Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country

BACKGROUND

The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia.

METHODS

A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 - three times the Indonesian GDP per capita in 2021 - the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE).

RESULTS

The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%.

CONCLUSIONS

Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

Timing of Anterior Cruciate Ligament Surgery

This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.

Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis

BACKGROUND

The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury.

PURPOSE

To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies.

RESULTS

Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after.

CONCLUSION

ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.

The optimal window for reconstruction of the anterior cruciate ligament (ACL) with respect to quadriceps atrophies lies within 21 to 100 days

PURPOSE

The study's objective was to determine the optimal window for anterior cruciate ligament (ACL) reconstruction with respect to quadriceps atrophies and clinical outcome.

METHODS

For this retrospective, comparative study, 115 patients aged under 35 were included, who received an ACL reconstruction between 2011 and 2016. They were divided into four groups, depending on the time to surgery, to determine the optimal window for reconstruction: (group 1: ≤21 d, group 2: <21d-56d≥, group 3: >56d-100d≥, group 4: >100d). Follow-up was performed one month postoperatively, after a mean of 4.9 (±5.3) months, and after a mean of 3.5 (±1.4) years. Primary endpoints included quadriceps muscle status, range of motion (ROM), pain, swelling, the International Knee Documentation Committee Subjective Knee Form (IKDC), the Lysholm-Score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner-Activity-Scale (TAS).

RESULTS

Significantly more quadriceps atrophies were observed in group 1 and group 4, representing reconstructions earlier than 21 and later than 100 days (29% and 41% vs. 9%; p = 0.032). The measurements of knee extension (p = 0.082) and ROM (p = 0.123) were comparable in all groups. Group 1 showed the least pain (0% vs. 15%; p = 0.285) and swelling (0% vs. 23%; p = 0.077) compared to all other groups one month postoperatively. A comparison of postoperative clinical scores revealed no significant differences, with group 1 exhibiting the lowest TAS levels.

CONCLUSION

In patients who underwent ACL reconstruction within three weeks or after more than 100 days, a significantly higher incidence of quadriceps atrophy was observed, possibly attributable to the initial inflammatory phase or the delayed reconstruction affecting quadriceps function. However, this impairment may not be observable in elite athletes who undergo reconstruction within hours of the injury.

Efficacy and safety of early versus delayed reconstruction for anterior cruciate ligament injuries: A systematic review and meta-analysis

OBJECTIVE

To critically evaluate the efficacy and safety of early versus delayed anterior cruciate ligament reconstruction (ACLR) for anterior cruciate ligament (ACL) injuries based on the different cut-off values of the timing of operation.

METHODS

PubMed, Medline, Embase, Cochrane library, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang Digital Periodical database were searched from inception to November 2022 without language restrictions. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing early ACLR with delayed ACLR for ACL injuries were included.

RESULTS

Twenty-four studies (10 RCTs and 14 CSs) were included. According to the information from included studies, 3 weeks, 4 weeks, 6 weeks, 6 months, and 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR. When 4 weeks were considered as the cut-off value, early ACLR could significantly improve Lysholm score, IKDC score and VAS score at 6 and 12 months postoperatively and decrease the incidence of adverse events compared with delayed ACLR (P < 0.05). However, no statistically significant difference in positive rate of Lachman test and incidence of meniscus injuries and chondral lesions between the two groups when 3 weeks, 6 weeks, 6 months or 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR (P > 0.05).

CONCLUSION

The present study suggests that early ACLR, especially conducted within 3-4 weeks after ACL injuries, may be more effective for improving knee function and relieving pain compared with delayed ACLR. More high-quality RCTs are warranted.

Early ACL reconstruction shows an improved recovery of isokinetic thigh muscle strength compared to delayed or chronic cases

INTRODUCTION

The recovery of periarticular strength is a major criterion in return-to-play testing. The rationale of the study was to assess the impact of the delay of surgery (∆ between injury and surgery) on knee extensor and knee flexor strength of anterior cruciate ligament (ACL)-deficient patients six months after reconstruction.

MATERIALS AND METHODS

In a retrospective cohort study, all patients with ACL ruptures between 03/2015 and 12/2019 were analyzed. Inclusion criteria were isolated ACL rupture without any associated lesions undergoing a reconstruction using ipsilateral hamstring tendon autograft and adherence to isokinetic strength testing before and at 5-7 months postoperatively. These patients were then clustered into three groups: EARLY reconstruction (∆ < 42 days), DELAYED reconstruction (∆42-180d), and CHRONIC (∆ > 180d). Knee extensor and flexor strength of the ipsi- and contralateral leg were analyzed by concentric isokinetic measurement (60°/s). Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q) ratio), and the corresponding limb symmetry indices.

RESULTS

n = 444 patients met the inclusion criteria. From EARLY to DELAYED to CHRONIC, a progressive reduction in postoperative strength performance was observed in knee extension (1.65 ± 0.45 to 1.62 ± 0.52 to 1.51 ± 0.5 Nm/kg resp.) and flexion (1.22 ± 0.29 to 1.18 ± 0.3 to 1.13 ± 0.31 Nm/kg resp.) strength on the ACL reconstructed leg. This general loss in periarticular strength was already apparent in the preoperative performance even on the healthy side. When controlling for the preoperative performance using ANCOVA analysis, EARLY performed significantly better than DELAYED (extension p = 0.001, flexion p = .02) and CHRONIC (extension p = 0.005, flexion p < 0.001). Also, there were significantly higher values for H/Q ratio in the injured leg across all groups where the H/Q ratio increased from EARLY to CHRONIC and from pre- to postoperative values.

CONCLUSIONS

With respect to the force generating capacity when returning-to-play, it is advantageous to seek for an early ACL reconstruction within the first 12 weeks after the injury. The increasing loss of thigh muscle strength observed in delayed or chronic cases affects the injured and also the non-injured leg.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients

Background

The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown.

Purpose/Hypothesis

The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity.

Study Design

Cohort study; Level of evidence, 3.

Methods

From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test.

Results

Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months.

Conclusion

At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Synovial Fluid Inflammatory Profiles did not Differ between Isolated Anterior Cruciate Ligament and Multi-ligament Knee Injuries

Objective and design

The purpose of this study was to compare synovial concentrations of pro- and anti-inflammatory cytokines between multiple-ligament knee injured (MLKI) and anterior cruciate ligament (ACL)-injured patients.

Subjects

14 patients with MLKI and 10 patients with isolated ACL injury.

Methods

Synovial fluid was aspirated from the operative knee at the time of surgery and the concentrations of pro- and anti-inflammatory markers in the synovial fluid were determined. Structures injured, the time between injury and surgery, and demographic factors were collected. Linear regressions were used to determine the association between injury pattern and synovial inflammatory markers when controlling for age, BMI, and time between injury and surgery.

Results

When adjusting for group differences in age, BMI and the time between injury and surgery, no group differences were detected (interferon gamma (p = 0.11), interleukin-1beta (IL-1b, p = 0.35), IL-2 (p = 0.28), IL-4 (p = 0.64), IL-6 (p = 0.37), IL-8 (p = 0.54), IL-10 (p = 0.25), IL-12p70 (p = 0.81), IL-13 (p = 0.31), and tumor necrosis factor-alpha (p = 0.90)).

Conclusion

Synovial fluid inflammatory markers did not differ between MLKI and isolated ACL injuries. MLKIs have a greater prevalence of postoperative arthrofibrosis when compared to isolated ACL injuries; however, this may be due in part to factors other than the inflammatory status of the joint.

Poorer functional Outcomes in Patients with Multi-Ligamentous Knee Injury with Concomitant Patellar Tendon Ruptures at 5 years Follow-Up

PURPOSE

Multi-ligamentous knee injuries (MLKIs) are high-energy injuries that may infrequently present with concomitant patellar tendon rupture. There is limited information in the literature regarding these rare presentations, with even less information regarding clinical outcomes. Using propensity-score matching, the purpose of this study was to compare the outcomes of MLKIs with and without patellar tendon ruptures and to investigate the overall predictors of these outcomes.

METHODS

Twelve patients who underwent surgical repair for combined MLKI and patellar tendon rupture from 2011 to 2020 with minimum 1-year follow-up data were identified from two separate institutions. Patients were propensity-score matched with a 1:1 ratio with controls based on age, body mass index (BMI), gender, and time from surgery. Patient-reported outcomes included International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm and Tegner scores.

RESULTS

Twelve MLKIs with concomitant patellar tendon injuries were identified out of a multicenter cohort of 237 (5%) patients sustaining MLKI and were case matched 1:1 with 12 MLKIs without extensor mechanism injuries. The average follow-up was 5.5 ± 2.6 years. There were no differences in Schenck Classification injury patterns. There were significant differences found across IKDC (Patellar Tendon mean: 53.1 ± 24.3, MLKI mean 79.3 ± 19.6, P < 0.001) and Lysholm scores (Patellar Tendon mean: 63.6 ± 22.3, MLKI mean 86.3 ± 10.7, P < 0.001) between the two, illustrating poorer outcomes for patients with concomitant patellar tendon ruptures.

CONCLUSION

In the setting of MLKI, patients who have a concomitant patellar tendon rupture have worse functional outcomes compared to those without. This information will be important for patient counseling and might be considered to be added to Schenck classification, reflecting its prognostic value.

LEVEL OF EVIDENCE

Level IV.

"Cost-effectiveness of ACL treatment is dependent on age and activity level: a systematic review"

PURPOSE

To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two.

METHODS

All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list.

RESULTS

Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective.

CONCLUSION

Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels.

LEVEL OF EVIDENCE

Systematic review of level III studies.

Anticoagulant Usage After Anterior Cruciate Ligament Reconstruction Is Associated With Increased Rate of Manipulation Under Anesthesia

BACKGROUND

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR.

METHODS

The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA.

RESULTS

We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001).

DISCUSSION

In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

Optimal Timing of Anterior Cruciate Ligament Reconstruction in Patients With Anterior Cruciate Ligament Tear: A Systematic Review and Meta-analysis

IMPORTANCE

The timing of surgery has been regarded as a key factor in anterior cruciate ligament reconstruction (ACLR), and early vs delayed ACLR remains a controversial topic.

OBJECTIVE

To synthesize up-to-date published data from randomized clinical trials (RCTs) comparing early vs elective delayed ACLR for patients with ACL deficiency, in terms of clinical outcomes and complications.

DATA SOURCES

The PubMed, Cochrane Library, and Web of Science databases were systematically searched until September 9, 2022.

STUDY SELECTION

All published RCTs comparing clinical and functional outcomes and complications associated with early ACLR vs elective delayed ACLR.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted relevant data and assessed the methodological quality following the PRISMA guidelines.

MAIN OUTCOMES AND MEASURES

Due to the clinical heterogeneity, the random-effects model was preferred. The primary outcomes were functional outcomes and complications. The Mantel-Haenszel test was used to evaluate dichotomous variables and the inverse variance method was used to assess continuous variables.

RESULTS

This meta-analysis included 972 participants in 11 RCTs stratified by follow-up duration. The following factors did not differ between early and delayed ACLR: operative time (mean difference, 4.97; 95% CI, -0.68 to 10.61; P = .08), retear (OR, 1.52; 95% CI, 0.52-4.43; P = .44), and infection (OR, 3.80; 95% CI, 0.77-18.79; P = .10). There were also no differences between groups in range of motion, knee laxity, International Knee Documentation Committee (IKDC rating scale), and Tegner score. IKDC score (mean difference, 2.77; 95% CI, 1.89-3.66; P < .001), and Lysholm score at 2-year follow-up (mean difference, 2.61; 95% CI, 0.74-4.48; P = .006) significantly differed between early and delayed ACLR. In addition, the timing of surgery was redefined in the included RCTs and subgroup analyses were performed, which validated the robustness of the principal results.

CONCLUSION AND RELEVANCE

This systematic review and meta-analysis found that early ACLR was not superior to delayed ACLR in terms of most factors analyzed, except for IKDC and Lysholm scores. This information should be available to patients with ACL deficiency and clinicians as part of the shared decision-making process of treatment selection.

Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis

BACKGROUND

To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed.

OBJECTIVE

The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR).

METHODS

Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3-6 months, 7-12 months, > 1-2 years, > 2-5 years, > 5 years).

RESULTS

Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2-25.3]; KSES: 5.0 [4.4-5.5]) compared with 3-6 months following ACLR (TSK-11: 19.6 [18.7-20.6]; KSES: 19.6 [18.6-20.6]). Meta-analysis suggests similar kinesiophobia > 3-6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only.

CONCLUSIONS

Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3-6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.

The Functional Outcomes of Delayed Surgical Reconstruction in Nonsport-Induced Multiligament Knee Injuries: A Retrospective Cohort Study

Multiligament knee injuries (MLKIs) are among the most detrimental injuries, which can cause significant compromise of joint stability and function. Our aim was to investigate the functional outcomes of nonsport-induced MLKIs who presented late after injury and underwent delayed arthroscopic reconstruction. In a retrospective cohort of 18 MLKI patients (19 knees, January 2012-2018) who had undergone arthroscopic reconstruction, we assessed the knee range of motion, return to work/sport, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner scores. The preoperative scores were retrieved from the patients' registry database. We reviewed their surgical notes and extracted the operation data, including the damaged ligaments, stages of the surgery, and associated meniscal injury. There were 14 males and 4 females with a mean age of 30.57 ± 10.31 years. The mean time from injury to surgery was 17.31 ± 11.98 months. The most common injury was anterior cruciate ligament/posterior cruciate ligament (31.6%). The mechanisms of injury were motor vehicle accidents (72.2%), falls (22.2%), and sports (5.6%). The reconstruction was either single (61.2%) or multiple stage (38.8%). The pre- and postoperative scores were 45.31 ± 7.30 versus 79.16 ± 11.86 IKDC, 3.84 ± 1.26 versus 8.37 ± 1.16 Tegner, and 60.42 ± 7.68 versus 89.42 ± 8.81 Lysholm, respectively. All the scores showed significant improvement at mean follow-up of 24.05 ± 9.55 months (p < 0.001). In conclusion, delayed arthroscopic reconstruction of MLKIs significantly improved the functional outcomes and return to work in patients presenting late to the orthopaedic clinic. There was no relationship between the demographic variables, mechanism of injury, number of injured ligaments, and the stages of surgery and the functional outcomes in this group of patients.

Remnant preservation may improve proprioception after anterior cruciate ligament reconstruction

Aim

Our aim was to evaluate the literature investigating proprioception improvement after anterior cruciate ligament reconstruction (ACLR) and test the hypothesis that ACL tibial remnant-preserving reconstruction (ACLR-R) is more beneficial than standard technique (ACLR-S) in terms of postoperative proprioceptive function with various reported tests, including joint position sense (JPS) and threshold to detect passive motion (TTDPM).

Methods

An online search was performed in Embase, MEDLINE/PubMed, Cochrane, SPORTDiscus, and Web of Science databases before 5 October 2020, on the basis of the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Key terms [(‘ACLR’ or ‘ACL-R’ or ‘anterior cruciate ligament reconstruction’) AND (‘remnant’ or ‘stump’) AND (‘proprioception’ or ‘proprioceptive’)] were used. The Oxford Centre for Evidence-Based Medicine and The McMaster Critical Review Form for Quantitative Studies were used for quality assessment. In total, four articles comparing proprioceptive functions between ACLR-R and ACLR-S were included, two of which were randomized clinical trials rated as level of evidence II, and two were retrospective cohort studies rated as level of evidence III. The outcomes were then compared. Evaluation of proprioception involved joint position sense (JPS) [reproduction of active positioning (RAP) and reproduction of passive positioning (RPP)] and threshold to detect passive motion (TTDPM) tests.

Results

Only four studies were included, with a total of 234 patients (119 ACLR-R patients and 115 ACLR-S patients). High heterogeneity in characteristics and outcome measurements was observed among the studies. Three studies performed sparing technique, and one performed tensioning technique. One study tested RAP and reported better results at an average of 7 months follow-up in ACLR-R (P < 0.05). Three studies tested RPP, one of which measured RPP within 12 months after surgery and reported better results in ACLR-R than in ACLR-S (P < 0.05). The other two studies reported similar results; however, the findings of one study were statistically insignificant. TTDPM was tested in one study, with no statistically significant difference found.

Conclusion

The current literature, although limited, reported proprioception improvement after ACLR-R (compared with ACLR-S) in terms of JPS. However, owing to the heterogeneity of the relevant studies, further research is required to determine remnant preservation effect on knee proprioceptive restoration.

Level of evidence

Level III, systematic review of Level II and III studies.

Diagnosis and Treatment of Schatzker Type II Tibial Plateau Fracture with An Isolated Bone Fragment: A Case Report and Literature Review

BACKGROUND

An isolated bone fragment from the posterolateral tibial plateau retrieved from the patellofemoral compartment is a rarely seen Schatzker type II tibial plateau fracture and is prone to misdiagnosis. To the best of our knowledge, this injury mechanism has not been previously described.

CASE PRESENTATION

A 63-year-old female sustained left knee pain and activity limitation after falling off an electric bicycle. Local hospital ignored the intra-articular bone fragment and failed to provide effective treatment. This case described an uncommon Schatzker type II tibial plateau fracture with an isolated bone fragment, its physical examination and radiological findings, the potential injury mechanism, and surgical protocol.

CONCLUSIONS

Combining the physical examination and radiological findings to evaluate the potential injury mechanism is important for developing an appropriate surgical protocol.

Acute Versus Delayed Surgical Intervention in Multiligament Knee Injuries: A Systematic Review

Background:

The optimal timing of surgical intervention for multiligament knee injuries remains controversial.

Purpose:

To review the clinical and functional outcomes after acute and delayed surgical intervention for multiligament knee injuries.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We performed a search of the PubMed, Embase, Cochrane Library, and Web of Science databases from inception to September 2020. Eligible studies reported on knee dislocations, multiligament knee injuries, or bicruciate ligament injuries in adult patients (age, ≥18 years). In addition to comparing outcomes between acute and delayed surgical intervention groups, we conducted 3 subgroup analyses for outcomes within isolated knee injuries, knee injuries with concomitant polytrauma/fractures, and high-level (level 2) studies.

Results:

Included in the analysis were 31 studies, designated as evidence level 2 (n = 3), level 3 (n = 8), and level 4 (n = 20). These studies reported on 2594 multiligament knee injuries sustained by 2585 patients (mean age, 25.1-65.3 years; mean follow-up, 12-157.2 months). At the latest follow-up timepoint, the mean Lysholm (n = 375), International Knee Documentation Committee (IKDC) (n = 286), and Tegner (n = 129) scores for the acute surgical intervention group were 73.60, 67.61, and 5.06, respectively. For the delayed surgical intervention group, the mean Lysholm (n = 196), IKDC (n = 172), and Tegner (n = 74) scores were 85.23, 72.32, and 4.85, respectively. The mean Lysholm (n = 323), IKDC (n = 236), and Tegner (n = 143) scores for our isolated subgroup were 83.7, 74.8, and 5.0, respectively. By comparison, the mean Lysholm (n = 270), IKDC (n = 236), and Tegner (n = 206) scores for the polytrauma/fractures subgroup were 83.3, 64.5, and 5.0, respectively.

Conclusion:

The results of our systematic review did not elucidate whether acute or delayed surgical intervention produced superior clinical and functional outcomes. Although previous evidence has supported acute surgical intervention, future prospective randomized controlled trials and matched cohort studies must be completed to confirm these findings.

Timing of Anterior Cruciate Ligament Reconstruction and Relationship With Meniscal Tears: A Systematic Review and Meta-analysis

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are common, but the ideal timing for ACL reconstruction after injury is unclear with regard to meniscal insult.

PURPOSE

To determine whether there is a relationship between timing from ACL rupture to ACL reconstruction and development of meniscal tears within this period.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic literature search was undertaken independently by 2 reviewers using the Cochrane method for systematic reviews in 5 online databases. The reviewers performed independent data extraction and assessment of risk of bias and study quality. The search included any comparative study, including randomized controlled trials (RCTs), prospective and retrospective cohort studies, and case-control studies of an adult population, that assessed the relationship between timing of ACL reconstruction surgery and rates of meniscal tears.

RESULTS

After screening, 12 studies (No. of participants = 3042) out of 3390 records were included for analysis: 3 RCTs (n = 272), 2 prospective cohort studies (n = 307), and 7 retrospective cohort studies (n = 2463). In analysis of these studies, rates of reported meniscal tears were compared for ACL procedures performed at 3 and 6 months after injury. Meta-analysis of 5 studies (n = 2012) showed that ACL reconstruction performed >3 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 3 months of injury (estimated OR, 2.235; 95% CI, 1.183-4.223; P = .013) but not with a higher rate of lateral meniscal tears. Similarly, meta-analysis of 4 studies (n = 990) showed that ACL reconstruction performed >6 months after injury was associated with a higher rate of medial meniscal tears compared with ACL reconstruction performed within 6 months of injury (estimated OR, 2.487; 95% CI, 1.241-4.984; P = .01) but not with a higher rate of lateral meniscal tears.

CONCLUSION

Our results suggest that delay of ACL reconstruction surgery >3 months after injury is associated with a higher rate of medial meniscal tears within this prereconstruction time frame. Further high-quality prospective studies may help determine whether this is a causal effect. However, based on current evidence, in those patients for whom ACL reconstruction is indicated, ACL reconstruction within 3 months of injury may be recommended.

REGISTRATION

CRD42016032846 (PROSPERO).

Does a Delay in Anterior Cruciate Ligament Reconstruction Increase the Incidence of Secondary Pathology in the Knee? A Systematic Review and Meta-Analysis

OBJECTIVE

Previous systematic reviews looking at timing of anterior cruciate ligament reconstruction (ACLR) examined the functional outcomes and range of motion; however, few have quantified the effect of timing of surgery on secondary pathology. The goal of this study was to analyze the effects of early ACLRs versus delayed ACLR on the incidence of meniscal and chondral lesions.

DATA SOURCES

We searched MEDLINE, EMBASE, and CINAHL on March 20, 2018, for randomized control trials (RCTs) that compared early and delayed ACLR in a skeletally mature population. Two reviewers independently identified trials, extracted trial-level data, performed risk-of-bias assessments using the Cochrane Risk of Bias tool, and evaluated the study methodology using the Detsky scale. A meta-analysis was performed using a random-effects model with the primary outcome being the total number of meniscal and chondral lesions per group.

RESULTS

Of 1887 citations identified from electronic and hand searches, we included 4 unique RCTs (303 patients). We considered early reconstruction as <3 weeks and delayed reconstruction as >4 weeks after injury. There was no evidence of a difference between early and late ACLR regarding the incidence of meniscal [relative risk (RR), 0.98; 95% confidence interval (CI), 0.74-1.29] or chondral lesions (RR, 0.88; 95% CI, 0.59-1.29), postoperative infection, graft rupture, functional outcomes, or range of motion.

CONCLUSIONS

We found no evidence of benefit of early ACLR. Further studies may consider delaying surgery even further (eg, >3 months) to determine whether there are any real benefits to earlier reconstruction.

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

PURPOSE

The purpose of this study was to compare clinical outcomes and incidence of concomitant injuries in patients undergoing early vs delayed surgical treatment of single anterior cruciate ligament (ACL) injury and multiligament knee injury (MLKI).

METHODS

A literature search using PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, and Scopus from their inception to April 30, 2020 was conducted. Studies with levels I to IV evidence reporting the incidence of meniscus or cartilage injury according to early vs delayed surgery in single ACL injuries and MLKIs were included. In the meta-analysis, data based on the number of meniscus and cartilage injuries were extracted and pooled. Lysholm and Tegner scores were analyzed using two-sample Z-tests to calculate the non-weighted mean difference (NMD). A meta-regression analysis was also performed to determine the effect of single ACL injury and MLKI/study design.

RESULTS

Sixteen studies on single ACL injury and 14 studies on MLKI were included in this analysis. In the analysis, there were significant decreases in Lysholm score (NMD - 5.3 [95% confidence interval (CI) - 7.37 to - 3.23]) and Tegner score (NMD - 0.25 [95% CI - 0.45 to - 0.05]) and increases in risk of meniscus tear (odds ratio [OR] 1.73 [95% CI 1.1-2.73], p = 0.01) and cartilage injury (OR 2.48 [95% CI 1.46-4.2], p = 0.0007) in the delayed surgery group regardless of single ACL injury or MLKI. The result of the meta-regression analysis indicated that single ACL injury and MLKI/study design were not significant moderators of overall heterogeneity (p > 0.05).

CONCLUSIONS

Our study suggests that delayed ACL surgery significantly resulted in a higher risk of meniscus tear and cartilage injury and decreased Lysholm and Tegner scores compared to early ACL surgery. The Lysholm scores in the delayed MLKI surgery group were significantly decreased, but the risks of meniscus tear and cartilage injury in the delayed MLKI surgery group remained unclear.

LEVEL OF EVIDENCE

Level III, meta-analysis.

Outcomes of single bundle arthroscopic anterior cruciate ligament reconstruction in a limited resource setting

OBJECTIVES

Despite various challenges, orthopaedic sports surgeons are still providing the arthroscopic service in low-income and middle-income countries like Nepal; however, it is hardly being reported. The main purpose of this study was to compare the clinical outcomes and complications of patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) in the urban group and that of the rural group.

METHODS

We evaluated a total of 194 patients, including 98 patients in the urban group and 96 patients in the rural group, undergoing arthroscopic ACLR between August 2015 and February 2018, and had completed a minimum of 2-year follow-up. Subjective evaluations were performed using the Tegner-Lysolm score and International Knee Documentation Committee (IKDC) subjective knee evaluation form. Laxity assessments were performed using the Lachman test and the Pivot-shift test. Functional evaluation included the range of motion, single-leg hop test and overall IKDC score. Radiological assessment was performed according to the IKDC guidelines. SPSS was used for data analysis.

RESULTS

There was statistically significant differences in the subjective assessments between 2 groups. No statistically significant differences existed between 2 groups in terms of laxity and functional assessments. However, the proportion of laxity, in terms of Lachman test and Pivot-shift test, was higher in the young and active individuals and the proportion of abnormal and severely abnormal in all parameters of functional outcomes was higher in the older female in the rural group. Graft failure occurred in 19 (17.6%) knees in the urban group and 17 (16.8%) knees in the rural group. Graft failure in the urban group was higher in young and active male patients, whereas failure in the rural group was more in female patients. Similarly, overall infection occurred in 13 (6.2%) knees, including 5 (2.3%) deep infections and 8 (3.8%) superficial infections.

CONCLUSION

We advised similar rehabilitation protocol for all the patients; however, the outcomes were significantly lower in patients living in rural areas as they are found to have poor compliance with the rehabilitation protocol. The overall graft failure rate was 17.2%; however, the reoperation rate was higher in the urban group than the rural group. The rate of deep infection was higher in the rural group as compared with the urban group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Results of Treatment of the Multiple Ligament Injured (Dislocated) Knee

Knee dislocations leading to multiligament knee injuries are associated with a wide variety of bony, ligamentous, soft tissue, and neurovascular injury patterns. Numerous management strategies have been proposed including nonoperative treatment and surgical repair or reconstruction. In recent years, an emphasis has been placed on anatomic repair and reconstruction principles, which have shown superior outcomes compared with older techniques. However, despite these advances, clinical outcomes continue to vary widely, with many patients experiencing chronic pain, stiffness, loss of range of motion, instability, and failure to return to work or sports. The purpose of this chapter is to review clinical outcomes following combined anterior and posterior cruciate ligament, medial collateral ligament, and posterolateral corner injuries sustained during a knee dislocation. Understanding the available treatment options and reported outcomes will allow surgeons to individualize management to address each patient's specific injury pattern and functional goals.

Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group

A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

Pre-operative Joint Inflammation has no Bearing on Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction at 1-Year Follow-Up; a Prospective Study

BACKGROUND

To study the effect of pre-operative joint inflammation on clinical outcome at 1 year follow-up following ACL reconstruction surgery.

METHODS

Male patients, aged 18-40 years, suffering from isolated ACL injury were included. All patients were randomly divided into two groups based on the type of graft used: Group A: semitendinosus gracilis graft with preserved insertions (STG-PI), Group B: bone-patellar tendon-bone graft (BPTB). Patients were categorised based on the time of presentation after injury: (a) within 6 weeks of injury, (b) between 6 and 12 weeks of injury, (c) after 12 weeks of injury. Synovial fluid levels of Interlukin-1, Interlukin-6 and TNF-α were measured in all the ACL deficient knees by taking a joint fluid sample intra-operatively.

RESULTS

The total number of patients in the study was 59; 23 in group A (STG-PI) and 36 in group B (BPTB). Mean age of patients was 26 ± 5.146 years. 14 out of 59 (23.7%) patients presented within 6 weeks of injury, 16 (27.11%) patients presented between 6 and 12 weeks after injury and 29 (49.1%) patients presented after 12 weeks of injury. IL-6 levels were significantly high in group with < 6 weeks of injury than in group with > 12 weeks since injury. IL-6 had significant correlation with VAS scores, KT 1000, Lysholm knee scores and Tegner level of activity. There was no difference in outcome (pain scores, mechanical stability, Lysholm knee score and Tegner level of activity) at 1 year follow-up when patients with different time intervals since injury were compared.

CONCLUSION

The clinical outcome in terms of pain score, mechanical stability, functional scores and return to sporting activity is comparable, irrespective of the time since injury, at short term follow-up.

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears.

PURPOSE/HYPOTHESIS

The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines.

RESULTS

Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P > .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis.

CONCLUSION

This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications.

STUDY REGISTRATION

CRD42019119319 (PROSPERO).

Arthroscopy and COVID-19: Impact of the pandemic on our surgical practices

The aim of this article is to study systematically current evidence on status of arthroscopic surgeries during the COVID-19 pandemic. We aim to study (1) changes in global arthroscopic practices, (2) recommendations on reducing risk to patients and health care workers (HCW), (3) changes in follow-up protocols of these patients. Systematic search was carried out by two different reviewers using three different online databases for all studies published in the English language before April 2020. The total number of abstracts screened initially was 314. After screening of these abstracts, a total of 13 studies were included for the systematic review. Numbers of orthopaedic injuries have seen a sharp fall during this time. Most elective surgical facilities were also closed at this time. Most studies have recommended telemedicine as an essential medium of providing continued care to patients during COVID-19. Studies have recommended that a conservative approach should be preferred for most patients with ligament injuries, and alternative procedures that have less requirement for an operating room should be explored. Common recommendation in all studies is that procedures of more elective nature should be postponed to a safer time frame when the transmission of COVID-19 virus in the population has declined. When surgeries are resumed, there is a need for triage of arthroscopy procedures from more important or urgent to less important ones. Elective surgical procedures should preferably be started with patients with no co-morbidities and lesser risk of peri-operative complications. All patients undergoing surgery and health care personnels should have some screening for disease. Attempts should be made to have shortest hospital stay. Choice of anaesthetic procedure should emphasize on minimal aerosolization of the virus. Regional anaesthesia is the preferred choice as far as possible. Most guidelines have recommended that patient follow up should be made telephonically or on video-conferencing.

Editorial Commentary: Fifty Is the New 30? Do Patients in Their 50s Deserve an Anterior Cruciate Ligament Reconstruction?

Evidence suggests that anterior cruciate ligament reconstruction in patients older than 50 years of age has similar outcomes when compared with younger patients. However, poorer results are associated with advanced degenerative intra-articular chondral changes. The caveat here is that these conclusions are mainly based on retrospective level IV case series. The question is whether functionally unstable patients 50 years and older, whether active or not, benefit from surgical reconstruction and the answer is clearly yes. It provides restoration of function and should be considered in active older patients with subjective instability who have not responded to nonoperative treatment.

Acute reconstruction results in less sick-leave days and as such fewer indirect costs to the individual and society compared to delayed reconstruction for ACL injuries

PURPOSE

To compare the total number of sick-leave days caused by the knee injury from the day of injury and over the first year between acute (within 8 days) and delayed (6-10 weeks) anterior cruciate ligament reconstruction (ACLR) and also assess other clinical outcomes during this period.

METHODS

Seventy patients with an acute ACL injury and Tegner level of 6 or more were randomized to acute (within 8 days) or delayed (after 6-10 weeks) ACLR. Patient-reported outcomes; objective IKDC and manual stability measurements were assessed at 6 and 12 months. With data from the Swedish Social Insurance Agency (Försäkringskassan) information about the number of sick-leave days due to the knee injury over the following 12 months was collected and compared between the two groups.

RESULTS

Seventy-one percent received compensation for sick leave (26 in the acute versus 23 in the delayed group). The mean number of sick-leave days for the acute group was significantly lower (M = 56.9, SD = 36.4) compared to the delayed group (M = 88.5, SD = 50.2), p < 0.05. The acute group was also significantly stronger in flexion in both slow and fast angle velocities according to Biodex^®. No other differences were found between the groups in other clinical assessments or in terms of associated injuries.

CONCLUSION

Acute and delayed ACLR provided comparable clinical outcomes after 12 months. Acute reconstruction resulted in less sick-leave days and as such fewer indirect costs to the individual and society. These findings suggest that if patients requiring ACLR can be identified early and ACLR can be performed in the acute phase, socioeconomic costs can potentially be reduced by minimizing time off work.

LEVEL OF EVIDENCE

II.

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

PURPOSE

A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used and at what follow-up time those outcomes should be assessed.

METHODS

To establish a standardized approach to assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method.

RESULTS

In general, outcomes after ACL treatment can be divided into four robust categories-early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated.

CONCLUSION

This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

LEVEL OF EVIDENCE

V.

Acute ACL reconstruction shows superior clinical results and can be performed safely without an increased risk of developing arthrofibrosis

PURPOSE

To compare acute ACL reconstruction (ACLR) within 8 days of injury with delayed reconstruction after normalized range of motion (ROM), 6-10 weeks after injury. It was hypothesized that acute ACL reconstruction with modern techniques is safe and can be beneficial in terms of patient-reported outcomes and range of motion.

METHODS

The effect of acute and delayed ACLR was randomized studied on 70 patients with high recreational activity level, Tegner level 6 or more, between 2006 and 2013. Patient-reported outcomes, objective IKDC, KOOS, and manual stability measurements were documented during the 24-month follow-up period.

RESULTS

The acute ACLR group did not result in increased stiffness and showed superior outcome regarding strength and how the patient felt their knee functioning at 24 months. In addition, the acute group was not inferior to the delayed group in any assessment. Regarding patient-related outcomes in KOOS, both groups showed significant improvements in all subscales, but no difference was found between the groups. Functional return (FR) rate was almost double compared to the Swedish knee ligament register and treatment failure (TF) rate was reduced by half, no significant difference between the groups. No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups.

CONCLUSION

Acute ACLR within 8 days of injury does not appear to adversely affect ROM or result in increased stiffness in the knee joint and was not inferior to the delayed group in any assessment when compared to delayed surgery.

LEVEL OF EVIDENCE

I.

Graft Fixation and Timing of Surgery Are Predictors of Early Anterior Cruciate Ligament Revision: A Cohort Study from the Swedish and Norwegian Knee Ligament Registries Based on 18,425 Patients

The identification of surgical risk factors for early anterior cruciate ligament (ACL) revision is important when appropriate treatment for patients undergoing primary ACL reconstruction is selected. The purposes of this study were to determine the short-term ACL revision rate of patients undergoing primary ACL reconstruction and to identify surgical risk factors for ACL revision within 2 years of primary ACL reconstruction.

Is Remnant Preservation in Anterior Cruciate Ligament Reconstruction Superior to the Standard Technique? A Systematic Review and Meta-Analysis

Purpose

This is a systematic review and meta-analysis of current evidence that aims at comparing the clinical outcomes of remnant-preserving anterior cruciate ligament reconstruction (ACLR) and standard ACLR.

Methods

A systematic review of randomized controlled studies and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of II was performed. Studies were included by strict inclusion and exclusion criteria. Extracted data were summarized as preoperative conditions, postoperative clinical outcomes, and postoperative complications. When feasible, meta-analysis was performed with RevMan5.3 software. Study methodological quality was evaluated with the modified Coleman methodology score (CMS).

Results

Eleven studies (n = 466 remnant-preserving and n = 536 standard) met the inclusion criteria. The mean modified CMS for all included studies was 85.8 (range: 77–92 on a 100-point scale). In total, 466 patients underwent remnant-preserving ACLR by 3 different procedures: standard ACLR plus tibial remnant tensioning (n = 283), selective-bundle augmentation (n = 49), and standard ACLR plus tibial remnant sparing (n = 134). Remnant-preserving ACLR provided a superior outcome of postoperative knee anterior stability (WMD = −0.42, 95% CI, −0.66, −0.17; P < 0.01) and Lysholm score (WMD = 2.01, 95% CI, 0.53 to 3.50; P < 0.01). There was no significant difference between the two groups with respect to second-look arthroscopy (OR = 1.38, 95% CI, 0.53, 3.62; P=0.51), complications (OR = 1.24 95% CI, 0.76, 2.02; P=0.39), International Knee Documentation Committee (IKDC) subject scores, IKDC grades, Lachman test, and pivot-shift test.

Summary/conclusion

Remnant-preserving ACLR promotes similar graft synovial coverage and revascularization to standard ACLR. Equivalent or superior postoperative knee stability and clinical scores were observed for remnant-preserving ACLR compared with standard ACLR. No significant difference in the total complication rate between the groups was evident.

Prospective Evaluation of Range of Motion in Acute ACL Reconstruction Using Patellar Tendon Autograft

Background:

Optimal timing of anterior cruciate ligament (ACL) reconstruction has been a topic of controversy. Reconstruction has historically been delayed for at least 3 weeks, given previous studies reporting a high risk of postoperative arthrofibrosis and suboptimal clinical results.

Purpose:

To prospectively evaluate postoperative range of motion following acutely reconstructed ACLs with patellar tendon autograft.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients (age >18 years) who had ACL reconstruction as soon as possible after injury, regardless of the condition or preoperative range of motion of the injured knee, underwent reconstruction with patellar tendon autograft. An identical standard surgical technique and postoperative rehabilitation were employed for all patients. Postoperative assessment included active range of motion measurements with a goniometer. Subjective outcomes were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS).

Results:

A total of 25 consecutive patients who met the inclusion criteria were enrolled. The mean age was 27.9 years (range, 20-48 years), and 19 were men. The time from injury to surgery was a mean 4.5 days (range, 1-9 days). The mean objective follow-up was 10.9 months (range, 3 days–19.4 months), and range of motion was regained at a mean 4.4 months (range, 1-9 months). Three meniscal repairs and 3 microfractures were performed concomitantly. There was 1 graft failure at 3 years postoperatively, noted at 50 months of subjective follow-up. There was no loss of extension >3° as compared with the contralateral knee in any patient. There was no loss of flexion >5° as compared with the contralateral knee in any patient who completed objective follow-up. The mean KOOS at final subjective follow-up was 82.8 (range, 57.7-98.8) at a mean 56.6 months postoperative (n = 14/24; range, 48-58 months).

Conclusion:

Excellent clinical results can be achieved following ACL reconstruction performed ≤9 days after injury with patellar tendon autograft. The authors found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.

Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes

PURPOSE

The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture.

MATERIALS AND METHODS

It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts' anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated.

RESULTS

The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes.

CONCLUSIONS

Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction

PURPOSE

Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions.

METHODS

A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified.

RESULTS

The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue.

CONCLUSION

The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue.

LEVEL OF EVIDENCE

IV.

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

Background

Anterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort.

Methods

A systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist.

Results

A statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias.

Conclusions

Although there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry  may help to provide clearer guidance.

Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review

Background

Delayed anterior cruciate ligament (ACL) reconstruction may be associated with increased risk of subsequent knee joint damage and osteoarthritis (OA). The relationship between recurrent instability episodes and meniscal or cartilage damage after first-time ACL injury is unknown.

Purpose

To assess the association between recurrent knee instability episodes and prevalence of meniscal lesions, cartilage damage, and OA after first-time ACL injury.

Study Design

Systematic review; Level of evidence, 4.

Methods

Six electronic databases were systematically searched using keywords and Medical Subject Heading terms. Studies selected were of English language, included original data, had a prospective design, and provided an outcome of recurrent instability and meniscal lesions, cartilage damage, or OA after first-time ACL injury. Adjusted odds ratios (ORs) were extracted or unadjusted ORs (95% CI) were calculated. PRISMA guidelines were followed, and 2 independent raters assessed study quality using Downs and Black criteria.

Results

Of 905 potentially relevant studies, 7 were included. Sample sizes ranged from 43 to 541, and Downs and Black scores ranged from 2 to 12. Clinical and methodological heterogeneity precluded meta-analysis. Six studies reported a positive association between recurrent instability episodes and medial meniscal damage (OR range, 3.46 [95% CI, 1.24-9.99] to 11.56 [1.37-521.06]). The association between instability episodes and lateral meniscal or cartilage damage was inconsistent. No studies examined the association between instability episodes and OA.

Conclusion

This systematic review provides preliminary evidence that recurrent instability episodes after first-time ACL injury may be associated with increased odds of medial meniscal damage. This highlights the importance of early diagnosis, education, and treatment for individuals with ACL injury, all of which must include a specific focus on the prevention and management of instability episodes. High-quality, prospective cohort studies are needed that assess the effects of diagnostic and treatment delay, recurrent instability episodes on secondary meniscal and cartilage damage, and OA after an initial ACL injury.

The Long-Term Outcome After Early and Late Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare long-term clinical and radiographic outcomes in patients undergoing either early (group A) or late (group B) surgery after anterior cruciate ligament (ACL) injury.

METHODS

ACL reconstruction using hamstring tendon autografts was performed in 30 patients in group A (median age, 23 years; range, 17-49 years) and 31 patients in group B (median age, 27 years; range, 17-38 years). The patients in group A were operated on within 5 months (median, 3 months; range, 2-5 months) of injury, whereas those in group B were operated on more than 24 months (median, 30 months; range, 24-48 months) after injury. The follow-up period was 10 years (median, 117 months [range, 77-222 months] in group A and 129 months [range, 77-206 months] in group B; P = .44). Multiple objective clinical evaluation tests and patient-reported outcome measures were obtained preoperatively and at follow-up. At follow-up, radiographic assessments of knee osteoarthritis (OA) bilaterally were performed.

RESULTS

The frequency of meniscectomy at the index operation was significantly lower in group A (20%) than in group B (52%) (P = .01). There were no significant differences between the groups in terms of Tegner and Lysholm scores and laxity tests both preoperatively and at follow-up. Both groups improved over time in terms of Tegner and Lysholm scores (P < .05). At follow-up, significantly more medial-compartment OA in the index knee was found in group B than in group A (P = .037) according to the Ahlbäck classification system. The index knee showed significantly more OA than the contralateral knee in both groups (P < .01).

CONCLUSIONS

Patients who underwent early ACL reconstruction required significantly fewer meniscectomies at the index operation than patients who underwent late reconstruction and showed significantly less OA on the medial side of the knee 10 years after reconstruction. However, no significant differences were found between the groups in terms of clinical assessments.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique

Background:

Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood.

Purpose:

To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique.

Study Design:

Case series; Level of evidence, 4.

Methods:

Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed.

Results:

Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb.

Conclusion:

The femoral physeal-sparing with transphyseal tibial drilling “hybrid” technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

Effect of the Timing of Anterior Cruciate Ligament Reconstruction on Clinical and Stability Outcomes: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the effect of the timing of anterior cruciate ligament (ACL) reconstruction on clinical and stability outcomes by analyzing high-quality studies that assessed timing as a primary objective.

METHODS

The MEDLINE, EMBASE, and Cochrane database were systematically searched. The inclusion criteria were as follows: (1) English articles, (2) noncomparative study or relevant study reporting clinical and/or stability results, and (3) timing of the ACL reconstruction as a primary objective. Study type, level of evidence, randomization method, exclusion criteria, number of cases, age, sex, timing of ACL reconstruction, follow-up, clinical outcomes, stability outcomes, and other relevant findings were recorded. Statistical analysis of the Lysholm scores and KT-1000 arthrometer measurements after early and delayed ACL reconstruction was performed using R version 3.3.1.

RESULTS

Seven articles were included in the final analysis. There were 6 randomized controlled trials and 1 Level II study. Pooled analysis was performed using only Level I studies. All studies assessed the timing of ACL reconstruction as a primary objective. The definition of early ranged broadly from 9 days to 5 months and delayed ranged from 10 weeks to >24 months, and there was an overlap of the time intervals between some studies. The standard timing of the delayed reconstruction was around 10 weeks from injury in the pooled analysis. After pooling of data, clinical result was not statistically different between groups (I²: 47%, moderate level of heterogeneity). No statistically significant difference was observed in the KT-1000 arthrometer measurements between groups (I²: 76.2%, high level of heterogeneity) either.

CONCLUSION

This systematic review and meta-analysis performed using currently available high-quality literature provides relatively strong evidence that early ACL reconstruction results in good clinical and stability outcomes. Early ACL reconstruction results in comparable clinical and stability outcomes compared with delayed ACL reconstruction.

LEVEL OF EVIDENCE

Level II, a systematic review and meta-analysis of Level I and II studies.

Functional outcome of an early anterior cruciate ligament reconstruction in comparison to delayed: Are we waiting in vain?

BACKGROUND

Surgical techniques of ACL reconstruction (ACLR) have evolved over the past three decades along with debate regarding timing of reconstruction. It was a widespread belief that the timing of surgery was an important factor in determining the resulting stiffness after ACLR. Delayed rather than early reconstruction of the ACL is the current recommended treatment since it is thought to give a better functional outcome. However, there is no consensus in the literature regarding the optimal time of surgical intervention. The purpose of this study was to compare the range of motion and functional outcome in patients who underwent ACLR early with those that were delayed.

MATERIALS AND METHODS

The patients were randomized into two groups; patients who underwent the procedure within three weeks were kept in Group I (Early) and those patients who were reconstructed after six weeks were categorized as Group II (Delayed). Hamstring grafts were used and a standard protocol of surgery and physiotherapy was followed. The range of motion, IKDC and Tegner scores were compared.

RESULTS

A hundred and four patients underwent ACLR; fifty-three patients were grouped as Group I (Early) and fifty one as Group II (Delayed). The range of motion of both groups was comparable. The IKDC and Tegner scores were also comparable for early (Group I) ACLR and the patients who had their ACL reconstructed after a delay of at least 6 weeks (Group II).

CONCLUSION

There are no clinical differences in terms of range of motion and functional results between early and delayed ACLR.

Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to knee ligament sprain. J Orthop Sports Phys Ther. 2017;47(11):A1-A47. doi:10.2519/jospt.2017.0303.

Acute non-contact anterior cruciate ligament tears are associated with relatively increased vastus medialis to semimembranosus cross-sectional area ratio: a case-control retrospective MR study

OBJECTIVE

Hamstring muscle deficiency is increasingly recognized as a risk factor for anterior cruciate ligament (ACL) tears. The purpose of this study is to evaluate the vastus medialis to semimembranosus cross-sectional area (VM:SM CSA) ratio on magnetic resonance imaging (MRI) in patients with ACL tears compared to controls.

MATERIALS AND METHODS

One hundred knee MRIs of acute ACL tear patients and 100 age-, sex-, and side-matched controls were included. Mechanism of injury, contact versus non-contact, was determined for each ACL tear subject. The VM:SM CSA was measured on individual axial slices with a novel method using image-processing software. One reader measured all 200 knees and the second reader measured 50 knees at random to assess inter-reader variability. The intraclass correlation coefficient (ICC) was calculated to evaluate for correlation between readers. T-tests were performed to evaluate for differences in VM:SM CSA ratios between the ACL tear group and control group.

RESULTS

The ICC for agreement between the two readers was 0.991 (95% confidence interval 0.984-0.995). Acute ACL tear patients have an increased VM:SM CSA ratio compared to controls (1.44 vs. 1.28; p = 0.005). Non-contact acute ACL tear patients have an increased VM:SM CSA ratio compared to controls (1.48 vs. 1.20; p = 0.003), whereas contact acute ACL tear patients do not (1.23 vs. 1.26; p = 0.762).

CONCLUSION

Acute non-contact ACL tears are associated with increased VM:SM CSA ratios, which may imply a relative deficiency in hamstring strength. This study also demonstrates a novel method of measuring the relative CSA of muscles on MRI.

Factors affecting knee laxity following anterior cruciate ligament reconstruction using a hamstring tendon

BACKGROUND

The aim of the present study was to investigate the correlation between the pre-operative and intraoperative factors that predict postoperative knee laxity following anterior cruciate ligament (ACL) reconstruction using a hamstring tendon.

METHODS

The subjects included 108 patients (male, n=49; female, n=59) with ACL-deficient knees who had undergone double-bundle reconstruction. The median time between injury and surgery (TBIS) was 27.5weeks (range one to 504). The patients were divided into two groups according to the side-to-side difference (SSD) in anterior translation on a stress radiograph one year after undergoing the operation (Group A: SSD of <3mm and Group B: SSD of ≥3mm) and were compared regarding such factors as age at surgery, sex, body mass index, pivot shift test, TBIS, pre-operative laxity, concomitant ligament, meniscus, and articular cartilage injury. A logistic regression analysis was performed to identify the factors associated with knee laxity.

RESULTS

The postoperative SSD values after one year were correlated with the TBIS (r=0.28; P<0.01). Eighty-one and 27 knees were classified into Groups A and B, respectively, based on the SSD at one year after surgery. The TBIS in Group B (60.2weeks) was significantly longer than that in Group A (16.6weeks; P<0.01). A logistic regression analysis showed that there was a significant association between the TBIS and postoperative knee laxity (P<0.01; odds ratio 1.013; 95% CI 1.002-1.023).

CONCLUSION

Increased knee laxity was associated with the time between injury and surgery.

Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis

BACKGROUND

Whether early or delayed surgical intervention in patients with multi-ligament injuries results in better outcomes, is of current and controversial debate.

PURPOSE

The purpose of this study was to perform a meta-analysis comparing early versus late surgical treatment of multi-ligament knee injuries.

METHODS

We performed a systematic review of Medline, Embase, Scopus, and Google Scholar to identify relevant studies in the English and German literature. Eligibility criteria included studies comparing early or delayed surgical interventions for multi-ligament knee injuries, with a minimum follow-up of two years, reporting the primary clinical outcome using a validated functional scoring system and range of motion. Exclusion criteria were patients treated with multi-trauma, head injury, non-union, lower extremity fractures, or a documented history of previous knee injuries. Publication bias was assessed by funnel plot, and the risk of bias was established using the Cochrane Collaboration's risk of bias tool. Heterogeneity was assessed using χ² and I₂ statistic.

RESULTS

Eight studies (n=260 patients) were included in the analysis. 149 patients were treated early with a mean of 10.6days; 111 patients were treated late with a mean of 294days. The pooled estimate for clinical outcome demonstrated that early surgery resulted in significantly higher Lysholm scores (SMD 0.669, 95% CI: 0.379 to 0.959, p=0.0001, I₂=0%). Thirty-one per cent of all patients with early surgery had a normal or near normal knee, whereas only 15% of patients with late reconstruction reported the knee to be normal or near normal. The pooled estimates for total ROM did not demonstrate a significant difference between the groups (SMD 0.113, 95% CI: -0.271 to 0.498, p=0.564, I₂=35.57%).

CONCLUSIONS

The results of this meta-analysis suggest that early surgical intervention in multi-ligament injuries of the knee produces a significantly superior clinical outcome, compared to late reconstruction. Although an overall trend of improved total range of knee motion was also demonstrated, this was very small and unlikely to be clinically relevant.

LEVEL OF EVIDENCE

Level 4; Systematic review and meta-analysis.

Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work

PURPOSE

The dynamic intraligamentary stabilization (DIS) technique is based on a different treatment approach than ACL reconstruction in that it intends to promote self-healing of the ligament. It is only recommended for acute injuries (<21days). The purpose of the present study was to compare DIS and ACLR with respect to the extent of work incapacity, revision rates, secondary arthroscopies, and treatment costs during recovery.

METHODS

The study was a post-hoc analysis of prospectively collected data in the Swiss National Accident Insurance Fund (SUVA) database. All registered DIS cases treated until 31 December 2012 were included in the study. ACLR cases were matched to DIS cases using a propensity score approach and analysed in a follow-up period of 2 years after injury. Paired Student's T-test and the Chi-square test were used to compare the outcome measures.

RESULTS

All 53 DIS patients were matched to an ACLR pair. The mean time period from injury to surgery was 14days for DIS and 50days for ACLR (p<0.001). Overall work incapacity was 13% for DIS and 17% for ACLR resulting in a difference of nearly 1 month of absence from work (p=0.03). The course of postoperative work incapacity was very similar between the groups, while the work incapacity prior to surgery lower in the DIS group. We found no difference in treatment costs, secondary arthroscopies and revision rates.

CONCLUSION

DIS patients benefited from nearly one month shorter absence from work than ACLR patients. This difference is likely related to the early surgical timing that is recommended for DIS. Since no differences were found between DIS and ACLR in terms of treatment costs, secondary arthroscopies and revision rates, the study supports the choice of DIS as an additional treatment option for acute ACL injuries. Further comparative studies are proposed to improve the evidence about optimal timing and best practice in ACL treatment.

Influence of the Injury-to-Surgery Interval on the Healing Potential of Human Anterior Cruciate Ligament-Derived Cells

BACKGROUND

Vascular CD34+ cells in anterior cruciate ligament (ACL) tissue have the potential for high proliferation and multilineage differentiation that can accelerate tendon-bone healing. While patient characteristics, such as age, can affect tendon-bone healing, the influence of elapsed time after injury on the healing process is unclear.

HYPOTHESIS

Cells obtained during the early phase after injury will exhibit a greater tendon-bone healing potential compared with chronic phase counterparts when applied to an immunodeficient rat model of ACL reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Adult human ACL-ruptured tissue was harvested from patients undergoing arthroscopic primary ACL reconstruction and classified into 2 groups based on the time elapsed between injury and surgery: (1) early group (≤3 months from injury) and (2) chronic group (>3 months from injury). In addition, 76 ten-week-old female immunodeficient rats underwent ACL reconstruction, followed by intracapsular administration of one of the following: (1) ACL-derived cells from the early group (n = 5), (2) ACL-derived cells from the chronic group (n = 5), or (3) phosphate-buffered saline (PBS) only (n = 5). During the 8 weeks after surgery, histological (weeks 2, 4, 8), immunohistochemical (week 2), radiographic (weeks 0, 2, 4, 8), and biomechanical (week 8) analyses were performed to evaluate tendon-bone healing.

RESULTS

In the early group, the histological evaluation showed early healing, induction of endochondral ossification-like integration, and mature bone ingrowth. Micro-computed tomography showed that the tibial bone tunnels at week 4 and week 8 were significantly reduced in the early group compared with those in the chronic group and PBS group ( P < .05). Moreover, biomechanical tensile strength was significantly greater in the early group than in the other groups ( P < .05). An accelerated healing potential in the early group was further demonstrated by the enhancement of intrinsic angiogenesis/osteogenesis and human-derived vasculogenesis/osteogenesis.

CONCLUSION

Compared with human ACL-derived cells obtained during the chronic phase, cells obtained during the early phase after injury have a greater tendon-bone healing potential when used in an immunodeficient rat model of ACL reconstruction.

CLINICAL RELEVANCE

During ACL reconstruction surgery, transplanting ACL remnant tissue in the early phase after injury could accelerate and enhance tendon-bone healing.

Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology

PURPOSE

Anterior cruciate ligament (ACL) ruptures are often associated with primary meniscal and cartilage lesions. Late reconstruction of ACL-deficient knees may increase the risk of developing secondary meniscal and cartilage lesions; hence, the timing of ACL repair is of the utmost importance. Because meniscus outcome is also a potential predictor for osteoarthritis (OA), this study compared ACL repair within the first 6 months after injury to that of surgery conducted 7-12 months after injury with regard to the incidence of meniscal and cartilage lesions.

METHODS

This prospective cross-sectional study included all complete isolated primary ACL ruptures treated in our institution within 1 year after trauma over a 12-month period. Exclusion criteria were revision ACL, complex ligament injuries, previous knee surgery, and missing injury data. Cartilage lesions were classified according to the score established by the International Cartilage Repair Society (ICRS score) and meniscal tears according to their treatment options.

RESULTS

Two hundred and thirty-three of 730 patients (162 men, 71 women) with ACL repair met the inclusion criteria. 86.3 % of surgical interventions were conducted within 6 months and 13.7 % after 6 months of trauma. Severe cartilage lesions grade III-IV did not significantly differ between the different time points of ACL repair (<6 months 39.9 %; >6 months 31.3 %; p = n.s.). Medial meniscus lesions received significantly higher meniscal repair in early compared to delayed ACL repair. Significantly higher rate of meniscal repair of the medial meniscus was seen in cases of early ACL repair compared to delayed (<6 months 77.2 %, >6 months 46.7; p = 0.022). The rate of medial meniscal repair in early ACL repair was significantly higher for women (89.5-0 %; p = 0.002), however, not for men (73.3-53.8 %; p = n.s.). No differences were found for lateral meniscal lesions, with regard to neither the different time points (p = n.s.) nor the sex (p = n.s.).

CONCLUSIONS

Because of the significantly higher rate of prognostically advantageous meniscal repair, the recommendation for an ACL reconstruction within 6 months after trauma was made to preserve the meniscus and reduce the risk of developing OA.

LEVEL OF EVIDENCE

Prospective cross-sectional cohort study, Level II.

Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction

PURPOSE

The purpose of the present study is the comparison of acute ACL reconstruction with or without meniscus repair within 48 h after injury and a delayed surgery during the inflammation-free interval. It was hypothesized that acute ACL reconstruction results in inferior patient reported outcomes and higher frequency of range of motion deficits.

METHODS

The effect of acute (within 48 h) and delayed (during the inflammation-free interval) ACL surgery was prospectively studied on 160 consecutive patients with ACL injury between January 2010 and December 2011. Subgroup analyses were performed to evaluate patients with an additional meniscus repair separately from isolated ACL surgeries. During the study period, partial meniscectomies were recorded to evaluate time dependent meniscus reparability. Patient reported outcomes, objective IKDC and manual stability measurements were documented during the 24-month follow-up period. The Pearson Chi-squared test was used to evaluate objective outcome measures. The Mann-Whitney U test was performed to analyse the results of patient reported outcomes. Statistical significance was set at p < 0.05.

RESULTS

For patients who underwent isolated ACL reconstruction, no statistical significant difference was observed at any time point regarding objective and subjective outcome measures. Significantly fewer patients who underwent acute combined ACL reconstruction and meniscus repair had an extension deficit between 3° and 5° at 12 months following surgery (3.7 vs. 22.2 %, p < 0.05). No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups. Further, surgical timing did not influence the reparability of the meniscus.

CONCLUSION

An acute ACL reconstruction within 48 h is preferable in highly active patients or competitive athletes.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.