ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up

Comparison of Time-Zero Primary Stability Between a Biodegradable Magnesium Bone Staple and Metal Bone Staples for Knee Ligament Fixation: A Biomechanical Study in a Porcine Model

Background

Bone staples have been shown previously to be a viable modality for cortical tendon graft fixation in ligament knee surgery. However, soft tissue reactions have been reported, making implant removal necessary. Magnesium alloys are a promising material for biodegradable orthopaedic implants, with mechanical properties closely resembling those of human bone.

Purpose

To compare the primary stability of a biodegradable bone staple prototype made from magnesium to bone staples made from metal in the cortical fixation of tendon grafts during knee surgery.

Study Design

Controlled laboratory study.

Methods

Primary stability of peripheral tendon graft fixation was assessed in a porcine model of medial collateral ligament reconstruction. Two commercially available metal bone staples (Richards fixation staple with spikes [Me1] and spiked ligament staple [Me2]) were compared with a magnesium bone staple prototype for soft tissue fixation. Primary stability was assessed using a uniaxial materials testing machine. Cyclic loading at 50 and 100 N was applied for 500 cycles each, followed by load-to-failure testing.

Results

After 500 cycles at 50 N, elongation was 1.5 ± 0.5 mm in the Me1 group, 1.9 ± 0.5 mm in the Me2 group, and 1.8 ± 0.4 mm in the magnesium group. After 1000 cycles of loading (500 cycles at 50 N and 500 at 100 N), elongation was 3.6 ± 0.9 mm in the Me1 group, 3.5 ± 0.6 mm in the Me2 group, and 4.1 ± 1.0 mm in the magnesium group. No significant differences regarding elongation were found between the groups. Load to failure was 352 ± 115 N in the Me1 group, 373 ± 77 N in the Me2 group, and 449 ± 92 N in the magnesium group, with no significant difference between the groups.

Conclusion

In this study, the magnesium bone staples provided appropriate time-zero biomechanical primary stability in comparison with metal bone staples and may therefore be a feasible alternative for cortical fixation of tendon grafts in knee surgery.

Clinical Relevance

The biodegradability of magnesium bone staples would eliminate the need for later implant removal.

Does combined anterior cruciate ligament and anterolateral ligament reconstruction improve return to sport?

PURPOSE

Only 50-65% of patients return to their previous sporting level after ACL rupture. The literature reports a reduced rate of graft rupture when an anterolateral ligament reconstruction (ALLR) is associated with ACL reconstruction. ACL reconstruction combined with ALL allows a higher return to sport at pre-injury level than isolated reconstruction in patients playing pivot-contact sports.

METHODS

A retrospective, single-centre study between 2012 and 2020 comparing reconstruction by hamstring tendon technique, isolated ACLR vs ACL with ALLR. An isokinetic test was performed at 6 months post-operatively and patients were re-contacted at a minimum 2-year follow-up to assess their level and delay to return to sport, graft rupture rate and functional evaluation.

RESULTS

83 patients were included, 42 in ACLR group and 41 in ACL + ALLR group. Four patients were lost to follow-up and 79 patients were analysed. No significant difference was found on the level of return to sport (28.2% vs. 42.5%; p = 0.18), return to competition (43% vs. 60%; p = 0.18), delay to sports return, isokinetic assessment, functional scores, but a significant difference was found on graft rupture rate in favour of ALLR (12.8% vs. 0%; p = 0.02).

CONCLUSION

In our study, the addition of an ALL to ACL reconstruction did not improve pre-injury sports recovery or return to competition.

STUDY DESIGN

Cohort study, level of evidence 4.

Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review

BACKGROUND

New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types.

PURPOSE

To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring).

STUDY DESIGN

Systematic review; Level of evidence, 5.

METHODS

An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts.

RESULTS

Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups.

CONCLUSION

HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

BACKGROUND

The semitendinosus (ST) tendon can be used by itself as a graft for anterior cruciate ligament (ACL) reconstruction. An increasing number of these procedures are being done while preserving the ST's tibial attachment, but there are no data on the remodeling of an attached ST (aST) graft.

PURPOSE

To compare graft remodeling on magnetic resonance imaging (MRI) scans at 1 year after ACL reconstruction between standard free ST graft and aST graft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This prospective study enrolled 180 patients who were undergoing ACL reconstruction: 90 with the ST graft and 90 with the aST graft. The analysis was performed 1 year after the surgery. The main endpoint was the signal-to-noise quotient (SNQ) on MRI scans (T1-weighted sequence). The secondary endpoints were tibial tunnel widening (TTW), graft maturation (Howell classification), retear rate, new surgery rate, Simple Knee Value, Lysholm score, International Knee Documentation Committee (IKDC) score, postoperative Tegner score, difference between pre- and postoperative Tegner scores, ACL-Return to Sport after Injury (ACL-RSI), return-to-sports rate, and time to return to sports.

RESULTS

The mean adjusted SNQ was 1.18 (95% CI, 0.72-1.65) in the aST group and 3.88 (95% CI, 3.42-4.34) in the ST group (P < .001). The new surgery rate was 2.2% in the aST group and 10% in the ST group (P = .029). The median Lysholm score was significantly higher in the aST group (99; interquartile range [IQR], 95-100) than in the ST group (95; IQR, 91-99) (P = .004). The mean time to return to sports was significantly shorter in the aST group (248.73 ± 141.62 days) than the ST group (317.23 ± 144.69 days) (P = .002). No statistically significant difference was found between groups in the TTW (P = .503), Howell graft maturity grade (P = .149), retear rate (P > .999), Simple Knee Value (P = .061), postoperative Tegner score (P = .320), pre- to postoperative difference in Tegner score (P = .317), ACL-RSI (P = .097), IKDC score (P = .621), and return-to-sports rate (P > .999).

CONCLUSION

At 1 year postoperatively, remodeling of an ST graft assessed using MRI is better when its distal attachment is left intact.

Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

It is clear that the anterolateral ligament has an important role in rotational knee stability. However, whether patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) can benefit from anterolateral augmentation (ALA) is still controversial.

Purpose

To compare the effects of isolated ACLR versus ACLR combined with ALA (ACLR+ALA) on clinical outcomes and knee stability.

Study Design

Systematic review; Level of evidence, 1.

Methods

The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of the PubMed, Embase, and Cochrane Library Central Register of Controlled Trials databases was undertaken to identify all randomized controlled trials (RCTs) comparing isolated ACLR with ACLR+ALA for the treatment of ACL injuries in the last 15 years. The Cochrane Collaboration risk-of-bias tool and the revised Jadad scale were utilized by 2 independent reviewers to determine the quality of RCTs. Relevant data were extracted and compared between procedures, and heterogeneity across the RCTs was assessed using the I ² statistic.

Results

The initial search yielded 849 articles. A total of 14 studies (1850 patients; 941 ACLR and 909 ACLR+ALA) satisfied the eligibility criteria for the meta-analysis. There were no significant differences between the procedures in terms of patient-reported outcomes (International Knee Documentation Committee score, Tegner score, Knee injury and Osteoarthritis Outcome Score) or return-to-sport rates. However, patients who underwent ACLR+ALA had better knee stability based on the pivot-shift test (risk ratio [RR], 1.06 [95% CI, 1.02 to 1.10]; P = .0008), Lachman test (RR, 1.03 [95% CI, 1.00 to 1.07]; P = .04), and side-to-side difference in anterior laxity (standardized mean difference, -0.55 [95% CI, -0.98 to -0.12]; P = .01) as well as a lower incidence of graft failure (RR, 0.30 [95% CI, 0.19 to 0.45]; P < .01) compared with patients who underwent isolated ACLR.

Conclusion

ALA can be considered as a reinforcement of ACLR to improve anteroposterior and anterolateral rotational stability of the knee and reduce the risk of failure. The patient-reported outcomes of isolated ACLR were similar to those of ACLR+ALA, and both procedures provided improved knee function.

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis

INTRODUCTION

Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R.

PATIENTS AND METHODS

A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective.

RESULTS

In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value = 0.465).

CONCLUSION

Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft.

LEVEL OF EVIDENCE

Level 1; Randomized Comparative Study.

Combined Lateral Extra-Articular Tenodesis or Combined Anterolateral Ligament Reconstruction and Anterior Cruciate Ligament Reconstruction Improves Outcomes Compared to Isolated Reconstruction for Anterior Cruciate Ligament Tear: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To conduct a network meta-analysis (NMA) comparing the results of randomized controlled trials (RCTs) among patients who underwent either isolated anterior cruciate ligament (ACL) reconstruction or combined lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR).

METHODS

RCTs that compared isolated ACL reconstruction and combined LET or ALLR were included with minimum 12 months follow-up. Studies that used the double-bundle technique were excluded. Outcome assessment included the number of positive pivot shifts, amount of anterior tibial translation, and International Knee Documentation Committee (IKDC) subjective, Tegner, and Lysholm scores. Bayesian NMA and the surface under the cumulative ranking area (SUCRA) were evaluated.

RESULTS

A total of 1,077 patients from 11 RCTs were enrolled in this study. In NMA, the odds ratios (ORs) of positive pivot shift were significantly lower in ACL + ALLR (OR: 0.17; 95% CI: 0.027-0.67) than isolated ACL reconstruction, but no difference between ACL + ALLR and ACL + LET. There were no significant differences in anterior tibial translation among the techniques, but the IKDC subjective and Lysholm scores of ACL + ALLR and ACL + LET were significantly higher than isolated ACL reconstruction. ACL + ALLR were the most preferred in terms of residual pivot shift, anterior tibial translation, and IKDC subjective scores (SUCRA = 88.2%, 86.4%, and 93.1%, respectively). Additional lateral procedures resulted in significantly lower risk of graft failure (OR: 0.27; 95% CI: 0.1-0.71) than isolated ACL reconstruction.

CONCLUSIONS

ACL + ALLR were found to have significantly better outcomes in terms of knee rotational stability and graft failure rate than isolated ACL reconstructions, but the clinical outcomes were uncertain after a minimum 12 months follow-up. Considering the greatest probability of obtaining better knee rotational stability in this NMA, ACL + ALLR was found to be the most preferred technique for patients with ACL injury.

LEVEL OF EVIDENCE

Level II, network meta-analysis and systematic review of Level I and II studies.

Patient-Reported Measures Associated with the Return to Pre-Injury Levels of Sport 2 Years after Anterior Cruciate Ligament Reconstruction

The International Knee Documentation Committee Subjective Knee Form (IKDC2000) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) are knee-specific measures. However, their association with a return to sports after anterior cruciate ligament reconstruction (ACLR) is unknown. This study aimed to investigate the association between the IKDC2000 and the KOOS subscales and the return to the same pre-injury level of sport two years after ACLR. Forty athletes that were two years post-ACLR participated in this study. Athletes provided demographic information, filled out the IKDC2000 and KOOS subscales, and indicated whether they returned to any sport and whether they returned to the same pre-injury level (same duration, intensity, and frequency). In this study, 29 (72.5%) athletes returned to play any sport and eight (20%) returned to the same pre-injury level. The IKDC2000 (r: 0.306, p = 0.041) and KOOS quality of life (KOOS-QOL) (r: 0.294, p = 0.046) significantly correlated with the return to any sport, but it was age (r: -0.364, p = 0.021), BMI (r: -0.342, p = 0.031), IKDC2000 (r: 0.447, p = 0.002), KOOS-pain (r: 0.317, p = 0.046), KOOS sport and recreation function (KOOS-sport/rec)(r: 0.371, p = 0.018), and KOOS QOL (r: 0.580, p > 0.001) that significantly correlated with a return to the same pre-injury level. High KOOS-QOL and IKDC2000 scores were associated with returning to any sport, and high KOOS-pain, KOOS-sport/rec, KOOS-QOL, and IKDC2000 scores were all associated with returning to the same pre-injury level of sport.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles' tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles' tendon, and deltoid ligament repair demonstrates improved time-zero biomechanical and promising short to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint over-constraint, nerve paresthesia, and infection.

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review

PURPOSE

Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data.

METHODS

Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS.

RESULTS

One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery.

CONCLUSION

This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature.

LEVEL OF EVIDENCE

IV.

Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials

BACKGROUND

Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions.

PURPOSE

To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 1.

METHODS

Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.

RESULTS

A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group.

CONCLUSION

Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.

There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction

PURPOSE

The purpose of the current study is to systematically review and network meta-analyze the current evidence in the literature to ascertain if there is a superior lateral extra-articular augmentation technique in conjunction with anterior cruciate ligament (ACL) reconstruction (ACL.R) with respect to knee stability, re-rupture rates and functional outcomes.

METHODS

The literature search was performed based on the PRISMA guidelines. Cohort studies comparing ACL.R to ACL.R + lateral extra-articular augmentation were included. Lateral extra-articular techniques included were anterolateral ligament reconstruction (ALL.R), Cocker-Arnold, Lemaire, Losee, Maraccaci, and McIntosh. Clinical outcomes were compared between ACL.R alone and the different lateral extra-articular augmentation techniques using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score.

RESULTS

Twenty-eight studies with a total of 2990 patients were included. ACL.R + Cocker-Arnold technique had the highest P-Score for ACL re-ruptures and residual pivot-shift. ACL.R + Cocker-Arnold, Lemaire, and ALL.R all significantly reduced the rate of ACL re-rupture, and residual pivot-shift, compared to ACL.R alone. There was no significant difference between any of the lateral extra-articular augmentation techniques and ACL.R alone. ALL.R had the highest P-Score for return to play, and return to play at pre-injury level.

CONCLUSION

This study established that ACL.R + Cocker-Arnold, Lemaire and ALL.R resulted in significantly lower ipsilateral ACL re-ruptures, as well as reduced pivot-shift, compared to ACL.R alone. Whereas, the other lateral extra-articular augmentation techniques did not reduce pivot-shift and re-rupture. Additionally, functional outcomes and return to play were comparable between those who underwent ACL.R and lateral extra-articular augmentation and ACL.R alone.

LEVEL OF EVIDENCE

III.

Comparing post-operative pain between single bundle and double bundle anterior cruciate ligament reconstruction: a retrospective study

Background

In anterior cruciate ligament (ACL) reconstruction, the clinical outcome and level of post-operative pain are important factors. To date there have been no studies evaluating differences in post-operative pain between single bundle and double bundle ACL reconstruction with a hamstring graft.

Hypothesis/purpose

We hypothesized that post-operative pain in single bundle ACL reconstruction would be less than in double bundle ACL reconstruction. This study was to compare post-operative pain between patients undergoing single bundle versus double bundle ACL reconstruction.

Study design

Cohort study.

Methods

This was a retrospective study comparing post-operative pain scores between single bundle and double bundle ACL reconstruction. Each patient was given our standard regimen of oral diclofenac (25 mg/tab) three times per day and paracetamol (500 mg/tab) six times per day for 1 day post-operatively. If the patient complained of moderate to severe pain (pain numeric rating scale (PNRS) > 3), 3 mg of morphine was injected intravenously every 3 h for 24 h and 1 mg of morphine as a rescue medication every 1 h for 24 h. PNRS and morphine consumption were recorded at 4-h intervals for 24 h.

Results

209 patients were included in this study of whom 102 and 107 patients received single bundle and double bundle ACL reconstruction, respectively. The average post-operative pain scores of the single bundle group were lower at all time points. Linear mixed effect regression analyses showed that the single bungle group had lower post-operative pain than the double bundle group after adjusting for confounders (beta = − 0.45; 95% CI = − 0.838, − 0.062) but there was no statistically significant difference between numbers of bundle ACL reconstruction with regard to morphine consumption.

Conclusion

Single bundle ACL reconstruction had significantly lower post-operative pain scores than double bundle ACL reconstruction.

Clinical relevance

Double bundle ACL reconstruction results in higher post-operative pain, which may slow the start of rehabilitation and reduce patient satisfaction. In middle-aged adult patients with low-demand activities, we suggest performing a single bundle ACL reconstruction.

Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis

BACKGROUND

Residual rotational instability after isolated anterior cruciate ligament reconstruction (ACLR) has been a challenge for many years. Anterolateral extra-articular procedures (AEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET), are performed as a surgical option for additional rotational stability, but clear evidence for their usefulness is lacking.

PURPOSE

To conduct a systematic review and meta-analysis of the literature regarding the efficacy of AEAP in primary ACLR.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

A literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. MEDLINE, EMBASE, and the Cochrane Library were searched in April 2020, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 3444 studies were screened, and 20 studies (11 randomized controlled trials and 9 nonrandomized studies) were evaluated. Functional outcomes, stability, and complications were compared between patients who underwent primary ACLR with AEAP and those who underwent isolated primary ACLR. For subgroup analysis, outcomes were compared according to AEAP technique (ALLR vs LET) and time from injury to surgery (≤12 vs >12 months). The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool, Jadad scale, and Newcastle-Ottawa Scale.

RESULTS

Compared with isolated ACLR, combined ACLR with AEAP led to improved pivot-shift grades and graft failure rates, regardless of the AEAP technique or of time from injury to surgery. A limited, marginal improvement in subjective function score was observed in patients who underwent AEAP combined with ACLR. In contrast to ALLR, patients who underwent LET combined with ACLR had an increased risk of knee stiffness and adverse events.

CONCLUSION

Our review suggests that when there is a need to improve rotational stability and subjective function, AEAP combined with primary ACLR can be considered regardless of time from injury. ALLR appeared to be a better option for improving rotational stability compared with LET.

Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation

BACKGROUND

In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated.

HYPOTHESIS

In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected.

RESULTS

A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up.

CONCLUSION

Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents.

CLINICAL RELEVANCE

Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.

Rehabilitation duration and time of starting sport-related activities associated with return to the previous level of sports after anterior cruciate ligament reconstruction

OBJECTIVES

To determine predictors for return to previous level of sports after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional; SETTING: Athletic teams.

PARTICIPANTS

Ninety-one athletes who had ACLR with hamstring-tendon autograft within 1-5 years participated in this study. Athletes indicated their sport participation levels, injury profile, rehabilitation duration, and time to start sport-related activities (running, cutting-pivoting) after ACLR. Athletes answered whether they returned to the same previous level of frequency, duration, and intensity of sports.

MAIN OUTCOME MEASURES

Athletes' characteristics, injury and surgical factors, duration of post-operative rehabilitation program, and time to start sport-related activities after ACLR were evaluated by univariate logistic regression to determine predictors for return to previous level of sports.

RESULTS

Nine athletes (10%) returned to their self-described previous level of sports. Predictors for returning to previous level of sports were rehabilitation duration >4 months (OR:6.78; p = .011), time to start running ≤4 months (OR:8.62; p = .047) and cutting-pivoting <6 months after surgery (OR:5.02; p = .030).

CONCLUSION

Longer post-operative rehabilitation duration and time to start sport-related activities after ACLR predicted return to previous level of sports. Spending adequate time in post-operative rehabilitation program and time-based resumption of sports-related activities after ACLR might be key factors for returning to previous sports level.

Return to Play After Anterior Cruciate Ligament Reconstruction with Extra-Articular Augmentation: A Systematic Review

PURPOSE

The purpose of the current study is to systematically review the current evidence in the literature to ascertain rates of return to play after ACLR with extra-articular augmentation (EA).

METHODS

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they evaluated and reported on return to play after ACLR + EA; case studies and review articles were excluded. The outcomes measured focused on (1) return to play, (2) return to play at the same or higher level, and (3) timing of return to play. Qualitative analysis and quantitative analysis were performed using SPSS.

RESULTS

Overall, 19 studies met our inclusion criteria. Among patients undergoing primary ACLR, 82.8% to 100% were able to return to play, with 64% to 100% able to return at the same or higher level of play. All professional athletes were able to return to play, and 85.7% to 100% were able to return to the same level of preoperative play. The mean time to return was 5 to 11 months in those undergoing primary ACLR + EA. Among those undergoing revision ACLR, 50% to 88.4% were able to return to play, with 41.5% to 77.8% able to return at the same or higher level of play. None of the 5 studies that compared rate of return to play (at any level) between ACLR + EA and ACLR alone found a significant difference between them. However, among the 6 studies that compared rate of return to play at the same level between ACLR + EA and ACLR alone, 2 studies found a significantly higher rate of return to play with ACLR + EA.

CONCLUSION

ACLR + EA resulted in high levels of return to play in those undergoing either primary or revision ACLR. Additionally, comparative studies of patients undergoing primary ACLR with or without EA reported similarly high rates of return to play.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up

PURPOSE

The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria.

METHODS

A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2 years. Stratified variable analysis of the groups was also performed.

RESULTS

There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52 months and 27 months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P < 0.001) favoured ACL reconstruction with LEAT compared to ACL reconstruction alone. Sports with frequent change of direction maneuvers and higher rates of ACL injury (rugby, soccer, skiing) favoured ACL reconstruction with LEAT versus ACL reconstruction alone (P = 0.001). No significant difference in re-operation rate or type of surgery was found between the two surgical groups after propensity matching but 13 patients in the ACL reconstruction-only group re-injured their ACL, 8 of whom required supplementary LEAT at the time of revision surgery.

CONCLUSION

Patient-reported outcomes and return to multi-directional sports after ACL reconstruction favour LEAT at the time of ACL reconstruction when narrow inclusion criteria are applied.

Lateral Augmentation Procedures in Anterior Cruciate Ligament Reconstruction: Anatomic, Biomechanical, Imaging, and Clinical Evidence

BACKGROUND

There has been an increasing interest in lateral-based soft tissue reconstructive techniques as augments to anterior cruciate ligament reconstruction (ACLR). The objective of these procedures is to minimize anterolateral rotational instability of the knee after surgery. Despite the relatively rapid increase in surgical application of these techniques, many clinical questions remain.

PURPOSE

To provide a comprehensive update on the current state of these lateral-based augmentation procedures by reviewing the origins of the surgical techniques, the biomechanical data to support their use, and the clinical results to date.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the literature was conducted via the Medline, EMBASE, Scopus, SportDiscus, and CINAHL databases. The search was designed to encompass the literature on lateral extra-articular tenodesis (LET) procedures and the anterolateral ligament (ALL) reconstruction. Titles and abstracts were reviewed for relevance and sorted into the following categories: anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes.

RESULTS

The search identified 4016 articles. After review for relevance, 31, 53, 27, 35, 45, and 78 articles described the anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes of either LET procedures or the ALL reconstruction, respectively. A multitude of investigations were available, revealing controversy in addition to consensus in several categories. The level of evidence obtained from this search was not adequate for systematic review or meta-analysis; thus, a current concepts review of the anatomy, biomechanics, imaging, surgical techniques, and clinical outcomes was performed.

CONCLUSION

Histologically, the ALL appears to be a distinct structure that can be identified with advanced imaging techniques. Biomechanical evidence suggests that the anterolateral structures of the knee, including the ALL, contribute to minimizing anterolateral rotational instability. Cadaveric studies of combined ACLR-LET procedures demonstrated overconstraint of the knee; however, these findings have yet to be reproduced in the clinical literature. The current indications for LET augmentation in the setting of ACLR and the effect on knee kinematic and joint preservation should be the subject of future research.

Clinical Results of Lateral Extra-Articular Tenodesis

In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.

Influence of the Anterolateral Ligament on Knee Laxity: A Biomechanical Cadaveric Study Measuring Knee Kinematics in 6 Degrees of Freedom Using Dynamic Radiostereometric Analysis

Background:

An anterior cruciate ligament (ACL) rupture often occurs during rotational trauma to the knee and may be associated with damage to extracapsular knee rotation–stabilizing structures such as the anterolateral ligament (ALL).

Purpose:

To investigate ex vivo knee laxity in 6 degrees of freedom with and without ALL reconstruction as a supplement to ACL reconstruction.

Study Design:

Controlled laboratory study.

Methods:

Cadaveric knees (N = 8) were analyzed using dynamic radiostereometry during a controlled pivotlike dynamic movement simulated by motorized knee flexion (0° to 60°) with 4-N·m internal rotation torque. We tested the cadaveric specimens in 5 successive ligament situations: intact, ACL lesion, ACL + ALL lesion, ACL reconstruction, and ACL + ALL reconstruction. Anatomic single-bundle reconstruction methods were used for both the ACL and the ALL, with a bone-tendon quadriceps autograft and gracilis tendon autograft, respectively. Three-dimensional kinematics and articular surface interactions were used to determine knee laxity.

Results:

For the entire knee flexion motion, an ACL + ALL lesion increased the mean knee laxity (P < .005) for internal rotation (2.54°), anterior translation (1.68 mm), and varus rotation (0.53°). Augmented ALL reconstruction reduced knee laxity for anterior translation (P = .003) and varus rotation (P = .047) compared with ACL + ALL–deficient knees. Knees with ACL + ALL lesions had more internal rotation (P < .001) and anterior translation (P < .045) at knee flexion angles below 40° and 30°, respectively, compared with healthy knees. Combined ACL + ALL reconstruction did not completely restore native kinematics/laxity at flexion angles below 10° for anterior translation and below 20° for internal rotation (P < .035). ACL + ALL reconstruction was not found to overconstrain the knee joint.

Conclusion:

Augmented ALL reconstruction with ACL reconstruction in a cadaveric setting reduces internal rotation, varus rotation, and anterior translation knee laxity similar to knee kinematics with intact ligaments, except at knee flexion angles between 0° and 20°.

Clinical Relevance:

Patients with ACL injuries can potentially achieve better results with augmented ALL reconstruction along with ACL reconstruction than with stand-alone ACL reconstruction. Furthermore, dynamic radiostereometry provides the opportunity to examine clinical patients and compare the recontructed knee with the contralateral knee in 6 degrees of freedom.

Comparison of anterior cruciate ligament reconstruction methods between reverse "Y" plasty reconstruction and traditional single-bundle technique-A cadaveric study

Background

In 2009, a reverse “Y” plasty anterior cruciate ligament (ACL) reconstruction technique was proposed, with double-tibial tunnel and single-femoral tunnel, and the result obtained proved that the reverse “Y” plasty technique was satisfactory. This cadaveric study was designed to compare the reverse “Y” plasty reconstruction method with the conventional single-bundle technique for the first time.

Methods

In this study, 30 cadaveric knees were used and were randomly divided into five groups with six knees each. Six cadaveric knees with intact ACL were treated as the control group, and another six knees with ruptured ACL were treated as the rupture group. In group A, the single-bundle technique was used. In groups B and C, reverse “Y” plasty technique was used, and the grafts were fixed with absorbable biointerference screws in tibiae and absorbable biointerference screws (Group B) or Endobutton (Group C) in femora. Five groups were tested with an MTS material testing machine (MTS-858) by the use of a cyclic loading of 134 N at 15°, 30°, 60° and 90° of knee flexion and a combined 7-Nm valgus torque and 5-Nm internal tibial rotation torque at 15°, 30°, 45° and 60° of knee flexion.

Results

Both single-bundle and reverse “Y” plasty groups demonstrated similar anterior–posterior stability compared with the control group, whereas the single-bundle group showed inferior rotational stability tested at 30° and 45° of knee flexion than the reverse “Y” plasty group and control group. These two different fixation methods at the femoral site (Group B and C) showed no difference in anterior–posterior and rotational stability.

Conclusions

The new reverse “Y” plasty ACL reconstruction method may restore normal knee stability, especially rotational stability, better than single-bundle reconstruction.

The translational potential of this article

This study provides strong support for the new reverse “Y” plasty ACL reconstruction technique and is expected to propose a new surgical approach with good biomechanical features.

Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee

PURPOSE

The role of concomitant extra-articular procedures in improving the outcome of ACL reconstruction has experienced a recent resurgence in interest. The aim of this article is to highlight the differences in philosophies and outcomes of historical lateral extra-articular tenodesis (LET) and contemporary, anterolateral reconstruction.

METHODS

A narrative review was performed using PubMed/MEDLINE using the keywords "lateral extra-articular tenodesis" and "anterolateral ligament reconstruction".

RESULTS

Results of search strategy: Thirty-seven studies [13 reporting clinical outcomes of isolated LET in ACL deficient knees and 24 comparing isolated anterior cruciate ligament reconstruction (ACLR) with ACLR + LET] and 1 study on anterolateral ligament (ALL) reconstruction were identified as relevant and included in the review. Results of literature review: Isolated extra-articular reconstructions are rarely performed in contemporary practice. They are associated with a high rate of persistent anterior instability and early degenerative change. Combined ACL reconstruction and lateral extra-articular tenodeses results in a significant reduction in the prevalence of residual pivot shift, but the majority of the studies do not demonstrate any significant difference with respect to patient-reported outcome measures and return to sport. Although several authors report a trend towards decreased graft rupture rates, significant differences were not demonstrated in most studies. In a single clinical study, combined anatomic ACL and anterolateral ligament reconstruction was reported to be associated with a threefold reduction in graft rupture rates and improved return to sport compared to isolated ACL graft choices.

CONCLUSIONS

Historically performed, combined ACL reconstruction and lateral extra-articular tenodeses are associated with improved knee kinematics. Although trends towards decreased graft rupture rates are reported by several authors, the majority did not demonstrate a significant difference, likely as a result of small and underpowered studies using post-operative immobilisation and delayed rehabilitation protocols. More recently, combined ACLR and ALL reconstruction has been shown to be associated with significant improvements in graft failure and return to sport rates when compared to isolated ACLR. However, these results are from a single clinical series with only medium-term follow-up.

LEVEL OF EVIDENCE

IV.

Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs?

Study Design Prospective cohort study. Background While meeting objective criterion cutoffs is recommended prior to return to sports following anterior cruciate ligament (ACL) reconstruction, the number of young athletes who meet recommended cutoffs and the impact of cutoffs on longitudinal sports participation are unknown. Objectives To test the hypothesis that a higher proportion of young athletes who meet recommended cutoffs will maintain the same level of sports participation over the year following return-to-sport clearance compared to those who do not meet recommended cutoffs. Methods At the time of return-to-sport clearance, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), quadriceps and hamstring strength limb symmetry index (LSI), and single-leg hop test LSI were assessed. Proportions of participants who met individual (IKDC score of 90 or greater; strength and hop test LSIs of 90% or greater) and combined cutoffs were calculated. Proportions of participants who continued at the same level of sports participation over the year following return-to-sport clearance (assessed using the Tegner activity scale) were compared between those who met and did not meet cutoffs. Results Participants included 115 young athletes (88 female). The proportions meeting individual cutoffs ranged from 43.5% to 78.3%. The proportions meeting cutoffs for all hop tests, all strength tests, and all combined measures were 53.0%, 27.8%, and 13.9%, respectively. A higher proportion of participants who met cutoffs for both strength tests maintained the same level of sports participation over the year following return-to-sport clearance than those who did not (81.3% versus 60.2%, P = .02). Conclusion The proportions of young athletes after ACL reconstruction recently cleared for return to sports who met the combined criterion cutoffs were low. Those who met the criterion cutoffs for both strength tests maintained the same level of sports participation at higher proportions than those who did not. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther 2017;47(11):825-833. Epub 7 Oct 2017. doi:10.2519/jospt.2017.7227.

The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis

Background

The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.

Purpose

To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR.

Study Design

Systematic review; Level of evidence, 3.

Methods

Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures.

Results

Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P = .008; I² = 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; P = .10; I² = 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes.

Conclusion

In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study With 10-Year Results

BACKGROUND

A long-term follow-up comparing double-bundle and single-bundle techniques for anterior cruciate ligament (ACL) reconstruction has not been reported before.

HYPOTHESIS

Double-bundle ACL reconstruction may have fewer graft ruptures, lower rates of osteoarthritis (OA), and better stability than single-bundle reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Ninety patients were randomized for double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). Evaluation methods consisted of a clinical examination, KT-1000 arthrometer measurements, International Knee Documentation Committee (IKDC) and Lysholm knee scores, and a radiographic examination of both the operated and contralateral knees.

RESULTS

Eighty-one patients (90%) were available at the 10-year follow-up. Eleven patients (1 in the DB group, 7 in the SBB group, and 3 in the SBM group) had a graft failure during the follow-up and went on to undergo revision ACL surgery ( P = .043). In the remaining 70 patients at 10 years, no significant group differences were found in the pivot-shift test findings, KT-1000 arthrometer measurements, or knee scores. The most OA findings were found in the medial compartment of the knee, with 38% of the patients in the operated knee and 28% of the patients in the contralateral nonoperated knee. However, no significant group difference was found. The most severe OA changes were in the patients who had the longest delay from the primary injury to ACL reconstruction ( P = .047) and in the patients who underwent partial meniscal resection at the time of ACL reconstruction ( P = .024).

CONCLUSION

Double-bundle ACL reconstruction resulted in significantly fewer graft failures than single-bundle ACL reconstruction during the follow-up. Knee stability and OA rates were similar at 10 years. The most severe OA changes were found in the patients who had the longest delay from the primary injury to ACL reconstruction and in the patients who underwent partial meniscal resection at the time of ACL reconstruction.

Reoperation Rates After Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction: A Series of 548 Patients From the SANTI Study Group With a Minimum Follow-up of 2 Years

BACKGROUND

Early clinical results of anterolateral ligament (ALL) reconstruction are promising, but concerns exist due to high rates of complications after other types of lateral extra-articular tenodesis. The rate of surgery after combined anterior cruciate ligament (ACL) and ALL reconstruction is not known.

PURPOSE

To determine the rate of reoperation after combined ACL and ALL reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis of prospectively collected data from the Scientific ACL Network International (SANTI) Study Group database was performed to include all patients who had undergone combined ACL and ALL reconstruction between January 2012 and June 2014. At the end of the study period, all patients were contacted by telephone, and the operative notes of those who stated that they had undergone reoperation were reviewed to determine the type and rates of the subsequent procedures performed. Descriptive data were analyzed for the entire patient cohort.

RESULTS

The study population comprised 548 quadruple hamstring graft (4HT)+ALL reconstructions. The mean age (±SD) was 24.3 ± 7.9 years (range, 11.9-55.7 years), and 70.3% of subjects were male. The mean duration of follow-up was 35.5 ± 8.0 months (range, 24-54 months). Seventy-two patients (13.1%) underwent ipsilateral reoperation. This comprised a total of 77 procedures. Graft revision occurred in 14 knees (2.6%) at a mean of 18.3 months (±7.4 months) after the index procedure. There were 63 reoperations for ipsilateral, non-graft rupture-related indications (meniscus, n = 30; arthrofibrosis, n = 22; removal of hardware, n = 4; deep infection, n = 3; arthroscopic lavage without infection, n = 4). The only specific complications related to the ALL procedure (n = 3) were all related to femoral hardware that required removal. In both univariate and multivariate analyses, only the presence of a medial meniscal lesion at the index procedure was significantly associated with ipsilateral reoperation (odds ratio, 2.58; 95% CI, 1.43-4.76; P = .002).

CONCLUSION

The reoperation rate after combined ACL and ALL reconstruction in this series is broadly comparable to the reoperation rate after isolated ACL reconstruction as reported in previous studies. In addition, the high rates of knee stiffness and reoperation reported in historical series of nonanatomic, lateral extra-articular tenodesis were not observed in the current series.

Anatomic Anterolateral Ligament Reconstruction of the Knee Leads to Overconstraint at Any Fixation Angle

BACKGROUND

Anterior cruciate ligament (ACL) tears are one of the most common injuries among athletes. However, the ability to fully restore rotational stability with ACL reconstruction (ACLR) remains a challenge, as evidenced by the persistence of rotational instability in up to 25% of patients after surgery. Advocacy for reconstruction of the anterolateral ligament (ALL) is rapidly increasing because some biomechanical studies have reported that the ALL is a significant contributor to internal rotational stability of the knee.

HYPOTHESIS/PURPOSE

The purpose of this study was to assess the effect of ALL reconstruction (ALLR) graft fixation angle on knee joint kinematics in the clinically relevant setting of a concomitant ACLR and to determine the optimal ALLR graft fixation angle. It was hypothesized that all fixation angles would significantly reduce rotational laxity compared with the sectioned ALL state.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten nonpaired fresh-frozen human cadaveric knees underwent a full kinematic assessment in each of the following states: (1) intact; (2) anatomic single-bundle (SB) ACLR with intact ALL; (3) anatomic SB ACLR with sectioned ALL; (4) anatomic SB ACLR with 7 anatomic ALLR states using graft fixation angles of 0°, 15°, 30°, 45°, 60°, 75°, and 90°; and (5) sectioned ACL and ALL. Internal rotation during a 5-N·m internal rotation torque and anterior translation during an 88-N anterior load were recorded at 15° flexion intervals between 0° and 120°. Axial plane translation and internal rotation during a simulated pivot-shift test (combined 5-N·m internal rotation and 10-N·m valgus torques) were recorded between 0° and 60°. Kinematic changes were measured and compared with the intact state for all reconstructed and sectioned states.

RESULTS

Anatomic ALLR at all graft fixation angles significantly overconstrained internal rotation of the knee joint beyond 30° of flexion and at 45° and 60° during the pivot-shift test. Furthermore, there were no significant knee kinematic differences between any tested graft fixation angles during anterior drawer, pivot-shift, and internal rotation tests.

CONCLUSION

Anatomic ALLR in conjunction with an ACLR significantly reduced rotatory laxity of the knee beyond 30° of knee flexion. However, ALLR, regardless of fixation angle, resulted in significant overconstraint of the knee.

CLINICAL RELEVANCE

ALLR at any fixation angle overconstrained native joint kinematics and should be performed with careful consideration. Further investigation into the application and target population for ALLR is strongly recommended.

Hamstring graft tibial insertion preservation versus detachment in anterior cruciate ligament reconstruction: a prospective randomized comparative study

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction with hamstring graft (HG) is a commonly performed procedure. Despite the type of reconstruction chosen, the detached HG undergoes a remodeling process known as ligamentization. In order to shorten the ligamentization process, the maintenance of HG tibial insertion, aimed to spare the tendons vascular supply, has been postulated. The aim of this paper is to report the results of a prospective randomized study comparing clinical and MRI results between two different ACL reconstructive procedures with and without HG tibial insertion preservation.

METHODS

Forty patients (mean age 27.5 ± 9.5 years) were enrolled and randomly divided into two groups. The study group underwent an ACL reconstruction using a distally inserted HG, while the control group underwent a technique encompassing HG tibial detachment. Subjective and objective IKDC score was administered preoperatively and at 3-, 6-, 12- and 24-month follow-up. Graft morphology was assessed through MRI evaluation performed at 6-month follow-up.

RESULTS

Clinical results were excellent in both groups. Regarding MRI results, a better intra-articular graft morphology was observed in the study group (Tau = 0.313, p = 0.024). No differences in graft integration were noticed.

CONCLUSION

The main finding of this preliminary study is that preservation of the hamstring tibial insertion seems to enhance graft ligamentization with improved morphology of the intra-articular portion of the graft compared to a detachment of the hamstring tendons from the tibial side. Further well-designed studies with higher number of patients as well as more serial MRI evaluations are required to validate these preliminary findings.

Clinical Outcomes of Combined Lateral Extra-articular Tenodesis and Intra-articular Anterior Cruciate Ligament Reconstruction in Addressing High-Grade Pivot-Shift Phenomenon

PURPOSE

To evaluate the clinical outcomes of combined lateral extra-articular tenodesis (LET) and intra-articular anterior cruciate ligament (ACL) reconstruction (ACLR) in addressing the high-grade pivot-shift phenomenon.

METHODS

The PubMed/Medline database was searched for articles reporting clinical outcomes of combined LET and intra-articular ACLR in treating ACL injuries with high-grade pivot shift. High-grade pivot shift was defined as the presence of moderate to severe rotational instability shown by a grade II or III manual pivot shift preoperatively (grade 0, normal; grade I, glide; grade II, clunk; and grade III, locking, according to International Knee Documentation Committee [IKDC] form). The postoperative manual pivot-shift grading during the clinical follow-up visit was the primary outcome variable. Moreover, the prevalence of residual pivot shift (grade I, II, or III), distribution of objective IKDC scores, and anterior knee stability were also compared between patients with and without an additional LET procedure.

RESULTS

Seven studies were included. Overall, 326 patients (326 knees) with high-grade pivot shift underwent combined LET and intra-articular ACLR with a mean follow-up period of 46.2 months (range, 24 to 76 months). There were 274 patients (84.1%) with grade 0, 42 (12.9%) with grade I, and 10 (3.0%) with grade II pivot shift at the final follow-up. Among the 5 comparative studies, the prevalence of residual pivot shift was significantly lower (P < .05) in patients with LET plus ACLR (13.3%, 30 of 226) than those with isolated ACLR (27.2%, 67 of 246). However, the distribution of objective IKDC scores and anterior knee stability showed no significant differences between groups.

CONCLUSIONS

The combination of LET and intra-articular ACLR was effective in eliminating the high-grade pivot-shift phenomenon. For ACL injuries with high-grade pivot shift, LET plus ACLR provided a significant reduction in the prevalence of residual pivot shift but no differences in objective IKDC scores and anterior knee stability compared with isolated ACLR at short-term follow-up.

LEVEL OF EVIDENCE

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

Comparison of Graft Failure Rate Between Autografts Placed via an Anatomic Anterior Cruciate Ligament Reconstruction Technique: A Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND

Recent data from the Danish anterior cruciate ligament (ACL) registry demonstrated increased reoperation rates for hamstring tendon autografts when an anatomic ACL reconstruction is performed. This is consistent with reports of greater time needed for hamstring tendon autografts to mature compared with other autografts.

PURPOSE

To review the literature comparing graft failure rate between patellar and hamstring tendon autografts placed anatomically and to determine if there are differences in return to preinjury activity levels between autografts.

STUDY DESIGN

Systematic review with meta-analysis and meta-regression.

METHODS

The PubMed, MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies published from January 1, 2000, through March 7, 2014. To compare postoperative outcomes between patellar tendon and hamstring tendon autografts, summary event rates for graft failure and return to preinjury activity level were calculated. A meta-analysis was performed to calculate a summary odds ratio (OR) for graft failure between autografts using the studies that directly compared the 2 autografts. Meta-regression analyses were performed to assess the influence of postoperative follow-up time on graft failure rate.

RESULTS

A total of 28 studies reported graft failures for patellar tendon (6 studies) and hamstring tendon (26 studies) autografts used with anatomic ACL reconstruction; 4 of the 28 were comparison studies. Graft failure rate was not significantly different between patellar tendon (7.0% [95% CI, 4.6%-10.5%]) and hamstring tendon autografts (3.9% [95% CI, 2.7%-5.6%]). The odds of graft failure were slightly higher for hamstring tendon autografts (OR, 1.21 [95% CI, 0.63-2.33]), but this difference was not significant (P = .57). The rate of patients returning to preinjury activity levels was not significantly different between patellar (n = 1 study; 58.1% [95% CI, 40.4%-73.9%]) and hamstring tendon autografts (n = 5 studies; 75.6% [95% CI, 43.7%-92.5%]). Overall graft failure rate was positively associated with postoperative follow-up time, but this effect was only significant with hamstring tendon autografts (P < .05).

CONCLUSION

Differences in graft failure rate between patellar tendon and hamstring tendon autografts were not significant. Although follow-up time was only found to have a significant influence on hamstring tendon graft failure rates, this was likely due to the smaller sample of studies assessing patellar tendon graft failures. Differences in return to preinjury activity levels could not be determined due to the lack of studies assessing that outcome. Both patellar and hamstring tendon autografts demonstrate a low risk of failure and moderately high return to activity level after anatomic ACL reconstruction.

A systematic review of single- versus double-bundle ACL reconstruction using the anatomic anterior cruciate ligament reconstruction scoring checklist

PURPOSE

The aim of this systematic review was to apply the anatomic ACL reconstruction scoring checklist (AARSC) and to evaluate the degree to which clinical studies comparing single-bundle (SB) and double-bundle (DB) ACL reconstructions are anatomic.

METHODS

A systematic electronic search was performed using the databases PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to January 2014 comparing SB and DB ACL reconstructions with clinical outcome measurements were included. The items from the AARSC were recorded for both the SB and DB groups in each study.

RESULTS

Eight-thousand nine-hundred and ninety-four studies were analysed, 77 were included. Randomized clinical trials (29; 38%) and prospective comparative studies (29; 38%) were the most frequent study type. Most studies were published in 2011 (19; 25%). The most commonly reported items for both SB and DB groups were as follows: graft type (152; 99%), femoral and tibial fixation method (149; 97% respectively), knee flexion angle during graft tensioning (124; 8%) and placement of the tibial tunnel at the ACL insertion site (101; 66%). The highest level of documentation used for ACL tunnel position for both groups was often one dimensional, e.g. drawing, operative notes or o'clock reference. The DB reconstruction was in general more thoroughly reported. The means for the AARSC were 6.9 ± 2.8 for the SB group and 8.3 ± 2.8 for the DB group. Both means were below a proposed required minimum score of 10 for anatomic ACL reconstruction.

CONCLUSIONS

There was substantial underreporting of surgical data for both the SB and DB groups in clinical studies. This underreporting creates difficulties when analysing, comparing and pooling results of scientific studies on this subject.

Complex function of the knee joint: the current understanding of the knee

Since the early years of orthopaedics, it is a well-known fact that anatomy follows function. During the evolution of mankind, the knee has been optimally adapted to the forces and loads acting at and through the knee joint. However, anatomy of the knee joint is variable and the only constant is its complex function. In contrast to the time of open surgery, nowadays the majority of reconstructive knee surgery is done arthroscopically. Keyhole surgery is less invasive, but on the backside, the knee surgeon lacks daily visualisation of the complex open anatomy. As open anatomical knowledge is less present in our daily practice, it is even more important to highlight this complex anatomy and function of the knee. It is the purpose of this review to perform a systematic review of knee anatomy, highlight the complex function of the knee joint and present an overview about recent and current knowledge about knee function. Level of evidence Systematic review, Level IV.

Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature

PURPOSE

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction would provide greater control of rotational laxity and improved clinical outcomes compared with ACL reconstruction alone.

METHODS

Two independent reviewers searched 9 databases for randomized and nonrandomized clinical studies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All years and 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focused on biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the Cochrane Collaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MEDmetric, San Diego, CA), and International Knee Documentation Committee scores.

RESULTS

The literature search yielded 3,612 articles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met the inclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the results were nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of the ACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. A meta-analysis showed a statistically significant difference for the pivot-shift test (P = .002, I2 = 34%) in favor of ACL reconstruction with LET. No difference was found between the groups for International Knee Documentation Committee scores (P = .75, I2 = 19%) and KT-1000/-2000 measurements (P = .84, I2 = 34%).

CONCLUSIONS

Meta-analysis showed a statistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficient internal validity, sample size, methodologic consistency, and standardization of protocols and outcomes.

LEVEL OF EVIDENCE

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

Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis

BACKGROUND

ACL reconstruction aims to restore knee function and stability; however, rotational stability may not be completely restored by use of standard intraarticular reconstruction alone. Although individual studies have not shown the superiority of combined ACL reconstruction compared with isolated intraarticular reconstruction in terms of function and stability, biomechanical principles suggest a combined approach may be helpful, therefore pooling (meta-analyzing) the available randomized clinical studies may be enlightening.

QUESTIONS/PURPOSES

We performed a meta-analysis to determine whether combining extraarticular with intraarticular ACL reconstruction would lead to: (1) similar knee function measured by the IKDC evaluation, return-to-activity, and Tegner Lysholm scores, compared with isolated intraarticular reconstruction; (2) increased stability measured by pivot shift and instrumented Lachman examination; and (3) any differences in complications and adverse events?

METHODS

To identify randomized controlled trials (RCTs) comparing combined intra- and extrarticular ACL reconstruction (combined reconstruction) with intraarticular ACL reconstruction only, we searched MEDLINE, EMBASE, SPORTDiscus, Latin American and Caribbean Health Sciences (LILACS), and the Cochrane Central Register of Controlled Trials, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The main outcomes we sought were patient function and stability and complications after ACL reconstruction. Of 386 identified studies, eight RCTs were included (n=682 participants; followup, 12-84 months; men to women ratio, 2.17:1) in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, we found a moderate quality of evidence of the included studies.

RESULTS

When functional outcomes were compared, we found no difference between patients who underwent intraarticular ACL reconstruction only and those who underwent combined reconstruction (IKDC, return-to-activity, and Tegner Lysholm scores). However, patients who underwent combined reconstruction were more likely to show improved stability based on the pivot shift test (risk ratio [RR], 0.95; 95% CI, 0.91-0.99; p=0.02) and Lachman test (RR, 0.93; 95% CI, 0.88-0.98; p=0.01). In addition, our meta-analysis found no difference between the two treatments in terms of general complications or adverse events (RR, 1.31; 95% CI, 0.70-2.34; p=0.40) and the proportion of patients whose reconstructions failed (RR, 2.88; 95% CI, 0.73-11.47; p=0.13).

CONCLUSION

Combined intra- and extraarticular ACL reconstruction provided marginally improved knee stability and comparable failure rates but no difference in patient-reported functional outcomes scores. Complications and adverse events such as knee stiffness may be underreported and technical factors such as graft placement were difficult to evaluate. Future studies are needed to determine whether the small differences in additional stability warrant the potential morbidity of the additional extraarticular procedure and to determine long-term failure rates.

Preservation of hamstring tibial insertion in anterior cruciate ligament reconstruction: a review of the current literature

Hamstring graft (HG) used in anterior cruciate ligament (ACL) reconstruction undergoes a biological modification process called "ligamentization" in the early postoperative period that proceeds through three different phases: an early graft-healing phase with central graft necrosis, a phase of proliferation, and finally, a ligamentization phase toward the properties of the intact ACL. The fastening of this process could result in more aggressive rehabilitation protocols as well as faster sport resumption. A recent literature supports the preservation of HG tibial attachment in order to enhance "ligamentization" process. Aim of this literature review is to describe all the techniques described that spare HG tibial insertion and the obtained results in order to evaluate evidence that would substantiate the maintenance of HG tibial insertion in ACL reconstruction. A search was performed using the following keywords "ACL reconstruction" in combination with "hamstrings," "hamstrings insertion," "tibial insertion," "ligamentization," and "over the top"; 18 articles were found to be relevant. Among these, eight randomized clinical trials (RCTs) were found. The RCT analyzed presented a high number of biases regarding the analyzed topic, thus making impossible to draw definitive evidences to validate HG tibial insertion sparing in ACL reconstruction. Despite the satisfactory results in many clinical series and the promising results in anatomic and animal studies, well-designed prospective clinical trials with large cohort of patients associated with MRI evaluation are mandatory to assess the beneficial effects of HG attachment preservation in ACL reconstruction.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

PURPOSE

Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.

METHODS

We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.

CONCLUSIONS

The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.

LEVEL OF EVIDENCE

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

No difference in revision rates between single- and double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish national knee ligament register

PURPOSE

The purpose was to compare revision rates and patient-reported outcomes between single- and double-bundle anterior cruciate ligament (ACL) reconstructions.

METHODS

All patients from the Swedish National Knee Ligament Register from 2005 through 2011 who underwent primary ACL reconstruction with hamstring autografts were included. Patients with concomitant injuries, except meniscal and chondral injuries, were excluded. By December 31, 2011, 16,791 primary isolated ACL reconstructions had been registered, of which 16,281 were single-bundle and 510 were double-bundle. Cumulative revision rates were estimated using Kaplan-Meier analysis. The Knee injury and Osteoarthritis Outcome Score (KOOS) and EQ-5D were calculated at 1- and 2-year follow-ups.

RESULTS

The revision rate showed no statistically significant differences between the groups (P = .30). Over the 7-year observation period, 347 single-bundle (2.1%) and 8 double-bundle (1.6%) ACL reconstructions were revised. No significant differences in the KOOS or EQ-5D were found between the groups postoperatively. In addition, there were no differences in postoperative improvements in the KOOS or EQ-5D at 1- and 2-year follow-ups.

CONCLUSIONS

Revision rates after single- and double-bundle ACL reconstructions were low. No differences were found in revision rates, KOOS, and EQ-5D between the 2 techniques.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Is double-bundle anterior cruciate ligament reconstruction superior to single-bundle? A comprehensive systematic review

PURPOSE

To describe current evidence on single- and double-bundle anterior cruciate ligament (ACL) reconstruction, in terms of differences in knee kinematics, functional outcomes, patient-reported outcomes and graft failures.

METHODS

An electronic search was made using PubMed (MEDLINE), EMBASE and Cochrane Library. Studies published from January 1995 to August 2011 were included, and an updated search was made in PubMed in July 2012. Therapeutic studies, level of evidence I-III, for isolated primary ACL tears written in English comparing single- and double-bundle reconstruction reporting clinical outcome were included. Quality appraisal based on Cochrane Collaboration's tool for assessing risk of bias was performed.

RESULTS

Of 7,154 potentially eligible studies, 60 papers were included (25 randomised controlled trials, 21 prospective comparative studies, 14 retrospective comparative studies), comprising 4,146 patients (2,072 single-bundle, 2,074 double-bundle). Minor differences were found between study types. An analysis of graft failures revealed fewer re-ruptures in double-bundle reconstruction than single-bundle, 19 and 44, respectively. Up to 45 % of the studies reported a superior outcome in double-bundle reconstruction in terms of antero-posterior laxity, measured with the Lachman, anterior drawer, KT-1000/2000 and navigation. Measurements of rotatory laxity revealed superior results in double-bundle reconstruction measured with pivot shift and navigation in 18/42 (8/15 anatomically reconstructed) and 9/20 studies, respectively. Patient-reported outcome measures and functional outcomes did not differ to a large extent; however, differences when identified were almost exclusively in favour of double-bundle reconstruction.

CONCLUSION

Based on current evidence, double-bundle reconstruction appears to have fewer re-ruptures and less antero-posterior and rotatory laxity. Furthermore, no differences were found in short-term patient-reported outcome measures or objective findings. However, detailed statistical analyses of the included studies divided into homogeneous groups are needed to avoid reporting bias and to confirm any statistical difference.

Mid- to long-term results of single-bundle versus double-bundle anterior cruciate ligament reconstruction: randomized controlled trial

PURPOSE

To evaluate the mid-to long-term results of a randomized controlled trial of single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a semitendinosus tendon.

METHODS

Seventy-eight patients who underwent primary ACL reconstruction with an autologous semitendinosus tendon were prospectively randomized into 2 groups: SB reconstruction (n = 39) and DB reconstruction (n = 39). In both groups, grafts were fixed at 30° of flexion with a total tension of 80 N. The following evaluation methods were used: clinical examination, KT-1000 arthrometer (MEDmetric, San Diego, CA) measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery.

RESULTS

Fifty-three patients (25 in SB group and 28 in DB group) who were followed up for a minimum of 3 years (mean, 69 months; range, 36 to 140 months) were evaluated. Preoperatively, there were no differences between the groups. Postoperatively, the Lachman and pivot-shift test results were better in the DB group (P = .024 and P < .0001, respectively). KT measurements were better in the DB group (mean, 1.4 mm v 2.7 mm; P = .0023). The Tegner score was also better in the DB group (P = .033). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear.

CONCLUSIONS

In ACL reconstruction using the transtibial approach, DB reconstruction was significantly better than SB reconstruction regarding anterior and rotational stability during the 3- to 12-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the DB group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the DB group; however, there were no differences in the other subjective findings.

LEVEL OF EVIDENCE

Level II, lesser-quality prospective randomized trial.

Effect of tunnel placements on clinical and magnetic resonance imaging findings 2 years after anterior cruciate ligament reconstruction using the double-bundle technique

PURPOSE

The purpose of the study reported here was to find out if the clinical and magnetic resonance imaging (MRI) findings of a reconstructed anterior cruciate ligament (ACL) have an association. Our hypothesis, which was based on the different functions of the ACL bundles, was that the visibility of the anteromedial graft would have an impact on anteroposterior stability, and the visibility of the posterolateral graft on rotational stability of the knee.

METHODS

This study is a level II, prospective clinical and MRI study (NCT02000258). The study involved 75 patients. One experienced orthopedic surgeon performed all double-bundle ACL reconstructions. Two independent examiners made the clinical examinations at 2-year follow-up: clinical examination of the knee; KT-1000, International Knee Documentation Committee and Lysholm knee evaluation scores; and International Knee Documentation Committee functional score. The MRI evaluations were made by two musculoskeletal radiologists separately, and the means of these measurements were used.

RESULTS

We found that the location of the graft in the tibia had an impact on the MRI visibility of the graft at 2-year follow-up. There were significantly more partially or totally invisible grafts if the insertion of the graft was more anterior in the tibia. No association was found between the clinical results and the graft locations.

CONCLUSION

Anterior graft location in the tibia can cause graft invisibility in the MRI 2 years after ACL reconstruction, but this has no effect on the clinical recovery of the patient.

Return to sport after anterior cruciate ligament reconstruction in professional soccer players

BACKGROUND

To investigate time to return to sport and rate of professional sport activity in a homogenous group of competitive soccer players 4 years after anterior cruciate ligament (ACL) reconstruction and rehabilitation.

METHODS

Twenty-one male professional soccer players (mean age 22.9±5.4 years) underwent non-anatomical double-bundle autologous hamstring ACL reconstruction and followed the same rehabilitative protocol. Clinical evaluation was performed preoperatively and at 3, 6 and 12-month follow-up. Data regarding return to train and official match, sport activity, complications and revision surgeries were collected at 4-year follow-up.

RESULTS

Laxity test (KT-2000) and total KOOS mean score resulted in a significant improvement from the preoperative status to the 12-month follow-up (p<0.0001). The KOOS mean value showed a significant progressive improvement from the preoperative status to 6-month follow-up (p=0.0010) as well, while values collected at 6 and 12-month follow-up were comparable (p=0.2349). Returned to official matches 186±53 days after surgery. After 12 months, 95% came back to the same activity level performed before injury. Four years after ACL reconstruction, 15 patients (71%) were still playing competitive soccer. One patient (5%) underwent ACL failure and subsequent revision.

CONCLUSIONS

The ACL reconstruction with the presented technique followed by patient-tailored rehabilitation, allowed 95% and 62% professional male soccer players to return to the same sport activity 1 year and 4 years after surgery respectively. However, 71% were still able to play competitive soccer at final follow-up. Clinical scores were restored after 6 months.

LEVEL OF EVIDENCE

IV, case series.

Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction: a systematic review, meta-analysis, and meta-regression

BACKGROUND

While numerous cadaveric, in vivo, and clinical studies have compared transtibial and independent drilling of femoral tunnels during anterior cruciate ligament reconstruction, there is no evidence-based consensus on which technique affords the best outcome.

HYPOTHESIS

There is no difference in clinical outcome between transtibial and independent drilling of femoral tunnels.

STUDY DESIGN

Systematic review with meta-analysis and meta-regression.

METHODS

Cadaveric, in vivo, and clinical studies comparing transtibial and independent drilling techniques were systematically identified. A qualitative synthesis of nonrandomized studies and meta-analysis of randomized controlled trials (RCTs) were performed. In addition, a meta-regression analysis of RCTs that did not directly compare drilling techniques was performed.

RESULTS

A total of 49 studies were included in the qualitative review, and 15 were included in the meta-analysis; 22 studies were included in the meta-regression. In biomechanical studies, independent drilling placed the center of the femoral tunnel closer to the center of the femoral footprint (mean difference, 2.69 mm; 95% CI, 0.46-4.92; P < .00001). Independent drilling reduced anterior tibial translation with the Lachman examination (mean difference, 2.2 mm; 95% CI, 0.34-4.07; P = .02), 134 N of anterior load (mean difference, 1 mm; 95% CI, 0.29-1.71; P = .006), and simulated pivot shift (mean difference, 3.36 mm; 95% CI, 1.88-4.85; P < .00001). The meta-analysis showed improved Lysholm scores with independent drilling (mean difference, -0.62 points; 95% CI, -1.09 to -0.55; P = .009), although the clinical relevance of this small difference is questionable. There were no significant differences in International Knee Documentation Committee (IKDC) objective scores or Tegner scores between groups. With the meta-regression, there were no significant differences in failure rates or IKDC objective scores.

CONCLUSION

While there are biomechanical data suggesting improved knee stability and more anatomic graft placement with independent drilling, no significant clinical differences were found between the 2 techniques.

CLINICAL RELEVANCE

The current evidence shows that transtibial and independent drilling techniques have equivalent clinical outcomes at short-term to midterm follow-up. The long-term effects of subtle differences in tunnel position and postoperative knee kinematics should be further studied in dedicated, prospective cohort and randomized studies.

Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review

BACKGROUND

As one of the purposes of anterior cruciate ligament reconstruction (ACLR) is to return athletes to their preinjury activity level, it is critical to understand variables influencing return to sport. Associations between return to sport and variables representing knee impairment, function and psychological status have not been well studied in athletes following ACLR.

PURPOSE

The purpose of this review was to summarise the literature reporting on variables proposed to be associated with return to sport following ACLR.

STUDY DESIGN

Systematic review.

METHODS

Medline, EMBASE, CINAHL and Cochrane databases were searched for articles published before November 2012. Articles included in this review met these criteria: (1) included patients with primary ACLR, (2) reported at least one knee impairment, function or psychological measure, (3) reported a return to sport measure and (4) analysed the relationship between the measure and return to sport.

RESULTS

Weak evidence existed in 16 articles suggesting variables associated with return to sport included higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher Marx Activity score, higher athletic confidence, higher preoperative knee self-efficacy, lower kinesiophobia and higher preoperative self-motivation.

CONCLUSIONS

Weak evidence supports an association between knee impairment, functional and psychological variables and return to sport. Current return to sport guidelines should be updated to reflect all variables associated with return to sport. Utilising evidence-based return to sport guidelines following ACLR may ensure that athletes are physically and psychologically capable of sports participation, which may reduce reinjury rates and the need for subsequent surgery.

"Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future

PURPOSE

The aims of this study were to provide a systematic review of the literature on "ligamentization" in hamstring tendon (HT) grafts after anterior cruciate ligament (ACL) reconstruction and analyze the postoperative remodeling process in human patients and animal models.

METHODS

We performed a search in the Medline, PubMed, Embase and The Cochrane Library databases, followed by a manual search of reference lists to identify relevant articles. Only studies that investigated the ligamentization of hamstring grafts by histologic examination and comprehensively reported on the remodeling process were deemed eligible for review.

RESULTS

A total of 4 studies were determined appropriate for systematic review: 2 of the included studies investigated human ACL grafts and 2 were performed in animal models. The studies included the examination of 79 human hamstring graft biopsy specimens and grafts of 27 skeletally mature sheep. To verify the remodeling process, authors reported on various aspects of cellularity, vascularity, and collagen organization. None of the included studies reached a level of evidence higher than 3.

CONCLUSIONS

A postoperative ligamentization process can be found in HT grafts after ACL reconstruction and shows a typical progression through 3 distinguishable remodeling phases in humans and in animal models, whereas the progression and intensity of remodeling is distinctly increased in animals.

CLINICAL RELEVANCE

Because postoperative remodeling influences biomechanical properties of hamstring grafts, a better understanding of this process and its timing could lead to substantial improvements in postoperative care strategies and indirectly to the optimization of surgical techniques.