Tegner activity level scored 6.5 ± 0.9 in group I and 6.3 ± 0.8 in group II at 12 months, p = 0.014. The Lysholm knee score measured 91.1 ± 2.2 in group I and 88.6 ± 3.5 in group II at 12 months, p = 0.001. Five-year dynamic observation showed relapses of anterior-medial instability of the knee joint in 10 patients (13.9 %), with 4 patients in group I (10.3 %) and 6 patients in group II (18.2 %).Discussion Outcomes of proximal ACL tears with intact synovium can be as good as with ACL repair. Removal of the torn cruciate ligament with the synovium being intact and grafting may be an unnecessary and aggressive approach.Conclusion Dynamic intraligamentous stabilization as compared to early ACL repair shows a faster recovery of physical activity at a short term and less relapses of knee joint instability at a long term.

Comparison of efficacy of intrathecal hyperbaric ropivacaine and hyperbaric bupivacaine in terms of enhanced recovery after surgery (ERAS) for ACL reconstructions

: Bupivacaine is the drug of choice in spinal anaesthesia (SA), while Ropivacaine with its comparatively shorter duration of motor block allows early mobilization post ACL reconstruction surgery which is a crucial factor in Early Recovery after Surgery. : In this randomized double-blind comparative study of a total of 60 patients irrespective of gender undergoing ACL reconstruction surgery were studied. After Administration of SA to group R (2.5ml of 0.75% Heavy Ropivacaine) &amp; group B (2.5ml of 0.5% Bupivacaine) both were compared for their post-operative effects with Bromage score, Aldrete score &amp; Visual Analogue Score. : The time required for complete regression of motor blockade in group R (144.5+26.1 mins) &amp;#60; group B (181±21.3mins) which allowed for early mobilization which over all provides better and faster recovery.: Hyperbaric Ropivacaine when compared to Bupivacaine promises better results in terms of early ambulation and intraoperative hemodynamic stability promoting ERAS in patients undergoing ACL reconstruction surgeries. Promoting ERAS policy will reduce the duration of hospital stay, thereby improving the cost-effectiveness of health services.

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.

Comparing Clinical Outcomes of Early and Elective Reconstruction in Patients with Anterior Cruciate Ligament Tears

Purpose: The optimal time of treatment for anterior cruciate ligament tears remains controversial. Two times are early (&lt; 6 weeks) and elective (≥ 6 weeks) reconstruction. This retrospective study tested the hypothesis that clinical outcomes are similar between the two time groups for anterior cruciate ligament reconstruction. Methods: A total of 61 patients were included in this study. Thirty and 31 patients were in the early and elective reconstruction groups, respectively. The collected patient data included a preoperative and 2-year postoperative range of motion, visual analog scale scores, anterior stability tests, and clinical knee scores. Results: There were no significant differences in the 2-year postoperative range of motion, visual analog scale scores, or anterior stability tests. The Lysholm and International Knee Documentation Committee knee evaluation form scores were significantly higher in the early reconstruction group than in the elective reconstruction group. Conclusions: Early anterior cruciate ligament reconstruction is a more effective clinical knee score than elective reconstruction in treating anterior cruciate ligament tears.

Comparing and predicting the outcome of anterior cruciate ligament reconstruction performed within one year and one year after injury

Background: The anterior cruciate ligament reconstruction (ACLR) should not be delay too long to get a good outcome but how long delay could be considered acceptable is not known. The objective of this study was to assess the outcome of surgery performed within and after a year of injury. We also predicted the operative outcome if the surgery is further delayed and several associated factors were also evaluated if they could influence the outcome. Methodology: Thirty-six patients were recruited in the early group where surgery is performed within a year of injury and thirty were in the delayed group where surgery was after a year of injury. Age, sex, body mass index, Tegner activity level and duration from the time of injury to surgery were evaluated. Surgical outcomes were measured at one year follow up after surgery were Lysholm score and limb symmetry index (LSI). Results: Mean time from injury to surgery for early and delayed groups were eight months and 18 months. Timing from injury to surgery affects the outcome parameters. Both groups showed good outcomes but the early group showed better LSI and Lysholm scores (p&lt;0.5). LSI was better in predicting the outcome of surgery compared to Lysholm score (67% vs 43%). Conclusions: Early ACLR showed better outcome but the late ACLR still demonstrate acceptable result in the absent of high grade cartilage lesion. LSI is better at predicting the outcome of surgery. Bangladesh Journal of Medical Science Vol. 22 No. 04 October’23 Page : 876-881

Influence of time from injury to surgery on knee biomechanics during walking in patients with anterior cruciate ligament reconstruction

ABSTRACT The pilot study aimed to determine whether the time from injury to surgery influences on postoperative knee biomechanics during walking in patients with anterior cruciate ligament reconstruction (ACLR). Thirty-two patients with unilateral ACLR (early, 10 patients; delayed, 22 patients) and 30 control subjects participated in this study. All examinations for patients with ACLR were performed preoperatively and at 12 months postoperatively and comprised passive knee joint laxity, knee muscle strength, and knee kinematics and kinetics during walking. At both time points, there were no significant differences in passive knee joint laxity and knee muscle strength between the early ACLR and delayed ACLR groups. Preoperatively, both the early ACLR and delayed ACLR patients exhibited significantly reduced knee extension movement from midstance to terminal stance compared to the control subjects. Moreover, the delayed ACLR patients exhibited significantly decreased peak external knee flexion moment compared to the control subjects. At 12 months postoperatively, the early ACLR patients showed significant improvement in knee extension movement from midstance to terminal stance compared to pre-ACLR, while the delayed ACLR patients did not show significant improvement in this knee extension movement. It can be concluded that early ACLR may be more beneficial to improve knee biomechanics during walking.

More than six months delay in anterior cruciate ligament reconstruction is associated with a higher risk of pre-reconstruction meniscal and chondral damage

Background: There is no consensus regarding the optimal timing of anterior cruciate ligament reconstruction (ACLR) and its clinical importance. Here, we compared the rate of the pre-reconstruction meniscus and cartilage injury, also the knee function, between the early ACLR (within six months of injury) and late ACLR (after six months of the injury). Methods: Retrospectively, 192 patients with an ACL tear who underwent ACLR within six months of injury (n=53) or after six months of injury (n=132) were included. Autograft bone patellar tendon bone was used as the graft choice. The rate of pre-reconstruction meniscal injury and chondral damage (Outerbridge classification) was compared between the two groups. The knee function, evaluated in the last follow-up using the Lysholm knee scale, was also compared. Results: The mean time from injury to surgery was 3.9±1.3 mo in the early group and 8.8±2.3 mo in the late group The pre-reconstruction meniscal injury was detected in 24 (45.3%) patients in the early ACLR group and 93 (66.9%) patients in the late ACLR group (P=0.006). Pre-reconstruction chondral damage was detected in six (11.3%) patients of the early ACLR group and 32 (23%) patients of the late ACLR group (P=0.049). The mean Lysholm knee scale was 86.7±6 (range 82-92) in the early ACLR group and 81.9±4.4 (range 80-84) in the late ACLR group (P&lt;0.001). Conclusion: The higher rate of pre-reconstruction meniscal and chondral damage and lower functional score in the late ACLR group suggests avoiding ACLR delay more than six months after the injury. Level of Evidence: IV.

Poster 315: Fifteen-Year Radiographic Follow-Up of a Prospectively Randomized Clinical Trial Comparing Early versus Delayed Anterior Cruciate Ligament Reconstruction.

Objectives: Post-traumatic osteoarthritis (PTOA) after anterior cruciate ligament (ALC) injury remains a difficult problem. PTOA is considered to be the consequence of an initial mechanical disruption or injury to the cartilage. Recent literature has suggested that 50-60% of reconstructed knees demonstrate post- traumatic arthritis at long term follow up. Several studies evaluating synovial fluid have suggested that inflammatory cytokines present after injury may contribute to post-traumatic arthritis. Therefore, the purpose of this study was to compare the rate of post-traumatic osteoarthritis between acutely reconstructed ACLs (within 21 days) and delayed ACL reconstructions (greater than 6 weeks). Methods: This study is a retrospective review of a previous prospectively randomized controlled clinical trial where ACL reconstructions were randomized to either early (within 21 days) or delayed (beyond 6 weeks) reconstruction using hamstring autograft. Bilateral weight bearing radiographs were obtained at a minimum of 15-year follow-up. Radiographs were analyzed using the Kellgren-Lawrence classification system by a musculoskeletal radiologist. Seventy patients were enrolled in the study and 1 was excluded because of infection. Therefore, the original study cohort consisted of sixty-nine patients (34 acute, 35 delayed) with an average of 27.3 years at the time of surgery. Follow-up radiographs were obtained for 58 total patients (28 acute, 30 delayed). Results: The average time from injury to surgery in the acute group was 9 days (2-18) and 85 days (42- 192) in the delayed group. At an average follow up of 15.6 years, post-operative radiographs were obtained in a total of 58 patients (28 acute, 30 delayed). In the acute cohort, 53.5% of patients had greater than Grade 3 PTOA compared to 60.0% in the delayed cohort (p=0.1). In the acute cohort, 42.8% (12/28) had Grade 3 PTOA and 10.7% (3/28) had Grade 4 PTOA compared to 46.7% (14/30) Grade 3 PTOA and 13.3% (4/30) Grade 4 PTOA in the delayed cohort (p=0.1). Four patients in the delayed cohort had undergone a total knee arthroplasty compared to 2 patients in the early cohort. In the acute cohort, the average KOOS score was 61.7% in patients with &gt; Grade 3 PTOA compared to 80.6% in those with &lt; Grade 3. In the delayed cohort, in the average KOOS was 56.8% in patients with &gt; Grade 3 PTOA compared to 77.9 in those with &lt; Grade 3. Conclusions: In conclusion, we found that early ACL reconstruction resulted in no difference in the rate of post-reconstruction osteoarthritis of the knee compared to delayed reconstruction. At fifteen-year radiographic follow-up, both cohorts resulted in high rates of post-traumatic osteoarthritis. Furthermore, patients with greater than Grade 3 PTOA demonstrated worse KOOS scores in both cohorts.

Treatment for Acute Anterior Cruciate Ligament Tear in Young Active Adults

BackgroundAnterior cruciate ligament (ACL) injury of the knee is common in young active adults and often has severe and sometimes lifelong consequences. The clinical management of this injury remains debated. A prior trial of early versus delayed optional ACL repair showed no differences in outcomes at 2 years.MethodsWe present the 11-year follow-up of a randomized clinical trial involving 121 young active adults (mean age 26yo, 74% male) with an acute sports-related ACL tear. We compared patient-reported and radiographic outcomes between those randomized to receive early ACL reconstruction (ACLR) followed by exercise therapy (N=62) and those treated with early exercise therapy plus optional delayed ACLR (N=59). The primary end point at 11 years was change from baseline in the mean of four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) — pain, symptoms, function in sports and recreation, and knee-related quality of life (KOOS4; range of scores, 0 [worst] to 100 [best]; minimal important change=9).ResultsIn all, 88% of the cohort followed up at 11 years (53/62 in the early vs. 54/59 in the optional late ACL repair groups), and 52% of those assigned to optional delayed ACLR underwent ACLR. Mean improvement in KOOS4 from baseline to 11 years was 46 points for those assigned to early ACLR plus exercise therapy and 45 points for those assigned to exercise therapy plus optional delayed ACLR (between-group difference, 1.6 points; 95% confidence interval [CI], −8.8 to 5.6; P=0.67 after adjustment for baseline score, full analysis set). About two thirds of the full cohort reported meeting the case definition for a “patient-acceptable symptom state” (KOOS4 patient-acceptable symptom state threshold value=79), whereas 44% had developed radiographic osteoarthritis of their injured knee. Mean summed incident radiographic osteoarthritis feature scores, scores range from 0 to 30 where higher scores indicate more severe joint damage, were 2.4 for the group assigned to early ACLR and 1.0 for the group assigned to exercise therapy plus optional delayed ACLR (mean difference, 1.0; 95% CI, 0.1 to 1.9).ConclusionsAt 11-year follow-up, among young active adults with acute ACL tears assigned to early ACLR plus exercise versus initial exercise therapy with the option of delayed ACLR, there were no differences in patient-reported outcomes. (Funded by the Swedish Research Council; ISRCTN number, ISRCTN84752559.)

EE365 Cost-Utility Analysis of Early Reconstruction Surgery Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears in Low and Middle-Income Country

Considerable debate remains regarding the preferred strategy for managing individuals following an ACL tears. This study aimed to determine the more cost-effective strategy between early ACL reconstruction surgery (early ACLR) versus rehabilitation plus optional delayed reconstruction (rehabilitation) for ACL tears in LMIC, focusing on Indonesia.

Long-term outcomes of lateral femoral notch after early anterior cruciate ligament reconstruction

To investigate the outcome of lateral femoral notch (LFN) after early anterior cruciate ligament (ACL) reconstruction and evaluate the recovery of knee joint function after the operation. The clinical data of 32 patients who underwent early ACL reconstruction from December 2015 to December 2019 were retrospectively analyzed. The study included 18 males and 14 females, aged 16 to 54 years old, with an average age of (25.39±2.82) years. The body mass index (BMI) of the patients ranged from 20 to 30 kg/cm2, with an average of (26.15±3.09) kg/cm2. Among them, 6 cases were caused by traffic accidents, 19 by exercise, and 7 by the crush of heavy objects. MRI of all patients showed LFN depth was more than 1.5 mm after injury, and no intervention for LFN was performed during surgery. Preoperative and postoperative depth, area, and volume of LFN defects were observed by MRI data. International Cartilage Repair Society (ICRS) score, Lysholm score, Tegner activity levels, and knee injury and osteoarthritis outcome score (KOOS) were analyzed before and after the operation. All patients were followed up from 2 to 6 years with an average of (3.28±1.12) years. There was no significant difference in the defect depth of LFN from (2.31±0.67) mm before the operation to (2.53±0.50) mm at follow-up (P=0.136). The defect area of LFN was decreased from (207.55±81.01)mm2 to (171.36±52.69)mm2 (P=0.038), and the defect volume of LFN was decreased from (426.32±176.54) mm3 to (340.86±151.54)mm3 (P=0.042). The ICRS score increased from (1.51±0.34) to (2.92±0.33) (P<0.001), the Lysholm score increased from (35.37±10.54) to (94.46±8.45) (P<0.001), and the Tegner motor score increased from (3.45±0.94) to (7.56±1.28), which was significantly higher than that of the preoperative data (P<0.001). The KOOS score of the final follow-up was 90.42±16.35. With the increase of recovery time after anterior cruciate ligament reconstruction, the defect area and volume of LFN decreased gradually, but the defect depth remained unchanged. The knee joint function of the patients significantly improved. The cartilage of the LFN defect improved, but the repair effect was not good.

Early ACL reconstruction shows an improved recovery of isokinetic thigh muscle strength compared to delayed or chronic cases

IntroductionThe recovery of periarticular strength is a major criterion in return-to-play testing. The rationale of the study was to assess the impact of the delay of surgery (∆ between injury and surgery) on knee extensor and knee flexor strength of anterior cruciate ligament (ACL)-deficient patients six months after reconstruction.Materials and methodsIn a retrospective cohort study, all patients with ACL ruptures between 03/2015 and 12/2019 were analyzed. Inclusion criteria were isolated ACL rupture without any associated lesions undergoing a reconstruction using ipsilateral hamstring tendon autograft and adherence to isokinetic strength testing before and at 5–7 months postoperatively. These patients were then clustered into three groups: EARLY reconstruction (∆ < 42 days), DELAYED reconstruction (∆42-180d), and CHRONIC (∆ > 180d). Knee extensor and flexor strength of the ipsi- and contralateral leg were analyzed by concentric isokinetic measurement (60°/s). Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q) ratio), and the corresponding limb symmetry indices.Resultsn = 444 patients met the inclusion criteria. From EARLY to DELAYED to CHRONIC, a progressive reduction in postoperative strength performance was observed in knee extension (1.65 ± 0.45 to 1.62 ± 0.52 to 1.51 ± 0.5 Nm/kg resp.) and flexion (1.22 ± 0.29 to 1.18 ± 0.3 to 1.13 ± 0.31 Nm/kg resp.) strength on the ACL reconstructed leg. This general loss in periarticular strength was already apparent in the preoperative performance even on the healthy side. When controlling for the preoperative performance using ANCOVA analysis, EARLY performed significantly better than DELAYED (extension p = 0.001, flexion p = .02) and CHRONIC (extension p = 0.005, flexion p < 0.001). Also, there were significantly higher values for H/Q ratio in the injured leg across all groups where the H/Q ratio increased from EARLY to CHRONIC and from pre- to postoperative values.ConclusionsWith respect to the force generating capacity when returning-to-play, it is advantageous to seek for an early ACL reconstruction within the first 12 weeks after the injury. The increasing loss of thigh muscle strength observed in delayed or chronic cases affects the injured and also the non-injured leg.Level of EvidenceIII, retrospective cohort study.

RISK FACTORS FOR REOPERATION FOR ARTHROFIBROSIS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction.Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis.9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis.Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction.

Optimal Timing of Anterior Cruciate Ligament Reconstruction in Patients With Anterior Cruciate Ligament Tear

The timing of surgery has been regarded as a key factor in anterior cruciate ligament reconstruction (ACLR), and early vs delayed ACLR remains a controversial topic. To synthesize up-to-date published data from randomized clinical trials (RCTs) comparing early vs elective delayed ACLR for patients with ACL deficiency, in terms of clinical outcomes and complications. The PubMed, Cochrane Library, and Web of Science databases were systematically searched until September 9, 2022. All published RCTs comparing clinical and functional outcomes and complications associated with early ACLR vs elective delayed ACLR. Two reviewers independently extracted relevant data and assessed the methodological quality following the PRISMA guidelines. Due to the clinical heterogeneity, the random-effects model was preferred. The primary outcomes were functional outcomes and complications. The Mantel-Haenszel test was used to evaluate dichotomous variables and the inverse variance method was used to assess continuous variables. This meta-analysis included 972 participants in 11 RCTs stratified by follow-up duration. The following factors did not differ between early and delayed ACLR: operative time (mean difference, 4.97; 95% CI, -0.68 to 10.61; P = .08), retear (OR, 1.52; 95% CI, 0.52-4.43; P = .44), and infection (OR, 3.80; 95% CI, 0.77-18.79; P = .10). There were also no differences between groups in range of motion, knee laxity, International Knee Documentation Committee (IKDC rating scale), and Tegner score. IKDC score (mean difference, 2.77; 95% CI, 1.89-3.66; P < .001), and Lysholm score at 2-year follow-up (mean difference, 2.61; 95% CI, 0.74-4.48; P = .006) significantly differed between early and delayed ACLR. In addition, the timing of surgery was redefined in the included RCTs and subgroup analyses were performed, which validated the robustness of the principal results. This systematic review and meta-analysis found that early ACLR was not superior to delayed ACLR in terms of most factors analyzed, except for IKDC and Lysholm scores. This information should be available to patients with ACL deficiency and clinicians as part of the shared decision-making process of treatment selection.

Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial

ObjectivesEvaluate the natural course of anterior cruciate ligament (ACL) healing on MRI within 5 years of acute ACL rupture and compare 2-year and 5-year outcomes based on healing status and...