Revision ACL reconstruction in skeletally mature athletes younger than 18 years

Revision Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Patients Yields Low Rates of Graft Failure and Good Functional Scores, but Low Rates of Return to Sport: A Systematic Review

PURPOSE

To evaluate outcomes after revision anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients in terms of graft failure rate and functional patient outcomes.

METHODS

A systematic review of Cochrane, Embase, Scopus, Ovid, and PubMed databases was performed for all original clinical studies that reported outcomes of pediatric and adolescent patients undergoing revision ACLR. Non-English studies and studies not reporting both graft failure rates and an additional outcome measure were excluded. We evaluated patient demographics, injury mechanisms, surgical technique characteristics, concomitant injuries, failure rates, patient-reported outcome measures (PROMs), complications, and return to sports rates. Risk of bias (ROB) was assessed with the methodological index for nonrandomized studies (MINORS).

RESULTS

Five studies with a total of 239 knees in 234 patients were included. Failure of the revision ACLR ranged from 9% to 21%. Return to previous level of activity ranged between 27% and 68%. PROMs were variable, with good Lysholm Knee Scoring Scale score (range 84.5-93.7), moderate Tegner Activity Score (range 5.5-9.0), and good International Knee Documentation Committee knee scores (range 79.9-80.0). Allograft was used in 48% of revisions, followed by bone patellar tendon bone autograft in 34%, and hamstrings (HS) autograft in 14%. Meniscus injury and cartilage injury was present in 53.1% to 92.5% and 5.5% to 59.4% of knees, respectively. Gwet's AC1 coefficient was 0.89, indicating a high degree of interrater reliability. The average MINORS score was 6, and heterogeneity was low (I2 = 9%). The included studies did not present with sufficient detail to disaggregate clinical outcomes by patient sex.

CONCLUSIONS

Revision ACLR yields a graft failure ranging from 9 to 20%. Revision patients experience good PROMs but low rates of return to preinjury level of sport. Further, revision ACLR was associated with high rates of intra-articular damage and relatively low rates of meniscal repair at the time of second surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV evidence.

Approximately half of pediatric or adolescent patients undergoing revision anterior cruciate ligament reconstruction return to the same level of sport or higher: A systematic review

PURPOSE

To summarise the surgical techniques and clinical outcomes in paediatric and adolescent patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR).

METHODS

Three databases (MEDLINE, PubMed and EMBASE) were searched from inception to 29 July 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, rupture and return to sport (RTS) were extracted.

RESULTS

Eight studies comprising 706 (711 knees) patients were included (48.7% female). The mean age at r-ACLR was 17.1 years (range: 16.5-18.0). Autografts (67.5%) were more common than allografts (32.2%) in revision, with bone-patellar tendon-bone (BPTB) being the most prevalent autograft source (59.6%). Bone grafts were used in seven patients (4.8% of 146 patients). The most common femoral and tibial fixation techniques were interference screws (37.6% and 38.1%, of 244 patients, respectively). The most common tunnelling strategy was anatomic (69.1% of 236 patients), and meniscus repairs were performed in 39.7% of 256 patients. The re-rupture rate was 13.0% in 293 patients. RTS at the same level or higher was 51.6% in 219 patients. The mean (SD) Lysholm score was 88.1 (12.9) in 78 patients, the mean (SD) Tegner score was 6.0 (1.6) in 78 patients, and the mean (SD) IKDC score was 82.6 (16.0) in 126 patients.

CONCLUSION

R-ACLR in paediatric and adolescent patients predominantly uses BPTB autografts and interference screw femoral and tibial fixation with concomitant meniscal procedures. Rates of re-rupture and RTS at the same level or higher were 13.0% and 51.6%, respectively. Information from this review can provide orthopaedic surgeons with a comprehensive understanding of the most commonly used operative techniques and their outcomes for revision ACLR in this population.

LEVEL OF EVIDENCE

Level IV.

Reconsideration of Return-to-Sport Decision-Making After Pediatric ACL Injury: A Scoping Review

CONTEXT

Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%.

OBJECTIVES

(1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes.

DATA SOURCES

PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature.

STUDY SELECTION

Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies.

STUDY DESIGN

Scoping review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart.

RESULTS

Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported.

CONCLUSION

RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review

OBJECTIVE

We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes.

DATA SOURCES

PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized.

MAIN RESULTS

Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low.

CONCLUSION

Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

Outcomes of revision anterior cruciate ligament reconstruction in soccer players : a cohort study

Aims

There is limited information on outcomes of revision ACL reconstruction (rACLR) in soccer (association football) athletes, particularly on return to sport and the rate of additional knee surgery. The purpose of this study was to report return to soccer after rACLR, and to test the hypothesis that patient sex and graft choice are associated with return to play and the likelihood of future knee surgery in soccer players undergoing rACLR.

Methods

Soccer athletes enrolled in a prospective multicentre cohort were contacted to collect ancillary data on their participation in soccer and their return to play following rACLR. Information regarding if and when they returned to play and their current playing status was recorded. If they were not currently playing soccer, they were asked the primary reason they stopped playing. Information on any subsequent knee surgery following their index rACLR was also collected. Player demographic data and graft choice were collected from their baseline enrolment data at rACLR.

Results

Soccer-specific follow-up was collected on 76% (33 male, 39 female) of 95 soccer athletes. Subsequent surgery information was collected on 95% (44 male, 46 female). Overall, 63% of athletes returned to soccer a mean 9.6 months (SD 5.8) after index revision surgery but participation in soccer decreased to 19% at a mean of 6.4 years (SD 1.3) after surgery. There was no significant association of patient sex or graft choice with return to play, time of return to play, or long-term return to play. Females were more likely than males to have subsequent knee surgery following rACLR (20% (9/46) vs 5% (2/44); p = 0.050). The rate of recurrent graft tear (5.6%; 5/90) was similar between males and females.

Conclusion

Approximately two-thirds of soccer players return to sport after rACLR, but the rate of participation drops significantly over time. Neither patient sex nor graft choice at the time of rACLR were associated with return to play. Female soccer players face a higher risk for additional knee surgery after rACLR than male soccer players.

Cite this article: Bone Jt Open 2021;2(12):1043–1048.

Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

PURPOSE

To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger.

METHODS

A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded.

RESULTS

We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies.

CONCLUSIONS

There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently.

CLINICAL RELEVANCE

A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

A Narrative Review of Four Different New Techniques in Primary Anterior Cruciate Ligament Repair: "Back to the Future" or Another Trend?

Recently, four different operative techniques, referring to the primary anterior cruciate ligament (ACL) repair, were described. These are the dynamic intraligamentary stabilization (DIS) with Ligamys™, the Bridge-enhanced repair (BEAR), the use of internal brace, and the refixation with suture anchors. The purpose of this study was to assess the already-published, clinical, and pre-clinical results of those techniques. A literature review was conducted and implemented by three independent researchers. Inclusion criteria were clinical or cadaveric or animal studies about patients suffering from ACL rupture, who were treated with one of those four different arthroscopic techniques of primary ACL repair. There were 10 clinical trials dealing with the different techniques of primary ACL repair and 12 cadaveric or animal studies. The majority of the published clinical trials investigated the dynamic intraligamentary stabilization (DIS), while only four studies referred to the three other surgical techniques. Most of the clinical trials suggested that primary ACL repair should be done during the first 14–21 days after a proximal ACL rupture and not later. Further clinical evidence is needed for the techniques of bridge-enhanced ACL repair, internal brace, and suture anchors ACL refixation in order to support the animal and cadaveric biomechanical studies. Till now, the existing clinical trials were not enough to establish the use of those techniques in the ACL-ruptured patients. On the contrary, the Dynamic intraligamentary stabilization with Ligamys™ device demonstrated very promising results in different types of clinical studies.

Outcomes and Return to Sport After Revision Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

Background

The number of adolescent anterior cruciate ligament (ACL) injuries is rising with increased participation in higher level athletics at earlier ages. With an increasing number of primary ACL reconstructions (ACLRs) comes a rise in the incidence of revision ACLRs.

Purpose

To evaluate the clinical results of revision ACLR across a group of high-level adolescent athletes with at least 2-year follow-up.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective review of 21 adolescent athletes (age range, 10-19 years) who underwent revision ACLR with at least 2-year follow-up was conducted. Patient-reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, Tegner activity level scale, and modified Cincinnati Knee Rating System. Return to sport (RTS) and overall patient satisfaction were also assessed.

Results

The mean age at the time of surgery was 16.5 years (range, 14-19 years), and the mean follow-up was 46.4 months (range, 24-97 months); 42.9% of patients were female, and 52.4% of patients participated in collision sports. The mean time to failure after primary ACLR was 13.1 ± 8.0 months, and the most common mechanism of failure was noncontact in at least 66.7% of cases. The revision graft type included bone-patellar tendon-bone (BPTB) in 71.4% of cases; 26.7% of BPTB grafts were from the contralateral extremity. Concomitant procedures were performed for intra-articular lesions in 71.4% of patients. The mean patient satisfaction rate was 95.3%. There were 3 cases of a graft reinjury at a mean of 25 months postoperatively. The mean PROM scores were as follows: IKDC, 87.5 ± 12.7; Tegner, 7.2 ± 2.0; Lysholm, 93.7 ± 9.8; and Cincinnati, 93.4 ± 10.0. Of those attempting to RTS, 68.4% of patients successfully returned at the same level of competition. Patients with a lateral compartment chondral injury were less likely to RTS (P < .05). Independent variables shown to have no significant relationship to PROMs or RTS included age, follow-up, sport classification, associated meniscal tears, revision graft size/type, and concomitant procedures.

Conclusion

Revision ACLR can be an effective surgical option in adolescents participating in collision and contact sports, with good to excellent subjective outcome scores. At a minimum 2-year follow-up, a graft rupture after revision ACLR occurred in 14% of cases. Of the athletes attempting to RTS, 68.4% returned to their preinjury level of competition.

Anterior cruciate ligament revision with Achilles tendon allograft in young athletes

BACKGROUND

Return to sport after revision ACL reconstruction is a controversial topic, several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non anatomic double-bundle revision ACL reconstruction with Achilles allograft.

HYPOTHESIS

The present revision technique was effective in terms of stability, return to sport and functional outcomes.

MATERIAL AND METHODS

All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A split Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and re-injury or re-operations were evaluated.

RESULTS

Twenty-six athletes (23 males, three females) with a mean age of 23.4±3.6 years were evaluated at a mean follow-up of 6.0±1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7±1.5 (3-9 range) months. The mean Lysholm score showed a significant improvement from 64.4±8.1 at pre-operative status to 83.8±11.3 at final follow-up (P<.0001). Seven patients (30%) were rated as excellent, nine (39%) as good, five (22%) as fair and 2 (9%) as poor. Three patients (12%) experienced a further graft rupture after a mean 2.6 years, (3.5 months-48 months range) and two had >5mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean six years follow-up was 81%.

CONCLUSION

The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at six years mean follow-up.

TYPE OF STUDY AND LEVEL OF EVIDENCE

Retrospective case series, level IV.

Superior return to sports rate after patellar tendon autograft over patellar tendon allograft in revision anterior cruciate ligament reconstruction

PURPOSE

After revision anterior cruciate ligament reconstruction (ACLR), the rate of return to the pre-injury type of sport (RTS type) is low and graft choice might be an important factor. The aim of this study was to determine whether there is a difference in outcome after revision ACLR using a patellar tendon allograft compared to an ipsilateral patellar tendon autograft. It was hypothesized that the rate of RTS type using an ipsilateral patellar tendon autograft will be superior to using patellar tendon allograft.

METHODS

The design is a retrospective cohort study. Inclusion criteria were patients who underwent revision ACLR with a minimum follow-up of 1 year after revision using a patellar allograft or ipsilateral autograft. Primary study parameter was rate of RTS type. Secondary study parameters were RTS level, subscores of the KOOS, the IKDC_subjective, the Tegner score and reasons for no RTS.

RESULTS

Eighty-two patients participated in this study (36 allografts and 46 autografts). In patients with a minimum follow-up of 1 year, rate of RTS type was 51.4% for the patellar tendon allograft and 62.8% for the patellar tendon autograft group (n.s.). In patients with a minimum follow-up rate of 2 years, rate of RTS type was 43.3 versus 75.0%, respectively (p = 0.027). No differences in secondary study parameters were found. In patients with a minimum follow-up of 1 year, rate of RTS type was significantly higher (p = 0.025) for patients without anxiety compared to patients who were anxious to perform certain movements.

CONCLUSION

After a minimum follow-up of 2 years, rate of RTS type is in favour of using an ipsilateral patellar tendon autograft when compared to using a patellar tendon allograft in patients undergoing revision ACLR; after a minimum follow-up of 1 year, no significant difference was found. In revision ACLR, the results of this study might influence graft choice in favour of autologous graft when the use of an allograft or autograft patellar tendon is considered.

LEVEL OF EVIDENCE

III.

Clinical Outcomes in Revision Anterior Cruciate Ligament Reconstruction: A Meta-analysis

PURPOSE

The purpose of this meta-analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower-level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations.

METHODS

A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta-analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity.

RESULTS

Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow-up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval [CI], 1.8%-12.3%). Mean instrumented laxity as side-to-side difference was 2.5 mm (95% CI, 1.9-3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64-77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85-77.61), and mean Lysholm score was 86.18 (95% CI, 79.08-93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%-91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%-6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%-6.7%).

CONCLUSIONS

In this meta-analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery.

LEVEL OF EVIDENCE

Meta-analysis of Level II studies, Level II.

Neuromuscular Training Availability and Efficacy in Preventing Anterior Cruciate Ligament Injury in High School Sports: A Retrospective Cohort Study

OBJECTIVE

To document neuromuscular training (NMT) availability and its relationship to anterior cruciate ligament (ACL) injuries in 4 major high school sports by gender, sport, and rural/urban geography, with the hypothesis that increased exposure to NMT would be associated with fewer ACL injuries.

DESIGN

A retrospective cohort study.

SETTING

All Minnesota high schools identified in the Minnesota State High School League (MSHSL) database for fall 2014 boys' football and soccer, and girls' volleyball and soccer.

PARTICIPANTS

All high school athletic directors were surveyed to report their school's fall 2014 experience; 53.5% returned the survey reporting experience with one or more of the sports.

INTERVENTION

Athletic directors documented each sport's preseason and in-season exposure to NMT (plyometric exercises, proximal/core muscle strengthening, education and feedback regarding proper body mechanics, and aerobics) and licensed athletic trainers.

MAIN OUTCOMES

Reported ACL injuries by sport, gender and rural/urban.

RESULTS

More than two-thirds of teams incorporated facets of NMT into their sport. Among male athletes, soccer players exposed to licensed athletic trainers experienced significantly fewer ACL injuries (P < 0.005), and NMT was associated with significantly fewer ACL injuries in football (P < 0.05) and soccer (P < 0.05). Female athletes did not demonstrate similar associated improvements, with volleyball injuries associated with increased NMT (P < 0.001), and soccer injuries not associated with NMT. However, girl soccer players in rural settings reported fewer ACL injures compared with urban teams (P < 0.001).

CONCLUSIONS

Most fall high school sports teams were exposed to NMT, which was associated with fewer ACL injuries for male, but not for female athletes. Improved gender- and sport-specific preventive training programs are indicated.

Allograft Augmentation of Hamstring Autograft for Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction

BACKGROUND

Younger patients and those with smaller hamstring autograft diameters have been shown to be at significantly greater risk of graft failure after anterior cruciate ligament (ACL) reconstruction. To date, there is no information in the literature about the clinical success and/or cost-effectiveness of increasing graft diameter by augmenting with semitendinosus allograft tissue for younger patients.

HYPOTHESIS

Hybrid hamstring grafts are a cost-effective treatment option because of a reduced rate of graft failure.

STUDY DESIGN

Cohort study (economic and decision analysis); Level of evidence, 3.

METHODS

We retrospectively identified patients younger than 18 years who had undergone ACL reconstruction by a single surgeon between 2010 and 2015. During this period, the operating surgeon's graft selection algorithm included the use of bone-patellar tendon-bone (BTB) autografts for the majority of patients younger than 18 years. However, hamstring autografts (hamstring) or hybrid hamstring autografts with allograft augment (hybrid) were used in skeletally immature patients and in those whom the surgeon felt might have greater difficulty with postoperative rehabilitation after BTB graft harvest. Patient demographics, graft type, graft diameter, the time the patient was cleared to return to activity, and the need for secondary surgical procedures were compared between the hamstring and hybrid groups. The clinical results were then used to assess the potential cost-effectiveness of hybrid grafts in this select group of young patients with an ACL injury or reconstruction.

RESULTS

This study comprised 88 patients (hamstring group, n = 46; hybrid group, n = 42). The 2 groups did not differ in terms of age, sex, timing of return to activity, or prevalence of skeletally immature patients. Graft diameters were significantly smaller in the hamstring group (7.8 vs 9.9 mm; P < .001), which corresponded with a significantly greater rate of graft failure (13 of 46 [28.3%] vs 5 of 42 [11.9%]; P = .049). As a result of the reduced revision rate, the hybrid graft demonstrated incremental cost savings of US$2765 compared with the hamstring graft, and the hybrid graft was the preferred strategy in 89% of cases.

CONCLUSION

Driven by increased graft diameters and the reduced risk of revision, hybrid grafts appear to be a more cost-effective treatment option in a subset of younger patients with an ACL injury.

Technical Considerations in Revision Anterior Cruciate Ligament (ACL) Reconstruction for Operative Techniques in Orthopaedics

As the incidence of anterior cruciate ligament (ACL) reconstruction continues to increase, the rate of revision surgery continues to climb. Revision surgery has inherent challenges that must be addressed in order to achieve successful results. The cause of the primary ACL reconstruction failure should be determined, and careful preoperative planning should be performed to address the cause(s) of failure. Each patient undergoing revision surgery should undergo a thorough history and physical examination, receive full length alignment radiographs, lateral radiographs, 45-degree flexion weight-bearing postero-anterior radiographs, and patellofemoral radiographs. 3-dimensional computed topography (CT) scan should be performed to assess tunnel position and widening. Magnetic resonance imaging (MRI) should be used to assess for intra-articular soft tissue pathology. Meniscal tears, meniscal deficiency, anterolateral capsule injuries, bony morphology, age, activity level, connective tissue diseases, infection, graft choice, and tunnel position can all impact the success of ACL reconstruction surgery. Meniscal lesions should be repaired, and in cases of persistent rotatory instability, extra-articular procedures may be indicated. Furthermore, osteotomies may be needed to correct malalignment or excess posterior tibial slope. Depending on the placement and condition of the original femoral and tibial tunnels, revision surgery may be performed in a single procedure or in a staged manner. In most cases, the surgery can be performed in one procedure. Regardless, the surgeon must communicate with the patient openly regarding the implications of revision ACL surgery and the treatment plan should be developed in a shared fashion between the surgeon and the patient.

Functional recovery following primary ACL repair with dynamic intraligamentary stabilization

BACKGROUND

Recently, a new technique, dynamic intraligamentary stabilization (DIS) was introduced for the acute repair of ACL ruptures. The purpose of this study was to report the functional recovery for patients undergoing acute anterior cruciate ligament (ACL) repair alongside DIS.

METHODS

Forty five patients sustaining acute ACL rupture and treated with DIS repair were retrospectively evaluated. Limb symmetry index of the hop test as well as knee function by means of range of motion, knee swelling, pain and maximum strength were evaluated. Following completion of the rehabilitation program, the difference in anterior-posterior translation (Δ-AP Translation), IKDC, Tegner score (TAS) was additionally analyzed.

RESULTS

Forty five (13 females, 32 males) patients were included in the study. Mean age was 26years (range 18 to 54years). Median time to successfully complete hop test was 22.0weeks (range 11 to 32weeks) postoperatively. Median limb symmetry index 91.6%±8.3%. Median delta anterior-posterior translation compared to the healthy side was plus 0.0mm±1.6mm. Median IKDC was 89.5±6.5. Mean Tegner score (TAS) at 12months of follow-up was seven (range four to nine). Three patients suffered a rerupture during the first 12 postoperative months.

CONCLUSIONS

DIS technique with proper rehabilitation following acute ACL rupture provides successful functional recovery and low rerupture rate at one-year follow-up.

Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger

BACKGROUND

The current body of literature surrounding anterior cruciate ligament (ACL) survival and the variables contributing to further ACL injuries after primary ACL reconstruction in children and adolescents is limited, with no long-term evidence examining the incidence and contributing factors of further ACL injuries in this younger patient population.

PURPOSE

To determine the long-term survival of the ACL graft and the contralateral ACL (CACL) after primary reconstruction in patients aged ≤18 years and to identify the factors that increase the odds of subsequent ACL injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients having undergone primary ACL reconstruction at age ≤18 years between 1993 and 1998 who were included in a prospective database by a single surgeon were considered for this study. Single-incision endoscopic ACL reconstruction was performed with either an autologous bone-patellar tendon-bone graft or a hamstring tendon graft. At a minimum of 15 years after ACL reconstruction, patients completed a subjective survey involving the International Knee Documentation Committee (IKDC) questionnaire in addition to questions regarding current symptoms, further ACL injuries, family history of ACL injury, and current level of activity.

RESULTS

A total of 288 adolescents (age range, 13-18 years) met the inclusion criteria, of whom 242 (84%) were reviewed at a mean of 16 years and 6 months after ACL reconstruction. Of these patients, 75 (31%) sustained a further ACL injury: 27 (11.2%) suffered an ACL graft rupture, 33 suffered a CACL injury (13.6%), and 15 sustained both an ACL graft rupture and a CACL injury (6.2%) over 15 years. Survival of the ACL graft was 95%, 92%, 88%, 85%, and 83% at 1, 2, 5, 10, and 15 years, respectively, and survival of the CACL was 99%, 98%, 90%, 83%, and 81%, respectively. Survival of the ACL graft was less favorable in those with a family history of ACL injury than in those without a family history (69% vs 90%, respectively; hazard ratio [HR], 3.6; P = .001). Survival of the CACL was less favorable in male patients than in female patients (75% vs 88%, respectively; HR, 2.1; P = .03) and in those who returned to competitive team ball sports than in those who did not (78% vs 89%, respectively; HR, 2.3; P = .05).

CONCLUSION

After ACL reconstruction in patients aged ≤18 years, a further ACL injury occurred in 1 in 3 patients over 15 years. The 15-year survival rate of the ACL graft was 83%, and the 15-year survival rate of the CACL was 81%. The ACL graft and CACL were most vulnerable within the first 5 years after index surgery. A family history of ACL rupture significantly increased the risk for ACL graft ruptures, and a CACL injury was more common in male patients and those who returned to team ball sports. High IKDC scores and continued participation in sports were maintained over the long term after ACL reconstruction in the adolescent population.

Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport

PURPOSE

An increasing number of patients undergo revision anterior cruciate ligament (ACL) reconstruction, with the intention of returning to sport being a major indication. The aim of this study is to assess the available evidence for clinical improvement and return to sport, to understand the real potential of this procedure in regaining functional activity, and to facilitate improved counselling of patients regarding the expected outcome after revision ACL reconstruction.

METHODS

The search was conducted on the PubMed database. Articles reporting clinical results for revision ACL reconstruction were included. A meta-analysis was performed on return to sport, and results were compared to the literature on primary ACL reconstruction. Other specific clinical outcomes (Lysholm, Tegner, IKDC Objective scores) were also included in the meta-analysis.

RESULTS

Of the 503 identified records, a total of 59 studies involving 5365 patients were included in the qualitative data synthesis. Only 31 articles reported the rate of return to sport. Whereas 73 % of good objective results and satisfactory subjective results were documented, 57 % of patients did not return to the same level of sport activity, significantly inferior to that of a primary procedure.

CONCLUSION

The real potential of revision ACL reconstruction should not be overestimated due to the low number of patients able to return to their previous activity level, significantly inferior with respect to that reported for primary ACL reconstruction. This finding will help physicians in the clinical practice providing realistic expectations to the patients. Future studies should focus on participation-based outcome measures such as return to sport and in strategies to improve the results in terms of return to previous activities after revision ACL reconstruction.

LEVEL OF EVIDENCE

Systematic review and meta-analysis including Level IV studies, Level IV.

After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis

BACKGROUND

Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions.

PURPOSE

The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction.

MATERIAL AND METHODS

A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well.

RESULTS

Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively.

CONCLUSIONS

In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level.

Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction

BACKGROUND

Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision.

PURPOSE

To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months' follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale.

RESULTS

The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last follow-up. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3.

CONCLUSION

Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS.

Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft

BACKGROUND

The return-to-sport and reinjury rates are not well defined after revision anterior cruciate ligament (ACL) reconstruction.

HYPOTHESIS

School-age athletes would have a higher rate of return to sports and reinjury to either knee after revision ACL surgery compared with college or recreational athletes.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients were prospectively studied after revision ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft. Participants were grouped by competitive sport levels of school age (mean age, 16.6 ± 0.9 years; n = 84), college (19.6 ± 1.2 years; n = 58), or recreational adult (27.6 ± 4.1 years; n = 117). An activity survey was used to determine the specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) knee survey and Cincinnati Knee Rating System (CKRS) survey responses were also obtained.

RESULTS

The rate of return to the same sport at the same level was 62 of 84 school-age athletes (74%), 43 of 58 college athletes (74%), and 73 of 117 recreational athletes (62%) (P = .1065). The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group (P = .6706). The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the school-age group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group (P = .9501). At 2 years postoperatively, the mean IKDC subjective total score was 86.1 ± 11.7 points and the mean CKRS total score was 89.7 ± 11.1 points.

CONCLUSION

Revision ACL reconstruction with BPTB autograft and perioperative rehabilitation allowed high school and college athletes to return to sports at the preinjury level at a rate of 74%; the return rate for recreational-level adults was 62%. Reinjury rates in the first 5 years after revision surgery ranged from 2% to 5%, which is lower than what has been reported for young competitive athletes after primary surgery.

Anterior cruciate ligament injuries: diagnosis, treatment, and prevention

The number of anterior cruciate ligament (ACL) injuries reported in athletes younger than 18 years has increased over the past 2 decades. Reasons for the increasing ACL injury rate include the growing number of children and adolescents participating in organized sports, intensive sports training at an earlier age, and greater rate of diagnosis because of increased awareness and greater use of advanced medical imaging. ACL injury rates are low in young children and increase sharply during puberty, especially for girls, who have higher rates of noncontact ACL injuries than boys do in similar sports. Intrinsic risk factors for ACL injury include higher BMI, subtalar joint overpronation, generalized ligamentous laxity, and decreased neuromuscular control of knee motion. ACL injuries often require surgery and/or many months of rehabilitation and substantial time lost from school and sports participation. Unfortunately, regardless of treatment, athletes with ACL injuries are up to 10 times more likely to develop degenerative arthritis of the knee. Safe and effective surgical techniques for children and adolescents continue to evolve. Neuromuscular training can reduce risk of ACL injury in adolescent girls. This report outlines the current state of knowledge on epidemiology, diagnosis, treatment, and prevention of ACL injuries in children and adolescents.

Reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a review of current concepts: AAOS exhibit selection

Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes but are now observed with increasing frequency. Treatment strategies have evolved as recent studies have identified unique considerations specific to the skeletally immature patient. The current literature now supports the trend toward early operative treatment to restore knee stability and prevent progressive meniscal and/or articular cartilage damage, but the optimal approach to ACL reconstruction in this age group remains controversial. Despite the reported clinical success of transphyseal reconstruction, iatrogenic growth disturbance secondary to physeal damage remains a genuine concern. The reluctance to place drill-holes across open physes has led to the development of numerous "physeal-sparing" reconstruction techniques using anatomic femoral and tibial footprints that have adequately restored anteroposterior and rotational knee stability in biomechanical studies but have demonstrated mixed results in the clinical setting. The intent of this review is to (1) highlight the unique anatomic considerations pertaining to ACL reconstruction in the skeletally immature athlete, (2) discuss preoperative clinical and radiographic assessment of the pediatric patient with a suspected ACL injury, (3) review transphyseal and physeal-sparing reconstruction techniques and highlight surgical technical considerations, (4) present clinical outcomes according to patient and technique-specific factors, and (5) review age-specific injury prevention treatment strategies and a novel treatment algorithm based on skeletal maturity. ACL reconstruction in the skeletally immature athlete typically results in a successful clinical outcome, yet the optimal surgical technique is still controversial. This review will help guide the management of ACL injuries in the pediatric athlete.