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Schwartzberg R. Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction Produces Excellent Results: Adjustable Cortical Suspensory Fixation Provides Rigid Tibial Fixation for All Ages. Arthroscopy 2024; 40:2289-2291. [PMID: 38493934 DOI: 10.1016/j.arthro.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024]
Abstract
All-inside anterior cruciate ligament (ACL) reconstruction is the most minimally invasive ACL reconstruction technique available. Systematic review and meta-analysis show equally excellent outcomes for all-inside ACL reconstruction as compared with full tibial tunnel ACL reconstruction. Advantages of the all-inside technique may include improved tibial side fixation, improved stability, less tunnel widening, improved cosmesis, and less postoperative pain. Interference screw fixation using a full tibial tunnel technique can be complicated by inferior proximal tibial bone density. All-inside ACL reconstruction preserves the integrity of the tibial cortex and lends itself to cortical suspension fixation. Given modern adjustable suspensory cortical fixation and excellent clinical outcomes, surgeons should consider all-inside ACL reconstruction as a primary ACL reconstruction technique.
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Rilk S, Goodhart GC, van der List JP, Von Rehlingen-Prinz F, Vermeijden HD, O'Brien R, DiFelice GS. Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38967267 DOI: 10.1002/ksa.12239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/21/2024] [Accepted: 04/26/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR). METHODS A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools. RESULTS A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction. CONCLUSIONS ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sebastian Rilk
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Medical University of Vienna, Vienna, Austria
| | - Gabriel C Goodhart
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Fidelius Von Rehlingen-Prinz
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harmen D Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert O'Brien
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, New York, USA
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Chandanani M, Volpin A. Lateral femoral tunnel preparation and graft fixation for anterior cruciate ligament reconstruction-A discussion. World J Clin Cases 2024; 12:3277-3280. [PMID: 38898836 PMCID: PMC11185389 DOI: 10.12998/wjcc.v12.i17.3277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/12/2024] [Accepted: 04/29/2024] [Indexed: 06/04/2024] Open
Abstract
This article provides a discussion and commentary around the recent advances in arthroscopic anterior cruciate ligament reconstruction (ACLR), with a focus on the aspects of lateral femoral tunnel preparation and graft fixation techniques. The paper explores and comments on a recently published review by Dai et al, titled "Research progress on preparation of lateral femoral tunnel and graft fixation in ACLR", while providing insight into its relevance within the field of ACLR, and recommendations for future research.
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Affiliation(s)
- Mehak Chandanani
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, United Kingdom
| | - Andrea Volpin
- Department of Trauma and Orthopaedics, National Health Service Grampian, Elgin IV30 1SN, United Kingdom
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Alessio-Mazzola M, Tradati D, Slongo M, Belluati A, Placella G, Salini V. Transtibial versus anteromedial transportal femoral tunnel in single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized controlled trials. Musculoskelet Surg 2024:10.1007/s12306-024-00823-3. [PMID: 38814430 DOI: 10.1007/s12306-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported.
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Affiliation(s)
- M Alessio-Mazzola
- Unità di Ortopedia e Traumatologia, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
| | - D Tradati
- Unità di Ortopedia e Traumatologia, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
| | - M Slongo
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
| | - A Belluati
- Orthopaedic and Trauma Department, Hospital Santa Maria delle Croci, Viale Vincenzo Randi, 5, 48121, Ravenna, Italy
| | - G Placella
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
| | - V Salini
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132, Milan, Italy
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Gabr A, Mancino F, Robinson J, Hage W, O'Leary S, Spalding T, Haddad FS. Satisfactory 5-year functional outcomes following primary ACL reconstructions from the UK National Ligament Registry. Knee Surg Sports Traumatol Arthrosc 2024; 32:798-810. [PMID: 38426562 DOI: 10.1002/ksa.12071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). METHODS A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 years and 5 years following the index procedure. RESULTS During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 years and 5 years postoperatively. CONCLUSION Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ayman Gabr
- West Suffolk Hospital NHS Trust, Bury St Edmunds, UK
- University College London Hospitals NHS Trust, London, UK
| | - Fabio Mancino
- University College London Hospitals NHS Trust, London, UK
| | | | | | - Sean O'Leary
- The Royal Berkshire Hospital NHS Trust, Reading, UK
| | | | - Fares S Haddad
- University College London Hospitals NHS Trust, London, UK
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Yau WP. Modification of Outside-In Technique In Preparing Femoral Tunnel During Anterior Cruciate Ligament Reconstruction-"PL-Portal Outside-In Technique". Arthrosc Tech 2024; 13:102811. [PMID: 38312877 PMCID: PMC10837789 DOI: 10.1016/j.eats.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/26/2023] [Indexed: 02/06/2024] Open
Abstract
We propose modifying the outside-in technique by adopting a posterolateral (PL) portal as the working portal to introduce the anterior cruciate ligament reconstruction (ACLR) aiming guide while keeping the anteromedial portal as the viewing portal, the "PL-portal outside-in technique." This modification facilitates the preparation of an anatomical femoral tunnel, even when preserving a "big" ACL remnant or in small joint scenarios, such as pediatric ACLR. There is a minimal learning curve in adopting this technique because a standard 30° arthroscope is used, and the viewing portal is anterior.
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Affiliation(s)
- Wai Pan Yau
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong
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Schwartzberg R. Editorial Commentary: Anteromedial Portal Drilling of the ACL Femoral Socket Avoids Transtibial Constraint Results in Anatomic Reconstruction and Superior Outcomes. Arthroscopy 2023; 39:1526-1528. [PMID: 37147079 DOI: 10.1016/j.arthro.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 05/07/2023]
Abstract
Femoral and tibial tunnel locations for ACL grafts should be predicated on anatomy. Regarding femoral ACL socket or tunnel creation, multiple techniques have been debated. Network meta-analysis shows that the anteromedial portal (AMP) technique results in better anteroposterior and rotational stability than does the "standard" constrained, transtibial technique based on side-to-side differences in laxity and pivot-shift tests, as well as IKDC objective scores. The AMP provides a direct shot at the anatomic ACL origin on the femur. It avoids the osseous constraint of the reamer that hampers transtibial approaches. It avoids the extra incision required by the outside-in technique and the accompanying graft obliquity. Despite the need for knee hyperflexion and the potential for shorter femoral sockets, the AMP technique should be easily reproducible for an accomplished ACL surgeon to reproduce the patient's anatomy.
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