Cost-effectiveness of anterior cruciate ligament reconstruction: a preliminary comparison of single-bundle and double-bundle techniques

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Is Not Superior to Anatomic Single-Bundle Reconstruction at 10-Year Follow-up: A Randomized Clinical Trial

BACKGROUND

The anatomic double-bundle (DB) technique is purported to be a superior technique due to its mimicking of the double-stranded anatomic formation of the anterior cruciate ligament (ACL). Previous studies with 2-, 5- and 10-year follow-up are conflicted as to whether this technique is superior to the previous gold standard method of ACL reconstruction, the anatomic single-bundle (SB) reconstruction.

PURPOSE/HYPOTHESIS

The aim of this prospective randomized study was to compare the outcomes of the anatomic DB technique and anatomic SB technique with independent drilling at 10 years after anterior cruciate ligament (ACL) reconstruction. We hypothesized that DB ACL reconstruction would result in a better outcome in terms of the pivot-shift test.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 105 patients (33 women, 72 men; median age, 27 years [range, 18-52 years]) were randomized and underwent ACL reconstruction (DB group: n = 53; SB group: n = 52). All reconstruction procedures were performed anatomically by identifying the ACL footprint, using the anteromedial portal for femoral tunnel drilling, and utilizing interference screws for tibial and femoral fixation. One blinded observer examined the patients both preoperatively and at follow-up (median, 120 months [range, 112-134 months]). Multiple subjective and objective clinical evaluations were used to assess the outcomes. Radiographic assessments of osteoarthritis were performed using the Ahlbäck, Kellgren-Lawrence, and Fairbank classification systems early postoperatively and at the final follow-up.

RESULTS

Preoperatively, no differences were found between the study groups. Overall, 70 patients (67%; DB group: n = 39; SB group: n = 31) were available for analysis at 10-year follow-up. No significant difference could be shown between the groups in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, single-leg hop test result, range of motion measurements, Lysholm knee score, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score (KOOS) score. Correspondingly, no differences were found between the groups regarding the presence of radiographic osteoarthritis at follow-up. Both groups improved at follow-up compared with preoperatively in terms of the pivot-shift grade, knee laxity measurements using the KT-1000 arthrometer, manual Lachman grade, Lysholm knee score, and KOOS score (P < .05 [highest P value for any comparison]).

CONCLUSION

The anatomic DB technique was not superior to the anatomic SB technique with independent drilling at 10-year follow-up in regard to objective and subjective measurements. As such, one could argue that there is no need for the continued use of the anatomic DB technique in an unselected population.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

OBJECTIVE

Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

DESIGN

Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

ELIGIBILITY

Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

RESULTS

Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

CONCLUSION

There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Comparison of mechanical properties in interference screw fixation technique and organic anterior cruciate ligament reconstruction method: a biomechanical study

BACKGROUND

Bone and Site Hold Tendon Inside (BASHTI) technique is an organic implant-less technique for anterior cruciate ligament (ACL) reconstruction with some clinical advantages, such as speeding up the healing process, over implantable techniques. The study aims to compare the mechanical properties of BASHTI technique with the conventional interference screw technique.

METHODS

To investigate the mechanical properties, 20 in-vitro experimental tests were conducted. Synthetic dummy bone, along with fresh digital bovine tendons, as a graft, were used for experiments. Three loading steps were applied to all specimens, including a preconditioning, a main cyclic, and a pull-out loading.

RESULTS

The mechanical characters of an interference screw technique using an 8 mm tendon diameter, including fixation strength, average cyclic stiffness (ACS), and average pull-out stiffness (APS) were found to be 439 ± 132 N, 10.3 ± 5.3 kN/mm, and 109 ± 40 N/mm, respectively. In the case of an interference screw using a 9 mm tendon, the fixation strength, ACS, and APS were obtained 549 ± 87 N, 10.3 ± 4.7 kN/mm, and 91 ± 13 N/mm, respectively. In parallel, the fixation strength, APS, and ACS of BASHTI technique using an 8 mm tendon were 360 ± 123 N, 3.3 ± 0.6 kN/mm, and 79 ± 27 N/mm, respectively, while, for 9 mm tendon 278 ± 103 N, 2.4 ± 1.2 kN/mm, and 111 ± 40 N/mm, were reported for fixation strength, APS, and ACS respectively when BASHTI technique was used.

CONCLUSION

About 50% of interference screw samples showed superior mechanical properties compared to BASHTI technique, but in another half of the samples, the differences were not significant (N.S.). However, due to organic advantages of BASHTI technique and lower cost, it could be used as a substitute for interference screw technique, especially where fast recovery is expected.

Association between knee symptoms, change in knee symptoms over 6-9 years, and SF-6D health state utility among middle-aged Australians

OBJECTIVES

Health state utilities (HSUs) are an input metric for estimating quality-adjusted life-years (QALY) in cost-utility analyses. Currently, there is a paucity of data on association of knee symptoms with HSUs for middle-aged populations. We aimed to describe the association of knee symptoms and change in knee symptoms with SF-6D HSUs and described the distribution of HSUs against knee symptoms' severity.

METHODS

Participants (36-49-years) were selected from the third follow-up (completed 2019) of Australian Childhood Determinants of Adult Health study. SF-6D HSUs were generated from the participant-reported SF-12. Association between participant-reported WOMAC knee symptoms' severity, change in knee symptoms over 6-9 years, and HSUs were evaluated using linear regression models.

RESULTS

For the cross-sectional analysis, 1,567 participants were included; mean age 43.5 years, female 54%, BMI ± SD 27.18 ± 5.31 kg/m². Mean ± SD HSUs for normal, moderate, and severe WOMAC scores were 0.820 ± 0.120, 0.800 ± 0.120, and 0.740 ± 0.130, respectively. A significant association was observed between worsening knee symptoms and HSUs in univariable and multivariable analyses after adjustment (age and sex). HSU decrement for normal-to-severe total-WOMAC and WOMAC-pain was - 0.080 (95% CI - 0.100 to - 0.060, p < 0.01) and - 0.067 (- 0.085 to - 0.048, p < 0.01), exceeding the mean minimal clinically important difference (0.04). Increase in knee pain over 6-9 years was associated with a significant reduction in HSU.

CONCLUSION

In a middle-aged population-based sample, there was an independent negative association between worse knee symptoms and SF-6D HSUs. Our findings may be used by decision-makers to define more realistic and conservative baseline and ongoing HSU values when assessing QALY changes associated with osteoarthritis interventions.

Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment

BACKGROUND

The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions.

PURPOSE

To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions.

RESULTS

A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified.

CONCLUSION

The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.

Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study

OBJECTIVES

To describe feasibility, adherence, acceptability, and outcomes of a cognitive-behavioral-based physical therapy (CBPT-ACLR) intervention for improving postoperative recovery after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Pilot study.

SETTING

Academic medical center.

PARTICIPANTS

Eight patients (mean age [SD] = 20.1 [2.6] years, 6 females) participated in a 7-session telephone-based CBPT-ACLR intervention beginning preoperatively and lasting 8 weeks after surgery.

MAIN OUTCOME MEASURES

At 6 months, patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life (QOL) subscales, International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), and Knee Self-Efficacy Scale (K-SES), return to sport (Subjective Patient Outcome for Return to Sports), and satisfaction. Minimal clinically important difference (MCID) was used for meaningful change.

RESULTS

Seven (88%) patients completed all sessions. Seven (88%) patients exceeded MCID on the TSK, 6 (75%) on the PCS, 5 (63%) on the KOOS sports/recreation subscale, 4 (50%) on the IKDC, and 3 (38%) on the KOOS QOL subscale. Three (38%) patients returned to their same sport at the same level of effort and performance. All patients were satisfied with their recovery.

CONCLUSIONS

A CBPT-ACLR program is feasible and acceptable for addressing psychological risk factors after ACLR.

Impaired neuromuscular control up to postoperative 1 year in operated and nonoperated knees after anterior cruciate ligament reconstruction

The current study was performed to assess serial changes in neuromuscular control until 1 year postoperatively in nonathletic patients undergoing anterior cruciate ligament reconstruction (ACLR).Ninety-six patients were included. Serial neuromuscular control tests were performed preoperatively, at 6 months, and 1 year postoperatively. Neuromuscular control was evaluated using acceleration time (AT) and dynamic postural stability (overall stability index, OSI). Functional activity levels were assessed using the Tegner activity-level scale.Preoperative AT of quadriceps and hamstrings in operated knees was 78.9 ± 6.4 and 86.5 ± 6.2 ms, respectively, which significantly reduced to 56.9 ± 2.0 and 62.5 ± 2.8 ms at 1 year (P = 0.006 and 0.002, respectively). In nonoperated knees, preoperative AT of quadriceps and hamstrings was 47.6 ± 1.7 and 56.5 ± 1.7 ms, respectively, which was significantly prolonged to 54.3 ± 2.0 and 67.9 ± 2.7 ms at 1 year (P = 0.02 and 0.001, respectively). Preoperative OSI of nonoperated knees was 1.2 ± 0.0°. It significantly increased to 1.5 ± 0.1° at 1 year (P < 0.001). In operated knees, preoperative OSI was 1.8 ± 0.1°. It significantly decreased to 1.4 ± 0.1° at 1 year (P = 0.001). Tegner scale at 6 months and 1 year were significantly lower than pre-operative scale (P < 0.001). AT and OSI on both knees showed significant negative correlation with Tegner scale at 6 months and 1 year.Neuromuscular control in both knees was not restored to preoperative levels of the nonoperated knees until 1 year after ACLR. Therefore, clinicians and physical therapists should attempt to enhance neuromuscular control in both nonoperated and operated knees.

Cost-effectiveness of treatments for non-osteoarthritic knee pain conditions: A systematic review

INTRODUCTION

Knee pain is common in adolescents and adults and is associated with an increased risk of developing knee osteoarthritis. The aim of this systematic review was to gather and appraise the cost-effectiveness of treatment approaches for non-osteoarthritic knee pain conditions.

METHOD

A systematic review was conducted according to the PRISMA guidelines and registered on PROSPERO (CRD42016050683). The literature search was done in MEDLINE via PubMed, EMBASE, The Cochrane Library, and the National Health Service Economic Evaluation Database. Study selection was carried out by two independent reviewers and data were extracted using a customized extraction form. Study quality was assessed using the Consensus on Health Economic Criteria list.

RESULTS

Fifteen studies were included. The majority regarded the treatment of anterior cruciate ligament (ACL) injuries, but we also identified studies evaluating other knee pain conditions such as meniscus injuries, cartilage defects, and patellofemoral pain syndrome. Study interventions were categorized as surgical or non-surgical interventions. The surgical interventions included ACL reconstruction, chondrocyte implantation, meniscus scaffold procedure, meniscal allograft transplantation, partial meniscectomy, microfracture, and different types of autografts and allografts. The non-surgical management consisted of physical therapy, rehabilitation, exercise, counselling, bracing, and advice. In general, for ACL injuries surgical management alone or in combination with rehabilitation appeared to be cost-effective. The quality of the economic evaluations was of moderate to high quality.

CONCLUSION

There was insufficient evidence to give a firm overview of cost-effective interventions for non-osteoarthritic knee pain, but surgical treatment of acute ACL injury appeared cost-effective. There is very little data regarding the cost-effectiveness of non-surgical interventions for non-traumatic knee conditions.

Anterolateral Complex Reconstruction: Another Fad or Method to Improve ACL Outcomes?

Anterolateral rotational laxity of the knee is a persistent problem following anterior cruciate ligament reconstruction (ACLR) that can lead to increased rates of graft failure. Renewed interest in the anterolateral complex of the knee has led to a resurgence in the use of adjunctive techniques such as lateral extra-articular tenodesis and anterolateral ligament reconstruction. Use of these techniques can restore normal knee kinematics and potentially thereby reduce the rate of graft failure. Historically, experience with modified ACLR techniques such as the double-bundle ACLR have shown that improved biomechanics is not always reflected in clinical outcome trials. Additional procedures also come with additional costs and further economic analysis needs to be performed to clarify whether these additional costs are offset by improved clinical and societal outcomes in the longer-term.

Limb asymmetry during recovery from anterior cruciate ligament reconstruction

There is limited literature that follows a population of Anterior Cruciate Ligament Reconstruction (ACLR) patients through recovery. Our aim was to examine differences in movement and loading patterns across time and between limbs over four visits during 12 months post-ACLR. We hypothesized that kinematic and kinetic data during a stop-jump would have time- and limb-dependent differences through 12 months post-surgery. Twenty-three ACLR athletes performed five vertical stop-jumps at 4, 5, 6, and 12 months post-op with motion capture and force plate data collection. The peak knee flexion (PKF) was different between the 4 and 12, 5 and 6, and the 5 and 12 month visits with earlier months exhibiting higher PKF. The peak vertical ground reaction force (vGRF) was lower at 4 than at 5 and 6 months. The peak posterior ground reaction force (pGRF) was lower at 4 months than all other visits. Frontal knee and sagittal hip range of motion (ROM) were different between 12 months and each previous visit. Asymmetries were present in peak vGRF, peak knee extension moment and impulse up to 12 months. The loading rate and peak pGRF demonstrated between limb differences up to 6 months; limb stiffness demonstrated differences up to 5 months post-ACLR. PKF was only asymmetric at the 4 month visit. While some variables improved in the 12 months post-ACLR, limb asymmetries in peak knee extension moment, peak vGRF and impulse persisted up to 12 months. Additionally, frontal plane knee and sagittal hip ROM had not normalized at 12 months. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1887-1893, 2018.

Parathyroid hormone-(1–34) ameliorated knee osteoarthritis in rats via autophagy

Anterior cruciate ligament (ACL) tear can lead to osteoarthritis (OA). However, parathyroid hormone (PTH)-(1–34) was found to alleviate OA progression in a papain-induced OA model. Autophagy is a protective mechanism in normal cartilage, and its aging-related loss is linked with chondrocyte death and OA. Thus we examined the roles of autophagy in PTH treatment in OA after ACL transection (ACLT). Thirty-six rats were randomized into three groups: control group, ACLT-induced OA (OA) group, and OA with intra-articular PTH-(1–34) treatment (OA+PTH) group. Weight-bearing and treadmill tests were evaluated. Cartilage matrix was determined by a histological evaluation of glycosaminoglycan (GAG), Osteoarthritis Research Society International (OARSI) score, chondrocyte apoptosis, and immunohistochemistry. Rats in the OA group had significantly decreased weight bearing and running endurance. The histological results indicated that GAG, collagen type II, and chondrocyte autophagy had decreased but that the OARSI score, terminal differentiation markers (collagen type X and Indian hedgehog), and chondrocyte apoptosis had increased in the OA group. Additionally, PTH-(1–34) treatment significantly improved weight bearing and treadmill endurance, preserved GAG and collagen type II, and reduced the OARSI score and terminal differentiation markers. Finally, PTH-(1–34) ameliorated chondrocyte apoptosis by regulating the expression of autophagy-related proteins, through reducing mechanistic target of rapamycin (mTOR) and p62 and enhancing microtubule-associated protein-1 light chain 3 (LC3) and beclin-1. Reconstructive surgery after ACL rupture cannot prevent OA occurrence. Intra-articular PTH-(1–34) treatment can alleviate OA progression after ACLT and histological molecular changes. Possible mechanisms are reducing chondrocyte terminal differentiation and apoptosis, with increasing autophagy.

NEW & NOTEWORTHY Anterior cruciate ligament (ACL) tear can lead to osteoarthritis (OA). Intra-articular parathyroid hormone (PTH)-(1–34) significantly improved weight bearing and treadmill endurance, preserved glycosaminoglycan and collagen type II, and reduced Osteoarthritis Research Society International (OARSI) score and terminal differentiation. Finally, PTH-(1–34) ameliorated chondrocyte apoptosis by regulating the expression of autophagy-related proteins, through reducing mechanistic target of rapamycin (mTOR) and p62 and enhancing microtubule-associated protein-1 light chain 3 (LC3) and beclin-1. PTH-(1–34) can alleviate OA progression after ACL transection. Possible mechanisms are reducing chondrocyte terminal differentiation and apoptosis, with increasing autophagy.

National Athletic Trainers' Association Position Statement: Prevention of Anterior Cruciate Ligament Injury

OBJECTIVE

  To provide certified athletic trainers, physicians, and other health care and fitness professionals with recommendations based on current evidence regarding the prevention of noncontact and indirect-contact anterior cruciate ligament (ACL) injuries in athletes and physically active individuals.

BACKGROUND

  Preventing ACL injuries during sport and physical activity may dramatically decrease medical costs and long-term disability. Implementing ACL injury-prevention training programs may improve an individual's neuromuscular control and lower extremity biomechanics and thereby reduce the risk of injury. Recent evidence indicates that ACL injuries may be prevented through the use of multicomponent neuromuscular-training programs.

RECOMMENDATIONS

  Multicomponent injury-prevention training programs are recommended for reducing noncontact and indirect-contact ACL injuries and strongly recommended for reducing noncontact and indirect-contact knee injuries during physical activity. These programs are advocated for improving balance, lower extremity biomechanics, muscle activation, functional performance, strength, and power, as well as decreasing landing impact forces. A multicomponent injury-prevention training program should, at minimum, provide feedback on movement technique in at least 3 of the following exercise categories: strength, plyometrics, agility, balance, and flexibility. Further guidance on training dosage, intensity, and implementation recommendations is offered in this statement.

Similar cost-utility for double- and single-bundle techniques in ACL reconstruction

PURPOSE

The aim was to estimate the cost-utility of the DB technique (n = 53) compared with the SB (n = 50) technique 2 years after ACL reconstruction.

METHODS

One hundred and five patients with an ACL injury were randomised to either the Double-bundle (DB) or the Single-bundle (SB) technique. One hundred and three patients (SBG n = 50, DBG n = 53) attended the 2-year follow-up examination. The mean age was 27.5 (8.4) years in the SBG and 30.1 (9.1) years in the DBG. The cost per quality-adjusted life years (QALYs) was used as the primary outcome. Direct costs were the cost of health care, in this case outpatient procedures. Indirect costs are costs related to reduce work ability for health reasons. The cost-utility analysis was measured in terms of QALY gained.

RESULTS

The groups were comparable in terms of clinical outcome. Operating room time was statistically significantly longer in the DBG (p = 0.001), making the direct costs statistically significantly higher in the DBG (p = 0.005). There was no significant difference in QALYs between groups. In the cost-effectiveness plane, the mean difference in costs and QALYs from the trial data using 1000 bootstrap replicates in order to visualise the uncertainty associated with the mean incremental cost-effectiveness ratio (ICER) estimate showed that the ICERs were spread out over all quadrants. The cost-effectiveness acceptability curve showed that there was a 50% probability of the DB being cost-effective at a threshold of Euro 50,000.

CONCLUSION

The principal findings are that the DB is more expensive from a health-care perspective. This suggests that the physician may choose individualised treatment to match the patients' expectations and requirements.

Quadriceps force and anterior tibial force occur obviously later than vertical ground reaction force: a simulation study

BACKGROUND

Although it is well known that quadriceps force generates anterior tibial force, it has been unclear whether quadriceps force causes great anterior tibial force during the early phase of a landing task. The purpose of the present study was to examine whether the quadriceps force induced great anterior tibial force during the early phase of a landing task.

METHODS

Fourteen young, healthy, female subjects performed a single-leg landing task. Muscle force and anterior tibial force were estimated from motion capture data and synchronized force data from the force plate. One-way repeated measures analysis of variance and the post hoc Bonferroni test were conducted to compare the peak time of the vertical ground reaction force, quadriceps force and anterior tibial force during the single-leg landing. In addition, we examined the contribution of vertical and posterior ground reaction force, knee flexion angle and moment to peak quadriceps force using multiple linear regression.

RESULTS

The peak times of the estimated quadriceps force (96.0 ± 23.0 ms) and anterior tibial force (111.9 ± 18.9 ms) were significantly later than that of the vertical ground reaction force (63.5 ± 6.8 ms) during the single-leg landing. The peak quadriceps force was positively correlated with the peak anterior tibial force (R = 0.953, P < 0.001). Multiple linear regression analysis showed that the peak knee flexion moment contributed significantly to the peak quadriceps force (R ² = 0.778, P < 0.001).

CONCLUSION

The peak times of the quadriceps force and the anterior tibial force were obviously later than that of the vertical ground reaction force for the female athletes during successful single-leg landings. Studies have reported that the peak time of the vertical ground reaction force was close to the time of anterior cruciate ligament (ACL) disruption in ACL injury cases. It is possible that early contraction of the quadriceps during landing might induce ACL disruption as a result of excessive anterior tibial force in unanticipated situations in ACL injury cases.

Comparison of outcome after anatomic double-bundle and antero-medial portal non-anatomic single-bundle reconstruction in ACL-injured patients

PURPOSE

The aim of this study was to compare anatomic double-bundle anterior cruciate ligament reconstruction with non-anatomic single-bundle reconstruction.

METHODS

In a prospective consecutive series, 94 unselected patients [45 anatomic double-bundle (ADB) and 49 non-anatomic single-bundle (SB)] underwent ACL reconstruction involving hamstring tendon autograft, interference screw fixation on both the femoral and tibial side and drilling the femoral tunnel(s) through the antero-medial portal in both groups. In the ADB group, the remnants of the ACL were identified and the grafts were placed anatomically. In the SB group, traditional placement of the graft was performed in a less anatomic manner. Pre-operatively, the groups were comparable in terms of age, gender, time between injury and operation and associated injuries. One independent physiotherapist performed all the pre-operative and post-operative assessments.

RESULTS

The follow-up period was 26 (22-34) and 24 (23-30) months in the ADB and SB groups, respectively (p = 0.005). At follow-up, 78 % in the ADB group and 74 % in the SB group had a negative pivot-shift test (n.s.). The KT-1000 134N measurements were 2 (-5 to 10.5) and 2 (-4 to 7) mm in the ADB and SB groups, respectively (n.s.). At follow-up, the extension deficit was significantly larger in the ADB group than in the SB group (p = 0.001). The Tegner activity scale was significantly higher in the ADB group both pre-operatively and at follow-up (p = 0.03 and p = 0.004). In overall terms, both groups had improved significantly at the two-year follow-up.

CONCLUSION

In an unselected group of ACL-injured patients, anatomic double-bundle reconstruction did not result in better rotational or antero-posterior stability measurements than antero-medial portal non-anatomic single-bundle reconstruction at the two-year follow-up.

LEVEL OF EVIDENCE

III.

Improving ACL Reconstruction Outcomes

Anterior cruciate ligament (ACL) reconstruction is a common and predominantly successful surgical intervention. But are there specific preoperative patient characteristics or intraoperative surgeon decisions that lead to better or worse outcomes? And can understanding brain function changes of patients after ACL reconstruction reveal insights into the ways that postsurgical rehabilitation can be improved to further enhance outcomes? These intriguing and clinically applicable questions are addressed in this webinar titled "Improving ACL Reconstruction Outcomes," hosted jointly by JOSPT and JBJS. The webinar is based on 2 published research articles-one from JBJS and the other from JOSPT. Participants in this continuing education activity are asked to read both articles carefully before watching the webinar. JBJS co-author Kurt Spindler, MD, discusses findings from a longitudinal analysis that identified certain baseline patient characteristics and intraoperative choices that predicted higher and lower SF-36 Physical Component scores after ACL reconstruction. JOSPT co-author Dustin Grooms, PhD, ATC, shares recently published results of a controlled laboratory study that employed functional MRI to investigate brain-activation differences between patients who did and did not undergo ACL reconstruction. Moderated by Kevin Wilk, PT, DPT, FAPTA, a leading authority on rehabilitation of sports injuries, the webinar includes additional insights from expert commentators Eric McCarty, MD, and Karin Grävare Silbernagel, PT, PhD, ATC.

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.

Comparison of Anatomic Double- and Single-Bundle Techniques for Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autografts: A Prospective Randomized Study With 5-Year Clinical and Radiographic Follow-up

BACKGROUND

The aim of this prospective randomized study was to compare the outcomes of the anatomic double-bundle (DB) and anatomic single-bundle (SB) techniques 5 years after anterior cruciate ligament (ACL) reconstruction. Since more effective restoration of rotational laxity is considered the main advantage of the DB technique, the pivot-shift test was the primary outcome variable of the study.

HYPOTHESIS

Double-bundle ACL reconstruction will result in a better outcome in terms of the pivot-shift test.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 105 patients (33 women, 72 men; median age, 27 years; range, 18-52 years) were randomized and underwent ACL reconstruction (DB group, n = 53; SB group, n = 52). All reconstructions were performed anatomically by identifying the ACL footprints, using the anteromedial portal for the femoral tunnel drilling, and utilizing interference screw for tibial and femoral fixation. A single blinded observer examined the patients preoperatively and at follow-up (median, 64 months; range, 55-75 months). Multiple subjective and objective clinical evaluation tests and radiographic assessments of osteoarthritis (OA) were performed using the Ahlbäck, Kellgren-Lawrence, and Fairbank grading systems at 6 weeks postoperatively and at the final follow-up evaluation.

RESULTS

Preoperatively, no differences were found between the study groups, apart from the preinjury Tegner activity level, which was lower in the DB group (SB: mean, 7.8 [range, 3-9]; DB: mean, 7.3 [range, 0-9]; P = .02). Eighty-seven patients (83%) were available for examination at the 5-year follow-up. Statistical differences could not be found between the groups in terms of the pivot-shift test, KT-1000 arthrometer laxity measurements, manual Lachman test, single-legged-hop test, square-hop test, range of motion, Lysholm knee scoring scale, Tegner activity scale, or Knee injury and Osteoarthritis Outcome Score. Correspondingly, no differences were found between the groups regarding the presence of OA at follow-up. However, a significant increase of OA was found within the DB group at the 5-year follow-up. Both groups improved at follow-up compared with the preoperative assessment in terms of the laxity tests, hop tests, and scoring scales.

CONCLUSION

At the 5-year follow-up of an unselected group of patients, anatomic DB reconstruction was not superior to anatomic SB reconstruction in terms of the pivot-shift test.

Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques

The influences and mechanisms of the physiology, rupture and reconstruction of the anterior cruciate ligament (ACL) on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades. The knee is a complex joint with shifting contact points, pressures and axes that are affected when a ligament is injured. The ACL, as one of the intra-articular ligaments, has a strong influence on the resulting kinematics. Often, other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes. Knowing the surgical options, anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.

Comparison of Knee Kinematics After Single-Bundle Anterior Cruciate Ligament Reconstruction via the Medial Portal Technique With a Central Femoral Tunnel and an Eccentric Femoral Tunnel and After Anatomic Double-Bundle Reconstruction: A Human Cadaveric Study

BACKGROUND

Anatomic femoral tunnel placement in anterior cruciate ligament (ACL) reconstruction is considered to be a key to good primary stability of the knee. There is still no consensus on whether a centrally placed single bundle in the anatomical femoral footprint can compare with anatomic double-bundle (DB) reconstruction.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine knee kinematics after single-bundle ACL reconstruction via the medial portal technique using 2 different femoral tunnel positions and to compare results with those of the anatomic DB technique. The hypotheses were that (1) single-bundle reconstruction using the medial portal technique with a centrally placed femoral tunnel relative to the native footprint (SB-central technique) would more closely restore intact knee kinematics compared with the same reconstruction technique with an eccentric femoral tunnel drilled in the anteromedial bundle footprint (SB-AM technique) and (2) DB reconstruction would result in superior kinematics compared with the SB-central technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Knee kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force-moment sensor system. Kinematics in simulated pivot-shift and 134-N anterior tibial loading tests were determined in different conditions within the same specimen: (1) intact ACL, (2) deficient ACL, (3) SB-AM, (4) SB-central, and (5) DB.

RESULTS

All reconstruction techniques significantly reduced anterior tibial translation (ATT) compared with a deficient ACL at 0°, 15°, 30°, 60°, and 90° in the anterior tibial loading test (P < .01, repeated-measures analysis of variance) and at 0°, 15°, and 30° in the simulated pivot-shift test (P < .001). There were no significant differences in the SB-central group and the DB group compared with the intact ACL. Reconstruction in the SB-AM group resulted in significantly increased ATT compared with the intact ACL in near-to-extension angles in both tests (0°, 15°, and 30°; P < .01). SB-central and DB reconstructions both resulted in significantly reduced ATT, in some tests at ≤30°, compared with SB-AM reconstruction (P < .05). No significant differences between the SB-central and DB groups were found (P > .05).

CONCLUSION

The SB-central technique restored intact knee kinematics more closely than did SB-AM reconstruction at time zero. There were no differences in knee kinematics between the DB and SB-central techniques.

CLINICAL RELEVANCE

Anatomic single-bundle ACL reconstruction provides similar knee kinematics as anatomic double-bundle reconstruction.

A Randomized Clinical Trial Comparing Patellar Tendon, Hamstring Tendon, and Double-Bundle ACL Reconstructions: Patient-Reported and Clinical Outcomes at a Minimal 2-Year Follow-up

OBJECTIVE

To compare 3 anatomically positioned autografts for anterior cruciate ligament (ACL) reconstruction, by measuring patient-reported disease-specific quality of life at 2 years postoperatively.

DESIGN

Double-blinded, randomized clinical trial with intraoperative computer-generated treatment allocation. Patients and an independent trained evaluator were blinded.

SETTING

University-based orthopedic referral practice.

PATIENTS

Three hundred thirty patients (14-50 years; 183 male patients) with isolated ACL deficiency were equally randomized to: (1) patellar tendon, PT: 28.7 years (SD = 9.7); (2) quadruple-stranded hamstring tendon, HT: 28.5 years (SD = 9.9); and (3) double bundle using HT, DB: 28.3 years (SD = 9.8); 322 patients completed 2-year follow-up.

INTERVENTION

Anterior cruciate ligament reconstruction using PT, HT, or DB autografts.

MAIN OUTCOME MEASURES

Measured at baseline, 1 and 2 years postoperatively-primary: anterior cruciate ligament quality-of-life scores; secondary: International Knee Documentation Committee (IKDC) scores, KT-1000 arthrometer, pivot shift, range of motion, Tegner activity, Cincinnati Occupational Scale, and single-leg hop. Proportions of correct graft type guesses by the patients and evaluator assessed blinding effectiveness.

RESULTS

Baseline characteristics were not different. Anterior cruciate ligament quality-of-life scores increased over time for all groups (P = 0.001) but were not different at 2 years (P = 0.591): PT = 84.6 (SD = 16.6, 95% confidence interval [CI] = 81.4-87.8), HT = 82.5 (SD = 17.7, 95% CI = 79.2-85.9), and DB = 82.4 (SD = 17.5, 95% CI = 79.1-85.7). Two-year KT-1000 side-to-side differences (PT = 1.86 mm; HT = 2.97 mm; DB = 2.65 mm) were statistically significant between PT-HT (P = 0.002) and PT-DB (P = 0.044). The remaining secondary outcomes were not statistically different. Correct graft type guesses occurred 51% of the time for patients and 46% for the evaluator.

CONCLUSIONS

Two-year disease-specific quality-of-life outcome was not different between the ACL reconstruction techniques. The PT reconstructions had significantly lower side-to-side differences on static stability measures. Patient and evaluator blinding was achieved.

LEVEL OF EVIDENCE

Level 1 (Therapeutic Studies).

CLINICAL RELEVANCE

This high-quality, large, double-blind randomized clinical trial (RCT) addresses the insufficient evidence in the literature comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture in adults. In addition to the clinical and functional results, this RCT uniquely reports on the disease-specific, patient-reported quality-of-life outcome at 2 years postoperatively.

Cost-effectiveness analyses in orthopaedic sports medicine: a systematic review

BACKGROUND

As increasing attention is paid to the cost of health care delivered in the United States (US), cost-effectiveness analyses (CEAs) are gaining in popularity. Reviews of the CEA literature have been performed in other areas of medicine, including some subspecialties within orthopaedics. Demonstrating the value of medical procedures is of utmost importance, yet very little is known about the overall quality and findings of CEAs in sports medicine.

PURPOSE

To identify and summarize CEA studies in orthopaedic sports medicine and to grade the quality of the available literature.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was performed to compile findings and grade the methodological quality of US-based CEA studies in sports medicine. The Quality of Health Economic Studies (QHES) instrument and the checklist by the US Panel on Cost-effectiveness in Health and Medicine were used to assess study quality. One-sided Fisher exact testing was performed to analyze the predictors of high-quality CEAs.

RESULTS

Twelve studies met inclusion criteria. Five studies examined anterior cruciate ligament reconstruction, 3 studies examined rotator cuff repair, 2 examined autologous chondrocyte implantation, 1 study examined hip arthroscopic surgery, and 1 study examined the operative management of shoulder dislocations. Based on study findings, operative intervention in sports medicine is highly cost-effective. The quality of published evidence is good, with a mean quality score of 81.8 (range, 70-94). There is a trend toward higher quality in more recent publications. No significant predictor of high-quality evidence was found.

CONCLUSION

The CEA literature in sports medicine is good; however, there is a paucity of studies, and the available evidence is focused on a few procedures. More work needs to be conducted to quantify the cost-effectiveness of different techniques and procedures within sports medicine. The QHES tool may be useful for the evaluation of future CEAs.

Baseline predictors of health-related quality of life after anterior cruciate ligament reconstruction: a longitudinal analysis of a multicenter cohort at two and six years

BACKGROUND

Limited information exists regarding predictors of general quality of life following anterior cruciate ligament (ACL) reconstruction with up to six-year follow-up. We hypothesized that certain variables evaluated at the time of ACL reconstruction will predict the general quality of life as measured by the Short Form-36 (SF-36).

METHODS

All unilateral ACL reconstructions from 2002 to 2004 in patients currently enrolled in a prospective multicenter cohort were evaluated. Patients preoperatively completed the SF-36 validated outcome instrument. Surgeons documented intra-articular pathological conditions and treatment, as well as the ACL reconstruction surgical technique. At baseline and at a minimum of two and six years postoperatively, patients completed the SF-36. Longitudinal analysis was performed for the two-year and six-year end points.

RESULTS

Of the initial 1512 subjects, at least one follow-up questionnaire was obtained from 1411 subjects (93%). The cohort was 44% female, and the median patient age at enrollment was twenty-three years. The mean scores were 41.9 points for the Physical Component Summary (PCS) and 51.7 points for the Mental Component Summary (MCS) at baseline, 53.6 points for the PCS and 52.0 points for the MCS at two years, and 54.0 points for the PCS and 52.4 points for the MCS at six years. Significant predictors of a higher PCS score were a higher baseline PCS score, younger age, lower baseline body mass index, having >50% of the lateral meniscus excised, or having no treatment done on a lateral meniscal tear. In contrast, significant predictors of a lower PCS score were a shorter follow-up time since surgery, revision ACL reconstruction, smoking at baseline, fewer years of education, and chondromalacia of the lateral tibial plateau. The mean utility gained at six years after ACL reconstruction was 5.3 quality-adjusted life years (QALYs).

CONCLUSIONS

Large improvements in the PCS (with an effect size of 1.2) were noted at two years and were maintained at six years after ACL reconstruction. Lower education and smoking were significant predictors of lower PCS and MCS scores. ACL reconstruction resulted in a relatively high gain of QALYs.

Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common among young athletes. Biomechanical studies have led to the development of training programs to improve neuromuscular control and reduce ACL injury rates as well as screening tools to identify athletes at higher risk for ACL injury. The purpose of this study was to evaluate the cost-effectiveness of these training methods and screening strategies for preventing ACL injuries.

METHODS

A decision-analysis model was created to evaluate three strategies for a population of young athletes participating in organized sports: (1) no training or screening, (2) universal neuromuscular training, and (3) universal screening, with neuromuscular training for identified high-risk athletes only. Risk of injury, risk reduction from training, and sensitivity and specificity of screening were based on published data from clinical trials. Costs of training and screening programs were estimated on the basis of the literature. Sensitivity analyses were performed on key model parameters to evaluate their effect on base case conclusions.

RESULTS

Universal neuromuscular training of all athletes was the dominant strategy, with better outcomes and lower costs compared with screening. On average, the implementation of a universal training program would save $100 per player per season, and would reduce the incidence of ACL injury from 3% to 1.1% per season. Screening was not cost-effective within the range of reported sensitivity and specificity values.

CONCLUSIONS AND CLINICAL RELEVANCE

Given its low cost and ease of implementation, neuromuscular training of all young athletes represents a cost-effective strategy for reducing costs and morbidity from ACL injuries. While continued innovations on inexpensive and accurate screening methods to identify high-risk athletes remain of interest, improving existing training protocols and implementing neuromuscular training into routine training for all young athletes is warranted.

A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction

BACKGROUND

The aim of the study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using either the double-bundle or single-bundle technique with hamstring tendon autografts in an unselected group of patients.

HYPOTHESIS

Double-bundle ACL reconstruction will render a better outcome on the pivot-shift test.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A randomized series of 103 patients (33 women, 70 men; median age, 27 years; range, 18-52 years) with a unilateral ACL rupture underwent anatomic ACL reconstruction. The double-bundle technique was used in 53 patients, and the single-bundle technique was used in 50 patients. The ACL footprint was visualized, and the femoral tunnel was drilled through the anteromedial portal; interference screw fixation was used at both ends. The patients were examined preoperatively and at a median of 26 months (range, 22-42 months) after the reconstruction by a blinded observer. The primary variable was the pivot-shift test.

RESULTS

At 2-year follow-up, 98 patients (93%) were examined. Clinical assessments at follow-up revealed no significant differences between the double-bundle and single-bundle groups in terms of the pivot-shift test, KT-1000 arthrometer laxity measurements, manual Lachman test, range of motion, Lysholm knee scoring scale, Tegner activity scale, Knee Injury and Osteoarthritis and Outcome Score (KOOS), 1-legged hop test, and square hop test. A significant improvement was seen in both groups compared with the preoperative values in terms of most clinical assessments.

CONCLUSION

In this prospective randomized study, the primary variable, the pivot-shift test, and other subjective and objective outcome variables revealed no significant differences between the double-bundle and single-bundle techniques at 2 years after ACL reconstruction in an unselected group of patients.

The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort

BACKGROUND

Subsequent surgeries have a profound effect on patient satisfaction and outcome after primary anterior cruciate ligament reconstruction (ACLR). There have been no prospective studies to date describing the rate and predictors (surgical and patient variables) of all subsequent knee surgeries at short-term and midterm follow-up along with analyses of surgical and patient variables that are associated with subsequent surgeries.

PURPOSE

To report the rate and predictors of all subsequent surgeries at short-term and midterm follow-up along with associated patient variables.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 980 patients (540 male) were prospectively enrolled in a Multicenter Orthopaedic Outcomes Network (MOON) cohort from January 2002 to December 2003. The 2- and 6-year follow-up information for subsequent procedures was obtained. Operative reports were obtained, and all procedures were categorized.

RESULTS

One hundred eighty-five patients underwent a subsequent surgery on the ipsilateral leg (18.9%) and 100 on the contralateral knee (10.2%) at 6-year follow-up. On the ipsilateral knee, there was a 7.7% rate of ACL revisions, a 13.3% rate of cartilage procedures, a 5.4% rate of arthrofibrosis procedures, and a 2.4% rate of procedures related to hardware. For the contralateral knee, there was a 6.4% rate of primary ACL ruptures. Younger age at the index surgery and the use of allografts were predictors (risk factors) for subsequent surgery. Revision ACLR, female sex, body mass index, and surgical exposure were not significant predictors.

CONCLUSION

At 6-year follow-up, 18.9% of patients who had undergone ACLR underwent subsequent surgeries on the ipsilateral knee. The rates between an ipsilateral ACLR graft versus a contralateral normal ACL tear were similar (7.7% vs 6.4%, respectively). Younger age and the use of allografts were risk factors for subsequent surgery.

Revision ACL reconstruction using contralateral hamstrings

PURPOSE

Due to the increasing number of primary anterior cruciate ligament (ACL) reconstructions, the need for revision surgery has risen. The aim of this study was to evaluate the use of contralateral doubled semitendinosus and gracilis tendon (DGST) for revision anterior cruciate ligament reconstruction.

METHODS

Twelve patients undergoing revision ACL reconstruction with hamstring tendon were examined at an average follow-up of 3 years. All patients underwent a thorough subjective and objective evaluation, which included a KT-1000 arthrometric evaluation, and a radiographic examination.

RESULTS

Subjective evaluation yielded a median score of 5.5 (range 2-9) on the Tegner activity scale. The mean Lysholm score was 95 (SD 9.5), and the mean subjective IKDC 2000 score was 95.4 (SD 7.8). At physical examination, a negative Lachman test was found in ten patients; one patient had a positive Lachman test with a firm end-point, and one other patient had a clearly positive Lachman test. Two patients had a grade 1+ on pivot shift testing. Only 1 patient showed a side-to-side difference more than 5 mm at the maximum manual KT-1000 arthrometer. Three patients (25 %) showed initial signs of osteoarthritis.

CONCLUSIONS

The results of the study show that the use of hamstring tendons harvested from the unaffected knee represents a valid option for revision surgery following a failed primary ACL reconstruction using DGST grafts.

LEVEL OF EVIDENCE

IV.

Health-related quality of life and direct costs in patients with anterior cruciate ligament injury: single-bundle versus double-bundle reconstruction in a low-demand cohort--a randomized trial with 2 years of follow-up

PURPOSE

To evaluate health-related quality of life (HRQL) in patients undergoing anterior cruciate ligament (ACL) reconstructive surgery by use of 2 procedures and to estimate the direct costs of surgery.

METHODS

We performed a 2-year randomized, prospective intervention study of 2 surgical ACL reconstruction techniques (anatomic single bundle [SB] v double bundle [DB]). Fifty-five consecutive outpatients, with a mean age of 30.88 years, were randomized to SB or DB ACL reconstruction. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to measure HRQL (primary outcome). ACL injuries were assessed by the International Knee Documentation Committee (IKDC) score (secondary outcome). The use of medical resources and their costs were evaluated.

RESULTS

We included 52 patients in the final analyses (23 in the SB group and 29 in the DB group). At baseline, there were no significant differences in study variables. At 2 years of follow-up, there were no significant differences in SF-36 and IKDC scores between groups. However, compared with baseline, the SF-36 physical function, physical role, bodily pain, social function, and emotional role scores were significantly better in the SB group (P < .05), whereas only the physical function dimension score was better in the DB group (P = .047). IKDC scores at 2 years improved significantly in the SB group (P < .001) and DB group (P = .004) compared with baseline. There was a significant correlation between the SF-36 physical function, physical role, and bodily pain dimensions and the IKDC score at 2 years (P < .05). The costs were € 3,251 for the SB group and € 4,172 for the DB group.

CONCLUSIONS

HRQL and medical outcomes were similar between SB and DB ACL reconstruction techniques, 2 years after surgery. However, the SB technique was more cost-effective.

Anatomical single bundle anterior cruciate ligament reconstruction

We present a review of the literature looking at the anatomy of the Anterior Cruciate Ligament, the biomechanical aspects of ACL reconstruction, review the outcomes of single and double bundle ACL reconstruction and present the current techniques for anatomic single bundle reconstruction.