Marx Activity Research Articles

5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers

Background: Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. Purpose: To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. Study Design: Case series; Level of evidence, 4. Methods: Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. Results: A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). Conclusion: Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Preoperative Predictors of Arthroscopic Partial Meniscectomy Outcomes: The APM Index Score

Background: Preoperative risk factors contributing to poor outcomes after arthroscopic partial meniscectomy (APM) have not yet been consolidated and codified into an index scoring system used to predict APM success. Purpose: To create an index score using available preoperative factors to predict the likelihood of favorable postoperative outcomes after APM. Study Design: Case-control study; Level of evidence, 3. Methods: A consecutive cohort of patients undergoing primary APM were enrolled in this study. Patients completed pre- and postoperative patient-reported outcome measure (PROM) questionnaires that included the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, Veterans RAND 12-Item Health Survey (VR-12 Physical and Mental), and Marx Activity Rating Scale (MARS). Multivariable logistic regression models were performed to evaluate independent predictors of KOOS Pain, Symptoms, and Activities of Daily Living scores and achievement of the minimal clinically important difference (MCID) and substantial clinical benefit (SCB). The authors assigned points to each variable proportional to its odds ratio, rounded to the nearest integer, to generate the index score. Results: In total, 468 patients (mean age, 49 years [SD, 10.4 years; range, 19-81 years]) were included in this study. In the univariate analysis, shorter symptom duration, lower Kellgren-Lawrence (KL) grade, lower preoperative KOOS Pain value, and lower VR-12 Physical score were associated with a higher likelihood of clinical improvement at 1 year. In the multivariable model for clinical improvement with MCID, symptom duration (<3 months: OR, 3.00 [95% CI, 1.45-6.19]; 3-6 months: OR, 2.03 [95% CI, 1.10-3.72], compared with >6 months), KL grade (grade 0: OR, 3.54 [95% CI, 1.66-7.54]; grade 1: OR, 3.04 [95% CI, 1.48-6.26]; grade 2: OR, 2.31 [95% CI, 1.02-5.27], compared with grade 3), and preoperative KOOS Pain value (score <45: OR, 3.00 [95% CI, 1.57-5.76]; score of 45-60: OR, 2.80 [95% CI, 1.47-5.35], compared with score >60) were independent significant predictors for clinical improvement. The scoring algorithm demonstrated that a higher total score predicted a higher likelihood of achieving the MCID: 0 = 40%, 1 = 68%, 2 = 80%, 3 = 89%, and 4 = 96%. Conclusion: Using this model, the authors developed an index score that, using preoperative factors, can help identify which patients will achieve clinical improvement after APM. Longer symptom duration and higher KL grade were associated with a decreased likelihood of clinical improvement as measured by KOOS Pain at 1 year postoperatively.

The influence of body mass index on physical activity engagement following anterior cruciate ligament reconstruction: A systematic literature review

BackgroundThe objective of this study was to summarize available literature that explored the impact of body mass index (BMI) on physical activity participation among individuals who were subjected to the anterior cruciate ligament reconstruction (ACLR). MethodsA total of three electronic databases, including Web of Science, Scopus, and PubMed, were comprehensively searched to identify relevant investigations. The following inclusion criteria were applied: (1) study design was observational; (2) participants underwent the ACLR; (3) BMI was estimated as a predictor variable; and (4) outcomes evaluated referred to physical activity. The risk of bias was assessed with the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. ResultsAfter a database search, 787 studies were found, and only 10 of them met each of the eligibility criteria and were included in the qualitative analysis. Regarding respondents' characteristics, 7171 individuals underwent ACLR, 4080 males and 3091 females, with a mean age of 25.5 years. Most importantly, the average BMI of the examined population was 24.9 kg/m2. In all studies, physical activity was evaluated subjectively using the Tegner activity scale and the Marx activity scale. The main findings unambiguously demonstrated that a negative relationship between BMI and physical activity engagement was observed. More specifically, there is convincing evidence that BMI over 25 kg/m2 harmfully affected subjectively assessed physical activity in individuals with a history of ACLR. ConclusionThe results obtained in the presented research indicated that increased values of BMI were a factor that correlated with reduced physical activity levels in the ACLR population. Hence, taking into account the clinical and health implications of reduced physical activity participation, stimulation of a healthy lifestyle, such as a combination of adequately designed physical exercise and nutrition, seems necessary for the analyzed population.

Validity and Reliability of the Marx Activity Rating Scale (MARS) for Patients with Knee Problems

Objective: The Marx Activity Rating Scale (MARS) is a recently developed in English to assess patients’ who have knee problems activity level. However, there is no Turkish validation for it. Materials and Methods: MARS was translated into Turkish language according to the recommended stages by Beaton et al. 100 Patients (mean age, 30.90 ± 10.46) with various types of the knee problems were included. Each participant completed the MARS twice at fourteen day intervals to determine the test-retest reliability using the interrater correlation coefficient and Cronbach's alpha evaluating internal-consistency. Spearman's correlation coefficient was done to measure construct validity between the MARS, the EUROQoL (EQ-5D), the International Knee Documentation Committee (IKDC) Scale. Results: A total of 100 patients (37 females, 63 males) completed the Turkish-language MARS. The reliability of the test-retest was 0.905, with Cronbach's alpha of 0.828 at the initial and 0.782 for the retest. High correlations were found between the IKDC and MARS (r =0.253). MARS also strongly correlated with the EQ5D-VAS component score (r =0.265). Floor or ceiling effects were not found for the overall MARS score. Conclusion: MARS is a valid, reliable and might be preferred for patients with numerous knee problems. Keywords: Validity, Reliability, Knee, Activity.

Outcomes of Anterior Cruciate Ligament Reconstruction With Independently Tensioned Suture Tape Augmentation at 5-Year Follow-up

Background: Reconstruction using autograft remains the gold standard surgical treatment for anterior cruciate ligament (ACL) injuries. However, up to 10% to 15% of patients will suffer a graft failure in the future. Cadaveric studies have demonstrated that the addition of suture tape augmentation to ACL autograft constructs can increase graft strength and reduce elongation under cyclical loading. Purpose/Hypothesis: This study aimed to investigate the clinical outcomes and rerupture rates after ACL reconstruction (ACLR) with suture tape augmentation. We hypothesized that augmentation with suture tape would lead to lower rerupture rates. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary ACLR using hamstring or patellar tendon autografts augmented with suture tape between 2015 and 2019 were recruited prospectively. Patients with multiligament injuries or a concomitant lateral extra-articular procedure were excluded. Patients were observed in person for 6 months, and patient-reported outcome measures (PROMs) were collected at 2 and 5 years postoperatively. All patients were contacted, and records were reviewed to determine the incidence of graft failure. PROMs collected were as follows: Knee injury and Osteoarthritis Outcome Score (KOOS), Veterans RAND 12-Item Health Survey (VR-12), Tegner and Marx activity scores, and visual analog scale for pain (VAS). Results: A total of 97 patients, with a mean age of 34.7 (±13.4) years, were included (76% men; 52 hamstring and 45 patellar tendon grafts). The mean graft diameter was 8 (±1) mm. There was 1 rerupture (1.1%) out of the 90 patients who were contactable at a mean of 5 years postoperatively. Median KOOS scores at 2 years were as follows: Pain, 94; Symptoms, 86; Activities of Daily Living, 99; Sport and Recreation, 82; and Quality of Life, 81. The postoperative scores were significantly higher than the preoperative scores (P < .001). The VR-12 Physical score improved from 43 preoperatively to 55 at 2 years and remained at 56 at 5 years. The VAS pain, Tegner, and Marx scores were 0, 6, and 9, respectively, at 2 years postoperatively. There was no difference in PROMs between graft types. Conclusion: This study demonstrates encouraging results of suture tape augmentation of autograft ACLR for both hamstring and patellar tendon grafts. The failure rate of 1.1% at a mean follow-up of 5 years is lower than published rates for reconstruction, and PROMs results are satisfactory. The technique is safe to use and may permit a return to the preinjury sporting level with a lower chance of reinjury.

Outcomes of bone-patellar tendon-bone autograft and quadriceps tendon autograft for ACL reconstruction in an all-female soccer player cohort with mean 4.8-year follow up

ObjectiveThe purpose is to compare functional outcomes, return to soccer rates, and revision rates in an all-female soccer player cohort undergoing quadriceps tendon (QT) autograft ACLR versus bone-patellar tendon-bone (BPTB) autograft ACLR. MethodsFemale soccer players who sustained an ACL rupture and underwent primary anatomic, single-bundle ACLR with BPTB autograft or QT autograft were included. Demographic and surgical characteristics were collected. Outcomes of interest included Tegner score, International Knee Documentation Committee (IKDC) score, Marx score, return to soccer rates, and failure rates. ResultsData on 23 patients undergoing BPTB autograft ACLR and 14 undergoing QT autograft ACLR was available. Average age was 18.7 years, and average follow up was 4.8 years. Overall, 76 ​% (28/37) returned to soccer and 5.4 ​% (2/37) underwent revision ACLR. No major significant differences were found in demographic or surgical characteristics. No differences were found in postoperative IKDC scores, preoperative, postoperative, or change from pre-to postoperative Marx activity scores, or pre-and postoperative Tegner scores between the groups. QT autograft ACLR patients had significantly less change in Tegner scores pre-to postoperatively compared to the BTPB autograft ACLR group (0.6 ​± ​1.2 versus 2.1 ​± ​1.8; p ​= ​0.02). Both groups had similar rates of return to soccer [78 ​% (18/23) BPTB autograft ACLR versus 71 ​% (10/14) QT autograft ACLR; p ​= ​0.64] and rates of revision (8.7 % (2/23) BPTB autograft ACLR; 0 % (0/14) QT autograft ACLR. ConclusionResults of this study suggest that BPTB autograft ACLR and QT autograft ACLR produce comparable, successful functional and return to soccer outcomes in this all-female soccer player cohort study. Larger, prospective studies are needed to improve the strength of conclusions and provide more information on the optimal graft choice for female soccer players. Surgeons can use the results of this study to counsel female soccer players on expected outcomes after ACLR. Level of EvidenceIII.

Comparison of failure risk and outcome scores following meniscus repair among adolescent and adult patients

Background:There are few studies assessing the impact of age at time of surgery on meniscus repair failure risk and patient-reported outcome scores. We sought to determine whether age at time of meniscus repair surgery affects failure risk and patient-reported outcome scores.Methods:Patients who underwent meniscus repair during 2006-2013 were evaluated for meniscus repair failure and patient-reported outcome scores using the Knee Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Marx Activity score at mean follow-up 6.5±2.0 yr post-operative. A multivariable linear regression analysis was used to assess the influence of patient age on patient-reported outcome scores following meniscus repair.Results:A total of 170 patients with mean age 27.8±10.1 yr (59% male) were identified, including 29 patients age 18 and younger and 141 patients over 18. Increasing patient age was associated with significantly lower IKDC (P=0.027), KOOS-ADL (P=0.003), and Marx activity scores (P&lt;0.001). Repair failure occurred in 46 patients (27.1%) overall, including 7 failures (24.1%) in patients 18 and under and 39 failures (27.7%) in patients over 18. The logistic regression analysis demonstrated no association between age and meniscus repair failure risk when controlled for ACL reconstruction and BMI (P=0.69).Conclusion:Increased age is associated with poorer IKDC, KOOS-ADL, and Marx Activity scores following meniscus repair. However, there is no difference in failure of healing of meniscus repair between adolescent patients and adults.Level of Evidence:III

Validation of a Survey to Characterize Barriers to Physical Activity After Anterior Cruciate Ligament Reconstruction.

Although 84% of patients expected to return to activity within 1 year of anterior cruciate ligament (ACL) reconstruction (ACLR), as few as 24% will return to their preinjury level of activity. By considering a patient's perceptions of reengagement in activity after ACLR, clinicians and researchers may be better equipped to implement interventions that are patient centered. To describe the validation of the ACL Reasons survey, a tool to aid clinicians and researchers in understanding patient perceptions of barriers to physical activity (PA) engagement after ACLR. Cross-sectional study. The ACL Reasons survey was administered via Qualtrics to 78 patients 6 to 24 months after primary, unilateral ACLR. Patients were categorized as active, more challenging, or less active based on their responses to the ACL Reasons. Development of the ACL Reasons survey occurred via an iterative process of drafting and revising based on feedback from a team of external expert reviewers. Tegner activity level, Marx activity score, the Knee injury and Osteoarthritis Outcomes Score (KOOS), ACL Return to Sport after Injury score, and Tampa Scale of Kinesiophobia score were compared among groups using analysis-of-variance and Kruskal Wallis tests. Groups differed based on Tegner activity level (P < .001), Marx activity score (P = .01), KOOS pain score (P = .02), KOOS symptom score (P = .04), KOOS sports and recreation score (P < .001), KOOS quality of life score (P < .001), ACL Return to Sport after Injury score (P < .001), and Tampa Scale of Kinesiophobia score (P < .001), with the less active group performing worse on each. Knee symptoms, fear of knee symptoms or movement, and fear of injury were the most common reasons for the change in PA engagement. These results support the validity of the ACL Reasons survey as a tool for identifying barriers to PA engagement after ACLR. This tool may help facilitate communication between patients with ACLR and their health care providers to enhance patient-centered care.

Paper 62: Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients with High Baseline Pre-Injury Marx Activity Level

Paper 62: Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients with High Baseline Pre-Injury Marx Activity Level

Paper 15: 5 Year Radiographic and Functional Outcomes of Non-Operative Treatment of Completely Displaced Clavicle Fractures in Teenagers, A Prospective Study

Objectives: Optimal treatment for displaced clavicle fractures in adolescents remains controversial, with many surgeons favoring operative reduction and fixation. To prospectively assess patient reported outcomes (PROs) in teenagers undergoing non-operative treatment of a completely displaced clavicle fracture ≥ 5 years post-injury. Furthermore, bilateral clavicle imaging was used to determine the association between these outcomes and the presence or absence of bony remodeling. Methods: This study used a subset of patients previously enrolled in a multicenter study looking at adolescent clavicle fractures. Patients from a single institution and ≥ 13 years at the time of injury, with non-operatively treated completely displaced clavicle fractures who were ≥5 years out from their initial injury were able to participate in the study. Patients were clinically evaluated for evidence of scapular dyskinesia, strength deficits, and cosmetic concerns. Bilateral clavicle imaging was used to assess residual shortening, displacement, and angulation. PROs included: ASES, QuickDASH, Marx Shoulder Activity Scale, and return to sport data. Results: Twenty-four patients were available for follow-up, of whom 17 (71%) consented to the additional imaging. The mean age at the time of injury was 14.5±1.1 years with 89% being male. At a mean follow-up of 6.1 years, all fractures healed and no interventions were necessary (Figure 1). Significant remodeling was observed across all measurements with improvements of 70% in mean shortening (22.8 mm to 6.8 mm, p&lt;0.001), 73% in superior displacement (13.4 mm to 3.6 mm, p&lt;0.001), and 83% in angulation (10.4˚ to 1.8˚, p&lt;0.001) (Figure 2). Thirteen patients (72%) had initial shortening &gt; 2 cm and all remodeled to &lt; 2 cm. PROs were almost universally excellent with no patients reporting shoulder pain and mean ASES, quickDASH, and Marx activity scores of99±3, 1±3, and 20±1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Majority (58%) were completely satisfied with the appearance of their shoulder, 38% were more satisfied than not, one patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 returned to sporting activities if interested. No PROs were associated with bony remodeling (p&gt;0.05). Conclusions: Teenage patients with completely displaced clavicle fractures can expect excellent radiographic and clinical outcomes 5 years post-injury if treated non-operatively. This study further supports the role of non-operative treatment for teenagers, with nearly perfect outcomes reported bringing into question the role of acute operative management of these fractures given its associated risks and costs.

Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study

Background: Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood. Purpose/Hypothesis: The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients’ inability to return to preinjury activity levels. Results: A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients’ inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient’s ability to return to preinjury activity level. Conclusion: At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

Poster 149: Donor Site Morbidity Following Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Versus Bone-Patellar Tendon-Bone Autograft: Results at 2-Year Follow-up

Objectives: Bone-patellar tendon-bone (BTB) autograft has historically been regarded as the gold standard for anterior cruciate ligament reconstruction (ACLR). Despite widespread utilization of BTB autografts, multiple complications following BTB harvest have been reported, including anterior knee pain, difficulty kneeling, patellar tendon rupture, patella fracture, tendon contracture, and numbness. The quadriceps tendon (QT) autograft has been proposed as an alternative graft in young, high demand patients to achieve comparable clinical outcomes while avoiding complications associated with BTB autograft. Recently, a novel 10-question donor site morbidity (DSM) instrument was developed by Hacken et al that was used to evaluate DSM following BTB ACLR. However, to date, the instrument has not been used to evaluate DSM following QT harvest. Therefore, a retrospective evaluation of DSM following ACLR with QT versus BTB autograft was performed. Methods: All patients who underwent ACLR with QT autograft between January 2018 and February 2020 were identified in a single institution registry and matched to a control group of patients who underwent BTB autograft ACLR on the basis of age and sex. DSM was assessed using a 10-question DSM instrument and scores were compared to traditional patient reported outcome measures including the IKDC, Marx Activity Scale, and SANE scores. Post-operative complications including quadriceps tendon rupture, patella fractures, and graft failure were assessed via registry query. Multivariate analysis was conducted to investigate factors associated with DSM. Results: Thirty-two QT patients (15M,17F) with a mean age of 23.0 years (range 13-45) were compared to 61 BTB patients (32M,29F) with a mean age of 22.2 (range 13-45) who responded at a minimum 24- months after surgery. DSM scores were rated good or excellent in 26/31 QT patients(81%) versus 44/61 BTB patients(72%) (P=0.45). Significant differences were noted between graft types with respect to presence of numbness, with 37/61 BTB patients(61%) versus 10/32 QT patients(31%) reporting mild, moderate, or diminished sensation to light touch(P=0.02). Differences were also noted in kneeling pain, with 30/61 BTB patients(49%) versus 6/32 QT patients(19%) reporting either mild pain with kneeling or inability to kneel on hard surfaces (P=0.01). Finally, differences were reported in patient-reported presence of quadriceps wasting, with 20/32 QT patients(38%) reporting atrophy versus 15/61 BTB patients(25%) (P=0.01). However, no differences were noted in pain at donor site, size of numbness, difficulty with stairs or prolonged sitting, anterior knee pain, or incision cosmesis(P&gt;0.05). Multivariate analysis demonstrated that graft type, sex, body mass index (BMI), operative age, and meniscus integrity were not associated with DSM scores(P&gt;0.05). Correlations between PROMS and DSM showed correlations with IKDC, Marx, and SANE(P&lt;0.01). There were no instances of quad tendon rupture, patella fracture, or ACL graft failure in either group. Conclusions: DSM following ACLR with QT and BTB autograft demonstrated good to excellent results in the majority of patients. Significantly more BTB patients experienced numbness at the harvest site and pain with kneeling compared to QT patients. However, more patients reported quadriceps atrophy following QT compared to BTB autograft. PROMS correlated with DSM scores, suggesting that these instruments may be impacted by DSM following ACLR.

Reduced Incidence of Revision Anterior Cruciate Ligament Reconstruction With Internal Brace Augmentation.

Revision rates and outcome measures after anterior cruciate ligament reconstruction (ACLR) with suture tape as an internal brace is not well-documented because of the emerging nature of the technique. ACLR with internal bracing (IB) would lead to decreased revision ACLR compared with traditional ACLR while exhibiting comparable patient outcomes. Cohort study; Level of evidence, 3. A total of 200 patients were included in this study. Patients aged between 13 and 39 years at the time of surgery who underwent primary autograft ACLR with IB between 2010 and 2020 and were enrolled in our institution's registry with a minimum of 2-year follow-up were identified and matched 1 to 1 with a non-internal brace (no-IB) group based on concomitant procedures and patient characteristics. Pre- and postoperatively, patients completed the Knee injury and Osteoarthritis Outcome Score, Marx activity rating scale, Veterans RAND 12-Item Health Survey, and visual analog scale for pain. Knee laxity measurements via the KT-1000 arthrometer were included in the pre- and postoperative objective clinical assessments. A total of 100 IB patients were matched with 100 no-IB patients based primarily on concomitant procedures and secondarily on patient characteristics. The IB group underwent significantly fewer revision ACLRs (1% vs 8%; P = .017). Even though the no-IB group had a significantly longer mean final follow-up time (48.6 months [95% CI, 45.4-51.7] vs 33.4 months [95% CI, 30.3-36.5]; P < .001), the time elapsed from the original ACLR to the revision did not differ significantly between groups, and the mean ages for the IB and no-IB groups were comparable (19 vs 19.9 years). All postoperative patient-reported outcome scores between the 2 groups were comparable and significantly improved postoperatively except for the Marx score, which significantly decreased stepwise for both groups postoperatively. KT-1000 measurements significantly improved in both groups after surgery with the IB and no-IB cohorts yielding comparable results at the manual maximum pull (0.97 vs 0.65 mm). ACLR with IB resulted in a significantly decreased risk of revision ACLRs while maintaining comparable patient-reported outcomes. Therefore, incorporating an internal brace into ACLR appears to be safe and effective within these study parameters.

Paper 27: Preoperative Risk Factors of Subsequent Ipsilateral ACL Revision Surgery following an ACL Restoration Procedure

Objectives: To identify the preoperative risk factors for revision ACL surgery within the first two years after BEAR ACL repair procedure. Methods: Data from the prospective BEAR I, II, and III trials were used to determine preoperative risk factors for ACL revision surgery. All subjects with a complete ACL tear (ages between 13-47 years, depending on the trial), who passed all other inclusion/exclusion trial criteria, and underwent a primary BEAR procedure within 30-50 days from injury (dependent on trial) were included. Demographic data (age, sex, BMI), baseline patient-reported outcomes (IKDC Subjective Score, Marx Activity score), pre-operative imaging characteristics (ACL stump length, notch size, tibial slopes), and intraoperative findings (knee hyperextension, meniscal tear status) were evaluated to determine their contribution to ipsilateral revision ACL surgery risk. Results: 123 subjects, median age 17.6 years (IQR 16-23), including 67 (54%) females, met study criteria. 18 (15%) patients required revision ACL surgery in the first two years following the BEAR procedure. In bivariate analyses, younger age (p=.011), having a contact injury at the time of the initial tear (p=.048), and increased medial tibial slope (p=.029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified two independent predictors of revision: patient age and medial tibial slope. The odds of an ipsilateral revision surgery were decreased by 32% for each one-year increase in age (OR=0.684, 95% CI = 0.517 to 0.905, p=.008), and increased by 28% per each degree of increase in medial tibial slope (OR=1.280, 95% CI =1.024 to 1.601, p=.030). Sex, baseline IKDC or Marx score, knee hyperextension, or meniscus status were not significant predictors of revision. Conclusions: Younger age and higher medial tibial slope were predictors of increased odds of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration surgery.

Paper 42: A Novel Machine Learning (ML) Algorithm to Predict Outcomes after Revision ACLR (rACLR) in the Multicenter Anterior Cruciate Ligament Reconstruction Study (MARS) Cohort

Objectives: The multicenter anterior cruciate ligament reconstruction study (MARS) Group has implicated several factors that influence revision anterior cruciate ligament (rACLR) outcomes. As machine learning (ML) becomes increasingly utilized in the orthopaedic literature, the application of ML methodology to MARS cohort data presents a valuable opportunity to translate data into patient-specific insights. This study sought to apply novel ML methodology to the MARS cohort data in order to determine 1) an optimal predictive model of rACLR graft failure and 2) features that are most predictive of rACLR graft failure in context of the predictive model. Methods: The MARS Group of 83 surgeons and 52 sites prospectively enrolled a cohort of patients undergoing rACLR. Patients were followed up at 2 and 6 years postoperatively regarding patient-reported outcomes (PROs), additional surgeries, and incidence of graft failure. Surgeon reported intraoperative findings and preoperative radiographic measures were obtained. Data was preprocessed and 381 demographic, clinical, and surgical features were used to build five machine learning models predictive of graft failure at 6 years postoperatively. Models used included traditional logistic regression (LR), XGBoost, Gradient Boosting, Random Forest, and a validated ensemble algorithm, AutoPrognosis (AP). Validated performance metrics for binary outcome prediction models were used to determine discriminative power and calibration. Individual feature importance was calculated for the highest performing models using partial dependence and perturbation-based feature importance. Results: The cohort included 831 patients who completed six year follow up, and 5.8% (n=48) of whom experienced graft failure. While all models had moderate to good concordance, AP demonstrated the highest discriminative power compared to other models (Model: AUROC | AP: 0.722 | Random Forest: 0.621 | Gradient Boosting: 0.654 | XGBoost: 0.690 | Logistic Regression: 0.630). The AP model was well-calibrated, with calibration scores similar to the other studied models (Model: Brier Score | AP: 0.054 | Random Forest: 0.054 | Gradient Boosting: 0.059 | XGBoost: 0.059 | Logistic Regression: 0.102). Features deemed important for AP differ from those for LR model performance. For AP, partial dependence feature importance calculations demonstrated the following top five contributors to model predictive ability: surgeon years of experience, prior femoral tunnel position measured via preoperative radiograph, compromised prior ACLR femoral tunnel position and size, and baseline patient age. Similarly, AP perturbation-based calculations showed the following top five features that contribute most to the AUROC performance: baseline patient age, current ACLR graft type, years since previous ACLR, prior ACLR femoral tunnel position, and prior tibial tunnel position on sagittal view preoperative radiographs. Perturbation-based calculations showed the following top five features that contribute most to the AUPRC performance: current ACLR graft type, baseline patient age, prior tibial tunnel position on sagittal view preoperative radiographs, previous ipsilateral medial meniscus repair, and baseline SF-36 subscale scores for patient vitality. Other leading contributors to model predictive ability included baseline PROs including SF-36 subscale scores for physical function, mental health and composite mental health, KOOS quality of life, WOMAC pain, and MARX activity rating scores. Conclusions: Of the studied models in this preliminary analysis, AP appears to most accurately predict rACLR graft failure. These findings build on prior studies, identifying key surgical, clinical, radiographic, and patient-reported factors contributing to the model’s ability to predict rACLR graft failure at 6 years postoperatively. Further work includes creation of a clinical risk calculator using important feature inputs, and the use of survival modeling to determine risk scores at various postoperative time points.

Poster 314: Hamstring Autograft Diameter Effect on Surgical Outcome in a Prospective ACL Reconstruction Patient Cohort

Objectives: The purpose was to investigate the effect of hamstring autograft diameter on risk of graft failure and subsequent either knee surgery following ACLR in a prospective cohort. Background: Optimization of graft selection and incorporation in anterior cruciate ligament (ACL) reconstruction (ACLR) is an evolving science. Recent studies suggest hamstring tendon autograft diameter may influence outcomes in primary ACLR, with a larger diameter acting as a protective factor against ACL graft rupture. Further evidence using a prospective patient database is valuable in corroborating the association between ACL autograft diameter and patient outcomes. Methods: Prospective data was collected for a cohort of patients undergoing primary ACLR from February 2015 to February 2018. Exclusion criteria included non-hamstring graft selection, allograft augmentation, skeletally immature patients, revision ACLR, prior contralateral ACLR, and multiligament injuries. Cases from 10 fellowship-trained surgeons within a single institution were included. Recorded tunnel size was utilized as a surrogate for autograft diameter. The contribution of age, sex, BMI and operating surgeon on autograft diameter was studied via mixed effect modeling. The effect of hamstring tendon autograft diameter on risk of subsequent surgery was measured using multivariable linear regression modeling that controlled for patient and surgery characteristics including age, sex, BMI, Marx activity score, and graft diameter. Two-year outcomes were collected for incidence of subsequent surgery to either knee, including ipsilateral revision ACLR and contralateral primary ACLR. Results: Of the patients undergoing ACLR with hamstring autograft who met inclusion criteria, there was 90.5% follow up for subsequent surgery outcomes at minimum of 2 years, resulting in 381 patients. Female sex and lower BMI was associated with smaller autograft diameter and operating surgeon had a significant effect on autograft diameter. 59 patients (15.5%) had subsequent ipsilateral surgery and 27 patients (7.09%) had revision ACLR within 2 years. 29 patients (7.61%) had contralateral subsequent knee surgery and 20 patients (5.25%) had primary contralateral ACLR within 2 years. After controlling for age, sex, BMI, and baseline Marx activity score, hamstring autograft diameter was not associated with risk of all ipsilateral subsequent knee surgery (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.56 - 1.36, p = 0.536). Baseline Marx score greater than or equal to 12 was associated with risk of all ipsilateral subsequent knee surgery with OR 2.55 (CI 1.41 – 4.59, p = 0.002). After controlling for age, sex and BMI, hamstring autograft diameter was not associated with risk of revision ACLR (OR 0.71, CI 0.38 - 1.33, p = 0.286). Age was associated with risk of ipsilateral revision ACLR with OR 0.16 (CI 0.05 – 0.51, p = 0.002). After controlling for age, sex and BMI, hamstring autograft diameter was not associated with risk of all contralateral subsequent knee surgery (OR 0.89, CI 0.50 - 1.59, p = 0.703) including contralateral ACLR (OR 0.78, CI 0.39 - 1.59, p = 0.501). Age was found to be a significant prognostic variable of contralateral ACLR with OR 0.30 (CI 0.10 – 0.93, p = 0.037). No variables within the model were associated with risk of all contralateral subsequent surgery events. Conclusions: Hamstring autograft diameter greater than 8mm was not associated with risk of revision ACLR or other subsequent surgery in the ipsilateral or contralateral knee in a multivariable logistic regression analysis of a prospective patient cohort. Lower age was associated with risk of ipsilateral revision ACLR and contralateral ACLR. Baseline Marx activity score greater than or equal to 12 was associated with risk of all subsequent ipsilateral knee surgery. [Table: see text][Table: see text][Table: see text][Table: see text]

Poster 299: Body mass index does not affect outcomes following isolated medial patellofemoral ligament reconstruction

Objectives: Patellar instability may cause significant pain and disability and recurrent dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL). Obesity is a known risk factor for complications following numerous surgical procedures, yet there exists a lack of data regarding the influence of body mass index (BMI) on outcomes following MPFL reconstruction. The purpose of this study was to evaluate complications and outcomes following isolated MPFL reconstruction in obese and non-obese patients. We hypothesized that patients with a BMI ≥ 30 would exhibit increased complication risk and worse patient-reported outcomes. Methods: A billing query identified all patients at one academic medical center who underwent isolated MPFL reconstruction over an 8 year period. Chart review extracted demographic, physical exam, radiographic, surgical, and complication data. Patients were contacted and outcomes were assessed with the Norwich Patellar Instability (NPI) score, Marx activity rating, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Complications and outcomes were compared based on the presence of a BMI ≥ 30 kg/m2. Results: A total of 161 patients who underwent isolated MPFL reconstruction were included. Of this cohort, there were115 with BMI &lt; 30 and 46 with BMI ≥ 30. Early outcomes (time in brace, time to weight bearing) and postop complications (deep vein thrombosis, infection, pain, repeat dislocation/instability) were similar between groups (p&gt;0.50). A total of 97 patients (60%) completed patient-reported outcomes at a mean of 5 years post-operative, with no differences noted in patient- reported outcomes based on BMI (Table). Conclusions: Obesity (defined as BMI ≥ 30) was not associated with increased complications of poorer patient- reported outcomes 5 years following isolated MPFL reconstruction. [Table: see text]

Poster 344: Reduced Incidence of Anterior Cruciate Ligament Reconstruction Revision with Internal Brace Augmentation: A Retrospective Matched Cohort Study with a minimum 2-year Follow-up

Objectives: The primary purpose of this study was to investigate retear rates in patients who underwent ACLR with and without internal bracing in a matched cohort study. Additionally, we also sought to investigate if there were any differences in clinical and patient-reported outcomes between the groups. We hypothesized that ACLR with internal bracing would reduce the incidence of revisions in a safe and effective manner. Methods: A total of 200 patients were included in this study. Patients between the ages of 13-39 at the time of surgery who underwent primary autograft ACLR with internal bracing (IB group) between October 2010 and July 2020 and were enrolled in our institution’s registry with a minimum of 2-year follow-up were identified and matched 1:1 with a non-internal brace (no-IB) group based on patient demographics and concomitant procedures. Every patient completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale (MARS), Veterans RAND 12-Item Health Survey (VR- 12), and the Visual Analog Scale (VAS) pre- and postoperatively. KT-1000 arthrometer measurements were included in the pre- and postoperative objective, clinical assessments. Results: The IB group underwent significantly less revision ACLRs (1% vs. 8%, p = 0.017). Additionally, the average time elapsed from the original ACLR to the revision did not differ significantly and the average ages for the IB and the no-IB groups were comparable (19.0-years-old vs. 19.9-years-old). 5 patients in the no-IB group underwent a total of 9 meniscal procedures among them at the time of their revision ACLR compared to just one in the IB group (p = 0.009). There were also 4 patients in the no-IB group that underwent anterolateral ligament reconstruction at the time of their revisions (4 vs. 0, p = 0.043). All postoperative patient-reported outcome measures (PROMs) significantly increased in both groups with the exception of the MARS score which significantly decreased in both groups postoperatively. KT-1000 measurements significantly improved in both groups following surgery with the IB and no-IB cohorts yielding comparable results at the manual maximum pull (0.97mm vs. 0.65mm). Conclusions: ACLR with internal bracing resulted in an 88% decrease in revision ACLRs while maintaining comparable patient reported outcomes. Incorporating an Internal brace into ACLR is therefore safe and effective within these study parameters. [Table: see text][Table: see text][Table: see text]

Poster 331: ACL Graft Tear or Contralateral ACL Tear: Which is Worse???

Objectives: Anterior cruciate ligament (ACL) graft tears and contralateral ACL tears are both relatively common following primary ACL reconstruction (ACLR). While some prior studies have combined these injuries as an outcome variable (“subsequent cruciate injury”), there is little prior work comparing the outcomes of these injuries. We hypothesize that patient reported outcome measures (PROMs) and activity level are lower following revision ACLR than following contralateral ACLR. Methods: From a prospective cohort study of 2333 patients who underwent primary, unilateral ACLR, 298 patients were identified who underwent revision ACLR or contralateral ACLR within 5 years of primary ACLR. Following exclusion of 11 patients who had both injuries, 256 patients were eligible for study inclusion, including 124 patients who underwent revision ACLR and 132 patients who underwent contralateral ACLR. Patients were contacted for follow-up at 6 years after the primary ACL reconstruction and PROMs were collected including subjective International Knee Documentation Committee (IKDC) score, Knee Osteoarthritis pain (KOOS-Pain) and knee-related quality of life (KOOS- QOL) subscales, and Marx activity level. Patient demographic and initial injury factors, surgical factors, and PROMs were compared between groups. Multiple regression models were used to determine whether side of subsequent surgery (revision versus contralateral ACLR) was a significant predictor of outcome. Results: Two hundred trenty-three of 256 patients (87%) were contacted and completed PROMs at 6 years following primary ACLR. The median time from primary ACLR to second ACL surgery was lower in the revision group (1.3 years) than the contralateral group (2.0 years, p &lt; 0.001). The revision group also demonstrated a lower incidence of partial lateral meniscectomy and was more likely to have received an allograft for the primary ACLR. There were no significant differences in age, sex, smoking status, pre- operative knee laxity, articular cartilage status at primary ACLR, medial meniscus status at primary ACLR, sport, or pre-operative PROMs between the two groups. At follow-up, the revision ACLR group demonstrated lower Marx activity level and PROMs than the contralateral injury group (Table 1). When controlling for the above factors, the revision ACL group demonstrated a 7.8 point lower IKDC (p&lt;0.001), a 3.2 point lower KOOS-pain (p=0.012), a 10.4 point lower KOOS-QOL (p&lt;0.001), and 2.0 point lower Marx score (p=0.002) than the contralateral ACLR group. Conclusions: Patients who undergo revision ACL R demonstrate with poorer PROMs and lower activity level than those who undergo subsequent revision ACLR. [Table: see text]

Ten-Year Outcomes of Second-Generation, All-Inside Meniscal Repair in the Setting of ACL Reconstruction.

Meniscal repair is the goal, whenever possible, for the treatment of meniscal injury. The purpose of this study was to evaluate the long-term clinical success of meniscal repair performed with a second-generation, all-inside repair device with a concomitant anterior cruciate ligament (ACL) reconstruction. This was a retrospective review of prospectively collected patients who underwent meniscal repair by a single surgeon using the all-inside FAST-FIX Meniscal Repair System (Smith & Nephew) in conjunction with a concurrent ACL reconstruction. Eighty-one meniscal repairs (81 patients) were identified: 59 medial repairs and 22 lateral repairs. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Marx Activity Rating Scale score. Ten-year follow-up was obtained for 85% (69) of 81 patients. Nine patients (13% of 69) underwent a failed meniscal repair (6 medial, 3 lateral), corresponding to a failure rate of 12% (6 of 50) for medial repairs and 16% (3 of 19) for lateral repairs. The mean time to failure was 2.8 years (range, 1.2 to 5.6 years) for the medial repairs and 5.8 years (range, 4.2 to 7.0 years) for the lateral repairs (p = 0.002). There was no difference in mean patient age, sex, body mass index, graft type, or number of sutures utilized between successful repairs and failures. Postoperative KOOS and IKDC outcome scores significantly improved over baseline scores (p < 0.001). There was no significant difference in patient-reported outcomes at 10 years between the group with successful repairs and those who had a failed repair. This report of long-term follow-up results of primary second-generation, all-inside meniscal repair demonstrates its relative success when it is performed with concurrent ACL reconstruction. After a minimum follow-up of 10 years, 84% to 88% of the patients continued to demonstrate successful repair. Failure of medial meniscal repairs occurred significantly earlier compared with lateral meniscal repairs. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.