Primary Anterior Cruciate Ligament Reconstruction Research Articles

Characteristics of early complications in isolated primary anterior cruciate ligament reconstruction surgery.

The early complications of isolated anterior cruciate ligament reconstruction surgery (ACLR) have not been well characterized using large databases. This study aims to characterize incidence, impact, and risk factors for short-term operative complications following elective, isolated ACLR surgery. We hypothesize that demographic and perioperative factors may predict 30-day complications after isolated ACLR. This case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (2005-2017) used Current Procedural Terminology codes to identify elective, isolated ACLR patients. Patients undergoing concomitant procedures were excluded. Complications were analyzed using bivariate analysis against demographic variables. Multiple stepwise logistic regression was used to identify independent risk factors for morbidity after ACLR. A total 12,790 patients (37.0% female, p = 0.674) were included with a mean age of 32.2years old (SD 10.7years, p < 0.001). Mean BMI was 27.8kg/m2 (6.5) where 28.9% of patients had a BMI > 30 (p = 0.064). The most common complications were wound-related (0.57%). In cases with complications, there were higher rates of (1.3% vs 0.8%, p = 0.004) prolonged operation (> 1.5h), higher rate (2.9% vs 1.8%, p = 0.004) of extended length of stay (≥ 1day), unplanned reoperation (15.8% vs 0.3%, p < 0.001), and unplanned readmission (17.5% vs 0.3%, p < 0.001). Multivariate analysis showed prolonged operative time (p = 0.001), dyspnea (p = 0.008), and non-ambulatory surgery (p = 0.034) to be predictive of any complication. Dependent functional status (p = 0.091), mFI-5 > 0.2 (= 0.173), female sex (p = 0.191), obesity (p = 0.101), and smoking (p = 0.113) were not risk factors for complications. ACLR is associated with low rates of morbidity and readmissions. The most common comorbidities, complications, and predictors of morbidities were identified to aid surgeons in further reducing adverse outcomes of ACLR. Operative time > 1.5h, dyspnea, and non-ambulatory surgery are predictive of complications.

The presence of a deep lateral femoral notch sign in ACL-injured patients is associated with a 2.7° steeper posterior tibial slope and a 19% higher frequency of lateral meniscal injuries.

The purpose of this study was to study the relationship between the presence of a deep lateral femoral notch sign (DLFNS) in anterior cruciate ligament (ACL)-injured patients and a higher posterior lateral tibial slope (LPTS), a reduced meniscal bone angle (MBA), a higher LPTS/MBA ratio and a higher incidence of concomitant injuries in primary ACL tears. A retrospective case-control study was performed in patients submitted to primary ACL reconstruction with an available preoperative magnetic resonance imaging (MRI) scan. Patients with ACL tears and a femoral impactation with a depth ≥2 mm were assorted to the DLFNS groupand patients with ACL tear and without a DLFNS to the control group. LPTS and MBA were measured in MRI. The presence of concomitant injuries (meniscal, posterior cruciate ligament, medial collateral ligament, lateral collateral ligament and bone injuries) was assessed in MRI. Quantitative data are presented in the median ± interquartile range (IQR). There were 206 patients included in the study, with 46 patients assorted to the DLFNS group and 160 patients to the control group. In the DLFNS group, the median LPTS was 6.7° (IQR: 4.0-8.2) versus 4.0° in the control group (IQR: 2.2-6.5) (p = 0.003). The LPTS/MBA ratio was significantly higher in the DLFNS group, with a median of 0.32 (IQR: 0.19-0.44), in comparison to the control group, with a median of 0.19 (IQR: 0.11-0.31) (p < 0.001). The multivariable logistic regression analysis showed that the LPTS is an independent risk factor to having a DLFNS (odds ratio [OR] = 1.161; 95% confidence interval [CI]: 1.042-1.293, p = 0.007). There was a higher incidence of concomitant lateral meniscal injuries in the DLFNS group (67% vs. 48%, p = 0.017). In patients with ACL tears, the presence of a DLFNS is associated with a steeper lateral posterior tibial slope, as well as a higher incidence of concomitant lateral meniscal injuries. Level III.

Clinical outcomes of primary anterior cruciate ligament reconstruction using six-strand hamstring autograft

Objectives: Quadrupled and five-strand hamstring tendon (HT) autografts are commonly used in anterior cruciate ligament reconstruction (ACLR), but there is significant variability in graft diameter. The six-strand HT autograft has been introduced to increase graft diameter in patients with undersized HT grafts and may achieve better clinical outcomes. None of the studies has reported clinical outcomes following this technique in Indian patients. We investigated clinical outcomes in patients who underwent primary ACLR using a six-strand HT autograft technique with a minimum six-month follow-up. Materials and Methods: Fifty-five patients who underwent primary ACLR using six-strand HT autografts with interference screw fixation were included in the study. These patients were followed up at three and six months for the evaluation of clinical outcomes. Subjective evaluations included the TegnerLysholm score, anterior cruciate ligament-quality-of-life (ACL-QOL) score, and International Knee Documentation Committee (IKDC) subjective score. Laxity assessments of the knees were performed using the Lachman test and the pivot-shift test. Functional evaluation of the patients was performed with an overall IKDC objective score. Results: The mean IKDC subjective score was significantly improved at three-month (63.42 ± 5.38) and six-month (82.82 ± 7.49) follow-up after surgery (P &lt; 0.05) when compared with pre-operative scores (50.55 ± 1.84). A similar finding was also noted with the Tegner-Lysholm score and ACL-QOL score in our study. All patients have achieved normal to near-normal functional outcomes at six months in our study without any major complications. The most commonly found complication was paresthesia (21.80%) in the present study. Conclusion: In the primary ACLR, six-strand hamstring autograft achieves similar clinical outcomes and complications as reported with four-strand or five-strand HT autografts. However, the percentages of patients who achieved normal to near-normal outcomes were higher in the present study (100%) as compared to earlier reported data using four-strand or five-strand HT autografts (~85%). The six-strand graft technique is a useful means of increasing graft diameter when faced with an undersized hamstring graft.

RISK FACTORS FOR MENISCAL REPAIR FAILURE FOLLOWING CONCURRENT PRIMARY ACL RECONSTRUCTION: RESULTS FROM THE NEW ZEALAND ACL REGISTRY

BackgroundAnterior cruciate ligament (ACL) reconstruction with concomitant meniscal injury occurs frequently. Meniscal repair is associated with improved long-term outcomes compared to resection but is also associated with a higher reoperation rate. Knowledge of the risk factors for repair failure may be important in optimizing patient outcomes.PurposeThis study aimed to identify the patient and surgical risk factors for meniscal repair failure, defined as a subsequent meniscectomy, following concurrent primary ACL reconstruction.MethodsData recorded by the New Zealand ACL Registry and the Accident Compensation Corporation, the New Zealand Government's sole funder of ACL reconstructions and any subsequent surgery, was reviewed. Meniscal repairs performed with concurrent primary ACL reconstruction was included. Root repairs were excluded. Univariate and multivariate survival analysis was performed to identify the patient and surgical risk factors for meniscal repair failure.ResultsBetween 2014 and 2020, a total of 3,024 meniscal repairs were performed during concurrent primary ACL reconstruction (medial repair = 1,814 and lateral repair = 1,210). The overall failure rate was 6.6% (n = 201) at a mean follow-up of 2.9 years, with a failure occurring in 7.8% of medial meniscal repairs (142 out of 1,814) and 4.9% of lateral meniscal repairs (59 out of 1,210). The risk of medial failure was higher in patients with a hamstring tendon autograft (adjusted HR = 2.20, p = 0.001), patients aged 21–30 years (adjusted HR = 1.60, p = 0.037) and in those with cartilage injury in the medial compartment (adjusted HR = 1.75, p = 0.002). The risk of lateral failure was higher in patients aged ≤ 20 years (adjusted HR = 2.79, p = 0.021) and when the procedure was performed by a surgeon with an annual ACL reconstruction case volume of less than 30 (adjusted HR = 1.84, p = 0.026).ConclusionWhen performing meniscal repair during a primary ACL reconstruction, the use of a hamstring tendon autograft, younger age and the presence of concomitant cartilage injury in the medial compartment increases the risk of medial meniscal repair failure, whereas younger age and low surgeon volume increases the risk of lateral meniscal repair failure.

Test-retest reliability and longitudinal validity of drop vertical jump biomechanics during rehabilitation after ACL reconstruction

Hip and knee biomechanics measured during a drop vertical jump (DVJ) can be used to assess patients undergoing rehabilitation after anterior cruciate ligament (ACL) reconstruction. To confidently interpret such data for use as outcome measures, additional information about reliability and validity is required. Therefore, the objective of this study was to estimate the test–retest reliability and longitudinal validity of selected lower limb biomechanics assessed during a DVJ in patients undergoing rehabilitation after ACL reconstruction. Biomechanical analysis of the DVJ in primary unilateral ACL reconstruction patients (22.3 ± 5.5y) were tested twice within 1-week at 6-months post-surgery (n = 46), and again at 12-months post-surgery (n = 36). Peak and initial contact knee angles and moments, hip impulse, vertical ground reaction forces (VGRF), isokinetic knee extension and flexion strength, and global ratings of change (GRC) were assessed. Reliability was evaluated based on the 6-month post-surgery data using intraclass correlation coefficients (ICC2,1), standard errors of measurement and minimum detectable change. Longitudinal validity was evaluated by assessing change from 6 to 12 months, using standardized response means (SRM), and by assessing the correlation (Pearson’s r) of change in landing biomechanics with change in strength, and GRC. ICCs ranged from 0.58 to 0.90 for peak knee abduction and flexion moments, 0.44–0.85 for knee flexion and abduction angles, 0.82–0.93 for VGRFs, and 0.42–0.65 for hip impulse. SRMs and correlations of change ranged from 0.00 to 0.50. Reliability and longitudinal validity of DVJ measures varied, ranging from poor-to-excellent; the present results assist in their interpretation when assessed during rehabilitation after ACL reconstruction.

Association of Graft Maturity on MRI With Return to Sports at 9 Months After Primary Single-Bundle ACL Reconstruction With Autologous Hamstring Graft.

The relationship between graft maturity on magnetic resonance imaging (MRI) and return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction is unclear. To compare signal-to-noise quotient (SNQ) values and ACL graft T2* (gradient echo) values between patients who did RTS and those who did not RTS (NRTS) after ACL reconstruction and to evaluate the predictive value of T2* mapping for RTS after ACL reconstruction. Case-control study; Level of evidence, 3. At a minimum of 9 months after arthroscopic single-bundle ACL reconstruction with autologous hamstring tendon graft, 82 patients underwent RTS assessment as well as MRI evaluation. The patients were classified into RTS (n = 53) and NRTS (n = 29) groups based on the results of the assessment. The SNQ values in the proximal, middle, and distal regions of the graft and the T2* values of the graft were measured on MRI. The correlation between T2* values and RTS was assessed using Spearman correlation analysis. Receiver operating characteristic curves were constructed to compare the diagnostic performance, and the optimal T2* cutoff value for detecting RTS was determined based on the maximum Youden index. At 9 months after ACL reconstruction, the proximal, middle, and mean SNQ values in the RTS group were significantly lower than those in the NRTS group (proximal: 17.15 ± 4.85 vs 19.55 ± 5.05, P = .038; middle: 13.45 ± 5.15 vs. 17.75 ± 5.75, P = .001; mean: 12.37 ± 2.74 vs 15.07 ± 3.32, P < .001). The T2* values were lower in the RTS group (14.92 ± 2.28 vs 17.69 ± 2.48; P < .001) and were correlated with RTS (r = -0.41; P = .02). The area under the curve of T2* was 0.79 (95% CI, 0.75-0.83), and the optimal cutoff value for T2* was 16.65, with a sensitivity and specificity for predicting failure to RTS of 67.9% and 88.2%, respectively. Study findings indicated that the SNQs (mean, proximal, and middle) and the T2* values of the graft in the RTS group were significantly lower than those in NRTS group. A T2* value of 16.65 was calculated to predict patients who failed RTS tests with a sensitivity of 67.9% and specificity of 88.2%.

No Association Between Injury-Related Fear and Isokinetic Quadriceps Strength in Individuals With a History of Anterior Cruciate Ligament Reconstruction.

Injury-related fear and quadriceps strength are independently associated with secondary anterior cruciate ligament (ACL) injury risk. It is not known whether injury-related fear and quadriceps strength are associated, despite their individual predictive capabilities of secondary ACL injury. The purpose of this study was to examine the association between injury-related fear and quadriceps strength in individuals at least 1year after ACL reconstruction (ACLR). Cross-sectional study. Forty participants between the ages of 18 and 35years at least 1year post unilateral primary ACLR. Participants completed the Tampa Scale of Kinesiophobia-11 (TSK-11) and a standard isokinetic quadriceps strength assessment using the Biodex Isokinetic Dynamometer. Pearson Product-Moment correlations were used to examine the linear association between the TSK-11 scores and peak torque (in nanometers per kilogram) for each limb and between the TSK-11 scores and limb symmetry indices for each limb. Pearson Product-Moment correlation coefficients (r) were interpreted as very high (.90-1.00), high (.70-.90), moderate (.50-.70), low (.30-.50), and no correlation (.00-.30). The average TSK-11 score was 18.2 (5.3), average ACLR peak quadriceps torque was 1.9 (0.50)N·m/kg, average contralateral peak quadriceps torque was 2.3 (0.48)N·m/kg, and average limb symmetry index was 85.3% (12.6%). There was no statistically significant correlation between the TSK-11 and peak quadriceps torque on the ACLR limb (r = .12, P = .46), the TSK-11 and contralateral limb (r = .29, P = .07), or the TSK-11 and limb symmetry index (r = -.18, P = .27). There was no association between kinesiophobia and peak isokinetic quadriceps strength in individuals at least 1year post-ACLR. Both factors, independently, have been shown to influence risk of secondary injury in patients after ACLR.

Prolonged Physiotherapy after Anterior Cruciate Ligament Reconstruction Does Not Improve Muscular Strength and Function.

Background: After the rupture of the anterior cruciate ligament (ACL), surgery is proposed in the case of knee instability or for athletes who want to return to a pivotal and/or contact sport. The current trend is to extend physiotherapy sessions until a patient's return to sport. We aimed to assess the interest in prolonging the physiotherapy sessions up to 4 postoperative months to restore muscle knee strength and function. Methods: From a historical cohort, 470 patients (24.3 ± 8.7 years) were included; 312 (66%) were males. They all had undergone a primary ACL reconstruction with a hamstring procedure. The number of physiotherapy sessions was established at 4 postoperative months. The main study parameters to assess the benefit of prolonged physiotherapy were the isokinetic limb symmetry index (LSI) for the quadriceps and the hamstrings as well as the Lysholm score. Results: At 4 postoperative months, 148 patients (31.4%) still had physiotherapy sessions. This group had performed 49 ± 14 physiotherapy sessions at the time of evaluation compared to 33 ± 9 sessions performed by the group that stopped physiotherapy at 3 months post-ACL reconstruction. The isokinetic knee LSI and the Lysholm score were not different between the two groups. Continued physiotherapy sessions were associated with female gender, previous high sport level, meniscal repair, lateral tenodesis and outpatient rehabilitation at the beginning of the rehabilitation management, while knee pain complications were not associated. Conclusions: No significant correlation was found between the number of physiotherapy sessions and the knee strength LSI or the Lysholm score. Prolonging patient physiotherapy sessions after 3 months post-ACL reconstruction seems ineffective in improving knee strength recovery and function.

Patients’ under 25 subjective readiness to return to sport after ACL reconstruction with bone-patellar-bone grafts: Autograft vs. allograft

PurposeTo assess the difference in perceived readiness to return to sport (RTS) within the first year postoperative period between individuals undergoing anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) autografts or allografts. MethodsThis was a prospective cohort study of patients undergoing primary ACL reconstruction done either with BTB autograft or allograft from 2010 to 2018. Skeletally mature patients aged 14 to 25 were eligible for inclusion. Patients completed the Marx Activity Rating Scale (MARS) questionnaire postoperatively evaluating perceived ability to perform various activities to compare subjective ability to RTS. Those patients who were outside outlined cohort age, failed to complete a single post-operative survey, underwent revision procedures, or underwent simultaneous or staged additional ligament surgery were excluded. ResultsFifty-nine patients (20.1 ± 3.19 years, 57.6 % Male) were included in the study. Sixteen patients underwent ACL reconstruction with allograft (19.8 ± 3.43 years) while 43 patients received autograft (20.2 ± 3.13). At 3 months autograft recipients reported higher perceived ability to cut (P = .003). At 6-months, allograft recipients reported higher perceived ability to run (P = .033), cut (P = .048), and decelerate (P = .008) as well as a higher overall perceived ability to RTS (P = .032). At all other times, there was no significant difference between cohorts’ subjective readiness to perform activities. ConclusionThe results of this study indicate that at times within the first year of recovery following ACL reconstruction, patients who receive allografts and autografts may have significantly different perceived ability to perform activities or RTS. However, while present at various times throughout the first year of recovery, any difference in perceived ability to perform activities or in overall RTS is no longer present at 12 months. Level of evidenceLevel II, Prospective cohort study.

Anterior Cruciate Ligament Reconstruction Surgery Outcomes: A Comparison Between Patients Who Underwent the Procedure During the COVID-19 Pandemic and a Cohort Treated Prior to the Pandemic.

Background and objective During the coronavirus disease 2019 (COVID-19) pandemic, many elective orthopedic surgeries, including anterior cruciate ligament reconstruction(ACLR), were temporarily postponed. The purpose of this study was to compare the outcomes of ACLR in patients who underwent surgery during the COVID-19pandemic with those in a cohort treated before the pandemic. Materials and methods This retrospective review compared patients who underwent primary ACLR during two periods: March to June 2020 (the pandemic group) and January to December 2018 (the pre-pandemic group). Matched cohorts (1:1) were created using propensity matching. Time from injury-to-first visit, injury-to-surgery, and first visit-to-surgery were calculated. Subjective and objective outcomes, minimal clinically important difference (MCID) achievement, and complication rates were recorded for up to two years postoperatively. Statistical analysis included 𝛘2 or Fisher's exact tests for categorical data, and t- or Wilcoxon signed-rank tests for continuous data with significance set at P< 0.05. Results The pandemic and pre-pandemic groups consisted of 33 and 217 patients, respectively.Matched cohorts consisted of 33 patients each. The time from injury-to-surgery and the first visit-to-surgery was prolonged in the pandemic group. When unmatched, visual analog scale (VAS) scores at three months postoperatively and Patient-Reported Outcomes Measurement Information System (PROMIS)-pain interference (PI) at six months postoperatively and at the final follow-up were higher in the pandemic group. When matched, PROMIS-PI at six months postoperatively was higher in the pandemic group, and VAS scores at one year postoperatively were higher in the pre-pandemic group. MCID achievement and complication rates did not significantly differ between the groups. Conclusions ACLR procedures were significantly delayed in the early months of the COVID-19 pandemic. While patients treated before and during the pandemic experienced varying pain levels during recovery, their functional outcomes, MCID achievement, and complication rates did not differ significantly.

A novel practical method to predict anterior cruciate ligament hamstring graft size using preoperative MRI

BackgroundPredicting hamstring graft size preoperatively for anterior cruciate ligament (ACL) reconstruction is important for preempting an insufficient diameter in graft size intraoperatively, possibly leading to graft failure. While there are multiple published methods using magnetic resonance imaging (MRI) picture archiving and communication systems (PACS), most are not feasible and practical. Our study aims to (1) practically predict the ACL hamstring graft size in a numerically continuous manner using the preoperative MRI from any native MRI PACS system, (2) determine the degree of correlation between the predicted and actual graft size, and (3) determine the performance of our prediction method if we define an adequate actual graft size as ≥ 8 mm.MethodsA retrospective review of 112 patients who underwent primary ACL reconstruction with quadrupled hamstring semitendinosus-gracilis grafts at a tertiary institution was conducted between January 2018 and December 2018. Graft diameter can be predicted in a numerically continuous manner as √[2*(AB + CD)], where A and B are the semitendinosus cross-sectional length and breath, respectively, and C and D are the gracilis cross-sectional length and breath, respectively.ResultsA moderately positive correlation exists between the predicted and actual graft diameter (r = 0.661 and p < .001). Our method yields a high specificity of 92.6% and a moderate sensitivity of 67.2% if we define an adequate actual graft size as ≥ 8 mm. An area under receiver-operating characteristic curve shows good discrimination (AUC = 0.856).ConclusionsWe present a practical method to predict the ACL hamstring graft size with high specificity using preoperative MRI measurements.

Evaluation of Failed ACL Reconstruction: An Updated Review.

Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.

The Periosteum–Patellar Tendon–Bone Autograft for Anatomic, Single-Bundle Anterior Cruciate Ligament Reconstruction With Press-Fit Tibial Fixation

Optimal graft choice and fixation technique are still ongoing topics of debate for primary and revision anterior cruciate ligament reconstruction. Interference screws are frequently used as graft fixation devices but can sometimes lead to tunnel widening, cyst formation, chronic inflammation, screw breakage, and persistent pain. Tibial tunnel widening is of special concern because it is often associated with graft failure. This technical note introduces a graft technique with a periosteum–patellar tendon–bone autograft and a press-fit tibial fixation approach that could be a viable option for secure anterior cruciate ligament reconstruction while offering the possibility of a quicker postoperative recovery, less pain, and a quicker return to everyday activities.

Periarticular cocktail injection is more useful than nerve blocks for pain management after anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament (ACL) reconstruction is commonly associated with moderate-to-severe postoperative pain. Notably, various pain control strategies, a femoral nerve block (FNB) with a lateral femoral cutaneous nerve block (LFCNB), adductor canal block (ACB) with LFCNB, or periarticular cocktail injection (PI), have been investigated. However, no studies compare the effects of FNB with LFCNB, ACB with LFCNB, and PI for pain control after ACL reconstruction. This study aimed to evaluate the impact of FNB with LFCNB, ACB with LFCNB, and PI for pain relief in the early postoperative period after ACL reconstruction. MethodsThis retrospective controlled clinical trial enrolled 299 patients who underwent primary ACL reconstruction at our hospital between April 2016 and October 2022. We categorized these cases into groups based on the use of PI (PI group), FNB with LFCNB (FNB group), and ACB with LFCNB (ACB group) for pain management. We selected 40 cases each, with matched age, sex, and body mass index (BMI) from each group, resulting in 120 cases for analysis. In the FNB and ACB groups, 0.75% ropivacaine 15 ml was injected under ultrasound guidance preoperatively. In the PI group, a mixture of 0.75% ropivacaine 20 ml, normal saline 20 ml, and dexamethasone 6.6 mg was injected half at the start of surgery and the rest just before wound closure. Patient demographics (age, sex, height, body weight, and BMI) and surgical data (the requirement for meniscal repair, operative time, and tourniquet inflation time) were analyzed. After ACL reconstruction, patients' numerical rating scale pain scores (NRS) (0-10) were recorded at 30 min and 4, 8, 12, 24, 48, and 72 h postoperatively. NRS were then compared among the three groups using analysis of variance. In addition, within each group, these data were compared between the NRS ≥7 and NRS ≤6 groups using a t-test. ResultsThere were no significant differences in patient demographics and surgical data. Pain scores were significantly higher in the PI group than in the FCB and ACB groups 30 min postoperatively, but they were lower at 12, 24, 48, and 72 h postoperatively. In the FNB group, there were no significant differences in the demographic and surgical data by NRS pain score. In the ACB group, the number of men was significantly higher in the NRS ≥7 group than in the NRS ≤6 group (p = 0.015). In the PI group, tourniquet inflation time was significantly longer in the NRS ≥7 group than in the NRS ≤6 group (p = 0.008). ConclusionsFollowing ACL reconstruction using a hamstring autograft, periarticular cocktail significantly reduced early postoperative pain compared with nerve block combinations.

Mid-term Results of a Single-Stage Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis of 36 Cases

Background. Revision anterior cruciate ligament reconstruction is becoming more and more common in the knee surgery due to the annual increase in the number of primary anterior cruciate ligament reconstructions. Choosing the most suitable graft and determining the staging of the surgical treatment by preoperative assessment of the possibility of performing the most anatomical revision canals and their interposition with the primary canals are the main factors that influence treatment results.&#x0D; Aim of the study — comparative assessment of the results of using hamstring tendon and peroneus longus tendon autografts in a one-stage revision reconstruction of the anterior cruciate ligament.&#x0D; Methods. A retrospective analysis of the medical records of 36 patients who underwent revision anterior cruciate ligament reconstruction was performed. The patients were divided into two groups: in the patients of the study group (n = 19) a peroneus longus tendon (PLT) autograft was used, in the comparison group (n = 17) a hamstring tendon autograft (HT) was applied. Subjective and objective evaluation using the KOOS, IKDC, and Lysholm scales was performed, and position of the central entry points of the primary and revision canals was determined.&#x0D; There were no statistically significant differences in the objective assessment of the knee joint stability. Significantly better results of subjective assessment of the knee function according to the Lysholm and KOOS scales were obtained in the PLT group (p = 0.042 and p0.001, respectively). Position of revision canals corresponded to the standard values, but position of the femoral canal had a slight cranial and anterior displacement. It was also found that the PLT graft diameter was statistically significantly larger than the HT graft diameter (p0.001).&#x0D; Results. There were no statistically significant differences in the objective assessment of the knee joint stability. Significantly better results of subjective assessment of the knee function according to the Lysholm and KOOS scales were obtained in the PLT group (p = 0.042 and p0.001, respectively). Position of revision canals corresponded to the standard values, but position of the femoral canal had a slight cranial and anterior displacement. It was also found that the PLT graft diameter was statistically significantly larger than the HT graft diameter (p0.001).&#x0D; Conclusion. One-stage revision anterior cruciate ligament reconstruction is a safe and effective surgical procedure providing satisfactory objective and subjective clinical results. Use of peroneus longus tendon autograft allows to obtain better results in comparison with the hamstring tendon autograft.

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport. To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS. A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021. Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria. Systematic review and meta-analysis. Level 2 to 4. The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return. The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%). This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ.

There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic. The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair. Cohort study; Level of evidence, 3. A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate. A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007). The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.

The Effect of Primary ACL Reconstruction on Career Longevity in English Premier League and Championship Soccer Players Compared With Uninjured Controls: A Matched Cohort Analysis

Background: Because of the multitude of variables that affect the retirement decisions of professional soccer players, it has proven difficult to isolate the effect of undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) on career longevity. Purpose: To compare the career longevity of professional soccer players after a primary ACLR with that of an uninjured matched control cohort. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a consecutive series of primary ACLR was performed between 2008 and 2018 in professional male soccer players from the senior author's practice. Each athlete with ACLR was matched to 3 control athletes who had not undergone ACLR according to age, league, playing position, and preinjury game appearances/minutes played. Player career statistics—including league, game appearances, and game minutes—were compiled for each year until retirement or July 1, 2022. Results: A total of 82 soccer players in the English Premier League or Championship at the time of their primary ACLR were matched to 246 control athletes. The mean career length after ACLR was 6 ± 2.6 years, while that of the matched control athletes was 7.6 ± 2.8 years (P < .001). After primary ACLR, an athlete had a 2 times greater chance of retirement compared with the matched control athlete (hazard ratio, 2.19; P < .001). At 5 years after ACLR, 16% of athletes had retired from professional soccer, while 8.5% of the matched cohort were retired (P = .060). By 10 years, 72% of the ACLR cohort had retired compared with 43% of the matched cohort (P < .001). Forwards were more likely to have shortened careers compared with goalkeepers (P = .021); however, no significant differences were observed between midfielders, defenders, and forwards. Within the ACLR cohort, a contralateral ACL tear during the athlete's career caused a 2.30 times (P = .022) increased chance of retirement compared with athletes with only 1 ACL tear during their career. Mechanism of injury, meniscal pathology, graft rerupture, and chondral lesions did not affect career length. Conclusion: Professional male soccer players who underwent ACLR had decreased career length by approximately 1.6 years compared with a matched player cohort.

Ten-year results from the UK National Ligament Registry: Patient characteristics and factors predicting nonresponders for completion of outcome scores.

The aim of this study was to report the demographic and mechanism of injury data in the UK National Ligament Registry (NLR) at 10 years and determine factors leading to poor compliance with completion of Patient-Reported Outcome Scores (PROMs). A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR) were included. Patient demographics, mechanism of injury and patient compliance with completing PROMs were analysed. Patient characteristics were further analysed in relation to compliance with completing the different PROMs at the predefined time points. Patients were identified as nonresponders if they had not completed either 1- or 2-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). A total of 17,492 patients were included in this study. The average age for patients undergoing ACLR between 2013 and 2022 was 29.4 (SD, 10.3). Seventy percent were men and 30% women. Football was the most common activity associated with an ACL injury. Patient compliance with recording PROMs was 55% preoperatively and 37%, 32% and 24% at 1-, 2- and 5-year postoperative follow-up, respectively. Nonresponders represented 54% of eligible patients. Multivariate analyses showed that sex, age, smoking, time interval between injury and surgery and low socioeconomic status were associated with low compliance with postoperative PROM completion (p < 0.001). This study reports the demographic characteristics for patients on the NLR since 2013. Male sex, young age, increased waiting time between injury and surgery, smoking and lower socioeconomic class were predictors of low compliance with completion of postoperative PROMs on the UK NLR. Understanding the factors that affect patient compliance with PROMs improves our ability to provide targeted interventions and information to specific patient populations with the aim of enhancing inclusiveness and representation of population in the registry. Level III.

Hamstring Tendon Autograft Is Associated With Increased Knee Valgus Moment After Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis

Background: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone–patellar tendon–bone autograft at 6 months postoperatively in an adolescent population. The authors’ hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. Study Design: Controlled laboratory study. Methods: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. Results: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg (P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10–2 vs −35 × 10–2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10–2 vs −4 × 10–2 N·m/kg, respectively; P = .0426). Both the QT with bone block (–12 × 10–2 vs −3 × 10–2 N·m/kg, respectively; P = .0265) and QT (–13 × 10–2 vs −3 × 10–2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. Conclusion: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. Clinical Relevance: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.