101
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Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pécora JR, Gobbi RG, Camanho GL. Surgical Timing Does Not Interfere on Clinical Outcomes in Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament: A Comparative Study With Minimum 2-Year Follow-Up. Arthroscopy 2021; 37:1909-1917. [PMID: 33539981 DOI: 10.1016/j.arthro.2021.01.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases. METHODS Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated. RESULTS Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups. CONCLUSIONS Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic trial.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo; Hospital Sírio Libanês, São Paulo, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo; Hospital Sírio Libanês, São Paulo, Brazil.
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
| | - Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo
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102
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Russu OM, Pop TS, Ciorcila E, Gergely I, Zuh SG, Trâmbițaș C, Borodi PG, Incze-Bartha Z, Feier AM, Georgeanu VA. Arthroscopic Repair in Tibial Spine Avulsion Fractures Using Polyethylene Terephthalate Suture: Good to Excellent Results in Pediatric Patients. J Pers Med 2021; 11:434. [PMID: 34069562 PMCID: PMC8160716 DOI: 10.3390/jpm11050434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/15/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The objective of the arthroscopic treatment in tibial spine avulsion fractures (TSAF) is to achieve firm reduction and strong internal fixation while still having the patient undergo a minimally invasive procedure. MATERIAL AND METHODS The study was performed on 12 young patients with avulsion fracture of the anterior tibial spine. All 12 patients had type 3 Modified Meyers and McKeever fractures. The injury mechanism was direct anterior to posterior trauma in full leg length hyperextension with sport trauma reported in all cases. The physical examination revealed decreased range of motion, extension deficit, and pain during walking. Radiology, MRI, and CT pathologic findings described complete fracture of the anterior tibial spine with no clear signs of callus formation at the time of examination. All patients underwent arthroscopic suture surgical treatment. The Tegner, the Lysholm, and the International Knee Documentation Committee (IKDC) scores were used to evaluate subjective outcomes at three and six months after the surgery. Radiographs were used to assess callus formation and healing status of the fracture. RESULTS The mean IKDC score was 33.4 ± 23.3 (p = 0.032) preoperatively and 84.2 ± 14.3 at final follow-up (p = 0.0032, CI = 95%). The mean Tegner score improved from 3.8 ± 1.1 pre-operatively to 6.7 ± 2.2 at six months follow-up (p = 0.0231, CI = 95%). The Lysholm score differed significantly at baseline compared to final follow-up (53.7 ± 17.3 vs. 87.7 ± 9.9; p = 0.0066, CI = 95%). In all cases (n = 12), the radiographs taken after six months revealed the healing of the fracture in the anatomic position without secondary displacement. No functional knee instability was detected at the end of the study. CONCLUSIONS The study provides preliminary promising results regarding fracture healing, knee stability, and functional subjective scores. Patient selection was a major factor of success prediction for this technique.
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Affiliation(s)
- Octav Marius Russu
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Tudor Sorin Pop
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Emilian Ciorcila
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - István Gergely
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Sándor-György Zuh
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Cristian Trâmbițaș
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Department of Anatomy and Embryology, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania
| | - Paul Gabriel Borodi
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Zsuzsanna Incze-Bartha
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Department of Anatomy and Embryology, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania
| | - Andrei Marian Feier
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (I.G.); (S.-G.Z.); (C.T.); (Z.I.-B.); (A.M.F.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
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103
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Vermeijden HD, van der List JP, O'Brien RJ, DiFelice GS. Primary Repair of Anterior Cruciate Ligament Injuries: Current Level of Evidence of Available Techniques. JBJS Rev 2021; 9:01874474-202105000-00001. [PMID: 33956672 DOI: 10.2106/jbjs.rvw.20.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Recently, there has been a resurgence of interest in primary anterior cruciate ligament (ACL) repair that has the potential to preserve native tissue using a more minimally invasive approach. Multiple repair techniques for different tear types have been reported over the last decade. » From a healing perspective, proximal tears can be reapproximated directly to the femoral wall because they have better intrinsic healing capacity than midsubstance tears. These procedures can be classified further as direct suture repair with or without static or dynamic augmentation. Current evidence does not support direct repair of midsubstance tears because of their limited healing capacity. In many instances, biological augmentation is needed to enhance the healing potential of the ACL. » While ACL repair is certainly not an effective surgical approach for all tears or in all patients, this procedure can be an effective and less morbid alternative to ACL reconstruction in carefully selected patients. » The overall current reported level of evidence of published studies has ranged from low to moderate, and thus there is a need for higher-quality, comparative studies in which outcomes of larger patient groups are compared with the current gold standard of ACL reconstruction.
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Affiliation(s)
- Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert J O'Brien
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
| | - Gregory S DiFelice
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
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104
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van der List JP, Vermeijden HD, Sierevelt IN, Rademakers MV, Falke MLM, Helmerhorst GTT, Hoogeslag RAG, van der Wal WA, van Noort A, Kerkhoffs GMMJ. Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial. BMC Musculoskelet Disord 2021; 22:399. [PMID: 33931067 PMCID: PMC8088019 DOI: 10.1186/s12891-021-04280-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/20/2021] [Indexed: 01/11/2023] Open
Abstract
Background For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. Methods This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. Discussion Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. Trial registration Registered at Netherlands Trial Register (NL9072) on 25th of November 2020.
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.
| | - Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.,Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Mark L M Falke
- Department of Orthopaedic Surgery, Flevoziekenhuis, Almere, The Netherlands
| | | | - Roy A G Hoogeslag
- Department of Orthopaedic Surgery, Centre for Orthopaedic Surgery OCON, Hengelo, The Netherlands
| | - Wybren A van der Wal
- Department of Orthopaedic Surgery, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Arthur van Noort
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam UMC, University of Amsterdam, Academic Center for Evidence based Sports medicine (ACES), Amsterdam, The Netherlands.,Amsterdam UMC, Amsterdam Collaboration on Health & Safety in Sports (ACHSS), University of Amsterdam and Vrije Universiteit Amsterdam IOC Research Center, Amsterdam, The Netherlands
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105
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Fayard JM, Penet A, Bauwens PH, Thaunat M. Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Reconstruction With a Single-Strand Gracilis Graft. Arthrosc Tech 2021; 10:e2607-e2617. [PMID: 34868868 PMCID: PMC8626561 DOI: 10.1016/j.eats.2021.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023] Open
Abstract
There has been renewed interest in anterior cruciate ligament (ACL) repair procedures in the past decade. Even though ACL reconstruction is still considered the gold standard, ACL repair is an alternative in selected patients. However, the risk of failure owing to isolated ACL repair remains a concern. Intra-articular augmentation has been proposed to protect the repair during the healing period. In the same way, the protective effect of anterolateral ligament reconstruction on the ACL graft is increasingly recognized. We describe a combined ACL repair and anterolateral ligament reconstruction technique with a single-strand gracilis for the intra-articular portion and as an anterolateral graft to protect the ACL repair during the healing phase.
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Affiliation(s)
| | | | | | - Mathieu Thaunat
- Address correspondence to Mathieu Thaunat, M.D., Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Hôpital Privé Jean Mermoz, Groupe Ramsay GDS, 69008 Lyon, France.
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106
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Frank RM, Bradsell H, Thompson SR. What's New in Sports Medicine. J Bone Joint Surg Am 2021; 103:653-659. [PMID: 33849047 DOI: 10.2106/jbjs.21.00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Rachel M Frank
- Department of Orthopaedic Surgery (R.M.F.), University of Colorado School of Medicine (R.M.F. and H.B.) , Aurora , Colorado
| | - Hannah Bradsell
- Department of Orthopaedic Surgery (R.M.F.), University of Colorado School of Medicine (R.M.F. and H.B.) , Aurora , Colorado
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107
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Smith PA. Editorial Commentary: Repair the Anterior Cruciate Ligament When You Can: Add Suture Tape Augmentation and Dress for Success. Arthroscopy 2021; 37:1242-1244. [PMID: 33812527 DOI: 10.1016/j.arthro.2020.12.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 02/02/2023]
Abstract
Preserving the native anterior cruciate ligament (ACL) through primary repair has seen a resurgence over the past few years-rightfully so-given the inherent advantages of repairing the ACL over reconstruction. The issue is how best to repair the ACL and protect it to optimize healing. Suture tape augmentation techniques have shown promising low failure rates, and recent biomechanical studies have demonstrated benefits of the suture tape and optimal fixation methods for ACL repair. So, I believe it is time for orthopaedic surgeons to strongly consider routine suture tape augmentation use for improved outcomes with primary ACL repair.
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108
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Flannery SW, Kiapour AM, Edgar DJ, Murray MM, Fleming BC. Automated magnetic resonance image segmentation of the anterior cruciate ligament. J Orthop Res 2021; 39:831-840. [PMID: 33241856 PMCID: PMC8005419 DOI: 10.1002/jor.24926] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 02/04/2023]
Abstract
The objective of this study was to develop an automated segmentation method for the anterior cruciate ligament that is capable of facilitating quantitative assessments of the ligament in clinical and research settings. A modified U-Net fully convolutional network model was trained, validated, and tested on 246 Constructive Interference in Steady State magnetic resonance images of intact anterior cruciate ligaments. Overall model performance was assessed on the image set relative to an experienced (>5 years) "ground truth" segmenter in two domains: anatomical similarity and the accuracy of quantitative measurements (i.e., signal intensity and volume) obtained from the automated segmentation. To establish model reliability relative to manual segmentation, a subset of the imaging data was resegmented by the ground truth segmenter and two additional segmenters (A, 6 months and B, 2 years of experience), with their performance evaluated relative to the ground truth. The final model scored well on anatomical performance metrics (Dice coefficient = 0.84, precision = 0.82, and sensitivity = 0.85). The median signal intensities and volumes of the automated segmentations were not significantly different from ground truth (0.3% difference, p = .9; 2.3% difference, p = .08, respectively). When the model results were compared with the independent segmenters, the model predictions demonstrated greater median Dice coefficient (A = 0.73, p = .001; B = 0.77, p = NS) and sensitivity (A = 0.68, p = .001; B = 0.72, p = .003). The model performed equivalently well to retest segmentation by the ground truth segmenter on all measures. The quantitative measures extracted from the automated segmentation model did not differ from those of manual segmentation, enabling their use in quantitative magnetic resonance imaging pipelines to evaluate the anterior cruciate ligament.
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Affiliation(s)
- Sean W. Flannery
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA
| | - David J. Edgar
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA
| | - Braden C. Fleming
- Center for Biomedical Engineering, Brown University,
Providence, RI,Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI
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Hoogeslag RAG, Buitenhuis MB, Brouwer RW, Derks RPH, van Raak SM, Veld RHI'. Standard MRI May Not Predict Specific Acute Anterior Cruciate Ligament Rupture Characteristics. Orthop J Sports Med 2021; 9:2325967121992472. [PMID: 33855093 PMCID: PMC8010830 DOI: 10.1177/2325967121992472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background There has been renewed interest in the concept of anterior cruciate ligament (ACL) suture repair (ACLSR). Morphologic characteristics of the ruptured ACL remnant play a role in deciding whether a patient is eligible for ACLSR. However, no classification of these characteristics of ACL rupture on magnetic resonance imaging (MRI) scans has yet been compared with intraoperative findings in the context of ACLSR. Purpose To investigate the value of using preoperative MRI to predict specific characteristics of acute complete ACL rupture. Study Design Cohort study (diagnostic); Level of evidence, 2. Methods A total of 25 patients were included. Two radiologists classified ACL rupture location and pattern on preoperative 1.5-T MRI scans with a standard sequence; the results were compared with the corresponding findings at arthroscopy conducted by a single surgeon. The agreement between the MRI and surgical findings was calculated using Cohen κ values. Furthermore, the reliability coefficients of the MRI classifications within and between radiologists were calculated. Results The agreement between MRI classification and arthroscopic findings for ACL rupture location was slight (Cohen κ, 0.016 [radiologist 1] and 0.087 [radiologist 2]), and for ACL rupture pattern, this was poor to slight (Cohen κ, <0 and 0.074). The intraobserver reliability of MRI classification for ACL rupture location was moderate for radiologist 1 and slight for radiologist 2 (Cohen κ, 0.526 and 0.061, respectively), and for ACL rupture pattern, this was slight for radiologist 1 and 2 (Cohen κ, 0.051 and 0.093, respectively). The interobserver reliability of MRI classification for ACL rupture location and pattern was slight between radiologists (Cohen κ, 0.172 and 0.040, respectively). Conclusion In the current study, we found poor to slight agreement between MRI classification and arthroscopic findings of specific ACL rupture characteristics. In addition, the intra- and interobserver reliability for MRI classification of the ACL rupture characteristics was slight to moderate.
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Affiliation(s)
| | | | - Reinoud W Brouwer
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Rosalie P H Derks
- Department of Musculoskeletal Radiology ZGT, Hengelo, the Netherlands
| | - Sjoerd M van Raak
- Department of Musculoskeletal Radiology ZGT, Hengelo, the Netherlands
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Karamchedu NP, Murray MM, Sieker JT, Proffen BL, Portilla G, Costa MQ, Molino J, Fleming BC. Bridge-Enhanced Anterior Cruciate Ligament Repair Leads to Greater Limb Asymmetry and Less Cartilage Damage Than Untreated ACL Transection or ACL Reconstruction in the Porcine Model. Am J Sports Med 2021; 49:667-674. [PMID: 33534613 PMCID: PMC8099149 DOI: 10.1177/0363546521989265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The extent of posttraumatic osteoarthritis (PTOA) in the porcine anterior cruciate ligament (ACL) transection model is dependent on the surgical treatment selected. In a previous study, animals treated with bridge-enhanced ACL repair using a tissue-engineered implant developed less PTOA than those treated with ACL reconstruction (ACLR). Alterations in gait, including asymmetric weightbearing and shorter stance times, have been noted in clinical studies of subjects with osteoarthritis. HYPOTHESIS Animals receiving a surgical treatment that results in less PTOA (ie, bridge-enhanced ACL repair) would exhibit fewer longitudinal postoperative gait asymmetries over a 1-year period when compared with treatments that result in greater PTOA (ie, ACLR and ACL transection). STUDY DESIGN Controlled laboratory study. METHODS Thirty-six Yucatan minipigs underwent ACL transection and were randomized to receive (1) no further treatment, (2) ACLR, or (3) bridge-enhanced ACL repair. Gait analyses were performed preoperatively, and at 4, 12, 26, and 52 weeks postoperatively. Macroscopic cartilage assessments were performed at 52 weeks. RESULTS Knees treated with bridge-enhanced ACL repair had less macroscopic damage in the medial tibial plateau than those treated with ACLR or ACL transection (adjusted P = .03 for both comparisons). The knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading at 52 weeks than the knees treated with ACL transection (adjusted P < .05 for both comparisons). Although not significant, there was a trend that knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading (adjusted P < .10 for both comparisons) compared with ACLR. CONCLUSION Contrary to our hypothesis, the surgical treatment resulting in less macroscopic cartilage damage (ie, bridge-enhanced ACL repair) exhibited greater asymmetry in load-related gait parameters than the other surgical groups. This finding suggests that increased offloading of the surgical knee may be associated with a slower rate of PTOA development. CLINICAL RELEVANCE Less cartilage damage at 52 weeks was found in the surgical group that continued to protect the limb from full body weight during gait. This finding suggests that protection of the knee from maximum stresses may be important in minimizing the development of PTOA in the ACL-injured knee within 1 year.
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Affiliation(s)
- Naga Padmini Karamchedu
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jakob T. Sieker
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Benedikt L. Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriela Portilla
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Meggin Q. Costa
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Janine Molino
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
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ACL Repair: A Game Changer or Will History Repeat Itself? A Critical Appraisal. J Clin Med 2021; 10:jcm10050912. [PMID: 33652689 PMCID: PMC7956607 DOI: 10.3390/jcm10050912] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 01/13/2023] Open
Abstract
Until the past decade the common thought was that the anterior cruciate ligament (ACL) was not able to heal and restore knee stability. In this manuscript a brief review of studies of the developers and the early adaptors of four different modern ACL repair techniques are presented. The present status and considerations for the future of ACL repair and its research are shared. After promising short- to midterm ACL healing results by the developers, the results of the early adaptors show more variety in terms of rerupture and reintervention for other reasons. Risk factors for failure are a young age, high preinjury sports activity level, midsubstance ruptures and impaired integrity of the ACL bundles and the synovial sheath. There is a call for more clinical data and randomized clinical trials. Conclusion: an important finding of the past decade is that the ACL is able to heal and subsequently restabilize the knee. Patient selection is emphasized: the ideal patient is a non-high athlete older than 25 and has an acute proximal one bundle ACL rupture. Further research will have to show if ACL repair could be a game changer or if history will repeat itself.
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112
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Scull G, Fisher MB, Brown AC. Fibrin-Based Biomaterial Systems to Enhance Anterior Cruciate Ligament Healing. MEDICAL DEVICES & SENSORS 2021; 4:e10147. [PMID: 34458685 PMCID: PMC8386506 DOI: 10.1002/mds3.10147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Anterior cruciate ligament (ACL) tears are a common and potentially career-ending injury, particularly for athletes and soldiers. Partial and complete ruptures of this ligament cause instability in the knee, and the ACL does not have the capacity for healing due, in part, to its position within the highly thrombolytic synovial fluid environment of the knee joint. Traditional methods of ACL reconstruction, such as graft replacement with attached bone anchors for bone integration, restore stability, but do not prevent the development of post-traumatic osteoarthritis. To enhance therapeutic treatment options, novel fibrin-based technologies and repair techniques have been recently explored and show promise for improved patient outcomes. Through modification of existing surgical methods, such as the use of fibrin glues incorporating growth factors and cells and the implementation of scaffolds containing platelet-rich plasma, platelet-rich fibrin, and other blood derivatives, surgeons are attempting to overcome the shortcomings of traditional treatments. This mini-review will detail current efforts using fibrin-based treatments and discuss opportunities to further enhance ACL healing.
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Affiliation(s)
- Grant Scull
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC 27695
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695
| | - Matthew B. Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC 27695
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695
| | - Ashley C. Brown
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC 27695
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC 27695
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113
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Shiroud Heidari B, Ruan R, De-Juan-Pardo EM, Zheng M, Doyle B. Biofabrication and Signaling Strategies for Tendon/Ligament Interfacial Tissue Engineering. ACS Biomater Sci Eng 2021; 7:383-399. [PMID: 33492125 DOI: 10.1021/acsbiomaterials.0c00731] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tendons and ligaments (TL) have poor healing capability, and for serious injuries like tears or ruptures, surgical intervention employing autografts or allografts is usually required. Current tissue replacements are nonideal and can lead to future problems such as high retear rates, poor tissue integration, or heterotopic ossification. Alternatively, tissue engineering strategies are being pursued using biodegradable scaffolds. As tendons connect muscle and bone and ligaments attach bones, the interface of TL with other tissues represent complex structures, and this intricacy must be considered in tissue engineered approaches. In this paper, we review recent biofabrication and signaling strategies for biodegradable polymeric scaffolds for TL interfacial tissue engineering. First, we discuss biodegradable polymeric scaffolds based on the fabrication techniques as well as the target tissue application. Next, we consider the effect of signaling factors, including cell culture, growth factors, and biophysical stimulation. Then, we discuss human clinical studies on TL tissue healing using commercial synthetic scaffolds that have occurred over the past decade. Finally, we highlight the challenges and future directions for biodegradable scaffolds in the field of TL and interface tissue engineering.
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Affiliation(s)
- Behzad Shiroud Heidari
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Rui Ruan
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia 6009, Australia
| | - Elena M De-Juan-Pardo
- School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,Science and Engineering Faculty, Queensland University of Technology, Brisbane, Queensland, 4000, Australia
| | - Minghao Zheng
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia 6009, Australia.,Perron Institute for Neurological and Translational Science, Nedlands, Western Australia 6009, Australia
| | - Barry Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia.,BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh EH9 3FD, United Kingdom
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114
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Anterior cruciate ligament tear patterns in young patients: An arthroscopic multicenter study. J Clin Orthop Trauma 2021; 16:168-175. [PMID: 33717953 PMCID: PMC7920093 DOI: 10.1016/j.jcot.2020.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In the last decade, there has been a renewed interest in anterior cruciate ligament (ACL) preservation surgeries in the younger patients. Several ACL preservation techniques such as primary repair, augmented repair, and scaffold repair have been described based on the particular tear type and pattern. The purpose of this study was to determine the distribution of tear patterns in young patients presenting with an acute ACL injury. METHODS A prospective observational study was performed at two tertiary children's hospitals. Patients under 18 years undergoing ACL reconstruction within 8 weeks of initial injury were included from 2017 to 2019. Tear patterns were classified by two orthopedic surgeons from each of the two centers during arthroscopic ACL reconstruction into 4 types: I. Avulsion off the femur, II. <10% of total ACL length tear from femoral end, III. Mid-substance tear and IV. Single bundle tear. For reliability, the four surgeons classified ACL injury (2 rounds each) based on de-identified intraoperative videos of 33 randomly selected surgical ACL cases. Inter and intra-rater reliability studies were calculated using Kappa statistics. RESULTS 224 patients (123 males, 101 females) with mean age of 16 (range: 9-18) years were enrolled in this study. Fifty-seven (25%) patients reported contact injury while 167 (75%) reported non-contact. Isolated ACL injury was recorded in 70 (31%) patients, while concomitant injuries were recorded in 154 patients (69%). The most common associated injury was lateral meniscus tear (35%), followed by lateral and medial meniscus tears (20%). According to our classification, 31 (14%) patients were Type I, 30 (13%) were Type II, 139 (62%) were Type III, 18 (8%) were Type IV. The intra-rater reliability was excellent for 2 reviewers, good for 1 and marginal for another. The overall inter-rater reliability for all 4 reviewers was marginal for both readings. There was no statistical difference in the occurrence of type of tear based on the mechanism of injury (contact vs non-contact) or age of the patients. CONCLUSIONS This is the first multicenter study using an arthroscopic assessment to classify the location of ACL tear in the young population. It gives us further insight on the possible application for surgeries to preserve the ACL in this group. Larger studies incorporating these findings with MRI evaluation and ACL repair techniques are needed to confirm the utility of this information to decide the eligibility for repair in pediatric patients.
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115
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Knotless Primary Anterior Cruciate Ligament Repair with Adjustable Loop Device and Internal Brace Augmentation. Arthrosc Tech 2020; 9:e1967-e1975. [PMID: 33381407 PMCID: PMC7768549 DOI: 10.1016/j.eats.2020.08.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/28/2020] [Indexed: 02/03/2023] Open
Abstract
With the recent resurgence of primary anterior cruciate ligament repair, it is important to strive for optimal patient outcomes. This knotless primary repair procedure takes advantage of the use of an adjustable loop device, which allows for intraoperative retensioning by the surgeon. This technical advancement combined with augmentation with an internal brace could potentially minimize gap formation at the repair site, thereby increasing repair stability and ultimate outcome.
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116
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Hughes JD, Lawton CD, Nawabi DH, Pearle AD, Musahl V. Anterior Cruciate Ligament Repair: The Current Status. J Bone Joint Surg Am 2020; 102:1900-1915. [PMID: 32932291 DOI: 10.2106/jbjs.20.00509] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jonathan D Hughes
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cort D Lawton
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Andrew D Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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117
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Locke RC, Ford EM, Silbernagel KG, Kloxin AM, Killian ML. Success Criteria and Preclinical Testing of Multifunctional Hydrogels for Tendon Regeneration. Tissue Eng Part C Methods 2020; 26:506-518. [PMID: 32988293 PMCID: PMC7869878 DOI: 10.1089/ten.tec.2020.0199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/20/2020] [Indexed: 12/16/2022] Open
Abstract
Tendon injuries are difficult to heal, in part, because intrinsic tendon healing, which is dominated by scar tissue formation, does not effectively regenerate the native structure and function of healthy tendon. Further, many current treatment strategies also fall short of producing regenerated tendon with the native properties of healthy tendon. There is increasing interest in the use of cell-instructive strategies to limit the intrinsic fibrotic response following injury and improve the regenerative capacity of tendon in vivo. We have established multifunctional, cell-instructive hydrogels for treating injured tendon that afford tunable control over the biomechanical, biochemical, and structural properties of the cell microenvironment. Specifically, we incorporated integrin-binding domains (RGDS) and assembled multifunctional collagen mimetic peptides that enable cell adhesion and elongation of stem cells within synthetic hydrogels of designed biomechanical properties and evaluated these materials using targeted success criteria developed for testing in mechanically demanding environments such as tendon healing. The in vitro and in situ success criteria were determined based on systematic reviews of the most commonly reported outcome measures of hydrogels for tendon repair and established standards for testing of biomaterials. We then showed, using validation experiments, that multifunctional and synthetic hydrogels meet these criteria. Specifically, these hydrogels have mechanical properties comparable to developing tendon; are noncytotoxic both in two-dimensional bolus exposure (hydrogel components) and three-dimensional encapsulation (full hydrogel); are formed, retained, and visualized within tendon defects over time (2-weeks); and provide mechanical support to tendon defects at the time of in situ gel crosslinking. Ultimately, the in vitro and in situ success criteria evaluated in this study were designed for preclinical research to rigorously test the potential to achieve successful tendon repair before in vivo testing and indicate the promise of multifunctional and synthetic hydrogels for continued translation. Impact statement Tendon healing results in a weak scar that forms due to poor cell-mediated repair of the injured tissue. Treatments that tailor the instructions experienced by cells during healing afford opportunities to regenerate the healthy tendon. Engineered cell-instructive cues, including the biomechanical, biochemical, and structural properties of the cell microenvironment, within multifunctional synthetic hydrogels are promising therapeutic strategies for tissue regeneration. In this article, the preclinical efficacy of multifunctional synthetic hydrogels for tendon repair is tested against rigorous in vitro and in situ success criteria. This study indicates the promise for continued preclinical translation of synthetic hydrogels for tissue regeneration.
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Affiliation(s)
- Ryan C. Locke
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | - Eden M. Ford
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, Delaware, USA
| | | | - April M. Kloxin
- Department of Chemical and Biomolecular Engineering, University of Delaware, Newark, Delaware, USA
- Department of Materials Science and Engineering, University of Delaware, Newark, Delaware, USA
| | - Megan L. Killian
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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118
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Freiberger C, Kiapour AM, Liu S, Henderson RN, Barnett S, Sant NJ, Proffen BL, Fleming BC, Ecklund K, Kramer DE, Micheli LJ, Murray MM, Yen YM. Higher Physiologic Platelet Counts in Whole Blood Are Not Associated With Improved ACL Cross-sectional Area or Signal Intensity 6 Months After Bridge-Enhanced ACL Repair. Orthop J Sports Med 2020; 8:2325967120927655. [PMID: 32656289 PMCID: PMC7331772 DOI: 10.1177/2325967120927655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: A bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR) procedure places an extracellular matrix implant, combined with autologous whole blood, in the gap between the torn ends of the ligament at the time of suture repair to stimulate healing. Prior studies have suggested that white blood cell (WBC) and platelet concentrations significantly affect the healing of other musculoskeletal tissues. Purpose/Hypothesis: The purpose of this study was to determine whether concentrations of various blood cell types placed into a bridging extracellular matrix implant at the time of ACL repair would have a significant effect on the healing ligament cross-sectional area or tissue organization (as measured by signal intensity). We hypothesized that patients with higher physiologic platelet and lower WBC counts would have improved healing of the ACL on magnetic resonance imaging (MRI) (higher cross-sectional area and/or lower signal intensity) 6 months after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 61 patients underwent MRI at 6 months after bridge-enhanced ACL repair as part of the BEAR II trial. The normalized signal intensity and average cross-sectional area of the healing ligament were measured from a magnetic resonance stack obtained using a gradient echo sequence. The results were stratified by sex, and univariate and multivariate regression analyses determined significant correlations between blood cell concentrations on these 2 magnetic resonance parameters. Results: In unadjusted analyses, older age and male sex were associated with greater healing ligament cross-sectional area (P < .04) but not signal intensity (P > .15). Adjusted multivariable analyses indicated that in female patients, a higher monocyte concentration correlated with a higher ACL cross-sectional area (β = 1.01; P = .049). All other factors measured, including the physiologic concentration of platelets, neutrophils, lymphocytes, basophils, and immunoglobulin against bovine gelatin, were not significantly associated with either magnetic resonance parameter in either sex (P > .05 for all). Conclusion: Although older age, male sex, and monocyte concentration in female patients were associated with greater healing ligament cross-sectional area, signal intensity of the healing ligament was independent of these factors. Physiologic platelet concentration did not have any significant effect on cross-sectional area or signal intensity of the healing ACL at 6 months after bridge-enhanced ACL repair in this cohort. Given these findings, factors other than the physiologic platelet concentration and total WBC concentration may be more important in the rate and amount of ACL healing after bridge-enhanced ACL repair.
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Affiliation(s)
- Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata M Kiapour
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shanshan Liu
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas J Sant
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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119
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Barnett S, Badger GJ, Kiapour A, Yen YM, Henderson R, Freiberger C, Proffen B, Sant N, Trainor B, Fleming BC, Micheli LJ, Murray MM, Kramer DE. Females Have Earlier Muscle Strength and Functional Recovery After Bridge-Enhanced Anterior Cruciate Ligament Repair. Tissue Eng Part A 2020; 26:702-711. [PMID: 32589515 DOI: 10.1089/ten.tea.2020.0057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: While a sex effect on outcomes following anterior cruciate ligament (ACL) reconstruction surgery has been previously documented, less is known following bridge-enhanced ACL repair (BEAR). We hypothesized that female sex would have significantly worse early functional outcomes and higher retear rates following primary repair of the ACL enhanced with a tissue-engineered scaffold. Methods: Sixty-five patients (28 males and 37 females), age 14-35 with a complete ACL tear underwent primary repair of the ACL enhanced with a tissue-engineered scaffold (bridge-enhanced ACL repair) within 45 days of injury. International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome (KOOS) scores, as well as instrumented anteroposterior (AP) laxity through KT-1000 testing and functional outcome measures were obtained at time points up to 2 years postoperatively and compared between males and females using mixed model repeated measures analyses and chi square tests. Results: There was no significant sex difference on the postoperative IKDC Subjective Score at 3, 6, 12, or 24 months or any of the five KOOS scores at 12 and 24 months. Instrumented AP laxity testing demonstrated mean (standard deviation) side-to-side differences that were similar in the two sexes at 2 years; 1.7 (2.7) mm and 1.5 (3.7) mm in females and males, respectively, p = 0.72. At 6 months postoperatively, males had a larger deficit in hamstring strength on the operated leg (14.0% vs. 1.7%; p = 0.03) and a larger deficit in quadriceps strength on the operated leg (11.3% vs. 2.0%; p = 0.004); however, no sex difference was noted at 12 or 24 months. Females demonstrated superior single leg hop testing at 6 and 12 months ([91.3% vs. 78.1%, p = 0.001], [96.9% vs. 87.0%, p = 0.01] respectively). There were no significant sex differences on ipsilateral (males; 14.3% vs. females; 13.9%, p = 1.00) or contralateral (males; 3.6% vs. females; 2.8%, p = 1.00) ACL reinjury rates. Conclusions: Female subjects had better hamstring and quadriceps strength indices at 6 months than males as well as better hop test results at the 6 and 12-month time period. Despite this, there was no significant sex difference on patient-reported outcomes and objective AP laxity testing at time points up to 2 years postoperatively. Impact statement This is the first study comparing sex specific outcomes following the bridge-enhanced ACL repair technique (BEAR). The results of this study suggest that females have earlier recovery of both muscle strength and functional outcomes compared to their male counterparts. This is an important finding when considering future modifications to postoperative care and rehabilitation in females and males following this tissue-engineered BEAR technique.
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Affiliation(s)
- Samuel Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Ata Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Sant
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bethany Trainor
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopedics, Bioengineering Labs, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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