Anterior cruciate ligament rupture: reconstruction surgery and rehabilitation. A nation-wide survey of current practice

Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT

Background

Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment.

Objective(s)

To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation).

Design

A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out.

Setting

Twenty-nine NHS orthopaedic units in the United Kingdom.

Participants

Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee.

Interventions

Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol.

Main outcome measures

The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage.

Results

Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively.

Limitations

Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic.

Conclusions

Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation.

Future work

Confirmatory studies and those to explore the influence of fidelity and compliance will be useful.

Trial registration

This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367.

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.

METHODS

We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.

FINDINGS

Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.

INTERPRETATION

Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management.

FUNDING

The UK National Institute for Health Research Health Technology Assessment Programme.

Comparison of the clinical and cost effectiveness of two management strategies (rehabilitation versus surgical reconstruction) for non-acute anterior cruciate ligament (ACL) injury: study protocol for the ACL SNNAP randomised controlled trial

Background

Anterior cruciate ligament (ACL) rupture is a common knee injury that can lead to poor quality of life, decreased activity and increased risk of secondary osteoarthritis of the knee. Management of patients with a non-acute ACL injury can include a non-surgical (rehabilitation) or surgical (reconstruction) approach. However, insufficient evidence to guide treatment selection has led to high variation in treatment choice for patients with non-acute presentation of ACL injury.

The objective of the ACL SNNAP trial is to determine in patients with non-acute anterior cruciate ligament deficiency (ACLD) whether a strategy of non-surgical management (rehabilitation) (with option for later ACL reconstruction only if required) is more clinically effective and cost effective than a strategy of surgical management (reconstruction) without prior rehabilitation with all patients followed up at 18 months.

Methods

The study is a pragmatic, multi-centre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Patients with a symptomatic non-acute ACL deficient knee will be randomised to either non-surgical management (rehabilitation) or surgical management (reconstruction). We aim to recruit 320 patients from approximately 30 secondary care orthopaedic units from across the United Kingdom. Randomisation will occur using a web-based randomisation system. Blinding of patients and clinicians to treatment allocation will not be possible because of the nature of the interventions. Participants will be followed up via self-reported questionnaires at 6, 12 and 18 months. The primary outcome is the Knee injury and Osteoarthritis Outcome Score (KOOS) at 18 months post randomisation. Secondary outcomes will include a return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee specific quality of life and resource usage.

Discussion

At present, no evidence-based treatment of non-acute ACL deficiency exists, particularly in the NHS. Moreover, little consensus exists on the management approach for these patients. The proposed trial will address this gap in knowledge regarding the clinical and cost effectiveness of ACL treatment and inform future standards of care for this condition.

Trial registration

ISRCTN: 10110685. Registered on 16 November 2016. ClinicalTrials.gov: NCT02980367. Registered in December 2016.

Anterior cruciate ligament reconstruction-related patient injuries: a nationwide registry study in Finland

Background and purpose - Treatment outcomes of anterior cruciate ligament (ACL) injuries are generally good, but complications after ACL reconstruction (ACLR) can result in long-lasting problems. Patient injury claims usually fall on the more severe end of the complication spectrum. They are important to investigate because they may reveal the root causes of adverse events, which are often similar regardless of the complication's severity. Therefore, we analyzed ACL-related patient injuries in Finland, the reasons for these claims, causes of complications, and grounds for compensation.Patients and methods - We analyzed all claims filed at the Patient Insurance Centre (PIC) between 2005 and 2013 in which the suspected patient injury occurred between 2005 and 2010. This study also reviewed all original patient records and available imaging studies. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).Results - There were 248 patient injury claims, and 100 of these were compensated. Compensated claims were divided into 4 main categories: skill-based errors (n = 46), infections (n = 34), knowledge-based errors (n = 6), and others (n = 14). Of the compensated skill-based errors, 34 involved graft malposition, 26 of them involved the femoral-side tunnel. All compensated infections were deep surgical site infections (DSSI).Interpretation - This is the first nationwide study of patient injuries concerning ACLRs in Finland. The most common reasons for compensation were DSSI and malposition of the drill tunnel. Therefore, it would be possible to decrease the number of serious complications by concentrating on infection prevention and optimal surgical technique.

Functional outcome of an early anterior cruciate ligament reconstruction in comparison to delayed: Are we waiting in vain?

BACKGROUND

Surgical techniques of ACL reconstruction (ACLR) have evolved over the past three decades along with debate regarding timing of reconstruction. It was a widespread belief that the timing of surgery was an important factor in determining the resulting stiffness after ACLR. Delayed rather than early reconstruction of the ACL is the current recommended treatment since it is thought to give a better functional outcome. However, there is no consensus in the literature regarding the optimal time of surgical intervention. The purpose of this study was to compare the range of motion and functional outcome in patients who underwent ACLR early with those that were delayed.

MATERIALS AND METHODS

The patients were randomized into two groups; patients who underwent the procedure within three weeks were kept in Group I (Early) and those patients who were reconstructed after six weeks were categorized as Group II (Delayed). Hamstring grafts were used and a standard protocol of surgery and physiotherapy was followed. The range of motion, IKDC and Tegner scores were compared.

RESULTS

A hundred and four patients underwent ACLR; fifty-three patients were grouped as Group I (Early) and fifty one as Group II (Delayed). The range of motion of both groups was comparable. The IKDC and Tegner scores were also comparable for early (Group I) ACLR and the patients who had their ACL reconstructed after a delay of at least 6 weeks (Group II).

CONCLUSION

There are no clinical differences in terms of range of motion and functional results between early and delayed ACLR.

Web-based survey results: surgeon practice patterns in Italy regarding anterior cruciate ligament reconstruction and rehabilitation

PURPOSE

The aim of this study was to report Italian orthopaedic surgeons' management of choice for ACL reconstruction and rehabilitation, and to compare surgical applications and rehabilitation approaches of Italian surgeons to the current approaches of "ACL Study Group". A secondary purpose was to compare the preferences of subgroup based on graft choice, surgical techniques and experience.

METHODS

A web-based survey was developed to investigate the attitudes of members of a national association specialized in sports traumatology and knee surgery (SIGASCOT) regarding surgical techniques, routine post-operative applications, rehabilitation approaches and starting time of specific activities and exercises following ACL reconstruction.

RESULTS

The response rate was 17 % (131 questionnaires). The most popular graft type was hamstring tendon (81 % in male patients, and 91 % in female patients). The rate of continuous passive motion use was 55 %. Half surgeons routinely used a brace (49 %), usually a hinged brace. In total, 33.0 % of surgeons allowed patients to load the operated knee as much as tolerated within the first 2 weeks. Fifty-nine per cent of surgeons did not limit full flexion within the first 2 weeks. Most surgeons advise to wait until 4 months or more (97 %) for return to sports not requiring contact, and 6 months or more for full-contact sport (86 %).

CONCLUSIONS

This survey demonstrates clear trends in the practice of ACL reconstruction and rehabilitation in Italy. The data obtained from the SIGASCOT members revealed a more conservative approach when compared to the current approaches of "ACL Study Group".

LEVEL OF EVIDENCE

Cross-sectional survey, Level III.

What Makes a Successful Survey? A Systematic Review of Surveys Used in Anterior Cruciate Ligament Reconstruction

PURPOSE

To characterize and assess the methodological quality of patient and physician surveys related to anterior cruciate ligament reconstruction, and to analyze the factors influencing response rate.

METHODS

The databases MEDLINE, Embase, and PubMed were searched from database inception to search date and screened in duplicate for relevant studies. Data regarding survey characteristics, response rates, and distribution methods were extracted. A previously published list of recommendations for high-quality surveys in orthopaedics was used as a scale to assess survey quality (12 items scored 0, 1, or 2; maximum score = 24).

RESULTS

Of the initial 1,276 studies, 53 studies published between 1986 and 2016 met the inclusion criteria. Sixty-four percent of studies were distributed to physicians, compared with 32% distributed to patients and less than 4% to coaches. The median number of items in each survey was 10.5, and the average response rate was 73% (range: 18% to 100%). In-person distribution was the most common method (40%), followed by web-based methods (28%) and mail (25%). Response rates were highest for surveys targeted at patients (77%, P < .0001) and those delivered in-person (94%, P < .0001). The median quality score was 12/24 (range = 8.5/24 to 21/24). There was high inter-rater agreement using the quality scale (intraclass correlation coefficient = 0.92), but there was no correlation with the response rate (Rho = -0.01, P = .97).

CONCLUSIONS

Response rates vary based on target audience and distribution methods, with patients responding at a significantly higher rate than physicians and in-person distribution yielding significantly higher response rates than web or mail surveys.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Primary anterior cruciate ligament reconstruction: perioperative considerations and complications

Anterior cruciate ligament (ACL) injuries are among the most commonly studied orthopaedic injuries. Despite having an excellent prognosis, complications do occur. The timely recognition and management of complications is imperative to ensure the success of reconstruction. Avoiding such complications requires thorough preoperative planning, proficient technical skills to properly manage intraoperative complications, and an extensive knowledge of possible postoperative complications.

Anterior cruciate ligament remnant tissue harvested within 3-months after injury predicts higher healing potential

Background

No study has examined the possible factors associated with different characteristics of stem-like cells derived from anterior cruciate ligament (ACL) remnants. And the purpose of the study is to elucidate whether demographic factors are associated with healing potential of stem-like cells derived from the ACL remnants tissue.

Methods

Thirty-six ACL remnants were harvested from patients who received primary arthroscopic ACL reconstruction. Interval from injury to surgery, age, sex, and combined meniscal or chondral injuries were analyzed. Cells were isolated from remnant tissues and their healing potential was evaluated by: 1) characterization of surface markers (CD34, CD44, CD45, CD146, CD29, and Stro-1), 2) cell expansion, 3) osteogenic differentiation, and 4) endothelial differentiation. Finally, using multivariable logistic regression to evaluate the relation between demographic factors and healing potential parameters. Adjusted odds ratios (OR) were calculated, and the significant difference was set at p < 0.05.

Results

ACL remnant tissue harvested less than 90 days after injury predicted higher fractions of stem-like cells [CD34+ (OR = 6.043, p = 0.025), CD44 + (OR = 8.440, p = 0.011), CD45+ (OR = 16.144, p = 0.015), and CD146+ (OR = 9.246, p = 0.015)] and higher expansion potential (passage 3: OR = 9.755, p = 0.034; passage 10: OR = 33.245, p = 0.003). Regarding osteogenic differentiation, higher gene expression of Osteocalcin (OR = 22.579, p = 0.009), Alkaline phosphatase (OR = 6.527, p = 0.022), and Runt-related transcription factor 2 (OR = 5.247, p = 0.047) can also be predicted. Younger age predicted higher CD34+ levels (20 ≤ age <30 years, OR = 2.020, p = 0.027) and higher expansion potential at passage 10 (10 ≤ age <20 years, OR = 25.141, p = 0.026). There was no significant relation found between meniscal or chondral injuries and ACL healing potential.

Conclusion

Our results indicated that the ACL remnant tissue harvested within 3-months after injury yields higher healing potential, suggesting early surgical intervention may achieve better clinical results.

ANTERIOR CRUCIATE LIGAMENT INJURY: TREATMENT AND REHABILITATION. CURRENT PERSPECTIVES AND TRENDS

Objective: The aim of this study was to evaluate the procedures used by knee surgeons in Brazil for treating and rehabilitating anterior cruciate ligament injuries. Methods: A questionnaire consisting of 21 closed questions was developed, addressing topics relating to treatment and rehabilitation after anterior cruciate ligament reconstruction. The questionnaire was applied to Brazilian knee surgeons during the three days of the 42^nd Brazilian Congress of Orthopedics and Traumatology in 2010. Results: A total of 226 surgeons filled out the questionnaire completely. The most commonly used types of graft were hamstrings tendons and the central third of the ipsilateral patellar tendon, which were used by 82.3% and 53.5% of the sample, respectively. The technique of reconstruction with a single transtibial band was the first preference and was used by 66.4% of the participants. A period of 1 to 4 weeks between injury and surgical procedure was considered ideal by most participants (52.65%). Complaints from patients that the knee was ‘giving way’ or unstable and presence of a positive pivot shift maneuver were the most decisive factors considered in making the decision to operate the patient. Patient satisfaction and absence of complaints of instability during the postoperative period were the criteria deemed to be most important for the surgery to be considered a success. Conclusions: There are clearly evolving trends in treating and rehabilitating the anterior cruciate ligament in Brazil. However, more prospective controlled studies are needed in order to evaluate the clinical and scientific benefits of these trends.

A meta-analysis of anterior cruciate ligament reconstruction with autograft compared with nonirradiated allograft

BACKGROUND

To compare autograft with non-irradiated allograft for reconstruction of anterior cruciate ligament.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases, as well as unpublished and ongoing studies were searched through up to 20 July 2013 to identify studies meeting the pre-stated inclusion criteria.

RESULTS

A total of 12 studies (n=1167, including 597 patients in the autograft group and 570 patients in the allograft group) were included. The methodological scores for randomized controlled trials ranged from two to four (total score: seven), and for non-randomized prospective studies and cohort studies ranged from four to seven (total score: 12). Except for the Lysholm score (WMD, -1.46; P<0.05) showing a statistically significant difference but a small and clinically irrelevant difference, there was no significant difference between autograft and non-irradiated allograft with respect to the overall IKDC (International Knee Documentation Committee) level, subjective IKDC score, Tegner score, complication, ROM (range of motion), Pivot-shift test, Anterior drawer test, Lachman test, Daniel's one-leg hop test, Harner's vertical jump test, and Instrumented knee laxity test. The results were consistent across a series of sensitivity analyses and subgroup analyses.

CONCLUSIONS

Patients with autograft exhibited little clinical advantage over non-irradiated allograft with respect to knee stability, function and side effects. The robustness of the findings might need to be further validated due to the relatively small number of randomized controlled trials.

LEVEL OF EVIDENCE

Level II, meta-analysis of prospective studies.

Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia

BACKGROUND

A number of studies have found comparable results after anterior cruciate ligament (ACL) reconstruction with patellar tendon autografts and hamstring autografts; however, few studies have been large enough to reveal differences in risk of revision with regard to clinical and demographic factors.

PURPOSE

To present the distribution of grafts for ACL reconstruction based on data in the Scandinavian ACL registries and to compare the risk of revision between patellar tendon autografts and hamstring autografts. Potential associations with other clinical and demographic factors were also explored.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 45,998 primary ACL reconstructions, including 6736 patellar tendon autografts and 38,666 hamstring autografts, were identified in the Scandinavian ACL registries. The overall median follow-up time was 3 years (range, 0-8 years). To compare the risk of revision between groups of patients, univariate Kaplan-Meier analysis (with log-rank test) and the Cox proportional hazard regression model were applied. The hazard rate ratio with 95% CI was reported as a measure of effect.

RESULTS

Patellar tendon and hamstring autografts were used in 14.6% and 84.1% of the patients, respectively. The remaining patients received allografts, direct sutures, or other graft types (1.3%). The primary ACL injury occurred during soccer, team handball, or alpine activities in 67.5% of the patients in the patellar tendon group and 66.2% in the hamstring group. A total of 156 patients in the patellar tendon group and 1042 patients in the hamstring group underwent revision. The overall risk of revision was significantly lower in the patellar tendon group versus the hamstring group (hazard rate ratio = 0.63; 95% CI, 0.53-0.74), and it decreased with increasing age at surgery, although not strictly linearly. The lower risk of revision in the patellar tendon group was consistently observed across subgroups of patient sex, age, and concomitant cartilage injury (P > .05, test for interaction) but seemed to be slightly more pronounced for patients injured during certain pivoting activities (soccer, team handball, and alpine activities) compared with other activities (hazard rate ratio = 0.57 vs 0.81; P = .058, test for interaction).

CONCLUSION

The majority of primary ACL reconstructions in Scandinavia are performed with hamstring autografts. Results from the present large prospective study show that patients receiving patellar tendon autografts have a statistically significantly lower risk of revision compared with patients receiving hamstring autografts.

Cruciate ligament loading during common knee rehabilitation exercises

Cruciate ligament injuries are common and may lead to dysfunction if not rehabilitated. Understanding how to progress anterior cruciate ligament and posterior cruciate ligament loading, early after injury or reconstruction, helps clinicians prescribe rehabilitation exercises in a safe manner to enhance recovery. Commonly prescribed therapeutic exercises include both weight-bearing exercise and non-weight-bearing exercise. This review was written to summarize and provide an update on the available literature on cruciate ligament loading during commonly used therapeutic exercises. In general, weight-bearing exercise produces smaller loads on the anterior cruciate ligament and posterior cruciate ligament compared with non-weight-bearing exercise. The anterior cruciate ligament is loaded less at higher knee angles (i.e. 50-100 degrees). Squatting and lunging with a more forward trunk tilt and moving the resistance pad proximally on the leg during the seated knee extension unloads the anterior cruciate ligament. The posterior cruciate ligament is less loaded at lower knee angles (i.e. 0-50 degrees), and may be progressed from level ground walking to a one-leg squat, lunges, wall squat, leg press, and the two-leg squat (from smallest to greatest). Exercise type and technique variation affect cruciate ligament loading, such that the clinician may prescribe therapeutic exercises to progress ligament loading safely, while ensuring optimal recovery of the musculoskeletal system.

A tale of 10 European centres - 2010 APOSSM travelling fellowship review in ACL surgery

The purpose of ESSKA- APOSSM Travelling fellowship is to better understand the epidemiology, management and surgical techniques for sports across continents. There has been a progressive evolution in ACL reconstruction and there is variation in technique in ACL reconstruction amongst the most experienced surgeons in different continents. During this one month fellowship, we saw various ACL reconstruction techniques using different graft sources, with a variety of graft fixation methods, with the common aim of recreating an anatomical ACL reconstruction.

Femoral tunnel-interference screw divergence in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft: A comparison of two techniques

BACKGROUND

Interference screw is a popular fixation device used to rigidly fix bone-patellar tendon-bone (B-PT-B) graft both in femoral and tibial tunnels in anterior cruciate ligament (ACL) reconstruction. Parallel placement of screw is difficult in transtibially drilled femoral tunnel but always desired as it affects pullout strength of the graft. Commonly, interference screw into the femoral tunnel is inserted through the anteromedial (AM) or accessory AM portal. These portals are not-in-line with the transtibially drilled femoral tunnel. Furthermore, these portals increase the divergence of the interference screw in the femoral tunnel. We hypothesized that interference screw placement through patellar tendon (PT) portal (through donor defect) in transtibially drilled femoral tunnel can be less divergent. We report the prospective randomized study to investigate the difference of divergence of interference screw placed through PT portal and AM portal and its clinical relevance.

MATERIALS AND METHODS

Forty-one patients underwent femoral tunnel B-PT-B graft fixation through AM portal (group 1) and other 41 (group 2) through PT portal. Femoral tunnel-interference screw divergence was measured on postoperative digital lateral X-rays. Ha's method was used to grade divergence. The clinical outcome was assessed by postoperative intervention knee documentation committee grading (IKDC) and Lysholm score at 2 years followup.

RESULTS

Mean tunnel-screw divergence in sagittal plane through AM portal was 13.38° (95% CI: 12.34-14.41) and through PT portal was 7.20° (95% CI: 6.25-8.16) (P<0.0001). In AM portal group, 82.9% patients had divergence in either grade 3 or 4 category, whereas in PT portal group, 82.9% patients were in grade 1 or 2 category (P<0.0001). Mean Lysholm score were 92.8 and 94.5 at two-year follow-up in both groups which were statistically not significant. The International knee documentation committee grades of patients in both groups were similar and had no statistical significance.

CONCLUSION

Femoral interference screw placement through the PT portal leads to significantly less screw divergence as compared with screw placement through the AM portal. However, this difference in divergence is not reflected in clinical outcome.

Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

There is no consensus in the literature regarding the optimal timing of surgical reconstruction of the ruptured anterior cruciate ligament (ACL). Previous authors have suggested that early reconstruction may facilitate an early return to work or sport but may increase the incidence of post-operative complications such as arthrofibrosis. This study systematically reviewed the literature to determine whether ACL reconstruction should be performed acutely following rupture. Medline, CINAHL, AMED, EMBASE databases and grey literature were reviewed with a meta-analysis of pooled mean differences where appropriate. Six papers including 370 ACL reconstructions were included. Early ACL reconstructions were considered as those undertaken within a mean of 3 weeks post-injury; delayed ACL reconstructions were those undertaken a minimum of 6 weeks post-injury. We found there was no difference in clinical outcome between patients who underwent early compared to delayed ACL reconstruction. However, this conclusion is based on the current literature which has substantial methodological limitations.

Recovery in functional non-copers following anterior cruciate ligament rupture as detected by gait kinematics

OBJECTIVES

To evaluate if gait compensation strategies for selected kinematic variables can be identified in anterior cruciate ligament (ACL) deficient non-copers using two-dimensional (2D) clinical gait analysis.

DESIGN

Prospective observational design, repeated measures.

SETTING

University hospital, out-patients department.

PATIENTS

Sixty-three patients that attended the acute knee screening service were diagnosed with an acute ACL rupture and consented to participate. A sub-set of 15 copers/adapters and 13 non-copers were eligible for final analysis because they were contactable for sub-classification and had gait analysis at 1 and 4 months post-injury.

MAIN OUTCOME MEASURES

2D video gait analysis for sagittal plane hip, knee and ankle kinematics and time-distance variables.

RESULTS

At 4 months post-injury non-copers demonstrated significantly less recovery of knee angle (F((1,1))=5.79, p<0.024), hip displacement angle (F((1,1))=4.89, p<0.036), step length (F((1,1)) =6.80, p=0.015), cadence (F((1,1))=5.85, p=0.023) and velocity (F((1,1))=10.89, p=0.003), compared to copers/adapters. Also non-copers demonstrated altered correlations between gait parameters.

CONCLUSION

At 4 months post-injury non-copers had an inferior gait performance compared to copers/adapters for kinematics and time-distance variables. 2D clinical kinematic gait analysis, particularly of the hip and knee can inform early rehabilitation techniques and monitor recovery.

Knee immobilization for pain control after a hamstring tendon anterior cruciate ligament reconstruction: a randomized clinical trial

BACKGROUND

This study will attempt to evaluate the efficacy of knee immobilization on patient pain levels after an anterior cruciate ligament reconstruction.

HYPOTHESIS

There is no difference in visual analog scale pain scores 2 days after anterior cruciate ligament reconstruction between patients who wear a knee immobilizer and those who do not wear a knee immobilizer.

STUDY DESIGN

Randomized clinical trial; Level of evidence, 1.

METHODS

Patients aged 18 to 40 years who met study inclusion criteria were eligible. Patients meeting intraoperative inclusion criteria were randomized (immobilizer or no immobilizer) after wound closure. The immobilizer used was a soft, unhinged brace with Velcro straps. Preoperative, intraoperative, and postoperative protocols were standardized. The primary outcome was patient self-assessed pain using a 0-to-100-mm visual analog scale at day 2 after surgery. Secondary outcomes included pain and analgesic use in the first 14 days after surgery, complications, and range of motion (approximately 3 weeks postoperatively). A sample size estimate was calculated and resulted in the need for 44 patients per group.

RESULTS

A total of 102 patients were enrolled; 88 patients were randomized, and 14 were excluded intraoperatively. There was no difference in mean visual analog scale pain scores at 2 days after surgery between immobilized and nonimmobilized patients (32.6 and 35.2, respectively; P = .59; difference, -2.6; 95% confidence interval, -12.2 to 6.9). There were no differences between groups in medication consumed, range of motion, or complications. Pain and analgesic use were the same for both groups at 7 and 14 days postoperatively.

CONCLUSION

No differences in pain or any of the secondary outcomes were detected between immobilized and nonimmobilized patients at any point during the first 14 days after anterior cruciate ligament reconstruction.

[Reconstruction of the anterior cruciate ligament of the knee]

BACKGROUND/AIM

Numerous papers on reconstruction of the anterior cruciate ligament of the knee (ACL) contribute to the significance of this method. The aim of this study was to analyze the outcome of the use of this surgical treatment method regardless the type of surgical intervention, graft, and the choice of the material for fixing.

METHODS

The study included 324 patients treated within the period from April 1997 to April 2004. Arthroscopically assisted ACL reconstruction was typically performed using the central one-third of the patellar ligament, as a graft, with bone blocks. Fixing was performed using screws (spongy or interferential, Mitek type). In the cases who required revision of the surgery, we used a graft m. semitendinosus and m. gracilise (STG) or a graft of the patellar ligament (B-Pt-B). Fixation in these cases was performed using absorptive wedges according to the Rigidfix technique or metallic implants.

RESULTS

The analysis included the results of the reconstruction of the anterior cruciate ligament of the knee (B-Pt-B or STG graft) in 139 of the knees. Chronic injuries were revealed in 132 (94.9%) of the knees. According to the anamnesis and clinical findings, the feeling of instability prevailed in 132 (94.9%) of the knees, pain in 72 (51.7%), effluents in 24 (17.2%), and blockages in 13 (9.3%). Early and late postoperative complications were noticeable in 3.5% each. Hypotrophy of the upper knee musculature up to 2 cm was present in 53.9% of the operated knees, while minor contractions in 13.6% of them. The final result of the reconstruction graded begusing the Lysholm Scale was 85.2, simultaneous reconstructions of other ligaments 75.3, and revision surgery 68.0. First-grade degenerative postoperative changes according to the K/L Scale were found in 55.0% of the surgically treated knees, while the worst, four-grade one in 2.5%.

CONCLUSION

On the basis of these findings, we can conclude that this method is the method of choice in preventing further "worsening" of the chronically instable knee. The surgical technique of choice is arthroscopically assisted reconstruction using a B-Pt-B or STG graft.

Classification of functional recovery of anterior cruciate ligament copers, non-copers, and adapters

OBJECTIVES

(a) To identify whether differences exist in the pattern of recovery with respect to functional outcomes for acutely ruptured anterior cruciate ligament deficient (ACLD) copers, adapters, and non-copers. (b) To identify clinically relevant outcomes that could distinguish between three functional subgroups.

METHODS

A longitudinal study was used to measure gait variables and distance hop at regular intervals after injury using a digital camcorder and computer for quantitative analysis. A sample of 63 ACLD subjects entered the study; 42 subjects were measured at least three times. At 12-36 months after injury, subjects were classified as functional copers, adapters, or non-copers on the basis of which of their preinjury activities they had resumed. To determine the pattern of recovery, repeated measurements were analysed using a least squares fit of the data.

RESULTS

17% of ACLD subjects were classified as functional copers, 45% as adapters, and 38% as non-copers. Only 5% of those who participated in high demand activities before injury returned to them. ACLD copers had recovered above the control mean for all gait variables by 40 days after the injury. Hopping distance did not recover to the control mean. Non-copers struggled to recover to control limits and remained borderline for all the gait variables.

CONCLUSIONS

Distinctive patterns of functional recovery for three subgroups of ACLD subjects have been identified. Gait variables and activity level before injury were the most useful variables for distinguishing between the subgroups. If potential for recovery is identified early after injury, then appropriate treatment can be given.

National audit of post-operative management in spinal surgery

Background

There is some evidence from a Cochrane review that rehabilitation following spinal surgery may be beneficial.

Methods

We conducted a survey of current post-operative practice amongst spinal surgeons in the United Kingdom in 2002 to determine whether such interventions are being included routinely in the post-operative management of spinal patients.

The survey included all surgeons who were members of either the British Association of Spinal Surgeons (BASS) or the Society for Back Pain Research. Data on the characteristics of each surgeon and his or her current pattern of practice and post-operative care were collected via a reply-paid postal questionnaire.

Results

Usable responses were provided by 57% of the 89 surgeons included in the survey. Most surgeons (79%) had a routine post-operative management regime, but only 35% had a written set of instructions that they gave to their patients concerning this. Over half (55%) of surgeons do not send their patients for any physiotherapy after discharge, with an average of less than two sessions of treatment organised by those that refer for physiotherapy at all. Restrictions on lifting, sitting and driving showed considerable inconsistency both between surgeons and also within the recommendations given by individual surgeons.

Conclusion

Demonstrable inconsistencies within and between spinal surgeons in their approaches to post-operative management can be interpreted as evidence of continuing and significant uncertainty across the sub-speciality as to what does constitute best care in these areas of practice. Conducting further large, rigorous, randomised controlled trials would be the best method for obtaining definitive answers to these questions.

Knee immobilization in the immediate post-operative period following ACL reconstruction: a survey of practice patterns of Canadian orthopedic surgeons

OBJECTIVE

This study was designed to determine the practice patterns and rationale for knee immobilizer use in immediate post-operative period following an anterior cruciate ligament (ACL) reconstruction.

DESIGN

Descriptive cross-sectional survey.

SETTING

Canada.

PARTICIPANTS

A random sample of 50% of Canadian orthopedic surgeons registered with the Canadian Orthopaedic Association (COA).

MAIN OUTCOME MEASURE

Self-reported survey responses regarding knee immobilizer use, surgeon characteristics, graft type and type of practice.

RESULTS

Complete survey response rate was 36.1% (122/338). There was a lack of consensus regarding knee immobilizer use; 47.7% of responding surgeons use a knee immobilizer in the immediate post-operative period while 52.3% do not. There were no trends in characteristics such as fellowship training, number of years in practice and type of practice between surgeons who use and do not use a knee immobilizer. The reported reasons for immobilization were: pain reduction in the post-operative period (51.6%), graft site protection (38.7%), maintaining full extension (19.4%) and habit (12.9%). The length of time the immobilizer was used ranged from 5-42 days.

CONCLUSIONS

The lack of consensus reported in the current study and published literature reflects a lack of scientific evidence in the area of post-operative knee immobilization. The need for a randomized clinical trial to assess the efficacy of knee immobilizer use after ACL reconstruction is evident. The authors recommend using peri-operative pain as an outcome measure in future studies investigating immobilization in the immediate post-operative period.

Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis

OBJECTIVES

To compare bone-patellar tendon-bone autografts with hamstring autografts for reconstruction of the anterior cruciate ligament.

DATA SOURCES

Medline, WebSPIRS, Science Citation Index, Current Contents databases, and Cochrane Central Register of Controlled Trials. Review methods All randomised controlled trials reporting one or more outcome related to stability (instrumented measurement of knee laxity, Lachman test, or pivot shift test) and morbidity (anterior knee pain, kneeling test, loss of extension, or graft failure). Study quality was assessed by using a 5 point scale. Random effect models were used to pool the data. Heterogeneity in the effect of treatment was tested on the basis of study quality, randomisation status, and number of tendon strands used.

RESULTS

24 trials of 18 cohorts (1512 patients) met the inclusion criteria. Study quality was poor for nine studies and fair for nine studies. The weighted mean difference of the instrumented measurement of knee laxity was 0.36 (95% confidence interval 0.01 to 0.71; P = 0.04). Relative risk of a positive Lachman test was 1.22 (1.01 to 1.47; P = 0.04), of anterior knee pain 0.57 (0.44 to 0.74; P < 0.0001), of a positive kneeling test 0.26 (0.14 to 0.48; P < 0.0001), and of loss of extension 0.52 (0.34 to 0.80; P = 0.003). Other results were not significant.

CONCLUSION

Morbidity was lower for hamstring autografts than for patellar tendon autografts. Evidence that patellar tendon autografts offer better stability was weak. The poor quality of the studies calls into question the robustness of the analyses.

Outcome and risk factors after anterior cruciate ligament reconstruction: a follow-up study of 948 patients

PURPOSE

The aim of the study was to assess the outcome and risk factors after anterior cruciate ligament (ACL) reconstruction in a large group of patients.

TYPE OF STUDY

Case series.

METHODS

Included in this retrospective study were 948 patients (323 female, 625 male) with a symptomatic unilateral ACL rupture, who underwent arthroscopic reconstruction using patellar tendon autograft and interference screw fixation at 3 Swedish hospitals. The median age of the patients at the time of the index operation was 26 years (range, 14 to 53 years). The patients underwent surgery at a median of 12 months (range, 0.5 to 360 months) after their injury. Independent physiotherapists performed the follow-up examinations at a median of 32 months (range, 21 to 117 months) postoperatively.

RESULTS

Of the 948 patients, 550 (58%) underwent meniscal surgery before, during, or after the ACL reconstruction. The median Tegner activity level was 8 (range, 2-10) before injury, 3 (range, 0-9) preoperatively, and 6 (range, 1-10) at follow-up (P < .0001 preoperative v follow-up). At follow-up, the median Lysholm score was 90 points (range, 14-100), the median KT-1000 anterior side-to-side laxity difference was 1.5 mm (range, -6 to 13 mm), and the median 1-leg hop test quotient was 95% (0% to 167%) compared with the contralateral normal side. At follow-up, 69.3% of the patients were classified as normal or nearly normal according to the International Knee Documentation Committee evaluation system. However, 36% of the patients were unable to or had severe problems performing the knee-walking test. Inferior results correlated with increased time period between the index injury and reconstruction and concomitant joint damage found at the index operation.

CONCLUSIONS

Overall, the results were good after ACL reconstruction using patellar tendon autograft and interference screw fixation. Concomitant joint damage and a long time period between the injury and reconstruction are major risk factors for inferior outcome after ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, case series.

Cruciate ligament reconstruction

Injuries to the cruciate ligaments of the knee can be disabling. Advances in treatment over recent years have made their early diagnosis imperative. Surgical reconstruction is not appropriate for all. Once surgical candidates have been identified a number of reconstructive options exist.

Muscle and tendon morphology after reconstruction of the anterior cruciate ligament with autologous semitendinosus-gracilis graft

BACKGROUND

The autologous semitendinosus-gracilis graft is the first choice of many orthopaedic surgeons when reconstructing the anterior cruciate ligament. The effect that graft harvest has on muscle and tendon morphology remains unclear. The purpose of this study was to describe these effects more completely.

METHODS

Magnetic resonance images were acquired from eight patients before the anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft and then again postoperatively after they had returned to sports. Muscle and tendon morphology was described by determining the volume and peak cross-sectional area of each structure on digitally reconstructed images. The effects that the procedure had on muscle and tendon length were evaluated separately and then together as a muscle-tendon complex.

RESULTS

Anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft resulted in a marked decrease in volume, cross-sectional area, and length of the semitendinosus and gracilis muscles. Tendon regeneration occurred in varying degrees in nearly all subjects. The morphology of the biceps femoris and semimembranosus muscles suggested that they had been compensating for the reduced semitendinosus and gracilis muscle function. Although semitendinosus and gracilis muscle retraction occurred following tendon stripping, nearly all of the subjects displayed evidence of at least partial tendon regeneration.

CONCLUSIONS

Anterior cruciate ligament reconstruction with semitendinosus-gracilis autograft had a marked impact on semitendinosus and gracilis muscle morphology. However, this altered muscle morphology did not appear to have a clinically important impact on short-term outcomes. The biceps femoris and semimembranosus muscles appear to compensate for reduced semitendinosus and gracilis function. Tendon regeneration is observed in most people, but it is often incomplete at six months.

A comparison of autogenous patellar tendon and hamstring tendon grafts for anterior cruciate ligament reconstruction

Several graft options exist for reconstruction of the deficient ACL. The most commonly used grafts are the BPTB and quadrupled hamstring tendon autografts. Based on a comprehensive review of the literature, one graft is not superior to the other. Advantages and disadvantages are associated with the use of each graft. Surgeons who perform ACL reconstruction should be familiar with the use of both grafts.

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

The patella tendon is the most commonly used graft source for ACL reconstruction because of its biomechanical strength and stiffness, the availability of bone-to-bone healing on either end, and the ability to firmly secure the graft within the tunnels. Consistently good results have been reported in the literature, with expectations to return to all activities at pre-injury levels of performance. We outline our technique for endoscopic ACL reconstruction using a patella tendon autograft. The technique is divided into the critical stages of pre-operative assessment, graft harvest, notch preparation, tunnel placement, graft passage, graft fixation, and rehabilitation. Methods for avoiding pitfalls and overcoming mishaps are described.