Primary Anterior Cruciate Ligament Research Articles

App-based analysis of the femoral tunnel position in ACL reconstruction using the quadrant method.

The purpose of this study was to examine the intra- and interobserver variability of an app-based analysis of the femoral tunnel position using the quadrant method in primary anterior cruciate ligament reconstruction. Between 12/2020 und 12/2021 50 patients who underwent primary anterior cruciate ligament reconstruction were included in this retrospective study. Intraoperative strictly lateral fluoroscopic images of the knee with marked femoral tunnel were analyzed by four observers using the quadrant method. For retest reliability analysis, measurements were repeated once by 2 observers after 4 weeks. The femoral tunnel position of all included patients averaged 27.86% in the depth relation and 15.61% in the height relation. Statistical analysis showed an almost perfect intra- and interobserver reliability in the depth and height relation. The ICC was 0.92 in the depth relation and 0.84 in the height relation. The Pearson's correlation coefficient in the depth and height relation of observer 1 (0.94/0.81) was only slightly different from the Pearson's correlation coefficient of observer 2 (0.92/0.85). The app-based tunnel analysis took on average 59 ± 16s per measurement. The femoral tunnel analysis with the app-based quadrant method has an almost perfect intra- and interobserver reliability. By smartphone camera, a fast and highly accurate, if necessary also intraoperative, control of the tunnel position can be performed. Level 3-diagnostic retrospective cohort study.

Addition of anterolateral ligament reconstruction to primary anterior cruciate ligament reconstruction could benefit recovery of functional outcomes

This study aimed to compare functional outcomes sequentially up to 1 year after combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) and isolated ACLR. Fifty patients who underwent ACLR with versus without ALLR were analyzed at four different time points (preoperatively and 3, 6, and 12 months postoperatively). For the functional outcomes, muscle strength and acceleration time (AT) were measured using an isokinetic dynamometer. Proprioception was evaluated using joint position sense and dynamic postural stability. Patient-reported outcomes were measured using the Tampa Scale for Kinesiophobia (TSK-11) scores. Functional performance was assessed using single-leg hop distance (SLHD) and Limb Symmetry Index. In the operated knees, quadriceps (at 6 months postoperatively, p = 0.003) and hamstring (at 6 and 12 months postoperatively, p < 0.001) strength were significantly higher in the combined ACLR and ALLR group than the isolated ACLR group. The TSK-11 (at 6 and 12 months postoperatively, p < 0.001) was significantly lower in the combined ACLR and ALLR group than the isolated ACLR group. SLHD was significantly higher in the combined ACLR and ALLR group than the isolated ACLR group (at 6 months, p = 0.022 and at 12 months, p = 0.024). The addition of ALLR to primary ACLR yielded better muscle performance, fear of movement, and functional performance than isolated ACLR.

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.

Comparison of Side-to-Side Difference in Posterior Tibial Slope in Knees With Acute Versus Chronic Anterior Cruciate Ligament Deficiency.

The posterior tibial slope (PTS) is an important feature in knee joint biomechanics and indicates anterior-posterior knee stability. Increased PTS is a known risk factor for both primary anterior cruciate ligament (ACL) rupture and postreconstruction rerupture. To investigate the effect of long-term exposure to ACL deficiency on the PTS and the sagittal anatomy of the proximal tibia. Cross-sectional study; Level of evidence, 3. A total of 44 patients (38 men, 6 women) with a history of knee injury and ACL rupture confirmed by magnetic resonance imaging and physical examination were included in this study. Patients were divided into those with chronic ACL deficiency (group 1: injured ≥5 years prior; n = 22) and acute ACL deficiency (group 2: injured <1 year prior; n = 22). The medial and lateral tibial plateau PTS and anterior tibial translation were measured on monopodal weightbearing knee radiographs at 20° of flexion. The mechanical tibiofemoral angle (MTFA) and the medial proximal tibial angle (MPTA) were measured using an orthoroentgenogram. The side-to-side difference between the affected and unaffected knees was also calculated for all measurements. The mean duration of exposure to ACL deficiency was 7.6 years (range, 5-15 years) in group 1 and 4.4 months (range, 1-11 months) in group 2. Regarding the side-to-side differences in angular measurements, a higher medial PTS (affected vs unaffected: 12.4° vs 10.1°; P = .007), higher lateral PTS (11° vs 8.9°; P = .011), and increased varus alignment on both the MTFA (4.3° vs 2.4°; P = .036) and the MPTA (84.9° vs 86.3°; P = .033) were found in group 1, while no significant differences in angular measurements were found in group 2. Compared with group 2, patients in group 1 had a significantly higher side-to-side difference in the medial PTS (2.3° vs 0.1°; P = .0001), lateral PTS (2.1° vs 0.4°; P = .0001), and MPTA (1.4° vs 0.1°; P = .002). This study showed that the affected knees of patients with chronic ACL deficiency (≥5 years) had higher medial and lateral PTS compared with the unaffected contralateral knees. Therefore, when planning ACL reconstruction for patients with a history of long-term ACL deficiency, it is crucial to measure the preoperative PTS accurately.

Outcomes of Primary Anterior Cruciate Ligament (ACL) Repair for Proximal Tears: A Systematic Review and Meta-Analysis.

The purpose of this study is to compare failure rates among different techniques of primary anterior cruciate ligament (ACL) repair for the treatment of proximal ACL ruptures. Meta-analysis and systematic review were completed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guidelines were followed. Studies from Embase, Cochrane, and PubMed published between June 2011 and June 2022 reporting outcomes of primary ACL repair on proximal tears with a minimum two-year follow-up were included. Primary ACL repair was divided into dynamic, static, and non-augmented repair. The primary outcome was failure rates, and the secondary outcomes included patient-reported outcomes (PROs) and anterior tibial stability (ATT). Eighteen studies on primary ACL repair were included, with a total of 614 patients (ages rangingfrom 6 to 65, 60% male). Only two studies were level 1 randomized controlled clinical trials. The static repair had a failure rate of 33 out of 261 (12.6%), non-augmented was 17 out of 179 (9.4%), and dynamic repair was 31 out of 174 (17.8%); no statistically significant difference was found comparing the failure rates (p = 0.090). PROs using the International Knee Documentation Committee (IKDC) and Lysholm scores had weighted averages of 91.7 (95% confidence interval (CI): 89.6-93.8) and 94.7 (95% CI: 92.7-96.7), respectively. ATT had a weighted average of 1.668 mm (95% CI: 1.002-2.334). The primary findings of this paper include a 12.6% combined failure rate for primary proximal ACL repair with no significant difference in failure rate or PROs when accounting for the methodology of repair at a minimum two-year follow-up. It is important to note the lack of high-quality randomized controlled trials, the heterogeneity of included studies, and the lack of long-term data. Despite these limitations, the findings of the current analysis suggest that primary repair may be a useful treatment option for indicated candidates with proximal ACL ruptures. Further long-term and higher-quality comparative studies on ACL reconstruction are warranted.

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.

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.

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.

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.

Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes

To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes. All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone. In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation. ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%. Level IV, retrospective case series.

Preoperative Low Resilience Is Associated With Female Patients, Whereas High Resilience Is Associated With Improved Mental Health Scores During Anterior Cruciate Ligament Reconstruction

To evaluate the relationship between resilience, as measured by the Brief Resilience Scale (BRS), and patient-reported outcome measures (PROMs) after primary anterior cruciate ligament reconstruction (ACLR). A cohort of 72 patients undergoing primary ACLR were followed for a minimum of 2 years. Preoperative BRS scores were collected, and patients were categorized into low resilience (LR), normal resilience (NR), and high resilience (HR). PROMs including the visual analog scale (VAS), measuring overall pain level from 0 to 10, the Veterans Rand (VR) 12-Item Health Survey Physical Component and Mental Components, Knee Injury and Osteoarthritis Outcomes Score, and Marx Activity Rating Scale were collected preoperatively as well as up to 2 years postoperatively and compared among the various resilience groups. BRS scores were significantly associated with VAS, VR 12-Item Health Survey Mental Component, and KOOS outcome scores. There was a significant difference among all 3 resilience groups (P= .0382) in change of VAS score from baseline to 2 years postoperatively, with a mean difference of 2.5 points, 1.1 points, and 0.7 points for LR, NR, and HR groups, respectively. There was a significant association of greater VR 12-Item Health Survey Mental Component scores, with greater resilience scores preoperatively (P < .0001) and at both 1 (P= .0034) and 2 years (P= .0235) postoperatively. Greater resilience scores were associated with greater KOOS scores at 1 year postoperatively (P= .0270). Female patients were more likely to fall into the LR group (80%). In this cohort of patients undergoing ACLR, low resilience is positively associated with greater improvement in pain, and female patients tend to fall more into the LR group. At 1 year postoperatively, greater resilience scores were positively associated with greater aggregated KOOS scores. At 1 and 2 years postoperatively, greater resilience was positively associated with improved VR-12M scores. Level II, prospective cohort study.

Increased risk for early revision with quadriceps graft compared with patellar tendon graft in primary ACL reconstructions.

Bone patella-tendon bone (BPTB) and hamstring tendon (HT) autografts are the most used grafts in primary anterior cruciate ligament (ACL) reconstructions (ACLR) in Norway. Quadriceps tendon (QT) autograft has gained more popularity during the past years. The purpose of this study is to compare revision rates and patient-reported outcomes of primary QT with BPTB and HT autograft ACL reconstructions in Norway at 2-year follow-up. It was hypothesized that there would be no difference in 2-year revision rates between all three autografts. Data included primary ACLR without concomitant ligament surgeries, registered in the Norwegian Knee Ligament Register from 2004 through 2021. Revision rates at 2 years were calculated using Kaplan-Meier analysis. Hazard ratios (HR) for revision were estimated using multivariable Cox regression analysis with revision within 2 years as endpoint. Mean change in patient-reported outcome was recordedpreoperatively and at 2 years through the Knee Injury and Osteoarthritis Outcome Score (KOOS) subcategories 'Sport' and 'Quality of Life' was measured for patients that were not revised and analysed with multiple linear regression. A total of 24,790 primary ACLRs were identified, 10,924 with BPTB, 13,263 with HT and 603 with a QT graft. Patients in the QT group were younger (23.5 years), more of them were women (58.2%) and over 50% had surgery <3 months after injury. The QT group had the highest prevalence of meniscal injuries (61.9%). Revision estimates at 2-years were 3.6%, 2.5% and 1.2% for QT, HT and BPTB, respectively (p < 0.001). In a Cox regression analysis with QT as reference, BPTB had a lower risk of revision (HR 0.4, 95% Cl 0.2-0.7, p < 0.001). No significant difference was observed in the revision risk between QT and HT (HR 1.1, 95% Cl 0.7-1.8, n.s.). The two most common reported reasons for revision were: traumatic graft rupture and nontraumatic graft failure. There were no differences between the groups in change of KOOS in subcategories 'Sport' and 'Quality of Life' at 2-years follow-up. The 2-year risk of revision after ACLR with QT was higher than BPTB and similar to HT. No difference was found between the groups in patient-reported outcomes. This study provides valuable insights for both surgeons and patients when making decisions about the choice of autografts in primary ACL reconstructions. Level II.

Primary anterior cruciate ligament repair-morphological and quantitative assessment by 7-T MRI and clinical outcome after 1.5 years.

The purpose of this study was to assess morphological and quantitative changes of the anterior cruciate ligament (ACL) and cartilage after ACL repair. 7T MRI of the knee was acquired in 31 patients 1.5 years after ACL repair and in 13 controls. Proton density-weighted images with fat saturation (PD-fs) were acquired to assess ACL width, signal intensity, elongation, and fraying. T2/T2* mapping was performed for assessment of ACL and cartilage. Segmentation of the ACL, femoral, and tibial cartilage was carried out at 12 ROIs. The outcome evaluation consisted of the Lysholm Knee Score and International Knee Documentation Committee (IKDC) subjective score and clinical examination. ACL showed a normal signal intensity in 96.8% and an increased width in 76.5% after repair. Fraying occurred in 22.6% without having an impact on the clinical outcome (Lysholm score: 90.39 ± 9.75, p= 0.76 compared to controls). T2 analysis of the ACL revealed no difference between patients and controls (p= 0.74). Compared to controls, assessment of the femoral and tibial cartilage showed a significant increase of T2* times in all ROIs, except at the posterolateral femur. Patients presented a good outcome in clinical examination with a Lysholm score of 87.19 ± 14.89 and IKDC of 80.23 ± 16.84. T2 mapping results suggest that the tissue composition of the ACL after repair is similar to that of a native ACL after surgery, whereas the ACL exhibits an increased width. Fraying of the ACL can occur without having any impact on functional outcomes. T2* analysis revealed early degradation at the cartilage. MRI represents a noninvasive diagnostic tool for the morphological and compositional assessment of the anterior cruciate ligament after repair, whereas knowledge about post-surgical alterations is crucial for adequate imaging interpretation. • There has been renewed interest in repairing the anterior cruciate ligament with a proximally torn ligament. • T2 times of the anterior cruciate ligament do not differ between anterior cruciate ligament repair patients and controls. • T2 mapping may serve as a surrogate for the evaluation of the anterior cruciate ligament after repair.

Risk factors for reoperation for arthrofibrosis following primary anterior cruciate ligament reconstruction.

The purpose of this study is to identify the rate and risk factors for a reoperation for arthrofibrosis following primary anterior cruciate ligament (ACL) reconstruction. Prospective data recorded in the New Zealand ACL Registry were cross-referenced with data from the Accident Compensation Corporation (ACC). Primary ACL reconstructions performed between April 2014 and May 2021 were analysed. The ACC database was used to identify patients who underwent a reoperation for a diagnosis of arthrofibrosis. Multivariable survival analysis was performed to compute adjusted hazard ratios (aHR) and 95% confidence intervals. A total of 12,296 primary ACL reconstructions were analysed, of which 230 underwent a reoperation for arthrofibrosis (1.9%) at a mean follow-up of 3.6 years. A higher risk of arthrofibrosis was observed in females (aHR = 1.76, p = 0.001), patients with a history of previous knee surgery (aHR = 1.82, p = 0.04) and when a transtibial drilling technique was used (aHR = 1.53, p = 0.03). ACL reconstruction >6 months after injury had the lowest rate of arthrofibrosis (1.3%, aHR = 0.45, p = 0.01). There was no difference in risk between early surgery within 6 weeks versus delayed surgery between 6 weeks and 6 months after injury (2.9% versus 2.1%, aHR = 0.78, not significant). Female sex, previous knee surgery and a transtibial drilling technique increased the risk of reoperation for arthrofibrosis. Early surgery within 6 weeks of injury was not associated with an increased risk when compared with surgery between 6 weeks and 6 months after injury. Level III.

Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury

PurposeTo compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) versus immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR). MethodsCPT code 29888 was queried from January 2012 to April 2020. Subjects aged under 22 who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age greater than 22, treatment after 6 months, revision ACLR, concurrent osteotomy, or multi-ligamentous injury. All subjects required a minimum of one year follow-up. Demographics and intra-operative pathology was recorded. Data was analyzed for factors affecting intra-articular injury and stratified by sport. ResultsOf 927 patients (739 SM,188 SI), the average age was 16.63 and 14.00 for the SM and SI cohorts, respectively(p<.001). There were more SM males (51.4%) compared to SI males (81.9%)(p<.001); however in univariate analysis gender did not significantly affect the rates of meniscal(p=.519) or chondral injury(p=.961). 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (p<.001), and underwent higher rates of partial meniscectomy(p=.022). Male sex conferred meniscal injury (95%CI[0.43,0.81],p=.001). BMI prognosticated medial meniscal (95%CI[1.01,1.06],p=.002) and medial chondral injuries (95%CI[1.02,1.09],p<.001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95%CI[0.00,0.06],p=.002), LMT (95%CI[0.00,0.75],p=.034), and chondral injury (95%CI[0.00,0.49],p=.049). In sport sub-analysis, soccer ACL injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (p=.016,p=.003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes(p=.001) via contact mechanisms(p=.025). ConclusionSkeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status impact risk of sports related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk. Level of EvidenceIII – Retrospective Cohort Study

Patients with Bilateral ACL Reconstruction (ACLR) have 3x the Rate of Posterior Tibial Slope Greater than 12-Degrees Compared to Unilateral ACLR: MRI and Radiographic Evaluation

Objectives: Increased posterior tibial slope (PTS) is a risk factor for primary anterior cruciate ligament (ACL) tear and graft failure, but PTS has not been well-defined in those who have experienced bilateral ACL injuries. We aimed to compare PTS angles, as well as the rate of elevated PTS (&gt;12° on lateral radiograph; &gt;7° on MRI), between patients who underwent bilateral ACL reconstruction (ACLR) vs unilateral ACLR. A secondary purpose was to examine whether these associations remained consistent on both plain radiographs and MRIs. Methods: We retrospectively identified patients who underwent primary ACLR at our institution from the years 2012 to 2020. Patients with non-simultaneous bilateral ACLR (n=53) were propensity matched to those with unilateral ACLR (n=53) by age, sex, and BMI. Exclusion criteria were: rotated lateral radiographs, inadequate quality MRI, concomitant ligament injury or fracture. Unilateral ACLRs with less than 5-year follow-up were further excluded. Three blinded readers measured PTS on lateral radiographs, while medial (MPTS) and lateral PTS (LPTS) were measured on MRI. Bivariate regression was performed to determine correlation between radiograph and MRI measurements. Results: A final cohort of 106 patients was analyzed (mean age: 27.4 ± 10.5 years, 49.1% male, BMI: 25.5 ± 4.3). PTS in the bilateral ACLR cohort was significantly greater than the unilateral ACLR cohort on radiographs (11.26° vs 10.13°, p=0.044) and LPTS (7.32° vs 6.08°, p=0.012), but not MPTS (4.55° vs 4.17°, p=0.467). The percentage of bilateral patients with radiograph PTS &gt;12° was 41.0%, compared to 13.2% in unilateral cohort (p=0.012). The bilateral cohort had a significantly greater rate of LPTS &gt;7° compared to unilateral patients (53.8% vs 32.1%, p=0.016), but not MPTS (p=0.467). On MRI, LPTS (5.93° ± 3.20°) was significantly greater than MPTS (5.12° ± 2.78°, p&lt;0.001). There was weak correlation between MPTS-radiograph ( R=0.24, p=0.02) and LPTS-radiograph was not significantly correlated ( R=0.03, p=0.810). Conclusions: Patients who underwent bilateral ACLR had significantly greater PTS on radiographs and LPTS on MRI compared to those with unilateral ACLR. The rate of PTS &gt;12° was 3.1x greater among bilateral ACLR compared to unilateral ACLR. PTS measurements on radiographs demonstrated weak-to-negligible correlation with MRI measurements, suggesting future normative PTS values should be reported specific to the imaging modality.

Association of Quadriceps Tendon Harvest for ACL Reconstruction With Development of Osteochondritis Dissecans of the Patella in Pediatric Patients.

There are various reported complications after primary anterior cruciate ligament reconstruction (ACLR) necessitating additional surgery in skeletally immature patients, regardless of technique and autograft type. To analyze the rate and type of complications encountered with soft tissue quadriceps tendon autograft (QTA) for ACLR in patients ≤18 years as well as the overall rate of second surgery, unrelated to the use of the QTA. Case series; Level of evidence, 4. A total of 141 patients ≤18 years who underwent ACLR with a QTA and had minimum 6-month follow-up were included. All patients underwent ACLR by utilizing a full-thickness soft tissue QTA. Complications associated with the QTA harvest site and use of QTA were reported. The mean age of the included cohort (84 men, 57 women) was 14.8 ± 1.6 years. The average follow-up was of 2.0 ± 1.2 years. A total of 30 (21%) patients had a subsequent complication that required surgical intervention; in 11 (8%) patients, the complication was specifically associated with the use of a QTA, whereas in 19 (13%) patients, the complication was related to the ACLR. In addition, 13 (9%) patients underwent a contralateral ACLR procedure. Of the QTA-related complications, 2 patients developed osteochondritis dissecans (OCD)-like lesions in the superior aspect of the patella, 2 patients had injured their quadriceps extensor mechanism and required surgical repair, and 8 patients had a subsequent procedure to remove nonabsorbable sutures used for donor site quadriceps tendon closure. One of the patients who underwent the removal of nonabsorbable sutures also had an arthroscopic debridement of patellar chondral damage. We reported complications encountered with soft tissue QTA for ACLR. The complication rate for QTA harvest was 8%. However, given that the removal of nonabsorbable sutures from the donor site was caused by the surgical technique used, the revised nonsuture-related complication rate for QTA graft harvest was 2%. Although the use of a QTA has recently gained popularity due to its high return-to-sport and low graft-failure rates, surgeons should be aware of the complications associated with using this graft type.

Low Preoperative Brief Resilience Scale Scores Are Associated With Inferior Preoperative and Short-Term Postoperative Patient Outcomes Following Primary Autograft Anterior Cruciate Ligament Reconstruction

To assess preoperative Brief Resilience Scale (BRS) scores as they relate to postoperative patient outcomes following primary autograft anterior cruciate ligament reconstruction (ACLR). All patients who underwent primary autograft ACLR from 2016 to 2021 and had a patient-reported follow-up of 1 year and a clinical follow-up of 6 months were included in final data analysis. Patients completed validated PROMs pre- and postoperatively. All patients were objectively assessed with range of motion (ROM) and KT-1000 arthrometer testing. Return to sport (RTS) data were obtained for all applicable patients. Patients were divided into 3 groups based on ± ½ the standard deviation for the mean preoperative BRS score. In total, 170 patients who underwent primary autograft ACLR with a mean age of 20.1 years (range, 13-57 years) and a mean final follow-up time of 2.9 years (range, 1.0-5.8 years) were included in the final analysis. The mean preoperative BRS scores for the high-resilience (HR, n= 67), average-resilience (AR, n= 42), and low-resilience (LR, n= 61) groups were 28.1 (95% CI, 27.8-28.9), 24.5 (95% CI, 24.3-24.6), and 21.1 (95% CI, 20.5-21.7), respectively (P < .001). The HR group demonstrated significantly higher preoperative and postoperative patient-reported outcome measures (PROMs) compared to the AR and LR groups, with more differences seen with the LR group. The HR group demonstrated better knee extension in postoperative month 3 compared to the LR group (0.6° [95% CI, -1.2° to 0.1°] vs -2.3° [95% CI, -3.3° to -1.3°], P= .006). The HR group demonstrated a faster RTS time compared to the LR group (6.4 months [95% CI, 6.1-6.7] vs 7.6 months [95% CI, 7.1-8.1], P= .002). No differences were seen in RTS rate, knee flexion, or KT-1000 arthrometer measurements between the 3 groups. Low preoperative BRS scores were associated with inferior PROMs preoperatively and in the short-term postoperative period compared to those with higher preoperative BRS scores. Additionally, patients with lower preoperative BRS scores demonstrated a higher degree of knee extension loss 3 months postoperatively as well as a slower RTS. Level III, retrospective cohort study.

Correlation of Hamstring Tendon Size in Pre-Operative MRI Measurement with Intra-Operative Graft Size in Primary Anterior Cruciate Ligament (ACL) Reconstruction

Correlation of Hamstring Tendon Size in Pre-Operative MRI Measurement with Intra-Operative Graft Size in Primary Anterior Cruciate Ligament (ACL) Reconstruction

Lower Extremity Reaction Time in Individuals With Contact Versus Noncontact Anterior Cruciate Ligament Injuries After Reconstruction.

Deficits in perceptual-motor function, like visuomotor reaction time (VMRT), are risk factors for primary and secondary anterior cruciate ligament (ACL) injury. Noncontact ACL injuries have been associated with slower reaction time, but whether this association exists for patients with contact ACL injuries is unknown. Exploring differences in VMRT among individuals with contact versus noncontact ACL injuries may provide a more comprehensive understanding of modifiable risk factors. To compare lower extremity VMRT (LEVMRT) in individuals with contact or noncontact ACL injuries after ACL reconstruction (ACLR). Cross-sectional study. Research laboratory. A total of 36 participants with primary, unilateral ACLR completed an LEVMRT assessment (contact ACL injury = 20 [56%], noncontact ACL injury = 16 [44%]). The LEVMRT was assessed bilaterally and collected using a series of wireless light discs deactivated by individuals with their feet. The ACLR-active LEVMRT (ie, ACLR limb is deactivating lights) and ACLR-stable LEVMRT were compared using separate analyses of covariance to determine the association with contact or noncontact injury using time since surgery as a covariate. After controlling for time since surgery, a difference and large effect size between groups was found for the ACLR-stable LEVMRT (P = .010; η2 = 0.250) but not for the ACLR-active (P = .340; η2 = 0.065) condition. The contact group exhibited slower ACLR-stable LEVMRT (521.7 ± 59.3 milliseconds) than the noncontact group (483.4 ± 83.9 milliseconds). Individuals with contact ACL injury demonstrated a slower LEVMRT while their ACLR limb was stabilizing. The group differences during the ACLR-stable LEVMRT task might indicate deficits in perceptual-motor function when the surgical limb maintains postural control during a reaction time task. After ACLR, individuals with contact injuries may need additional motor learning interventions to enhance perceptual-motor functioning.