The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries

How Variable Are Achilles Allografts Used for Anterior Cruciate Ligament Reconstruction? A Biomechanical Study

BACKGROUND

Allograft tendon used in anterior cruciate ligament reconstruction (ACLR) requires sterilization before implantation. Low-dose gamma irradiation is a means of sterilization that may minimize tissue damage.

PURPOSE

To quantify the variability in mechanical properties between low-dose irradiated Achilles tendon allografts used for ACLR.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 15 intact outer-third Achilles tendon allograft specimens were collected from the remains of full Achilles allografts used for intraoperative ACLR at a single hospital. All grafts were obtained from a single tissue bank and underwent proprietary disinfection and low-dose gamma irradiation (1.5-2.5 Mrad). Biomechanical testing was carried out to measure tendon elongation, failure location during tensile testing, maximum stress, maximum strain, and modulus of elasticity. The mean and standard deviation were calculated for each outcome measure, and the variability between specimens was calculated by the coefficient of variation (CV). The effect of donor age on graft material properties was examined by use of linear regression. One-way analysis of variance was performed to compare differences in the mechanical properties across failure locations.

RESULTS

During cyclic testing, tendon elongation averaged 1.4% ± 1.6% with a CV of 118%. During failure testing, the maximum stress averaged 12.2 ± 4.1 MPa, maximum strain averaged 21.0% ± 6.3%, and modulus of elasticity averaged 95.5 ± 30.8 MPa. The CVs for maximum stress, maximum strain, and modulus of elasticity were 34%, 30%, and 32%, respectively. Ten tendons failed in the midsubstance and 5 failed at the tendon-bone enthesis. No differences were noted in mechanical properties between grafts that failed in the midsubstance versus those that failed at the enthesis. Donor age did not correlate with allograft elongation during cyclic load or any of the material property measures during failure testing.

CONCLUSION

The variabilities in the material properties and graft elongation during cyclic loading of Achilles tendon allografts used in ACLR fall within the range of properties reported in the literature for other ACLR allografts. Material properties do not differ by donor age or graft failure location observed during failure testing.

CLINICAL RELEVANCE

Surgeons should be aware that there exists considerable variation in the mechanical properties of Achilles allograft tendons used for ACLR. This variability is difficult to detect by tissue bank screening or the treating surgeon's inspection and may contribute to the heterogeneity in outcomes of allograft ACLR.

Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction

PURPOSE

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients', roles are in the treatment decision.

METHODS

A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients' preferences.

RESULT

Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patient's wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patient's wishes as important for the decision to recommend ACL reconstruction.

CONCLUSION

Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction.

LEVEL OF EVIDENCE

Diagnostic study: Level III.

Orthobiologics in Pediatric Sports Medicine

Orthobiologics are biological substances that allow injured muscles, tendons, ligaments, and bone to heal more quickly. They are found naturally in the body; at higher concentrations they can aid in the healing process. These substances include autograft bone, allograft bone, demineralized bone matrix, bone morphogenic proteins, growth factors, stem cells, plasma-rich protein, and ceramic grafts. Their use in sports medicine has exploded in efforts to increase graft incorporation, stimulate healing, and get athletes back to sport with problems including anterior cruciate ligament ruptures, tendon ruptures, cartilage injuries, and fractures. This article reviews orthobiologics and their applications in pediatric sports medicine.

Criteria for Return to Sport after Anterior Cruciate Ligament reconstruction with lower reinjury risk (CR'STAL study): protocol for a prospective observational study in France

INTRODUCTION

The decision regarding when to return to sport after an anterior cruciate ligament reconstruction (ACLR) is an important one. Using a variety of subjective and objective parameters, various attempts have been made to determine an optimal timeline for a return to sport after ACLR, but none have been validated.The aim of the present study is therefore to determine which criteria or combination of criteria could allow to return to sport with the lowest possible risk of reinjury.

METHODS AND ANALYSIS

This study is a prospective cohort, single-centre study, with repeated assessments at 6, 9 and 12 months post-ACL surgical reconstruction and including a 3-year follow-up of patients' sporting activity and reinjuries. 275 patients will be included to test explanatory variables. Postural control analysis, knee laxity, questionnaires (International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia-11 (TSK-11), Anterior Cruciate Ligament-Return to Sport After Reinjury (ACL-RSI) and Single Assessment Numeric Evaluation (SANE)), modified Star Excursion Balance Test, running and sprinting biomechanics, Hop Tests and Isokinetic Tests will all be used. The primary outcome will be any reinjury during the follow-up period, defined as a graft rupture, a contralateral ACL rupture or any injury necessitating an interruption of training and requiring a medical consultation. Two groups will be constituted during the follow-up, separating reinjured from non-reinjured patients. In addition, classic analysis and data mining approaches will be used to build predictive models.

ETHICS AND DISSEMINATION

The results of this study will be disseminated through peer-reviewed publications and scientific presentations. Ethical approval was obtained through the ethics committee of the University Hospital of Saint-Etienne (reference number IRBN522015/CHUSTE).

Outcomes at a Minimum of 2 Years After Medial Collateral Ligament Reconstruction Using Partial-Thickness Quadriceps Tendon-Bone Autograft

This study reports outcomes at a minimum of 2 years after a technique using quadriceps tendon-bone autograft for medial collateral ligament reconstruction. This technique effectively restored medial stability in medial collateral ligament-deficient knees. It is particularly valuable when nonirradiated allograft is unavailable or harvesting medial knee restraints (semitendinosus) for medial collateral ligament reconstruction is to be avoided. [Orthopedics. 2017; 40(3):e557-e562.].

Factors Associated With Improved Function and Maintenance of Sports Activities at 5 to 10 Years After Autologous Hamstring ACL Reconstruction in Young Men

Background:

There are limited data regarding associated factors of return to sports activities at more than 5 years after anterior cruciate ligament (ACL) reconstruction.

Purpose:

To test interrelationships between patient characteristics, concomitant articular lesions, graft laxity, and maintenance of sports activities at 5 to 10 years after ACL reconstruction. It was hypothesized that at 5 to 10 years after the operation in young adult men, maintenance of greater activity level and better knee function would be associated with greater preinjury activity level, younger age at reconstruction, absence of concomitant articular lesions, and minimal graft laxity at follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

One hundred six men with autologous hamstring ACL reconstruction between the ages of 18 and 35 years were reviewed at 5 to 10 years after surgery. Excluded patients had contralateral ACL tear, revision reconstruction, or another injury impairing function. Fifty-five patients were eligible and available for follow-up. Independent variables included preinjury Tegner score, time interval from injury to surgery, smoking status, age, articular lesions, KT side-to-side difference, and pivot-shift grade. Main outcome measures were Tegner activity level, International Knee Documentation Committee (IKDC) subjective score, and Knee injury and Osteoarthritis Outcome Scale (KOOS) score at 5 to 10 years after surgery.

Results:

Greater Tegner activity level at follow-up was associated in a regression model with greater preinjury Tegner activity level (correlation coefficient, 0.423; P = .01), lower KT difference (correlation coefficient, –0.278; P = .04), and negative pivot shift (correlation coefficient, –0.277; P = .05). Younger age at operation predicted return to greater Tegner activity level in a univariate analysis (correlation coefficient, –0.266; P = .05) but not in a regression model (not significant). Chondral lesions at surgery predicted lower IKDC subjective scores (71.4 ± 14.3 vs 84.1 ± 11.5; P < .01) and KOOS scores but did not affect maintenance of sports activities.

Conclusion:

At 5 to 10 years after autologous hamstring ACL reconstruction in young men, predictors of greater sports activity level are primarily high preinjury activity level and reestablishment of knee laxity. Younger age at operation and moderate chondral lesions have lower impact in this respect.

Injury Prevention in Youth Sports

Children and adolescents are now participating in competitive sports at younger ages and with increasing intensity. As a result, increasing numbers of young athletes are presenting to pediatricians for care of sports-related injuries and advice about prevention. Understanding and identifying modifiable risk factors for injury in the young athletic population is a critical first step in injury prevention. Risk factors vary by sport, age, and sex. This article reviews the most common risk factors for injury and the evidence to support proposed strategies for prevention. [Pediatr Ann. 2017;46(3):e99-e105.].