Preinjury Tegner Activity Level Research Articles

No Clinical Advantage of Harvesting a Patellar Bone Block Compared With All Soft-Tissue Graft in Primary Quadriceps Tendon Anterior Cruciate Ligament Reconstruction

PurposeTo compare patient-reported outcomes measurements (PROMs) and subsequent surgical interventions in patients treated with anterior cruciate ligament reconstruction (ACLR) using either quadriceps tendon autograft with a patellar bone block (bQT) or soft tissue only (sQT). MethodsAll ACLRs performed between 01.2010 and 03.2022 were prospectively followed for 24 months and retrospectively evaluated. All primary ACLRs with full 24 months of follow-up data, without any previous surgery or any additional ligamentous interventions, were matched for major ACL risk factors, including gender, age, Tegner activity level (TAL), pivoting sports, and concomitant injuries. PROMs (Lysholm score, Visual Analog Scale (VAS) for pain, and TAL) and subsequent surgical interventions were registered after 6, 12, and 24 months postoperative. Binary logistic regression was used to assess the influence of graft type, age, preinjury TAL, gender, pivoting sports and concomitant interventions on the need to undergo subsequent surgery. ResultsAfter matching, 246 patients were included in the final analysis. Both groups did not differ regarding any preoperative patient demographics or intraoperative details. At final follow-up, no significant difference in mean Lysholm score (sQT: 90.8±10.6, bQT: 91.8±10.6, p= .46), median TAL (sQT: 6 [1-10], bQT: 6 [1-10], p= .53) and VAS for pain (sQT: 0.7±1.1, bQT: 0.7±1.2, p= .70) was reported between both groups. 70.3% (sQT-A: 70.7%, bQT: 69.9%, p= .89) of patients returned to or exceeded their preinjury activity level. In terms of revision ACLR, there was no statistically significant difference between bQT (3.3%) and sQT (4.1%). Similarly, no difference was observed in contralateral ACLR (bQT: 7.3% sQT: 11.4%). Regression analysis indicated that none of the studied factors, including the use of a patellar bone block, influenced subsequent surgery, revision ACLR, or contralateral ACLR. ConclusionHarvesting an additional patellar bone block in quadriceps tendon ACL reconstruction does not seem to impact postoperative patient-reported outcomes, ACL revision- or contralateral ACL reconstruction rates. Level of EvidenceLevel 3 – Cohort Study

Arthroscopic Broström-Gould Repair Has Comparable Radiological and Clinical Outcomes Compared to Traditional Open Broström-Gould Repair in High-Demand Patients

Category: Arthroscopy; Sports Introduction/Purpose: This study sought to confirm whether traditional open Broström–Gould repair and arthroscopic Broström–Gould repair for chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high- demand patients. Methods: This retrospective case–cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström–Gould repair and were followed up for ≥ 2 years. Patients were divided into the arthroscopic Broström–Gould repair group (AS Group) and the open Broström–Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K– P) scores, and American Orthopaedic Foot and Ankle Society ankle–hindfoot (AOFAS) scores were evaluated clinically. Results: A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K–P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K–P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.). Conclusion: Traditional open and arthroscopic Broström–Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström–Gould repair may represent a viable surgical alternative to open Broström–Gould repair in high-demand patients.

High Prevalence of Superficial and Deep Medial Collateral Ligament Injuries on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Tears

To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears. In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P= .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P= .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P= .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001). The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5%+ 24.8%= 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries. Level III, retrospective cohort study.

Analyses of associated factors with concomitant meniscal injury and irreparable meniscal tear at primary anterior cruciate ligament reconstruction in young patients

Purpose:Although several factors related to the concomitant meniscal injury at anterior cruciate ligament reconstruction (ACL-R) have been investigated in a general population, few studies have identified the risk factors of meniscal tear severity in young patients in which the majority of ACL tears occur. The purpose of this study was to analyze the associated factors with meniscal injury and irreparable meniscal tear and the timeline for medial meniscal injury at ACL-R in young patients. Methods:A retrospective analysis of young patients (13 to 29 years of age) who underwent ACL-R by a single surgeon from 2005 to 2017 was conducted. Predictor variables (age, sex,body mass index [BMI], time from injury to surgery [TS], and pre-injury Tegner activity level) for meniscal injury and irreparable meniscal tear were analyzed with multivariate logistic Results:Four hundred and seventy-three consecutive patients with an average of 31.2 months post-operative follow-up were enrolled in this study. The risk factors for medial meniscus injury were TS (<= 3 months) (odds ratio [OR], 3.915; 95% CI, 2.630-5.827; P < .0001) and higher BMI (OR, 1.062; 95% CI, 1.002-1.125; P = 0.0439). The presence of irreparable medial meniscal tears correlated with higher BMI (OR, 1.104; 95% CI, 1.011-1.205; P = 0.0281) ConclusionAn increased time from ACL tear to surgery of 3 months was strongly associated with an increased risk of medial meniscus injury, but not related to irreparable medial meniscal tear at primary ACL reconstruction in young patients. Level of EvidenceLevel IV.

Paper 14: Generalized joint hypermobility leads to an 8-fold increase in the odds of sustaining a second ACL injury within 24 months of return to sport after ACL reconstruction

Objectives: To investigate the association between generalized joint hypermobility (GJH) and the 24-month incidence of a second ipsilateral or contralateral anterior cruciate ligament (ACL) injury in a population of patients who return to sport (RTS) after ACL reconstruction (ACL-R). Methods: Data for this study were queried from a Swedish rehabilitation specific registry called Project ACL. Ethical approval for this project was granted by the Regional Ethical Review Board in Sweden (registration numbers: 265-13, T023-17) and the Swedish Ethical Review Authority (registration number: 2020-02501). Patients with a primary ACL tear treated with ACL-R who were 16-50 years old and registered in Project ACL between 2014 – 2019 were considered eligible for inclusion. Return to sport was defined as a return to ³6 Tegner activity level. Patients with 5 positive tests on the Beighton scale were considered to fulfill criteria for GJH. Patients with missing GJH data, and patients with Tegner activity level &lt;6 preoperatively or at the time of RTS were excluded from further analysis. The study population was divided into GJH and non-GJH groups based on the screening criteria. The extracted data for eligible patients consisted of demographics, surgical variables and patient reported outcome measures (Table 1). Incidence of a second (ipsilateral or contralateral) ACL injury during the follow-up period after ACL-R was registered as a dichotomous variable. Demographic, injury-related, surgical and follow-up data were reported using descriptive statistics including frequency (n) and proportion (%) for categorical variables and mean ± standard deviation (SD) or median with range for continuous variables. For comparison between groups Fisher’s Exact test was used for dichotomous variables, Chi Square Exact test was used for non-ordered categorical variables and the Fisher’s Non Parametric Permutation Test was used for continuous variables. Univariable logistic regression was performed to determine the influence of GJH and timing of RTS (Tegner activity level ³ 6) on the odds of a second ACL injury following ACL-R within 2 years of RTS. Results: A total of 153 patients were deemed eligible for this study. Primary ACL-R was performed in 34 (22%) patients with GJH and 119 (78%) non-GJH patients. Patients with GJH were younger at the time of ACL-R (21.8 vs 24.5 years; p = 0.049) and had a shorter time from surgery to RTS (8.1 vs. 10.3 months; p = 0.044). Within 24 months of RTS, 6 (17.6%) patients with GJH and 3 (2.5%) non-GJH patients had a second ACL injury ( p = 0.0082). Return to preinjury Tegner activity level was achieved by 29 (85.3%) GJH patients and 114 (74.5%) non-GJH patients ( p = 0.15; Table 1). There was no statistically significant difference in preoperative and postoperative Knee Injury and Osteoarthritis Outcome Score subscales and psychometric measures of risk appraisal at RTS between the GJH and non-GJH groups (Table 2). The odds of sustaining a second ACL injury was 8.29 in GJH compared to non-GJH patients (95% confidence interval = 1.95-35.18; p = 0.0042; area under the receiver operating characteristic curve = 0.74; Table 3). Conclusions: Patients with GJH undergoing ACL-R have an 8 times greater odds of sustaining a second ACL injury after RTS. Consequently, GJH should be considered a risk-factor for repeat ipsilateral or contralateral ACL injury, and the importance of joint laxity assessment should be emphasized in patients who aim to return to high-intensity sports following ACL-R. [Table: see text][Table: see text][Table: see text][Table: see text]

Arthroscopic Broström-Gould repair has comparable radiological and clinical outcomes compared to traditional open Broström-Gould repair in high-demand patients.

This study sought to confirm whether traditional open Broström-Gould repair and arthroscopic Broström-Gould repair forchronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients. This retrospective case-cohort study included high-demand patients, as determined by a pre-injury Tegner Activity Level ≥ 6, who underwent Broström-Gould repair and were followed up for ≥ 2years. Patients were divided into the arthroscopic Broström-Gould repair group (AS Group) and the open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The Tegner Activity Levels, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically. A total of 65 patients (31 from the AS Group and 34 from the Open Group) were included in the study. There were no differences in age, sex, body mass index, preoperative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups (n.s.). The preinjury median Tegner Activity Level was 7 and unchanged at the final follow-up in both groups. Postoperative stress radiographs showed improvement; however, the groups did not differ significantly. The FAOS, K-P scores, and AOFAS scores improved in each group (P < 0.001). However, the clinical scores did not differ between the groups (all n.s.). Traditional open and arthroscopic Broström-Gould repair for CAI in high-demand patients had comparable radiological and clinical outcomes. Clinically, arthroscopic Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair in high-demand patients. Level III.

High prevalence of meniscal ramp lesions in anterior cruciate ligament injuries

PurposeTo evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries.MethodsData from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions.ResultsA total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32–4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01–1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61–8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40–13.68; P = 0.001).ConclusionThe overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons’ and radiologists’ suspicion of these tears.Level of evidenceIII.

Collagen wrapping and local platelet-rich fibrin do not improve the survival rates of ACL repair with dynamic intraligamentary stabilization: a retrospective case series after ≥5 years postoperatively

PurposeAnterior cruciate ligament (ACL) repair has been recommended as a treatment principle for ACL tears. Several authors have advocated a potential role for primary repair techniques in the ACL decision tree. However, long-term results have been controversial. This study aims to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization (DIS) with and without augmentation.MethodsBetween 2014 and 2019, 102 patients with isolated proximal ACL ruptures underwent DIS repair within 21 days from injury and were available for follow-up either clinically or telephonically after ≥5 years postoperatively. In 45 cases, DIS repair was augmented with collagen fleece wrapping, platelet-rich fibrin (PRF) or both. Failure was defined as traumatic re-rupture or conversion to ACL reconstruction. The patients being available for physical examination underwent a.-p. stability measurement with a KT-1000 device. Functional outcome was measured with the IKDC, Tegner and Lysholm scores. Kaplan-Meier survival analysis, Log-Rank Test and Binominal logistic regression were performed.ResultsAfter a minimum 5-year follow-up, 71/102 (69.6%) DIS repairs were not re-reptured and clinically and/or subjectively stable. Augmentation did not improve survival rates (p = 0.812). The identified factors influencing failure were a younger age and a pre-injury Tegner activity level of ≥7. 95.7% of those patients with an intact ACL repair had normal or near normal knee function based on the IKDC scoring system.ConclusionsThe 5-year overall survival rate of DIS was 69.6%. Collagen fleece wrapping and local PRF application did not improve survival. Patients not suffering failure of repair demonstrated high satisfaction. Nevertheless, the results are inferior to those of established ACL reconstruction procedures.Level of evidenceCase series, Level IV.

Joint awareness and return to pre-injury level of activities after ACL reconstruction in athletes vs non-athletes.

The outcome of arthroscopic anterior cruciate ligament reconstruction (ACLR) in the non-athlete population is under-reported. The study aimed to compare the functional outcomes of ACLR in the non-athlete and athlete population by patient reported outcome measures (PROMs)- International Knee Documentation Committee score (IKDC), Lysholm knee scoring scale, Forgotten joint score (FJS-12) and return to pre-injury activity level. The study also correlated the FJS-12 score with other commonly used PROM's (IKDC and Lysholm). This was a prospective comparative study including patients undergoing ACLR. Patients were divided into two groups. Group-1 (non-athletes) and Group-2 (athletes, defined as those with pre-injury Tegner activity level > 5). Demographic profile, management of associated meniscal injury, perioperative and midterm complications were noted. All patients had 24months follow-up. Knee laxity assessment by pivot shift test, functional outcome scores (Lysholm and IKDC) and FJS-12 were assessed preoperatively and postoperatively at 12 and 24months. Group 1 and 2 included 69 and 47 participants, respectively, (total 116 patients). The mean age of group 1 was significantly higher than group 2 (33.1 ± 8.0 vs 25.0 ± 4.9years; p < 0.005). There was no statistically significant difference in PROMs and FJS-12 scores between the groups at any follow-up. Return to pre-injury Tegner activity level post-ACLR was 88.4% (n = 61) and 46.8% (n = 22) in group 1 and 2, respectively (p). The ceiling effect in FJS-12, IKDC, and Lysholm scores were achieved by 9.3%, 19.5%, and 34.7% of patients (n = 116), respectively, at 2-year follow-up. The ceiling effect of FJS-12, Lysholm, and IKDC scores between the groups at final follow-up was not statistically significant (p = 1, p = .524, p = .09, respectively). The functional outcome of ACLR was comparable between athletes and non-athletes. FJS-12 has a lower ceiling effect and better discriminatory power than Lysholm and IKDC scores. FJS-12 score can be satisfactorily used in ACLR to observe and monitor changes in patient satisfaction and outcome. II, Prospective comparative study.

Age, time from injury to surgery and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction

PurposeTo identify preoperative, intraoperative and postoperative factors associated with revision anterior cruciate ligament reconstruction (ACLR) within 2 years of primary ACLR.MethodsPatients who underwent primary ACLR at our institution, from January 2005 to March 2017, were identified. The primary outcome was the occurrence of revision ACLR within 2 years of primary ACLR. Univariate and multivariate logistic regression analyses were used to evaluate preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, graft diameter, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [side-to-side (STS) anterior laxity, limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for revision ACLR.ResultsA total of 6,510 primary ACLRs were included. The overall incidence of revision ACLR within 2 years was 2.5%. Univariate analysis showed that age < 25 years, BMI < 25 kg/m2, time from injury to surgery < 12 months, pre-injury Tegner activity level ≥ 6, LM repair, STS laxity > 5 mm, quadriceps strength and single-leg-hop test LSI of ≥ 90% increased the odds; whereas, MM resection and the presence of a cartilage injury reduced the odds of revision ACLR. Multivariate analysis revealed that revision ACLR was significantly related only to age < 25 years (OR 6.25; 95% CI 3.57–11.11; P < 0.001), time from injury to surgery < 12 months (OR 2.27; 95% CI 1.25–4.17; P = 0.007) and quadriceps strength LSI of ≥ 90% (OR 1.70; 95% CI 1.16–2.49; P = 0.006).ConclusionAge < 25 years, time from injury to surgery < 12 months and 6-month quadriceps strength LSI of ≥ 90% increased the odds of revision ACLR within 2 years of primary ACLR. Understanding the risk factors for revision ACLR has important implications when it comes to the appropriate counseling for primary ACLR. In this study, a large spectrum of potential risk factors for revision ACLR was analyzed in a large cohort. Advising patients regarding the results of an ACLR should also include potential risk factors for revision surgery.Level of evidence III.

Primary Partial Transphyseal Anterior Cruciate Ligament Reconstruction in Children with Open Physes

The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred as it has been shown to have chondroprotective benefits in this population. Due to concerns with growth disturbances following ACL reconstruction in skeletally immature patients, results of various physical-sparing, partial-transphyseal, or complete-transphyseal techniques have been explored. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. Therefore, the purpose of this study was to report the outcomes of a partial-transphyseal, over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients. All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using the partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p <0.05. Overall, 22 males and 2 females (25 knees) with a mean age of 13.0 years (Standard Deviation [SD], 1.7 years) were included in the study. The mean postoperative follow-up was 2.1 years (SD, 1.7 years). There were four cases of ACL graft rupture (16%). All patients successfully returned to unrestricted sport at an average time of 7.3 months. Preinjury and postoperative Tegner activity levels were documented in 22 knees, of which 21/22 (95%) returned to the same or higher level. There were no documented cases of clinically significant longitudinal or angular growth disturbance. Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular, OTT position on the femur in skeletally immature affords minimal risk of growth disturbance with a graft rupture rate of 16% and a 95% return to sport at the same or higher level.

CLINICAL OUTCOMES AFTER TWO-STAGE BICRUCIATE KNEE LIGAMENT RECONSTRUCTION.

ABSTRACTObjective: To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction. Methods: The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02). Results: With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36). Conclusion: Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.

Low Rate of Return to Preinjury Tegner Activity Level Among Recreational Athletes: Results at 1 Year After Primary ACL Reconstruction.

Background:There is limited information about the functional recovery and rate of return to preinjury levels of sports among recreational athletes after anterior cruciate ligament reconstruction (ACLR).Purpose:To investigate the recovery of quadriceps or hamstring strength, assess functional performance, and determine the rate of return to preinjury sports levels among recreational athletes at 1 year after ACLR.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 91 recreational-level athletes who underwent anatomic single-bundle ACLR were enrolled. We evaluated the limb symmetry index (LSI) of the quadriceps and hamstring peak torque strength at 60°, in addition to hop test performance (single-leg, triple, crossover, and 6-m timed), patient-reported outcomes, and pre- versus postoperative Tegner activity levels. Outcomes were compared between younger (age <25 years) and older patients (age ≥25 years).Results:There were 48 patients in the younger group and 43 patients in the older group. At 1-year follow-up, the overall LSIs for quadriceps strength and hamstring strength were 77% and 86%, respectively, and the LSIs of the hop tests were 79% for single-leg, 81% for triple, 84% for crossover, and 85% for 6-m timed hop. Overall, only 24% patients returned to their preinjury Tegner level, and only 8% of patients met the criteria for return to pivoting, cutting, and jumping sports. At 1-year follow-up, the younger group showed significantly more quadriceps strength than the older group (85% vs 64%; P = .0001), better single, triple, crossover, and 6-m timed hop test results (85% vs 69%, P = .003; 84% vs 75%, P = .046; 91% vs. 74%, P < .001; and 91% vs 76%, P = .003, respectively), higher Lysholm score (87 vs 74; P < 0.001) and International Knee Document Committee score (82 vs 66; P < .001), and a higher rate of return to preinjury Tegner level (35% vs 12%; P = .009).Conclusion:Only 24% of patients returned to the preinjury Tegner level at 1 year after ACLR (35% younger group vs 12% older group; P = .009). This information might be helpful in setting realistic expectations for recreational athletes after surgery.

Similar functional outcomes of arthroscopic reconstruction in patients with isolated Posterior Cruciate Ligament (PCL) and combined Anterior Cruciate Ligament (ACL) and PCL tears

BackgroundPosterior Cruciate Ligament (PCL) injuries seldom occur in isolation and majority occurs in conjugation with other ligament injuries. Posterior Cruciate Ligament (PCL) reconstruction continues to be taken into consideration as a complicated surgical procedure, with heterogeneity in literature regarding clinical and functional outcomes in isolated PCL and combined ACL and PCL injuries. MethodsThe retrospective evaluation of patients with isolated PCL reconstruction (group 1) and combined Anterior Cruciate Ligament (ACL) and PCL reconstruction (group 2) was performed. A total of 66 patients with either isolated PCL or combined ACL and PCL reconstruction surgeries that met the inclusion criteria, were included in the study. These patients were assessed for functional outcome scores including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Lysholm score, International Knee Documentation Committee (IKDC) and Tegner activity score at a minimum follow-up of 5 years. ResultsThe mean follow-up of patients was 82.09 ± 12.43 months in group 1 and 79.36 ± 11.24 months in group 2, with a total of 29 patients in group 1 and 21 patients in group 2. Both the groups were found to be comparable in terms of age, gender, duration of injury and pre-injury Tegner activity level. Post-surgical functional outcome scores (WOMAC score, Lysholm score and Tegner score) were found to be comparable between 2 groups at a mean follow-up of 5 years. Further, 22 patients in group 1 and 16 patients in group 2 had normal or near normal objective IKDC outcome scores at a mean follow-up of 5 years. ConclusionsNo differences were observed in functional outcome scores (WOMAC score, Lysholm score, Tegner score and IKDC score) between isolated reconstructed PCL and combined ACL and PCL reconstructed patients.

Arthroscopic Reduction and Fixation by Cerclage Wire Loop for Tibial Spine Avulsion in Adults: Short-term Results.

Background:Several arthroscopic techniques for the treatment of avulsion tibial spine fractures have been described in the literature.Purpose:To evaluate the outcomes of the arthroscopically assisted stainless steel wiring technique in the treatment of avulsed tibial spine in adults.Study Design:Case series; Level of evidence, 4.Methods:This retrospective study involved 28 patients (28 knees), 16 to 42 years of age, with tibial spine avulsion fracture that was treated using arthroscopic reduction and cerclage wire fixation by a single surgeon between March 2015 and August 2018. The degrees of avulsion in these patients were type II (n = 12), type III (n = 10), and type IV fractures (n = 6). Clinical assessment included International Knee Documentation Committee (IKDC) objective score (which noted swelling), range of knee movement, Tegner activity scale, Lachman test, and pivot-shift test compared with the normal opposite knee.Results:The mean follow-up period was 24.1 months (range, 18-30 months). The mean IKDC score was 93.7 (range, 88.5-98.9); the IKDC score was normal in 22 patients and nearly normal in 6 patients. The Lachman test was grade 1 in 25 patients and grade 2 in 3 patients, whereas the pivot-shift test was grade 0 in 26 patients and grade 1 in 2 patients. All patients achieved their preinjury Tegner activity levels. Radiological assessment showed healing in all patients within a mean of 12 weeks after surgery.Conclusion:The outcomes of all patients were satisfactory; fixation by cerclage wiring permitted reduction of tibial spine fragment anatomically to its fracture bed, provided stable fixation in displaced tibial spine avulsion, and allowed for early rehabilitation and weightbearing because of stable fixation.

Analysis of modified double-bundle anterior cruciate ligament reconstruction with implantless fixation on tibial side

PurposeTo avoid potential problems of double-bundle anterior cruciate ligament reconstruction (ACLR), various modifications have been reported. This study analyzed a novel technique of modified double-bundle (MDB) ACLR without implant on tibial side in comparison to single-bundle (SB) ACLR. MethodsEighty cases of isolated anterior cruciate ligament tear (40 each in SB group or MDB group) were included. SB ACLR was performed by outside in technique with quadrupled hamstring graft fixed with interference screws. In MDB group, ACLR harvested tendons were looped over each other at the center and free ends whipstitched. Femoral tunnel was created by outside in technique. Anteromedial tibial tunnel was created with tibial guide at 55°. The anatomic posterolateral aiming guide (Smith-Nephew) was used to create posterolateral tunnel. With the help of shuttle sutures, the free end of gracillis was passed through posterolateral tunnel to femoral tunnel followed by semitendinosus graft through anteromedial tunnel to femoral tunnel. On tibial side the graft was looped over bone-bridge between external apertures of anteromedial and posterolateral tunnel. Graft was fixed with interference screw on femoral side in 10° knee flexion. International Knee Documentation Committee (IKDC), Tegner score, Pivot shift and knee laxity test (KLT, Karl-Storz) were recorded pre- and post-surgery. At one year magnetic resonance imaging (MRI) was done. Statistical analysis was done by SPSS software. ResultsMean preoperative KLT reading of (10.00 ± 1.17) mm in MDB group improved to (4.10 ± 0.56) mm and in SB group it improved from (10.00 ± 0.91) mm to (4.80 ± 0.46) mm. The mean preoperative IKDC score in MDB group improved from (49.49 ± 8.00) to (92.5 ± 1.5) at one year and that in SB group improved from (52.5 ± 6.9) to (88.4 ± 2.6). At one-year 92.5% cases in MDB group achieved their preinjury Tegner activity level as compared to 60% in SB group. The improvement in IKDC, KLT and Tegner scale of MDB group was superior to SB group. MRI confirmed graft integrity at one year and clinically at 2 years. ConclusionMDB ACLR has shown better outcome than SB ACLR. It is a simple technique that does not require fixation on tibial side and resultant graft is close to native ACL.

Therapeutic Response of Extracorporeal Shock Wave Therapy for Insertional Achilles Tendinopathy Between Sports-Active and Nonsports-Active Patients With 5-Year Follow-up.

Background:Insertional Achilles tendinopathy (IAT) is a common cause of posterior heel pain. Extracorporeal shock wave therapy (ESWT) has proven to be an effective treatment, but the relationship between therapeutic responses and sports activity levels has not been studied.Purpose:To compare the clinical outcomes of ESWT used to treat IATs between sports-active and nonsports-active patients over 5 years.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective study was conducted on 33 patients with IAT who received ESWT from October 2012 to September 2013. Patients were classified into 2 groups according to their preinjury Tegner activity level: a sports-active group, defined as patients who self-reported to be regular joggers (SA group; Tegner activity level >3; n = 16), and a nonsports-active group (control group; Tegner activity level ≤3; n = 17). The mean age was 31 ± 7 years for the SA group and 37 ± 10 years for the control group. The Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire scores and visual analog scale (VAS) pain scores were used to evaluate the clinical outcomes before treatment, immediately after treatment, and 5 years after treatment. Ultrasonography was also used to assess the insertional Achilles tendon quality.Results:Before treatment, there were no significant differences between the groups with regard to VAS scores, while the VISA-A score in the SA group was higher than that in the control group. After ESWT, both groups had increased VISA-A scores and decreased VAS scores, indicating improvement. At 5-year follow-up, the SA group had a significantly lower mean VAS score (0.3 ± 0.8 vs 1.6 ± 1.3; P = .001) and a significantly higher mean VISA-A score (90 ± 4 vs 78 ± 7; P < .001) compared with the control group. There was no significant difference between the groups regarding the calcification and neovascularization of the Achilles tendon based on ultrasonography.Conclusion:ESWT can improve the symptoms of Achilles tendinopathy, and patients with IAT who had greater sports activity levels had better therapeutic responses than nonsports-active patients after 5-year follow-up.

Age, gender, quadriceps strength and hop test performance are the most important factors affecting the achievement of a patient-acceptable symptom state after ACL reconstruction

PurposeTo assess the percentage of patients achieving an acceptable symptom state 2 years after primary anterior cruciate ligament reconstruction (ACLR) and to identify factors affecting its achievement, in a large cohort.MethodsPatients who underwent primary ACLR at Capio Artro Clinic, Stockholm, Sweden, from 2005 to 2015, were identified in our clinic registry. Patients who had completed the Knee injury and Osteoarthritis Outcome Score (KOOS) at the 2-year follow-up were included. The primary outcome was the achievement of a patient-acceptable symptom state (PASS) for each KOOS subscale. A multivariate logistic regression analysis was used to determine whether patient age, gender, time from injury to surgery, pre-injury Tegner activity level, graft type, cartilage injury, the presence of medial meniscus (MM) or lateral meniscus (LM) resection or repair and the recovery of 6-month symmetrical (limb symmetry index [LSI] of ≥ 90%) isokinetic quadriceps or hamstring strength and single-leg-hop test performance were factors associated with the achievement of a PASS for each KOOS subscale.ResultsA total of 2335 primary ACLRs were included. More than 60% of the patients reported a PASS on four of the five KOOS subscales. Age ≥ 30 years and an LSI of ≥ 90% for 6-month isokinetic quadriceps strength increased the odds of achieving a PASS across all KOOS subscales. Female gender reduced the odds of achieving a PASS on the Pain (OR 0.76; 95% CI 0.62–0.94; P = 0.01), activities of daily living (ADL) (OR 0.79; 95% CI 0.64–0.97; P = 0.02) and sport and recreation (OR 0.72; 95% CI 0.58–0.89; P = 0.003) subscales. The presence of an MM repair reduced the odds of achieving a PASS on the Pain (OR 0.59; 95% CI 0.36–0.96; P = 0.03) subscale. Hamstring tendon (HT) autograft rather than bone-patellar tendon-bone (BPTB) autograft showed increased odds (OR 2.02; 95% CI 1.31–3.10; P = 0.001), whereas a cartilage injury showed reduced odds (OR 0.73; 95% CI 0.55–0.97; P = 0.03) of achieving a PASS on the sport and recreation subscale. An LSI of ≥ 90% for 6-month single-leg-hop test performance increased the odds of achieving a PASS on the ADL (OR 1.37; 95% CI 1.09–1.71; P = 0.005), Sport and Recreation (OR 1.40; 95% CI 1.11–1.77; P = 0.004), and quality of life (OR 1.28; 95% CI 1.00–1.63; P = 0.04) subscales.ConclusionMore than 60% of the patients reported an acceptable symptom state on four of the five KOOS subscales 2 years after primary ACLR. Age ≥ 30 years and female gender were the non-modifiable factors that consistently increased and reduced, respectively, the odds of achieving a PASS. A symmetrical 6-month isokinetic quadriceps strength and single-leg-hop test performance were the modifiable factors that consistently increased the opportunity of achieving a PASS 2 years after primary ACLR.Level of evidenceIII.

Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction

PurposeTo assess the percentage of patients achieving symmetrical knee function 6 months after primary anterior cruciate ligament (ACL) reconstruction (ACLR) and to identify factors affecting its achievement, in a large cohort.MethodsData were extracted from our clinic database. Patients who underwent primary ACLR from 2000 to 2015 and were assessed with the isokinetic quadriceps and hamstring muscles strength tests and single-leg-hop test at the 6-month follow-up were included in the study. Demographic data, information on the graft used, cartilage injuries and concomitant meniscal surgery were reviewed. Patients who reached a limb symmetry index (LSI) of ≥ 90% in all three tests were considered to have achieved symmetrical knee function. A multivariate logistic regression analysis was used to determine whether patient age, gender, time from injury to surgery, pre-injury Tegner activity level, graft type, cartilage injury and the presence of medial meniscus (MM) or lateral meniscus (LM) resection or repair were factors associated with the achievement of symmetrical knee function 6 months after primary ACLR.ResultsA total of 4093 patients (54.3% males) with a mean age of 28.3 ± 10.7 years were included. Data from all three tests were available for 3541 patients. The proportion of patients that achieved a LSI of ≥ 90% was 35.7%, 47.3% and 67.9% for isokinetic quadriceps muscle strength, hamstring muscles strength and the single-leg-hop test, respectively. A total of 693 patients (19.6%) achieved symmetrical knee function, reaching a LSI of ≥ 90% in all three tests. Older age (≥ 30 years) (OR, 0.50; 95% CI 0.41–0.61; P < 0.001), MM resection (OR, 0.75; 95% CI 0.57–0.98; P = 0.03) and MM repair (OR, 0.63; 95% CI 0.40–0.98; P = 0.04) reduced the odds, whereas the use of hamstring tendon (HT) autograft (OR, 2.28; 95% CI 1.51–3.45; P < 0.001) over bone–patellar tendon–bone (BPTB) autograft increased the odds of achieving symmetrical knee function.ConclusionOnly 19.6% of the patients achieved symmetrical knee function 6 months after primary ACLR. Age ≥ 30 years, MM resection and MM repair reduced the chance, whereas the use of HT autograft over BPTB autograft increased the chance of achieving symmetrical knee function 6 months after primary ACLR. This study shows that most of the patients are yet to regain symmetrical knee function 6 months after primary ACLR and, moreover, it identifies several factors affecting its achievement in a large cohort. The results of this study should be used to counsel patients about their expected functional recovery and to optimize rehabilitation and maximize knee function after ACLR.Level of evidenceIII.

Surgical excision of symptomatic mature posttraumatic myositis ossificans: characteristics and outcomes in 32 athletes.

The purpose of this study was to report characteristics and outcomes of surgical excision of symptomatic mature posttraumatic myositis ossificans in adult athletes. The hypothesis was that surgical excision of the ossified mass in these circumstances can effectively relief symptoms and result in return to high-level sports with minimal postoperative complications. All operations involving excision of posttraumatic heterotopic ossifications performed between 1987 and 2015 were reviewed. Included cases had isolated excision of posttraumatic myositis ossificans, whereas excluded cases had: (1) concomitant reattachment of tendon to bone; (2) chronic overuse injuries which preceded the development of the heterotopic mass or large calcifications which were excised from tendon-to-bone insertions; and (3) excision of heterotopic ossification from a ligament, capsule, or tendon insertion following avulsion injury without tendon-to-bone repair. After surgery, return to sports was allowed at 4-6weeks. Of 57 athletes undergoing excision of heterotopic ossifications, 32 were eligible as isolated excision of posttraumatic myositis ossificans. Twenty-four (75%) were ice hockey or soccer players. Median age was 23years. Prior to surgery, patients were unable to continue their sports. At surgery, the ossification was excised from a thigh muscle in 27 (84%) cases. Median follow-up was 2years (range 1-20years). Outcome was Good/Excellent in 26 (81%) patients, corresponding to return to preinjury sports with minimal symptoms at sports activities. Preinjury Tegner activity level was resumed after surgery in 30 of 32 (94%) athletes, of whom 28 (94%) were involved in high-level sports corresponding to Tegner levels 8-10. No postoperative complications were recorded other than minimal insensitive areas at the periphery of skin incisions. In high-level athletes who present chronic disabling mature posttraumatic myositis ossificans that interferes with their sports career, surgical excision of the heterotopic mass results in effective clinical improvement with return to sports and minimal postoperative risks. Case series, Level IV.