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Yamasaki S, Hashimoto Y, Iida K, Han C, Kinoshita T, Nishino K, Nishida Y, Takigami J, Nakamura H. Quadriceps Tendon With Bone Autograft Has Better Stability and Magnetic Resonance Imaging Maturation Than Hamstring Tendon Autograft After Anterior Cruciate Ligament Reconstruction in Patients With Knee Hyperextension. Arthroscopy 2024; 40:1234-1244. [PMID: 37597704 DOI: 10.1016/j.arthro.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/22/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction between methods using quadriceps tendon with bone (QTB) and hamstring tendon (HT) in patients with hyperextension of the knee. METHODS The medical records of patients with knee hyperextension greater than 8° who underwent arthroscopic ACL reconstruction between October 2010 and October 2020 with follow-up for at least 2 years (median, 3 years; interquartile range [IQR], 2.0-4.6 years) were retrospectively reviewed. Side-to-side difference in anterior translation, pivot-shift test grade, Lysholm score, and graft intensity using the Howell grade on magnetic resonance imaging at final follow-up were compared between the QTB and HT groups. RESULTS The HT and QTB groups consisted of 42 patients and 21 patients, respectively. The overall mean age was 21.5 years (range, 14-48 years), and the median Tegner Activity Scale score was 6 (range, 3-9). Postoperatively, the median side-to-side difference in anterior translation was 1.75 mm (IQR, 1-3 mm) in the HT group and 1.0 mm (IQR, 0-1.75 mm) in the QTB group (P = .01). Pivot-shift testing showed grade 0 in 74.7%, grade 1 in 18.7%, and grade 2 in 6.6% of patients in the HT group and grade 0 in 85.7% and grade 1 in 14.3% of those in the QTB group (P = .03). The median postoperative Lysholm score was 99 in both groups. Graft signal intensity showed a significant between-group difference: grade I in 52%, grade II in 36%, and grade III in 12% of patients in the HT group versus grade I in 85.7%, grade II in 9.5%, and grade III in 4.8% of those in the QTB group (P = .03). CONCLUSIONS In patients who underwent ACL reconstruction for hyperextension of the knee, QTB yielded better clinical outcomes than HT with respect to anterior stability, rotational stability, and graft signal intensity on median 2-year follow-up magnetic resonance imaging. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Shinya Yamasaki
- Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan.
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ken Iida
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Changhun Han
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takuya Kinoshita
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuya Nishino
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Funk C, Hardy R, Brand J. Editorial Commentary: Surgical Modifications Should Be Considered Preoperatively in Individuals With Knee Hyperextension Beyond Neutral to Avoid a Retear Post-Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:908-909. [PMID: 38219117 DOI: 10.1016/j.arthro.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 01/15/2024]
Abstract
Anterior cruciate ligament retears are a multifactorial process, which makes it difficult for risk assessment metrics to predict chances of recurrence. However, these metrics provide surgeons with recommendations as to when additional safeguards should be implemented. Since a key goal in any surgical procedure is positive long-term patient outcomes, understanding predictive metrics and associated limitations is imperative for positive outcomes.
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Helito CP, da Silva AGM, Sobrado MF, Guimarães TM, Gobbi RG, Pécora JR. Patients With More Than 6.5° of Knee Hyperextension are 14.6 Times More Likely to Have Anterior Cruciate Ligament Hamstring Graft Rupture and Worse Knee Stability and Functional Outcomes. Arthroscopy 2024; 40:898-907. [PMID: 37579954 DOI: 10.1016/j.arthro.2023.07.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE To create a cut-off point for hyperextension that best discriminates retear and to verify whether this cut-off point can predict retear regardless of other characteristics after primary anterior cruciate ligament (ACL) reconstruction with hamstrings autograft. METHODS A cohort of patients submitted to primary isolated ACL reconstruction with hamstrings autografts was retrospectively evaluated. Patients were stratified according to the degree of passive knee hyperextension measured in the normal contralateral knee. The following data were collected: patient age and sex, time from injury to surgery, knee hyperextension, KT-1000 and pivot-shift, associated meniscus injury, intra-articular graft size, follow-up time, graft failure, and postoperative Lysholm and subjective International Knee Documentation Committee scores. RESULTS Data from 457 patients were evaluated. Median age was 31 years. Thirty-two (7.0%) presented with retear. There was a significant difference in hyperextension between patients with and without retear (P < .001), with the cut-off point established by the receiver operating characteristic curve from 6.5°. Patients with greater hyperextension had a statistically greater frequency of women, longer injury time, greater intra-articular graft diameter, greater postoperative KT-1000, and greater frequency of retear, whereas the subjective International Knee Documentation Committee and Lysholm scores were statistically lower in patients with greater hyperextension. Only hyperextension showed a statistically significant association with re-rupture (P < .001). The odds of retear in patients with hyperextension greater than 6.5 was 14.65 times the odds of patients with hyperextension less than 6.5. CONCLUSIONS Patients with more than 6.5° of hyperextension are 14.6 times more likely to have a graft rupture than patients with lower hyperextension when submitted to ACL reconstruction with hamstring tendons. Also, they present worse knee stability by the KT-1000 test and worse functional outcomes. Therefore, patients with this degree of hyperextension should not have isolated reconstruction with hamstrings as their first choice. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil; Hospital Sírio Libanês, São Paulo - SP, Brazil
| | - Andre Giardino Moreira da Silva
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil.
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil; Hospital Sírio Libanês, São Paulo - SP, Brazil
| | - Tales Mollica Guimarães
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo - SP, Brazil
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Vivacqua TA, Winkler PW, Lucidi GA, Firth AD, Musahl V, Getgood A. Lateral Extra-articular Tenodesis Does Not Decrease Graft Failure in Revision Anterior Cruciate Ligament Reconstruction When Combined With Quadriceps or Patellar Tendon Grafts. Arthroscopy 2024:S0749-8063(24)00090-2. [PMID: 38331366 DOI: 10.1016/j.arthro.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To compare return-to-sport (RTS) rates, graft failure rates, and clinical outcomes in patients who underwent revision anterior cruciate ligament reconstruction (R-ACLR) with additional lateral extra-articular tenodesis (LET) versus isolated R-ACLR. METHODS A retrospective review of the medical records of patients who underwent R-ACLR with or without a modified Lemaire LET procedure was performed. Seventy-four patients with at least 2 years of follow-up who had high-grade positive pivot-shift test findings were included. Concomitant procedures such as meniscectomy and meniscal repair were collected, along with any complications and/or graft failure. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee Subjective Knee Form score were collected. The ability to RTS was defined as fully, partially, or not returned. RESULTS Of the patients, 39 underwent isolated R-ACLR (mean age ± standard deviation, 29.2 ± 12.2 years) whereas 35 underwent an additional LET procedure (mean age, 24.6 ± 7.4 years). The mean length of follow-up in the R-ACLR group was 56.6 ± 26.5 months compared with 44.3 ± 17.6 months in the R-ACLR-LET group (P = .02) (range, 24-120 months). Patient-reported outcome measures were higher in the R-ACLR-LET group, with the KOOS Activities of Daily Living (93.5 ± 2.0 vs 97.2 ± 1.6, P = .03) and KOOS Sport (63.0 ± 3.6 vs 74.3 ± 3.8, P = .05) subdomain scores reaching the level of statistical significance. No differences were found in the other KOOS subdomain scores or the International Knee Documentation Committee scores. Failure rates were not significantly different between the groups (12.8% for R-ACLR vs 11.4% for R-ACLR-LET, P = .99). There were 13 patients (72.2%) in the R-ACLR group and 14 patients (60.8%) in the R-ACLR-LET group who did not RTS. CONCLUSIONS R-ACLR with additional LET showed similar failure and RTS rates to isolated R-ACLR after failed ACLR. The R-ACLR-LET group showed better functional results with significantly higher KOOS subdomain scores for activities of daily living, as well as sports and recreation. However, this study was unable to recommend the modified Lemaire LET procedure to be routinely used in R-ACLR patients. LEVEL OF EVIDENCE Level III, retrospective comparative therapeutic trial.
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Affiliation(s)
- Thiago Alberto Vivacqua
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Philipp W Winkler
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria; Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Gian Andrea Lucidi
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Andrew D Firth
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Volker Musahl
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Alan Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.
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Rezansoff A, Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PCM, Peterson D, Bardana D, Getgood AMJ. Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate. Arthroscopy 2024; 40:384-396.e1. [PMID: 37270112 DOI: 10.1016/j.arthro.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/02/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. METHODS This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. RESULTS We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001). CONCLUSIONS At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Alex Rezansoff
- University of Calgary Sport Medicine Centre, Calgary, Canada
| | - Andrew D Firth
- Health and Rehabilitation Sciences, Faculty of Health Sciences, Western University, London, Canada
| | - Dianne M Bryant
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada; School of Physical Therapy, Western University, London, Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Robert G McCormack
- Department of Orthopedics, University of British Columbia, Vancouver, Canada; New West Orthopaedic & Sports Medicine Centre, New Westminster, Canada
| | - Mark Heard
- Department of Surgery, University of Calgary, Calgary, Canada; Banff Sport Medicine, Banff, Canada
| | - Peter B MacDonald
- Department of Surgery, University of Manitoba, Winnipeg, Canada; Pan Am Clinic, Winnipeg, Canada
| | - Tim Spalding
- University Hospitals Coventry and Warwickshire National Health Service Trust, Coventry, England
| | - Peter C M Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, Ghent, Belgium; Antwerp Orthopedic Center, Antwerp, Belgium
| | - Devin Peterson
- Department of Surgery, Queen's University, Kingston, Canada
| | - Davide Bardana
- Department of Surgery, McMaster University, Hamilton, Canada; Department of Surgery, Queen's University, Kingston, Canada
| | - Alan M J Getgood
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada.
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van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies. Arthroscopy 2024; 40:632-647.e1. [PMID: 37207919 DOI: 10.1016/j.arthro.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees. METHODS An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale. RESULTS Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift. CONCLUSIONS The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees. CLINICAL RELEVANCE This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.
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Dietvorst M, Verhagen S, van der Steen M, van Douveren FMP, Janssen RA. Anterolateral augmentation procedures during anterior cruciate ligament reconstructions in skeletally immature patients: Scoping review of surgical techniques and outcomes. J Exp Orthop 2024; 11:e12012. [PMID: 38455455 PMCID: PMC10915482 DOI: 10.1002/jeo2.12012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/02/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose Graft failure rates after anterior cruciate ligament reconstruction (ACLR) in children and adolescents are higher compared to adults. Anterolateral augmentation procedures have recently generated increased focus regarding their ability to reduce graft failure rates. Concerns in skeletally immatures are potential growth disturbances and overconstraint after anterolateral augmentation. The aim of this scoping review is to provide an overview of all current anterolateral augmentation procedures in skeletally immature patients and to discuss surgical techniques, clinical and biomechanical outcomes. Methods This scoping review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement extension for scoping reviews. On 22 December 2022, an information specialist performed a systematic literature search in Cochrane, PubMed (Medline) and EMBASE databases. Inclusion criteria were anterolateral augmentation procedures, including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in combination with ACLR in skeletally immatures. Results Twenty studies were included after screening 1.485 abstracts. Seventeen studies describe LET techniques, four studies ALLR techniques and one study both techniques. Biomechanical data is scarce and shows conflicting results. Two studies compared ACLR with LET to ACLR in skeletally immatures with promising results in favour of the combined procedure. There were no differences in outcomes between LET and ALLR. Conclusions Several LET and ALLR techniques have been described for skeletally immature patients and the first clinical data on LET and ALLR is available, which showed promising results. Further research is necessary to evaluate the risk of growth disturbances and overconstraint in skeletally immatures. Level of Evidence Level IV.
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Affiliation(s)
- Martijn Dietvorst
- Department of Orthopaedic Surgery & TraumaMaxima Medical CentreEindhovenThe Netherlands
| | - Stéphanie Verhagen
- Department of Orthopaedic Surgery & TraumaMaxima Medical CentreEindhovenThe Netherlands
| | - Marieke C. van der Steen
- Department of Orthopaedic Surgery & TraumaMaxima Medical CentreEindhovenThe Netherlands
- Department of Orthopaedic Surgery & TraumaCatharina Hospital EindhovenEindhovenThe Netherlands
| | | | - Rob P. A. Janssen
- Department of Orthopaedic Surgery & TraumaMaxima Medical CentreEindhovenThe Netherlands
- Orthopaedic Biomechanics, Department of Biomedical EngineeringEindhoven University of TechnologyEindhovenThe Netherlands
- Chair Value‑Based Health Care, Department of Paramedical SciencesFontys University of Applied SciencesEindhovenThe Netherlands
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Zhao D, Pan JK, Lin FZ, Luo MH, Liang GH, Zeng LF, Huang HT, Han YH, Xu NJ, Yang WY, Liu J. Risk Factors for Revision or Rerupture After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2023; 51:3053-3075. [PMID: 36189967 DOI: 10.1177/03635465221119787] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Di Zhao
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Jian-Ke Pan
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fang-Zheng Lin
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ming-Hui Luo
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Gui-Hong Liang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ling-Feng Zeng
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - He-Tao Huang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan-Hong Han
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nan-Jun Xu
- The Second Clinical School of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei-Yi Yang
- Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jun Liu
- Department of Sports Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, China
- The Fifth Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
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Zsidai B, Piussi R, Thomeé R, Sundemo D, Musahl V, Samuelsson K, Hamrin Senorski E. Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction. Br J Sports Med 2023; 57:972-978. [PMID: 37192830 PMCID: PMC10423474 DOI: 10.1136/bjsports-2022-106183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVES To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R). METHODS Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS. RESULTS A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures. CONCLUSION Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.
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Affiliation(s)
- Bálint Zsidai
- Department of Orthopaedics, Göteborgs universitet Institutionen för kliniska vetenskaper, Goteborg, Sweden
| | - Ramana Piussi
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Roland Thomeé
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | - David Sundemo
- Institute of Clinical Sciences, Department of Orthopeadics, University of Gothenburg, Gothenburg, Europe, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Gothenburg, Sweden
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10
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Heard M, Marmura H, Bryant D, Litchfield R, McCormack R, MacDonald P, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Getgood A. No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction - Results from the stability randomized trial. J ISAKOS 2023; 8:246-254. [PMID: 36646169 DOI: 10.1016/j.jisako.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Results from the Stability Study suggest that adding a lateral extra-articular tenodesis (LET) to a hamstring tendon autograft reduces the rate of anterior cruciate ligament reconstruction (ACLR) failure in high-risk patients. The purpose of this study is to report adverse events over the 2-year follow-up period and compare groups (ACLR alone vs. ACLR + LET). METHODS Stability is a randomized clinical trial comparing hamstring tendon ACLR with and without LET. Patients aged 14-25 years with an ACL deficient knee were included. Patients were followed and adverse events documented (type, actions taken, resolution) with visits at 3, 6, 12, and 24 months postoperatively. Adverse events were categorized as none, minor medical, minor surgical, contralateral ACL rupture, or graft rupture. Patient reported outcome measures (PROMs) collected at each visit included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score (IKDC), and ACL Quality of Life Questionnaire (ACL-QOL). RESULTS In total, 618 patients were randomized (mean age 18.9 years, 302 (49%) male). Forty-five patients (7%) suffered graft rupture; 34 (11%) in the ACLR group compared to 11 (4%) in the ACLR + LET group (RRR = 0.67, 95% CI 0.36 to 0.83, p < 0.001). There were no differences in effusion or infection rates between groups. The ACLR + LET group experienced an increased number of hardware removals (10 vs. 4). Overall, the rate of minor medical events (11%), minor surgical events (7%), and ipsilateral or contralateral ACL tears (10%) were low considering the high-risk patient profile. Increasing severity of adverse events was associated with lower PROMs at 24 months post-operative. Patients in the ACLR + LET group reported greater degree of pain at 3 months only. There were no clinically significant differences in range of motion between groups. CONCLUSIONS The addition of LET to hamstring tendon autograft ACLR in young patients at high risk of re-injury resulted in a statistically significant reduction in graft rupture. While the addition of LET may increase rates of hardware irritation, there was no significant increase in overall rates of minor medical adverse events, minor surgical events, or overall re-operation rates. The concerns regarding complications associated with a LET did not materialize in this study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- M Heard
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; Banff Sport Medicine, T1W 0L5, Canada
| | - H Marmura
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - D Bryant
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - R Litchfield
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada
| | - R McCormack
- Department of Orthopaedics, University of British Columbia, V5Z 1M9, Canada; New West Orthopaedic & Sports Medicine Centre, V3L 5P5, Canada
| | - P MacDonald
- Department of Surgery, University of Manitoba, R3A 1R9, Canada; Pan Am Clinic, R3M 3E4, Canada
| | - T Spalding
- University Hospital Coventry and Warwickshire NHS Trust, CV2 2DX, UK
| | - P Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, 9000, Belgium; Antwerp Orthopedic Center, 2018, Belgium
| | - D Peterson
- Department of Surgery, McMaster University, L8S 4K1, Canada
| | - D Bardana
- Department of Surgery, Queen's University, K7L 2V7, Canada
| | - A Rezansoff
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; University of Calgary Sport Medicine Centre, T2N 1N4, Canada
| | - A Getgood
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada.
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11
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Baker HP, Bowen E, Sheean A, Bedi A. New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough? J Bone Joint Surg Am 2023; Publish Ahead of Print:00004623-990000000-00808. [PMID: 37205735 DOI: 10.2106/jbjs.22.01079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | | | - Andrew Sheean
- San Antonio Military Medical Center, San Antonio, Texas
| | - Asheesh Bedi
- Northshore University Health System, Skokie, Illinois
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12
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Monllau JC, Perelli S, Costa GG. Anterior cruciate ligament failure and management. EFORT Open Rev 2023; 8:231-244. [PMID: 37158400 PMCID: PMC10233803 DOI: 10.1530/eor-23-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Anterior cruciate ligament (ACL) reconstruction failure can be defined as abnormal knee function due to graft insufficiency with abnormal laxity or failure to recreate a functional knee according to the expected outcome. Traumatic ruptures have been reported as the most common reason for failure. They are followed by technical errors, missed concomitant knee injuries, and biological failures. An in-depth preoperative examination that includes a medical history, clinical examinations, advanced imaging, and other appropriate methods is of utmost importance. There is still no consensus as to the ideal graft, but autografts are the favorite choice even in ACL revision. Concomitant meniscal treatment, ligamentous reconstruction, and osteotomies can be performed in the same surgical session to remove anatomical or biomechanical risk factors for the failure. Patient expectations should be managed since outcomes after ACL revision are not as good as those following primary ACL reconstruction.
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Affiliation(s)
- Juan Carlos Monllau
- Department of Orthopaedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- ICATKnee, Institut Catalá de Traumatologia i Medicina de l'Esport (ICATME), Hospital Universitari Dexeus, UAB, Barcelona, Spain
| | - Simone Perelli
- Department of Orthopaedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- ICATKnee, Institut Catalá de Traumatologia i Medicina de l'Esport (ICATME), Hospital Universitari Dexeus, UAB, Barcelona, Spain
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13
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Inclan PM, Brophy RH. Revision anterior cruciate ligament reconstruction. Bone Joint J 2023; 105-B:474-480. [PMID: 37121594 DOI: 10.1302/0301-620x.105b5.bjj-2022-1064.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.
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Affiliation(s)
- Paul M Inclan
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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14
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Tuca M, Valderrama I, Eriksson K, Tapasvi S. Current trends in anterior cruciate ligament surgery. A worldwide benchmark study. J ISAKOS 2023; 8:2-10. [PMID: 36154898 DOI: 10.1016/j.jisako.2022.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To benchmark current trends on anterior cruciate ligament reconstruction (ACLR) surgery. METHODS The largest worldwide ACLR survey to date was performed during May 2020, targeted to reach representation of all continents. It was submitted electronically to all International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports surgeons (n = 3,026), asking those who perform ACLR to respond. RESULTS With a final sample size of 2,107, the overall response rate was 69.6%. Median years of practice as orthopaedic surgeon was 15 (range 1-52) and 49.6% of all respondents were defined as high-volume surgeons (>50 ACLR annually). Hamstrings tendon autograft was the preferred graft for primary ACLR (80.3%) and the medial portal femoral drilling was the most frequently used technique (78.5%). Cortical buttons (82.7%) and bioabsorbable screws (62.7%) were the preferred fixation methods for hamstring tendon autograft ACLR in femur and tibia, respectively. Metallic screws (45.2%) were the preferred fixation methods for bone patellar tendon bone autograft in femur and tibia. Most of the respondents routinely used pre-tensioning techniques for their graft preparation (63.8%), but less than half of surgeons preferred antibiotic soaking of the grafts (45.3%). The preferred knee position for graft fixation was 10-30° of knee flexion and neutral rotation (57.0%). The addition of anterolateral augmentation (or extra-articular tenodesis) was infrequent in primary and isolated ACLR (10.0%), but a statistically significant raise was seen for revision surgeries (20.0%). Most used brace in the initial postoperative rehabilitation (54.9%) and the time to allow patients to fully resume sports was at an average of 8.9 ± 2.0 months. Treatment algorithm of paediatric ACL injuries exhibited a low consensus among the respondents. CONCLUSION This worldwide survey benchmarks the current trends in ACL reconstruction, achieving the largest participation of surgeons to date. Among the great variety of options available for ACL reconstructions, surgeons' preferences showed some differences according to their location and expertise. Reporting trends in practice, and not only the evidence, is important to medical education and providing patients the safest care possible. This is a Level V, expert opinion study.
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Affiliation(s)
- María Tuca
- Pontificia Universidad Catolica de Chile, School of Medicine, Chile; Department of Orthopedics, Hospital Clinico Mutual de Seguridad, Santiago de Chile, Chile.
| | - Ignacio Valderrama
- Facultad de Medicina, Universidad de Chile, Santiago, Chile; Department of Orthopaedic Surgery, Hospital San José, Santiago, Chile
| | - Karl Eriksson
- Department of Orthopedics, Stockholm Söder Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockolm, Sweden
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15
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Vivacqua T, Thomassen S, Winkler PW, Lucidi GA, Rousseau-Saine A, Firth AD, Heard M, Musahl V, Getgood AM. Closing-Wedge Posterior Tibial Slope-Reducing Osteotomy in Complex Revision ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671221144786. [PMID: 36655015 PMCID: PMC9841842 DOI: 10.1177/23259671221144786] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/13/2022] [Indexed: 01/13/2023] Open
Abstract
Background A posterior tibial slope (PTS) >12° has been shown to correlate with failure of anterior cruciate ligament (ACL) reconstruction (ACLR). PTS-reducing osteotomy has been described to correct the PTS in patients with a deficient ACL, mostly after failure of primary ACLR. Purpose To report radiologic indices, clinical outcomes, and postoperative complications after PTS-reducing osteotomy performed concurrently with revision ACLR (R-ACLR). Study Design Case series; Level of evidence, 4. Methods A review of medical records at 3 institutions was performed of patients who had undergone PTS-reducing osteotomy concurrently with R-ACLR between August 2010 and October 2020. Radiologic parameters recorded included the PTS, patellar height according to the Caton-Deschamps Index (CDI), and anterior tibial translation (ATT). Patient-reported outcomes (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]), reoperations, and complications were evaluated. Results Included were 23 patients with a mean follow-up of 26.7 months (range, 6-84 months; median, 22.5 months). Statistically significant differences from preoperative to postoperative values were found in PTS (median [range], 14.0° [12°-18°] vs 4.0° [0°-15°], respectively; P < .001), CDI (median, 1.00 vs 1.10, respectively; P = .04) and ATT (median, 8.5 vs 3.6 mm, respectively; P = .001). At the final follow-up, the IKDC score was 52.4 ± 19.2 and the KOOS subscale scores were 81.5 ± 9.5 (Pain), 74 ± 21.6 (Symptoms), 88.5 ± 8 (Activities of Daily Living); 52.5 ± 21.6 (Sport and Recreation), and 48.8 ± 15.8 (Quality of Life). A traumatic ACL graft failure occurred in 2 patients (8.7%). Reoperations were necessary for 6 patients (26.1%) because of symptomatic hardware, and atraumatic recurrent knee instability was diagnosed in 1 patient (4.3%). Conclusion Tibial slope-reducing osteotomy resulted in a significant decrease of ATT and can be considered in patients with a preoperative PTS ≥12° and ≥1 ACLR failure. In highly complex patients with multiple prior surgeries, the authors found a reasonably low graft failure rate (8.7%) when utilizing PTS-reducing osteotomy. Surgeons must be aware of potential complications in patients with multiple previous failed ACLRs.
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Affiliation(s)
- Thiago Vivacqua
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Stephan Thomassen
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Philipp W. Winkler
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria.,Department of Sports Orthopaedics, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany.,Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gian A. Lucidi
- Department of Orthopedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Andrew D. Firth
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
| | - Mark Heard
- Banff Sport Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Volker Musahl
- Banff Sport Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alan M.J. Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.,Alan M.J. Getgood, MPhil, MD, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, ON, Canada N6A 3K7 ()
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16
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Sanborn RM, Badger GJ, Fleming BC, Kiapour AM, Fadale PD, Hulstyn MJ, Owens BD, Proffen B, Sant N, Portilla G, Freiberger C, Henderson R, Barnett S, Costa M, Chrostek C, Ecklund K, Micheli LJ, Murray MM, Yen YM, Kramer DE. Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure. Am J Sports Med 2023; 51:49-57. [PMID: 36412922 DOI: 10.1177/03635465221137873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.
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Affiliation(s)
- Ryan M Sanborn
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary J Badger
- Department of Medical Biostatistics, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ata M Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Paul D Fadale
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Michael J Hulstyn
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Brett D Owens
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Benedikt Proffen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Nicholas Sant
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Gabriela Portilla
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Christina Freiberger
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Rachael Henderson
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Samuel Barnett
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Meggin Costa
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Cynthia Chrostek
- Department of Orthopedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence Rhode Island, USA
| | - Kirsten Ecklund
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Lyle J Micheli
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Martha M Murray
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Yi-Meng Yen
- Department of Orthopedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts, USA
| | - Dennis E Kramer
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Cronström A, Tengman E, Häger CK. Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction. Sports Med 2023; 53:91-110. [PMID: 36001289 PMCID: PMC9807539 DOI: 10.1007/s40279-022-01747-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified. OBJECTIVE The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR. METHODS A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality. RESULTS Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture. CONCLUSION Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.
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Affiliation(s)
- Anna Cronström
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.
- Department of Health Sciences, Lund University, Lund, Sweden.
| | - Eva Tengman
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Charlotte K Häger
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
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18
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Chen Z, Xian Z, Chen H, Zhong Y, Wang F. Immediate effects of a buffered knee orthosis on gait in stroke patients with knee hyperextension. J Back Musculoskelet Rehabil 2022; 36:445-454. [PMID: 36278338 DOI: 10.3233/bmr-220069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients exhibit considerable variations in gait patterns especially in knee hyperextension in the stance phase after stroke. If knee hyperextension is untreated it may lead to pain, reduced independence in activities of daily living, deformities and instability. OBJECTIVE The aim of this study was to investigate the immediate effects of a buffered knee orthosis on gait of stroke patients with knee hyperextension. METHODS A total of nine patients with knee hyperextension after stroke were selected to wear buffered knee orthosis developed by Zhongshan Traditional Chinese Medicine Hospital and Ruike Medical Technology (Shanghai) Co., Ltd during walking training and daily walking. Then the gait analysis system of Motionanalysis was used to analyze and evaluate kinematic and spatiotemporal parameters of the gait in patients with independent walking or walking with a buffered knee orthosis. RESULTS After wearing the buffered knee brace, initial contact, maximum and minimum angles of support phase, the toe off the ground, maximum and minimum angles of swing phase on the injured side of knee and ankle increased. Minimum angle of support phase and maximum angle of swing phase on the uninjured side of ankle decreased, while the toe off the ground and minimum angles of swing phase increased significantly (all P< 0.05); There was no significant difference in other kinematics, in parameters between time and space, in walking speed among subjective gait parameters (P> 0.05). Walking distance, confidence, sense of security, and the feeling of walking hyperextension were all improved. In addition, the number of asymmetric kinematic parameters and spatiotemporal parameters decreased. CONCLUSION The buffered knee orthosis can effectively prevent knee hyperextension after stroke, improve the knee and ankle sagittal motion, gait asymmetry, gait subjective feeling, and does not affect gait space-time parameters.
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Affiliation(s)
- Zhibiao Chen
- Department of Rehabilitation, Zhongshan Rehabilitation Hospital (Shiqi Su Huazan Hospital), Zhongshan, Guangdong, China
| | - Zuxin Xian
- Department of Rehabilitation, Zhongshan TCM Hospital Affiliated to Guangzhou TCM University, Zhongshan, Guangdong, China
| | - Huanzhou Chen
- Department of Rehabilitation, Zhongshan TCM Hospital Affiliated to Guangzhou TCM University, Zhongshan, Guangdong, China
| | - Yuan Zhong
- Department of Rehabilitation, Zhongshan TCM Hospital Affiliated to Guangzhou TCM University, Zhongshan, Guangdong, China
| | - Feng Wang
- Department of Rehabilitation, Zhongshan TCM Hospital Affiliated to Guangzhou TCM University, Zhongshan, Guangdong, China
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19
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Bigouette JP, Owen EC, Lantz BBA, Hoellrich RG, Wright RW, Huston LJ, Haas AK, Allen CR, Cooper DE, DeBerardino TM, Dunn WR, Spindler KP, Stuart MJ, Albright JP, Amendola A(N, Annunziata CC, Arciero RA, Bach BR, Baker CL, Bartolozzi AR, Baumgarten KM, Bechler JR, Berg JH, Bernas GA, Brockmeier SF, Brophy RH, Bush-Joseph CA, Butler V JB, Carey JL, Carpenter JE, Cole BJ, Cooper JM, Cox CL, Creighton RA, David TS, Flanigan DC, Frederick RW, Ganley TJ, Garofoli EA, Gatt CJ, Gecha SR, Robert Giffin J, Hame SL, Hannafin JA, Harner CD, Harris NL, Hechtman KS, Hershman EB, Johnson DC, Johnson TS, Jones MH, Kaeding CC, Kamath GV, Klootwyk TE, Levy BA, Ma CB, Maiers GP, Marx RG, Matava MJ, Mathien GM, McAllister DR, McCarty EC, McCormack RG, Miller BS, Nissen CW, O’Neill DF, Owens BD, Parker RD, Purnell ML, Ramappa AJ, Rauh MA, Rettig AC, Sekiya JK, Shea KG, Sherman OH, Slauterbeck JR, Smith MV, Spang JT, Svoboda LTCSJ, Taft TN, Tenuta JJ, Tingstad EM, Vidal AF, Viskontas DG, White RA, Williams JS, Wolcott ML, Wolf BR, York JJ, York JJ. Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative. Am J Sports Med 2022; 50:1788-1797. [PMID: 35648628 PMCID: PMC9756873 DOI: 10.1177/03635465221094621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). HYPOTHESES Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. RESULTS At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. CONCLUSION Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.
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Affiliation(s)
| | - Erin C. Owen
- Slocum Research & Education Foundation, Eugene, OR USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tal S. David
- Synergy Specialists Medical Group, San Diego, CA USA
| | | | | | | | | | | | | | - James Robert Giffin
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London Ontario, Canada
| | - Sharon L. Hame
- David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | | | | | | | | | | | | | | | | | | | - Ganesh V. Kamath
- University of North Carolina Medical Center, Chapel Hill, NC USA
| | | | | | | | | | | | | | | | | | - Eric C. McCarty
- University of Colorado Denver School of Medicine, Denver, CO USA
| | - Robert G. McCormack
- University of British Columbia/Fraser Health Authority, British Columbia, Canada
| | | | | | | | - Brett D. Owens
- Warren Alpert Medical School, Brown University, Providence, RI USA
| | | | | | | | | | | | | | | | | | | | | | - Jeffrey T. Spang
- University of North Carolina Medical Center, Chapel Hill, NC USA
| | | | - Timothy N. Taft
- University of North Carolina Medical Center, Chapel Hill, NC USA
| | | | - Edwin M. Tingstad
- Inland Orthopaedic Surgery and Sports Medicine Clinic, Pullman, WA USA
| | - Armando F. Vidal
- University of Colorado Denver School of Medicine, Denver, CO USA
| | | | | | | | | | - Brian R. Wolf
- University of Iowa Hospitals and Clinics, Iowa City, IA USA
| | - James J. York
- Orthopaedic and Sports Medicine Center, LLC, Pasedena, MD
| | - James J York
- Investigation performed at Slocum Research and Education Foundation, Eugene, Oregon, USA
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20
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van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. Meniscal Tears, Posterolateral and Posteromedial Corner Injuries, Increased Coronal Plane, and Increased Sagittal Plane Tibial Slope All Influence Anterior Cruciate Ligament-Related Knee Kinematics and Increase Forces on the Native and Reconstructed Anterior Cruciate Ligament: A Systematic Review of Cadaveric Studies. Arthroscopy 2022; 38:1664-1688.e1. [PMID: 34883197 DOI: 10.1016/j.arthro.2021.11.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 10/27/2021] [Accepted: 11/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To obtain a comprehensive list of pathologies that cause increased anterior cruciate ligament (ACL) forces and pathologic knee kinematics to evaluate for in both primary and revision ACL reconstruction to decrease the risk of subsequent graft overload. METHODS An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 1990, and December 10, 2020. All articles investigating medial and lateral meniscal injury, (postero)lateral corner injury, (postero)medial corner/medial collateral ligament injury, valgus alignment, varus alignment, and tibial slope in relation to ACL (graft) force and knee kinematics were included. RESULTS Data of 43 studies were included. The studies reported that high-volume medial and lateral meniscectomies, peripheral meniscus tears, medial meniscus ramp tears, lateral meniscus root tears, posterolateral corner injuries, medial collateral ligament tears, increased tibial slope, and valgus and varus alignment were reported to have a significant impact on ACL (graft) force and related knee kinematics. CONCLUSIONS This systematic review on biomechanical cadaver studies provides a rationale to systematically identify and treat pathologies in ACL-injured knees, because when undiagnosed or left untreated, these specific concomitant pathologies could lead to ACL graft overload in both primary and revision ACL-reconstructed knees. CLINICAL RELEVANCE it is necessary that orthopaedic surgeons who treat ACL-injured knees understand the surgically relevant biomechanical consequences of additional pathologies and use this knowledge to optimize treatment in ACL-injured patients.
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Affiliation(s)
| | - Diederik T Meijer
- Department of Orthopedic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
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21
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Leon J, Flanigan DC, Colatruglio M, Ormseth B, Fitzpatrick S, Duerr RA, Kaeding CC, Magnussen RA. Larger Prior Tibial Tunnel Size Is Associated with Increased Failure Risk following Revision Anterior Cruciate Ligament Reconstruction. J Knee Surg 2022. [PMID: 35240716 DOI: 10.1055/s-0042-1743234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We hypothesize that larger prior tunnel size is associated with an increased risk of failure of single-stage revision anterior cruciate ligament reconstruction (ACLR) as defined by the performance of a re-revision (third) ACLR on the index knee. Retrospective review identified 244 patients who underwent single-stage revision ACLR at a single center with available preoperative radiographs. Patient and surgical factors were extracted by chart review. The maximum diameter of the tibial tunnel was measured on lateral radiographs and the maximum diameter of the femoral tunnel was measured on anteroposterior radiographs. Record review and follow-up phone calls were used to identify failure of the revision surgery as defined by re-revision ACLR on the index knee. One hundred and seventy-one patients (70%) were reviewed with a mean of 3.9 years follow-up. Overall, 23 patients (13.4%) underwent re-revision surgery. Mean tibial tunnel size was 12.6 ± 2.8 mm (range: 5.7-26.9 mm) and mean femoral tunnel size was 11.7 ± 2.8 mm (range: 6.0-23.0 mm). Re-revision risk increased with tibial tunnel size. Tibial tunnels 11 mm and under had a re-revision risk of 4.2%, while tunnels > 11 mm had a risk of 17.1% (relative risk: 4.1, p = 0.025). No significant association between femoral tunnel size and re-revision risk was noted. Patients with prior tibial tunnels > 11mm in diameter at revision surgery had significantly increased risk of re-revision ACLR. Further studies are needed to explore the relationship between prior tunnel size and outcomes of revision ACLR.
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Affiliation(s)
- Jacy Leon
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - David C Flanigan
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Matthew Colatruglio
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Benjamin Ormseth
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Sean Fitzpatrick
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Robert A Duerr
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Christopher C Kaeding
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
| | - Robert A Magnussen
- Department of Orthopaedics, OSU Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio
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22
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Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review. Clin J Sport Med 2022; 32:139-144. [PMID: 34173782 DOI: 10.1097/jsm.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes. DATA SOURCES PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized. MAIN RESULTS Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low. CONCLUSION Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.
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23
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Toker MB, Erden T, Toprak A, Taşer ÖF. Does anterolateral ligament internal bracing improve the outcomes of anterior cruciate ligament reconstruction in patients with generalized joint hypermobility? ULUS TRAVMA ACIL CER 2022; 28:320-327. [PMID: 35485559 PMCID: PMC10493536 DOI: 10.14744/tjtes.2022.39998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Generalized joint hypermobility (GJH) is a risk factor for anterior cruciate ligament (ACL) injury and ACL graft failure and is considered an indication for anterolateral ligament (ALL) reconstruction. The aim of this retrospective study was to compare functional outcomes, rupture rates, and residual instability in patients with GJH undergoing isolated ACL reconstruction or combined ACL reconstruction and ALL augmentation with internal bracing (ALL-IB). METHODS Sixty-eight patients with GJH and unilateral ACL injury were randomly assigned to undergo either isolated ACL reconstruction (Group 1) or combined ACL reconstruction and ALL-IB (Group 2). The patients were evaluated pre- and postoperatively; their medical histories; physical examination results; anterior knee translation, as measured using the KT-1000 arthrometer; and scores of validated knee assessments were recorded. RESULTS Groups 1 and 2 consisted of 37 and 31 patients, respectively. The mean follow-up was 30.1±4.1 and 28.1±2.9 months, respectively. In the final evaluation, the patients in Group 2 showed better rotational stability, as evaluated by the pivot-shift test (p=0.013); better anteroposterior stability, as evaluated by KT-1000 arthrometry (p=0.001); similar function (p=0.14 for the Lysholm, p=0.11 for the Cincinnati, and p=0.19 for the International Knee Documentation Committee subjective score); and failure rate (p=0.41). CONCLUSION The functional outcomes were similar between the groups. The stability outcomes after combined ACL and ALL-IB were better than those after isolated ACL reconstruction in patients with GJH. However, the technique and its results need to be validated in larger patient series and prospective randomized controlled trials.
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Affiliation(s)
- Mehmet Berkin Toker
- Department of Orthopaedics and Traumatology, Acıbadem Fulya Hospital Sports Medicine Center, İstanbul-Turkey
| | - Tunay Erden
- Department of Orthopaedics and Traumatology, Acıbadem Fulya Hospital Sports Medicine Center, İstanbul-Turkey
| | - Ali Toprak
- Department of Biostatistics and Medical Informatics, Bezmialem Vakıf University Faculty of Medicine, İstanbul-Turkey
| | - Ömer Faruk Taşer
- Department of Orthopaedics and Traumatology, Acıbadem Fulya Hospital Sports Medicine Center, İstanbul-Turkey
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24
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Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PC, Peterson D, Bardana D, Rezansoff A, Getgood AM, Willits K, Birmingham T, Hewison C, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declerq G, Vuylsteke K, Van Haver M. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med 2022; 50:384-395. [PMID: 35050817 PMCID: PMC8829733 DOI: 10.1177/03635465211061150] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.
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Affiliation(s)
| | | | - Robert Litchfield
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | - Tim Spalding
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alex Rezansoff
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | - Alan M.J. Getgood
- Alan M.J. Getgood, MD, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, London, ON N6A 3K7, Canada () (Twitter: FKSMC_Getgood)
| | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | - Bindu Mohan
- Fraser Orthopaedic Institute, New Westminster, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent, Belgium,Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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25
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Moreno Mateo F, Perea SH, Green DW. Lateral-extra articular tenodesis vs. anterolateral ligament reconstruction in skeletally immature patients undergoing anterior cruciate ligament reconstruction. Curr Opin Pediatr 2022; 34:71-75. [PMID: 34845153 DOI: 10.1097/mop.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent available evidence about lateral-extra articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction in young patients treated for anterior cruciate ligament (ACL) injury. RECENT FINDINGS The ALL of the knee acts as a secondary stabilizer of the knee preventing anterior translation and internal rotation. In vitro and in vivo biomechanical studies as well as prospective clinical trials have shown the importance of the ALL in knee biomechanics. The ALL injury has a synergetic impact on the knee stability in patients with acute ACL injury. ALL augmentation of ACL provides reduction of knee instability and graft failure and higher return to sport rates in high-risk patients. It has not been demonstrated that extra-articular procedures increase the risk of knee osteoarthritis secondary to knee over-constriction. Both Iliotibial band (ITB) ALL reconstruction and modified Lemaire LET have been shown safe and effective. Minimal biomechanical or clinical differences have been found between the two reconstruction methods. SUMMARY Young patients with ACL tears and risk factors such as laxity or pivot shift willing to return to sports may benefit from ALL augmentation. Therefore, it is essential to identify these high-risk patients to individualize treatment.
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Affiliation(s)
- Fernando Moreno Mateo
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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26
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Winkler PW, Vivacqua T, Thomassen S, Lovse L, Lesniak BP, Getgood AMJ, Musahl V. Quadriceps tendon autograft is becoming increasingly popular in revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:149-160. [PMID: 33591370 PMCID: PMC8800889 DOI: 10.1007/s00167-021-06478-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/25/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate trends in revision anterior cruciate ligament reconstruction (ACL-R), with emphasis on intra-articular findings, grafts, and concurrent procedures. It was hypothesized that revision ACL-Rs over time show a trend toward increased complexity with increased use of autografts over allografts. METHODS This was a two-center retrospective study including patients undergoing revision ACL-R between 2010 and 2020. Demographic and surgical data including intra-articular findings and concurrent procedures were collected and compared for the time periods 2010-2014 and 2015-2020. All collected variables were compared between three pre-defined age groups (< 20 years, 20-30 years, > 30 years), right and left knees, and males and females. A time series analysis was performed to assess trends in revision ACL-R. RESULTS This study included 260 patients with a mean age of 26.2 ± 9.4 years at the time of the most recent revision ACL-R, representing the first, second, third, and fourth revision ACL-R for 214 (82%), 35 (14%), 10 (4%), and 1 (< 1%) patients, respectively. Patients age > 30 years showed a significantly longer mean time from primary ACL-R to most recent revision ACL-R (11.1 years), compared to patients age < 20 years (2.2 years, p < 0.001) and age 20-30 years (5.5 years, p < 0.05). Quadriceps tendon autograft was used significantly more often in 2015-2020 compared to 2010-2014 (49% vs. 18%, p < 0.001). A high rate of concurrently performed procedures including meniscal repairs (45%), lateral extra-articular tenodesis (LET; 31%), osteotomies (13%), and meniscal allograft transplantations (11%) was shown. Concurrent LET was associated with intact cartilage and severely abnormal preoperative knee laxity and showed a statistically significant and linear increase over time (p < 0.05). Intact cartilage (41%, p < 0.05), concurrent medial meniscal repairs (39%, p < 0.05), and LET (35%, non-significant) were most frequently observed in patients aged < 20 years. CONCLUSION Quadriceps tendon autograft and concurrent LET are becoming increasingly popular in revision ACL-R. Intact cartilage and severely abnormal preoperative knee laxity represent indications for LET in revision ACL-R. The high rate of concurrent procedures observed demonstrates the high surgical demands of revision ACL-R. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Philipp W. Winkler
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA 15203 USA ,grid.15474.330000 0004 0477 2438Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Thiago Vivacqua
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Stephan Thomassen
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Lisa Lovse
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Bryson P. Lesniak
- grid.21925.3d0000 0004 1936 9000Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA 15203 USA
| | - Alan M. J. Getgood
- grid.39381.300000 0004 1936 8884Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON N6A 3K7 Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA.
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Katagiri H, Nakagawa Y, Miyatake K, Ozeki N, Kohno Y, Amemiya M, Sekiya I, Koga H. Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft. J Knee Surg 2021; 36:613-621. [PMID: 34952548 DOI: 10.1055/s-0041-1740927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft. METHODS Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test. RESULTS Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02). STUDY DESIGN This was a level 3 retrospective study. CONCLUSION Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.
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Affiliation(s)
- Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopedic Surgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Saitama, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutake Ozeki
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Yuji Kohno
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Masaki Amemiya
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Ichiro Sekiya
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Guimarães TM, Giglio PN, Sobrado MF, Bonadio MB, Gobbi RG, Pécora JR, Helito CP. Knee Hyperextension Greater Than 5° Is a Risk Factor for Failure in ACL Reconstruction Using Hamstring Graft. Orthop J Sports Med 2021; 9:23259671211056325. [PMID: 34820464 PMCID: PMC8606942 DOI: 10.1177/23259671211056325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The degree of knee hyperextension in isolation has not been studied in detail as a risk factor that could lead to increased looseness or graft failure after anterior cruciate ligament (ACL) reconstruction. Purpose: To analyze whether more than 5° of passive knee hyperextension is associated with worse functional outcomes and greater risk of graft failure after primary ACL reconstruction with hamstring tendon autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of patients who had primary ACL reconstruction with hamstring tendon autografts was divided into 2 groups based on passive contralateral knee hyperextension greater than 5° (hyperextension group) and less than 5° (control group) of hyperextension. Groups were matched by age, sex, and associated meniscal tears. The following data were collected and compared between the groups: patient data (age and sex), time from injury to surgery, passive knee hyperextension, KT-1000 arthrometer laxity, pivot shift, associated meniscal injury and treatment (meniscectomy or repair), contralateral knee ligament injury, intra-articular graft size, follow-up time, occurrence of graft failure, and postoperative Lysholm knee scale and International Knee Documentation Committee subjective form scores. Results: Data from 358 patients initially included in the study were analyzed; 22 were excluded because the time from injury to surgery was greater than 24 months, and 22 were lost to follow-up. From the cohort of 314 patients, 102 had more than 5° of knee hyperextension. A control group of the same size (n = 102) was selected by matching among the other 212 patients. Significant differences in the incidence of graft failure (14.7% vs 2.9%; P = .005) and Lysholm knee scale score (86.4 ± 9.8 vs 89.6 ± 6.1; P = .018) were found between the 2 groups. Conclusion: Patients with more than 5° of contralateral knee hyperextension submitted to single-bundle ACL reconstruction with hamstring tendons have a higher failure rate than patients with less than 5° of knee hyperextension.
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Affiliation(s)
- Tales Mollica Guimarães
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
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Lameire DL, Abdel Khalik H, Zakharia A, Kay J, Almasri M, de Sa D. Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review. Arthroscopy 2021; 37:2361-2376.e1. [PMID: 33771689 DOI: 10.1016/j.arthro.2021.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/05/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this systematic review was to evaluate the impact of bone grafting of patellar defects on reported anterior knee morbidity and subjective outcomes after bone-patellar tendon-bone autograft reconstruction of the anterior cruciate ligament. METHODS A systematic electronic search of MEDLINE, Embase, Web of Science, and the Cochrane Library was carried out. All English-language prospective randomized clinical trials published from January 1, 2000, to July 24, 2020, were eligible for inclusion. All studies addressing patellar defect grafting were eligible for inclusion regardless of the timing of surgery, graft type, surgical technique, or rehabilitation protocol. RESULTS A total of 39 studies with 1,955 patients were included for analysis. There were 796 patients in the no patellar grafting (NPG) group, with a mean age range of 22.7 to 33.0 years, and 1,159 patients in the patellar grafting (PG) group, with a mean age range of 17.8 to 34.7 years. The visual analog scale pain score ranged from 1.2 to 5.1 in the NPG group compared with 0.3 to 3.7 in the PG group. The proportion of patients with anterior knee pain ranged from 19% to 81% in the NPG group and from 15% to 32% in the PG group. Moderate to severe kneeling pain was reported in 22% to 57% of patients in the NPG group and 10% of those in the PG group. The percentage of patients with at least 3° of extension loss ranged from 4% to 43% in the NPG group and from 2% to 11% in the PG group. CONCLUSIONS PG favors decreased anterior knee pain, kneeling pain, and extension loss compared with non-grafted defects; however, the functional outcomes are comparable. Owing to the heterogeneity in reporting, statistical conclusions could not be drawn. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.
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Affiliation(s)
- Darius L Lameire
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan Abdel Khalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alexander Zakharia
- MacSports Research Program, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Almasri
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Mercy Health-Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio, U.S.A
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
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Krebs NM, Barber-Westin S, Noyes FR. Generalized Joint Laxity Is Associated With Increased Failure Rates of Primary Anterior Cruciate Ligament Reconstructions: A Systematic Review. Arthroscopy 2021; 37:2337-2347. [PMID: 33621648 DOI: 10.1016/j.arthro.2021.02.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate patients with generalized joint laxity (GJL) after primary anterior cruciate ligament reconstruction (ACLR) as to the risk of ACLR failure, graft selection success rates, and overall clinical outcomes. METHODS A systematic review of the PubMed and EMBASE databases was performed to identify studies published from the inception of the databases through February 4, 2020. The inclusion criteria were original studies written in English involving outcomes of patients with GJL who had undergone primary ACLR. RESULTS Nine studies met the inclusion criteria, which included 1,869 patients. Most underwent isolated bone-patellar tendon-bone (BPTB; n = 1062) or hamstring autograft (n = 696) ACLR. Overall, higher graft failure rates tended to occur in patients with GJL compared with patients without GJL (range per study: 6%-30% vs 0%-12.3%). Inferior results were also found patients with GJL in patient-reported outcome measures and postoperative knee stability determined by KT, Lachman, and pivot-shift tests. BPTB autografts tended to have lower failure rates than hamstring autografts in patients with GJL (range per study: 6%-21% vs 17.6%-30%). Only 1 study determined outcomes of a combined ACLR and extra-articular augmentation in patients with GJL. CONCLUSIONS Patients with GJL are at an increased risk of inferior outcomes and graft failure after primary ACLR. BPTB autografts may have more favorable stability outcomes compared with hamstring autografts in patients with GJL. However, the reported stability parameters and KT results, even with a BPTB autograft, remain inferior to non-GJL published results, and the added benefit of an extra-articular procedure to supplement the primary ACLR deserves consideration. LEVEL OF EVIDENCE Level III, systematic review of Level II and III investigations.
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Affiliation(s)
- Nathan M Krebs
- Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, Ohio, U.S.A
| | | | - Frank R Noyes
- Cincinnati SportsMedicine & Orthopaedic Center, Cincinnati, Ohio, U.S.A.; Noyes Knee Institute, Cincinnati, Ohio, U.S.A.; Department of Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio, U.S.A
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Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons. Arthroscopy 2021; 37:1559-1566. [PMID: 33539983 DOI: 10.1016/j.arthro.2021.01.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection. METHODS A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience. RESULTS Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics. CONCLUSIONS Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients. CLINICAL RELEVANCE Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.
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Lindanger L, Strand T, Mølster AO, Solheim E, Inderhaug E. Effect of Early Residual Laxity After Anterior Cruciate Ligament Reconstruction on Long-term Laxity, Graft Failure, Return to Sports, and Subjective Outcome at 25 Years. Am J Sports Med 2021; 49:1227-1235. [PMID: 33656379 DOI: 10.1177/0363546521990801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction (ACLR), and its clinical effect is undetermined. PURPOSE To investigate whether a 3- to 5-mm increase in anterior translation 6 months after ACLR affects the risk of graft failure, rate of return to sports, and long-term outcome. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS From a cohort of 234 soccer, team handball, and basketball players undergoing ACLR using bone-patellar tendon-bone graft, 151 athletes were included who attended 6-month follow-up that included KT-1000 arthrometer measures. A tight graft was defined as <3-mm side-to-side difference between knees (n = 129), a slightly loose graft as 3 to 5 mm (n = 20), and a loose graft as >5 mm (n = 2). Graft failure was defined as ACL revision surgery, >5-mm side-to-side difference, or anterolateral rotational instability 2+ or 3+ at 2-year follow-up. Finally, a 25-year evaluation was performed, including a clinical examination and questionnaires. RESULTS The rate of return to pivoting sports was 74% among athletes with tight grafts and 70% among those with slightly loose grafts. Also, return to preinjury level of sports was similar between those with slightly loose and tight grafts (40% vs 48%, respectively), but median duration of the sports career was longer among patients with tight grafts: 6 years (range, 1-25 years) vs 2 years (range, 1-15 years) (P = .01). Five slightly loose grafts (28%) and 6 tight grafts (5%) were classified as failures after 2 years (P = .002). Thirty percent (n = 6) of patients with slightly loose grafts and 6% (n = 8) with tight grafts had undergone revision (P = .004) by follow-up (25 years, range, 22-30 years). Anterior translation was still increased among the slightly loose grafts as compared with tight grafts at long-term follow-up (P < .05). In patients with tight grafts, 94% had a Lysholm score ≥84 after 24 months and 58% after 25 years, as opposed to 78% (P = .02) and 33% (P = .048), respectively, among patients with slightly loose grafts. CONCLUSION A slightly loose graft at 6 months after ACLR increased the risk of later ACL revision surgery and/or graft failure, reduced the length of the athlete's sports career, caused permanent increased anterior laxity, and led to an inferior Lysholm score.
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Affiliation(s)
- Line Lindanger
- Department of Orthopedics, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Torbjørn Strand
- Department of Orthopedics, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Orthopedics, Haukeland University Hospital, The Coastal Hospital at Hagevik, Bergen, Norway
| | - Anders Odd Mølster
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eirik Solheim
- Department of Orthopedics, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eivind Inderhaug
- Department of Orthopedics, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Six P, Caudin J, Thévenon A. Impact of knee recurvatum on machine-assessed muscle recovery from isokinetic after anterior cruciate ligament surgery. Sci Sports 2021. [DOI: 10.1016/j.scispo.2020.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
INTRODUCTION The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness. DISCUSSION Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well. CONCLUSION Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.
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Yamasaki S, Hashimoto Y, Iida K, Nishino K, Nishida Y, Takigami J, Takahashi S, Nakamura H. Risk factors for postoperative graft laxity without re-injury after double-bundle anterior cruciate ligament reconstruction in recreational athletes. Knee 2021; 28:338-345. [PMID: 33485163 DOI: 10.1016/j.knee.2020.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/18/2020] [Accepted: 12/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although high activity is a risk factor for graft failure after anterior cruciate ligament (ACL) reconstruction, the risk factors for postoperative laxity after ACL reconstruction in recreational athletes are unknown. METHODS We enrolled 91 patients (40 males, 51 females; mean age 29.2 years; mean follow-up 4.3 years) who scored ≤ 6 on the Tegner activity scale, underwent double-bundle ACL reconstruction between 2010 and 2018, and did not experience re-injury. In the stable group (75 patients, <3.0 mm side-to-side difference (SSD) in anterior translation, grade 0 or 1 pivot shift 1 year after surgery) and unstable group (16 patients, ≥3.0 mm SSD, ≥grade 2 pivot shift), multivariate logistic regression analyses adjusted for factors showing P ≤ 0.3 on univariate analysis assessed risk factors for graft laxity. Lysholm score and graft intensity on MRI (Howell grade) were compared at final follow-up. RESULTS Mean SSD in anterior translation was 0.7 mm (stable group) and 3.3 mm (unstable group). Pivot shift grades were 0 (88%) and 1 (12%) in the stable group, and 0 (12.5%), 1 (50%), and 2 (37.5%) in the unstable group. Multivariate regression analyses showed that younger age and knee hyperextension were significant risk factors for graft laxity (P = 0.018 and 0.0016; cutoffs 18 years old and 8°, respectively). Lysholm scores in both groups were comparable, but graft intensity on MRI demonstrated significantly worse Howell grade in the unstable group (P = 0.002). CONCLUSION Younger age and knee hyperextension were risk factors for postoperative graft laxity without re-injury in recreational athletes.
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Affiliation(s)
- Shinya Yamasaki
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan; Department of Orthopaedic Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | - Ken Iida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuya Nishino
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, 100-1 Kashiyama, Habikino, Osaka 583-0875, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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Ziegler CG, DePhillipo NN, Kennedy MI, Dekker TJ, Dornan GJ, LaPrade RF. Beighton Score, Tibial Slope, Tibial Subluxation, Quadriceps Circumference Difference, and Family History Are Risk Factors for Anterior Cruciate Ligament Graft Failure: A Retrospective Comparison of Primary and Revision Anterior Cruciate Ligament Reconstructions. Arthroscopy 2021; 37:195-205. [PMID: 32911007 DOI: 10.1016/j.arthro.2020.08.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/23/2020] [Accepted: 08/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess patient history, physical examination findings, magnetic resonance imaging (MRI) and 3-dimensional computed tomographic (3D CT) measurements of those with anterior cruciate ligament (ACL) graft failure compared with primary ACL tear patients to better discern risk factors for ACL graft failure. METHODS We performed a retrospective review comparing patients who underwent revision ACL reconstruction (ACLR) with a primary ACLR group with minimum 1-year follow-up. Preoperative history, examination, and imaging data were collected and compared. Measurements were made on MRI, plain radiographs, and 3D CT. Inclusion criteria were patients who underwent primary ACLR by a single surgeon at a single center with minimum 1-year follow-up or ACL graft failure with revision ACLR performed by the same surgeon. RESULTS A total of 109 primary ACLR patients, mean age 33.7 years (range 15 to 71), enrolled between July 2016 and July 2018 and 90 revision ACLR patients, mean age 32.9 years (range 16 to 65), were included. The revision ACLR group had increased Beighton score (4 versus 0; P < .001) and greater side-to-side differences in quadricep circumference (2 versus 0 cm; P < .001) compared with the primary ACLR group. A family history of ACL tear was significantly more likely in the revision group (47.8% versus 16.5%; P < .001). The revision group exhibited significantly increased lateral posterior tibial slope (7.9° versus 6.2°), anterolateral tibial subluxation (7.1 versus 4.9 mm), and anteromedial tibia subluxation (2.7 versus 0.5 mm; all P < .005). In the revision group, femoral tunnel malposition occurred in 66.7% in the deep-shallow position and 33.3% in the high-low position. The rate of tibial tunnel malposition was 9.7% from medial to lateral and 54.2% from anterior to posterior. Fifty-six patients (77.8%) had tunnel malposition in ≥2 positions. Allograft tissue was used for the index ACLR in 28% in the revision group compared with 14.7% in the primary group. CONCLUSION Beighton score, quadriceps circumference side-to-side difference, family history of ACL tear, lateral posterior tibial slope, anterolateral tibial subluxation, and anteromedial tibia subluxation were all significantly different between primary and revision ACLR groups. In addition, there was a high rate of tunnel malposition in the revision ACLR group.
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Affiliation(s)
- Connor G Ziegler
- Steadman Clinic Vail, Colorado, U.S.A.; New England Orthopedic Surgeons, Springfield, Massachusetts, U.S.A
| | - Nicholas N DePhillipo
- Steadman Clinic Vail, Colorado, U.S.A.; Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | | | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
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Vaudreuil N, Roe J, Salmon L, Servien E, van Eck C. Management of the female anterior cruciate ligament: current concepts. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Porter M, Shadbolt B. Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial. Am J Sports Med 2020; 48:1069-1077. [PMID: 32182127 DOI: 10.1177/0363546520910148] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The indications for the addition of anterolateral soft tissue augmentation to anterior cruciate ligament (ACL) reconstruction and its effectiveness remain uncertain. PURPOSE To determine if modified iliotibial band tenodesis (MITBT) can improve clinical outcomes and reduce the recurrence of ACL ruptures when added to ACL reconstruction in patients with a residual pivot shift. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS Patients with a primary ACL rupture satisfying the following inclusion criteria were enrolled: first ACL rupture, involved in pivoting sports, skeletally mature, no meniscal repair performed, and residual pivot shift relative to the contralateral uninjured knee immediately after ACL reconstruction. Patients were randomized to group A (no further surgery) or group B (MITBT added) and were followed up for 2 years. The patient-reported outcome (PRO) measures used were the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) subscale of sport/recreation (Sport/Rec), KOOS subscale of quality of life (QoL), Lysholm knee score (LKS), Tegner activity scale (TAS), recurrent ACL ruptures, or need for further surgery in either knee. Analysis of variance was used to compare PROs; the Wilcoxon test was used for the TAS; and the chi-square test was used for recurrence of ACL ruptures, meniscal injuries, and contralateral ACL ruptures (P < .05). RESULTS A total of 55 patients were randomized: 27 to group A (female:male ratio = 15:12; mean age, 22.3 ± 3.7 years) and 28 to group B (female:male ratio = 17:11; mean age, 21.8 ± 4.1 years). At 2-year follow-up, group A had a similar IKDC score (90.9 ± 10.7 vs 94.2 ± 11.2; respectively; P = .21), lower KOOS Sport/Rec score (91.5 ± 6.4 vs 95.3 ± 4.4, respectively; P = .02), similar KOOS QoL score (92.0 ± 4.8 vs 95.1 ± 4.3, respectively; P = .14), lower LKS score (92.5 ± 4.8 vs 96.8 ± 8.0, respectively; P = .004), lower TAS score (median, 7 [range, 7-9] vs 8 [range, 8-10], respectively; P = .03), higher rate of recurrence (14.8% vs 0.0%, respectively; P < .001), similar rate of meniscal tears (14.8% vs 3.6%, respectively; P = .14), and similar rate of contralateral ACL ruptures (3.7% vs 3.6%, respectively; P = .99) relative to group B. CONCLUSION The augmentation of ACL reconstruction with MITBT reduced the risk of recurrent ACL ruptures in knees with a residual pivot shift after ACL reconstruction and improved KOOS Sport/Rec, LKS, and TAS scores. REGISTRATION ACTRN12618001043224 (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Mark Porter
- Canberra Orthopaedics and Sports Medicine, Bruce, Australian Capital Territory, Australia
| | - Bruce Shadbolt
- Canberra Hospital, Garran, Australian Capital Territory, Australia
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Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, Peterson D, Bardana D, MacDonald PB, Verdonk PCM, Spalding T, Willits K, Birmingham T, Hewison C, Wanlin S, Firth A, Pinto R, Martindale A, O'Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Pritchett R, Payne K, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Millan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declercq G, Vuylsteke K, Van Haver M. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med 2020; 48:285-297. [PMID: 31940222 DOI: 10.1177/0363546519896333] [Citation(s) in RCA: 326] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. HYPOTHESIS We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. RESULTS A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 (P = .003) and KOOS (P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months (P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale (P = .11). CONCLUSION The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. REGISTRATION NCT02018354 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Alan M J Getgood
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert Litchfield
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mark Heard
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert G McCormack
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alex Rezansoff
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Devin Peterson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Davide Bardana
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter B MacDonald
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter C M Verdonk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kevin Willits
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Trevor Birmingham
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Chris Hewison
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Stacey Wanlin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Firth
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Pinto
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ashley Martindale
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Lindsey O'Neill
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Morgan Jennings
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michal Daniluk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dory Boyer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mauri Zomar
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karyn Moon
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Raely Pritchett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Krystan Payne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Brenda Fan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Bindu Mohan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Gregory M Buchko
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laurie A Hiemstra
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Kerslake
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jeremy Tynedal
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Greg Stranges
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sheila Mcrae
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - LeeAnne Gullett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Holly Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Legary
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Longo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mat Christian
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Celeste Ferguson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nick Mohtadi
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Rhamona Barber
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Denise Chan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Caitlin Campbell
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Garven
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karen Pulsifer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michelle Mayer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nicole Simunovic
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Duong
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Robinson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Levy
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Matt Skelly
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Fiona Howells
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Murray Tough
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Pete Thompson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Metcalfe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laura Asplin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alisen Dube
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Louise Clarkson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jaclyn Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Bolsover
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Carolyn Bradshaw
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Larissa Belgrove
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Francis Millan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sylvia Turner
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Verdugo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Janet Lowe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Debra Dunne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kerri McGowan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Charlie-Marie Suddens
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Geert Declercq
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kristien Vuylsteke
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mieke Van Haver
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pécora JR, Camanho GL, Demange MK. Combined Reconstruction of the Anterolateral Ligament in Patients With Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better Clinical Stability and a Lower Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction. Arthroscopy 2019; 35:2648-2654. [PMID: 31421960 DOI: 10.1016/j.arthro.2019.03.059] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/27/2019] [Accepted: 03/30/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare functional outcomes, residual instability, and rupture rates in patients with ligamentous hyperlaxity undergoing isolated anterior cruciate ligament (ACL) reconstruction or combined ACL and anterolateral ligament (ALL) reconstruction. METHODS Two groups of patients were evaluated and compared retrospectively. Both groups consisted of patients with ACL injuries and associated ligamentous hyperlaxity, defined based on the modified Beighton scale with a minimum score of 5. Group 1 patients underwent anatomical ACL reconstruction, and group 2 patients underwent anatomical ACL reconstruction combined with ALL reconstruction. Group 1 consisted of historical controls. The presence of associated meniscal injury, subjective International Knee Documentation Committee and Lysholm functional scores, KT-1000 measurements, the presence of a residual pivot-shift, and the graft rupture rate were evaluated. The study was performed at University of São Paulo in Brazil. RESULTS Ninety patients undergoing ACL reconstruction with ligamentous hyperlaxity were evaluated. The mean follow up was 29.6 ± 6.2 months for group 1 and 28.1 ± 4.2 months for group 2 (P = .51). No significant differences were found between the groups regarding Beighton scale, gender, the duration of injury before reconstruction, follow-up time, preoperative instability, or associated meniscal injuries. The mean age was 29.9 ± 8.1 years in group 1 and 27.0 ± 9.1 years in group 2 (P = .017). In the final evaluation, group 2 patients showed better anteroposterior clinical stability as evaluated by KT-1000 arthrometry (P = .02), better rotational stability as evaluated by the pivot-shift test (P = .03) and a lower reconstruction failure rate (21.7% [group 1] vs 3.3% [group 2]; P = .03). Clinical evaluations of postoperative functional scales showed no differences between the 2 groups (P = .27 for International Knee Documentation Committee; P = .41 for Lysholm). CONCLUSIONS Combined ACL and ALL reconstruction in patients with ligamentous hyperlaxity resulted in a lower failure rate and improved knee stability parameters compared to isolated ACL reconstruction. No differences were found in the functional scales. LEVEL OF EVIDENCE Level III, case control study.
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Affiliation(s)
- Camilo Partezani Helito
- Hospital Sírio-Libanês, São Paulo, Brazil; Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Getgood A, Bryant D, Firth A. The Stability study: a protocol for a multicenter randomized clinical trial comparing anterior cruciate ligament reconstruction with and without Lateral Extra-articular Tenodesis in individuals who are at high risk of graft failure. BMC Musculoskelet Disord 2019; 20:216. [PMID: 31092226 PMCID: PMC6521537 DOI: 10.1186/s12891-019-2589-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 04/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of anterior cruciate ligament reconstruction (ACLR) is to restore stability to the knee. Persistent rotational laxity following ACLR has been correlated with poor outcome and graft failure. We hypothesize that anterolateral complex reconstruction by way of a Modified Lemaire Lateral Extra-articular Tenodesis (LET) in combination with single bundle ACLR would reduce the risk of persistent rotatory laxity in young individuals who are deemed as being at high risk of failure. We will conduct a pragmatic, multicenter, randomized clinical trial comparing standard single bundle hamstring ACLR with combined ACLR and LET. Methods Six-hundred patients (300 per group) aged 25 years or less with an ACL deficient knee that meet two of the following three criteria will be included: 1) Grade 2 pivot shift or greater; 2) Returning to high risk cutting or pivoting sports; 3) Generalized ligamentous laxity. Participants will be seen at 3-months, 6-months, 12-months and 24-months post-operatively. The primary outcome measure is graft failure requiring revision ACLR or symptomatic instability associated with a positive asymmetric pivot shift indicating persistent rotational laxity. Patients will complete secondary outcome measures at each follow-up visit including patient-reported outcome measures, functional and biomechanical testing, and magnetic resonance imaging. Discussion This protocol is the first adequately powered randomized clinical trial investigating the effects of augmenting ACLR with an LET in patients at high-risk of graft failure. The successful completion of this trial has the potential to change surgical practice and provide evidence for the role of the LET in ACLR. Trial registration The trial is registered at ClinicalTrials.gov: NCT02018354, 23-12-2013.
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Affiliation(s)
- Alan Getgood
- Orthopaedic Sport Medicine Fellowship Director, Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Dianne Bryant
- Faculty of Health Sciences, Elborn College, University of Western Ontario, Room 1438, 1201 Western Rd, London, ON, N6C 1H1, Canada
| | - Andrew Firth
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada.
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