Revision Anterior Cruciate Ligament Reconstruction Research Articles

Combined use of cleft and truncated triangle signs helps improve the preoperative MRI diagnosis of lateral meniscus posterior root tears in patients with ACL injuries.

This study aimed to investigate whether combining the analysis of different magnetic resonance imaging (MRI) signs enhances the diagnostic accuracy of lateral meniscus posterior root tears (LMPRTs) in patients with anterior cruciate ligament (ACL) injuries. We hypothesised that analysing the cleft, ghost and truncated triangle signs and lateral meniscus extrusion (LME) measurement together would improve the preoperative MRI-based diagnosis of LMPRTs. This retrospective study used prospectively collected registry data from two academic centres, including patients undergoing primary or revision ACL reconstruction (ACLR) and LMPRT repair. The control group included age- and sex-matched (1:1) patients undergoing ACLR without any lateral meniscus tears. LME (mm) and the presence of cleft, ghost and/or truncated triangle signs were evaluated using preoperative MRI. In total, 252 patients (126 per group) were included. Individually, the cleft and truncated triangle signs achieved the highest sensitivity (60% and 62%, respectively) and accuracy (>89%). The presence of either sign increased sensitivity to 79% and enabled the correct classification of 93% of ACL injuries as having or not having an LMPRT, with high specificity (95%) and good positive predictive value (74%). This combination was considered the most efficient in reducing false positives and false negatives. The LME (cutoff value: 2.2 mm) and ghost sign had lower sensitivities (50% and 14%, respectively) and accuracies (83% and 87%) and were not part of the optimal combination. The cleft and/or truncated triangle signs on preoperative MRI reliably detected 79% of LMPRTs in this cohort, with high specificity (95%) and good positive predictive value (74%). This combination provides an effective method for achieving reasonable sensitivity while minimising false positives, aiding surgeons in preoperative diagnosis and planning for LMPRT repair. Level III.

Single-stage revision anterior cruciate ligament reconstruction for anatomic, massive dilated tunnels using “the sandwich technique”

At present, revision anterior cruciate ligament reconstruction (ACL-R) with dilated tunnels is managed as a two-stage procedure which results in longer recovery and rehabilitation as well as late return to sports. In the present “sandwich” technique, management of revision ACL-R with dilated tunnels can be carried out as a single-stage procedure, which basically entails sandwiching the tibia end of bone patellar tendon bone graft in between the allograft and the tibial tunnel. The present case highlights the use of a novel technique coined as the “sandwich technique” for managing revision ACL-R in a 38-year-old male with dilated femoral and tibial tunnels which is usually managed through staged procedures. Single-stage “sandwich technique” is a viable option in managing revision anterior cruciate ligament scenarios with massive, dilated tunnels, thus decreasing the morbidity, mental agonies, and financial obligations associated with an additional procedure.

Two-stage revision anterior cruciate ligament reconstruction reduces failure risk but leads to lesser clinical outcomes than single-stage revision after primary anterior cruciate ligament graft failure: a retrospective cohort study

BackgroundThere are no studies that compare the outcomes and complications of single-versus two-stage revision anterior cruciate ligament reconstruction (ACLR) after primary ACLR failure. This purpose of this study is to examine clinical and functional outcomes and complications associated with single and two-stage revision ACLR after primary ACLR failure.MethodsAll patients who underwent single or two-stage revision ACLR after primary ACLR failure between 2012 and 2021 with a minimum of a 2 year follow-up were included. Patients were excluded if they were not treated at our single academic institution, had inadequate follow-up, or had incomplete medical records. Revision intraoperative data, concomitant injuries, and complications were collected by chart review. Return to sport, numerical pain rating scale (NPRS) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Veteran Rands 12-item health survey (VR-12 scores) were collected.ResultsThe final analysis included 176 patients. A total of 147 (83.5%) had a single-stage revision ACLR (87 male, 60 female), and 29 (16.5%) had a two-stage revision ACLR (13 male, 16 female). Two-stage revision ACLR was significantly associated with anterior knee pain [odds ratio (OR) 4.36; 95% confidence interval (CI) 1.5 to 12.65; P = 0.007] but with lower failure rates (OR 0.12, 95% CI 0.02 to 0.9; P = 0.04). On multivariate analysis, a two-stage revision ACLR reduced the risk of graft failure by 85% (OR 0.15; 95% CI 0.02 to 1.17; P = 0.07). Two-stage revision ACLR was significantly associated with a lower KOOS pain score (OR −11.7; 95% CI −22.35 to −1.04; P = 0.031), KOOS symptoms score (OR −17.11; 95% CI −28.85 to −5.36; P = 0.004), KOOS Activities of Daily Living (ADL) score (OR −11.15; 95% CI −21.71 to −0.59; P = 0.039) and Veterans RAND 12-Item Health Survey (VR-12) physical component score (OR −9.99; 95% CI −15.77 to −4.22; P = 0.001).ConclusionsThe clinical outcomes and subjective patient scores significantly differed between the single-stage and two-stage revision ACLR after primary ACLR failure. Patients with a two-stage revision ACLR had a significantly reduced risk of revision graft failure but higher rates of postoperative anterior knee pain, lower pain scores, and lesser knee functional scores than single-stage revision patients.Study designRetrospective cohort study; level of evidence, 3

Lower ACLR Failure Rates in Bone–Soft Tissue Versus Soft Tissue–Only Allografts in Adults: A Systematic Review and Meta-analysis

Background: While allografts are commonly used for anterior cruciate ligament reconstruction (ACLR), evidence to guide specific allograft selection is lacking. Purpose: To compare clinical and graft failure rates after ACLR using soft tissue–only allografts and bone–soft tissue allografts in adults. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: English-language studies with clinical outcome data on primary and revision ACLR in adults with nonirradiated soft tissue–only and bone–soft tissue grafts were identified in the search. Data extracted included allograft type, patient characteristics, follow-up time, and failure rates. The cumulative failure rate was defined as International Knee Documentation Committee grade C/D, graft retear, grade ≥2+ Lachman, grade ≥2+ pivot shift, and/or side-to-side KT-1000 laxity of >5 mm. The graft rupture rate was defined solely by the proportion of patients who had a graft rupture. Meta-analyses using the inverse variance method were used to estimate the pooled rates with 95% CIs. Subgroup analysis was conducted to compare allograft types and determine whether age, sex, and follow-up time influenced the estimates. Results: A total of 14 studies met the inclusion criteria: 7 investigated bone–soft tissue allografts, 6 investigated soft tissue–only allografts, and 1 investigated both. The comparative study showed a difference in the cumulative failure rate between bone–patellar tendon–bone and soft tissue–only allografts. The pooled cumulative failure rates for bone–soft tissue and soft tissue–only allografts were 11% (95% CI, 7-17) and 20% (95% CI, 14-29), respectively ( P = .05). The pooled graft rupture rates for bone–soft tissue and soft tissue–only allografts were 6% (95% CI, 4-9) and 13% (95% CI, 7-23), respectively ( P = .07). Conclusion: The meta-analysis results showed that bone–soft tissue allografts have lower cumulative failure rates than soft tissue–only allografts. Bone–soft tissue allografts may be the preferred allograft choices for ACLR.

One-stage revision anterior cruciate ligament reconstruction: Preoperative evaluation, planning and surgical techniques. A review of current concepts.

Level V expert opinion.

Preventing Tunnel Overlap in Revision Anterior Cruciate Ligament Reconstruction Through Creation of a Single Anatomic Oval Femoral Tunnel

Preventing Tunnel Overlap in Revision Anterior Cruciate Ligament Reconstruction Through Creation of a Single Anatomic Oval Femoral Tunnel

Greater return to sports after anterior cruciate ligament reconstruction combined with anterolateral ligament reconstruction compared with anterior cruciate ligament reconstruction alone: A systematic review and meta-analysis.

This study aimed to compare the return to sports, return to competition, Tegner score and anterior cruciate ligament-return to sports injury (ACL-RSI) scores between patients who underwent ACL reconstruction (ACLR) combined with anterolateral ligament reconstruction (ALLR) and those who underwent ACLR alone. Two independent reviewers conducted a literature search in PubMed (MEDLINE), EMBASE, Google Scholar and the Cochrane Library in July 2024, followed by data extraction and quality assessment. This study followed the Preferred Reporting Items for Systematic Reviews and meta-analysis guidelines. The return to sports rate, return to competition rate, Tegner score and ACL-RSI score were compared between patients who underwent primary ACLR with ALLR and those who underwent isolated primary or revision ACLR. The methodological quality of the included studies was assessed via the Cochrane risk-of-bias tool and methodological items for nonrandomized studies. In total, 12,139 studies were screened, and 14 (four randomized controlled trials and 10 nonrandomized studies) studies were ultimately evaluated. Compared with isolated ACLR, ACLR combined with ALLR resulted in a higher rate of return to sports and competition. Nevertheless, no significant differences were found in the Tegner score or ACL-RSI score between the two groups. Patients who underwent ACLR in combination with ALLR had higher rates of return to sports and competition, but their Tegner activity and ACL-RSI scores were similar to those of patients who underwent ACLR alone. This finding may assist surgeons in making decisions when treating patients undergoing ACLR, especially athletes. Level III.

The use of four K-wires does not lead to a reduction of the MPTA in the context of a one-dimensional tibial deflection correction of patients with ACL re-rupture and pathologically increased tibial slope.

Anterior tibial closing wedge osteotomy (ATCWO) has been shown to significantly reduce failure rates of revision anterior cruciate ligament (ACL) reconstructions in patients with a posterior tibial slope (PTS) ≥12°. Recent findings suggest a slight but significant reduction of the medial proximal tibial angle (MPTA) resulting in a varus knee where the sagittal osteotomy plane is based on a total of two guide wires defining the osteotomy wedge without respecting the frontal plane. We hypothesize that the placement of a total of four guide wires intraoperatively can reduce the influence on the MPTA. This study retrospectively reports on a two-centre series of 42 ATCWOs for PTS correction between January 2022 and December 2023 at two clinical centres. A total of four guide wires were placed based on a true lateral intraoperative view of the tibia, with two positioned each at the cranial and at the caudal pole of the osteotomy wedge, serving as guides for the saw to create the osteotomy, with careful attention to ensuring that the proximal and distal K-Wires were placed parallel to each other. A retrospective analysis was conducted by examining true lateral and anteroposterior radiographs to identify changes in sagittal and coronal plane alignment. The study included 19 women and 23 men, with a mean age of 29.7 ± 8.6 years with first-time ACL revision surgery and a minimum PTS of ≥12°. PTS decreased significantly from 14.5 ± 2.8° preoperatively to 8.2 ± 1.9° post-operatively (p < 0.001). The aMPTA demonstrated no significant difference between preoperative (mean aMPTA: 86.9 ± 2.1°) and post-operative (mean aMPTA: 86.6 ± 1.9°) measurements (p > 0.05). With our technique of placing four guide wires to achieve precise guidance during the insertion of the osteotomy wedge, there is no substantial impact on the aMPTA during slope correction. Level IV.

After Anterior Cruciate Ligament Surgery, Variables Associated With Returning to the Same Surgeon If a Subsequent Antrior Cruciate Ligament Surgery Is Needed?

Anterior cruciate ligament reconstructions (ACLrs) unfortunately can require revision ACLr, or contralateral ACLr may be indicated (together subsequent ACLr). This study aimed to examine the rate of and factors associated with returning to the same surgeon. Patients who underwent ACLr and subsequent ACLr within 3 years were abstracted from the PearlDiver database. Patient factors and surgical factors were examined. Factors independently associated with changing the surgeon were examined. Overall, 63,582 ACLr patients were identified with 2,823 (4.4%) having a subsequent ACLr. These subsequent ACLrs were performed by the same surgeon for 1,329 (47.1%) and by a different surgeon for 1,494 (52.9%). Factors independently associated with changing surgeons were 90-day adverse events after index surgery (odds ratio [OR] 1.95), longer time to second surgery (OR 1.61), and second surgery on the ipsilateral knee (OR 1.28). Notably, sex, comorbidity, depression, psychoses, and insurance plan were not correlated with choosing changing surgeons. Over half of the patients who required a subsequent ACLr changed surgeons. Changing surgeons was associated with adverse events after index surgery, ipsilateral revisions, longer time to surgery, and patient age. However, there should be confidence that the other assessed factors were not associated with the decision to change surgeons.

Lack of association between revision ACL reconstruction and preoperative, intraoperative and post-operative factors at primary ACL reconstruction in children and adolescents.

To evaluate factors associated with revision anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR in children and adolescents. Children and adolescents (age <20 years at surgery) who underwent primary hamstring tendon ACLR at the Capio Artro Clinic, Stockholm, Sweden, between January 2005 and December 2018 were identified. Revision ACLR within 5 years of primary ACLR was captured in the Swedish National Knee Ligament Registry. Univariable and multivariable logistic regression analyses were used to evaluate the associations between revision ACLR and preoperative (age, sex, body mass index, time from injury to surgery, pre-injury Tegner activity level, medial collateral ligament injury, passive contralateral knee hyperextension [≤-5°]), intraoperative (medial meniscus and lateral meniscus [LM] resection or repair, cartilage injury and graft diameter) and post-operative (KT-1000 side-to-side anterior knee laxity, limb symmetry index for extension and flexion strength and single-leg-hop (SLH) test performance at 6 months) factors at primary ACLR. A total of 1888 patients (mean age: 16.0 ± 2.0, range: 8-19 years) who underwent primary ACLR were included. The overall incidence of revision ACLR within 5 years was 9.0% (170 out of 1888). Univariable analysis revealed that a time from injury to primary ACLR of <5 months (odds ratio [OR]: 2.27, 95% confidence interval [CI]: 1.61-2.35, p < 0.001) and LM resection (OR: 1.49, 95% CI: 1.00-2.20, p = 0.04) increased the odds of revision ACLR. Multivariable analysis showed that revision ACLR was significantly associated only with a time from injury to primary ACLR of <5 months (OR: 2.56, 95% CI: 1.72-3.70, p < 0.001). There was a lack of association between revision ACLR and preoperative, intraoperative and post-operative factors at primary ACLR in children and adolescents. A time from injury to primary ACLR of <5 months was the only factor associated with revision ACLR within 5 years. Level III.

Infratuberositary slope‐decreasing anterior closed wedge proximal tibial osteotomy is safe and shows rapid bone healing

AbstractPurposeDifferent techniques of slope‐decreasing anterior closed‐wedge proximal tibial osteotomy (ACW‐PTO) have been described. To determine the peri‐ and post‐operative complication rate and obtain data on bone healing in ACW‐PTO with an infratuberositary approach.MethodsA total of 170 consecutive ACW‐PTO of two sports‐orthopaedic centres were retrospectively evaluated (97 and 73, respectively). Routine follow‐up was performed after 6 weeks and was available in 166 cases (97.7%). Medical charts and x‐rays of these cases were reviewed with regard to technique‐specific complications. Lateral x‐rays (n = 155) at 6 weeks post‐operatively were evaluated with regard to bone healing (completely healed, partially healed or with no or delayed signs of bone healing). A multivariate binary logistic regression was performed to detect factors that influence bone healing.ResultsThere was one case with haematoma and superficial wound‐healing problems after 5 weeks with progression to a deep wound infection and revision surgery (plate exchange) at 11 weeks after the index surgery. One case with delayed bone healing was treated with plate exchange combined with revision anterior cruciate ligament reconstruction after 4 months. The further course of both cases was uneventful. No other complications were observed. Therefore, the overall complication rate was 1.2% (2 out of 166). Radiologic evaluation at 6 weeks showed complete healing in 104 cases (67.1%), partial healing in 50 cases (32.3%) and delayed healing only in the aforementioned case (0.6%), respectively. All cases of partial healing showed complete healing at 12 weeks. In regression analysis, a completely closed osteotomy (odds ratio [OR] = 3.5, p = 0.003) and compression of the osteotomy (OR = 2.5, p = 0.026) were significantly associated with complete bone healing at 6 weeks.ConclusionsACW‐PTO using an infratuberositary approach is very safe with regard to complication rate and shows rapid bone healing. The osteotomy should be completely closed and compression should be applied for optimal bone healing.Study DesignCase series with pooled data of two centres.Level of EvidenceLevel 4.

Cut-off value for the posterior tibial slope indicating the risk for retear of the anterior cruciate ligament.

The significance of the posterior tibial slope (PTS) has increasingly come into focus in anterior cruciate ligament (ACL) reconstruction being a risk factor for ACL graft failure. Nevertheless, inconsistent data on the critical value of the PTS exist. The purpose of this study was to define a cut-off value for the PTS in ACL surgery. In a retrospective cohort study, 350 revision ACL reconstructions (ACL-RR) with a failed ACL hamstring graft and 350 primary ACL reconstructions (ACL-R) were matched according to age, gender, concomitant injuries and graft characteristics and compared to a healthy control group. Using the proximal anatomic axis, lateral knee radiographs were evaluated for the PTS, interrater reliability was defined, ROC curves, Fischer's exact test and Baptista-Pike method were applied to define specificity and the odds ratio for a critical PTS value. Radiographic evaluation proved excellent interrater reliability (intraclass correlation coefficient 0.969). Evaluation of the PTS revealed 10.0 ± 2.2 (5-15) degrees in the ACL-RR group, 7.8 ± 1.8 (4.2-13) degrees in the ACL-R group and 6.6 ± 1.9 (3.6-12) degrees in the control group with significant differences between the groups (p < 0.001). A PTS value of 10.1 degrees proved a specificity of 98% for the prediction of an ACL graft failure and indicated an 11-fold risk for a retear of the ACL. A PTS exceeding 10.1 degrees carries an 11-fold risk for ACL graft failure and, therefore, should be considered in ACL reconstruction. These findings might serve as a cut-off value for the indication of a slope-reducing high tibial osteotomy in ACL surgery. Level III.

High Revision Rate After Transphyseal ACL Reconstruction in Skeletally Immature Patients.

Objectives: There remains considerable debate regarding the optimal management of anterior cruciate ligament (ACL) injuries in skeletally immature patients. This study aims to evaluate the clinical outcomes of transphyseal ACL reconstruction in patients with open growth plates. Methods: This retrospective study included skeletally immature patients with full-thickness ACL tears and confirmed open physis. ACL reconstructions were performed using a four-strand semitendinosus autograft, with an additional gracilis tendon graft if needed. The surgical technique emphasized tibial and femoral physeal-sparing tunnel placement to minimize disruption of the growth plates. Clinical assessment included measurements for limb length discrepancy, knee stability, and growth disturbances. Functional outcomes were evaluated using IKDC 2000, Lysholm, and KOOS scores, while ligament stability was assessed with KT-1000 arthrometer measurements at routine follow-up. Results: A total of 31 consecutive patients (15 females, 16 males; mean age 13.6 ± 1.8 years, range 9-16 years) were included. Mean follow-up was 49 ± 26 months (range 18-93 months). The mean time to return to sports was 8.8 ± 4.4 months. Eight patients (26%) experienced ACL graft rupture and underwent revision ACL reconstruction. One additional patient required partial meniscectomy. The overall revision rate was 29%. The mean subjective IKDC score was 91.8 ± 7.2, with Lysholm and KOOS scores of 96.6 ± 7.9 and 94.2 ± 5.3, respectively. No significant growth disturbances were noted. The mean side-to-side difference in KT-1000 testing was 2.2 ± 1.5 mm. Patients who underwent revision ACL reconstruction showed significantly greater length growth compared with those with intact ACL reconstruction (p = 0.02). Spearman correlation revealed a significant association between length growth and anterior tibial translation (p = 0.02, r = 0.46). Conclusions: Transphyseal ACL reconstruction in skeletally immature patients provides favorable clinical and radiological outcomes, with minimal risk of growth disturbance. Most patients returned to pre-injury levels of athletic activity. However, the high revision rate emphasizes the complexity of managing ACL injuries in this population.

Lateral Extraarticular Tenodesis in Revision Anterior Cruciate Ligament Reconstruction: An Analysis of Clinical Outcomes and Failure Rates.

Background/Objectives: Lateral extraarticular tenodesis (LET) has been advocated in revision anterior cruciate ligament reconstruction (ACLR) to improve knee stability and furthermore, decrease failure rates. The aim of this study was to compare clinical outcomes, knee laxity, and failure rates after revision ACLR with LET (ACLR + LET) versus without LET. It was hypothesized that ACLR + LET improves clinical outcomes and reduces the failure rate. Methods: A retrospective analysis of prospectively collected data was conducted to examine patients who underwent revision ACLR with and without LET between 2017 and 2021 with a minimum follow-up of 24 months. Patients with coronal malalignment (>5°), posterior tibial slope >12°, and concomitant injuries to collateral ligaments were excluded. Patient reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) subjective knee score, the Lysholm score, and the Tegner activity scale (TAS). Anterior knee laxity was measured with a Rolimeter and side-to-side difference (SSD) was determined. Revision ACLR failure was defined as ACL revision surgery and SSD > 5 mm. Group comparisons were performed using chi-square-, independent-samples students t-test or Mann-Whitney-U tests. Results: Of 56 eligible patients, 45 (80%, follow up, 23 isolated rACLR vs. 22 rACLR + LET) were included with a mean follow-up of 45.6 ± 15.8 months. Postoperative PROMs were not statistically different between rACLR and rACLR + LET groups (IKDC: 73.0 ± 18.9 vs. 68.7 ± 16.6, n.s.; Lysholm: 84.8 ± 12.3 vs. 77.7 ± 16.2, n.s.). Both groups showed similar TAS (rACLR vs. rACLR +LET (5; range 4-6 vs. 4; range 3-5; n.s.). Anterior knee laxity SSD was 2.4 ± 1.3 mm in the rACLR group and 1.8 ± 1.8 mm in the rACLR + LET group (n.s.). The failure rate was 13% in the rACLR group compared to 4.5% in the rACLR + LET group (n.s.). Conclusions: Isolated revision ACLR showed comparable postoperative patient-reported outcome measures and anterior knee laxity compared to ACLR + LET at mid-term follow up. The addition of a LET demonstrated a lower, though non-significant, failure rate after revision surgery. However, future studies with a prospective, randomized design and an increased number of patients are needed to clearly identify the exact indication for the use of additional LET.

Modifiable and non-modifiable risk factors affecting surgical failure after revision ACL reconstruction: a cohort study

BackgroundResearch on factors influencing the outcomes of revision anterior cruciate ligament (ACL) reconstruction is relatively scarce and mostly relies even on reports from a single group. Understanding the factors contributing to the failure of revision ACL reconstruction can provide valuable information for achieving better clinical outcomes and assist in patient counseling before surgery. Therefore, this study aimed to analyze the factors contributing to surgical failure after revision ACL reconstruction.MethodsThe medical records of consecutive patients who underwent single-bundle revision ACL reconstruction using the transportal technique between 2010 and 2020 and had a minimum follow-up of 2 years were retrospectively reviewed. Eligible patients were classified into two groups on the basis of the presence of surgical failure during the follow-up period (group NF, patients who did not experience surgical failure; group F, patients who experienced surgical failure). In this study, surgical failure after revision ACL reconstruction was defined as meeting any of the following conditions during follow-up: the presence of graft re-tear confirmed by magnetic resonance imaging (MRI), anterior–posterior laxity graded ≥ 2, or rotational laxity graded ≥ 2. A comparative analysis was conducted on demographic data, as well as peri-, intra-, and postoperative data between the groups. Additionally, a regression analysis was performed to investigate factors influencing surgical failure after revision ACL reconstruction.ResultsA total of 58 patients were included (group NF, 40 patients; group F, 18 patients). In between-group comparisons of demographic, peri-, and intra-operative data, group F exhibited a higher frequency of multiple revision surgeries (P = 0.001), increased preoperative osteoarthritis grade (P = 0.001), and shallower femoral tunnel depth (P = 0.002) compared with group NF. At the final follow-up, group F demonstrated relatively poor clinical outcomes, both subjectively and objectively. Multivariate regression analysis revealed that all variables that showed differences in the preceding comparisons were independent factors affecting surgical failure after revision ACL reconstruction.ConclusionsSurgical failure after revision ACL reconstruction can occur in a substantial number of patients, influenced by non-modifiable factors, such as cases corresponding to multiple revision surgery and preoperative osteoarthritis grade, and modifiable factors, such as femoral tunnel depth.

Anterior cruciate ligament reconstruction with suture tape augmentation in the high-risk, young population.

This study evaluated patient-reported outcome measures and reinjury rates in higher-risk adolescents and young adults aged 14-25years old following Anterior Cruciate Ligament reconstruction using autograft with suture tape augmentation (SA ACLR). We performed a retrospective case series of patients aged 14-25 who underwent SA ACLR by a single surgeon between 2016 and 2020. After a minimum of 2years of follow-up, data was collected on reinjury and patient reported outcome measures, including Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale (MARS), Single Assessment Numeric Evaluation (SANE), and Visual Analog Pain Scale (VAPS). 27 patients were identified. 4 were lost to follow-up, and 23 met inclusion criteria (11 male, 12 female). Average age was 20, and average follow-up was 2.5years. Failure rate was 8.7%, with two patients requiring revision ACL reconstruction. One patient required two additional meniscal operations with intraoperative findings demonstrating maintenance of an intact ACL. Postoperative patient-reported outcomes measures (PROMs) were obtained for the patients who did not require additional surgery (n = 20), and preoperative PROMs were available for 16 of these patients. Postoperatively, patients reported a mean VAPS of 0.74 ± 1.27, MARS of 8.05 ± 5.58, and SANE of 83.05 ± 16.47. Mean KOOS was 86.92 ± 11.77 with subscores Pain of 86.94 ± 12.94, Symptoms of 82.16 ± 14.96, ADL of 95.81 ± 8.10, Sport of 75.61 ± 21.52, and QOL of 70.64 ± 22.04. Paired t-tests demonstrated significant improvements in VAPS, SANE, and KOOS outcomes following surgery. Patients were significantly less active postoperatively as reported by the MARS. A multivariable regression analysis showed that increased age predicted poorer postoperative KOOS Pain outcomes, and female sex predicted inferior KOOS Pain and Sport outcomes. SA ACLR is a safe and effective surgical technique in the high failure risk young adult demographic, with a low reinjury rate and acceptable KOOS scores. Patients were active with minimal pain at minimum two years of follow-up. Female sex was a risk factor for poorer outcomes in this population.

Surgical Predictors of Clinical Outcome 6 Years After Revision ACL Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown. Purpose: To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient’s outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating score. Patients were followed up for 6 years and asked to complete the identical set of outcome instruments. Regression analysis was used to control for baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery. Results: A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P = .008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P < .01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P = .001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P < .05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P < .05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P≤ .04). Conclusion: There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients’ odds of having a significantly better 6-year clinical outcome in this cohort.

A Novel Machine Learning Model to Predict Revision ACL Reconstruction Failure in the MARS Cohort.

As machine learning becomes increasingly utilized in orthopaedic clinical research, the application of machine learning methodology to cohort data from the Multicenter ACL Revision Study (MARS) presents a valuable opportunity to translate data into patient-specific insights. To apply novel machine learning methodology to MARS cohort data to determine a predictive model of revision anterior cruciate ligament reconstruction (rACLR) graft failure and features most predictive of failure. Cohort study; Level of evidence, 3. The authors prospectively recruited patients undergoing rACLR from the MARS cohort and obtained preoperative radiographs, surgeon-reported intraoperative findings, and 2- and 6-year follow-up data on patient-reported outcomes, additional surgeries, and graft failure. Machine learning models including logistic regression (LR), XGBoost, gradient boosting (GB), random forest (RF), and a validated ensemble algorithm (AutoPrognosis) were built to predict graft failure by 6 years postoperatively. Validated performance metrics and feature importance measures were used to evaluate model performance. The cohort included 960 patients who completed 6-year follow-up, with 5.7% (n = 55) experiencing graft failure. AutoPrognosis demonstrated the highest discriminative power (model area under the receiver operating characteristic curve: AutoPrognosis, 0.703; RF, 0.618; GB, 0.660; XGBoost, 0.680; LR, 0.592), with well-calibrated scores (model Brier score: AutoPrognosis, 0.053; RF, 0.054; GB, 0.057; XGBoost, 0.058; LR, 0.111). The most important features for AutoPrognosis model performance were prior compromised femoral and tibial tunnels (placement and size) and allograft graft type used in current rACLR. The present study demonstrated the ability of the novel AutoPrognosis machine learning model to best predict the risk of graft failure in patients undergoing rACLR at 6 years postoperatively with moderate predictive ability. Femoral and tibial tunnel size and position in prior ACLR and allograft use in current rACLR were all risk factors for rACLR failure in the context of the AutoPrognosis model. This study describes a unique model that can be externally validated with larger data sets and contribute toward the creation of a robust rACLR bedside risk calculator in future studies. NCT00625885 (ClinicalTrials.gov identifier).

Youth Soccer Players Undergoing Anterior Cruciate Ligament Reconstruction Demonstrate High Rates of Continuation of Sport and Progression to Professional Level Soccer: A Seven Season Analysis in Twenty-Nine Brazilian Professional Soccer Teams

Objectives To evaluate the progression of youth male soccer athletes who undergo ACL reconstruction and track their progression from youth up to professional level play Methods 163 male players from 29 soccer teams underwent ACL reconstruction and were followed from 2015 to 2023. They were evaluated regarding category progression (under-13 to professional), type of graft used, presence of re- rupture, and return to sport/continuation of sport. Results Most injuries occurred in players in the under-17 (31.3%) and under-20 (47.2%) categories. A total of 111 patients continued playing after ligament reconstruction (68.1%), and 52 patients discontinued their careers (31.9%). Of the 163 athletes who underwent ACL reconstruction, 40 still play professionally (24.5%) and 71 are continuing participation in youth soccer and may still become professionals (43.6%). Among the professionals, 8 underwent an ACL revision reconstruction. The graft of choice in 77.3% of the reconstructions were the hamstring tendons. Conclusion Athletes from professional soccer teams who underwent ACL reconstruction while still playing in the youth teams of their clubs demonstrated a return to sport rate of 68.1%. Among players who returned to sport and became adult league professionals, 40 (83.3%) continued to play at the adult professional level, and 8 (16.7%) have discontinued their careers.

MCL augmentation using a peroneus longus split tendon autograft satisfactorily restores knee stability with no impairment in foot function and with a low failure rate for concurrent ACL reconstruction.

Addressing grade 2 and 3 medial-sided instabilities during anterior cruciate ligament (ACL) reconstruction is crucial to reduce the risk of ACL graft failure. This study introduced a minimally invasive, medial collateral ligament (MCL) augmentation technique using a peroneus longus split tendon autograft, which was fixed to the femoral deep MCL insertion and tibial superficial MCL insertion. This prospective, longitudinal, single-centre case series included patients who underwent MCL augmentation concurrent with primary or revision ACL reconstruction due to anteromedial instability. Preoperatively and at 1-year follow-up, clinical examinations, such as rolimeter test of anterior tibial translation and medial instability, knee (International Knee Documentation Committee subjective knee form [IKDC], Lsyholm, Knee Injury and Osteoarthritis Outcome Score [KOOS]) and foot function scores (American Orthopaedic Foot and Ankle Society score [AOFAS]) and complications, were analyzed. Thirty-one patients with a mean follow-up of 13.5 ± 2.6 months and a mean age of 27.8 ± 9.6 years were included. The side-to-side difference for anterior tibial translation significantly improved from preoperative to 1-year follow-up with an ACL reconstruction failure rate of 6.5%. No patient retained a grade 2 or 3 medial instability on valgus stress testing with 30° flexion. Significant improvements from preoperative to 1-year postoperative follow-up were observed in knee function scores: IKDC (48.9 ± 26.9- 71.3 ± 11.5, p < 0.001) and Lysholm (59.9 ± 28.5-80.5 ± 11.2, p = 0.002) as well as KOOS pain, ADL, sport and QoL, each reaching the respective minimal clinically important difference values. The foot function score AOFAS showed no significant impairment (100 ± 0-99.3 ± 2.5, p = 0.250). Complications included cyclops lesions of ACL reconstruction in three patients. At 1-year follow-up, MCL augmentation using a peroneus longus split tendon autograft for patients simultaneously undergoing ACL reconstruction satisfactorily restores knee stability, has a low ACL reconstruction failure rate and does not significantly impair foot function. Level IV therapeutic study; case series.