Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population-A 2-Year Follow-up Study

Good clinical outcomes of anterior cruciate ligament reconstruction in patients over 60 years of age

PURPOSE

To evaluate the clinical outcomes following arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) in patients over 60 years and to investigate the potential impact of preoperative osteoarthritis (OA) on these outcomes.

METHODS

A retrospective study included ACL-injured patients over 60 years who underwent primary arthroscopic ACLR between 2010 and 2020. The Lysholm score and the International Knee Documentation Committee (IKDC) score were assessed preoperatively and at the final follow-up. The Tegner activity scale was performed to evaluate patients' activity levels. Data on return to sports, patient satisfaction, subsequent injuries and complications were collected. Preoperative radiographs were used to grade OA according to the Kellgrene-Lawrence classification. Correlation analysis between OA and clinical outcomes was performed. The rates of achieving the minimal clinically significant difference and patient-acceptable symptoms state were documented.

RESULTS

A total of 37 patients were included in this study. The mean age at surgery was 62.3 ± 2.3 years, with a mean follow-up of 6.3 ± 3.2 years (range: 2.1-12.4). Patients showed statistically significant (all p < 0.001) improvements in the mean IKDC (38.9 ± 9.4-66.8 ± 12.5), Lysholm (48.8 ± 15.4-83.0 ± 12.8) and Tegner (1-3) scores. Fourteen patients (37.8%) returned to sports. No correlation was observed between the degree of preoperative OA and clinical outcomes (n.s.).

CONCLUSION

Patients over 60 years with symptomatic ACL-deficient knees could benefit from ACLR, even when mild to moderate OA is present preoperatively.

LEVEL OF EVIDENCE

Level IV.

Use of Unidirectional Porous β-Tricalcium Phosphate in the Tibial Tunnel for Anterior Cruciate Ligament Reconstruction: A Case Series

Bone defects in the tibial tunnel for anterior cruciate ligament (ACL) reconstruction can cause adverse events. The unidirectional porous tricalcium β-phosphate (UDPTCP) has the potential to be used as a filling substitute for bone defects. In this case series, we present the first nine cases in which UDPTCP was used as a bone substitute in the tibial tunnel during ACL reconstruction. The patients comprised six males and three females, with an average age of 32 years (range: 16-50 years). A cylindrical UDPTCP measuring 10 x 20 mm was molded to fit the tibial tunnel and then implanted. At the one-year postoperative follow-up, none of the patients demonstrated any complications, and bone remodeling was observed on radiographs. Therefore, UDPTCP may provide a safe and reliable filling substitute for the tibial tunnel in ACL reconstruction.

Anterior Cruciate Ligament Reconstruction in Patients Over 40 Years Old Shows Low Failure Rates: A Systematic Review

Purpose

To review the literature reporting on complications and failure rates after primary anterior cruciate ligament reconstruction (ACLR) in patients ≥40 years.

Methods

This was a secondary analysis from a prior systematic review of the MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases on studies evaluating clinical outcomes in ACLR patients ≥40 years. Studies were included based on the following criteria: English-language studies reporting on postoperative complications and/or ACLR failure rates in patients ≥40 years. Case reports, technical notes, studies with duplicate reporting of patient cohorts, or studies using publicly available registry data were excluded. ACLR failure definitions, failure rates, graft rupture rates, revision ACLR and non-ACLR revision rates, and complication rates were recorded.

Results

Twenty-one studies were included following full-text review. Autografts were used in 89.0% of cases. Definitions for ACLR failure varied, ranging from (1) revision ACLR, (2) graft rupture, (3) clinical examination of increased knee laxity, and (4) postoperative arthrofibrosis requiring an additional surgery. The median ACLR failure rate was 5.0% (range, 0%-12.1%) among the 9 studies reporting this outcome, with only 4 of the studies providing explicit definitions of failure. The median ACLR revision surgery, graft rupture, and non-ACLR revision surgery rates were 0% (range, 0%-7.7%), 2.7% (range, 0%-9.1%), and 7.2% (range 0%-34.4%), respectively. Commonly reported complications included pain (range, 0%-14.0%), stiffness (range, 0%-12.7%), hematoma (range, 2.5%-8.8%), neurovascular (range, 0%-41.7%), and undefined (range, 0%-13.8%).

Conclusions

ACLR in patients over 40 years old shows low failure rates.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Kinesiophobia Is Negatively Associated With Psychological Readiness to Return to Sport in Patients Awaiting Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify the factors associated with anterior cruciate ligament return to sport after injury (ACL-RSI) scores in patients awaiting ACL reconstruction (ACLR).

METHODS

This was a retrospective cross-sectional observational study conducted at a single clinical center. We recruited patients scheduled for primary ACLR, aged 16-45 years, and with modified Tegner activity scale scores ≥5 before ACL injury. The main outcome was psychological readiness to return to sport (RTS), as measured using the ACL-RSI scale. Participants' personal and injury-related information were obtained, and their psychological status (Tampa Scale for Kinesiophobia [TSK] and athletic identity measurement scale) and knee functions (effusion, range of motion, joint stability, and knee flexion angle during a single-leg squat) were examined. All variables were assessed the day before the surgery.

RESULTS

A total of 105 patients (median [interquartile range]: age, 20.0 [9.0] years; body mass index, 22.8 [4.3] kg/m2; days from injury to surgery, 63.0 [65.0] days; 44% female) were enrolled. Univariate analysis indicated that only the TSK score was associated with the ACL-RSI scores (r = -0.305; P = .02). Multiple regression analysis of factors, including sex, preinjury Tegner activity scale score, and days from injury to surgery, further showed that only the TSK score was associated with the ACL-RSI scores (P = .002; 95% confidence interval -1.738 to -0.394).

CONCLUSIONS

In patients awaiting ACLR, kinesiophobia was moderately negatively associated with psychological readiness to RTS, while other factors were not.

LEVEL OF EVIDENCE

Level III, retrospective cross-sectional observational study.

The Effect of Lower Limb Position on Anterior Cruciate Ligament Reconstruction on Uncommon Complications after Surgery

Background

To reduce the complications of orthopedic surgery, the desire for less invasive procedures, such as, knee arthroscopy to repair the anterior cruciate ligament, has increased. There are, currently, two common positions for limbs that are used during surgery depending on the surgeon's experience. Therefore, our aim was to investigate the effect of limb position on complications after anterior cruciate ligament reconstruction surgery.

Materials and Methods

From April 2016 to July 2020 at our orthopedic-sports trauma center, 688 patients between the ages of 18 and 50 with anterior cruciate ligament rupture underwent reconstruction surgery with a hamstring graft. Patients were divided into two groups in terms of limb position at the time of surgery. For three months, patients were evaluated for surgical complications, basic demographic information, and information during surgery.

Results

There was no statistically significant difference between the two groups in terms of demographic information, side of injury, preparation time, tourniquet time, operation time, and duration of hospitalization. At quarterly follow-up, there was no significant difference between the two groups in terms of postoperative complications (P = 0.976).

Conclusions

There is no difference between compartment syndrome and deep vein thrombosis in different situations, therefore, the surgeon should operate in any position he is skilled in. Also, surgeons should always pay special attention to these complications and provide necessary training to patients in order to prevent them.

Subjective Outcomes After Allograft Reconstruction and Nonoperative Treatment of Anterior Cruciate Ligament Ruptures Are Similar in Patients Aged 40 Years and Older: A 2:1 Propensity Score-Matched Analysis

Purpose

To compare subjective outcomes and rates of subsequent operations for patients aged 40 years and older with anterior cruciate ligament (ACL) ruptures who elected nonoperative management or allograft ACL reconstruction (ACLR).

Methods

This was a retrospective study comparing 2-year minimum results of nonoperative treatment and primary allograft ACLR among patients aged 40 years and older presenting to a single institution between the years 2005 and 2016. Patients who elected nonoperative management were 2:1 propensity score (PS)-matched to patients who elected ACLR based on age, sex, body mass index, sports-related mechanism of injury, Outerbridge grade III or IV chondral lesions, and medial or lateral meniscus tears. Univariate analysis was performed to compare subjective outcome measures of International Knee Documentation Committee and Marx activity level scores, subsequent operations, and satisfaction rates.

Results

After 2:1 PS matching, 40 ACLR and 20 nonoperative patients with mean ages of 52.2 years and 54.5 years, respectively, were included with a mean follow-up of 5.7 years (SD 2.1 years, range 2.3-10.6 years). There were no significant differences between the groups in any of the matching variables. There were no significant differences in International Knee Documentation Committee scores (81.9 ± 14.1, CI 77.4-86.5 vs 84.3 ± 12.8, CI 78.3-90.3, P = .53), Marx activity level scores (5.8 ± 4.8, CI 4.2-7.3 vs 5.7 ± 5.1, CI 3.3-8.1, P = .96), or satisfaction rates (100% vs 90%, P = .11) between the ACLR and nonoperative groups. Four (10%) patients who underwent ACLR sustained a graft treated with revision ACLR. 7 (17.5%) ACLR and 0 nonoperative patients subsequently received further ipsilateral knee surgeries (P = .08), including 2 total knee arthroplasties.

Conclusions

In this PS-matched analysis of patients aged 40 years and older with ACL ruptures, patients who elected nonoperative management had similar subjective outcomes compared with those who elected allograft ACLR. Patients who elected allograft ACLR did not have fewer subsequent operations than those who elected nonoperative treatment.

Level of Evidence

Level III, retrospective cohort study.

Operative Management for Anterior Cruciate Ligament Injury in Patients Over 40 Years Old Yields Increased Clinical Outcome: A Systematic Review

PURPOSE

To evaluate outcomes of anterior cruciate ligament (ACL) rupture in patients ≥40 years treated nonoperatively or with ACL reconstruction (ACLR).

METHODS

A review of MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases from inception to June 1, 2021, was performed to identify randomized controlled trials, prospective or retrospective cohorts, case controls, or case series that met the following criteria: English-language studies reporting at least one subjective and/or objective outcome measure in ACL rupture patients ≥40 years treated nonoperatively or by ACLR. No limits were placed on graft type, time-to-surgery/follow-up, or concomitant procedures. Variability in patient-reported outcome scores, including subjective IKDC score, Lysholm score, Tegner activity score, and Knee Injury and Osteoarthritis Outcome Score, was assessed to evaluate the utility of applying previously established clinically meaningful thresholds to pooled outcome data.

RESULTS

12,605 citations were identified using screening criteria. Sixty studies satisfied criteria following full-text review. As previous systematic reviews reported on earlier literature evaluating ACLR outcomes in patients ≥40 years, studies in this review were limited to include only those published in the last 10 years (40 studies). An additional 16 studies were excluded based on aims of the review not identified during initial screen. Although preoperative to postoperative population-based improvements in Lysholm score, Tegner score, and IKDC score surpassed minimal clinically important differences (MCID) in at least 50% of studies, the variability present in the pooled data may limit its application. No studies evaluated nonoperative outcomes.

CONCLUSIONS

Evidence supports operative management in patients ≥40 years, as studies generally demonstrated preoperative to postoperative improvements in clinical outcomes based on population-level changes. However, application of patient-level clinically relevant thresholds to pooled outcome data should be undertaken with caution as reporting of population-based outcome scores may not accurately reflect changes in individual patients.

LEVEL OF EVIDENCE

Systematic review, IV.

Return-to-Sport Outcomes After Anterior Cruciate Ligament Surgical Treatment May Be Improved by Attention to Modifiable Factors and Consideration of Nonmodifiable Factors

Today, we who treat athletes are able to effect immediate, significant improvement in anterior cruciate ligament (ACL) patient outcomes, regardless of surgical technique, by careful determination of when an athlete is ready to return to sport. "Prehabiliation," bracing, time after surgery to various rehabilitation activities, time after surgery until return to sport, functional testing, strength testing including limb symmetry indices, psychological readiness, age, gender, and type of sport are all factors influencing successful return to sport after ACL injury and treatment. Age and gender are not modifiable, and for some athletes, type of sport may be nonnegotiable. However, each of these factors could be thoughtfully considered before returning an athlete to sport after ACL treatment. All the other factors listed above, from prehab to bracing to strength to psychological readiness, may be modifiable.

Outcomes of Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years and Younger Than 30 Years

Background:

Few studies have compared the outcomes of anterior cruciate ligament (ACL) reconstruction between older patients and younger patients.

Purpose:

To evaluate the clinical and functional outcomes of ACL reconstruction with autologous hamstring tendon in patients >50 years and <30 years. It was hypothesized that the outcomes would be comparable between these age groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients >50 years (older group) or <30 years (younger group) who underwent ACL reconstruction surgery with autologous hamstring tendon between 2012 and 2015 at the authors’ hospital were retrospectively enrolled in this study. All patients had a minimum of 2 years of follow-up. Intraoperative findings, including cartilage and meniscal injury, were recorded, and clinical and functional outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores. We used the paired-samples t test for statistical analysis between the 2 age groups.

Results:

A total of 67 patients and 459 patients were included in the older and younger groups, respectively. Both groups achieved significant preoperative to postoperative improvement in IKDC (older group, from 41.4 to 88.9; younger group, from 49 to 91.2), Lysholm (older group, from 49.8 to 86.1; younger group, from 50.2 to 91.8), and Tegner (older group, from 2.7 to 4.4; younger group, from 4.6 to 6.9) (P < .05 for all) scores. The change in Tegner score from preinjury to postoperatively was not statistically significant in the older group (from 4.5 to 4.4; P = .471), although it was significant in the younger group (from 7.5 to 6.9; P < .05). No between-group differences were noted in preoperative or postoperative IKDC or Lysholm scores. Both age groups reached a high rate of return to sports activity, and no major complications or ACL retears were noted in either group.

Conclusion:

Comparable results after ACL reconstruction were achieved in patients >50 years compared with patients <30 years, with a high rate of return to sports activity and a low rate of complications at the 2-year follow-up. The younger group returned to a higher Tegner score, while the older group did not.

Comparison of Anterior Cruciate Ligament Tears Treated Nonoperatively Versus With Reconstruction: Risk of Subsequent Surgery

BACKGROUND

Anterior cruciate ligament (ACL) tears can be devastating injuries, leading to joint instability, meniscal tears, and subsequent arthritis. It is unknown whether ACL reconstruction (ACLR) alters the natural history of joint degeneration in the ACL-deficient knee compared with nonoperative treatment, and few studies have examined outcomes in middle-aged patients.

PURPOSE

The objective of this study was to compare the midterm risk of subsequent ipsilateral knee surgery in middle-aged patients after an ACL injury treated with initial conservative (nonoperative) management (CM) versus ACLR (operative management [OM]) within 6 months of the diagnosis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed an electronic database search from 2011 to 2012 for all patients aged 35 to 55 years with an initial diagnosis of magnetic resonance imaging-confirmed ACL tear. Patients who elected CM and those who underwent ACLR within 6 months of the diagnosis (OM) were identified. Index patient and clinical characteristics were collected from the health record. All patients were longitudinally observed until August 31, 2017. The primary outcome was subsequent ipsilateral knee surgeries, and secondary outcomes included contralateral knee surgeries, deep surgical-site infections, and venous thrombotic events.

RESULTS

The mean follow-up was 4.8 ± 0.6 years. The CM group included 463 patients (40.2%) and the OM group included 690 patients (59.8%). The mean ages were 43.9 ± 5.7 years and 42.7 ± 5.3 years for patients in the CM and OM groups, respectively (P < .001). Obesity and smoking were significantly more common in the CM group. During the follow-up, 180 patients (38.9%) in the CM group underwent subsequent ipsilateral knee surgery compared with 73 (10.6%) patients in the OM group (P < .001). The mean time to the first ipsilateral procedure was 0.9 ± 1.1 years in the CM and 2 ± 1.5 years in the OM group (P < .001). Delayed ipsilateral ACLRs were performed in 81 patients in the CM group (17.5%); non-ACLR ipsilateral knee surgeries were performed in 156 patients in the CM group (33.7%). Contralateral knee surgery rates were similar. In a regression model, after controlling for age, sex, the Charlson Comorbidity Index score, and smoking status, it was found that normal body mass index and CM group were risk factors for undergoing subsequent knee surgery or ipsilateral non-ACLR surgery.

CONCLUSION

Excluding delayed ACLR, subsequent ipsilateral knee surgeries were more common and occurred earlier in middle-aged patients with nonoperatively managed ACL tears compared with patients managed with reconstruction.

Joint awareness and return to pre-injury level of activities after ACL reconstruction in athletes vs non-athletes

PURPOSE

The outcome of arthroscopic anterior cruciate ligament reconstruction (ACLR) in the non-athlete population is under-reported. The study aimed to compare the functional outcomes of ACLR in the non-athlete and athlete population by patient reported outcome measures (PROMs)- International Knee Documentation Committee score (IKDC), Lysholm knee scoring scale, Forgotten joint score (FJS-12) and return to pre-injury activity level. The study also correlated the FJS-12 score with other commonly used PROM's (IKDC and Lysholm).

METHODS

This was a prospective comparative study including patients undergoing ACLR. Patients were divided into two groups. Group-1 (non-athletes) and Group-2 (athletes, defined as those with pre-injury Tegner activity level > 5). Demographic profile, management of associated meniscal injury, perioperative and midterm complications were noted. All patients had 24 months follow-up. Knee laxity assessment by pivot shift test, functional outcome scores (Lysholm and IKDC) and FJS-12 were assessed preoperatively and postoperatively at 12 and 24 months.

RESULTS

Group 1 and 2 included 69 and 47 participants, respectively, (total 116 patients). The mean age of group 1 was significantly higher than group 2 (33.1 ± 8.0 vs 25.0 ± 4.9 years; p < 0.005). There was no statistically significant difference in PROMs and FJS-12 scores between the groups at any follow-up. Return to pre-injury Tegner activity level post-ACLR was 88.4% (n = 61) and 46.8% (n = 22) in group 1 and 2, respectively (p). The ceiling effect in FJS-12, IKDC, and Lysholm scores were achieved by 9.3%, 19.5%, and 34.7% of patients (n = 116), respectively, at 2-year follow-up. The ceiling effect of FJS-12, Lysholm, and IKDC scores between the groups at final follow-up was not statistically significant (p = 1, p = .524, p = .09, respectively).

CONCLUSION

The functional outcome of ACLR was comparable between athletes and non-athletes. FJS-12 has a lower ceiling effect and better discriminatory power than Lysholm and IKDC scores. FJS-12 score can be satisfactorily used in ACLR to observe and monitor changes in patient satisfaction and outcome.

LEVEL OF STUDY

II, Prospective comparative study.

Effects of Platelet-Rich Plasma on Clinical Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background:

Many studies have documented the use of platelet-rich plasma (PRP) alongside anterior cruciate ligament (ACL) reconstruction (ACLR) in the management of ACL injury, but evidence on the benefits of PRP in improving the clinical outcomes of ACLR is inconsistent.

Purpose:

To help in our understanding, we undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) that evaluated the effects of PRP on patient-reported functional scores, the clinical assessments of knee function and structure, and complications.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

We searched 9 online databases for RCTs published in English or Chinese that examined the effects of PRP on ACLR. The primary outcome measures were visual analog scale (VAS) for pain and International Knee Documentation Committee (IKDC) scores. The secondary outcomes included KT-1000 arthrometer, pivot-shift test, Lysholm and Tegner scores, tunnel widening, graft characterization, and complications. Subgroup analyses were performed according to time of assessments. Fixed- and random-effects models were selected for data analysis.

Results:

A total of 14 studies were included. When PRP was injected to graft tunnels, the pooled VAS scores of the 2 groups were similar (P = .31), and the subgroup analysis found that VAS and IKDC only improved at 3 months postoperatively (P = .0003 and P < .00001, respectively). When PRP was used at the bone–patellar tendon–bone harvest sites, VAS was decreased in the first 6 months postoperatively (P < .00001), whereas IKDC score was not remarkably different (P = .07). After PRP injection, Lysholm scores at 3 months postoperatively was different between the 2 groups (P < .00001), but the Tegner scores (P = .86), KT-1000 measurements (P = .12), the positive rate of pivot-shift test (P = .64), the enlargement of tunnels (femoral, P = .91; tibial, P = .80), and the characterization of grafts (P = .05) were not different. No difference in complications was found in either group.

Conclusion:

PRP applied alongside ACLR could reduce postoperative pain and improve knee function in the short and medium terms but is ineffective in the long term. PRP does not improve knee stability and the enlargement of tunnels and does not accelerate the healing of grafts. Further studies would be required.

Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial

INTRODUCTION

Comparable data of functional outcomes of anterior cruciate ligament reconstruction using either hamstring- or quadriceps tendon grafts is controversial. This prospective, randomized controlled trial aims to provide data comparing both grafts regarding the functional outcome.

MATERIALS AND METHODS

A two centre trial involving symptomatic patients 18 years of age or older with an anterior cruciate ligament tear was conducted. We randomly assigned 27 patients to quadruple hamstring tendon reconstruction and 24 to quadriceps tendon reconstruction. The patients were evaluated preoperatively, at 3, 6, 12 and 24 months post-surgery. The primary outcome parameter was the side-to-side knee laxity measured with an arthrometer. Secondary outcomes included results in the International Knee Documentation Committee (IKDC) and Lysholm Scores and isokinetic testing of strength in knee extension and flexion.

RESULTS

Forty-four patients (86%) completed the 2-year follow-up. There was significantly improved knee stability at all time intervals with no difference between the two study groups. The manual side-to-side displacement improved by 4.7 ± 3.0 mm in patients with hamstring tendon reconstruction and 5.5 ± 2.9 mm in patients with quadriceps tendon reconstruction. In addition, muscle strength and outcome scores (IKDC and Lysholm Score) did not show any differences between the hamstring tendon group and the quadriceps tendon group. Patients in the hamstring tendon group returned to their pre-injury activity level after 95.2 ± 45.5 days while patients in the quadriceps tendon group needed 82.1 ± 45.6 days.

CONCLUSION

Quadriceps and hamstring tendon autografts yield comparably good results in primary anterior cruciate ligament reconstruction.

Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups

BACKGROUND

Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood.

HYPOTHESES

The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups.

RESULTS

The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes.

CONCLUSION

Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.

Tegner level is predictive for successful return to sport 2 years after anterior cruciate ligament reconstruction

PURPOSE

For a successful return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR), patients are recommended to attend a comprehensive rehabilitation program, followed by an RTS assessment, that is a combination of tests. The purpose of this study was to predict a successful return to sport using the results of the RTS assessment and self-reported questionnaires at minimum 2 years after ACLR.

METHODS

A total of 123 consecutive ACLR patients undertook an intensive rehabilitation program followed by a comprehensive RTS assessment that included an established combination of balance and strength tests, the ACL-return to sport after Injury scale (ACL-RSI) questionnaire and a KT1000 laximetry test. Preinjury and expected Tegner and Lysholm were collected at baseline, at RTS and prospectively collected at minimum 2-year follow-up. The patients were asked if they returned to their previous sport and at which level. All variables were included in a regression analysis predicting a successful return to previous sport, return to the same level of sport as well as the Tegner level at 2 years.

RESULTS

Sixty-two patients (50%) returned to their previous sport by the 2-year follow-up, without a difference in preinjury Tegner between these two groups (n.s.). Expected preoperative Tegner was the only significant predictor of a successful return to previous sport (p = 0.042; OR 1.300, 95% CI 1.010-1.672). Out of the 62 patients returning to their previous sport, 38 (61%) reported to be on the same or higher level. The only predictive variable for returning to the same level was the higher preinjury Tegner level (p = 0.048; OR 1.522). Multivariate regression analysis of Tegner level at 2 years found younger age to be the only predictive value. From the RTS assessment tests, the ACL-RSI questionnaire and the posterolateral balance test were predictive variables for Tegner at 2-year follow-up, albeit in the univariate regression analysis.

CONCLUSIONS

Preoperative Tegner and expected Tegner level collected prior to an ACL reconstruction can aid in the objective prediction of patients' return to sport after 2 years. High-level athletes are more likely to return to their previous sport and to the previous level. Younger patients achieve a higher Tegner level at 2 years.

LEVEL OF EVIDENCE

Level III study.

Return to Sports and Activity After Total Ankle Arthroplasty and Arthrodesis: A Systematic Review

BACKGROUND

There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). This systematic review summarizes the evidence on return to sports and activity after operative management with either TAR or AA for ankle osteoarthritis (OA).

METHODS

A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed. Risk of bias of included studies was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. Included studies reported sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being the percentage of sports participation and level of sports participation.

RESULTS

Twelve studies met inclusion criteria for analysis. There were 1270 ankle procedures, of which 923 TAR and 347 AA were performed. The mean reported patient age was 59.2 years and the mean BMI was 28 kg/m². The mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared with 63.7% postoperatively. The mean preoperative activity participation rate was 41% in the TAR cohort, but it improved to 59% after TAR, whereas the preoperative activity participation rate of 73% was similar to the postoperative rate of 70% in the AA cohort. The most common sports in the TAR and AA groups were swimming, hiking, cycling, and skiing.

CONCLUSION

Participation in sports activity was nearly 10% improved after operative management of ankle OA with TAR and remains high after AA. The existing literature demonstrated a large improvement in pre- to postoperative activity levels after TAR, with minimal change in activity after AA; however, AA patients were more active at baseline. The most frequent postoperative sports activities after operative management of ankle OA were swimming, hiking, cycling, and skiing. Participation in high-impact sports such as tennis, soccer, and running was consistently limited after surgery. This review of the literature will allow patients and foot and ankle surgeons to set evidence-based goals and establish realistic expectations for postoperative physical activity after TAR and AA.

LEVEL OF EVIDENCE

Level III, systematic review.

Comparable clinical and functional outcomes after anterior cruciate ligament reconstruction over and under 40 years of age

PURPOSE

The aim of the present meta-analysis was to update the literature on the outcomes and complications of ACL reconstruction in patients aged 40 years and older. It has been hypothesized that patients older than 40 years of age may have comparable clinical outcomes to those of younger patients.

METHODS

A systematic review of articles from 1996 to 2018 was completed using Pubmed, Medline, Cochrane Reviews, and Google Scholar databases using the keyword terms "anterior cruciate ligament reconstruction" and "middle-aged OR elderly OR over 40 OR age factors." Functional and clinical outcomes (International Knee Documentation Committee, Lysholm and Tegner score and KT-1000 arthrometer), complication and graft failure rate were evaluated.

RESULTS

Eleven articles met inclusion criteria. In total, 306 middle-aged patients and 566 younger patients were included in this study. The mean age of patients > 40 was 49 ± 7 (range 40-75) years with a mean follow-up of 25 ± 9 months (range 12-68). The mean age of younger patients was 26 ± 2.7 (range 15-39) years with a mean post-operative follow-up of 26.7 ± 11.5 months (range 3-64). The results were slightly higher (but no significantly different) towards the younger group in terms of objective IKDC (P = n.s.), Lysholm (P = n.s.) and Tegner (P = n.s.) scores and knee laxity assessment (P = n.s.). Complication rate (P = n.s.) and graft failure (P = n.s.) were low even in this cohort.

CONCLUSIONS

The present meta-analysis shows that patients older than 40 years achieve comparable clinical outcomes to those of younger patients following primary ACL reconstruction. This evidence may push the surgeons toward a more aggressive approach in this specific cohort of patients.

LEVEL OF EVIDENCE

III.

Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics.

PURPOSE

To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs).

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference.

RESULTS

This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that.

CONCLUSION

After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm.

CLINICAL RELEVANCE

After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

Uncommon Complications after Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACL-R) is a common surgical procedure, with good outcome in 75 to 97% of the cases. However, different complications have been described including infection, hemarthrosis, deep vein thrombosis (DVT), and pulmonary embolism (PE) with a rate ranging from 1 to 15%. There are few case reports in the literature describing rare complications after ACL-R and they can be divided into: (1) complications related to the fixation device (rupture, migration); (2) fractures (tibial or femoral side); (3) infections due to uncommon bacteria, mycobacterium, and mycosis; (4) rare vascular injuries; (5) nerve injuries; and (6) other rare complications. In case of fixation device rupture or migration, device removal can be easy but the diagnosis may be challenging. Patellar fracture after ACL-R may be related to harvesting and it is not uncommon. Conversely, femoral or tibial fractures are most frequently due to bone weakness related to bone tunnels. Some rare infections related to uncommon bacteria or mycosis are also described with potentially devastating joint damage. Popliteal artery injuries are uncommon in ACL-R but minor vessels damages are described with possible severe consequences for patients. Injuries to the infrapatellar branch of the saphenous nerve are not uncommon in ACL-R. However, there are few case reports also describing injuries to the saphenous nerve, the common peroneal nerve and the sciatic nerve. The aim of this paper is to review the literature describing uncommon complications after ACL-R, giving some more information about diagnosis and treatment.