Isolated After Anterior Cruciate Ligament Reconstruction Research Articles

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement

Background: The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood. Purpose: (1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue. Study Design: Controlled laboratory study. Methods: IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05). Results: The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003). Conclusion: LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue. Clinical Relevance: Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

The Posterior Tibial Slope Is Not Associated With Graft Failure and Functional Outcomes After Anatomic Primary Isolated Anterior Cruciate Ligament Reconstruction

Background: Biomechanical studies have shown that an increased medial posterior tibial slope (MPTS) may affect anteroposterior knee laxity and tibial shear forces, ultimately increasing the risk for graft failure after anterior cruciate ligament (ACL) reconstruction. Previous clinical studies have, however, reported inconclusive results. Purpose: The purpose of this study was to evaluate the relationship between the MPTS and graft failure as well as functional outcomes after anatomic primary isolated ACL reconstruction using a hamstring tendon autograft. It was hypothesized that an increased MPTS would be associated with a higher ACL graft failure rate. Furthermore, a higher MPTS would negatively correlate with functional outcomes in patients without ACL graft failure. Study Design: Case-control study; Level of evidence, 3. Methods: Consecutive patients who underwent isolated primary ACL reconstruction with an anteromedial portal drilling technique between January 2011 and December 2019 were retrospectively reviewed. The MPTS was measured on preoperative lateral knee radiographs. At a minimum of 24 months postoperatively, the ACL graft failure rate and patient-reported outcome measures (PROM; International Knee Documentation Committee subjective knee form, Lysholm score, Tegner Activity Scale, visual analog scale for pain and subjective instability) were evaluated. Differences in the MPTS between patients with and without ACL graft failure as well as the frequency of graft failure between those with an MPTS <12° and those with an MPTS ≥12° were assessed for statistical significance. Binary logistic regression analysis was performed to stratify the risk of graft failure with the following variables: MPTS, age at surgery, and sex. Correlation analysis was performed to evaluate the relationship between the MPTS and PROM in patients without ACL graft failure. Results: In total, 326 patients were included (median follow-up, 71.0 months [IQR, 49.0-104.0 months]). There was no significant difference in the MPTS between patients with and without graft failure (10.6°± 3.2° vs 11.2°± 2.8°, respectively; P = .264). Additionally, there was no significant difference in the frequency of graft failure between patients with an MPTS <12° and those with an MPTS ≥12° (15.6% vs 16.5%, respectively; P = .835). Binary logistic regression showed that younger age at the time of surgery (odds ratio, 1.069 [95% CI, 1.031-1.109]) was associated with graft failure; sex and MPTS were not associated with graft failure. In patients without ACL graft failure, there was no significant correlation between the MPTS and PROM. Conclusion: In patients who underwent anatomic primary isolated ACL reconstruction, an increased MPTS was not associated with a higher rate of graft failure or inferior functional outcomes. Younger age was a significant nonmodifiable risk factor for ACL graft failure.

Pregabalin does not reduce postoperative pain after outpatient ACL surgery: A case-control study

IntroductionIn France, prescribing pregabalin requires a secure prescription valid for 6 months since the decree of 12 February 2021, based on recommendations of the French Centre for Evaluation and Information on Pharmacodependence and Addiction vigilance (CEIP-A). This led to discontinuation of this treatment as a postoperative analgesic in the French ACL Study (FAST) cohort. We aimed to evaluate the impact of this change on early postoperative pain. HypothesisPregabalin is an important analgesic for reducing early postoperative pain after anterior cruciate ligament (ACL) repair. MethodsAt our healthcare facility, 584 patients from the FAST cohort who underwent primary isolated ACL reconstruction were included: 292 patients operated before June 1, 2021 who received pregabalin postoperatively and 292 patients operated after June 1, 2021 who did not receive pregabalin. The patients were matched based on age, sex, preoperative Lysholm and Tegner scores. Pain was evaluated on a visual analog scale (VAS) on D0 in the evening, D0 at night, D1, D2 and D3. ResultsThe patients who did not receive pregabalin had more severe pain at night on D0: 5.21 vs 5.68 (p=.048). There was no difference between groups in the postoperative pain at rest during the evening of D0 (p=.89), D1 (p=.33), D2 (p=.37) and D3 (p=.21). ConclusionIn the context of outpatient arthroscopic ACL reconstruction, pregabalin does not reduce early postoperative pain in a clinically significant manner. Level of evidenceIV; case-control study.

Only 10% of Patients With a Concomitant MCL Injury Return to Their Preinjury Level of Sport 1 Year After ACL Reconstruction: A Matched Comparison With Isolated ACL Reconstruction.

There is a need for an increased understanding of the way a concomitant medial collateral ligament (MCL) injury may influence outcome after anterior cruciate ligament (ACL) reconstruction. Patients with a concomitant MCL injury would have inferior clinical outcomes compared with a matched cohort of patients undergoing ACL reconstruction without an MCL injury. Matched registry-based cohort study; case-control. Level 3. Data from the Swedish National Knee Ligament Registry and a local rehabilitation outcome registry were utilized. Patients who had undergone a primary ACL reconstruction with a concomitant nonsurgically treated MCL injury (ACL + MCL group) were matched with patients who had undergone an ACL reconstruction without an MCL injury (ACL group), in a 1:3 ratio. The primary outcome was return to knee-strenuous sport, defined as a Tegner activity scale ≥6, at the 1-year follow-up. In addition, return to preinjury level of sport, muscle function tests, and patient-reported outcomes (PROs) were compared between the groups. The ACL + MCL group comprised 30 patients, matched with 90 patients in the ACL group. At the 1-year follow-up, 14 patients (46.7%) in the ACL + MCL group had return to sport (RTS) compared with 44 patients (48.9%) in the ACL group (P = 0.37). A significantly lower proportion of patients in the ACL + MCL group had returned to their preinjury level of sport compared with the ACL group (10.0% compared with 25.6%, adjusted P = 0.01). No differences were found between the groups across a battery of strength and hop tests or in any of the assessed PROs. The ACL + MCL group reported a mean 1-year ACL-RSI after injury of 59.4 (SD 21.6), whereas the ACL group reported 57.9 (SD 19.4), P = 0.60. Patients with a concomitant nonsurgically treated MCL injury did not return to their preinjury level of sport to the same extent as patients without an MCL injury 1 year after ACL reconstruction. However, there was no difference between the groups in terms of return to knee strenuous activity, muscle function, or PROs. Patients with a concomitant nonsurgically treated MCL injury may reach outcomes similar to those of patients without an MCL injury 1 year after an ACL reconstruction. However, few patients return to their preinjury level of sport at 1 year.

The incidence of deep vein thrombosis after anterior cruciate ligament reconstruction: An analysis using routine ultrasonography of 260 patients.

Recent studies regarding deep vein thrombosis (DVT) after anterior cruciate ligament (ACL) reconstruction investigated only symptomatic complications. The purpose of this study was to assess the true incidence of DVT after ACL reconstruction, regardless of symptom manifestation. Medical records of 260 patients who underwent isolated ACL reconstruction between January 2014 and December 2019 were retrospectively reviewed. Regardless of symptom manifestation, DVT was examined for all patients at 1 week postoperatively using ultrasonography. Demographics, injury mechanism (high energy direct injury and low energy indirect injury), soft tissue injury, preoperative anterior laxity, tourniquet time, and surgical technique (transtibial, anteromedial portal, and outside-in techniques) were investigated. Soft tissue injury was evaluated on magnetic resonance imaging (MRI) scans, based on the Tscherne classification. Risk factors for proximal DVT were identified using logistic regression analyses. A total of 21 (8.1%) patients showed DVT. 5 (1.9%) patients had thrombosis at the popliteal vein; however, none of them exhibited symptoms. The other 16 patients had thrombosis at the distal veins: 1 patient at the anterior tibial vein, 5 patients at the posterior tibial vein, 3 patients at the peroneal vein, 6 patients at the soleal vein, and 1 patient at the muscular branch vein. The risk factors for proximal DVT included high energy direct injury (p = 0.013, odds ratio = 10.62) and grade 2 soft tissue injury (p = 0.039, odds ratio = 6.78). The true incidence of DVT, including symptomatic and asymptomatic complications, were 8.1% after ACL reconstruction. This rate is higher than the previously known incidence which has been investigated only for symptomatic patients. Injury mechanism and soft tissue injury should be assessed when considering thromboprophylaxis.

The effect of meniscal pathology and management with ACL reconstruction on patient-reported outcomes, strength, and jump performance ten months post-surgery

BackgroundThe purpose of this study was to examine the differences in patient-reported outcome measures, isokinetic strength, plyometric ability and ability to meet return to play criteria ten months after anterior cruciate ligament (ACL) reconstruction surgery between those who underwent meniscectomy, those who underwent meniscal repair and those with no meniscal intervention alongside ACL reconstruction surgery. MethodsThree hundred and thirteen athletes with clinically and radiologically confirmed ACL ruptures were included in this study. Participants were grouped according to their intra-operative procedures (isolated ACL reconstruction surgery n = 155, ACL reconstruction surgery with meniscectomy n = 128, ACL reconstruction surgery with meniscal repair n = 30). Participants completed patient-reported outcome measures questionnaires (Marx Activity Rating Scale, the ACL Return to Sport after Injury and the International Knee Documentation Committee Score) and completed a battery of objective functional testing including isokinetic dynamometry and jump performance testing (countermovement jump and drop jump) between 9 and 11 months after surgery. ResultsNo significant between-group differences were identified in any metric relating to patient-reported outcome measures (p = .611), strength and jump measures (p = .411) or the ability to achieve symmetry-based return to play criteria (p = .575). ConclusionsClinically, these results suggest that concomitant meniscal surgery has no significant effects on patient-reported outcome measures, strength and jump metrics at the return to play stage post-operatively and can inform the pre-operative counselling of those awaiting ACL reconstruction surgery with likely meniscal intervention.

Remnant preservation provides good clinical outcomes after anterior cruciate ligament reconstruction

PurposeTo evaluate the association of remnant preservation (RP) and non-RP (NRP) with patient-reported outcome measures and subsequent graft rupture at a minimum 2-year follow-up after anterior cruciate ligament (ACL) reconstruction.MethodsPatients in this retrospective study underwent primary isolated ACL reconstruction by the RP or NRP technique with a four- to five-strand hamstring tendon graft. Multivariate linear or logistic regression and Cox regression analyses were performed to compare the physical and psychological outcomes by the International Knee Documentation Committee subjective knee form (IKDC-SKF) and the Japanese Anterior Cruciate Ligament questionnaire 25 (JACL-25), respectively; satisfaction rate; and prognosticators of graft rupture.ResultsIn total, 120 patients (mean age, 30.6 ± 12.7 years; 54 RP, 66 NRP) with a mean follow-up of 3.2 ± 1.6 years were enrolled in this study. At the latest postoperative follow-up, the RP group showed a mean IKDC-SKF score of 92.3 ± 8.5 and mean JACL-25 score of 13.2 ± 11.2, while these scores in the NRP group were 86.4 ± 12.2 and 24.4 ± 19.5, respectively (P = 0.016 and 0.007, respectively). No significant differences were found in the return-to-sports rate (RP vs. NRP, 79.5% vs. 67.5%) or satisfaction rate (RP vs. NRP, 89.2% vs. 74.4%) (n.s.); however, a significant difference was found in the rate of return to the preinjury sports level (RP vs. NRP, 64.1% vs. 37.5%; P = 0.014). The graft rupture rate was significantly higher in the NRP than RP group (9/66 vs. 1/54; hazard ratio 9.29; 95% confidence interval 1.04–82.81). Younger age (≤ 18 years) was the other important risk factor for graft rupture (hazard ratio 8.67; 95% confidence interval 2.02–37.13).ConclusionPatients who underwent ACL reconstruction with the RP technique obtained somewhat better physical and psychological results than those who underwent ACL reconstruction with the NRP technique. With respect to clinical relevance, patients treated with the RP technique may obtain better outcomes in terms of graft rupture and return to the preinjury sports level than those treated with the NRP technique, but with no differences in overall return to sports or satisfaction.Level of evidenceIV.

Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST).

Background:Successful return to sport after anterior cruciate ligament (ACL) reconstruction requires optimal physical and psychological recovery. The main validated tool to quantify a patient’s psychological readiness to return to sport after this surgery is the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale.Purpose:The primary aim was to analyze the progression of the ACL-RSI score from preoperatively to 2-year follow-up. A secondary goal was to identify the factors associated with returning to the same preinjury sport.Study Design:Cohort study; Level of evidence, 2.Methods:This prospective study included athletes older than 16 years in all sports and levels of play who underwent primary and revision isolated ACL reconstruction from 2012 to 2015 and responded to all study questionnaires at 2-year follow-up. The primary outcome was the ACL-RSI score obtained preoperatively and at 4-month, 6-month, 1-year, and 2-year follow-up. The secondary outcomes were return to sport (running and the same preinjury sport) and various functional scores. The optimal threshold value of the ACL-RSI score for returning to the same preinjury sport was determined with the receiver operating characteristic curve. Multivariate analysis was performed to identify other factors associated with returning to the same sport at 2-year follow-up.Results:A total of 681 patients were analyzed (467 men, 214 women; mean age, 30.2 ± 9.5 years); 298 (43.8%) patients were professional or competitive athletes. The ACL-RSI score improved significantly over time: 41.3 ± 25.4 preoperatively, 55.1 ± 21.3 at 4 months, 58.3 ± 22.3 at 6 months, 64.7 ± 24.2 at 1 year, and 65.2 ± 25.3 at 2 years (P < .00001). At 2-year follow-up, 74.9% of patients had returned to running and 58.4% to their same preinjury sport. The ACL-RSI score was significantly higher in patients who had returned to sport and in those who returned to the same level of play or higher (P < .00001). The optimal ACL-RSI score threshold to return to the same sport at 2-year follow-up was ≥65. Multivariate analysis showed that the predictive factors of returning to the same preinjury sport at 2-year follow-up were primary reconstruction, professional or competitive level of play, an ACL-RSI score ≥60 at 6-month follow-up, and the absence of postoperative complications.Conclusion:The psychological ACL-RSI score improved regularly after ACL reconstruction and was strongly and significantly associated with return to sport.Registration:NCT02511158 (ClinicalTrials.gov identifier)

Professional Athletes Are Not at a Higher Risk of Infections After Anterior Cruciate Ligament Reconstruction: Incidence of Septic Arthritis, Additional Costs, and Clinical Outcomes From the French Prospective Anterior Cruciate Ligament Study (FAST) Cohort

Background: The rate of septic arthritis in the knee after anterior cruciate ligament (ACL) reconstruction varies in the literature but is generally less than 1%. It has been reported to be higher in professional athletes (5.7%). Purpose: The primary goal was to evaluate the rate of septic arthritis after ACL reconstruction in professional athletes compared with other patients. The secondary goals were to analyze the risk factors; increased cost of infections; return to sport, satisfaction, and functional results at 1-year follow-up; and resolution rate of infections at final follow-up. Study Design: Case-control study; Level of evidence, 3. Methods: This retrospective analysis of prospective data included a continuous series of patients who underwent isolated ACL reconstruction between 2012 and 2016. The main outcome criterion was the development of intra-articular infections in the operated knee. An infection was suggested clinically (knee pain with fever and/or chills) and confirmed bacteriologically in deep tissue samples obtained during revision surgery. All infected patients underwent an emergency reoperation with lavage and debridement along with dual antibiotic therapy first by an intravenous route and then orally for 6 weeks. Results: A total of 1809 of 1859 patients included in the cohort during this period fulfilled inclusion criteria; there were 1632 (90.2%) who underwent primary reconstruction and 177 (9.8%) who underwent revision. The series included 1249 (69%) men and 560 (31%) women, with a mean age of 29.1 ± 9.8 years. Ninety-eight percent of the patients participated in a sport, including 90 (5.0%) at a professional level and 712 (39.4%) competitively. Septic arthritis of the knee developed after a mean 15.7 ± 5.5 days in 7 (0.38%) patients: 5 of 1632 (0.31%) who underwent primary reconstruction and 2 of 177 (1.13%) who underwent revision. Septic arthritis did not develop in any professional or competitive athletes; all affected patients were recreational athletes (P = .02). The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery (odds ratio [OR], 15; P = .002) and hemarthrosis during the immediate postoperative period (OR, 127.2; P = .002). There were no recurrent infections after a mean follow-up of 2.8 ± 1.2 years. Conclusion: None of the professional athletes in this cohort had septic arthritis after ACL reconstruction. There are no particular precautions to be taken in this population. The risk factors identified for the development of septic arthritis on multivariate analysis were prior knee surgery and hemarthrosis during the immediate postoperative period. Similar to all studies published on the subject, there were very few infected patients, which limits the identification of risk factors. Registration: NCT02511158 (ClinicalTrials.gov identifier)

Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry

PurposeTo determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction.MethodsPatients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively.ResultsA total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41–0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3–23.9], p = 0.005).ConclusionNon-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction.Level of evidenceCohort study, Level III.

Preoperative Ultrasonography Is Unreliable in Predicting Hamstring Tendon Graft Diameter for ACL Reconstruction.

Background:Hamstring autograft size <8 mm has been shown to be a predictor for failure after anterior cruciate ligament (ACL) reconstruction. The ability to predict graft size preoperatively is helpful in counseling patients about the possible need for graft augmentation.Purpose:To determine whether preoperative ultrasound (US) measurements of hamstring tendons can predict intraoperative graft diameter during ACL reconstruction.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Twenty patients undergoing unilateral isolated ACL reconstruction were prospectively enrolled in the study (10 males, 10 females; mean ± SD age, 22.8 ± 6.6 years; height, 175.1 ± 7.1 cm; weight, 81.4 ± 14.2 kg; body mass index, 26.5 ± 4.1 kg/m2). Hamstrings were assessed by US, and double-looped semitendinosus-gracilis hamstring size was independently calculated with a freehand selection method on a nonmagnified US image by 2 orthopaedic surgeons. Intraoperative autograft size was determined with a standard graft-sizing tool. Intra- and interrater reliability was measured with intraclass correlation coefficients (ICCs) and standard error of the measure (SEM). A receiver operating characteristic curve was calculated to assess the ability of the US measurement to predict intraoperative measurements.Results:The mean autograft diameter by US was 8.9 ± 0.98 mm, while the mean intraoperative hamstring graft size was 8.1 ± 0.89 mm. There was excellent intrarater (ICC2,1 = 0.95, SEM = 0.32 mm) and interrater (ICC2,1 = 0.88, SEM = 0.55 mm) reliability for US measurements. Receiver operating characteristic analysis showed that US did not consistently quantify graft size. Graft size did not significantly correlate with height, weight, or body mass index in our sample (P > .05).Conclusion:These results suggest that preoperative US imaging of the hamstring tendons is unreliable in predicting intraoperative graft diameter.

Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis

Background: Persistent clinical instability after anterior cruciate ligament (ACL) reconstruction may be associated with injury to the anterolateral structures and has led to renewed interest in anterolateral extra-articular procedures. The influence of these procedures on knee kinematics is controversial. Purpose/Hypothesis: The purpose was to investigate the biomechanical properties of anatomic anterolateral ligament (ALL) reconstruction and a modified Lemaire procedure (lateral extra-articular tenodesis [LET]) in combination with ACL reconstruction as compared with isolated ACL reconstruction in the setting of deficient anterolateral structures (ALL and Kaplan fibers). It was hypothesized that both techniques would reduce tibial internal rotation when combined with ACL reconstruction in the setting of anterolateral structure deficiency. Study Design: Controlled laboratory study. Methods: A 6 degrees of freedom robotic system was used to assess tibial internal rotation, a simulated pivot-shift test, and anterior tibial translation in 10 paired fresh-frozen cadaveric knees. The following states were tested: intact; sectioned ACL, ALL, and Kaplan fibers; ACL reconstruction; and an anterolateral extra-articular procedure (various configurations of ALL reconstruction and LET). Knees within a pair were randomly assigned to either ALL reconstruction or LET with a graft tension of 20 N and a randomly assigned fixation angle (30° or 70°). ALL reconstruction was then repeated and secured with a graft tension of 40 N. Results: In the setting of deficient anterolateral structures, ACL reconstruction was associated with significantly increased residual laxity for tibial internal rotation (up to 4°) and anterior translation (up to 2 mm) laxity as compared with the intact state. The addition of ALL reconstruction or LET after ACL reconstruction significantly reduced tibial internal rotation in most testing scenarios to values lower than the intact state (ie, overconstraint). Significantly greater reduction in laxity with internal rotation and pivot-shift testing was found with the LET procedure than ALL reconstruction when compared with the intact state. Combined with ACL reconstruction alone, both extra-articular procedures restored anterior tibial translation to values not significantly different from the intact state with most testing scenarios (usually within 1 mm). Conclusion: Residual laxity was identified after isolated ACL reconstruction in the setting of ALL and Kaplan fiber deficiency, and the combination of ACL reconstruction in this setting with either ALL reconstruction or the modified Lemaire LET procedure resulted in significant reductions in tibiofemoral motion at most knee flexion angles, although overconstraint was also identified. ALL reconstruction and LET restored anterior tibial translation to intact values with most testing states. Clinical Relevance: ALL reconstruction and lateral extra-articular tenodesis have been described in combination with intra-articular ACL reconstruction to address rotational laxity. This study demonstrated that both procedures resulted in significant reductions of tibial internal rotation versus the intact state independent of graft tension or fixation angle, although anterior tibial translation was generally restored to intact values. The influence of overconstraint with anterolateral knee reconstruction procedures has not been fully evaluated in the clinical setting and warrants continued evaluation based on the findings of this biomechanical study.

Anatomic Reconstruction of the Anterior Cruciate Ligament of the Knee With or Without Reconstruction of the Anterolateral Ligament: A Randomized Clinical Trial

Background: Rotational instability of the knee remains an issue after anterior cruciate ligament (ACL) reconstruction. Hypothesis/Purpose: The purpose was to evaluate the subjective and objective outcomes of combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. The hypothesis was that favorable outcomes can be achieved with this surgical procedure compared with isolated anatomic reconstruction of the ACL. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: One hundred ten patients with a unilateral ACL injury and high-grade pivot shift were randomly assigned to undergo either combined ACL and ALL reconstruction (group A) or isolated ACL reconstruction (group B). Preoperative and postoperative evaluations of the patients were conducted by obtaining history details, recording physical examination findings, measuring knee laxity using the KT-1000 arthrometer, and using validated outcome scores for the knee. P < .05 was considered as the cut-off level of statistical significance. The Fisher exact and Mann-Whitney U tests were used to assess statistical significance. Results: At a mean follow-up of 27 months, 53 and 50 patients in groups A and B, respectively, were available for analysis. No statistically different outcomes were found between the 2 groups except for the KT-1000 arthrometer values. The median KT-1000 arthrometer result for combined ACL and ALL reconstruction was 1.3 mm, while the median result for isolated ACL reconstruction was 1.8 mm (P < .001). None of the patients (n = 0; 0.0%) who underwent combined ACL and ALL reconstruction had anterior translation of greater than 5 mm at maximum pulling strength compared with their normal knees at final follow-up. On the other hand, 3 (6.0%) patients who underwent isolated ACL reconstruction had anterior translation of more than 5 mm. No serious complications were found in both groups. Conclusion: Combined ACL and ALL reconstruction was found to be effective in improving subjective and objective outcomes. Nevertheless, these findings were not significantly superior to isolated ACL reconstruction except for the instrumented knee laxity testing results. This might indicate that ALL reconstruction should not be performed routinely for patients undergoing ACL reconstruction.

Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity

Background: Injury to the posteromedial meniscocapsular junction has been identified after anterior cruciate ligament (ACL) rupture; however, there is a lack of objective evidence investigating how this affects knee kinematics or whether increased laxity can be restored by repair. Such injury is often overlooked at surgery, with possible compromise to results. Hypotheses: (1) Sectioning the posteromedial meniscocapsular junction in an ACL-deficient knee will result in increased anterior tibial translation and rotation. (2) Isolated ACL reconstruction in the presence of a posteromedial meniscocapsular junction lesion will not restore intact knee laxity. (3) Repair of the posteromedial capsule at the time of ACL reconstruction will reduce tibial translation and rotation to normal. (4) These changes will be clinically detectable. Study Design: Controlled laboratory study. Methods: Nine cadaveric knees were mounted in a test rig where knee kinematics were recorded from 0° to 100° of flexion by use of an optical tracking system. Measurements were recorded with the following loads: 90-N anterior-posterior tibial forces, 5-N·m internal-external tibial rotation torques, and combined 90-N anterior force and 5-N·m external rotation torque. Manual Rolimeter readings of anterior translation were taken at 30° and 90°. The knees were tested in the following conditions: intact, ACL deficient, ACL deficient and posteromedial meniscocapsular junction sectioned, ACL deficient and posteromedial meniscocapsular junction repaired, ACL patellar tendon reconstruction with posteromedial meniscocapsular junction repair, and ACL reconstructed and capsular lesion re-created. Statistical analysis used repeated-measures analysis of variance and post hoc paired t tests with Bonferroni correction. Results: Tibial anterior translation and external rotation were both significantly increased compared with the ACL-deficient knee after posterior meniscocapsular sectioning (P < .05). These parameters were restored after ACL reconstruction and meniscocapsular lesion repair (P > .05). Conclusion: Anterior and external rotational laxities were significantly increased after sectioning of the posteromedial meniscocapsular junction in an ACL-deficient knee. These were not restored after ACL reconstruction alone but were restored with ACL reconstruction combined with posterior meniscocapsular repair. Tibial anterior translation changes were clinically detectable by use of the Rolimeter. Clinical Relevance: This study suggests that unrepaired posteromedial meniscocapsular lesions will allow abnormal meniscal and tibiofemoral laxity to persist postoperatively, predisposing the knee to meniscal and articular damage.

Rates and Determinants of Return to Play After Anterior Cruciate Ligament Reconstruction in NCAA Division 1 College Football Athletes: A Study of the ACC, SEC, and PAC-12 Conferences.

Background:For competitive athletes, return to play (RTP) and return to preinjury levels of performance after anterior cruciate ligament (ACL) reconstruction are the main goals of surgery. Although outcomes of ACL surgery are well studied, details on factors influencing RTP in elite college football players have not been evaluated thoroughly.Purpose:To determine the rate of RTP following ACL surgery among National Collegiate Athletic Association (NCAA) Division 1 collegiate football athletes and to examine variables that may affect these rates. The hypothesis was that the RTP rate in this cohort will be influenced by factors reflecting skill and accomplishment; that is, athletes higher on the depth chart, those on scholarship, and those later in their careers will have higher RTP rates. It was also predicted that graft type and concomitant procedures may have an effect on RTP rates.Study Design:Case series; Level of evidence, 4.Methods:Using athlete- and surgery-specific data from participating institutions in 3 major Division 1 college football conferences, information on athletes who had ACL reconstruction from 2004 through 2010 was collected. Statistical analyses were performed to determine the RTP rate as a function of the variables, such as depth chart position, in the data collected.Results:Of the 184-player cohort, 82% of the athletes, including 94% of starters, were able to RTP. Rates were greater among athletes higher on the depth chart (P = .004) and on scholarship (P = .008). Year of eligibility also affected RTP rates (P = .047), which increased from the redshirt and freshman year to the sophomore and junior years, but then decreased slightly into the senior and fifth-year senior seasons. The use of an autograft versus allograft was associated with increased RTP (P = .045). There was no significant difference (P = .18) between players who underwent an isolated ACL reconstruction versus those who underwent additional procedures.Conclusion:More than 80% of football players at the Division 1 level were able to RTP following ACL reconstruction. Factors representative of a player’s skill were associated with higher rates of RTP. Surgery-specific variables, in general, had no effect on RTP, except for the use of autograft, which was associated with a greater RTP rate.

Rates and Determinants of Return to Play after Anterior Cruciate Ligament Reconstruction in Division I College Women Soccer Athletes: A Study of the Southeastern Conference

Objectives:We sought to determine the overall return to play (RTP) rate of female collegiate soccer athletes after anterior cruciate ligament (ACL) reconstruction in the Southeastern Conference (SEC). Additionally, we examined particular athlete related and surgical technique related variables as they correlated to RTP. We hypothesized that RTP after ACL reconstruction would be higher than previously published results and that it would be independent of graft type utilization or surgical techniques employed.Methods:Head team physicians and athletic training staff of the 14 institutions of the SEC were contacted to request participation in the study. All institutions were sent information regarding the nature of the study, a standardized spreadsheet with standardized response choices for the purpose of data collection from the participating institutions, and instructions regarding athlete inclusion criteria. The spreadsheet provided queried certain athlete and technical surgical related variables for ACL reconstructions performed at the participating institutions over the previous 8 years (2005-2013).Results:All 14 of the SEC institutions chose to participate and provided data. 79 reconstructions were reported with RTP data available for 78 women soccer athletes. Overall RTP rate was 84.6%. There was statistical significance in RTP rates favoring athletes in earlier years of eligibility versus later years (p<0.05). Athletes in eligibility years 4 and 5 combined had a RTP rate of 40%. Scholarship status likewise showed statistical significance (p<0.001) favoring RTP rate for scholarship athletes (91%) vs. non-scholarship athletes (45.5%). Athlete position (p=0.242) and depth chart status (p=0.110) showed no significant effect on RTP. In examining surgery specific variables; RTP rate for autograft (87.9%), allograft (75%), and combined graft (50%) demonstrated no difference (p=0.218). RTP rates were similar for the two most commonly used grafts: patellar tendon autograft and hamstring autograft (p=0.186). Femoral tunnel drilling technique showed no effect (p=0.725) on RTP rate for transtibial, accessory medial portal, or two incision techniques. When comparing multiple graft fixation constructs on both the femoral and tibial side, no difference was observed as it relates to RTP. RTP in isolated ACL reconstruction (77.3%) versus ACL reconstruction with concomitant procedures (88.9%) showed no difference. For players undergoing revision ACL reconstruction versus primary, RTP rate was 77.3% and 87.3% respectively, without significant difference (p=0.499).Conclusion:Of Division I collegiate women soccer athletes undergoing ACL reconstruction, overall RTP rate approaches 85%. Undergoing ACL reconstruction earlier in the college career before the 4th year of eligibility as well as the presence of a scholarship had a positive effect on RTP. Surgical factors including graft type, fixation methods, tunnel placement technique, concomitant knee surgery, and revision status played showed no significant effect on RTP rate.

Brace or no-brace after ACL graft? Four-year results of a prospective clinical trial

A controversial discussion is held on using stabilizing knee braces after anterior cruciate ligament (ACL) surgery. The current study investigated the influence of a stabilizing knee brace on results after ACL reconstruction using patellar tendon autografts. A prospective randomized study was started including 64 patients divided into two equal groups and treated with or without a stabilizing knee brace for 6 weeks post-operatively. A follow-up examination 4 years after operation comprised IKDC 2000, KT1000 measurement, a visual analogue pain scale (VAS; scores 0-10) and radiographic evaluation. The t test for independent and paired samples and the Pearson's Chi-square test were used for statistical analysis (p < 0.05). The primary endpoint was the difference in IKDC classification. Eighty-one per cent of the patients were examined 4 years post-operatively. IKDC 2000 subjective (brace group 90.5 ± 8.9, braceless group 93.2 ± 6.1) and objective results (brace A 30%, B 56%, C 16%; braceless A 32%, B 48%, C 20%) and instrumental measurement of anteroposterior laxity with KT1000 (brace 0.6 ± 2.4 mm, braceless 1.8 ± 3.4 mm) showed no significant differences. VAS pain results were significantly better in the braceless group at 1.0 ± 1.2 versus 1.9 ± 1.4 under sports activity or heavy physical work (p = 0.015). There were no radiographic differences concerning osteoarthritic findings and tunnel widening between the groups. Post-operative treatment with a stabilizing knee brace after ACL replacement showed no advantage over treatment without a brace at 4-year follow-up. The use of a knee-stabilizing brace after isolated ACL reconstruction with autologous patellar tendon graft is not recommended. II.

Cartilage Status in Relation to Return to Sports After Anterior Cruciate Ligament Reconstruction

Background: Osteoarthritis after anterior cruciate ligament (ACL) reconstruction receives much attention in orthopaedic science. Anterior cruciate ligament reconstruction is related to increased joint fluid volumes, bone marrow edema, and cartilage biochemical and morphological changes believed to cause fragile joint conditions. These joint conditions may not be able to adequately counter the imposed loads during sports. Hypothesis: At 6 months after surgery, knee cartilage displays inferior quality in ACL-reconstructed knees when compared with controls. This inferior quality is influenced by the time to return to sports and/or by the time to surgery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Fifteen patients treated with isolated ACL reconstruction were compared with 15 matched controls. In all participants, a 3-T magnetic resonance imaging cartilage evaluation was performed entailing quantitative morphological characteristics (3-dimensional volume/thickness), biochemical composition (T2/T2* mapping), and function (after a 30-minute run: in vivo deformation including recovery). Nonparametric statistics were executed reporting median (95% CI). Results: No volume and thickness between-group differences existed. In patients, medial femur (FM) T2 was higher (45.44 ms [95% CI, 40.64-51.49] vs 37.19 ms [95% CI, 34.67-40.39]; P = .028), whereas T2* was lower in the FM (21.81 ms [95% CI, 19.89-22.74] vs 24.29 ms [95% CI, 22.70-26.26]; P = .004), medial tibia (TM) (13.81 ms [95% CI, 10.26-16.78] vs 17.98 ms [95% CI, 15.95-18.90]; P = .016), and lateral tibia (TL) (14.69 ms [95% CI, 11.71-16.72] vs 18.62 ms [95% CI, 17.85-22.04]; P < .001). Patients showed diminished recovery at 30 minutes after a 30-minute run in the FM (−1.60% [95% CI, −4.82 to −0.13] vs 0.01% [95% CI, −0.34 to 1.23]; P = .040) and at 30 (−3.76% [95% CI, −9.29 to −1.78] vs 0.04% [95% CI, −1.52 to −0.72]; P = .004) and 45 minutes after exercise (−1.86% [95% CI, −4.66 to −0.40] vs 0.43% [95% CI, −0.91 to 0.77]; P = .024) in the TL. Eight patients returned to sports at 6 months or earlier. Return before 5 months (3/8 patients) was associated with increased cartilage thickness (in TM, TL, and lateral femur [FL]), deformation (in FL), and delayed recovery after running (in FL and FM). Median surgical delay was 10 weeks (range, 5-17 weeks). Surgery within 10 weeks (9/15 patients) was also associated with delayed cartilage recovery (in FL and FM). For the other parameters, no significant relationships could be established for either return to sports or surgical delay. Conclusion: At 6 months after surgery, cartilage in patients with ACL reconstruction shows diminished quality and in vivo resiliency compared with controls. Caution is advised in an early return to sports especially when dealing with patients who received prompt surgery. Possibly, high impacts on this qualitatively diminished cartilage might play a role in the development of osteoarthritis in ACL reconstruction. Replication in larger samples and follow-up are warranted.

Effects of articular cartilage and meniscus injuries at the time of surgery on osteoarthritic changes after anterior cruciate ligament reconstruction in patients under 40 years old

The development of osteoarthritis (OA) after anterior cruciate ligament (ACL) reconstruction is an unsolved problem. Articular cartilage and meniscus injuries are particularly important factors that contribute to OA progression. The purpose of this study was to investigate how articular cartilage and meniscus injuries at the time of surgery affected the development of OA under limited conditions retrospectively. Exclusion criteria of this study were (1) age 40 years or over, (2) previous surgery, (3) another combined knee ligament injury, and (4) unstable reconstructed knees. This study included 49 knees in 46 patients (average 26 years; range, 13-39 years) who had undergone isolated ACL reconstruction. Mean follow-up period was 3.9 years (range, 2-8 years). We classified patients into two groups, cartilage-damaged and non-damaged. Patients were also classified into two groups on the basis of treatment for meniscus: meniscectomy group and meniscus intact group. OA changes were investigated using weigh-bearing anteroposterior radiographs taken before surgery and at evaluation. OA changes were evaluated in terms of joint space narrowing, atrophy, sclerosis, cysts, spurs, flattening of the femoral condyle, concavity of the tibial condyle, and sharpening of the eminence. Each parameter was scored, and the total number of points was recorded as the OA score. Differences between the preoperative OA score and that at evaluation were defined as the increase of the OA score. OA progressed in 28 knees (57%). OA score was higher at evaluation than before surgery (P < 0.001). In the cartilage-damaged group, the Lysholm score at evaluation was lower (P < 0.05) and the increase in the OA score was higher than in the non-damaged group (P < 0.05). The increase in the OA score was higher in the meniscectomy group (P < 0.05). We concluded that patients with cartilage damage and who had undergone meniscectomy show more progression of OA. These patients require long-term follow-up. Level 4, case series, therapeutic studies, investigating the results of treatment.