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

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.

Delaying anterior cruciate ligament reconstruction for more than 3 or 6 months results in lower risk of revision surgery

BACKGROUND

The objective of this study is to investigate the risk of revision surgery when delaying anterior cruciate ligament reconstruction (ACLR) past 3 months or 6 months after injury.

MATERIALS AND METHODS

A total of 30,280 patients with isolated ACLR were identified in the Danish Knee Ligament Reconstruction Registry and divided into four groups; ACLR < 3 months, > 3 months, < 6 months, or > 6 months after injury. Primary outcome was revision surgery and secondary outcome were objective and subjective clinical outcome. The 2 year relative risk, crude, and adjusted hazard ratio (HR) were calculated.

RESULTS

Comparing ACLR < 3 months to ACLR > 3 months of injury the 2 year relative risk of revision surgery was found to be 1.81 (95% CI 1.46-2.23; P < 0.001) with an adjusted hazard ratio (HR) of 1.27 (95% CI 1.12-1.44; P < 0.001). Comparing ACLR < 6 months to ACLR > 6 months of injury the 2 year relative risk of revision surgery was found to be 1.61 (95% CI 1.34-1.92; P < 0.001) with an adjusted HR of 1.27 (95% CI 1.15-1.40; P < 0.001).

CONCLUSION

The risk of revision ACLR surgery was found to be increased when ACLR was performed within 3 months or 6 months of injury compared with later surgery. The 1 year postoperative objective knee laxity and the subjective patient-related outcome was found to be without a clinically significant difference; however, those with early ACLR (< 3 months or < 6 months) were found to have a higher activity level 1 year postoperatively. The information about increased risk of revision when having early surgery should be informed to patients when deciding timing of ACLR treatment.

LEVEL OF EVIDENCE

II.

Preferences in anterior cruciate ligament reconstruction: A survey among orthopedic surgeons in China

The purpose of this study was to reveal the current trends and preferences of Chinese orthopedic surgeons regarding anterior cruciate ligament (ACL) reconstruction through a nationwide web-based survey conducted in China. The survey questionnaire was distributed via WeChat to the chairmen of provincial orthopedic and sports medicine organizing committees in China, who then shared it in their respective WeChat workgroups. The questionnaire consisted of 52 multiple-choice questions covering 8 sections. Data collection was implemented by Questionnaire Star. A total of 812 valid questionnaires were returned: 94.21% of the respondents preferred single-bundle reconstruction of ACL, while 61.70% preferred autogenous semitendinosus plus gracilis reconstruction; 76.35% of the respondents preferred establishing the femoral tunnel first, while 47.29% preferred establishing the femoral tunnel through a medial auxiliary approach; and 85.10% of the respondents recommended patients to undergo surgery within 3 months after ligament injury. Besides, the vast majority of respondents chose to retain the ligamentous remnant bundle (92.98%) and recommended routine use of knee braces postoperatively (94.09%). It is recommended to perform arthroscopic single-bundle ACL reconstruction with the remnant preserving technique using a hamstring autograft within 3 months of ACL rupture, with support of postoperative functional braces.

IL-6 induces periostin production in human ACL remnants: a possible mechanism causing post-traumatic osteoarthritis

OBJECTIVE

Perostin (POSTN) and IL-6 consistently elevated after ACL injury, and ACL has been proposed as the major source of POSTN. However, there is a lack of evidence whether IL-6 induces ACL remnants to produce POSTN. This study aimed to investigate the effect of IL-6 on POSTN production in ACL fibroblasts, which may help us understand more about the mechanism of PTOA after ACL injury and ACL reconstruction.

METHODS

ACL remnants were harvested from 27 patients undergoing ACL reconstruction. Quantitative real-time polymerase chain reaction (PCR) was performed to examine the POSTN gene expression of ACL fibroblasts after treatment of different concentrations of IL-6. The POSTN protein production of ACL fibroblasts was determined using western blot analysis. The blockers of possible signaling pathways, including PI3K/Akt, Ras/MAPK, and JAK/STAT pathways, were added to test whether the effect of IL-6 on ACL fibroblast could be attenuated. ACL fibroblast and chondrocyte co-culture was carried out to determine the influence of ACL and IL-6 on chondrocytes.

RESULTS

Quantitative real-time PCR showed that IL-6 time-dependently and dose-dependently increased POSTN gene expression of ACL fibroblast. Western blot analysis also revealed that IL-6 dose-dependently induced POSTN protein production. Regarding the chronicity of ACL injury, the POSTN protein production was comparable between ACL remnants which were derived within 3 months of injury and at least 6 months after injury. PI3K/Akt blockers could attenuate the effect of IL-6 on ACL remnants, whereas Ras/MAPK and JAK/STAT did not decrease POSTN production. The coexistence of ACL and IL-6 induced more MMP-13 and ADAMTS-4 by chondrocytes.

CONCLUSIONS

IL-6 induced ACL remnants to produce POSTN. This effect could be attenuated by the PI3K/Akt blocker. Coexistence of IL-6 and ACL remnants may accelerate post-traumatic arthritis.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear

PURPOSE

The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender.

METHODS

Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%).

RESULTS

Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001).

CONCLUSION

Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury.

LEVEL OF EVIDENCE

Level III.

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.

Survival of anterior cruciate ligament reconstructions in active-duty military populations

PURPOSE

Anterior cruciate ligament tears and anterior cruciate ligament reconstruction (ACLR) are common in young athletes. The modifiable and non-modifiable factors contributing to ACLR failure and reoperation are incompletely understood. The purpose of this study was to determine ACLR failure rates in a physically high-demand population and identify the patient-specific risk factors, including prolonged time between diagnosis and surgical correction, that portend failure.

METHODS

A consecutive series of military service members with ACLR with and without concomitant procedures (meniscus [M] and/or cartilage [C]) done at military facilities between 2008 and 2011 was completed via the Military Health System Data Repository. This was a consecutive series of patients without a history of knee surgery for two years prior to the primary ACLR. Kaplan-Meier survival curves were estimated and evaluated with Wilcoxon test. Cox proportional hazard models calculated hazard ratios (HR) with 95% confidence intervals (95% CI) to identify demographic and surgical factors that influenced ACLR failure.

RESULTS

Of the 2735 primary ACLRs included in the study, 484/2,735 (18%) experienced ACLR failure within four years, including (261/2,735) (10%) undergoing revision ACLR and (224/2,735) (8%) due to medical separation. The factors that increased failure include Army Service (HR 2.19, 95% CI 1.67, 2.87), > 180 days from injury to ACLR (HR 1.550, 95% CI 1.157, 2.076), tobacco use (HR 1.429 95% CI 1.174, 1.738), and younger patient age (HR 1.024, 95% CI 1.004, 1.044).

CONCLUSION

The overall clinical failure rate of service members with ACLR is 17.7% with minimum four-year follow-up, where more patients are likely to fail due to revision surgery than medical separation. The cumulative probability of survival at 4 years was 78.5%. Smoking cessation and treating ACLR patients promptly are modifiable risk factors impacting either graft failure or medical separation.

LEVEL OF EVIDENCE

Level III.

Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes

BACKGROUND

Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients.

PURPOSE

To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery.

RESULTS

Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P = .006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P = .24).

CONCLUSION

In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury.

High revision arthroscopy rate after ACL reconstruction in men's professional team sports

PURPOSE

The study analysed unique data on anterior cruciate ligament (ACL) injuries among German professional male team sports over five consecutive seasons with the aim of improving medical outcomes in the future. Sport-specific differences in injury occurrence, concomitant injuries, timing of ACL reconstruction, graft type selection and short-term complications were examined.

METHODS

This retrospective study analysed trauma insurance data on all complete ACL tears from players with at least one competitive match appearance in the two highest divisions of German male basketball, ice hockey, football and handball. Each complete ACL tear registered by clubs or physicians between the 2014/15 and 2018/19 seasons with the German statutory accidental insurance for professional athletes (VBG) as part of occupational accident reporting was included.

RESULTS

In total, 189 out of 7517 players (2.5%) sustained an ACL injury, mainly in handball (n = 82; 43.4%) and football (n = 72; 38.1%) followed by ice hockey (n = 20; 10.6%) and basketball (n = 15; 7.9%).Seventeen players (9.0%) also sustained a second ACL injury. Thus, 206 ACL injuries were included in the analysis. The overall match incidence of ACL injuries was 0.5 per 1000 h and was highest in handballs (1.1 injuries per 1000 h). A total of 70.4% of ACL injuries involved concomitant injury to other knee structures, and 29.6% were isolated ACL injuries. The highest rate of isolated ACL injuries was seen in ice hockey (42.9%). All ACL injuries, except for one career-ending injury, required surgery. In the four analysed team sports, hamstring tendons (71.4%) were the most commonly used grafts for ACL reconstruction; football had the highest percentage of alternative grafts (48.7%). During rehabilitation, 22.9% of all surgically treated ACL injuries (n = 205) required at least two surgical interventions, and 15.6% required revision arthroscopy. The main cause of revision arthroscopy (n = 32; 50.0%) was range-of-motion deficit due to arthrofibrosis or cyclops formation.

CONCLUSION

The present study shows an overall high rate of revision arthroscopy after ACLR (15.6%), which should encourage surgeons and therapists to evaluate their treatment and rehabilitation strategies in this specific subpopulation. Hamstring tendon grafts are most commonly used for ACL reconstruction but have the highest revision and infection rates. Handball shows the highest ACL injury risk of the four evaluated professional team sports. Concomitant injuries occur in the majority of cases, with the highest share of isolated ACL injuries occurring in ice hockey.

LEVEL OF EVIDENCE

Level III.

Posterior Horn Lateral Meniscal Oblique Radial Tear in Acute Anterior Cruciate Ligament Reconstruction Incidence and Outcomes After All-Inside Repair: Clinical and Second-Look Arthroscopic Evaluation

BACKGROUND

The term posterior horn lateral meniscal oblique radial tear (LMORT) has emerged to characterize the tear patterns of the lateral meniscus in many patients with acute anterior cruciate ligament (ACL) injury. There is a lack of data regarding the exact incidence according to the types of LMORT and clinical outcomes.

PURPOSES

(1) To investigate the incidence of LMORT according to type in patients with acute ACL reconstruction (ACLR) and (2) to identify healing status after repair of LMORT via second-look arthroscopy and clinical outcomes.

STUDY DESIGN

Case series; Level of evidence: 4.

METHODS

Patients who underwent primary ACLR within 6 months of injury were retrospectively reviewed. The LMORT was classified into 4 types based on the severity and distance from the root: type 1 (partial tear <10 mm from the root), type 2 (complete tear <10 mm from the root), type 3 (partial tear >10 mm from the root), type 4a (complete tear >10 mm from the root), and type 4b (type 4a with longitudinal tear at the meniscocapsular junction). Only patients with LMORT were isolated, and the clinical outcomes were compared according to the healing status of LMORT in second-look arthroscopy.

RESULTS

Of 635 patients with ACLR, LMORT was identified in 97 patients (15.3%), and type 4 LMORT accounted for the largest proportion (n = 62; 32.6%) of 190 lateral meniscal tears. In 79 patients with LMORT who satisfied the 2-year follow-up period, all patient-reported outcomes (PROs), including the Lysholm (preoperative, 64.1; postoperative, 88.2) and International Knee Documentation Committee subjective (preoperative, 50.5; postoperative, 82.9) scores, were significantly improved (P < .001) 31.8 months postoperatively. Of the 61 patients who underwent second-look arthroscopy, 49 (80.3%) were classified into the complete healing group. There was no significant difference in postoperative PROs between the complete and partial healing groups.

CONCLUSION

The incidence of LMORT was 15.3% in patients with acute ACL injury, and type 4 LMORT was the most common type. Complete healing of LMORT was achieved in 80.3% of patients who underwent second-look arthroscopy, and the PROs were significantly improved postoperatively. Good clinical results can be achieved if the LMORT is repaired as much as possible during ACLR.

Relationship Between Timing of Anterior Cruciate Ligament Reconstruction and Chondral Injuries: A Systematic Review and Meta-analysis

BACKGROUND

After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear.

PURPOSE

To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged >16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model.

RESULTS

After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs >3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003).

CONCLUSION

Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage.

REGISTRATION

CRD42016032846 (PROSPERO).

Risk factors of cartilage lesion after anterior cruciate ligament reconstruction

Anterior cruciate ligament injury is the most common sports injury in orthopaedics, which can adversely affect knee joint function and exercise of patients. Using arthroscopy to reconstruct the anterior cruciate ligament has become the first choice for treating anterior cruciate ligament rupture. However, different degrees of articular cartilage injury of the knee can be observed in patients after anterior cruciate ligament reconstruction. More importantly, the articular cartilage injury after anterior cruciate ligament reconstruction indicates that it will develop into osteoarthritis in the long term. It is of great significance to fully understand the factors that lead to the occurrence and development of cartilage injury. This article reviews the effects of surgical methods, meniscus status, different grafts, time from injury to surgical intervention, postoperative knee joint stability, postoperative rehabilitation, knee joint anatomical factors, and demographic characteristics of patients on articular cartilage degeneration after anterior cruciate ligament reconstruction. The present review provides insights into the anterior cruciate ligament reconstruction, which can be used to investigate new treatment strategies to delay and prevent the progress of osteoarthritis. At the same time, it provides a holistic understanding of the influence of multiple factors on cartilage lesions after anterior cruciate ligament reconstruction.

A larger side-to-side difference in anterior knee laxity increases the prevalence of medial and lateral meniscal injuries in patients with ACL injuries

PURPOSE

The objective of this study was to investigate factors that influence the prevalence of medial and lateral meniscal injuries at the time of anterior cruciate ligament (ACL) reconstruction in patients with ACL injuries.

METHODS

Patients with ACL injuries at 9 institutions were enrolled in this multicentre study. Age, sex, duration between injury and surgery, pivot shift test grade, anterior knee laxity determined using the Kneelax 3 arthrometer, and other variables were assessed by logistic regression analysis. Meniscal conditions were evaluated via arthroscopy.

RESULTS

In all, 830 patients were enrolled. The prevalence of medial and lateral meniscal tears was 32.0% (266 knees) and 26.5% (220 knees), respectively. Significant factors that influenced the prevalence of medial meniscal injuries were age [odds ratio (OR) 1.03; P = 0.000], side-to-side differences in instrumented anterior knee laxity before surgery (OR 1.12; P = 0.002), duration between injury and surgery (≥ 12 months) (OR 1.86; P = 0.023), and pivot shift test grade (OR 1.36; P = 0.014). Significant factors of lateral meniscal injury were side-to-side differences in anterior knee laxity before surgery (OR 1.12; P = 0.003) and the male sex (OR 1.50; P = 0.027).

CONCLUSION

Greater anterior knee laxity, age, a longer duration between injury and surgery, and a higher pivot shift test grade predicted medial meniscal injury. Greater anterior knee laxity and the male sex predicted lateral meniscal injury. In patients with ACL injuries, the importance of side-to-side differences in anterior knee laxity should be rediscovered from the viewpoint of meniscal conditions.

LEVEL OF EVIDENCE

Level III.

Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries-Differentiation Based on Tendon Graft and Concomitant Injuries

Background: Although anterior cruciate ligament reconstruction (ACLR) is a well-established procedure and is standardly performed by orthopedic surgeons all over the world, there does not seem to be a standard protocol for early rehabilitation. The purpose of this study was to give answers to the following questions: (i) Does (a) the use of a specific tendon graft, and (b) potentially additional therapy of concomitant pathologies influence surgeons’ choice of a distinct postoperative rehabilitation protocol after ACLR? (ii) To what extent do these rehabilitation recommendations differ? Methods: Retrospective analysis of currently used early rehabilitation protocols after ACLR in German-speaking countries (GER, AUT and SUI) was conducted. Rehabilitation criteria included weight bearing, range of motion (ROM), the utilization of braces, continuous passive/active motion therapy (CPM/CAM), rehabilitation training and sport-specific training. Tendon grafts were differentiated as hamstring (HAM) and bone−patellar tendon−bone grafts (BTB). Concomitant pathologies included meniscus injuries (+M) and unhappy triad injuries (+UTI). Results: Most of the surveyed protocols were differentiated according to the used tendon graft or additional therapy of concomitant injuries (ACLR-differentiated, n = 147 vs. ACLR without graft differentiation, n = 58). When comparing ACLR-HAM and ACLR-BTB, significant differences were found regarding weight bearing (p = 0.01), ROM (p = 0.05) and the utilization of braces (p = 0.03). Regarding ACLR+M, an overall significant decelerated rehabilitation could be detected. After ACLR+UTI-therapy, a significant delayed start to full weight bearing (p = 0.002) and ROM (p < 0.001) was found. Conclusions: Most orthopedic surgeons from German-speaking countries differentiate early rehabilitation after ACLR according to the tendon graft used and therapy of concomitant pathologies. No consensus about early rehabilitation after ACLR is available. However, tendencies for an accelerated rehabilitation after ACLR-BTB and a more restrained rehabilitation of multiple injured knees were detected.

Predictive Factors Associated With Short-Term Clinical Outcomes and Time to Return to Activity After Arthroscopic Partial Meniscectomy in Nonathletes

Background:

Although arthroscopic partial meniscectomy is a widely implemented surgical procedure, studies investigating the time to return to activity (RTA) are rare.

Purpose:

To explore which factors are associated with the RTA times after arthroscopic partial meniscectomy and to investigate whether those factors can also improve short-term patient-reported outcomes.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The authors reviewed the records of patients who underwent isolated partial meniscectomy in their institution from January 2017 to December 2019. Patient and injury characteristics were documented, and time to RTA was obtained via phone interview in January 2021. Pre- and postoperative outcomes were assessed with the Lysholm score and International Knee Documentation Committee (IKDC) score. The chi-square test and independent-samples t test were used to evaluate differences in outcome scores and time to RTA according to the patient and injury characteristics, and risk factors with a P value <.1 in the univariate analysis were used in the binary regression.

Results:

Included were 215 patients (87 men and 128 women; mean age, 33.7 years [range, 24-75 years]). Of these patients, 204 provided information on time to RTA (mean, 3.3 months). By 3 months postoperatively, 49.5% (101/204) of patients could perform activities without knee-related restriction; this improved to 69.6% (142/204) at 6 months and 90.2% (184/204) at 12 months. On multivariate logistic regression analysis, age (OR, 0.39; 95% CI, 0.21-1.19; P = .044) and injury duration (OR, 0.20; 95% CI, 0.19-1.07; P = .032) were significantly associated with the time to RTA. IKDC scores improved significantly from 41.2 preoperatively to 76.7 postoperatively, and in the multivariate logistic regression model, female sex (OR, 2.67; 95% CI, 1.10-6.47; P = .030), body mass index (BMI) ≥27 kg/m² (OR, 2.96; 95% CI, 1.02-8.66; P = .047), and medial meniscal tear (OR, 0.20; 95% CI, 0.04-1.00; P = .050) were associated with inferior outcome scores.

Conclusion:

Patients aged 40 years and younger who underwent partial meniscectomy surgery within 6 months after a meniscal tear were more likely to have a shorter time to RTA, and female patients with obesity (BMI ≥27 kg/m2), especially those with medial meniscal tears, tended to have inferior clinical outcomes.

The Multivariate Relationship Between Primary Anterior Cruciate Ligament Reconstruction Timing and Revision Rates: A 10-Year Analysis

Background and objective

The optimal timing of anterior crucial ligament reconstruction (ACLR) remains a matter of controversy. A revision procedure is performed to improve knee function, correct instability, and enable a safe return to daily function when primary ACLR fails. The present study aimed to determine if the timing of primary ACLR is predictive of revision surgery.

Methods

All patients who underwent primary ACLR at the West Virginia University from January 2008 to December 2018 were identified. Patients were initially grouped into early (≤30 days) and late (>30 days) ACLR based on the onset of the initial injury. The major outcome measure of this study was the incidence of revision ACLR following primary ACLR.

Results

A total of 233 primary ACLRs were included. The incidence of ACLR revisions was 9.4%. The timing of primary ACLR, when categorized into early and late ACLRs, was not found to influence revision risk (p=0.384). Additionally, the damaged anatomical structures based on the postoperative diagnosis at the time of ACLR did not influence the odds of revision ACLR (p=0.9721).

Conclusion

Our study found that the timing of primary ACLR did not influence the revision rates when categorizing primary surgery time into early and late subgroups.

An older age, a longer duration between injury and surgery, and positive pivot shift test results increase the prevalence of articular cartilage injury during ACL reconstruction in all three compartments of the knee in patients with ACL injuries

PURPOSE

To investigate factors that influence the prevalence of articular cartilage injury in patients with anterior cruciate ligament (ACL) injury.

METHODS

This multicentre study included patients with ACL injury. Logistic regression analysis was conducted to identify factors that influence the prevalence of cartilage injury during ACL reconstruction.

RESULTS

A total of 811 patients were enrolled. The factors that significantly influenced the prevalence of cartilage injury were age (odds ratio [OR], 1.04; P = 0.000), a positive pivot shift test result (OR, 1.43; P = 0.021), medial meniscal injury (OR, 2.55; P = 0.000), and delayed surgery (≥ 12 months) (OR, 2.52; P = 0.028) in the medial compartment of the knee; age (OR, 1.05; P = 0.000), subjective grades of apprehension during the pivot shift test (OR, 1.46; P = 0.010), lateral meniscal injury (OR, 1.98; P = 0.003), femoro-tibial angle (FTA) (OR, 0.92; P = 0.006), and delayed surgery (≥ 12 months) (OR, 2.63; P = 0.001) in the lateral compartment; and age (OR, 1.06; P = 0.000), body mass index (OR, 1.07; P = 0.028), a positive pivot shift test result (OR, 1.60; P = 0.018), FTA (OR, 0.90; P = 0.006), and delayed surgery (≥ 12 months) (OR, 3.17; P = 0.008) in the patellofemoral compartment.

CONCLUSION

An older age, a longer duration between injury and surgery, and a positive pivot shift test result were positively associated with the prevalence of cartilage injury in three compartments in patients with ACL injuries. Early ACL reconstruction is recommended to prevent cartilage injury.

LEVEL OF EVIDENCE

Level III.

Early Return to Sports to Continue the Season after Anterior Cruciate Ligament Injury Is Not Recommended for Student Athletes

Objective:

The objectives of this study were to investigate whether student athletes with anterior cruciate ligament (ACL) injuries who returned to sports (RTS) without reconstruction could continue their sporting activities until the end of the season and whether there was an increase in secondary damage associated with knee instability.

Methods:

Altogether, 288 skeletally mature patients aged <25 years with new-onset isolated primary ACL injuries were included. Of these, 20 student athletes continued playing sports without ACL reconstruction to try to finish the season and were classified as the early return to sports (ERS) group; the remaining 268 patients, who immediately quit sports and underwent surgery, were classified as the non-ERS group. Knee symptoms and sporting performance for the rest of the season were assessed for the ERS group. The presence of secondary damage, e.g., meniscus injuries and chondral lesions, associated with instability were compared between the two groups.

Results:

Fourteen ERS-group athletes (70%) indicated that their knees had given way during sporting activities, and seven athletes (35%) were unable to complete the season. In the ERS group, the mean self-estimated performance level after injury was 3.8 ± 2.5 (numeric rating scale 0–10). Despite the RTS period being relatively short, medial meniscus tears (P <0.001) significantly increased in the ERS group, and three patients experienced locking of the medial meniscus and required immediate surgery.

Conclusions:

Although ERS without reconstruction to complete the season may be a reasonable strategy for ACL injury, patients’ self-estimated performance level was low and meniscal and cartilage injury rates significantly increased.

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement

BACKGROUND

The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery.

METHODS

Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05.

RESULTS

379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID).

CONCLUSION

Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

Anterior Cruciate Ligament Surgery Performed Less Than 3 Weeks After Injury Is Not Inferior to Delayed Surgery

Performing anterior cruciate ligament (ACL) surgery in the immediate period after injury is controversial. However, there may be instances where the opportunity cost of delayed surgery for the patient may be unacceptable. Concomitant meniscus injuries may also prevent the patient from regaining range of motion in the preoperative period. Every week that surgery is delayed may increase pain and impair mobility for this group of patients. We investigate the functional and clinical outcomes in patients with ACL surgery in the immediate 3-week period following ACL injury. A cohort study was performed to compare the outcome of early ACL (less than 3 weeks after injury) and late ACL surgery (more than 3 weeks after surgery). A total of 58 patients were followed up at fixed time points over a 2-year period. Clinical measurements (range of motion and knee laxity scores) and functional outcome scores (International Knee Documentation Committee, Lysholm's Knee and Tegner's scores) were used to document outcomes over time. The mean time to surgery from the time of injury in the early ACL surgery group was 2 weeks (standard deviation [SD] = 0.45) and the 20 weeks (SD = 9.64) in the late ACL surgery group. The absence or presence of meniscal injuries had no significant effect on the improvement over time for both groups of patients (p > 0.05). Patients in the early ACL group had faster rates of improvement for clinical measurements and functional outcome scores but had started out initially with poorer outcomes at baseline. However, both groups had comparable outcomes (p > 0.05) at the 1- and 2-year mark postsurgery. Patients in both groups had no adverse outcomes. ACL Surgery within 3 weeks of injury (2 weeks SD = 0.45) is safe and has comparable outcomes compared to patients with delayed surgery (20 weeks SD = 9.64).

Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques

Background:

Previous studies have suggested that increased mechanical stress due to acute graft bending angle (GBA) is associated with tunnel widening and graft failure after anterior cruciate ligament (ACL) reconstruction. Few studies have compared the GBA between the outside-in (OI) and the transportal (TP) techniques.

Purpose:

To evaluate the influence of GBA on clinical outcomes and tunnel widening after ACL reconstruction with OI versus TP technique.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in the study were 56 patients who underwent double-bundle ACL reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical outcomes (Lysholm, International Knee Documentation Committee, Tegner score, and knee laxity) 1 year postoperatively were evaluated. Computed tomography scans at 5 days and 1 year postoperatively were used for imaging measurements, and the femoral tunnel was divided into the proximal third, middle, and aperture sections. The GBA and cross-sectional area (CSA) were measured using image analysis software and were compared between groups. A correlation analysis was performed to determine if the GBA affected clinical outcomes or tunnel widening.

Results:

No significant difference was observed in clinical outcomes between the groups. The GBA of both the anteromedial (AM) and posterolateral bundles were more acute in the OI group compared with the TP group (P < .05). The CSA at the AM tunnel aperture increased significantly in the OI group (84.2% ± 64.3%) compared with the TP group (51.4% ± 36.7%) (P = .04). However, there were no differences in the other sections. In the Pearson correlation test, GBA was not correlated with tunnel widening or clinical outcomes.

Conclusion:

Regardless of technique, the GBA did not have a significant influence on tunnel widening or clinical outcomes. Considering a wider AM tunnel aperture, a more proximal and posterior AM tunnel position might be appropriate with the OI technique.

ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group

OBJECTIVES

The primary objective of this survey was to gauge the current global trends in anterior cruciate ligament reconstruction (ACLR) as reported by the members of the Anterior Cruciate Ligament (ACL) Study Group (SG).

METHODS

A survey was created and distributed among the members of the ACL SG consisting of 87 questions and 16 categories related to ACLR, including member demographics, preoperative management, primary ACLR techniques and graft choice, use of concomitant procedures and biological augmentation, postoperative rehabilitation, and more.

RESULTS

The survey was completed by the 140 members of the ACL SG. Fifty per cent of members are from Europe, 29% from the USA, 15% from the Asia-Pacific and the remaining 6% are from Latin America, the Middle East, New Zealand and Africa. Most (92%) do not believe there is a role for non-operative management of ACL tears in higher level athletes; conversely, most agree there is a role for non-operative management in lower impact athletes (92%). A single-bundle (90%) technique with hamstring autograft (53%) were most common for primary ACLR. Tunnel position varied among respondents. Sixty-one per cent do not use allograft for primary ACLR. Fifty per cent of respondents use cortical suspensory fixation on the femur, with variable responses on the tibia. Most (79%) do not use biologics in primary ACLR, while 83% think there is a selective role for extra-articular augmentation in primary ACLR. Fifty per cent prefer bone-tendon-bone autograft for revision ACLR and extra-articular augmentation is more commonly used (13% always, 26% often) than in primary ACLR (0% always, 15% often). A majority (53%) use a brace after primary ACLR. The most common responses for minimal time to return to play after primary ACLR were 6-8 months (44%) and 8-12 months (41%).

CONCLUSION

We presented the thoughts and preferences of the ACL SG on the management of ACL injuries. This survey will help to facilitate an ongoing discussion with regard to ACLR by providing global insights into the current surgical trends in ACLR.

LEVEL OF EVIDENCE

Level V, Expert Opinion.

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.

Effect of Early Residual Laxity After Anterior Cruciate Ligament Reconstruction on Long-term Laxity, Graft Failure, Return to Sports, and Subjective Outcome at 25 Years

BACKGROUND

In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction (ACLR), and its clinical effect is undetermined.

PURPOSE

To investigate whether a 3- to 5-mm increase in anterior translation 6 months after ACLR affects the risk of graft failure, rate of return to sports, and long-term outcome.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From a cohort of 234 soccer, team handball, and basketball players undergoing ACLR using bone-patellar tendon-bone graft, 151 athletes were included who attended 6-month follow-up that included KT-1000 arthrometer measures. A tight graft was defined as <3-mm side-to-side difference between knees (n = 129), a slightly loose graft as 3 to 5 mm (n = 20), and a loose graft as >5 mm (n = 2). Graft failure was defined as ACL revision surgery, >5-mm side-to-side difference, or anterolateral rotational instability 2+ or 3+ at 2-year follow-up. Finally, a 25-year evaluation was performed, including a clinical examination and questionnaires.

RESULTS

The rate of return to pivoting sports was 74% among athletes with tight grafts and 70% among those with slightly loose grafts. Also, return to preinjury level of sports was similar between those with slightly loose and tight grafts (40% vs 48%, respectively), but median duration of the sports career was longer among patients with tight grafts: 6 years (range, 1-25 years) vs 2 years (range, 1-15 years) (P = .01). Five slightly loose grafts (28%) and 6 tight grafts (5%) were classified as failures after 2 years (P = .002). Thirty percent (n = 6) of patients with slightly loose grafts and 6% (n = 8) with tight grafts had undergone revision (P = .004) by follow-up (25 years, range, 22-30 years). Anterior translation was still increased among the slightly loose grafts as compared with tight grafts at long-term follow-up (P < .05). In patients with tight grafts, 94% had a Lysholm score ≥84 after 24 months and 58% after 25 years, as opposed to 78% (P = .02) and 33% (P = .048), respectively, among patients with slightly loose grafts.

CONCLUSION

A slightly loose graft at 6 months after ACLR increased the risk of later ACL revision surgery and/or graft failure, reduced the length of the athlete's sports career, caused permanent increased anterior laxity, and led to an inferior Lysholm score.

Delayed Anterior Cruciate Ligament Reconstruction Increases the Risk of Abnormal Prereconstruction Laxity, Cartilage, and Medial Meniscus Injuries

PURPOSE

To determine the association between a delay in anterior cruciate ligament reconstruction (ACLR), age, sex, body mass index (BMI) and cartilage injuries, meniscus injuries, meniscus repair, and abnormal prereconstruction laxity.

METHODS

Patients who underwent primary ACLR at our institution from January 2005 to March 2017, with no associated ligament injuries, were identified. Logistic regression analyses were used to evaluate whether delay in ACLR, age, sex, and BMI were risk factors for cartilage and meniscus injuries, meniscus repair, and abnormal (side-to-side difference >5 mm) prereconstruction laxity.

RESULTS

A total of 3976 patients (mean age 28.6 ± 10.6 years, range 10-61 years) were included. The risk of cartilage injury increased with a delay in ACLR (12-24 months: odds ratio [OR] 1.20; 95% confidence interval [CI] 1.05-1.29; P = .005; and > 24 months: OR 1.20; 95% CI 1.11-1.30; P < .001) and age ≥30 years (OR 2.27; 95% CI 1.98-2.60; P < .001). The risk of medial meniscus (MM) injury increased with a delay in ACLR (12-24 months: OR 1.20; 95% CI 1.07-1.29; P = .001; and >24 months: OR 1.22; 95% CI 1.13-1.30; P < .001), male sex (OR 1.16; 95% CI 1.04-1.30; P = .04) and age ≥30 years (OR 1.20; 95% CI 1.04-1.33; P = .008). The risk of lateral meniscus (LM) injury decreased with a delay in ACLR of >3 months and age ≥30 years (OR 0.75; 95% CI 0.66-0.85; P < .001), whereas it increased with male sex (OR 1.32; 95% CI 1.22-1.41; P < .001). MM repairs relative to MM injury decreased with a delay in ACLR (6-12 months: OR 0.70; 95% CI 0.54-0.92; P = .01; 12-24 months: OR 0.69; 95% CI 0.57-0.85; P < .001; >24 months: OR 0.61; 95% CI 0.52-0.72; P < .001) and age ≥30 years (OR 0.60; 95% CI 0.48-0.74; P < .001). LM repairs relative to LM injury only decreased with age ≥30 years (OR 0.34; 95% CI 0.26-0.45; P < .001). The risk of having abnormal knee laxity increased with a delay in ACLR of >6 months and MM injury (OR 1.52; 95% CI 1.16-1.97; P = .002), whereas it decreased with a BMI of ≥25 (OR 0.68; 95% CI 0.52-0.89; P = .006).

CONCLUSIONS

A delay in ACLR of >12 months increased the risk of cartilage and MM injuries, whereas a delay of >6 months increased the risk of abnormal prereconstruction laxity and reduced the likelihood of MM repair. To reduce meniscus loss and the risk of jeopardizing knee laxity, ACLR should be performed within 6 months after the injury.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative study.

Trends in Meniscal Allograft Transplant in the Republic of Korea, 2010-2018: An Analysis Based on the Korean National Health Insurance Claims Database

Background:

Analyzing the current trends in meniscal allograft transplant (MAT) is important. However, no recent descriptive epidemiological study based on a national registry database has been reported.

Purpose:

To assess serial trends in the incidence of MAT in the Republic of Korea between 2010 and 2018, stratified by age and sex.

Study Design:

Descriptive epidemiology study.

Methods:

The number of MAT procedures between 2010 and 2018 was assessed using the Korean National Health Insurance claims database. We used code N0825 for isolated MAT and code N0820 for MAT combined with other procedures, such as ligament reconstruction, realignment surgery, and cartilage procedures. The incidence of MAT was calculated using the general population data of the Republic of Korea, and Poisson log-linear regression analysis was used to assess statistical serial trends.

Results:

A total of 369 patients underwent MAT in 2010 and 774 in 2018, with an increase of 47.6%. The incidence of MAT per 100,000 person-years in the Republic of Korea increased significantly during the period studied, from 0.75 in 2010 to 1.50 in 2018 (annual relative risk = 1.09; 95% CI, 1.08-1.10; P < .001), whereas the rate of MAT combined with other procedures increased from 5.1% in 2014 to 16.0% in 2018. MAT was mostly performed in men in their early 20s. Most MAT procedures were performed in the summer and winter, with distinct seasonal variances.

Conclusion:

In the Republic of Korea, the incidence of MAT in 2018 was 1.50 per 100,000 person-years, with an average annual increase of 10% since 2010. MAT was mostly performed in men in their early 20s, and the rate of MAT combined with other procedures has increased since 2014.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V.

Risk Factors Related to the Presence of Meniscal Injury and Irreparable Meniscal Tear at Primary Anterior Cruciate Ligament Reconstruction

Background:

Few studies have attempted to identify risk factors associated with irreparable meniscal tears at anterior cruciate ligament reconstruction (ACLR) and to describe follow-up data, such as the failure rate, after meniscal repair.

Purpose:

To investigate the associations of age, sex, body mass index (BMI), time to surgery (TTS), and preinjury Tegner score with the presence of meniscal injuries and irreparable meniscal tears at primary ACLR.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A retrospective review was performed on 784 patients who underwent primary ACLR by a single surgeon between 2005 and 2017 (406 men and 378 women; mean age, 25.8 years; mean BMI, 23.1; median TTS, 3 months; median preinjury Tegner score, 7). All patients had a minimum follow-up of 12 months (mean postoperative follow-up, 33.0 months). Multivariate logistic regression analysis was conducted to determine the association of patient variables with the presence of meniscal injuries and irreparable meniscal tears during primary ACLR.

Results:

The risk factor for medial meniscal injuries was TTS ≥3 months (odds ratio [OR], 4.213; 95% CI, 3.104-5.719; P < .001). The presence of irreparable medial meniscal tears increased with older age (OR, 1.053; 95% CI, 1.024-1.084; P < .001), higher BMI (OR, 1.077; 95% CI, 1.003-1.156; P = .042), and TTS ≥3 months (OR, 1.794; 95% CI, 1.046-3.078; P = .034). On multivariate analysis, none of the variables were significantly associated with lateral meniscal injuries and irreparable meniscal tears. The failure rate, defined as patients who needed additional medial meniscal surgery after medial meniscal repair, was 4.6%.

Conclusion:

Time from ACL injury to reconstruction of ≥3 months was strongly associated with medial meniscal injuries and irreparable medial meniscal tears at primary ACLR. Older age and increased BMI were also risk factors for the presence of irreparable medial meniscal tears at ACLR.

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.

Failed Meniscal Repairs After Anterior Cruciate Ligament Reconstruction Increases Risk of Revision Surgery

Background:

Failed anterior cruciate ligament (ACL) reconstruction (ACLR) can lead to reduced quality of life because of recurrent episodes of instability, restrictions in level of activity, and development of osteoarthritis. A profound knowledge of the causes of a failed surgery can ultimately help improve graft survival rates.

Purpose:

To investigate the patient-related risks of inferior outcomes leading to revision surgery after ACLR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

From a prospective cohort of primary ACLRs performed at a single center, patients who required later revision surgery were matched with a control group of uneventful primary ACLRs. Patient characteristics, data from the preoperative examinations, KT-1000 arthrometer laxity testing, Tegner activity scale, International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, and perioperative data from the initial surgery were included.

Results:

A total of 100 revision cases and 100 matched controls, with a median follow-up time of 11 years, were included in the study. Those who had undergone revision surgery were younger at the time of reconstruction and had a shorter time from injury to surgery than their matched controls (P = .006). The control group—of uneventful ACLRs—had a higher incidence of meniscal repair at reconstruction (P = .024). Also, the revision group more frequently experienced later failure of the previous meniscal repair (P = .004). Surgeon experience was not found to affect the risk of revision ACL surgery. Those who had undergone ACL revision surgery had more frequently received a hamstring tendon graft size of <8 mm (P = .018) compared with the controls.

Conclusion:

The current study demonstrated that failed meniscal repair and a hamstring tendon graft size of <8 mm were associated with primary ACLR failure. Also, younger age at the time of surgery and shorter time from injury to surgery were found to affect the risk of undergoing revision ACL surgery.

ACL injuries before 15 years of age: could the young become an athlete?

PURPOSE

The purpose of this study was to systematically assess the possibility for a patient younger than 15 to return to a competitive level of sport following an ACL injury.

METHODS

Four databases were analyzed (PubMed, MedLine, Cinahl, Cochrane Library and LISTA). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to guide the screening of the literature. Studies about functional and surgical treatments were included with a minimum of 5 years of mean follow-up. Methodological quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale.

RESULTS

Ten studies were included, corresponding to a total of 217 patients. All studies were retrospective with level 4 evidence. Seven studies reported results of a transphyseal technique reconstruction, two studies a physeal-sparing reconstruction, and one studied the results of a repair (« healing response »). Only one study compared functional treatment and surgery. The mean age of patients at the time of surgery was 12.29 years (range 2-16) with a mean follow-up of 7.9 years (range 5.5-18.3). Return to sport was possible for 80 to 100% of patients (average of 91.7%) at the final follow-up but the level for return to sport was reported in only four studies and found between 61 and 89% for return to the same level and at 42% for return to a competitive level. Evolution of the Tegner score was analyzed in five studies and was reported to decrease at the follow-up in three studies. ACL re-ruptures can be considered as failure of the graft (nine studies with surgical technique) and occurred with an average of 16%.

CONCLUSION

This review demonstrate that ACL reconstruction is superior to conservative treatment and 'healing response' in terms of revision rates and knee laxity. Return to sport is possible for more than 4/5 of patients but only two thirds of them were able to return to the same level or to competitive level, and failure rates of the graft were not superior to global population. However, qualities of included studies and variability of treatment limited the clinical application of results. Despite this, patients and parents should be informed that ACL injuries are lesions that may influence the level of sport at a 5-year follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review.

Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

Re-revision anterior cruciate ligament reconstruction showed more laxity than revision anterior cruciate ligament reconstruction at a minimum 2-year follow-up

PURPOSE

This study aimed to compare patient demographics, associated lesions (concurrent meniscal and chondral injuries), and clinical outcomes between revision and re-revision anterior cruciate ligament reconstructions.

METHODS

Patients who underwent revision or re-revision anterior cruciate ligament reconstruction between 2008 and 2016 with a minimum 2-year follow-up were retrospectively evaluated. Detailed patient demographic data, radiographic preoperative tunnel diameters, posterior tibia slope, and concurrent meniscal and chondral lesion were reviewed. Clinical scores and laxity tests' results were compared between the groups at the last follow-up.

RESULTS

Eighty-two patients (mean age, 33.8 ± 9.9 years; revision group, n = 62; re-revision group, n = 20) were included. The re-revision group showed a higher grade for preoperative arthritis (P < 0.001); more severe preoperative bone defects of the femoral (13.8 ± 2.6 vs 11.7 ± 2.7 mm, P = 0.004) and tibial tunnels (14.6 ± 2.4 vs 13.0 ± 2.3 mm, P = 0.010); and a higher prevalence of subtotal medial meniscectomy (P = 0.008) and chondral defects of the medial (P = 0.006) and lateral femoral condyles (P < 0.001), patella (P = 0.040), and trochlea (P = 0.036). At the final follow-up, the clinical scores did not differ significantly between the groups. However, the re-revision group showed more instability in the anterior drawer (P = 0.001), Lachman (P < 0.001), and pivot-shift (P < 0.001) tests, while a side-to-side difference was observed on the Telos stress radiographs (7.1 ± 4.7 vs 4.9 ± 3.7 mm, P = 0.038).

CONCLUSION

These findings showed that the patients who underwent re-revision had poor prognostic factors as compared with those who underwent revision anterior cruciate ligament reconstruction. Although the clinical scores did not differ significantly between the groups, the re-revision group showed more laxity at the 2-year follow-up.

LEVEL OF EVIDENCE

Cohort study; IV.

Magnetic resonance imaging can increase the diagnostic accuracy in symptomatic meniscal repair patients

PURPOSE

The purpose of this study was to evaluate meniscal repair healing in symptomatic patients through combined clinical assessment, magnetic resonance imaging (MRI) and re-arthroscopy. This study investigated the diagnostic accuracy of MRI and clinical assessment in determining failed meniscal repair in symptomatic meniscal repair patients, as verified by re-arthroscopy.

METHODS

Eighty patients were included. All had undergone a primary meniscal repair followed by an MRI and re-arthroscopy due to clinical symptoms of a meniscal lesion. A validated semi-quantitative scoring system was employed for identifying MRI-diagnosed healing failure. The clinical assessment was divided into joint swelling, joint-line tenderness, locking and a positive McMurray's test. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MRI and positive clinical findings were calculated using second-look arthroscopy as a standard.

RESULTS

The MRI results showed healing of 22 (27.5%) of the menisci and 58 (72.5%) unhealed menisci, whereas second-look arthroscopy identified 15 (19%) healed menisci and 65 (81%) unhealed menisci. The isolated MRI findings were 0.85, 0.8, 0.95 and 0.55 for sensitivity, specificity, PPV and NPV, respectively. The PPVs of the clinical assessments were 0.78, 0.85 and 0.94, with one, two and three clinical findings, respectively. A grade 3 MRI combined with joint-line tenderness presented a PPV of 0.98.

CONCLUSION

A supplementary MRI will increase diagnostic accuracy when fewer than three clinical findings are present in a symptomatic meniscal repair patient. The clinical relevance of this finding is that MRI contributes to enhancing the diagnostic accuracy of an unhealed meniscal repair when there are limited clinical signs of meniscal pathology.

LEVEL OF EVIDENCE

III.

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.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V.

The ACL-deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta-analysis (CRD42017076897)

INTRODUCTION

The purpose of this systematic review and meta-analysis was to analyze and compare the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction.

MATERIALS AND METHODS

A systematic search for articles comparing the rate of secondary meniscus and cartilage lesions diagnosed at different time points of ACL reconstruction was performed. PubMed central was the database used for the literature review.

RESULTS

Forty articles out of 1836 were included. In 35 trials (88%), there was evidence of a positive correlation between the rate of meniscus and/or cartilage lesions and the time since ACL injury. This correlation was more evident for the medial meniscus in comparison with the lateral meniscus. In particular, a delay of more than 6 months was critical for secondary medial meniscus injuries [risk ratio 0.58 (95% CI 0.44-0.79)] and a delay of more than 12 months was critical for cartilage injuries [risk ratio 0.42 (95% CI 0.29-0.59)]. Additionally, there is evidence that the chance for meniscal repair decreases as the time since ACL rupture increases.

CONCLUSION

Chronic instability in the ACL-deficient knee is associated with a significant increase of medial meniscus injuries after 6 months followed by a significant increase of cartilage lesions after 12 months.

Abnormal tibial alignment is a risk factor for lateral meniscus posterior root tears in patients with anterior cruciate ligament ruptures

PURPOSE

The purpose of this study was to identify if abnormal tibial alignment was a risk factor for lateral meniscus posterior root tears (LMPRT) in patients with acute anterior cruciate ligament (ACL) ruptures.

METHODS

The medical charts of 200 patients treated for ACL ruptures between 2013 and 2016 were retrospectively reviewed and evaluated. MRI images and reports were assessed for concurrent meniscal tears. Radiographs were reviewed for tibia vara and tibial slope angles and MRI reports identifying lateral root tears were compared to intraoperative reports to determine accuracy. Multiple logistic regression models were constructed to identify potential risk factors for LMPRTs.

RESULTS

Of the 200 patients reviewed, a total of 97 individuals with concurrent meniscal injuries were identified. In patients sustaining a concurrent meniscal injury, there was a 4% incidence of medial meniscus posterior root tears and a 10.3% incidence of LMPRTs. Patients sustaining an ACL injury with an LMPRT were found to have greater tibia vara angles (4.2 ± 1.0 vs. 2.9 ± 1.7; p = 0.024), increased tibial slopes (12.6 ± 1.5 vs. 10.7 ± 2.9; p = 0.034), and higher BMIs (27.3 ± 2.9 vs. 25.3 ± 5.9; p = 0.034) when compared to patients without meniscus tears. There was low agreement between MRI and arthroscopic findings (kappa rate = 0.54). Multiple logistic regression analysis demonstrated that a tibia vara angle > 3 was associated with a 5.2-fold increase (95% CI 0.99-27.01; p = 0.050), and a tibial slope > 12 with a 5.4-fold increase (95% CI 1.03-28.19; p = 0.046) in LMPRTs.

CONCLUSIONS

Patients with greater tibia varus angles, increased tibial slopes, and higher BMIs were found to have an increased risk of LMPRTs when sustaining an ACL rupture. There was a low rate of agreement between MRI and arthroscopy in identifying LMPRTs. In patients with ACL ruptures who have abnormal tibial alignment or increased BMI, physicians should be watchful for lateral meniscus posterior root tears.

LEVEL OF EVIDENCE

3.

Anterior cruciate ligament reconstruction performed within 12 months of the index injury is associated with a lower rate of medial meniscus tears

PURPOSE

To verify the correlation of time to surgery with the prevalence of concomitant intra-articular injuries detected on arthroscopy during anterior cruciate ligament (ACL) reconstruction.

METHODS

The medical records of 653 patients who underwent ACL reconstruction surgery were retrospectively analyzed. Univariate and multivariate logistic regression analysis was performed to identify factors that were associated with the presence of at least one intra-articular injury, medial meniscus tears, lateral meniscus tears and chondral injuries at the time of surgery. Further univariate analysis was conducted to determine the earliest time-point for surgery, after which the rate of concomitant injuries was significantly higher.

RESULTS

Longer time to surgery (OR 1.019 95% CI 1.010, 1.028, p = 0.000), male sex (OR 1.695 95% CI 1.074, 2.675 p = 0.023), and higher BMI (OR 1.050 95% CI 1.006, 1.097 p = 0.025) were correlated with a higher prevalence of medial meniscus tears. There was an increased prevalence of medial meniscus tears when surgery was carried out more than 12 months after the index injury (OR 2.274 95% CI 1.469, 3.522, p = 0.000). The correlation between longer time to surgery and chondral injuries approached statistical significance (OR 1.006 95% CI 0.999, 1.012, p = 0.073). However, a longer time to surgery was not associated with an increased prevalence of lateral meniscus tears (OR 1.003 95% CI 0.998, 1.009, p = n.s.).

CONCLUSIONS

Longer time to surgery is associated with an increased prevalence of medial meniscus tears in ACL reconstruction. Surgery performed within 12 months of the index injury reduces the prevalence of medial meniscus tears. Prioritizing males and overweight patients for counselling and early intervention can be considered.

LEVEL OF EVIDENCE

Therapeutic level III retrospective cohort study.

Relationship Between Time to ACL Reconstruction and Presence of Adverse Changes in the Knee at the Time of Reconstruction

Background:

Treatment of patients with anterior cruciate ligament (ACL) injuries is often complicated by secondary damage to the meniscus and cartilage.

Purpose:

To assess the association between time from ACL tear to ACL reconstruction (ACLR) and the presence of intra-articular injuries at the time of ACLR, including meniscal tears, irreparable meniscal tears, chondral damage, and knee compartment degenerative changes.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Consecutive patients undergoing primary ACLR performed by a single surgeon in a Canadian health system over a 5.5-year period were included. Age at ACLR, activity level prior to injury, time from injury to ACLR (TFI), presence and degree of radiographic osteoarthritic features (International Knee Documentation Committee [IKDC] score by tibiofemoral and/or patellofemoral compartment), and surgeon-recorded meniscal lesions (presence and treatment [repair or excision]) and chondral lesions (International Cartilage Repair Society [ICRS] scale grade >2) at time of ACLR were extracted from medical records. The association between TFI (in quartiles: first quartile [0-36 wk] through fourth quartile [110-1000 wk]) and each outcome was assessed with multivariable logistic regression adjusted for age at ACLR and activity level.

Results:

A total of 860 individual patient records were included. The median patient age was 27.0 years (range, 12-63 years), 47.5% were female (403/849), and 47.2% were classified as playing competitive or professional sports versus recreational sport (337/714). After adjustment for age and activity level, TFI was associated with presence of medial meniscal tear (odds ratio [OR] of fourth-quartile vs first-quartile patients, 3.86; 95% CI, 2.38-6.24; P < .001), medial meniscal tear requiring greater than two-thirds meniscectomy (OR, 5.64; 95% CI, 2.99-10.67; P < .001), medial femoral condyle chondral damage (OR, 3.42; 95% CI, 1.96-5.95; P < .001), and medial tibiofemoral radiographic osteoarthritic features (OR, 22.03; 95% CI, 5.17-93.86; P < .001). TFI was not associated with adverse outcomes in the lateral tibiofemoral or patellofemoral compartments.

Conclusion:

Increases in TFI are associated with medial meniscal tears, including irreparable medial meniscal tears, medial femoral condyle chondral damage, and early medial tibiofemoral compartment degenerative changes at time of ACLR. These findings highlight the importance of establishing a timely diagnosis and implementing an appropriate treatment plan for patients with ACL injuries. This approach may prevent further instability episodes that place patients at risk of sustaining additional intra-articular injuries in the affected knee. Further research is required to understand the implications of TFI and to determine whether decreasing the TFI alters the natural history after an ACL injury.

Graft Choice and the Incidence of Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Causal Analysis From a Cohort of 541 Patients

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction is important to prevent knee osteoarthritis. Neither of the 2 most common graft techniques-the patellar tendon (PT) or hamstring tendon (HS) graft-has demonstrated superiority in terms of the long-term osteoarthritis rate.

HYPOTHESIS

Based on the International Knee Documentation Committee (IKDC) radiographic grading system, PT grafts decrease the incidence of osteoarthritis by providing better knee stability as compared with HS grafts over 12 years of follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All adults with a first ACL rupture who underwent surgery with a PT or HS graft technique between January 2002 and December 2003 were included in the 2014 French Society of Orthopedic Surgery and Traumatology Symposium database. Baseline characteristics were collected. The primary endpoint was the occurrence of moderate to severe osteoarthritis in each group. The secondary endpoints included clinical subjective evaluations by the IKDC score and Knee injury and Osteoarthritis Outcome Score. To control the differences in baseline characteristics, the data were analyzed with propensity score matching.

RESULTS

In the cohort, 541 patients from 18 centers were included: 311 PT and 230 HS ACL reconstructions. The baseline characteristics were similar after inverse probability weighting treatment (IPWT). The occurrence of osteoarthritis was similar after IPWT (19.3% for PT and 19.6% for HS, P = .94). Age at surgery >29 years and IKDC osteoarthritis stage B at the index surgery were identified as risk factors for moderate to severe osteoarthritis. Most functional outcomes were significantly higher in the HS group; however, the difference between groups remained <10 points. Of the 106 patients who needed a medial meniscectomy, the proportion of patients with moderate to severe osteoarthritis was much higher in the HS group (43.5% vs 18.3%, P = .006). However, after IPWT, the difference was not statistically significant.

CONCLUSION

At 12 years of follow-up, neither graft technique was superior to the other in terms of the rate of osteoarthritis.

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.

Surgical timing of anterior cruciate ligament reconstruction to prevent associated meniscal and cartilage lesions

BACKGROUND

The purpose of this study was to analyze the association between the prevalence of meniscal and chondral lesions and the timing of surgery in patients undergoing primary anterior cruciate ligament (ACL) reconstruction to determine a safe time for surgery.

METHODS

This retrospective study involved 226 patients (91 females and 135 males; median age, 29 years) undergoing primary ACL reconstruction. Time interval from ACL injury to surgery (median, 4 months; range, 1-420 months) and concomitant meniscal and cartilage lesions in ACL reconstruction were reviewed. Receiver operating characteristic (ROC) curve analysis was used to determine the precise threshold interval to surgery to prevent meniscal or cartilage lesions. The risk of lesion occurrence after each cutoff period was determined using odds ratio (OR).

RESULTS

The incidences of medial meniscus (MM), lateral meniscus (LM), and cartilage lesions were 43.8%, 32.7%, and 27.4%, respectively. ROC analysis revealed that patients who waited for more than 6, 4, and 5 months for ACL reconstruction had a significantly greater risk of associated MM, LM, and chondral lesions, respectively. Patients who underwent ACL reconstruction ≥7 months after injury had OR of 4.1 (p < 0.001) for the presence of MM lesion as compared with those who underwent reconstruction within 6 months. Similarly, patients who underwent ACL reconstruction ≥5 months after injury had OR of 1.9 (p = 0.023) for the presence of LM lesion as compared with those who underwent reconstruction within 4 months, and patients who underwent ACL reconstruction ≥6 months after injury had OR of 2.9 (p < 0.001) for chondral lesion as compared with those who underwent reconstruction within 6 months.

CONCLUSION

ACL reconstruction should be performed within approximately 6 months after the injury to prevent associated meniscal or chondral lesions.

Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population

PURPOSE

To evaluate the anterior cruciate ligament graft failure rate in a population of 1376 patients submitted to single-bundle anterior cruciate ligament reconstruction procedure. It was hypothesized that the younger the patient, the greater the chance of a new anterior cruciate ligament graft ligament injury.

METHODS

A retrospective chart review was performed on patients who had SB anterior cruciate ligament reconstruction between the years, 2001 and 2016, with a minimum post-operative follow-up period of 6 months. The patient population was divided into three groups, according to age: group 1-under 16 years old; group 2-between 16 and 18 years old; and group 3-older than 18 years old. Data collected included sex, laterality and graft choice data.

RESULTS

In group 1 (under 16 years old), there were 61 primary ACL surgeries performed and 15 (24.6%) revision ACL surgeries. In group 2 (between 16 and 18 years old), there was 57 primary ACL procedures, of which 10 (17.5%) were revisions. In the group 3 (older than 18 years of age), 1258 surgeries were done with 116 (9.2%) revisions.

CONCLUSION

The rate of ACL revision surgery in patients under 16 years of age was significantly higher than that found in patients older than 18 years old. When compared to the population between 16 and 18 years old, there were a higher number of failure cases, however, statistically non-significant.

LEVEL OF EVIDENCE

IV.

The role of meniscal repair for prevention of early onset of osteoarthritis

BACKGROUND

The meniscus plays an important role in the integrity of the knee joint. Therefore, meniscus tissue preserving techniques for the therapy of meniscus injuries seem to be reasonable. One of the important questions is whether meniscal repair can prevent the knee joint from early onset of osteoarthritis.

METHODS

According to the review of the current literature, the principles of a successful meniscal repair are explained and the functional outcome and its impact on the prevention of osteoarthritis are analyzed in this article.

RESULTS

Current data show a positive impact of a successful meniscus repair on the functional outcome in long-term. By this a protective effect on the development of osteoarthritis via the repair of meniscus lesions to restore the meniscus integrity can be confirmed. However, higher rates of re-operations in context to meniscus suturing have to be considered.

CONCLUSION

Due to the improved functional outcomes as well as preventive effect on the development of osteoarthritis within the knee joint in long-term, it is of importance to preserve as much meniscus tissue as possible in meniscus therapy. Patients previously have to be informed about the higher revision rate in context to meniscus suturing.