Single-versus two-incision technique in anterior cruciate ligament replacement: influence on postoperative muscle function

Older Age, Poor Preoperative Quadriceps Muscle Strength, and Residual Pain as Risk Factors for Poor Quadriceps Muscle Strength Recovery at 1 Year After ACL Reconstruction: A TMDU MAKS Study of 402 Patients

Background

Poor postoperative quadriceps muscle strength recovery after anterior cruciate ligament reconstruction (ACLR) leads to delayed return to sports and lower patient satisfaction.

Purpose/Hypothesis

The purpose of this study was to examine factors that affect quadriceps muscle strength 1 year after ACLR. It was hypothesized that older age, poor preoperative quadriceps muscle strength, and residual pain would be risk factors for poor quadriceps muscle strength recovery.

Study Design

Case-control study; Level of evidence, 3.

Methods

Included were patients from multiple institutions who underwent primary ACLR using autologous hamstring tendon grafts between August 1, 2013, and March 31, 2018, and who had at least 1 year of follow-up data. Patients with past ligamentous injuries in the affected knee, previous injuries or operations in the contralateral knee, accompanying ligament injuries of grade 2 or 3, or inflammatory or other types of osteoarthritis were excluded. Patients were categorized as having muscle strength ≥80% (good strength recovery) or <80% (poor strength recovery) compared with the contralateral leg at 1 year postoperatively. Multivariate logistic regression analysis was performed to investigate the factors influencing postoperative quadriceps muscle strength. In addition, a categorical analysis was conducted based on factors extracted by the multivariate logistic regression analysis.

Results

A total of 402 patients were included. Multivariate logistic regression analysis revealed that age at surgery (P = .020), preoperative quadriceps muscle strength (P = .006), and postoperative Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain score (P = .002) were significantly associated with quadriceps muscle strength at 1 year postoperatively. The odds of poor muscle strength recovery according to categorical analysis were 5.0-fold higher for patients aged >40 versus ≤20 years, 4.2-fold higher for those with preoperative quadriceps muscle index <60% versus ≥80%, and 7.7-fold higher for those with a postoperative KOOS-Pain score of <85 versus 100.

Conclusion

Older age, poor preoperative quadriceps muscle strength, and low postoperative KOOS-Pain score were risk factors for poor quadriceps muscle strength 1 year after primary ACLR. Surgical indications, including age, preoperative active rehabilitation, and pain control, should be considered for optimization of postoperative quadriceps muscle strength recovery.

One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

BACKGROUND

Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint).

OBJECTIVES

To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model.

MAIN RESULTS

We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants).

AUTHORS' CONCLUSIONS

The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.

Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review

BACKGROUND

As the health care system in the United States (US) transitions toward value-based care, there is an increased emphasis on understanding the cost drivers and high-value procedures within orthopaedics. To date, there has been no systematic review of the economic literature on anterior cruciate ligament reconstruction (ACLR).

PURPOSE

To evaluate the overall evidence base for economic studies published on ACLR in the orthopaedic literature. Data available on the economics of ACLR are summarized and cost drivers associated with the procedure are identified.

STUDY DESIGN

Systematic review.

METHODS

All economic studies (including US-based and non-US-based) published between inception of the MEDLINE database and October 3, 2014, were identified. Given the heterogeneity of the existing evidence base, a qualitative, descriptive approach was used to assess the collective results from the economic studies on ACLR. When applicable, comparisons were made for the following cost-related variables associated with the procedure for economic implications: outpatient versus inpatient surgery (or outpatient vs overnight hospital stay vs >1-night stay); bone-patellar tendon-bone (BPTB) graft versus hamstring (HS) graft source; autograft versus allograft source; staged unilateral ACLR versus bilateral ACLR in a single setting; single- versus double-bundle technique; ACLR versus nonoperative treatment; and other unique comparisons reported in single studies, including computer-assisted navigation surgery (CANS) versus traditional surgery, early versus delayed ACLR, single- versus double-incision technique, and finally the costs of ACLR without comparison of variables.

RESULTS

A total of 24 studies were identified and included; of these, 17 included studies were cost identification studies. The remaining 7 studies were cost utility analyses that used economic models to investigate the effect of variables such as the cost of allograft tissue, fixation devices, and physical therapy, the percentage and timing of revision surgery, and the cost of revision surgery. Of the 24 studies, there were 3 studies with level 1 evidence, 8 with level 2 evidence, 6 with level 3 evidence, and 7 with level 4 evidence. The following economic comparisons were demonstrated: (1) ACLR is more cost-effective than nonoperative treatment with rehabilitation only (per 3 cost utility analyses); (2) autograft use had lower total costs than allograft use, with operating room supply costs and allograft costs most significant (per 5 cost identification studies and 1 cost utility analysis); (3) results on hamstring versus BPTB graft source are conflicting (per 2 cost identification studies); (4) there is significant cost reduction with an outpatient versus inpatient setting (per 5 studies using cost identification analyses); (5) bilateral ACLR is more cost efficient than 2 unilateral ACLRs in separate settings (per 2 cost identification studies); (6) there are lower costs with similarly successful outcomes between single- and double-bundle technique (per 3 cost identification studies and 2 cost utility analyses).

CONCLUSION

Results from this review suggest that early single-bundle, single (endoscopic)-incision outpatient ACLR using either BPTB or HS autograft provides the most value. In the setting of bilateral ACL rupture, single-setting bilateral ACLR is more cost-effective than staged unilateral ACLR. Procedures using CANS technology do not yet yield results that are superior to the results of a standard surgical procedure, and CANS has substantially greater costs.

Speed, not magnitude, of knee extensor torque production is associated with self-reported knee function early after anterior cruciate ligament reconstruction

PURPOSE

To examine the magnitude and speed of knee extensor torque production at the initiation of advanced anterior cruciate ligament (ACL) reconstruction rehabilitation and the associations with self-reported knee function.

METHODS

Twenty-eight subjects who were 12 weeks post-ACL reconstruction and 28 age- and sex-matched physically active controls participated in this study. Knee extensor torque was assessed bilaterally with an isokinetic dynamometer at 60°/s. The variables of interest were peak torque, average rate of torque development, time to peak torque and quadriceps symmetry index. Knee function was assessed with the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF).

RESULTS

Peak torque and average rate of torque development were lower on the surgical side compared to the non-surgical side and controls. Quadriceps symmetry index was lower in subjects with ACL reconstruction compared to controls. On the surgical side, average rate of torque development was positively correlated with IKDC-SKF score (r = 0.379) while time to peak torque was negatively correlated with IKDC-SKF score (r = -0.407).

CONCLUSIONS

At the initiation of advanced ACL reconstruction rehabilitation, the surgical side displayed deficits in peak torque and average rate of torque development. A higher rate of torque development and shorter time to peak torque were associated with better self-reported knee function. The results suggest that the rate of torque development should be addressed during advanced ACL reconstruction rehabilitation and faster knee extensor torque generation may lead to better knee function.

LEVEL OF EVIDENCE

III.

The function of the human anterior cruciate ligament and analysis of single- and double-bundle graft reconstructions

CONTEXT

There exists controversy on the ability of a single or double anterior cruciate ligament graft technique to restore anterior cruciate ligament function. This article examines the published experimental and clinical data supporting these surgical procedures in the ability to restore knee stability.

EVIDENCE ACQUISITION

An analysis of anterior cruciate ligament function and single- and double-graft reconstructions defined by selected biomechanical, robotic, kinematic, anatomical, and clinical studies.

RESULTS

The anterior cruciate ligament resists the combined motions of anterior tibial translation and internal tibial rotation, which defines the concept of rotational stability. This function prevents anterior tibial subluxation of the lateral and medial tibiofemoral compartments that accounts for the pivot-shift phenomena. The placement of single anterior cruciate ligament grafts high and proximal at the femoral attachment and posterior at the tibial attachment results in a vertical graft orientation. This graft placement results in a limited ability to provide rotational stability and is inferior when compared to a double-bundle graft procedure. Studies show that a more oblique single-graft orientation, in the sagittal and coronal plane, achieved from a central anatomic femoral and tibial location provides rotational stability similar to a double-bundle anterior cruciate ligament graft.

CONCLUSION

There exists insufficient experimental and clinical data to recommend the more complex double-bundle anterior cruciate ligament graft technique over a well-placed central anatomic single graft in terms of restoring knee rotational stability. Meticulous surgical technique for anterior cruciate ligament graft placement is necessary to avoid failure.

Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique

The anterior cruciate ligament has been and is of great interest to scientists and orthopaedic surgeons worldwide. Anterior cruciate ligament reconstruction was initially performed using an open approach. When the approach changed from open to arthroscopic reconstruction, a 2- and, later, 1-incision technique was applied. With time, researchers found that traditional arthroscopic single-bundle reconstruction did not fully restore rotational stability of the knee joint and a more anatomic approach to reconstruct the anterior cruciate ligament has been proposed. Anatomic anterior cruciate ligament reconstruction intends to replicate normal anatomy, restore normal kinematics, and protect long-term knee health. Although double-bundle anterior cruciate ligament reconstruction has been shown to result in better rotational stability in both biomechanical and clinical studies, it is vital to differentiate between anatomic and double-bundle anterior cruciate ligament reconstruction. The latter is merely a step closer to reproducing the native anatomy of the anterior cruciate ligament; however, it can still be done nonanatomically. To evaluate the potential benefits of reconstructing the anterior cruciate ligament in an anatomic fashion, accurate, precise, and reliable outcome measures are needed. These include, for example, T2 magnetic resonance imaging mapping of cartilage and quantification of graft healing on magnetic resonance imaging. Furthermore, there is a need for a consensus on which patient-reported outcome measures should be used to facilitate homogeneous reporting of outcomes.

ACL injury and surgical treatment options

The anterior cruciate ligament (ACL) has been the focus of a substantial amount of research. Thousands of studies have evaluated the structure and function of the intact ACL, as well as the best reconstruction techniques. Despite the amount of literature, many controversies remain regarding the ACL and its surgical reconstruction. This article reviews the anatomy and function of the native ACL, the nature of injury, and aspects of ACL reconstruction, including surgical approach, tunnel positioning, graft choice, and graft fixation.

Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstructions

BACKGROUND

Anterior cruciate ligament reconstruction employing transtibial tunnel techniques may result in less than ideal femoral and tibial vertical graft placement, with a residual pivot shift and instability symptoms.

HYPOTHESIS

Nonanatomical graft placement is highly prevalent among knees with failed primary and revision anterior cruciate ligament grafts.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 122 consecutive patients presented to the authors' center with a failed anterior cruciate ligament reconstruction. Radiographs, magnetic resonance imaging, and operative reports were used to define graft placement. Arthroscopic confirmation of graft placement was obtained in 92 knees during subsequent revision surgery. A nonanatomical graft placement was assigned when ≥50% of the graft was outside of the native tibial and femoral insertions. All patients prospectively completed Cincinnati Knee Rating System questionnaires.

RESULTS

A nonanatomical graft placement occurred in 107 of 122 (88%) knees; 61% of the grafts were entirely on the intercondylar femoral roof, and 35% extended posterior to the anterior cruciate ligament tibial attachment. A transtibial technique had been used in 83%. The mean values for the coronal and sagittal graft placement showed a significantly increased vertical orientation in comparison with a control group (P < .01). Forty-two of the 107 nonanatomical grafts had undergone 1 or more revisions without correction of the misplaced graft tunnels, and these subsequently failed.

CONCLUSION

The occurrence of nonanatomical graft placement in primary and revision knees may represent an inadequacy of transtibial tunnel drilling techniques to obtain graft placement within the native femoral and tibial footprints. In revision cases, the prior graft location requires close scrutiny so the new graft tunnels are placed at the native anterior cruciate ligament attachments. Independent drilling of tibial and femoral tunnels is recommended using either 2-incision or anteromedial portal techniques.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.

Scientific justification and technique for anterior cruciate ligament reconstruction using autogenous and allogeneic soft-tissue grafts

The DLSTG is the strongest and stiffest autogenous graft source available for reconstruction of the torn anterior cruciate ligament. Harvest morbidity is low compared with other autogenous graft sources, such as the patellar bone-tendon-bone graft. Soft-tissue allografts provide an excellent alternative for patients requiring revision surgery or for patients who want to avoid any morbidity associated with autogenous graft harvest. Successful use of any soft-tissue graft source, however, relies on precise placement of the tibial and femoral tunnels to prevent roof and PCL impingement and to restore tensile behavior in the graft tissue similar to the native ACL. The use of high-strength, high-stiffness fixation devices that secure the graft at the end of the tunnel promote tendon tunnel healing, restore stability without high graft tensioning, and allow safe, aggressive rehabilitation. The Bone Mulch Screw/WasherLoc screw system provides the surgeon with a consistent, reproducible technique that restores stability and function to the ACL-deficient knee using a soft-tissue graft in both males and females.

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

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