Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA football team physicians

Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Tibial Tubercle Trochlear Groove Distance Does Not Correlate With Patellar Tendon Length in Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To examine the relationship between tibial tubercle-trochlear groove (TT-TG) distance and patellar tendon length.

Methods

All healthy athletes who underwent anterior cruciate ligament reconstruction who had a magnetic resonance imaging (MRI) study of the knee on file between July 2018 and June 2019 at a single institution were retrospectively reviewed. Exclusion criteria included patients without an MRI study of the knee on file or with an MRI of insufficient quality precluding reliable calculation of TT-TG and patellar tendon length. MRIs were reviewed to calculate TT-TG, patellar tendon length, and Caton-Deschamps Index (CDI). Patient charts were reviewed to obtain anthropometric characteristics including sex, concomitant injuries, and previous knee procedures as well as age at time of MRI. Spearman correlations were used to assess the relationship between TT-TG, patellar tendon length, and CDI, with regression analysis performed to assess for relationships between TT-TG, patellar tendon length, and patient-specific factors.

Results

Overall, 235 patients (99 female [42.1%], 136 male [57.9%]; mean age: 30.0 years [23.0; 40.0]) were included. Inter-rater reliability between the 2 reviewers was 0.888 for TT-TG, 0.804 for patellar tendon length, and 0.748 for CDI, indicating strong agreement. The correlation between TT-TG and patellar tendon length was 0.021, indicating no true relationship. The correlation between TT-TG and CDI was -0.048 and that of patellar tendon length and CDI was 0.411, indicating a weak positive relationship. Regression analysis found that male sex is strongly correlated with a longer patellar tendon length (odds ratio 2.65, 95% confidence interval 1.33-3.97, P < .001).

Conclusions

In this study, no correlation was found between TT-TG and patellar tendon length or CDI. Male sex was correlated with a longer patellar length.

Level of Evidence

Level III.

Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis

PURPOSE

To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends.

METHODS

A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05.

RESULTS

Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed.

CONCLUSIONS

In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons.

CLINICAL RELEVANCE

Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.

The impact of bone graft type used to fill bone defects in patients undergoing ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft on kneeling, anterior knee pain and knee functional outcomes

PURPOSE

Multiple different materials are used for filling bone defects following bone-patellar tendon-bone (BPTB) graft ACL reconstruction surgery. The theoretical objective being to minimize kneeling pain, improve clinical outcomes and reduce anterior knee pain following surgery. The impact of these materials is assessed in this study.

METHODS

A prospective monocentric cohort study was conducted from January 2018 to March 2020. There were 128 skeletally mature athletic patients who underwent ACL reconstruction using the same arthroscopic-assisted BPTB technique, with a minimum follow-up of two years identified in our database. After obtaining approval from the local ethics committee, 102 patients were included in the study. Patients were divided into three groups based on type of bone substitute. The Bioactive glass 45S5 ceramic Glassbone™ (GB), collagen and hydroxyapatite bone void filler in sponge form Collapat® II (CP), and treated human bone graft Osteopure®(OP) bone substitutes were used according to availability. Clinical evaluation of patients at follow-up was performed using the WebSurvey software. A questionnaire completed in the 2nd post-operative year included three items: The ability to kneel, the presence of donor site pain, and the palpation of a defect. Another assessment tool included the IKDC subjective score and Lysholm score. These two tools were completed by patients preoperatively, and postoperatively on three occasions (6 months, 1 year, and 2 years).

RESULTS

A total of 102 patients were included in this study. In terms of Kneeling pain, the percentage of GB and CP patients' who kneel with ease were much higher than that of OP patients (77.78%, 76.5% vs 65.6%, respectively). All three groups experienced an important increase in IKDC and Lysholm scores. There was no difference in anterior knee pain between the groups.

CONCLUSION

The use of Glassbone® and Collapat II® bone substitutes reduced the incidence of kneeling pain compared to Osteopure®. There was no influence of the bone substitute type on the functional outcome of the knee or on the anterior knee pain at two years of follow.

[New treatment methods in competitive sports : What can we learn from the medical care of top athletes?]

BACKGROUND

As elite sport becomes more professional, the medical-psychological care of athletes is an important factor in providing them with the best possible support and thus optimising their performance. Our experience in the fields of prevention, conservative and surgical treatment, and rehabilitation also provides valuable insights for the treatment of our patients in daily practice.

PREVENTION

Designed to improve static and dynamic muscle strength, kinaesthetic sensitivity, and neuromuscular control, the FIFA 11+ injury prevention programme is a three-part warm-up programme that is widely used in coaching and recreational sports.

CONSERVATIVE TREATMENT

Platelet-rich plasma (PRP) is probably the most widely used orthobiologic treatment modality for the conservative management of tendon, muscle and cartilage injuries. Its effectiveness depends on the underlying pathology and the affected body region. The best evidence exists for the treatment of patellar tendinitis ("jumper's knee") and epicondylitis humeri radialis ("tennis elbow").

SURGICAL TREATMENT

The treatment of ACL injuries in competitive athletes is challenging due to the high physical demands. Prompt surgical intervention, anatomical reconstruction and additional extra-articular stabilisation are associated with improved surgical outcomes. Graft selection must be individualised, adapted to the needs of the athletes and our patients.

REHABILITATION

Electromyography (EMG) is a diagnostic tool to identify muscular imbalances in rehabilitation and, at the same time, to help reduce them through biofeedback training.

COGNITIVE TRAINING

Training for the development of basic cognitive skills helps to optimise performance through its potentially positive influence on the executive functions of athletes.

Anterior Cruciate Ligament Injury Prevention and Rehabilitation

At all levels of American football, knee injuries are common, with injuries to the anterior cruciate ligament (ACL) making up a significant proportion. Historically, ACL injuries were career-altering for professional players, but innovative techniques in surgery and rehabilitation have returned many to the field. While there is a consensus on surgical techniques for ACL reconstruction, significant discrepancies remain on injury prevention and rehabilitation programs. This review article describes the burden of ACL injury on players in the National Football League, best practices in injury prevention and rehabilitation, and evidence-based recommendations for preparing injured athletes to return to play.

Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone-Patellar Tendon-Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group

BACKGROUND

Bone-patellar tendon-bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR).

PURPOSE/HYPOTHESIS

The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non-graft rupture-related reoperation rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records.

RESULTS

A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged <20 years were at a particularly high risk of graft ruptures compared with patients aged >30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar.

CONCLUSION

Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India

BACKGROUND

Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice.

METHODS

A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed.

RESULTS

324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft.

CONCLUSION

Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.

Variations in common operations in athletes and non-Athletes

Background

Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes.

Aim

This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective.

Methods

A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review.

Results

There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete.

Conclusion

Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.

Risk of Graft Rupture After Adding a Lateral Extra-articular Procedure at the Time of ACL Reconstruction: A Retrospective Comparative Study of Elite Alpine Skiers From the French National Team

BACKGROUND

Elite alpine skiing is associated with a particularly high risk of anterior cruciate ligament (ACL) injuries, including graft ruptures. Despite a considerable focus on prevention, a reduction in injury rates has not been observed since the 1980s.

PURPOSE

To determine whether elite alpine skiers undergoing ACL reconstruction (ACLR) with a lateral extra-articular procedure (LEAP) had a lower rate of ACL graft rupture when compared with those who underwent isolated ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Elite skiers from the French ski team who had undergone ACLR, with or without a LEAP, and had a minimum follow-up of 2 years were identified from the national ski team database. Rates of secondary ACL injury were determined via interrogation of the database, review of medical notes, and a final telemedicine interview. A multivariable analysis using the penalized Cox model was performed to explore the relationship among graft rupture, surgical procedure type, and any potential explanatory variables.

RESULTS

Among 81 ACLR procedures analyzed, 50 were isolated and 31 were combined with a LEAP, which was performed using modified Lemaire or anterolateral ligament reconstruction. Graft rupture rates were 34.0% in the isolated ACLR group and 6.5% in the ACLR + LEAP group. Multivariable analysis demonstrated that adding a LEAP was associated with a significant reduction in risk of ACL graft rupture when compared with isolated ACLR (hazard ratio [HR], 5.286 [95% CI, 1.068-26.149]; P = .0412). Age (HR, 1.114; P = .1157), sex (HR, 1.573; P = .3743), and ACL graft type (HR, 1.417; P = .5394) were not significant risk factors.

CONCLUSION

Combined ACLR and LEAP were associated with a significant reduction in the rate of ACL graft rupture in elite alpine ski athletes. Those treated with isolated ACLR remain at extremely high risk of a second ACL injury.

National Football League Wide Receivers and Running Backs Have Decreased Production Following ACL Reconstruction: An Evaluation of Fantasy Football Performance as an Outcome Measure

Purpose

To use fantasy football points as a simple measure alongside on-field statistics to compare performance in National Football League (NFL) offensive skill position players before and after anterior cruciate ligament (ACL) reconstruction.

Methods

A retrospective review of all NFL quarterbacks (QB), running backs (RB), wide receivers (WR), and tight ends (TE) who sustained an isolated, unilateral ACL injury from 1988 to 2017 was conducted. Data were collected from public data sources, team releases, NFL injury reports, press releases, and other Internet resources. For each player, a matched control with similar demographics was identified. Their in-game performance post-ACL reconstruction was analyzed using fantasy football points as an outcome measure.

Results

A total of 13 QBs, 30 RBs, and 29 WRs who underwent ACL reconstruction from 1988 to 2017 and who met inclusion criteria were retrospectively identified and reviewed. Of the 13 quarterbacks included in the study, there was no statistically significant difference in fantasy football points between the pre- and post-ACL reconstruction groups, as well as post-ACL and matched control groups. There was a statistically significant decrease in career fantasy football performance of running backs post-ACL reconstruction compared with matched control groups (129.6 vs 553.6; P < .0001). There was also a statistically significant decrease in per game fantasy football points post-ACL reconstruction (4.4 vs 11.2; P < .0001). Lastly, WRs also demonstrated a decrease in career fantasy football performance post-ACL reconstruction compared with matched controls (145.3 vs 460.9; P = .002). In addition, they also had a decrease in per game fantasy football performance (5.0 vs 7.7; P = .042).

Conclusions

Quarterbacks did not have a statistically significant decrease in performance following ACL reconstruction based on fantasy football performance. Conversely, both running backs and wide receivers had decreased per game and career performance post-ACL reconstruction based on their fantasy football statistics. Furthermore, RBs had the largest decline in production each season over a 3-year period following ACLR compared to QBs and WRs, respectively.

Level of Evidence

Level III, case-control study.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in National Football League Players

Background:

Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions.

Purpose/Hypothesis:

The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR.

Study Design:

Descriptive epidemiology study.

Methods:

All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions.

Results:

Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%).

Conclusion:

The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.

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.

ACL Tears in the National Football League From 2013 to 2020: Analysis of the 2020 Season After Delays and Schedule Changes From the Early COVID-19 Pandemic Relative to Prior Seasons

Background:

The impact of fatigue and preseason preparation on anterior cruciate ligament (ACL) tears in the National Football League (NFL) are not well described. The 2020 NFL season did not include the standard preseason in response to changes secondary to the coronavirus disease-2019 (COVID-19) pandemic.

Purpose:

To evaluate the association of game play on ACL tears in NFL athletes and to determine if differences in ACL tear epidemiology were present based on season of play from 2013 to 2020.

Study Design:

Descriptive epidemiology study.

Methods:

ACL tears in NFL athletes were identified using publicly available data. Games played and snap counts at the time of injury were recorded for each athlete sustaining game-related injuries. Tear rates were determined, and injuries were also calculated per 1000 athlete-exposures. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated.

Results:

Overall, 379 ACL tears were identified, including 256 (67.6%) during game play and 118 (31.1%) during practice. Practice-based injuries were significantly higher in the preseason versus the remainder of the season. Games and snaps at the time of injury did not differ by year. The incidence rate of preseason injuries was significantly greater relative to in-season injuries (IRR = 2.68; 95% CI, 2.18-3.29; P < .00001). There was an elevated incidence rate of in-season injuries in 2020 relative to 2014-2019 combined (IRR = 1.49; 95% CI, 0.98-2.19; P = .048). In 2013 to 2019, the most frequent month of injury was the first month of the preseason in August (119/334 tears; 35.6%), whereas in 2020, the most frequent month was September (13/41 tears, 31.7%). The proportion of tears in September 2020 was not different from the proportion of tears in August 2013 to 2019.

Conclusion:

There was an increased proportion of in-season ACL tears in the 2020 NFL season relative to 2014 to 2019; this is attributable to a frameshift in the consistent trend of injuries in the 1st month to return of competitive play, with 2020 being in the regular season in September as opposed to the preseason in August.

Editorial Commentary: Large-Diameter Quadrupled Hamstring Autografts Are an Acceptable Option for National Collegiate Athletic Association Division I College Football Players: We Must Challenge Our Comfort Zone to Be Successful in the End Zone

The majority of surgeons caring for elite American football teams choose bone-patellar tendon-bone (BTB) autograft for anterior cruciate ligament reconstruction. As we strive to continue to improve currently favorable outcomes, we need to consider all options regarding graft choice, surgical technique, and postoperative rehabilitation. Advantages of BTB include an excellent track record, potential for faster incorporation with bone-to-bone healing. Disadvantages include risk of patellar fracture/tendon rupture and anterior knee pain. The pros of quadrupled hamstring (QH) graft include stronger graft (higher ultimate load to failure) and less anterior knee pain and stiffness, and the cons include loss of flexion/hamstring strength and slower healing in the tunnels. Several studies have shown that smaller grafts have higher failure rates, and recent research shows that QH grafts >9 mm had decreased risk of revision compared to BTB. We can now quadruple the semitendinosus tendon to provide elite athletes with even more robust grafts. Large-diameter QH autografts are an acceptable option for National Collegiate Athletic Association Division I college football players.

High Return to Play and Low Reinjury Rates in National Collegiate Athletic Association Division I Football Players Following Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Autograft

PURPOSE

The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players.

METHODS

A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play.

RESULTS

Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster.

CONCLUSION

QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes.

LEVEL OF EVIDENCE

IV, case series.

Editorial Commentary: The Anterior Cruciate Ligament May Be Safer Wearing a Suture Tape Augmentation Seat Belt: Click It or Ticket

Bone-patellar tendon-bone autograft for anterior cruciate ligament (ACL) reconstruction has the most data to support its use. However, there may still be room for improvement, and younger age, insufficient rehabilitation, altered neuromuscular patterns, and precocious return to play can increase risk of graft failure. High strength suture augmentation of soft-tissue repair or reconstruction has gained traction in a variety of applications for the knee, including medial collateral and posteromedial corner, lateral collateral ligament, posterior cruciate ligament, and ACL. For ACL reconstruction, the technique consists of using either suture or suture tape fixed at the femoral and tibial ACL footprints to allow for independent tensioning to back up the separately tensioned ACL reconstruction. The static augment serves as a load-sharing device, allowing the graft to see more strain during earlier levels of graft strain, until graft elongation occurs to a critical level whereby the augment will experience more strain than the graft. Hence, the "seat belt" analogy. This is distinct from static augmentation, where the high strength suture is fixed to the graft. Static augmentation (without tensioning separately from the graft) results in a load-sharing device and increased stiffness, but potential stress shielding compared with the "seat belt." If suture tape augmentation improves patient outcome, it is a worthwhile to "click it."

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.

Functional Bracing Following Anterior Cruciate Ligament Reconstruction: A Critical Analysis Review

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Anterior cruciate ligament (ACL) injuries remain common among athletes; these injuries require reconstruction to restore stability and enable successful return to sport.

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The role of postoperative dynamic knee bracing following ACL reconstruction in protecting graft integrity and promoting return to sport remains largely unknown.

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Limited biomechanical studies on functional bracing have reported decreased strain across the ACL with increasing anterior shear loading.

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Investigations evaluating functional brace use in clinical studies have not yet demonstrated consistent improvement in clinical outcomes, reduced graft retear rates, or improved return-to-sport rates in sports other than skiing.

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Additional investigation examining athletes of various ages participating in different sporting activities is necessary to better understand the role of functional bracing following ACL reconstruction.

Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons

PURPOSE

The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection.

METHODS

A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience.

RESULTS

Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics.

CONCLUSIONS

Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients.

CLINICAL RELEVANCE

Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes

PURPOSE

To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively.

METHODS

Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively.

RESULTS

We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035).

CONCLUSIONS

Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Hamstrings substitution via anteromedial portal with optional anterolateral ligament reconstruction is the preferred surgical technique for anterior cruciate ligament reconstruction: a survey among ESSKA members

PURPOSE

The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures.

METHODS

All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods.

RESULTS

Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500-66%), while a compression system was preferred on the tibial side by 537 (71% of the sample).

CONCLUSIONS

This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community.

LEVEL OF EVIDENCE

III.

ACL reconstruction in the professional or elite athlete: state of the art

Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete's sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to 'near peak' performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques-particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.

Return to Play Rates in NFL Wide Receivers and Running Backs After ACL Reconstruction: An Updated Analysis

Background:

Anterior cruciate ligament (ACL) ruptures are potentially career-threatening injuries to National Football League (NFL) skill position players. A 2006 study showed a return-to-play (RTP) rate of 79% for NFL running backs (RBs) and wide receivers (WRs). Since then, a number of factors affecting RTP, including style of play as well as rules regarding hits to the head, have changed how defensive players tackle offensive ball carriers.

Purpose/Hypothesis:

To determine whether the RTP rate for RBs and WRs in the NFL has changed since data were collected in the 2000s. Additionally, we evaluated player performance before and after ACL reconstruction (ACLR). We hypothesized that there will be a lower RTP rate than previously reported as well as a decrease in performance statistics after ACLR.

Study Design:

Descriptive epidemiology study.

Methods:

Publicly available NFL injury reports between the 2009-2010 and 2015-2016 seasons were utilized for RBs and WRs who underwent ACLR. Successful RTP was indicated by playing in at least 1 NFL game after reconstruction. Position-specific performance statistics from before and after reconstruction were gathered for these players, and the RTP players were compared against the players who did not RTP (dnRTP group). Pre- and postinjury performance measures were also compared against a matched control group of NFL RBs and WRs who had not sustained an ACL injury.

Results:

Overall, 61.8% of players (64.5% of RBs, 60% of WRs) returned to play at a mean of 13.6 months. Prior to injury, the RTP group had played in significantly more career games and had significantly more rushes and receptions per game than the dnRTP group; however, there was no significant difference in performance after ACLR. The WR RTP group had significantly decreased performance in all measured categories when compared with the control group.

Conclusion:

Our study found a lower RTP rate in RBs and WRs than previous studies conducted in the early 2000s. WRs who achieved RTP had decreased performance when compared with noninjured controls.

Preferences in anterior cruciate ligament reconstruction and return to sport: A survey among surgeons in the Netherlands

OBJECTIVE

The purpose of this study was to investigate the preferences of surgeons on technique for femoral tunnel placement, graft selection and criteria for return to sport in the Netherlands.

METHODS

A web-based survey among the Dutch Association of Arthroscopy was conducted.

RESULTS

A total of 125 members (24.0%) were included in the analysis. A total of 87.2% (n = 109) used hamstring autografts for primary ACL reconstruction followed by patellar tendon autograft (n = 11, 8.8%) and quadriceps tendon autograft (n = 5, 4.0%). The anteromedial technique was favored by 50.4% (n = 63), whereas 11.2% (n = 14) of the participants favored the transtibial technique. Return to sport after 9 months of primary ACL reconstruction was allowed by 75.2% (n = 94) of the participants. Regarding criteria to evaluate readiness to return to sport, the surgeons stated postoperative period (n = 107, 85.6%) and functional performance tests (n = 96, 76.8%) as important.

CONCLUSION

The majority of the participants of the Dutch Association of Arthroscopy favored the hamstring autografts for primary anterior cruciate ligament reconstruction. Furthermore, most participants stated postoperative time and functional performance tests as important criteria to evaluate readiness to return to sport. This is the first survey demonstrating a high preference of surgeons to use functional performance tests in the decision-making of readiness to return to sport.

Return to sports bridge program improves outcomes, decreases ipsilateral knee re-injury and contralateral knee injury rates post-ACL reconstruction

PURPOSE

To present the results of a return to sports bridge program designed to reduce knee injuries following ACL reconstruction and physical therapy.

METHODS

One hundred and fifty (male = 83, female = 67) patients participated in a whole body neuromuscular control, progressive resistance strength and agility training program. Post-program testing included functional movement form, dynamic knee stability, lower extremity power, agility, and sports skill assessments. Participants completed the Knee Outcome Survey-Sports Activity Scale (KOS-SAS) before and after program initiation. Pre-participation scores were re-estimated following program completion.

RESULTS

Global rating KOS-SAS score at program entry was 75 ± 13. Post-program global rating and calculated KOS-SAS were 91.0 ± 9.8 and 90.9 ± 9.7, respectively (p < 0.0001). Pre-participation KOS-SAS score re-estimates at program completion were 54.5 ± 23.3 and 57.3 ± 18.5, respectively. The approximately 20% lower pre-program KOS-SAS score re-estimates (p < 0.0001) observed at program completion suggests that subjects had inaccurately high sports readiness perceptions at program entry. Perceived overall sports activity knee function ratings improved from 2.9 ± 0.6 (abnormal) at program entry to 1.3 ± 0.5 (normal) at completion (p < 0.0001). Most subjects returned back to sports at or above their pre-injury performance skill/performance level (84%, 126/150). By 6.8 ± 3.2 years (range = 2-13 years) post-surgery, ten subjects had sustained an ipsilateral knee re-injury or contralateral knee injury (6.7%). The 2.7% non-contact contralateral and 1.3% non-contact ipsilateral knee injury rates observed were significantly lower than those cited in previous reports.

CONCLUSION

Supplementing primary ACL reconstruction and standard physical therapy with a return to sports bridge program prior to release to unrestricted sports performance was effective at improving patient outcomes and decreasing ipsilateral knee re-injury and contralateral knee injury rates.

LEVEL OF EVIDENCE

II.

Return to Play and Performance After Primary ACL Reconstruction in American Football Players: A Systematic Review

Background

Anterior cruciate ligament (ACL) injuries are among the most common sports-related injuries, and they can have a negative impact on players' ability to return to play (RTP). There is a paucity of literature focused on RTP after ACL reconstruction (ACLR) in collision sports.

Purpose

To characterize the impact that an ACL injury has on the ability to RTP and the post-ACLR performance level in American football players.

Study Design

Systematic review; Level of evidence, 4.

Methods

An electronic search was performed using the following databases: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the Cumulative Index to Nursing and Allied Health Literature. Included studies were written in English; were published since the year 2000; examined only American football players; and reported on RTP, performance, and/or career length after primary ACLR.

Results

The initial search yielded 442 unique studies. Of these, 427 were removed after screening, leaving 15 studies that met inclusion criteria. An additional 2 studies were identified in these studies' references, yielding a total of 17. The rate of RTP after ACLR for football players was 67.2% (1249/1859), and the mean time to return was 11.6 months (range, 35.8-55.8 weeks). Although considerable heterogeneity existed in the study design and outcomes measured, in general, a majority of football players experienced greater declines from their preinjury performance level than controls over the same time period.

Conclusion

An ACL injury negatively affected football players' ability to RTP and their post-ACLR performance. The degree of effect varied by several factors, including playing position, preinjury performance level, and National Football League Draft round. These results may be used by physicians and football players to develop reasonable expectations for returning to play and performance after an ACL injury.

Current Practice Patterns in Anterior Cruciate Ligament Reconstruction Among Fellowship-Trained Military Orthopaedic Surgeons

Purpose

To evaluate current practice patterns in anterior cruciate ligament reconstruction (ACLR) surgery among fellowship-trained military surgeons.

Methods

The MOTION database is a prospectively collected dataset of intraoperative variables across the Military Health System. This database was queried using Current Procedural Terminology code 29888 for ACLR among active-duty service members between October 2016 and December 2019. The intraoperative data pertaining to ACLR involving both isolated primary ACLRs and primary ACLRs combined with meniscal or chondral injuries were extracted with patient age, sex, and rank.

Results

Two hundred sixty-six primary ACLRs performed by 21 fellowship-trained orthopaedic surgeons at 9 MTFs were identified. The mean age of patients undergoing ACLR was 27.2 ± 7.7 years. Bone–patellar tendon–bone autograft was the most commonly used graft source (137 of 266 [51.5%] cases.) Meniscal injuries were treated with an isolated debridement in 53 of 156 (34.0%) tears, whereas meniscal repair was performed in 86 of 156 (55.1%) tears. Concomitant chondral pathology was noted in 43 of 266 cases (16.2%) and most commonly addressed with chondroplasty (25 of 49 [51.0%] chondral lesions).

Conclusions

Bone–patellar tendon–bone autograft was the most commonly used graft type in ACLR among fellowship-trained surgeons treating active-duty service members. Concomitant meniscal pathology was encountered at rates comparable with what has been previously reported, and meniscal repair was favored over meniscal debridement in more than 50% cases.

Level of Evidence

Level IV: Therapeutic case series.

Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players

BACKGROUND

For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation.

HYPOTHESIS

There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP.

RESULTS

A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone-patellar tendon-bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant.

CONCLUSION

The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.

Anterior Cruciate Ligament Injuries in the National Hockey League: Epidemiology and Performance Impact

OBJECTIVE

To determine the incidence of anterior cruciate ligament (ACL) injuries in the National Hockey League (NHL) and to examine the effects of this injury on return-to-play status and performance.

DESIGN

Case series; level of evidence, 4.

METHODS

This was a 2-phase study. Phase I used the NHL electronic injury surveillance system and Athlete Health Management System to collect data on ACL injuries and man games lost over 10 seasons (2006/2007-2015/2016). Data collected in phase I were received in deidentified form. Phase II examined the performance impact of an ACL injury. Players were identified through publically available sources, and performance-related statistics were analyzed. Data collected in phase II were not linked to data collected in phase I. A paired t test was used to determine any difference in the matching variables between controls and cases in the preinjury time period. A General linear model (mixed) was used to determine the performance impact.

RESULTS

Phase I: 67 ACL injuries occurred over 10 seasons. The incidence for all players was 0.42/1000 player game hours (forward, 0.61; defenseman, 0.32, goalie, 0.08) and by game exposure was 0.2/1000 player game exposures (forward, 0.33; defenseman, 0.11; goalie, 0.07). Forwards had a greater incidence rate of ACL tears with both game hours and game exposures when compared with defensemen and goalies (P < 0.001, <0.001; P = 0.008, <0.001, respectively). Phase II: 70 ACL tears (60 players) were identified. Compared with controls, players who suffered an ACL tear demonstrated a decrease in goals/season (P < 0.04), goals/game (P < 0.015), points/season (0.007), and points/game (0.001). Number of games and seasons played after an ACL injury did not differ compared with controls (P = 0.068, 0.122, respectively).

CONCLUSIONS

Anterior cruciate ligament injuries occur infrequently, as it relates to other hockey injuries. Despite a high return to play, the performance after an ACL injury demonstrated a decrease in points and goals per game and per season.

Professional Advancement and Performance of Amateur Baseball Players Selected in the Major League Baseball Draft With Previous Anterior Cruciate Ligament Reconstruction

BACKGROUND

The effect that an anterior cruciate ligament injury requiring reconstructive surgery has on the professional advancement and performance of amateur baseball players selected in the Major League Baseball draft is not known. Return to sports after anterior cruciate ligament reconstruction (ACLR) in professional athletes has been shown to be high, but mixed results with regard to performance and return to preinjury level have been demonstrated in other sports.

PURPOSE

To (1) investigate the highest level of professional advancement among Major League Baseball draftees with a history of ACLR before entering the draft, (2) examine how much time these players spent on the disabled list (DL) and determine if it was related to the knee, and (3) compare the batting and pitching performance of these players against healthy matched controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Predraft medical records of all players selected in the Major League Baseball draft from 2004 to 2008 were reviewed. Players with a documented anterior cruciate ligament injury treated with ACLR before the draft were included. For each study player, 3 controls were identified. Data were accumulated from the time when players were drafted through the 2015 season. Outcome variables included highest professional level of advancement, DL time, and batting and pitching performance.

RESULTS

Forty draftees with a history of ACLR (22 pitchers, 18 position players) were identified and matched to 120 controls (66 pitchers, 54 position players). The difference in the highest level of professional advancement between the groups was not statistically significant (P = .488). The mean total number of times and the mean total number of days on the DL were similar between the groups (1.83 vs 1.47, P = .297; 121.54 vs 109.62, P = .955); however, the mean number of times on the DL because of a knee injury was significantly different (0.28 vs 0.11, P = .004), as was the mean number of days on the DL because of a knee injury (17.36 vs 7.72, P = .009). Among pitchers, there were no differences in performance. Similarly, there were no differences among position players in batting performance.

CONCLUSION

There was no difference between draftees with a history of ACLR and their controls in terms of advancement from the minor to the major leagues. Additionally, pitching and batting performance were similar. Although the 2 groups spent similar time on the DL, the ACLR group spent more time on the DL because of a knee injury than the control group.

QUADRICEPS AUTOGRAFT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A LITERATURE REVIEW

ABSTRACT Introduction: Anterior cruciate ligament injury is one of the most prevalent musculoskeletal injuries. Therefore, several surgical techniques and graft types have been described for its reconstruction. Autologous hamstring tendon graft is one of the most frequently used, but use of the quadriceps tendon graft has gained prominence in recent years. Objective: To review the literature to compare the outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft versus hamstring tendon (HT) autograft. Methods: A literature review was conducted through PubMed to locate studies (Level of evidence I-III) comparing the outcomes of the QT autograft vs. the HT autograft in patients undergoing primary ACL reconstruction. Patients were assessed on the basis of re-rupture rate, ligament instability, patient-reported outcome scores, previous pain, and isokinetic tests. Results: Six studies were selected according to inclusion criteria. A total of 481 patients were evaluated, 243 in the QT group and 238 in the HT group. The total re-rupture rate was 1.6% (8 of 481), with 6 in the HT group and 2 in the QT group, but with no statistical difference between groups. One study found increased ligament instability in the HT group and another study found greater instability in the QT group, both with statistical significance. Regarding the patient-reported functional scores, only 01 study found statistical difference, with better results in the QT group. There was no difference in previous pain between groups in the selected studies. Regarding the isokinetic test, one study found a difference in flexor force in the HT group (p <0.01), with no difference in extensor force, while another two studies found an increased extensor force deficit in the QT group within up to 01 year of follow-up. The flexor/ extensor muscle strength ratio was higher in the QT group in both studies. Conclusion: ACL reconstruction with QT graft presents re-rupture rates, ligament instability, functional scores and donor site morbidity that are similar to the HT graft, in addition to preserving greater flexor force in proportion to extensor force. Level of evidence: IV; Review study.

Relationship of Knee Forces to Subjective Function Pre- and Post-ACL Reconstruction

PURPOSE

Although basic objective measures (e.g., knee laxity, strength, and hop tests) have been related to subjective measures of function, associations between knee-specific objective and subjective measures have yet to be completed. The objective was to determine if knee joint contact and ligament forces differ between pre- and post-anterior cruciate ligament (ACL) reconstructed states and if these forces relate to their patient's respective subjective functional ability scores.

METHODS

Twelve patients performed a hopping task before and after reconstruction. Magnetic resonance images and OpenSim were used to develop patient-specific models in static optimization and joint reaction analyses. Questionnaires concerning each patient's subjective functional ability were also collected and correlated with knee joint contact and ligament forces.

RESULTS

No significant differences were observed between deficient and reconstructed groups with respect to knee joint contact or ligament forces. Nevertheless, there were several significant (P < 0.05) moderate to strong correlations between subjective and objective measures including Tegner activity level to contact force in both states (r = 0.67-0.76) and International Knee Documentation Committee to compressive and anterior shear forces (r = 0.64-0.66).

CONCLUSION

Knee-specific objective measures of a patient's functional capacity can represent their subjective ability, which explains this relationship to a greater extent than past anatomical and gross objective measures of function. This consolidation is imperative for improving the current rehabilitation schema as it allows for external validation of objective and subjective functional measures. With poor validation of subjective function against objective measures of function, the reinjury rate is unlikely to diminish, continuing the heavy financial burden on health care systems.

Treatment of Anterior Cruciate Ligament Injuries in Professional Soccer Players by Orthopedic Surgeons

Objective  To describe the treatment provided by specialists for ACL lesions in professional soccer players. Methods  A cross-sectional study in which orthopedic surgeons affiliated to soccer teams competing in the Brazilian Soccer Championship answered a questionnaire about the treatment of ACL injuries in professional soccer players. Results  The specialists wait between one to four weeks after the ACL injury to perform the surgical treatment. They use a single incision and single-bundle reconstruction, assisted by arthroscopy, femoral tunnel drilling by an accessory medial portal, and quadruple flexor tendon autografts or patellar tendon autografts. After three to four months, the players are allowed to run in a straight line; after four to six months, they begin to practice exercises with the ball without contact with other athletes; and, after six to eight months, they return to play. The main parameter used to determine the return to play is the isokinetic strength test. The specialists estimate that more than 90% of elite soccer players return to playing professionally after an ACL reconstruction, and 60 to 90% return to play at their prior or at a greater level of performance. Conclusion  The present article successfully describes the main surgical practices and post-surgery management adopted by specialists in this highly-specific population of patients.

Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Professional Baseball Players

Background:

Anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for ACL tears to allow baseball players to return to sport (RTS). The optimal graft type and femoral tunnel drilling technique are currently unknown.

Hypothesis:

There is a high rate of RTS in professional baseball players after ACLR, with no significant difference in RTS rates or performance between cases and controls or between graft types or femoral drilling techniques.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

All professional baseball players who underwent ACLR between 2010 and 2015 were included. Demographic and performance data (pre- and postoperative) for each player were recorded. Performance metrics were then compared between cases and matched controls.

Results:

A total of 124 players (mean age, 23.7 ± 4.1 years; 83% minor league players) underwent ACLR. Of these, 80% returned to sport (73% to the same or higher level) at a mean 310 ± 109 days overall and 333 ± 126 days at the same or higher level. The most common graft type was an ipsilateral bone–patellar tendon–bone (BTB) autograft (n = 87; 70%). A total of 91 players underwent concomitant meniscal debridement or repair. No significant difference in any of the primary performance metrics existed from before to after ACLR. Compared with matched controls, no significant difference existed in RTS rates or any performance metrics after ACLR. No significant difference existed in RTS rates or primary performance outcome measures between graft types or femoral drilling techniques.

Conclusion:

The RTS rate for professional baseball players after ACLR was 80%. No significant difference in performance metrics existed between BTB and hamstring autografts or between femoral drilling techniques. Furthermore, no significant difference in performance or RTS rates existed between cases and matched controls. Femoral drilling technique and graft type did not affect performance and RTS rates in professional baseball players after ACLR.

The medial epicondyle of the distal femur is the optimal location for MRI measurement of semitendinosus and gracilis tendon cross-sectional area

PURPOSE

Graft diameter ≥ 8 mm reduces the risk of failure after anterior cruciate ligament reconstruction (ALCR) with hamstring tendon autograft. Pre-operative measurement of gracilis (GT) and semitendinosus (ST) cross-sectional area using MRI has been utilized but the optimal location for measurement is unknown. The main purpose of this study was to examine the cross-sectional areas of GT + ST at different locations and develop a model to predict whether a doubled hamstring graft of GT + ST will be of sufficient cross-sectional area for ACLR.

METHODS

A retrospective review was performed of 154 patients who underwent primary ACLR using doubled hamstring autograft. Cross-sectional area measurements of GT + ST on pre-operative MRI axial images were made at three locations: medial epicondyle (ME), tibiofemoral joint line (TJL), and tibial physeal scar (TPS) and calculated the correlation of intra-operative graft size for each location using the Pearson's correlation coefficient. A receiver operating characteristic (ROC) established a threshold that would predict graft diameter ≥ 8 mm.

RESULTS

Measurement of GT + ST at the ME had a stronger correlation (r = 0.389) to intra-operative graft diameter than measurements at the TJL (r = 0.256) or TPS (r = 0.240). The ROC indicated good predictive value for hamstring graft diameter ≥ 8 mm based on MRI measurement at the ME with the optimal threshold with the highest sensitivity and specificity as 18 mm².

CONCLUSION

Cross-sectional area measurement of GT + ST at the ME correlated most closely to intra-operative diameter of a doubled hamstring autograft compared to measurements at the TJL or the TPS. As graft diameter < 8 mm is correlated with higher failure rates of ACL surgery, the ability to pre-operatively predict graft diameter is clinically useful.

LEVEL OF EVIDENCE

Level III, prognostic study.

Predicting post-operative functional ability from pre-operative measures in ACL-injured individuals

PURPOSE

This study aimed to quantify the relationship between objective and subjective measures of functional ability and determine if measures in the deficient (ACLd) state were correlated to, and capable of predicting a patient's objective and subjective measures in the reconstructed (ACLr) state.

METHODS

Twenty ACL-injured participants completed hop and side cut movements prior to and 10 months post-reconstruction. Their subjective measures (Tegner, Lysholm, IKDC, KOOS, and KNEEs) were related to objective measures of functional ability (peak knee flexion, peak knee extensor moment, stiffness, knee joint center excursion (KJCE), and knee joint center boundary). Correlations were used to determine relationships between variables whereas regressions were used to identify ACLd score's predictive ability of an ACLr score.

RESULTS

Relationships between objective and subjective measures were task and ACL status dependent with KJCE and stiffness most commonly being related to subjective scores. The greatest correlation was between knee stiffness and Tegner in the ACLr group during the side cut (r = 0.69). Peak knee flexion angle (adj. R²  = 0.4-0.66) was the best objective predictor between ACLd and ACLr states while KOOS-ADL had the strongest correlations (r = 0.70-0.77) and Tegner had the greatest predictive power (odds ratio: 1.46-1.86) between states in both tasks.

CONCLUSION

Objective measures show a wide range of correlation to subjective measures with some being quite strong. Furthermore, objective measures in the ACLd state are more correlated and more often capable of predicting ACLr scores than the subjective measures of functional ability.

A Systematic Review of the Orthopaedic Literature Involving National Football League Players

Background

Orthopaedic injuries of National Football League (NFL) players can have a deleterious effect on their health, with minimal to no high-level evidence on the management of these injuries.

Purpose

To summarize all data published between January 1980 and March 2018 on orthopaedic injuries experienced by NFL candidates and professional players in the NFL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of studies examining orthopaedic injuries in the NFL was performed through the PubMed, Embase, and CINAHL databases. The review included studies of orthopaedic injuries in college football recruits attending the NFL Combine as well as professional NFL players. Excluded were studies of nonorthopaedic injuries, such as concussions, traumatic brain injury, facial injuries, and vascular injuries, as well as case reports.

Results

A total of 147 articles met the inclusion criteria and were divided into 11 topics based on anatomic site: general (16%), spine (13%), shoulder (13%), elbow (3%), hand and wrist (3%), trunk (0.7%), hip and pelvis (7%), thigh (3%), knee (24%), ankle (5%), and foot (12%). Of these studies, 74% were of level 4 evidence. Most studies obtained data from the NFL Combine database (26%), by searching the internet (24%), and via the NFL Injury Surveillance System (22%). Studies using internet search methods to identify injuries consistently found fewer participants than studies using the NFL Injury Surveillance System.

Conclusion

This systematic review provides National Collegiate Athletic Association and NFL team physicians with a single source of the most current literature regarding orthopaedic injuries in NFL players. Most research was published on knee, spine, shoulder, and foot injuries and consisted of level 4 evidence. A substantial portion of the published literature was based on data obtained from internet searches and may not accurately represent the NFL population.

The significant effect of the medial hamstrings on dynamic knee stability

PURPOSE

While hamstring autograft is a popular option for the general population, BTB autograft is still significantly more popular among professional athletes due to concerns of altering knee kinematics with hamstring harvest. This study seeks to quantify the contribution of the medial hamstrings to knee stability.

METHODS

Valgus knee laxity, anterior tibial translation, and rotational motion were measured in eight fresh-frozen cadaveric knees after forces were applied on the tibia in each plane (coronal, sagittal, and axial). Four muscle loading conditions were tested: (1) physiologic fully loaded pes anserinus, (2) semitendinosus only loaded, (3) gracilis only loaded, and (4) unloaded pes anserinus. The protocol was then repeated with the ACL transected.

RESULTS

In the ACL intact knee, the neutral position of the tibia with an unloaded pes anserinus was significantly more externally rotated (p < 0.01) and anteriorly translated (p < 0.05) at all knee flexion angles than a tibia with a physiologic loaded pes anserinus. Applying an external rotation torque significantly increased external rotation for the fully unloaded (p < 0.001), gracilis only loaded (p < 0.001), and semitendinosus only loaded (p < 0.01) conditions at all flexion angles. Applying a valgus torque resulted in a significant increase in laxity for the fully unloaded condition only at 30° of flexion (p < 0.05). Applying an anterior tibial force resulted in significant increase in anterior translation for the fully unloaded condition at all flexion angles (p < 0.01), and for the gracilis only loaded condition in 30° and 60° of flexion (p < 0.05). Similar results were seen in the ACL deficient model.

CONCLUSION

The medial hamstrings are involved in rotational, translational, and varus/valgus control of the knee. Applying anterior, external rotation, and valgus forces on the hamstring deficient knee significantly increases motion in those planes. Harvesting the gracilis and semitendinosus tendons alters native knee kinematics and stability. This is clinically relevant and should be a consideration when choosing graft source for ACL reconstruction, especially in the elite athlete population.

Assessment of objective dynamic knee joint control in anterior cruciate ligament deficient and reconstructed individuals

BACKGROUND

There is a lack of objective dynamic knee joint control measures that can be related to the status of the anterior cruciate ligament (ACL). The purpose of this study was to introduce two novel measures and apply a third to determine how dynamic knee joint control changes in relation to ACL status during dynamic movements.

METHODS

Twenty patients (13 male) were tested pre- (ACLd) and 10-months post- (ACLr) ACL reconstructive surgery and matched to an uninjured participant (CON). Kinetic and kinematic data were synchronously recorded with a force platform and motion capture system. Three objective control measures including dynamic angular stiffness, knee joint center excursion (KJCE), and knee joint center boundary (KJCB) were assessed for each participant when completing the side cut and hop tasks.

RESULTS

During the side cut, stiffness was found to be significantly lower in ACLd (0.06 ± 0.01 Nm/kg/°) and ACLr (0.07 ± 0.02 Nm/kg/°) compared to CON (0.08 ± 0.02 Nm/kg/°), while there were no differences in stiffness during the hop. No significant differences were observed in the KJCE during the side cut, while KJCE was significantly greater (p = 0.006) during the hop in CON compared to the ACLd. There were no differences in KJCB.

CONCLUSIONS

These high-functioning ACL injured in both ACLd and ACLr phases, aside from reduced stiffness, were able to complete both tasks with similar dynamic control as the CON. Although improvements in self-perceived control between ACLd and ACLr have been observed, this lack of improvement in objective control demonstrates a gap between a patient's self-efficacy and the level of control.

Anterior cruciate ligament reconstruction improves subjective ability but not neuromuscular biomechanics during dynamic tasks

PURPOSE

The purpose of this study was to identify high-functioning anterior cruciate ligament-deficient patients and assess the effects of reconstruction on their self-reported functionality, muscle activations and biomechanical properties.

METHODS

Twenty young and active patients participated pre- (11.5 ± 14.3 months post-injury) and again 10.5 ± 1.7 months post-reconstruction and were individually matched to 20 healthy controls. Participants completed hop and side cut movements while patient-related outcome measures, lower limb electromyography, kinetic, and whole body kinematic data were collected. One-dimensional statistical parametric mapping was used to test for group differences (healthy vs deficient; deficient vs reconstructed; reconstructed vs healthy).

RESULTS

When comparing healthy to anterior cruciate ligament-deficient participants, all questionnaires indicated significant lower subjective function while the only substantial biomechanical difference between these participants was a decreased knee extensor moment in both the hop (peak difference: 0.63 Nm/kg, p < 0.001) and side cut (peak difference: 0.76 Nm/kg, p < 0.001). When comparing patients' pre- and post-reconstruction, no biomechanical differences were observed whereas only half of the questionnaires (Tegner, Lysholm, KNEES-ADL, KNEES-Slackness, KNEES-Looseness, KNEES-Sport Behaviour, IKDC, and KOOS-QoL) indicated higher function in the reconstructed state. When comparing the reconstructed patients to the healthy participants, all questionnaires were still significantly higher in the healthy controls. The reconstructed group also had a smaller flexion angle (peak difference: 14.5°, p = 0.007) and knee extensor moment (peak difference: 0.62 Nm/kg, p < 0.001) during the hop and a smaller knee extensor moment (peak difference: 0.90 Nm/kg, p < 0.001) during the side-cut task.

CONCLUSION

At 10-months post-reconstruction, the current results indicate that in high-functioning anterior cruciate ligament-deficient patients, reconstruction had little impact on objective measures of functional ability during dynamic tasks although self-reported function was improved.

LEVEL OF EVIDENCE

Therapeutic prospective cohort study, Level II.

Determination of patellar tendon length for anterior cruciate ligament reconstruction using an anteroposterior knee radiograph

Background/Objective

Graft-tunnel length mismatch is a common intraoperative technical problem for anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone graft (BPTB). The patella-to-condyle and the patella-to-notch distances are two measurements in an anteroposterior knee radiograph. The objective of this study was to evaluate the sensitivities, specificities and reliabilities of those 2 measurements for detecting patients who had a patellar tendon length exceeding 45 mm.

Methods

Preoperative plain radiographs of patients who underwent ACLR with a BPTB graft were evaluated independently by two orthopaedic surgeons 3 times each at 2-weekly intervals. The sensitivities and specificities of the two measurements for detecting patients who have a patellar tendon length exceeding 45 mm were calculated. The optimal cutoff point was estimated using Youden index, and the receiver operating characteristic (ROC) curve and area under the curve (AUC) were evaluated with a 95% CI. As for the inter- and intra-rater reliabilities, intraclass correlation coefficients (ICC) were determined.

Results

One hundred and twenty-seven patients with an average age of 29.5 years old were evaluated. The mean patellar tendon length was 41.3 ± 5.0 mm. Patients with a length more than 45 mm (20 patients, 16%) had significantly higher patella-to-condyle and patella-to-notch distances, and more frequent use of bone staples for distal graft fixation than patients with a length ≤ 45 mm. To detect patients with a patellar tendon length over 45 mm, the optimal cutoff point for the patella-to-condyle distance was set at 14.5 mm, which had a sensitivity of 80%, specificity of 71%, and AUC of 0.76. In the case of the patella-to-notch distance, the cutoff point of 5.5 mm had a sensitivity of 80%, specificity of 66%, and AUC of 0.73. The intra- and inter-rater reliabilities of the two measurements were excellent, with ICCs of over 0.90.

Conclusions

Preoperative measurements of the patella-to-condyle and the patella-to-notch distances in AP knee radiographs can be valuable tools, with good sensitivities and specificities, for the determination of the patellar tendon length when using a BPTB graft for an ACLR. They had an acceptable level of discrimination capability and excellent reliability.

Quantifying anterior knee pain during specific activities after using the bone-patellar tendon-bone graft for arthroscopic anterior cruciate ligament reconstruction

Background/objective

There has been much debate about the optimal graft choice for an anterior cruciate ligament (ACL) reconstruction. Anterior knee pain is a common donor site problem when using a bone-patellar tendon-bone (BPTB) graft. However, knowledge of the characteristics of anterior knee pain during different daily activities is still limited. This study aimed to determine the incidence of anterior knee pain and to quantify the degree of pain during a range of daily living activities.

Methods

Thirty-five patients who were scheduled to undergo an ACL reconstruction with an autologous BPTB graft between February 2015 and December 2016 were enrolled. A visual analogue scale (VAS) for pain was recorded during each of the following activities: ascending at 30-degree slope, ascending and descending stairs, running, jumping, squatting, kneeling, sitting cross-legged, and sitting one-legged. Demographic data, the range of motion, the area of decreased sensation, and the IKDC score were collected and compared 3 and 6 months postoperatively.

Results

The 35 male patients had a mean age of 29.7 years. Postoperatively, the mean IKDC scores were 58.1 ± 9.8 at 3 months and 72.7 ± 10.5 at 6 months. The incidences of overall anterior knee pain were 62.9% and 34.3% at the 3- and 6-month time points. Kneeling was the only activity that produced severe pain. At 3 months postoperatively, kneeling's mean VAS pain score was 3.9 ± 2.9 (2.9, 4.9; 95% CI for mean for 17 patients [48.5%] with considerable pain), whereas at 6 months postoperatively, it was 2 ± 2.5 (1.2–2.9; 95% CI for mean for 9 patients [25.7%] with considerable pain). The area of numbness of the proximal leg decreased from 12.8 ± 18.3 cm² (6.4, 19.2; 95% CI for mean) to 3.2 ± 9.1 cm² (0.1, 6.5; 95% CI for mean) at 3 and 6 months postoperatively.

Conclusions

Kneeling was the most challenging activity in terms of creating considerable levels of anterior knee pain in patients who had undergone an ACL reconstruction using a BPTB graft. Other knee activities, however, did not create moderate or severe degrees of anterior knee pain. Both anterior knee pain and numbness at the proximal leg improved over time.

Trial registration number: TCTR2018–0630002.

Anterolateral Complex Reconstruction: Another Fad or Method to Improve ACL Outcomes?

Anterolateral rotational laxity of the knee is a persistent problem following anterior cruciate ligament reconstruction (ACLR) that can lead to increased rates of graft failure. Renewed interest in the anterolateral complex of the knee has led to a resurgence in the use of adjunctive techniques such as lateral extra-articular tenodesis and anterolateral ligament reconstruction. Use of these techniques can restore normal knee kinematics and potentially thereby reduce the rate of graft failure. Historically, experience with modified ACLR techniques such as the double-bundle ACLR have shown that improved biomechanics is not always reflected in clinical outcome trials. Additional procedures also come with additional costs and further economic analysis needs to be performed to clarify whether these additional costs are offset by improved clinical and societal outcomes in the longer-term.

New Trends in Anterior Cruciate Ligament Reconstruction: A Systematic Review of National Surveys of the Last 5 Years

The purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences related to the preferred graft, femoral tunnel positioning, fixation and tensioning methods, antibiotic and anti-thromboembolic prophylaxis, and use of tourniquet and drains. A systematic search of PubMed, Web of Science, and Cochrane Library was performed. Inclusion criteria were surveys of ACL reconstruction trends and preferences published in the past 5 years (2011–2016), involving members of national societies of orthopaedics. Information regarding survey modalities, population surveyed, graft choice both in the general or in the athletic population, surgical technique, fixation, use of antibiotic, tourniquet, drains, and anti-thromboembolic prophylaxis was extracted. Eight national surveys were included from Europe (three), North or Latin America (three), and Asia (two). Overall, 7,420 questionnaires were sent, and 1,495 participants completed the survey (response rate ranging from 16 to 76.6%). All surveys reported the hamstring tendon (HT) autograft as the preferred graft, ranging from 45 to 89% of the surveyed population, followed by bone-patellar tendon-bone (BPTB) graft (2–41%) and allograft (2–17%). Only two surveys focusing on graft choice in athletic population underlined how in high-demand sportive population the graft choices changes in favor of BPTB. Single-bundle reconstruction was the preferred surgical technique in the four surveys that investigated this issue. Five surveys were in favor of anteromedial (AM) portal and two in favor of trans-tibial technique. Suspension devices for femoral fixation were the preferred choice in all but one survey, while interference screws were the preferred method for tibial fixation. The two surveys that investigated graft tensioning were in favor of manual tensioning. The use of tourniquet, antibiotics, drains, and anti-thromboembolic prophylaxis were vaguely reported. A trend toward the preference of HT autograft was registered in all the surveys; however, sport participation has been highlighted as an important variable for increased use of BPTB. Single-bundle reconstruction with AM portal technique and suspension femoral fixation and screws fixation for the tibia seem the preferred solution. Other variables such as tensioning, antibiotic, anti-thromboembolic prophylaxis, tourniquet use, and drains were investigated scarcely among the surveys; therefore, no clear trends could be delineated. This is a Level V, systematic review of expert opinion study.

Quadriceps Tendon Autograft in Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the current evidence to ascertain whether quadriceps tendon autograft (QT) is a viable option in anterior cruciate ligament reconstruction.

METHODS

A literature review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Cohort studies comparing QT with bone-patellar tendon-bone autograft (BPTB) or hamstring tendon autograft (HT) were included. Clinical outcomes were compared, with all statistical analyses performed using IBM SPSS Statistics for Windows, version 22.0, with P < .05 being considered statistically significant.

RESULTS

We identified 15 clinical trials with 1,910 patients. In all included studies, QT resulted in lower rates of anterior knee pain than BPTB. There was no difference in the rate of graft rupture between QT and BPTB or HT in any of the studies reporting this. One study found that QT resulted in greater knee stability than BPTB, and another study found increased stability compared with HT. One study found that QT resulted in improved functional outcomes compared with BPTB, and another found improved outcomes compared with HT, but one study found worse outcomes compared with BPTB.

CONCLUSIONS

Current literature suggests QT is a viable option in anterior cruciate ligament reconstruction, with published literature showing comparable knee stability, functional outcomes, donor-site morbidity, and rerupture rates compared with BPTB and HT.

LEVEL OF EVIDENCE

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