Early Anterior Cruciate Ligament Reconstruction Research Articles

Does Anterior Cruciate Ligament Reconstruction Protect the Meniscus and Its Repair? A Systematic Review

Background:Anterior cruciate ligament (ACL) tear and meniscal injury often co-occur. The protective effect of early ACL reconstruction (ACLR) on meniscal injury and its repair is not clear. Critical literature review can support or change clinical strategies and identify gaps in the available evidence.Purpose:To assess the protective effect of ACLR on the meniscus and provide clinical guidelines for managing ACL tears and subsequent meniscal injury. We aimed to answer the following questions: (1) Does ACLR protect the meniscus from subsequent injury? (2) Does early ACLR reduce secondary meniscal injury compared with delayed ACLR? (3) Does ACLR protect the repaired meniscus?Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review was performed through use of MEDLINE and Embase electronic databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms included ACL, reconstruction, and meniscus. Studies describing primary ACLR and nonoperative treatment in adult patients were included, as well as studies indicating timing of ACLR. The included articles were assessed individually for risk of bias through use of the modified Cochrane Risk of Bias and MINORS (Methodological Index for Nonrandomized Studies) tools.Results:One level 2 randomized controlled trial and several level 3 and 4 studies indicated a protective effect of ACLR on meniscal injury compared with nonoperative treatment. There was weak (level 3) evidence of the protective effect of early ACLR on the meniscus. Meniscal repair failure was less frequent in patients with ACL reconstruction than in patients with ACL deficiency (level 4).Conclusion:The evidence collected in this review suggests a protective effect of ACLR for subsequent meniscal injury (level 2 evidence). ACLR should be performed within 3 months of injury (level 3 evidence). Meniscal injury requiring surgical repair in the ACL-deficient knee should be treated with repair accompanied by ACLR (level 3 evidence). The paucity of level 2 studies prevents the formation of guidelines based on level 1 evidence. There is a strong clinical need for randomized or prospective trials to provide guidelines on timing of ACLR and meniscal repair.

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group.

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

The Role of Patient Characteristics in the Success of Nonoperative Treatment of Anterior Cruciate Ligament Injuries

Background: Anterior cruciate ligament (ACL) tears can either be treated nonoperatively with physical therapy and then treated operatively if persistent instability is present, or be directly treated operatively. Advantages of early ACL reconstruction surgery include shorter time from injury to surgery and potentially fewer meniscal injuries, but performing early ACL reconstruction in all patients results in surgery in patients who might not need ACL reconstruction. It is important to assess in which patients nonoperative treatment is successful and which patients will require ACL reconstruction and thus might be better treated surgically in an earlier phase. Purpose: To identify patient characteristics that predict the success of nonoperative treatment. Study Design: Cohort study (Prognosis); Level of evidence, 2. Methods: All patients with complete ACL injuries who were evaluated between 2014 and 2017 at our clinic were included. The minimum follow-up was 2 years. The initial treatment and ultimate ACL reconstruction were reviewed. Univariate analysis was performed using Mann-Whitney U tests and chi-square tests and multivariate analysis using binary logistic regression. Results: A total of 448 patients were included with a median age of 26 years and median Tegner level of 7 and mean Tegner level of 6.4. At initial consultation, 210 patients (47%) were treated nonoperatively with physical therapy and 126 of these patients (60%) ultimately required ACL reconstruction. Nonoperative treatment failed in 88.9% of patients <25 years of age, 56.0% of patients 25 to 40 years, and 32.9% of patients >40 years (P < .001); and 41.9% of patients with Tegner level 3 to 6, and 82.8% of patients with Tegner level 7 to 10. Age <25 years (odds ratio [OR], 7.4; P < .001) and higher Tegner levels (OR, 4.2; P < .001) were predictive of failing nonoperative treatment in multivariate analysis. Patients in the failed nonoperative group had longer time from diagnosis to surgery than the direct reconstruction group (6.2 vs 2.2 months; P < .001), and more frequently had new meniscal injuries (17.4% vs 3.1%; P < .001) at surgery. Conclusion: Nonoperative treatment of ACL injuries failed in 60% of patients and was highly correlated with age and activity level. In patients aged 25 years or younger or participating in higher-impact sports, early ACL reconstruction should be considered to prevent longer delay between injury and surgery, as well as new meniscal injuries.

Does early anterior cruciate ligament reconstruction prevent development of meniscal damage? Results from a secondary analysis of a randomised controlled trial

ObjectivesTo determine development of new and worsening meniscal damage over 5 years after acute anterior cruciate ligament (ACL) injury comparing rehabilitation plus early ACL reconstruction (‘early-ACLR’) versus rehabilitation with optional...

Fate of the lateral femoral notch following early anterior cruciate ligament reconstruction

BackgroundThe goal of this longitudinal study was to investigate the fate of the lateral femoral notch (LFN), which is frequently seen as an impaction fracture of the lateral femoral condyle in patients with anterior cruciate ligament (ACL) tears. MethodsPatients who underwent early ACL reconstruction between 2006 and 2010 were reviewed. If post-injury magnetic resonance images showed an LFN greater than 1.5 mm in depth, patients with untreated LFN were followed. Two blinded observers performed quantitative and qualitative imaging analysis. ResultsSixteen patients (five women, 11 men) were available for follow-up nine years (six to 10 years) post-injury. The median defect area of the LFN significantly decreased from 2.3 cm2 (range: 0.9–3.8 cm2) to 1.6 cm2 (range: 0.4–3.2 cm2) (P < .001). The defect depth did not significantly change from 2.3 mm (range: 2.0–3.6 mm) to 2.5 mm (range: 1.3–3.6 mm) (P > .05). The International Cartilage Repair Society (ICRS) score increased from 1.5 (range: 0–3) post-injury to 2.0 (range: 0–4) at follow-up (P < .01). The Lysholm score was 93 (72–100), the Tegner activity level was 6 (3–9) and the knee injury and osteoarthritis outcome score (KOOS) score was 97 (91–100). ConclusionsThe defect area of the LFN decreased overtime, whereas the depth of the impression remained. Focal cartilage lesions were found in all except two patients post-injury and progressed during follow-up. However, patient-reported outcome scores were satisfying.

Risk Factors for Early Subsequent (Revision or Contralateral) ACL Reconstruction: A Retrospective Database Study.

Background:Many factors contribute to the risk for subsequent anterior cruciate ligament reconstruction (ACLR) within 2 years from the index procedure.Purpose/Hypothesis:The purpose of this study was 2-fold: (1) to evaluate the incidence of subsequent (revision or contralateral) ACLR at 2 years in a large cohort and (2) to explore the association between patient-specific factors and early subsequent ACLR risk by age group. We hypothesize that 2-year subsequent (revision or contralateral) ACLR rates will be low and that risk factors for subsequent (revision or contralateral) ACLR will vary depending on a patient’s age group.Study Design:Case-control study; Level of evidence, 3.Methods:The California Office of Statewide Health Planning and Development Ambulatory Surgery Database was retrospectively reviewed to assess the incidence of 2-year subsequent (revision or contralateral) ACLR and to identify patient-specific risk factors for early subsequent (revision or contralateral) ACLR by age group between 2005 and 2014.Results:Of 94,108 patients included, the rate of subsequent (revision or contralateral) ACLR was highest in patients younger than 21 years (2.4 per 100 person-years; 95% CI, 2.3-2.6) and lowest in those older than 40 years (1.3 per 100 person-years; 95% CI, 1.2-1.4). Younger age, white race (compared with Hispanic in all age groups and Asian in age <21 or >40 years), private insurance if age younger than 21 years, public insurance or worker's compensation claims if age older than 30 years were significantly associated with an increased risk of subsequent (revision or contralateral) ACLR at 2 years.Conclusion:Results of the present study provide insight into subsequent (revision or contralateral) ACL reconstruction, which can be used to assess and modify treatment for at-risk patients and highlight the need for data mining to generate clinically applicable research using national and international databases.

Does a Delay in Anterior Cruciate Ligament Reconstruction Increase the Incidence of Secondary Pathology in the Knee? A Systematic Review and Meta-Analysis.

Previous systematic reviews looking at timing of anterior cruciate ligament reconstruction (ACLR) examined the functional outcomes and range of motion; however, few have quantified the effect of timing of surgery on secondary pathology. The goal of this study was to analyze the effects of early ACLRs versus delayed ACLR on the incidence of meniscal and chondral lesions. We searched MEDLINE, EMBASE, and CINAHL on March 20, 2018, for randomized control trials (RCTs) that compared early and delayed ACLR in a skeletally mature population. Two reviewers independently identified trials, extracted trial-level data, performed risk-of-bias assessments using the Cochrane Risk of Bias tool, and evaluated the study methodology using the Detsky scale. A meta-analysis was performed using a random-effects model with the primary outcome being the total number of meniscal and chondral lesions per group. Of 1887 citations identified from electronic and hand searches, we included 4 unique RCTs (303 patients). We considered early reconstruction as <3 weeks and delayed reconstruction as >4 weeks after injury. There was no evidence of a difference between early and late ACLR regarding the incidence of meniscal [relative risk (RR), 0.98; 95% confidence interval (CI), 0.74-1.29] or chondral lesions (RR, 0.88; 95% CI, 0.59-1.29), postoperative infection, graft rupture, functional outcomes, or range of motion. We found no evidence of benefit of early ACLR. Further studies may consider delaying surgery even further (eg, >3 months) to determine whether there are any real benefits to earlier reconstruction.

How to repair an immediately post-operative anterior cruciate ligament reconstruction failure? About a clinical case

&lt;p class="abstract"&gt;We present a 23-year-old male with an early anterior cruciate ligament (ACL) reconstruction failure due to lateral wall blow-out, diagnosed on day one post-op. We were able to perform the revision using the original graft, and maintaining the initial tibial fixation, revising only the femoral fixation. At 1-year follow-up the patient is asymptomatic. In the early ACL reconstruction failures due to femoral wall blowout, it is possible to perform the revision surgery using the same graft and maintaining the same tibial fixation. This avoids de morbidity of a new graft harvest and the need for a new tibial tunnel.&lt;/p&gt;

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials

Background: Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears. Purpose/Hypothesis: The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction. Study Design: Meta-analysis. Methods: A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines. Results: Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P > .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis. Conclusion: This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications. Study Registration: CRD42019119319 (PROSPERO).

Pediatric ACL Tears: Natural History.

Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury. The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature. A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms "anterior cruciate ligament," "pediatric" and/or "adolescent," and "conservative" and/or "nonoperative treatment." A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format. Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event. The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.

Does early reconstruction of the anterior cruciate ligament prevent further meniscal damage? Secondary analysis of randomized controlled trial

Purpose: There is no low-risk-of-bias evidence to support the notion that surgical reconstruction of the anterior cruciate ligament (ACL) lowers the risk of future meniscal damage. Therefore, we investigated the loss of meniscal integrity on knee MRI over 5 years using data from the only randomized controlled trial in the field, comparing rehabilitation plus early ACL reconstruction vs a strategy of rehabilitation with optional delayed ACL reconstruction. Methods: We used longitudinal knee MRI data from 121 young active adults randomized to structured rehabilitation plus early ACL reconstruction (“early reconstruction” arm) or to structured rehabilitation with optional delayed ACL reconstruction (“optional delayed reconstruction” arm) (ISRCTN 84752559). Knee MRIs at baseline (after randomization but before treatment), and at the 5-year follow-up were read paired with knowledge of time sequence by one experienced musculoskeletal radiologist using the Anterior Cruciate Ligament Osteoarthritis Score (ACLOAS). Reader blinding to ACL-reconstructed knees at the 5-year follow-up was not feasible, but the reader was unaware of the specific study questions. Meniscal integrity was determined for all three segments of the medial and lateral meniscus. Worsening of meniscal integrity from baseline to the 5-year follow-up was defined as the occurrence of one or more of the following: i) an incident meniscal tear or progression of a pre-existing meniscal tear to involve another segment ii) incident loss of meniscus substance (due to maceration/destruction or surgical resection) iii) a new finding of status post meniscal repair, or iv) increase in medial or lateral meniscal body extrusion. With this dichotomized outcome, in an intention-to-treat analysis (ITT), we compared frequency of worsening of meniscal integrity on MRI in both treatment arms from baseline to 5 years using a logistic regression model. The model was adjusted for age, sex, and meniscal tears on MRI at baseline. For greater sensitivity and to evaluate severity of meniscal damage at 5 years, we also used a continuous outcome (integrity score) based on the sum of reclassified subregional meniscal grades from the ACLOAS (Table 1). For the integrity score, we used a zero-inflated Poisson regression model to compare severity of meniscal damage in an ITT analysis. This model was adjusted for age, sex, and baseline integrity score. Participants without baseline MRI readings were excluded from the analyses. Analyses were performed on knee level as well as on compartment level. Results: In the early reconstruction arm 62 participants were included, of which one was lost to follow-up. Four of the remaining 61 subjects had missing MRI readings at baseline. As a result, 57 subjects (mean [SD] age 26.6 [5.2] years, 81% men) remained for analysis. In the optional delayed reconstruction arm, 59 subjects (mean [SD] age 25.8 [4.7] years, 66% men) were included without loss to follow-up, with 30 subjects (51%) having had delayed ACL reconstruction within 5 years. Before treatment, the early reconstruction arm had more lateral meniscal damage detected on MRI (26% vs 7%), but medial meniscus damage was similar in both treatment arms (14% vs 15%). After 5 years, 19% of subjects in the early reconstruction arm had worsening of medial meniscal integrity vs 38% in the optional delayed reconstruction arm. For lateral meniscal integrity it was 38% vs 22%, respectively. We found a relative risk (RR) for worsening in meniscal integrity after 5 years on the knee level of 1.29 with a 95% confidence interval (CI) of 0.90-1.85 in the optional delayed reconstruction arm vs the early reconstruction arm. For worsening of medial meniscus integrity the RR was 1.95 (95% CI 1.06-3.57). For lateral meniscus the corresponding RR was 1.01 (95% CI 0.64-1.57). Relatively more subjects with an uninjured medial meniscus at baseline in the optional delayed reconstruction arm had worsening of medial meniscal integrity after 5 years compared to the early reconstruction arm (35% vs 12%). Meniscal worsening per segment is presented in Figure 1. Using meniscal integrity score as outcome, we found a 1.38 higher (severe) mean integrity score in the optional delayed reconstruction arm vs the early reconstruction arm (95% CI 1.07-1.78). For medial meniscus integrity, the corresponding model yielded a 1.80 higher mean score (95% CI 1.02-3.17), and for lateral meniscus integrity 1.04 (95% CI 0.63-1.75). Change in integrity score from baseline to the 5-year follow-up for the medial and the lateral meniscus for each treatment arm, respectively, is detailed in Figure 2. Conclusions: A strategy of early ACL reconstruction may reduce the risk of worsening of medial meniscus integrity following ACL injury. For the lateral meniscus, ACL reconstruction seems neither to be protective nor to increase the risk of future meniscal damage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

GRAFT CHOICE FOR ADOLESCENT ATHLETES RETURNING TO HIGH-RISK SPORTS: A MATCHED COHORT ANALYSIS OF PATELLAR TENDON AND HAMSTRING AUTOGRAFTS

Background: Graft selection for skeletally mature adolescents undergoing anterior cruciate ligament (ACL) reconstruction is guided by surgeon and patient preference. In young patients returning to high-risk cutting and pivoting sports, graft rupture is the most feared complication of ACL reconstruction. Some studies have demonstrated slightly lower rates of graft failure and decreased laxity in the short term associated with patellar tendon (BTB) autografts as compared to hamstring (HS) autografts, but these studies are limited by their heterogeneity of ages and activity level1-3. The purpose of this study is to compare the rates of graft failure between BTB and HS ACL reconstruction cohorts matched by age, sex, and sport. Methods: A single-institution retrospective review was performed of consecutive patients less than 19 years of age treated with ACL reconstructions using either patellar tendon (BTB) or hamstring (HS) autograft performed by a single surgeon. Skeletally mature or nearly mature patients in “high-risk” ACL injury sports (basketball, football, soccer, lacrosse, and gymnastics) were initially treated with hamstring autografts but the graft preference transitioned to BTB autografts as the preferred graft choice during the study period. This transition in graft preference for adolescents participating in “high risk” sports allows for a comparison of outcomes based on graft types. Inclusion criteria were ages 13 – 18 years, participation in a “high risk” sport, and minimum 6-month follow-up. The two cohorts of patients were matched by age, gender, and sport. The primary outcome measure was graft rupture. Results: One hundred fifty-two patients with an average age of 16 years (range 13 – 18 years) underwent ACL reconstruction during the study period. There were 71 BTB reconstructions and 81 HS reconstructions. There were 64 females and 88 males. There was no difference in age, sex, BMI, or laterality between groups. There were more patients who played soccer in the BTB cohort (44%) vs HS cohort (20%) and fewer who played basketball in the BTB cohort (24%) vs HS cohort (41%), p = 0.005. There were no differences between the BTB and HS cohorts in terms of meniscus tears (61% v 72%, p = 0.15), meniscus repair (21% v 32%, p = 0.13), or partial meniscectomy (32% v 33%, p = 0.90). Mean duration of follow-up was 28 months (range 7-57 months). There was no difference in follow-up between cohorts (BTB 28 months and HS 29 months, p = 0.19). There were a total of 16 graft ruptures (10.5%). There was no difference in the rate of graft rupture between cohorts (BTB 8.5% vs HS 12.3%, p = 0.60). Mean time to graft rupture was 21 months (range 8 – 35 months) and Kaplan-Meier survival curves demonstrated no difference between cohorts. Conclusions: ACL reconstruction in adolescents returning to high-risk sports can be performed utilizing BTB or HS autografts with similar rates of graft rupture. There is a trend toward lower rates of graft rupture associated with BTB autografts, but additional patients will be necessary to determine if this trend will become a statistically significant difference. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84(9):1503-1513. Ho B, Edmonds EW, Chambers HG et al. Risk factors for early ACL reconstruction failure in pediatric and adolescent patients: a review of 561 cases. J Pediatr Orthop 2016. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res 2017;475(10):2459-2468.

Bicompartmental locked bucket-handle tears of menisci concealing the concomitant anterior cruciate ligament injury for 2 years - a case report.

Locked bucket-handle tears of both medial and lateral menisci, called in literature "Jack and Jill lesion", with simultaneous anterior cruciate ligament (ACL) injury is an extremely unusual phenomenon. It was reported only in a few cases in literature, which were unfortunately highly differentiated in the field of trauma mechanism, treatment options and postoperative care. Authors presented a clinical case of patient with a locked knee joint, by the torn both menisci, what masked the simultaneous ACL rupture and supremely imitated a stable joint. The locked knee is a clinical case demanding the urgent intervention to prevent further damages to the joint structures. Surprisingly, the patient after locking of the menisci and migration of their inner fragments to the intercondylar notch, started to feel the affected joint stabile and dismissed from the further treatment for next 2 years. Complex trauma needs a complex treatment, and a single-stage or multi-stage surgical approach is performed. Authors chose a two-steps surgical procedure with primary meniscal repair and secondary, early ACL reconstruction.&#x0D;

Postoperative Therapeutic Effect of ACL Reconstruction at Different Periods

Objective: To analyze postoperative therapeutic effects of patients with fractured anterior cruciate ligament (ACL) that underwent autologous tendon reconstruction at early and late period. Methods: A total of 60 patients underwent autologous tendon reconstruction were enrolled and retrospectively analyzed via arthroscopes from December, 2015 to December, 2017 in our hospital, in which 30 patients treated with ACL reconstruction within 6 weeks of injury were selected as the early reconstruction group (Group A), and the other 30 cases with ACL reconstruction between 6 weeks and 6 months were as late reconstruction group (Group B); the therapeutic effect of early and late ACL reconstruction was analyzed by recording and comparing of several indexes, such as knee lysholm score, knee IKDC score, intraoperative hemorrhage, operation time, pre- and post-operative range of motion (ROM) of the knee, etc. Results: The pre- and post-operative lysholm scores and IKDC scores were compared between the two groups, without statistically significant results (P > 0.05). The knee ROM scores of the late reconstruction group were higher than those of the early group (P < 0.05), and the intraoperative blood loss in the late stage was less than that in the early group (P < 0.05), which exhibits that the short-term clinical efficacy of early and late arthroscopic autologous tendon reconstruction for knee ACL injury was similar, but the late reconstruction group was with less intraoperative bleeding, and better postoperative joint mobility recovery; in conclusion, it is recommended that patients can be operated between 6 weeks and 6 months after injury.

The Effectiveness of Strengthening of Hip Extensors and Ankle Plantar Flexors in Early Post-Anterior Cruciate Ligament Reconstruction

AbstractBackground: Impaired hip strength may underlie abnormal movement patterns, suggesting that diminished hip strength may increase the risk of ACL injury and re injury after anterior cruciate ligament reconstruction.Aim of Study: To investigate the effect of strengthening of hip extensors and ankle plantar flexors in early Anterior Cruciate Ligament reconstruction on knee effusion, knee function, hip, knee and ankle muscles strength.Methods: The study was conducted on 30 male patients referred from the orthopedic surgeon with early post operative Anteior Cruciate Ligament reconstruction by hamstring graft or patellar tendon graft after acute injuries, their age range from 18-40 years and were randomly assigned into two groups. Group A: Consisted of fifteen patients who had received open kinetic chain strengthening exercises for hip extensors and ankle plantar flexors in addition to the traditional accelerated program. Group B: Consisted of fifteen patients who had received the traditional accelerated program for 6 weeks (three sessions per week), effusion grading scale for effusion to assess effusion, handheld dynamometer to assess muscle power, Westen Ontario and MACmaster universities score and Time Up and Go test for functional assessment.Results: There was no significant difference between both groups for, hip extensors force and (TUG at 3 weeks). There was no significant difference between both groups for knee extensors torque between base line and 3 weeks and the same for plantar flexors force and WOMAC at 3 weeks. There was significant difference between both groups for knee extensors torque between 3 and 6 weeks, WOMAC at 6 weeks, TUG at 6 weeks and plantar flexors force between 3 and 6 weeks.Conclusion: Adding strengthening exercises of hip exten-sors and plantar flexors to the traditional accelerated protocol added more beneficial outcomes in relation to function after 6 weeks.

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury.

The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears. A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015at one institution. The age range was between 7 and 19years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery. Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions. Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes. Retrospective comparative study, Level III.

Risk Factors for Early ACL Reconstruction Failure in Pediatric and Adolescent Patients: A Review of 561 Cases.

Anterior cruciate ligament (ACL) reconstruction failure is relatively common in young high-risk athletes. The purpose of this study was to examine a single center's 10-year experience with ACL reconstructions in pediatric and adolescent patients to better define short-term failure rates and risk factors for revision ACL surgery. This institutional review board-approved retrospective study included all patients who underwent a primary ACL reconstruction between 2002 and 2013. Chart and radiographic review was performed to assess patient demographic, injury, and surgical data including growth plate status, concomitant ligament/meniscus/cartilage injury, surgical procedures, femoral drilling technique, graft source and type, femoral and tibial fixation devices, and graft size. Graft failures had to be confirmed both with clinical examination and magnetic resonance imaging or the patient had to undergo a revision ACL reconstruction. Potential factors associated with failure were evaluated using either parametric or nonparametric analysis as appropriate. A total of 561 ACL reconstructions were performed that met our inclusion criteria. The average patient age was 15.4 years (range, 5 to 19 y) and 53% of the patients were male. In all, 54 failures were identified for a 9.6% failure rate. Soft tissue grafts were twice as likely to fail compared with patellar tendon grafts (13% vs. 6%; P<0.001). Multivariate analysis revealed that graft choice (soft tissue vs. patellar tendon) was the primary variable predictive of failure (P<0.05), with interactions/mediating effects contributed by maturity (growth plate status) and ACL technique (P<0.05). The average time to failure was 13.6 months and hamstring grafts and anatomic femoral tunnels were both found to fail earlier (P<0.05). During the study period, approximately 8% of patients sustained a contralateral ACL injury. ACL failure rates in adolescent and pediatric patients vary based on patient age, graft selection, and surgical technique. Bone patellar tendon bone autografts had the lowest failure rate in this high-risk population. Level IV-retrospective case series.

Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis.

To evaluate the association between surgical timing and the incidence of secondary meniscal or chondral damage in children and adolescents with anterior cruciate ligament (ACL) ruptures. Three electronic databases, PubMed, MEDLINE, and EMBASE, were systematically searched from database inception until October 16, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported the incidence of meniscal and articular cartilage damage in children or adolescent athletes with ACL injuries as well as the timing of their ACL reconstruction (ACLR). Risk ratios were combined in a meta-analysis using a random effects model. A total of nine studies including 1353 children and adolescents met the inclusion criteria. The mean age of patients included was 14.2years (range 6-19), and 45% were female. There was a significantly decreased risk of concomitant medial meniscal injury in those reconstructed early (26%) compared to those with delayed reconstruction (47%) [pooled risk ratio (RR) = 0.49, 95% CI 0.36-0.65, p < 0.00001]. There was also a significantly reduced risk of medial femoral chondral (RR = 0.48, 95% CI 0.31-0.75, p = 0.001), lateral femoral chondral (RR = 0.38, 95% CI 0.20-0.75, p = 0.005), tibial chondral (RR = 0.45, 95% CI 0.27-0.75, p = 0.002), and patellofemoral chondral (RR = 0.41, 95% CI 0.20-0.82, p = 0.01) damage in the early reconstruction group in comparison to the delayed group. Pooled results from observational studies suggest that early ACLR results in a significantly decreased risk of secondary medial meniscal injury, as well as secondary medial, lateral, and patellofemoral compartment chondral damage in children and adolescents. This study provides clinicians with valuable information regarding the benefits of early ACL reconstruction in children and adolescents, and can be used in the decision making for athletes in this population. IV.

Impact of treatment strategy and physical performance on future knee-related self-efficacy in individuals with ACL injury

BackgroundIn people with anterior cruciate ligament (ACL) injury, high self-efficacy facilitates recovery, indicated by improved muscle function, reduced knee symptoms and increased physical activity. Impact of treatment on future self-efficacy is however not well investigated. The aims of the study were to 1) investigate knee-related self-efficacy 6 years after acute ACL injury in patients treated with exercise therapy alone or in combination with either early or the option of delayed ACL reconstruction (ACLR), and 2) to investigate associations between single-leg physical performance at various time points after ACL injury and knee self-efficacy at 6 years after injury.MethodsParticipants (n = 121) originated from the KANON-study (ISRCTN84752559), a treatment RCT including active adults with acute ACL injury treated with structured exercise therapy combined with early or the option of delayed ACLR. In this ancillary study, participants with knee self-efficacy data at 6 years (n = 89) were analyzed as treated; exercise therapy alone (n = 20), exercise therapy plus early ACLR (n = 46), and exercise therapy plus delayed ACLR (n = 23). The participants performed physical performance tests (hop, strength and balance) at the end the of exercise therapy (mean 10 (SD 6) months), and at 5 years, and rated their knee self-efficacy using Knee Self-Efficacy Scale (K-SES) questionnaire (0 to 10, worst to best) at 6 years.ResultsMedian K-SES score for the total group (n = 89) was 7.8 (IQR 5.9–9.0). There were no differences between treatment groups in K-SES scores at 6 years nor in physical performance at any time point (p ≥ 0.097). Worse knee flexion strength LSI (rsp = 0.341, p = 0.042) at the end of the exercise therapy, and worse LSI for single-leg hop test (rsp = 0.310, p = 0.005) at the end of the exercise therapy and at 5 years, correlated moderately with worse knee-related self-efficacy at 6 years. Low associations were observed between the remaining physical performance tests and K-SES scores (rsp ≤ 0.265, p ≥ 0.045).ConclusionKnee-related self-efficacy at 6 years after ACL injury did not differ between those treated with ACLR, performed early or as a delayed procedure, or exercise therapy alone. Good physical performance at the end of the exercise therapy, and at 5 years, appears to have a positive, yet small, impact on future knee-related self-efficacy.

The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis.

Background:The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.Purpose:To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR.Study Design:Systematic review; Level of evidence, 3.Methods:Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures.Results:Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P = .008; I 2 = 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; P = .10; I 2 = 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes.Conclusion:In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes.