Bone-patellar tendon-bone autograft could be recommended as a superior graft to hamstring autograft for ACL reconstruction in patients with generalized joint laxity: 2- and 5-year follow-up study

Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Rehabilitation after an anterior cruciate ligament (ACL) reconstruction requires patience, devotion, and discipline. Rehabilitation should be individualized to each patient's specific need and sport. Return to sport is a continuum throughout the rehabilitation, and patients should not return to performance before passing a battery of muscle function tests and patient-reported outcomes, as well as change of direction-specific tests. Return to full participation should be an agreement between the patient, physical therapist, surgeon, and coach. For minimal risk for second ACL injury, patients should continue with maintenance and prevention training even after returning to sport.

Recovery of Full Hyperextension After Anterior Cruciate Ligament Reconstruction Is Associated With Better Functional Outcomes but Greater Anterior Cruciate Ligament-Related Laxity After a Minimum 24-Month Follow-Up

PURPOSE

To evaluate patients who had anterior cruciate ligament (ACL) reconstruction with preoperative hyperextension and compare physical examination (KT-1000 and pivot shift) and patient-reported outcome measures of patients who recovered the entire hyperextension with patients who did not.

METHODS

Patients aged 18 to 60 years with more than 5° of knee hyperextension who had anatomic ACL reconstruction with any graft from June 2013 to June 2021 and at least a 24-month follow-up were evaluated retrospectively. Hamstrings and patellar tendon grafts were fixed around 20° to 30° of flexion and in full extension, respectively. Patients who could recover hyperextension were compared with patients who did not. Preoperative, intraoperative, and postoperative data, including physical examination and patient-reported outcome measures, were evaluated.

RESULTS

Of the 225 patients evaluated, 48 (21.3%) did not recover hyperextension, and 177 recovered full range of motion. Patients who did not recover hyperextension had a larger graft diameter (8.7 ± 0.7 mm [confidence interval, 8.502-8.898 mm] vs 8.3 ± 0.7 mm [confidence interval, 8.197-8.403 mm]; P = .018). Regarding the postoperative subjective variables, patients who recovered hyperextension showed improvement on all scales (International Knee Documentation Committee, Lysholm, Forgotten Joint Score, and Global Perceived Effect) evaluated compared with patients who did not recover the range of motion. Patients who recovered hyperextension also showed more laxity on physical examination, measured by the KT-1000 (1.8 ± 0.8 vs 1.1 ± 1.0; P = .0006) and the pivot shift (62.1% [grade 0] and 37.9% [grade 1] vs 79.2% [grade 0] and 20.8% [grade 1]; P = .027).

CONCLUSIONS

Patients with knee hyperextension who regained range of motion after ACL reconstruction have worse knee laxity than patients who regained full extension but not hyperextension. However, patients who recover full range of motion showed higher scores on subjective function scales, including a greater number of patients who achieved patient acceptable symptom state for the International Knee Documentation Committee score.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Lower rates of return to sport in patients with generalised joint hypermobility two years after ACL reconstruction: a prospective cohort study

BACKGROUND

Generalised joint hypermobility (GJH) has been associated with an increased risk of suffering an anterior cruciate ligament (ACL) injury. Patients with GJH exhibit lower muscle strength and poorer scores for patient-reported outcomes after ACL reconstruction, compared with patients without GJH. The aim of this study was to examine differences in the percentages of patients who return to sport (RTS) or pre-injury level of activity (RTP), muscle function and patient-reported outcomes at the time of RTS or RTP, as well as the time of RTS or RTP in patients with GJH compared with patients without GJH in the first two years after ACL reconstruction.

METHODS

This prospective study used data from an ACL- and rehabilitation-specific register located in Gothenburg, Sweden. Patients aged between 16 and 50, who had a primary ACL injury treated with reconstruction, were included. Data up to two years after ACL reconstruction were used and consisted of achieving RTS and RTP, results from isokinetic muscle function tests for knee extension and flexion and patient-reported outcomes (Knee Self-Efficacy Scale, Knee injury and Osteoarthritis Outcome Score and ACL-Return to Sport after Injury scale) at the time of RTS, as well as the time of RTP. A Beighton Score of ≥ 5/9 was used to define GJH. A Tegner Activity Scale of ≥ 6 was used to define RTS, while a Tegner equal to or above pre-injury level was used to define RTP.

RESULTS

A total of 1,198 patients (54.7% women) with a mean age of 28.5 ± 8.6 years were included. A smaller proportion of patients with GJH achieved RTS compared with patients without GJH (49.2% vs. 57.3%, Odds ratio: 0.720, p = 0.041). Furthermore, patients with GJH were marginally less symmetrical on the knee extension strength test, expressed as a Limb Symmetry Index, at the time of RTP compared with patients without GJH (87.3 ± 13.5 vs. 91.7 ± 14.3, Cohen's d = 0.142, p = 0.022). No further differences were found between groups regarding any muscle function tests or patient-reported outcomes.

CONCLUSION

A smaller proportion of patients with GJH achieved RTS compared with patients without GJH. Patients with GJH displayed less symmetrical knee extension strength at the time of RTP compared with patients without GJH.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction

OBJECTIVES

To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R).

METHODS

Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS.

RESULTS

A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures.

CONCLUSION

Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

Evaluation of the short-term outcomes of anatomic ACL reconstruction with hamstring autograft in patients with generalized joint laxity: A retrospective case-control study

PURPOSE

The outcomes of anterior cruciate ligament reconstruction (ACLR) in patients with generalized joint laxity (GJL) are not clearly understood. In this study, we compared the outcomes of ACLR with quadruple hamstring autograft between GJL and non-GJL patients.

METHODS

In a retrospective case-control study, 36 patients with GJL, according to the Beighton and Horan Joint Mobility Index, who underwent ACLR surgery, were included. Forty-four group-matched non-GJL patients were included in the control group. The mean follow-up of the patients was 20.65 ± 6.93‏ months. The outcomes of ACLR were evaluated by the Lachman test, pivot shift test, anterior tibial translation and KT-1000 side-to-side difference, and International Knee Documentation Committee (IKDC) scale.

RESULTS

The results of the Lachman and pivot shift test were not significantly different between the GJL and non-GJL patients (P = 0.67 and P = 0.27, respectively). The mean anterior tibial translation was 7.06 ± 1.41 mm in the GJL group and 6.11 ± 1.53 mm in the non-GJL group (P = 0.006). The mean KT-1000 side-to-side difference was 2.25 ± 1.31 mm in the case and 2.5 ± 1.44 mm in the control group (P = 0.42). The mean IKDC score of the patients was not significantly different between the GJL and non-GJL groups (66.1 ± 20.6 vs. 69.9 ± 16.1, P = 0.35). ACLR failure occurred in 2 (5.5%) patients of the GJL group and no patients of the control group (P = 0.21).

CONCLUSION

The present findings suggest ACLR with quadruple hamstring autograft as an adequate treatment for GJL patients, at least in short-term follow-up.

Rectangular bone-patellar tendon bone grafts reduce early graft failure in chronic ACL-Deficient knees

BACKGROUND

The aim of this study was to assess early graft failure after anterior cruciate ligament (ACL) reconstruction according to chronicity of ACL deficiency (ACLD) and clarify predisposing factors.

METHODS

A total of 731 patients who underwent anatomic ACL reconstruction were divided into 3 groups based on chronicity of ACLD: <6 months (Group 1), 6 months to 2 years (Group 2), and >2 years (Group 3). Types of ACL grafts used included single-bundle hamstring tendon (HT), multiple-bundle HT, and rectangular bone-patellar tendon-bone (BTB) grafts. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken to examine anterior tibial subluxation (ATS). All ACL grafts were evaluated by MRI at 6 months to identify graft failure. The group with the highest failure rate was further examined to compare possible risk factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors.

RESULTS

Early graft failure on MRI without any episode of postoperative trauma was observed in 7 (1.4%), 2 (1.8%), and 11 (9.2%) patients in Groups 1, 2, and 3, respectively, with a significantly higher rate in Group 3 (P < 0.001). Of the 119 patients in Group 3, significant differences were observed between intact and failure subgroups with regard to surgical procedure (P = 0.03), chondral lesions (P < 0.01), and preoperative ATS (P < 0.01). Multivariate logistic regression analysis revealed that surgical procedures (odds ratio, 3.8; 95%CI, 1.16-12.59) and preoperative ATS (odd ratio, 2.4; 95%CI, 1.26-4.38) were predisposing factors of early graft failure.

CONCLUSION

Patients with ACLD for >2 years experienced early graft failure with an incidence rate of 9.2%. Predisposing factors of early graft failure in these patients included the use of single-bundle HT grafts and preoperative ATS. The use of rectangular BTB grafts resulted in a lower graft failure rate.

STUDY DESIGN

Case Series.

Bench to Bedside: A Multidisciplinary Approach toward the Unknowns after ACL Injuries to Drive Individual Success

ACL injury and surgery are increasing in prevalence. Several challenges exist that can be obstacles to an individual achieving success after ACL surgery. A knowledge of these risk factors alongside a multidisciplinary collaborative team approach can result in a greater likelihood of achieving individual success after ACL surgery.

Generalized joint hypermobility does not influence 1-year patient satisfaction or functional outcome after ACL reconstruction

PURPOSE

The purpose of this study was to evaluate whether generalized joint hypermobility (GJH) influences postoperative results, including return to sport, patientreported outcomes, functional performance (hop tests), muscular strength, and the occurrence of ACL re-injury, in patients 1 year after anterior cruciate ligament (ACL) reconstruction.

METHODS

Data was extracted from a regional rehabilitation-specific registry containing information on patients with ACL injury. Patients between the ages of 16-50 years previously undergoing ACL reconstruction with available 1 year follow-up data were eligible for inclusion. Generalized joint hypermobility was assessed using the Beighton score (BS). Patients were examined one year postoperatively in terms of return to sport, patient-reported outcome, hop tests, muscular strength and the occurrence of reinjury. For purpose of analysis, patients were allocated into two groups, depending on the existence of GJH. The KOOS subscale of sports and recreation was considered the primary outcome. Analyses were performed both dichotomously and by using adjusted logistic regression, to consider potential confounders.

RESULTS

A total of 356 patients (41% males) were included, of which 76 (24% male) were categorized as having GJH. Patients with GJH had an inferior limb symmetry index preoperatively in terms of knee extension (mean 81.6 [SD 16.4] vs. 91.4 [SD 15.9], p = 0.02) and flexion strength (mean 91.9 vs. 99.1, p = 0.047) compared to patients without GJH. There was no difference between the groups in terms of the primary outcome, nor in any of the other postoperative outcomes. Nine patients (11.8%) in the group with GJH suffered ACL re-injury, compared with 13 patients (4.6%) in the control group (n.s.).

CONCLUSION

One year after ACL reconstruction the existence of GJH did not affect postoperative patient satisfaction, strength or functional outcome. No conclusive statements can be made regarding the influence of GJH on the risk of ACL re-injury in this particular study.

LEVEL OF EVIDENCE

Level II.

ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades

PURPOSE

Anterior cruciate ligament reconstruction (ACLR) aims to restore knee function and stability, allowing patients to return to the activities they enjoy and minimize further injury to the meniscus and cartilage and their ultimate progression to osteoarthritis. This study aims to present the evolution of graft choice over the last three decades according to members of the ACL Study Group (SG).

METHODS

Prior to the January 2020 ACL SG biannual meeting, a survey was administered consisting of 87 questions and 16 categories, including ACLR graft choice. A similar questionnaire has been administered prior to each meeting and survey results from the past 14 meetings (1992 through 2020, excluding 1994) are included in this work. Survey responses are reported as frequencies in percentages to quantify changes in practice over the surgery period.

RESULTS

In 1992, the most frequent graft choice for primary ACLR was bone-patellar tendon-bone (BTB) autograft, at nearly 90%. Hamstring tendon (HT) autografts have increased in popularity, currently over 50%, followed by just under 40% BTB autograft. Recently, quadriceps tendon (QT) autograft has increased in popularity since 2014.

CONCLUSION

Autograft (HT, BTB, QT) is an overwhelming favorite for primary ACLR over allograft. The preference for HT autograft increased over the study period relative to BTB autograft, with QT autograft gaining in popularity in recent years. Graft selection should be individualized for each patient and understanding the global trends in graft choice can help orthopaedic surgeons discuss graft options with their patients and determine the appropriate graft for each case.

LEVEL OF EVIDENCE

Level V, Expert Opinion.

Anterior Cruciate Ligament Reconstruction With Concomitant Meniscal Repair: Is Graft Choice Predictive of Meniscal Repair Success?

Background

When meniscal repair is performed during anterior cruciate ligament (ACL) reconstruction (ACLR), the effect of ACL graft type on meniscal repair outcomes is unclear.

Hypothesis

The authors hypothesized that meniscal repairs would fail at the lowest rate when concomitant ACLR was performed with bone--patellar tendon--bone (BTB) autograft.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent meniscal repair at primary ACLR were identified from a longitudinal, prospective cohort. Meniscal repair failures, defined as any subsequent surgical procedure addressing the meniscus, were identified. A logistic regression model was built to assess the association of graft type, patient-specific factors, baseline Marx activity rating score, and meniscal repair location (medial or lateral) with repair failure at 6-year follow-up.

Results

A total of 646 patients were included. Grafts used included BTB autograft (55.7%), soft tissue autograft (33.9%), and various allografts (10.4%). We identified 101 patients (15.6%) with a documented meniscal repair failure. Failure occurred in 74 of 420 (17.6%) isolated medial meniscal repairs, 15 of 187 (8%) isolated lateral meniscal repairs, and 12 of 39 (30.7%) of combined medial and lateral meniscal repairs. Meniscal repair failure occurred in 13.9% of patients with BTB autografts, 17.4% of patients with soft tissue autografts, and 19.4% of patients with allografts. The odds of failure within 6 years of index surgery were increased more than 2-fold with allograft versus BTB autograft (odds ratio = 2.34 [95% confidence interval, 1.12-4.92]; P = .02). There was a trend toward increased meniscal repair failures with soft tissue versus BTB autografts (odds ratio = 1.41 [95% confidence interval, 0.87-2.30]; P = .17). The odds of failure were 68% higher with medial versus lateral repairs (P < .001). There was a significant relationship between baseline Marx activity level and the risk of subsequent meniscal repair failure; patients with either very low (0-1 points) or very high (15-16 points) baseline activity levels were at the highest risk (P = .004).

Conclusion

Meniscal repair location (medial vs lateral) and baseline activity level were the main drivers of meniscal repair outcomes. Graft type was ranked third, demonstrating that meniscal repairs performed with allograft were 2.3 times more likely to fail compared with BTB autograft. There was no significant difference in failure rates between BTB versus soft tissue autografts.

Registration

NCT00463099 (ClinicalTrials.gov identifier).

Clinical Results of Combined ACL and Anterolateral Ligament Reconstruction: A Narrative Review from the SANTI Study Group

Lateral extraarticular procedures (LEAPs) in the anterior cruciate ligament (ACL)-injured knee were widely abandoned in the 1990s but have seen a recent resurgence. The aim of this review was to demonstrate that anterolateral ligament reconstruction (ALLR) is associated with evidence of significant advantages and no evidence of historical concerns. A narrative review of the literature was performed. Combined ACL + ALLR is associated with improved outcomes when compared against isolated ACL reconstruction, including a significantly lower risk of ACL graft rupture (hazard ratio [HR]: 0.327, 95% CI: 0.130-0.758), a significantly lower risk of reoperation for secondary meniscectomy following medial meniscal repair at the time of ACL reconstruction (HR: 0.443, 95% CI: 0.218-0.866), significantly increased likelihood of return to the preinjury level of sport following primary (odds ratio [OR]: 1.938, 95% CI: 1.174-3.224) and revision ACL reconstruction (57.1 vs. 25.6%, respectively; p = 0.008), and in chronic ACL injuries, less residual pivot shift (9.1 vs. 35.3%, p = 0.011), and better IKDC (92.7 ± 5.9 vs. 87.1 ± 9.0, p = 0.0013) and Lysholm (95.4 ± 5.3 vs. 90.0 ± 7.1, p < 0.0001) scores, and no evidence of historical concerns. Combined ACLR + ALLR is associated with excellent clinical outcomes with no evidence of the adverse events that led to the historical widespread abandonment of other types of LEAP. Specifically, comparative series have demonstrated significant advantages of ALLR when compared against isolated ACLR with respect to reduced rates of ACL graft rupture, secondary meniscectomy, persistent instability, and significantly improved functional outcomes and improved return to sport metrics.

Generalized Joint Laxity Is Associated With Increased Failure Rates of Primary Anterior Cruciate Ligament Reconstructions: A Systematic Review

PURPOSE

To investigate patients with generalized joint laxity (GJL) after primary anterior cruciate ligament reconstruction (ACLR) as to the risk of ACLR failure, graft selection success rates, and overall clinical outcomes.

METHODS

A systematic review of the PubMed and EMBASE databases was performed to identify studies published from the inception of the databases through February 4, 2020. The inclusion criteria were original studies written in English involving outcomes of patients with GJL who had undergone primary ACLR.

RESULTS

Nine studies met the inclusion criteria, which included 1,869 patients. Most underwent isolated bone-patellar tendon-bone (BPTB; n = 1062) or hamstring autograft (n = 696) ACLR. Overall, higher graft failure rates tended to occur in patients with GJL compared with patients without GJL (range per study: 6%-30% vs 0%-12.3%). Inferior results were also found patients with GJL in patient-reported outcome measures and postoperative knee stability determined by KT, Lachman, and pivot-shift tests. BPTB autografts tended to have lower failure rates than hamstring autografts in patients with GJL (range per study: 6%-21% vs 17.6%-30%). Only 1 study determined outcomes of a combined ACLR and extra-articular augmentation in patients with GJL.

CONCLUSIONS

Patients with GJL are at an increased risk of inferior outcomes and graft failure after primary ACLR. BPTB autografts may have more favorable stability outcomes compared with hamstring autografts in patients with GJL. However, the reported stability parameters and KT results, even with a BPTB autograft, remain inferior to non-GJL published results, and the added benefit of an extra-articular procedure to supplement the primary ACLR deserves consideration.

LEVEL OF EVIDENCE

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

Editorial Commentary: Diagnosis and Treatment of Generalized Joint Hypermobility in Patients With Anterior Cruciate Ligament Injury

Generalized joint hypermobility (GJH), or laxity, is defined as hyperextensibility of the synovial joints. Hypermobility is caused by alterations in the connective tissues, in turn caused by various factors including impaired function of collagen proteins. For measurement of knee GJH, we highly recommend using the Beighton score, the most frequently used method in both the sports medicine and other literature. Our recommendations on how to treat patients with anterior cruciate ligament (ACL) injury with generalized joint hypermobility include the following: (1) use patellar-tendon or quadriceps tendon autograft for ACL reconstruction; (2) always consider performing a lateral extra-articular tenodesis; and (3) make sure patients pass a return to sport test battery including strength, hop performance, subjective knee function, and movement quality. Delay to return to sport may be as long as 1 year after surgery.

Return to Sport After ACL Reconstruction With a BTB Versus Hamstring Tendon Autograft: A Systematic Review and Meta-analysis

Background

Anterior cruciate ligament (ACL) tears are debilitating injuries frequently suffered by athletes. ACL reconstruction is indicated to restore knee stability and allow patients to return to prior levels of athletic performance. While existing literature suggests that patient-reported outcomes are similar between bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts, there is less information comparing return-to-sport (RTS) rates between the 2 graft types.

Purpose

To compare RTS rates among athletes undergoing primary ACL reconstruction using a BTB versus HT autograft.

Study Design

Systematic review; Level of evidence, 4.

Methods

The MEDLINE, Embase, and Cochrane Library databases were searched, and studies that reported on RTS after primary ACL reconstruction using a BTB or HT autograft were included. Studies that utilized ACL repair techniques, quadriceps tendon autografts, graft augmentation, double-bundle autografts, allografts, or revision ACL reconstruction were excluded. RTS information was extracted and analyzed from all included studies.

Results

Included in the review were 20 articles investigating a total of 2348 athletes. The overall RTS rate in our cohort was 73.2%, with 48.9% returning to preinjury levels of performance and a rerupture rate of 2.4%. The overall RTS rate in patients after primary ACL reconstruction with a BTB autograft was 81.0%, with 50.0% of athletes returning to preinjury levels of performance and a rerupture rate of 2.2%. Patients after primary ACL reconstruction with an HT autograft had an overall RTS rate of 70.6%, with 48.5% of athletes returning to preinjury levels of performance and a rerupture rate of 2.5%.

Conclusion

ACL reconstruction using BTB autografts demonstrated higher overall RTS rates when compared with HT autografts. However, BTB and HT autografts had similar rates of return to preinjury levels of performance and rerupture rates. Less than half of the athletes were able to return to preinjury sport levels after ACL reconstruction with either an HT or BTB autograft.

A Randomized Controlled Trial of Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up

BACKGROUND

Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone-patellar tendon-bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients.

PURPOSE

The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire).

RESULTS

Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy.

CONCLUSION

There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.

All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger

PURPOSE

To compare clinical outcomes of knee anterior cruciate ligament (ACL) autograft reconstruction using all-inside quadrupled semitendinosus (AIST) versus bone-patellar tendon-bone (BPTB) in a high-risk athletic population 24 years or younger.

METHODS

Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the AIST (n = 32) or BPTB (n = 32) group and were followed for 2 years. Magnetic resonance imaging scans were obtained at 1-year follow-up, and radiographs were obtained at 2-year follow-up. All surgeries were performed by a single surgeon using an anteromedial portal to establish the femoral tunnel. The primary outcome measure was KT-1000 stability testing. Secondary outcome measures included International Knee Documentation Committee (IKDC) Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx Activity Scale, visual analog pain scale, and SF-12 (Mental and Physical).

RESULTS

At 2-year follow-up, no statistical difference existed with KT-1000-measured side-to-side laxity between AIST (0.3 ± 0.7 mm, 95% confidence interval 0.0-1.0 mm) and BPTB (0.0 ± 0.8 mm, confidence interval CI -0.3 to 1.1 mm) (P = .197). In addition, no statistical differences between the groups were found for IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx, SF-12 Mental, SF-12 Physical, or with regards to imaging findings. Patients with BPTB reported significantly greater postoperative pain scores at days 2 (P = .049), 3 (P = .004), and 7 (P = .015) and had significantly greater kneeling pain at 2 years (P < .019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% AIST, 74% BPTB; P = .415). Two graft retears (7%; P = .222) occurred in the AIST group. Three patients in the BPTB group experienced ACL tears in the contralateral knee (9%; P = .239).

CONCLUSIONS

ACL reconstruction with an all-inside quadrupled semitendinosus autograft construct is equivalent to patellar BPTB autograft based on KT-1000 stability testing in athletes 24 years or younger.

LEVEL OF EVIDENCE

randomized controlled trial with 92% 2-year follow-up, Level I.

Influence of operative technique on anterior cruciate ligament reconstruction in patients older than 50 years

BACKGROUND

A consequence of the steady growth in the worldwide population of elderly individuals who remain in good health and continue to engage in sports is an increase in the incidence of anterior cruciate ligament (ACL) rupture occurring after 50 years of age. ACL reconstruction was formerly reserved for young athletes but now seems to produce good outcomes in over 50s. The type of graft and graft fixation method were selected empirically until now, given the absence of investigations into potential relationships of these two parameters with the outcomes. The objective of this study was to assess associations linking the type of graft and the method of femoral graft fixation to outcomes in patients older than 50 years at ACL reconstruction.

HYPOTHESIS

The operative technique is not associated with the clinical outcomes or differential laxity.

MATERIAL AND METHODS

A multicentre retrospective cohort of 398 patients operated between 1 January 2011 and 31 December 2015 and a multicentre prospective cohort of 228 patients operated between 1 January 2016 and 30 June 2017 were conducted. Mean follow-up was 42.7 months in the retrospective cohort and 14.2 months in the prospective cohort. The primary evaluation criterion was the clinical outcome as assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Score (TAS). Differential laxity was the secondary evaluation criterion. The Wilcoxon rank sum test and Kruskal-Wallis test were used to compare groups, and p-values<0.05 were considered significant.

RESULTS

In the retrospective and prospective cohorts, hamstring tendons were used in 269 (67.6%) and 197 (86.4%) patients and extensor apparatus tendons in 124 (31.2%) and 31 (13.6%) patients. Femoral fixation in the retrospective cohort was cortical in 81 (20.4%) cases, by press-fit in 112 (28.1%) cases, and by interference screw in 205 (51.5%) cases; corresponding figures in the prospective cohort were 135 (59.2%), 17 (7.5%), and 76 (33.3%). The multivariate analysis of the retrospective data identified no significant associations of graft type or femoral fixation type with the KOOS, TAS, or differential laxity values. In the prospective cohort, hamstring grafts were associated with 0.6mm of additional laxity (p=0.007); compared to cortical fixation, press-fit fixation of patellar tendon grafts was associated with 0.3mm of additional laxity (p=0.029) and a 0.5-point lower TAS value (p=0.033), with no difference in KOOS values. None of these differences were clinically significant.

DISCUSSION

The various ACL reconstruction techniques used in patients older than 50 years produce similar outcomes. The technique can be chosen based on surgeon preference without regard for patient age.

LEVEL OF EVIDENCE

IV.

Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome after ACL reconstruction: a systematic review

Objectives

To investigate the association between generalised joint hypermobility (GJH) and ACL injury risk. Secondary aims involved evaluating associations between GJH and postoperative outcome (including graft-failure risk, knee laxity and patient-reported outcome). Furthermore, we aimed to compare the performance of different grafts in patients with GJH.

Methods

Databases MEDLINE/PubMed, EMBASE and the Cochrane Library were searched, including 2760 studies. Two reviewers independently screened studies for eligibility. A modified version of the MINORS score was applied for quality appraisal. Studies assessing GJH while reporting the risk of ACL injury and/or postoperative outcome were included.

Results

Twenty studies were included, using several different methods to determine GJH. There was consistent evidence showing that GJH is a risk factor for unilateral ACL injury in males, while in females, the results were conflicting. There was limited evidence associating GJH with increased knee laxity 5 years postoperatively. There was consistent evidence of inferior postoperative patient-reported outcome in patients with GJH. Moreover, there was limited yet consistent evidence indicating that patellar-tendon autografts are superior to hamstring-tendon autografts in patients with GJH in terms of knee laxity and patient-reported outcome. There was insufficient evidence to draw conclusions regarding the outcomes of bilateral ACL injury and graft failure.

Conclusions

In men, GJH was associated with an increased risk of unilateral ACL injury. Moreover, GJH was associated with greater postoperative knee laxity and inferior patient-reported outcome. Based on the available evidence, a patellar-tendon autograft appears to be superior to a hamstring-tendon autograft in patients with GJH. However, the included studies were heterogeneous and there is a need for consensus in the assessment of GJH within sports medicine.

Combined Reconstruction of the Anterolateral Ligament in Patients With Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better Clinical Stability and a Lower Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare functional outcomes, residual instability, and rupture rates in patients with ligamentous hyperlaxity undergoing isolated anterior cruciate ligament (ACL) reconstruction or combined ACL and anterolateral ligament (ALL) reconstruction.

METHODS

Two groups of patients were evaluated and compared retrospectively. Both groups consisted of patients with ACL injuries and associated ligamentous hyperlaxity, defined based on the modified Beighton scale with a minimum score of 5. Group 1 patients underwent anatomical ACL reconstruction, and group 2 patients underwent anatomical ACL reconstruction combined with ALL reconstruction. Group 1 consisted of historical controls. The presence of associated meniscal injury, subjective International Knee Documentation Committee and Lysholm functional scores, KT-1000 measurements, the presence of a residual pivot-shift, and the graft rupture rate were evaluated. The study was performed at University of São Paulo in Brazil.

RESULTS

Ninety patients undergoing ACL reconstruction with ligamentous hyperlaxity were evaluated. The mean follow up was 29.6 ± 6.2 months for group 1 and 28.1 ± 4.2 months for group 2 (P = .51). No significant differences were found between the groups regarding Beighton scale, gender, the duration of injury before reconstruction, follow-up time, preoperative instability, or associated meniscal injuries. The mean age was 29.9 ± 8.1 years in group 1 and 27.0 ± 9.1 years in group 2 (P = .017). In the final evaluation, group 2 patients showed better anteroposterior clinical stability as evaluated by KT-1000 arthrometry (P = .02), better rotational stability as evaluated by the pivot-shift test (P = .03) and a lower reconstruction failure rate (21.7% [group 1] vs 3.3% [group 2]; P = .03). Clinical evaluations of postoperative functional scales showed no differences between the 2 groups (P = .27 for International Knee Documentation Committee; P = .41 for Lysholm).

CONCLUSIONS

Combined ACL and ALL reconstruction in patients with ligamentous hyperlaxity resulted in a lower failure rate and improved knee stability parameters compared to isolated ACL reconstruction. No differences were found in the functional scales.

LEVEL OF EVIDENCE

Level III, case control study.

Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction

Hamstring autograft is one of the most used grafts for anterior cruciate ligament (ACL) reconstruction, although there are several graft preparation techniques. It is extremely difficult to mimic the biomechanical properties of the native ACL; thus, it is important to achieve a proper graft configuration, diameter, and length. To avoid reruptures, an optimal and reproducible hamstring autograft is desired. Hamstring autograft has been traditionally devalued when compared with other options such as bone-patellar tendon-bone autograft. The purpose of this Technical Note is to describe in detail a hamstring braid graft configuration that could potentially overcome the past disadvantages of ACL reconstruction.

Contralateral knee hyperextension is associated with increased anterior tibial translation and fewer meniscal injuries in the anterior cruciate ligament-injured knee

PURPOSE

To investigate the influence of hyperextension of the contralateral healthy knee on anterior tibial translation (ATT) and the presence of associated injuries in the anterior cruciate ligament (ACL)-injured knee.

METHODS

A local patient data register containing the surgical and clinical data of patients undergoing ACL reconstruction was analyzed. Patients were divided into groups according to the degree of hyperextension of the contralateral knee: normal (Group A ≤ 0°), mild (Group B 1°-5°), moderate (Group C 6°-10°), and severe (Group D > 10°). The ATT was measured in both knees preoperatively and 6 months postoperatively using the KT-1000 arthrometer. The presence of associated meniscal and cartilage injuries was noted. Using multivariate analysis, Groups B, C, and D were compared with Group A, using this group as a reference.

RESULTS

A total of 10,957 patients were available in the register and 8502 (Group A n = 4335, Group B n = 3331, Group C n = 771, Group D n = 65) were included in the final analysis. Groups B (10.3 mm; 95% CI 0.06-0.042, p < 0.0001) and C (10.6 mm; 95% CI 0.23-0.89, p = 0.006) showed significantly greater preoperative ATT in the injured knee compared with the control group (10.1 mm). Moreover, at the 6-month follow-up, greater ATT was observed for Groups B (8.5 mm; 95% CI 0.13-0.45, p < 0.0001), C (8.5 mm; 95% CI 0.02-0.60, p = 0.035), and D (9.1 mm; 95% CI - 0.08-1.77, p = 0.082) compared with Group A (8.2 mm). Meniscal injuries were less frequent in patients with contralateral hyperextension [Group B 903 (27.1%) p < 0.0001, Group C 208 (27.0%) p = 0.0003, and Group D 12 (18.5%), 0.012] compared with the control group [Group A 1479 (34.1%)].

CONCLUSION

Contralateral knee hyperextension is associated with greater pre- and postoperative ATT in the ACL-injured knee. In patients with contralateral knee hyperextension, concomitant injuries to the menisci are less frequent. Surgeons should consider grafts with superior properties regarding postoperative anteroposterior laxity to patients with contralateral knee hyperextension.

LEVEL OF EVIDENCE

Retrospective cohort study, Level IV.