A cost-effectiveness analysis comparing 3 anterior cruciate ligament graft types: bone-patellar tendon-bone autograft, hamstring autograft, and allograft

Surgical Techniques in Primary ACL Reconstruction: Getting It Right the First Time

The ideal anterior cruciate ligament reconstruction (ACLR) is an individualized anatomic approach aimed at restoring the native structure and function of the knee. Surgeons are tasked with difficult decisions during operative planning, including the optimal graft choice for the patient and appropriate anatomic tunnel placement. Special considerations should additionally be given for skeletally immature patients and those at high-risk for failure, including younger, active patients participating in pivoting sports. The purpose of this review is to provide an overview of the individualized approach to ACLR, including the necessary preoperative and operative considerations to optimize patient outcomes.

Autograft patellar bone-tendon-bone use does not increase operative time in anterior cruciate ligament reconstruction

Background

Anterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time.

Methods

All patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft.

Results

A total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27-33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001).

Conclusion

Operative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.

Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The rerupture or need for revision after anterior cruciate ligament reconstruction (ACLR) is a serious complication. Preventive strategies that target the early identification of risk factors are important to reduce the incidence of additional surgery.

PURPOSE

To perform a systematic review and meta-analysis to investigate risk factors for revision or rerupture after ACLR.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Literature searches were performed in PubMed, Embase, and Web of Science from database inception to November 2021 and updated in January 2022. Quantitative, original studies reporting potential adjusted risk factors were included. Odds ratios (ORs) were calculated for potential risk factors.

RESULTS

A total of 71 studies across 13 countries with a total sample size of 629,120 met the inclusion criteria. Fifteen factors were associated with an increase in the risk of revision or rerupture after ACLR: male sex (OR, 1.27; 95% CI, 1.14-1.41), younger age (OR, 1.07; 95% CI, 1.05-1.08), lower body mass index (BMI) (OR, 1.03; 95% CI, 1.00-1.06), family history (OR, 2.47; 95% CI, 1.50-4.08), White race (OR, 1.32; 95% CI, 1.08-1.60), higher posterolateral tibial slope (OR, 1.15; 95% CI, 1.05-1.26), preoperative high-grade anterior knee laxity (OR, 2.30; 95% CI, 1.46-3.64), higher baseline Marx activity level (OR, 1.07; 95% CI, 1.02-1.13), return to a high activity level/sport (OR, 2.03; 95% CI, 1.15-3.57), an ACLR within less than a year after injury (OR, 2.05; 95% CI, 1.81-2.32), a concomitant medial collateral ligament (MCL) injury (OR, 1.62; 95% CI, 1.31-2.00), an anteromedial portal or transportal technique (OR, 1.36; 95% CI, 1.22-1.51), hamstring tendon (HT) autografts (vs bone-patellar tendon-bone [BPTB] autografts) (OR, 1.60; 95% CI, 1.40-1.82), allografts (OR, 2.63; 95% CI, 1.65-4.19), and smaller graft diameter (OR, 1.21; 95% CI, 1.05-1.38). The other factors failed to show an association with an increased risk of revision or rerupture after ACLR.

CONCLUSION

Male sex, younger age, lower BMI, family history, White race, higher posterolateral tibial slope, preoperative high-grade anterior knee laxity, higher baseline Marx activity level, return to a high activity level/sport, an ACLR within less than a year from injury, a concomitant MCL injury, an anteromedial portal or transportal technique, HT autografts (vs BPTB autografts), allografts, and smaller graft diameter may increase the risk of revision or rerupture after ACLR. Raising awareness and implementing effective preventions/interventions for risk factors are priorities for clinical practitioners to reduce the incidence of revision or rerupture after ACLR.

Contralateral grafts have comparable efficacy to ipsilateral grafts in anterior cruciate ligament reconstructions: a systematic review

PURPOSE

To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.

METHODS

A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses.

RESULTS

Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture.

CONCLUSIONS

In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.

Economic Considerations on Costs and Pricing of Two Surgical Techniques for Treating Cranial Cruciate Disease in Dogs

In surgical treatment of cranial cruciate ligament disease in dogs, Tibial Plateau Levelling Osteotomy (TPLO) and Tibial Tuberosity Advancement (TTA) are commonly established procedures and have proven effective in restoring limb function. Unlike clinical outcome, economic aspects have not been studied as extensively. However, the surgical intervention poses an enormous financial burden on patients' owners. In a veterinary practice setting, this study compares prices for TPLO and TTA and examines prices differences as well as potential cost drivers. Charges for veterinary treatments are based on the Gebührenordnung für Tierärztinnen und Tierärzte (GOT), which is mandatory for veterinarians in Germany but allows a certain range in billing. This study found that TPLO is charged at a higher price than TTA; however, this might not cover the additional costs of this procedure. The price is also associated with weight, heavier dogs being more expensive. The underlying strategies for pricing decisions may be based on costs, as efforts for TPLO and heavier dogs are higher in terms of a prolonged surgical time, the number of staff involved and in surgeons' training. Price setting may also be based on a quality promise, suggesting better clinical outcome in a more expensive procedure. Future investigations should involve economic considerations and consider cost-effectiveness analysis when evaluating surgical treatment options.

Meniscus Work and Implant Selection Are Major Cost Drivers of Anterior Cruciate Ligament Reconstruction

Background The current study examines the financial charges associated with primary anterior cruciate ligament reconstruction (ACLR), specifically the contribution of graft choice, graft type, and concomitant meniscus surgery, in the outpatient hospital setting. Methods A retrospective financial billing review was performed on patients who underwent ACLR at a single academic medical center from January to December 2019. Age, BMI, insurance, length of operation, regional block, implants, meniscus surgery, graft type, and graft choice were extracted from hospital electronic patient records. Charges attributed with graft, anesthesia services, supplies, implants, surgeon fees, radiology charges, and total charges were collected. Total amount that insurance and patient paid were also obtained. Descriptive and quantitative statistics were performed. Results A total of 28 patients were studied (18 males, 10 females). The average age was 23.8 years. There were 20 concomitant meniscus surgeries. Six allografts and 22 autografts were used [eight bone-patellar tendon-bone (BPTB), eight hamstrings, six quadriceps]. The average and median total charge was $61,004 and $60,390, respectively (range: $31,403 to $97,914). The average insurance paid was $26,045 while out-of-pocket costs were $402. The average paid by private insurance was higher compared to government insurance ($31,111 vs. $11,066, p<0.001). Graft choice such as allograft vs. autograft (p=0.035) and meniscus surgery (p=0.048) were significant factors to the overall cost. Conclusions Graft choice, specifically the quadrupled hamstring autograft, and concomitant meniscal surgery are major contributors to variations in ACLR charges. Decreasing implant and graft costs and limiting surgical time can decrease charges associated with ACLR. We hope these findings can help guide surgeon financial decisions, by demonstrating the need to take into account the increased total charges and amount paid associated with specific grafts, meniscus surgery, and prolonged OR time.

Cost and Cost Driver Analysis of Anterior Cruciate Ligament Reconstruction Using Time-Driven Activity-Based Costing: Bone-Tendon-Bone Autograft Versus Hamstring Autograft

As health care transitions toward value-based care, orthopaedics has started to implement time-driven activity-based costing (TDABC) to understand costs and cost drivers. TDABC has not previously been used to study cost drivers in anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to use TDABC to (1) calculate bone-tendon-bone (BTB) and hamstring ACLR total costs of care and (2) evaluate the impact of graft choice and other factors on ACLR costs.

Methods

Data were collected from electronic medical records for primary ACLR from the institutional patient-reported outcome registry between 2009 and 2016 in 1 ambulatory surgery center. Patients receiving allograft, revision ACLR, or concomitant meniscal repair or ligament reconstruction were excluded. The total cost of care was determined using TDABC. Multivariate regression analysis was conducted between ACLR cost and group characteristics.

Results

A total of 328 patients were included; 211 (64.3%) received BTB autograft and 117 (35.7%) received hamstring autograft. The mean cost was $2,865.01 ± $263.45 (95% confidence interval: $2,829.26, $2,900.77) for BTB ACLR versus $3,377.44 ± $320.12 ($3,318.82, $3,436.05) for hamstring ACLR (p < 0.001). Operative time was 103.1 ± 25.1 (99.7, 106.5) minutes for BTB ACLR versus 113.1 ± 27.9 (108.0, 118.2) minutes for hamstring ACLR (p = 0.001). The total implant cost was $270.32 ± $97.08 ($257.15, $283.50) for BTB ACLR versus $587.36 ± $108.78 ($567.44, $607.28) for hamstring ACLR (p < 0.001). Hamstring graft (p = 0.006) and suspensory fixation on the femoral side (p = 0.011) were associated with increased costs.

Conclusions

The mean cost of care and operative time for BTB autograft ACLR are less than those for hamstring autograft ACLR. Operative time, implant choice, and graft choice were identified as modifiable cost drivers that can empower surgeons to manage primary ACLR costs while maximizing the value of the procedure.

Level of Evidence

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Categorize the existing clamps used for tensile test of human graft- a systematic review

Background

The use of tendon allografts for orthopedic repair has gained wide acceptance in recent years, most notably in anterior cruciate tendon reconstruction. Multiple studies support the use of tendon allografts and the benefits of its use are well accepted and understood. One of the important criteria of the use of tendon allografts is statistically similar histological and biomechanical properties to autographs. The aim of this systematic literature review is to investigate and categorize existing clamps used in the determination of the biomechanical properties of tendons such as maximum load, maximum strength, modulus of elasticity, ultimate strain, and stiffness. A variety of clamps for use during the endurance test of tendons were categorized according to the temperature used during the measurement. The clamps are divided into three groups: room temperature, cooled and heated clamps. The second goal of our review is to overview of clamps on the following aspects: name of clamp, author and date, type of clamps, type of endurance test (static or dynamic), type preloading (dynamic or static), type of tendon and measured and calculated parameters, and summarize in Table 3, as a comprehensive catalogue.

Methods

This systematic review was carried out in keeping with the PRISMA 2020 E&E and the PRISMA-S guidelines and checklists. A search was conducted for publications dating between 1991 and February 28th 2022 through three electronic databases (Web of Science, Scopus, and PubMed). We used Critical Appraisal Skills Program checklist to check the quality of included articles.

Results

The database search and additional sources resulted in 1725 records. 1635 records eliminated during the screening for various reasons (case report, other languages, book chapter, unavailable text/conference abstract, unrelated topic). The number of articles used in the final synthesis was 90. A variety of clamps for use during the endurance test of tendons were identified and categorized according to the temperature used during the measurement. Based on this, the clamps are divided into three groups: room temperature, cooled or heated clamps.

Conclusions

On the basis of the systematic literature review, mechanical parameters determined by usage with cooled clamps proved to be more reliable than with those at room temperature and with heated clamps. The collected information from the articles included name of clamp, author and date, type of clamps, type of endurance test (static or dynamic), type preloading (dynamic or static), type of tendon and measured and calculated parameters given in Table 3. summarized. The main advantage of the cooled clamps is that there is no limit to the type and length of the tendon. This study provides an overview of clamps and does not represent the modernity of any method.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05650-w.

Vancomycin Soaking Is Highly Cost-Effective in Primary ACLR Infection Prevention: A Cost-Effectiveness Study

BACKGROUND

Although presoaking grafts in vancomycin has been demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain.

PURPOSE

To 1) determine the cost-effectiveness of vancomycin presoaking during primary ACLR to prevent postoperative joint infections and 2) to establish the break-even cost-effectiveness threshold of the technique and determine its cost-effectiveness across various international health care settings.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 2.

METHODS

A Markov model was used to determine cost-effectiveness and the incremental cost-effectiveness ratio of additional vancomycin presoaking compared with intravenous antibiotic prophylaxis alone. A repeated search of the PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials databases, using the same criteria as a recent meta-analysis, was completed. A repeated meta-analysis of 9 cohort studies (level 3 evidence) was completed to determine the odds ratio of infection with vancomycin presoaking compared with intravenous antibiotics alone. Estimated costs of the vancomycin technique, treatment of infection, and further surgery were sourced from local hospitals and literature. Transitional probabilities for further surgery, including revision reconstruction and primary arthroplasty, were obtained from the literature. Probabilistic sensitivity analyses and a 1-way sensitivity analysis were performed to evaluate the ACLR infection rate break-even threshold for which the vancomycin technique would be no longer cost-effective.

RESULTS

The vancomycin soaking technique provides expected cost savings of $660 (USA), A$581 (Australia), and €226 (Spain) per patient. There was an improvement in the quality-adjusted life-years of 0.007 compared with intravenous antibiotic prophylaxis alone (4.297 vs 4.290). If the infection rate is below 0.014% with intravenous antibiotics alone, the vancomycin wrap would no longer be cost-effective.

CONCLUSION

The vancomycin presoaking technique is a highly cost-effective method to prevent postoperative septic arthritis after primary ACLR.

Medial Meniscus Transplantation and Bone-Tendon-Bone Anterior Cruciate Ligament Reconstruction

Performing medial meniscus allograft transplantation in combination with anterior cruciate ligament (ACL) reconstruction is technically demanding. Medial meniscus allograft transplantation in combination with ACL reconstruction may be indicated for patients with meniscal deficiency in whom ACL reconstruction has failed and patients with medial-sided knee pain secondary to meniscal deficiency in combination with ACL deficiency. Despite the complex nature of this combined surgical procedure, numerous studies have reported considerable clinical improvements at midterm and long-term follow-up. This technique article describes the indications, preoperative considerations, surgical technique, postoperative rehabilitation, and outcomes of medial meniscus allograft transplantation in combination with ACL reconstruction.

Vancomycin Presoaking of Anterior Cruciate Ligament Tendon Grafts Is Highly Cost-Effective for Preventing Infection

PURPOSE

This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs.

METHODS

Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR.

RESULTS

Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin.

CONCLUSIONS

Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction.

LEVEL OF EVIDENCE

IV, economic analysis.

Early cost estimating model for new bioabsorbable orthopedic implant candidates: A theoretical study

An early health technology assessment (HTA) study was performed to assess the need for developing a new bioabsorbable implant for the treatment of specific orthopedic injuries. The Anterior Cruciate Ligament Reconstruction (ACLR) procedure was selected based on the need and potential impact of bioabsorbable implants in the treatment of ACL injuries. The economic model considers the possible health events after an ACLR (failures and other complications such as stiffness and pain). A decision tree approach was used, and several sensitivity analyses were performed using a Monte Carlo simulation. A cost estimating model was applied comparatively for currently available metal and bioabsorbable implants against a potential new bioabsorbable implant with improved performance. A reduction in stiffness and pain symptoms were considered as targets for these new implants performance, with reduced inflammation resulting from the use of materials with appropriate biological and mechanical properties. The current study estimates that, under the assumptions made, the introduction of a new bioabsorbable implant in ACLR surgeries may generate yearly cost savings. The model estimates positive cost-benefits of the new implant when it reduces the probability of failure by more than 30%, or reduces at least 14% the probability of complications of an inflammatory nature. The development of a new bioabsorbable orthopedic implant for ACLR is encouraged by this study identifying the need for new bioabsorbable implants with improved biological and mechanical performance. The results of this early HTA have made it possible to anticipate design needs and objectives for the research and development of new orthopedic bioabsorbable implants.

Different sterilization and disinfection methods used for human tendons - a systematic review using mechanical properties to evaluate tendon allografts

Background

It is important to know the biomechanical properties of an allograft. This is because when looking to do a transplant of a tendon, the tendon must have very similar biomechanical properties to the original tendon. To use tendon allografts, it is critical to properly sterilize the tendon before implantation. In past decades, several sterilization procedures have been used. This study aimed to systematically evaluate the existing literature to compare the values of failure load/ultimate strength and Young’s modulus of elasticity of different sterilization methods on commonly used tendon allografts. Five major scientific literature databases (Web of Science, Science Direct, Scopus, PLOS ONE, Hindawi) and additional sources were used.

Results

Studies used had to show a particular sterilization method. Studies were identified to meet the following inclusion criteria: is a controlled laboratory study, gamma irradiation (dose reported), and other sterilization methods. Search for publications dated between 1991 and March 31st, 2020. The database search and additional sources resulted in 284 records. Two hundred thirty records eliminated during the screening for various reasons. The number of articles used in the final synthesis was 54.

Conclusions

Identified sterilization methods (gamma irradiation, ethylene oxid, supercritical carbon dioxide (SCCO2), BioCleanse, Electron Beam) are offered as a catalog of potential methods.

As a result of the broadness of the present research, it provides an overview of sterilization methods and their effect on the mechanical properties (failure load and Young’s modulus of elasticity) of tendons. It does not stand for the state-of-the-art of any single process. Based on a systematic literature review, we recommend freezing and gamma irradiation or electron beam at 14.8–28.5 kGy. These methods are effective at keeping or improving the mechanical properties, while fully sterilizing the inside and the outside of the tendon. Other sterilization method (ethylene oxide, supercritical carbon dioxide (SCCO2), BioCleanse) deteriorated the mechanical properties. These methods are not recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04296-4.

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.

Semitendinosus Tendon Augmentation for Prevention of Proximal Junctional Failure

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to compare the incidence of proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and clinical outcomes of patients who did and did not receive posterior ligament complex (PLC) augmentation using a semitendinosus allograft when undergoing long-segment posterior spinal fusion for adult spinal deformity.

SUMMARY OF BACKGROUND DATA

Clinical research on the augmentation of the PLC to prevent PJK and PJF has been limited to small case series without a comparable control group.

METHODS

From 2014 to 2019, a consecutive series of patients with adult spinal deformity who underwent posterior long-segment spinal fusion with semitendinosus allograft to augment the PLC (allograft) or without PLC augmentation (control) were identified. Preoperative and postoperative spinopelvic parameters were measured. PJK, PJF, and Oswestry Disability Index (ODI) scores were recorded and compared between the two groups. Univariate and multivariate analysis was performed. P ≤ 0.05 was considered significant.

RESULTS

Forty-nine patients in the allograft group and 34 patients in the control group were identified. There were no significant differences in demographic variables or operative characteristics between the allograft and control group. Preoperative and postoperative spinopelvic parameters were also similar between the two groups. PJK was present in 33% of patients in the allograft group and 32% of patients in the control group (P = 0.31). PJF did not occur in the allograft group, whereas six patients (18%) in the control group developed PJF (P = 0.01). Postoperative absolute ODI was significantly better in the allograft group (P = 0.007).

CONCLUSION

The utilization of semitendinosus allograft tendon to augment the PLC at the upper instrumented vertebrae in patients undergoing long-segment posterior spinal fusion for adult deformity resulted in a significant decrease in PJF incidence and improved functional outcomes when compared to a cohort with similar risk of developing PJK and PJFLevel of Evidence: 3.

Incorporation of Whipstitch Suture in Tibial Interference Fixation Improves Pullout in Anterior Cruciate Ligament Soft Tissue Grafts

INTRODUCTION

Interference screw fixation of soft tissue grafts is commonly used in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to determine whether including suture material at the graft-screw interface affects ultimate fixation strength of soft tissue grafts using a tibialis anterior tendon allograft model.

MATERIALS AND METHODS

Forty fresh-frozen human tibialis anterior tendon allografts were fixed to rigid polyurethane foam simulating the tibial tunnel. Twenty grafts underwent fixation with interference screws and 20 with interference bolts. Within each group, 10 grafts had suture in contact with either the screw or bolt. A load-to-failure test was then performed at a rate of 200 mm/min.

RESULTS

The group of allografts with sutures in the tibial tunnel had significantly higher load to failure than the group without sutures. Using interference screw fixation, failure load of the grafts without sutures in the tunnel (535.2 ± 73.40 N) was significantly lower (P = .001) than with sutures in the tunnel (696.3 ± 110.0 N). Using interference bolt fixation, failure load of the grafts without sutures in the tunnel (613.0 ± 83.46 N) was significantly lower (P <.0001) than with sutures in the tunnel (845.8 ± 87.23 N).

CONCLUSIONS

In a biomechanical model, suture within the tibial tunnel enhances fixation strength with both interference screw and bolt fixation for soft tissue tibialis anterior allografts. Additionally, there was no difference in load to failure when comparing failure of a screw with suture in the tunnel with an interference bolt without suture. Due to improved biomechanical properties, incorporation of suture in the bone-graft interface should be considered when performing soft tissue ACL allograft reconstructions. Failure at the tibial bone-graft interface is a known complication of ACL reconstruction, and incorporation of suture within the interface should be considered for improved biomechanical properties.

Radiographic assessment of bone tunnels after anterior cruciate ligament reconstruction: A comparison of hamstring tendon and bone-patellar tendon-bone autografting technique

Objectives

This study aims to compare the postoperative change of femoral and tibial tunnel widths after hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografting in primary anterior cruciate ligament (ACL) reconstruction surgery with the anteromedial portal technique.

Patients and methods

This case-control and retrospective study included 39 patients (36 males, 3 females; mean age 30.1±7.9; range, 17 to 44 years) who underwent primary ACL reconstruction surgery with either BPTB autografting method (BPTB group, n=18) or HT autografting method (HT group, n=21) between March 2014 and December 2016. Femoral fixation was achieved with bioabsorbable screw in BPTB group and endobutton in HT group. Tibial fixation was achieved with bioabsorbable interference screw in both groups. Femoral and tibial tunnel widths of groups were compared on digital radiographs.

Results

When we compared the baseline values with the second-year results, the mean of femoral tunnel widths were significantly lower on radiographs at the second-year evaluation in both groups (p<0.001 for all). However, the means of tibial tunnel widths were significantly lower only in the BPTB group (p<0.001 for BPTB group and p=0.616 for HT group). Change levels of anteroposterior and lateral widths were more prominent in BPTB group than HT group (p<0.001 for all).

Conclusion

Changes in tunnel widths show us superior ossification in BPTB grafting. This can be explained by superior bone-to-bone healing. As a result of radiological evaluation, we think that BPTB grafting can be more strong and durable.

Patellar Tendon Versus 4-Strand Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials With Mid- to Long-Term Follow-Up

PURPOSE

To compare patellar tendon (PT) autografts with 4-strand semitendinosus and gracilis (STG) autografts concerning knee stability, functional outcomes, as well as complications after anterior cruciate ligament (ACL) reconstruction at minimal follow-up of 5 years.

METHODS

A systematic search of the literature was performed in PubMed, Embase, and the Cochrane Library to identify published prospective randomized controlled trials on clinical studies comparing PT autograft and 4-strand STG autografts for ACL reconstruction. The results of the eligible studies were analyzed in terms of knee stability (laxity measurements, Lachman test, and pivot-shift test), functional outcomes (Lysholm score, International Knee Documentation Committee score, Cincinnati score, Tegner score, single-legged hop test, and return to preinjury activity level), and complications (loss of range of motion [ROM], pain, graft re-rupture, revision, and osteoarthritis [OA]).

RESULTS

Nine clinical studies with 630 patients (313 PT and 317 STG autografts) met the inclusion criteria. No statistically significant differences were found between the PT and STG group in Lachman test, pivot-shift test, International Knee Documentation Committee score, Cincinnati score, loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA rate. The STG group was found with less anterior knee pain (P = .003). There were no clinically significant differences for the outcomes of SSD, Lysholm score, and Tegner score.

CONCLUSIONS

Except for significantly greater risk of anterior knee pain, PT autograft had comparable results with 4-strand STG autograft in terms of knee stability and functional outcomes after ACL reconstruction with mid- to long-term follow-up. Besides, we found no statistically significant difference in loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA change, but these results were underpowered.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I studies.

The Effectiveness of Autograft Used in Anterior Cruciate Ligament Reconstruction of the Knee: Surgical Records for the New Generations of Orthopedic Surgeons and Synthetic Graft Revisit

Objective

In this article, we aim to revisit the synthetic graft and review the advantages and disadvantages between different types of grafts for patients who underwent anterior cruciate ligament (ACL) reconstruction in a tertiary medical institute for the new generations of surgeons.

Patients and Methods

Retrospectively, we identified 115 patients who underwent arthroscopic ACL reconstruction between 2006 and 2009. We were able to retrieve 74 patients from them. The 74 patients were divided into 32 patients who underwent primary arthroscopic ACL reconstruction with hamstring and patellar tendon autograft and 42 cases with an active biosynthetic composite (ABC) ligament. The mean the follow-up period for both groups was 7 years. The following information was obtained: standard demographic information (age, sex), clinical presentation, presence of trauma, associated injuries, types of grafts (autograft versus synthetic graft) and postoperative complications. Moreover, functional and clinical outcomes in addition to the satisfaction of patients using the international knee documentation committee (IKDC) score and knee injury and osteoarthritis outcome score (KOOS) were measured.

Results

We found that the natural (autograft) was better in terms of clinical and functional outcome than the synthetic one (the scores of KOOS and IKDC were better in natural grafts). Furthermore, the immediate postoperative results for the pivot and Lachman tests were better in natural grafts. On the other hand, the rate of re-rupture was similar for both groups. However, the long-term inflammatory changes and stiffness that is attributed to the immunological reactions were more in the synthetic grafts.

Conclusion

This study revisited the synthetic graft and provided evidence that the natural grafts are more beneficial with less complications, as they had better immediate and long-term postoperative clinical and functional outcomes. We recommend the utilization of autograft as first choice and the synthetic not to be used given the current criteria.

Effect of Graft Choice on Revision and Contralateral Anterior Cruciate Ligament Reconstruction: Results From the New Zealand ACL Registry

BACKGROUND

The patellar tendon is often considered the "gold standard" graft for reducing the risk of graft rupture after anterior cruciate ligament (ACL) reconstruction. However, its use may also be associated with an increased risk of injury to the contralateral ACL.

PURPOSE

To clarify the association between graft choice and the risk of revision and contralateral ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Prospective data captured by the New Zealand ACL Registry between April 2014 and December 2018 were reviewed. All primary ACL reconstructions performed using either a hamstring tendon or patellar tendon autograft were included. Cox regression survival analysis adjusting for patient factors was performed to compare the risk of revision and contralateral ACL reconstruction between the hamstring tendon graft and the patellar tendon graft.

RESULTS

A total of 7155 primary ACL reconstructions were reviewed, of which 5563 (77.7%) were performed using a hamstring tendon graft and 1592 (22.3%) were performed using a patellar tendon graft. Patients with a hamstring tendon graft had a revision rate of 2.7% compared with 1.3% in patients with a patellar tendon graft (adjusted hazard ratio [HR], 2.51; 95% CI, 1.55-4.06; P < .001). The patellar tendon graft was associated with an increased risk of contralateral ACL reconstruction compared with the hamstring tendon graft (adjusted HR, 1.91; 95% CI, 1.15-3.16; P = .012). The number needed to treat (NNT) with a patellar tendon graft to prevent 1 revision was 73.6. However, the NNT with a hamstring tendon graft to prevent 1 contralateral reconstruction was 116.3.

CONCLUSION

Use of a patellar tendon graft reduced the risk of graft rupture but was associated with an increased risk of injury to the contralateral ACL. Adequate rehabilitation and informed decision making on return to activity and injury prevention measures may be important in preventing subsequent injury to the healthy knee.

The effect of tourniquet type and thigh conicity on the length of hamstring autograft

PURPOSE

We studied the effect of using wide contoured pneumatic tourniquet (PT) versus ultra-narrow sterile exsanguination tourniquet (SET) on the length of hamstring autograft for anterior cruciate ligament (ACL) reconstruction in patients with tubular and conical thighs.

METHODS

Fifty-eight patients undergoing ACL reconstruction between 2012 and 2013 were assigned to either SET or PT groups. We measured the tendon graft length and width as well as the patients' height, weight, and thigh circumference of 10 cm proximal to the patella and the distance from the anterior-superior iliac spine to the medial malleolus (ASIS-MM). We defined the ratio between the ASIS-MM and the thigh circumference as the conicity index (CI). All grafts were measured after folding into half, and the found value was recorded as functional graft length (FGL). Tendon graft dimensions were correlated with the individual anthropometric data and with CI in each of the groups.

RESULTS

PT was used in 34 patients and SET on 24 patients. FGL was 12.7 ± 0.84 mean + standard deviation for the SET group versus 11.5 ± 1.61 for the PT group ( p = 0.0011) with a strong positive correlation between FGL and CI for the PT group ( R² = 0.625; p = 2.6 × 10^-8) but nonsignificant correlation for the SET ( R² = 0.222). Graft thickness was correlated with the patient age ( R² = 0.450) but not with CI or type of tourniquet used. We found the CI to be a better measure of thigh conicity than thigh circumference, length, height, weight, or body mass index individually.

CONCLUSION

We conclude that using the SET which occupies less space on the thigh yielded significantly longer hamstring autologous ACL graft compared to the PT and the FGL became essentially independent from the CI when the SET was used.

Italian consensus statement for the use of allografts in ACL reconstructive surgery

PURPOSE

Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making.

METHODS

In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members.

RESULTS

A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients.

CONCLUSIONS

Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R.

LEVEL OF EVIDENCE

IV, consensus of experts.

Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective

PURPOSE

To assess the clinical and cost-effectiveness of allografts versus autografts in the reconstruction of anterior cruciate ligaments.

METHODS

Systematic review of comparative clinical effectiveness and cost-effectiveness analysis.

RESULTS

Both autograft and allograft reconstruction are highly effective. Recent studies show little difference in failure rates between autografts and allografts (about 6% and 7%, respectively). In cost-effectiveness analysis, the price differential is the main factor, making autografts the first choice. However, there will be situations, particularly in revision ACL reconstruction, where an allograft may be preferred, or may be the only reasonable option available.

CONCLUSION

In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice.

LEVEL OF EVIDENCE

II.

Allografts in reconstruction of the posterior cruciate ligament: a health economics perspective

PURPOSE

To review the relative cost-effectiveness of allografts and autografts in reconstruction of the posterior cruciate ligament.

METHODS

Systematic review and cost-effectiveness analysis.

RESULTS

The available evidence does not show any significant difference in clinical effectiveness between autografts and allografts. Given that, only a cost analysis is provided, which shows that allografts are more costly.

CONCLUSION

Given the lack of any benefit of allografts over autografts, autografts should be preferred on cost grounds, if available. However, there may be situations where an allograft is indicated, for example, in multiple ligament reconstructions.

LEVEL OF EVIDENCE

IV.

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.

Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction

Background:

Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting.

Purpose:

To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool.

Study Design:

Cohort study (economic and decision analysis); Level of evidence, 3.

Methods:

All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs.

Results:

There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001).

Conclusion:

This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

Efficient delivery of recombinant human bone morphogenetic protein (rhBMP-2) with dextran sulfate-chitosan microspheres

Bone morphogenetic protein-2 (BMP-2) serves an important role in the development of bone and cartilage. However, administration of BMP-2 protein alone by intravenous delivery is not very effective. Sustained delivery of stabilized BMP-2 by carriers has been proven necessary to improve the osteogenesis effect of BMP-2. The present study constructed a novel drug delivery system using dextran sulfate (DS)-chitosan (CS) microspheres and investigated the efficiency of the delivery system on recombinant human bone morphogenetic protein (rhBMP-2). The microsphere morphology, optimal ratio of DS/CS/rhBMP-2, and drug loading rate and entrapment efficiency of rhBMP-2 CS nanoparticles were determined. L929 cells were used to evaluate the cytotoxicity and effect of DS/CS/rhBMP-2 microspheres on cell proliferation. Differentiation study was conducted using bone marrow mesenchymal stem cells (BMSCs-C57) cells treated with DS/CS/rhBMP-2 microspheres or the control microspheres. The DS/CS/rhBMP-2 microspheres delivery system was successfully established. Subsequent complexation of rhBMP-2-bound DS with polycations afforded well defined microspheres with a diameter of ~250 nm. High protein entrapment efficiency (85.6%) and loading ratio (47.245) µg/mg were achieved. Release of rhBMP-2 from resultant microspheres persisted for over 20 days as determined by ELISA assay. The bioactivity of rhBMP-2 encapsulated in the CS/DS microsphere was observed to be well preserved as evidenced by the alkaline phosphatase activity assay and calcium nodule formation of BMSCs-C57 incubated with rhBMP-2-loaded microspheres. The results demonstrated that microspheres based on CS-DS polyion complexes were a highly efficient vehicle for delivery of rhBMP-2 protein. The present study may provide novel orientation for bone tissue engineering for repairing and regenerating bone defects.

Hamstring Autograft for Foot and Ankle Applications

BACKGROUND

Hamstring tendon autografts may be used for foot and ankle surgeries, although reports on their effectiveness and morbidity in the foot and ankle literature are limited. We studied a cohort of patients who underwent hamstring harvest for foot and ankle applications, hypothesizing that morbidity to the knee would be limited.

METHODS

We studied a cohort of patients who underwent hamstring autograft for foot or ankle applications by a fellowship-trained sports and foot and ankle surgeon since 2011. Thirty-seven patients underwent isokinetic strength testing using a dynamometer an average of 38 months postoperatively. The average patient age was 45 ± 16 (range, 18-78) years, and 54% were women. Peak flexion and extension torque as well as flexion and extension torque at 30, 70, and 90 degrees of flexion were collected at 2 different testing speeds, 180 and 300 degrees/s. t tests were used for all comparisons.

RESULTS

At follow-up, 32 patients (86%) reported no pain at the harvest site; the remaining 5 patients reported mild to moderate symptoms. No patients were dissatisfied, and all would recommend the surgery to someone else. Flexion strength at higher degrees of flexion was significantly lower compared with extension strength as well as compared with flexion strength at lower degrees of flexion, when testing was performed at lower speed ( P < 0.05).

CONCLUSIONS

When used for foot and ankle surgery, hamstring autografts resulted in high patient satisfaction with minimal donor site morbidity. While knee flexion strength was decreased at higher degrees of flexion, this finding did not appear to be clinically significant.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Anterior cruciate ligament reconstruction: principles of treatment

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.

Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.

Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

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.

Allograft Augmentation of Hamstring Autograft for Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction

BACKGROUND

Younger patients and those with smaller hamstring autograft diameters have been shown to be at significantly greater risk of graft failure after anterior cruciate ligament (ACL) reconstruction. To date, there is no information in the literature about the clinical success and/or cost-effectiveness of increasing graft diameter by augmenting with semitendinosus allograft tissue for younger patients.

HYPOTHESIS

Hybrid hamstring grafts are a cost-effective treatment option because of a reduced rate of graft failure.

STUDY DESIGN

Cohort study (economic and decision analysis); Level of evidence, 3.

METHODS

We retrospectively identified patients younger than 18 years who had undergone ACL reconstruction by a single surgeon between 2010 and 2015. During this period, the operating surgeon's graft selection algorithm included the use of bone-patellar tendon-bone (BTB) autografts for the majority of patients younger than 18 years. However, hamstring autografts (hamstring) or hybrid hamstring autografts with allograft augment (hybrid) were used in skeletally immature patients and in those whom the surgeon felt might have greater difficulty with postoperative rehabilitation after BTB graft harvest. Patient demographics, graft type, graft diameter, the time the patient was cleared to return to activity, and the need for secondary surgical procedures were compared between the hamstring and hybrid groups. The clinical results were then used to assess the potential cost-effectiveness of hybrid grafts in this select group of young patients with an ACL injury or reconstruction.

RESULTS

This study comprised 88 patients (hamstring group, n = 46; hybrid group, n = 42). The 2 groups did not differ in terms of age, sex, timing of return to activity, or prevalence of skeletally immature patients. Graft diameters were significantly smaller in the hamstring group (7.8 vs 9.9 mm; P < .001), which corresponded with a significantly greater rate of graft failure (13 of 46 [28.3%] vs 5 of 42 [11.9%]; P = .049). As a result of the reduced revision rate, the hybrid graft demonstrated incremental cost savings of US$2765 compared with the hamstring graft, and the hybrid graft was the preferred strategy in 89% of cases.

CONCLUSION

Driven by increased graft diameters and the reduced risk of revision, hybrid grafts appear to be a more cost-effective treatment option in a subset of younger patients with an ACL injury.

A Biomechanical Comparison of Allograft Tendons for Ligament Reconstruction

BACKGROUND

Allograft tendons are frequently used for ligament reconstruction about the knee, but they entail availability and cost challenges. The identification of other tissues that demonstrate equivalent performance to preferred tendons would improve limitations. Hypothesis/Purpose: We compared the biomechanical properties of 4 soft tissue allograft tendons: tibialis anterior (TA), tibialis posterior (TP), peroneus longus (PL), and semitendinosus (ST). We hypothesized that allograft properties would be similar when standardized by the looped diameter.

STUDY DESIGN

Controlled laboratory study.

METHODS

This study consisted of 2 arms evaluating large and small looped-diameter grafts: experiment A consisted of TA, TP, and PL tendons (n = 47 each) with larger looped diameters of 9.0 to 9.5 mm, and experiment B consisted of TA, TP, PL, and ST tendons (n = 53 each) with smaller looped diameters of 7.0 to 7.5 mm. Each specimen underwent mechanical testing to measure the modulus of elasticity (E), ultimate tensile force (UTF), maximal elongation at failure, ultimate tensile stress (UTS), and ultimate tensile strain (UTε).

RESULTS

Experiment A: No significant differences were noted among tendons for UTF, maximal elongation at failure, and UTϵ. UTS was significantly higher for the PL (54 MPa) compared with the TA (44 MPa) and TP (43 MPa) tendons. E was significantly higher for the PL (501 MPa) compared with the TP (416 MPa) tendons. Equivalence testing showed that the TP and PL tendon properties were equivalent or superior to those of the TA tendons for all outcomes. Experiment B: All groups exhibited a similar E. UTF was again highest in the PL tendons (2294 N) but was significantly different from only the ST tendons (1915 N). UTϵ was significantly higher for the ST (0.22) compared with the TA (0.19) and TP (0.19) tendons. Equivalence testing showed that the TA, TP, and PL tendon properties were equivalent or superior to those of the ST tendons.

CONCLUSION

Compared with TA tendons, TP and PL tendons of a given looped diameter exhibited noninferior initial biomechanical strength and stiffness characteristics. ST tendons were mostly similar to TA tendons but exhibited a significantly higher elongation/UTϵ and smaller cross-sectional area. For smaller looped-diameter grafts, all tissues were noninferior to ST tendons. In contrast to previous findings, PL tendons proved to be equally strong.

CLINICAL RELEVANCE

The results of this study should encourage surgeons to use these soft tissue allografts interchangeably, which is important as the number of ligament reconstructions performed with allografts continues to rise.

Should the Ipsilateral Hamstrings Be Used for Anterior Cruciate Ligament Reconstruction in the Case of Medial Collateral Ligament Insufficiency? Biomechanical Investigation Regarding Dynamic Stabilization of the Medial Compartment by the Hamstring Muscles

BACKGROUND

Semitendinosus and gracilis muscles are frequently harvested for autologous tendon grafts for cruciate ligament reconstruction. This study investigated the joint-stabilizing effects of these hamstring muscles in cases of insufficiency of the medial collateral ligament (MCL).

HYPOTHESES

First, both the semitendinosus and gracilis muscles can actively stabilize the joint against valgus moments in the MCL-deficient knee. Second, the stabilizing influence of these muscles decreases with an increasing knee flexion angle.

STUDY DESIGN

Controlled laboratory study.

METHODS

The kinematics was examined in 10 fresh-frozen human cadaveric knees using a robotic/universal force moment sensor system and an optical tracking system. The knee kinematics under 5- and 10-N·m valgus moments were determined in the different flexion angles of the (1) MCL-intact and (2) MCL-deficient knee using the following simulated muscle loads: (1) 0-N (idle) load, (2) 200-N semitendinosus (ST) load, and (3) 280-N (200/80-N) combined semitendinosus/gracilis (STGT) load.

RESULTS

Cutting the MCL increased the valgus angle under all tested conditions and angles compared with the MCL-intact knee by 4.3° to 8.1° for the 5-N·m valgus moment and 6.5° to 11.9° for the 10-N·m valgus moment ( P < .01). The applied 200-N simulated ST load reduced the valgus angle significantly at 0°, 10°, 20°, and 30° of flexion under 5- and 10-N·m valgus moments ( P < .05). At 0°, 10°, and 20° of flexion, these values were close to those for the MCL-intact joint under the respective moments (both P > .05). The combined 280-N simulated STGT load significantly reduced the valgus angle in 0°, 10°, and 20° of flexion under 5- and 10-N·m valgus moments ( P < .05) to values near those for the intact joint (5 N·m: 0°, 10°; 10 N·m: 0°, 10°, 20°; P > .05). In 60° and 90° of flexion, ST and STGT loads did not decrease the resulting valgus angle of the MCL-deficient knee without hamstring loads ( P > .05 vs deficient; P = .0001 vs intact).

CONCLUSION

In this human cadaveric study, semitendinosus and gracilis muscles successfully stabilize valgus moments applied to the MCL-insufficient knee when the knee is near extension.

CLINICAL RELEVANCE

In the valgus-unstable knee, these data suggest that the hamstring muscles should be preserved in (multi-) ligament surgery when possible.

Technical Considerations in Revision Anterior Cruciate Ligament (ACL) Reconstruction for Operative Techniques in Orthopaedics

As the incidence of anterior cruciate ligament (ACL) reconstruction continues to increase, the rate of revision surgery continues to climb. Revision surgery has inherent challenges that must be addressed in order to achieve successful results. The cause of the primary ACL reconstruction failure should be determined, and careful preoperative planning should be performed to address the cause(s) of failure. Each patient undergoing revision surgery should undergo a thorough history and physical examination, receive full length alignment radiographs, lateral radiographs, 45-degree flexion weight-bearing postero-anterior radiographs, and patellofemoral radiographs. 3-dimensional computed topography (CT) scan should be performed to assess tunnel position and widening. Magnetic resonance imaging (MRI) should be used to assess for intra-articular soft tissue pathology. Meniscal tears, meniscal deficiency, anterolateral capsule injuries, bony morphology, age, activity level, connective tissue diseases, infection, graft choice, and tunnel position can all impact the success of ACL reconstruction surgery. Meniscal lesions should be repaired, and in cases of persistent rotatory instability, extra-articular procedures may be indicated. Furthermore, osteotomies may be needed to correct malalignment or excess posterior tibial slope. Depending on the placement and condition of the original femoral and tibial tunnels, revision surgery may be performed in a single procedure or in a staged manner. In most cases, the surgery can be performed in one procedure. Regardless, the surgeon must communicate with the patient openly regarding the implications of revision ACL surgery and the treatment plan should be developed in a shared fashion between the surgeon and the patient.

Does sterilization with fractionated electron beam irradiation prevent ACL tendon allograft from tissue damage?

PURPOSE

Allografts are frequently used for anterior cruciate ligament (ACL) reconstruction. However, due to the inherent risk of infection, a method that achieves complete sterilization of grafts is warranted without impairing their biomechanical properties. Fractionation of electron beam (FEbeam) irradiation has been shown to maintain similar biomechanical properties compared to fresh-frozen allografts (FFA) in vitro. Therefore, aim of this study was to evaluate the biomechanical properties and early remodelling of grafts that were sterilized with fractionated high-dose electron beam irradiation in an in vivo sheep model.

METHODS

ACL reconstruction was performed in 18 mature merino mix sheep. Sixteen were reconstructed with allografts sterilized with FEbeam irradiation (8 × 3.4 kGy) and two with FFA. Eight FFA from prior studies with identical surgical reconstruction and biomechanical and histological analyzes served as controls. Half of the animals were sacrificed at 6 and 12 weeks, and biomechanical testing was performed. Anterior-posterior laxity (APL) was assessed with an AP drawer test at 60° flexion, and load to failure testing was carried out. Histological evaluation of mid-substance samples was performed for descriptive analysis, cell count, crimp and vessel density. For statistical analysis a Kruskal-Wallis test was used for overall group comparison followed by a Mann-Whitney U test for pairwise comparison of the histological and biomechanical parameters.

RESULTS

Biomechanical testing showed significantly decreased stiffness in FEbeam compared to FFA at both time points (p ≤ 0.004). APL was increased in FEbeam compared to FFA, which was significant at 6 weeks (p = 0.004). Median of failure loads was decreased in FEbeam grafts, with 12 reconstructions already failing during cyclic loading. Vessel density was decreased in FEbeam compared to FFA at both time points, with significant differences at 12 weeks (p = 0.015). Crimp length was significantly shorter in FEbeam compared to FFA at both time points (p ≤ 0.004) and decreased significantly in both groups from 6 to 12 weeks (p ≤ 0.025).

CONCLUSION

ACL reconstruction with fractionated Ebeam sterilization significantly alters the biomechanical properties and the early remodelling process of treated grafts in vivo. Therefore, this sterilization method cannot be recommended for clinical application. As substantial changes in the remodelling are inherent in this study, care in the rehabilitation of even low-dose sterilized allografts, used for ACL reconstruction, is recommended.

A Multicenter Study of Early Anti-inflammatory Treatment in Patients With Acute Anterior Cruciate Ligament Tear

BACKGROUND

It is increasingly recognized that biochemical abnormalities of the joint precede radiographic abnormalities of posttraumatic osteoarthritis (PTOA) by as much as decades. A growing body of evidence strongly suggests that the progression from anterior cruciate ligament (ACL) injury to PTOA is multifactorial, involving the interplay between biomechanical disturbances and biochemical homeostasis of articular cartilage.

PURPOSE

The purposes of this randomized study using an acute ACL injury model were to (1) evaluate the natural progression of inflammatory and chondrodegenerative biomarkers, (2) evaluate the relationship between subjective reports of pain and inflammatory and chondrodegenerative biomarkers, and (3) determine if postinjury arthrocentesis and corticosteroid injection offer the ability to alter this biochemical cascade.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 49 patients were randomized to 4 groups: group 1 (corticosteroid at 4 days after ACL injury, placebo injection of saline at 2 weeks), group 2 (placebo at 4 days after ACL injury, corticosteroid at 2 weeks), group 3 (corticosteroid at both time intervals), or a placebo group (saline injections at both time intervals). Patient-reported outcome measures and synovial biomarkers were collected at approximately 4 days, 11 days, and 5 weeks after injury. The change between the time points was assessed for all variables using Wilcoxon tests, and the relationship between changes in outcome scores and biomarkers were assessed by calculating Spearman ρ. Outcomes and biomarkers were also compared between the 4 groups using Kruskal-Wallis tests.

RESULTS

No adverse events or infections were observed in any study patients. With the exception of matrix metalloproteinase 1 (MMP-1) and tumor necrosis factor-inducible gene 6 (TSG-6), chondrodegenerative markers worsened over the first 5 weeks while all patient-reported outcomes improved during this time, regardless of treatment group. Patient-reported outcomes did not differ between patients receiving corticosteroid injections and the placebo group. However, increases in C-telopeptide of type II collagen (CTX-II), associated with collagen type II breakdown, were significantly greater in the placebo group (1.32 ± 1.10 ng/mL) than in either of the groups that received the corticosteroid injection within the first several days after injury (group 1: 0.23 ± 0.27 ng/mL [ P = .01]; group 3: 0.19 ± 0.34 ng/mL [ P = .01]).

CONCLUSION

PTOA begins at the time of injury and results early on in dramatic matrix changes in the knee. However, it is encouraging that early intervention with an anti-inflammatory agent was able to affect biomarkers of chondral degeneration. Should early intervention lead to meaningful changes in either the onset or severity of symptomatic PTOA, the current treatment paradigm for patients with ACL injury may have to be restructured to include early aspiration and intra-articular intervention.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01692756.

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.

Patient-Centered Outcomes and Revision Rate in Patients Undergoing ACL Reconstruction Using Bone-Patellar Tendon-Bone Autograft Compared With Bone-Patellar Tendon-Bone Allograft: A Matched Case-Control Study

PURPOSE

To determine whether outcomes after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft are similar to those of BPTB allograft, while controlling for graft, surgical technique, and surgeon.

METHODS

This study was approved by the institutional review board at The Vail Valley Medical Center in Vail, Colorado. Patients 18 to 70 years old who underwent primary ACL reconstruction were included. Patients in each group were matched by age and gender. Patient demographic data, surgical data, and subjective data were collected prospectively. Subjective questionnaires were administered at a minimum of 2 years after ACL reconstruction.

RESULTS

This study included 192 knees (191 patients; 143 male, 48 female; mean age, 33 years; range, 18 to 57 years), with 96 knees in each group. No autografts required ACL revision. The revision rate for allograft group was 14% (n = 11; mean age, 23 years; range, 18 to 40 years). Of 11 revisions, 9 (82%) were ≤25 years old. In allograft group, patients ≤25 years old were 23 times (95% confidence interval, 4.4 to 123.0) more likely to require revision ACL reconstruction than patients >25 years (P < .001). Follow-up was available for 87% of patients (n = 156/180). Mean follow-up time in the allograft group was 4.7 years (range, 2.0 to 9.8 years), and in the autograft group, 8.6 years (range, 2.0 to 16.2 years; P < .001). There was no significant difference between allografts and autografts for mean Lysholm (85.6 v 83.4; P = .43), mean Tegner (6.0 v 5.4; P = .09), or mean patient satisfaction (9.0 v 8.8; P = .57). Lysholm score correlated to Tegner (rho = 0.404; P < .001) and patient satisfaction with outcome (rho = 0.443; P ≤ .001). Tegner was correlated with age at surgery (rho = -0.274; P < .001).

CONCLUSIONS

There was no significant difference in patient-centered outcomes based on graft type; however, the allograft group required more revisions. Patient satisfaction was high for both groups. ACL reconstruction using BPTB autograft or allograft produces similar outcomes; however, revision rates were higher for allografts.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level II, meta-analysis of prospective studies.

Is Canine Eruption Velocity Affected by the Presence of Allograft Within a Repaired Alveolar Cleft?

PURPOSE

To assess the rate of canine eruption in alveolar clefts repaired with cancellous autograft versus cancellous autograft mixed with allograft.

MATERIALS AND METHODS

This was a retrospective cohort study of patients in mixed dentition who underwent primary repair of uni- or bilateral alveolar cleft defects. Patients were divided into 2 groups based on the method of bony reconstruction (group 1, iliac crest autograft; group 2, iliac crest autograft harvested through a minimal access approach and mixed 1:2 with demineralized bone allograft). Secondary predictor variables were demographic and anatomic factors potentially related to canine eruption. The outcome variable was the velocity of canine eruption, measured as the change in vertical distance from the incisal edge to the maxillary occlusal plane (millimeters per month). Descriptive, bivariate, and linear regression statistics were computed.

RESULTS

The study sample included 57 alveolar cleft defects; 19 were repaired with autograft alone and 38 were repaired with autograft plus allograft. The sample's mean age was 9.9 ± 2.3 years at the time of repair. Thirty-one clefts (54.4%) were part of a bilateral deformity. Canine root formation was 50% complete at the time of surgery in most patients (59.6%). Mean duration of follow-up was 23.7 ± 13.2 months. Mean canine eruption velocity was 0.20 ± 0.18 mm per month and was not associated with the method of bony repair (P = .58).

CONCLUSION

The use of allograft bone to augment bone graft volume results in similar rates of canine eruption compared with autograft bone alone.

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.

Status and headway of the clinical application of artificial ligaments

The authors first reviewed the history of clinical application of artificial ligaments. Then, the status of clinical application of artificial ligaments was detailed. Some artificial ligaments possessed comparable efficacy to, and fewer postoperative complications than, allografts and autografts in ligament reconstruction, especially for the anterior cruciate ligament. At the end, the authors focused on the development of two types of artificial ligaments: polyethylene glycol terephthalate artificial ligaments and tissue-engineered ligaments. In conclusion, owing to the advancements in surgical techniques, materials processing, and weaving methods, clinical application of some artificial ligaments so far has demonstrated good outcomes and will become a trend in the future.

In vitro investigation of a tissue-engineered cell-tendon complex mimicking the transitional architecture at the ligament-bone interface

Restoration of the transitional ligament-bone interface is critical for graft-bone integration. We postulated that an allogenic scaffold mimicking the fibrogenic, chondrogenic, and osteogenic transition gradients could physiologically promote ligament-bone incorporation. The aim of this study was to construct and characterize a composite tendon scaffold with a continuous and heterogeneous transition region mimicking a native ligament insertion site. Genetically modified heterogeneous cell populations were seeded within specific regions of decellularized rabbit Achilles tendons to fabricate a stratified scaffold containing three biofunctional regions supporting fibrogenesis, chondrogenesis, and osteogenesis. The observed morphology, architecture, cytocompatibility, and biomechanics of the scaffolds demonstrated their improved bio-physico-chemical properties. The formation of the transitional regions was augmented via enhanced delivery of two transcription factors, sex determining region Y-box 9 and runt-related transcription factor 2, which also triggered early up-regulated expression of cartilage- and bone-relevant markers, according to quantitative PCR and immunoblot analyses. Gradient tissue-specific matrix formation was also confirmed within the predesignated regions via histological staining and immunofluorescence assays. These results suggest that a transitional interface could be replicated on an engineered tendon through stratified tissue integration. The scaffold offers the advantages of a multitissue transition involving controlled cellular interactions and matrix heterogeneity, which can be applied for the regeneration of the ligament-bone interface.