Does Anterior Cruciate Ligament Reconstruction Improve Functional and Radiographic Outcomes Over Nonoperative Management 5 Years After Injury?

The increased lateral tibial slope may result in inferior long-term clinical outcome after DB-ACL reconstruction

PURPOSE

To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction.

METHODS

We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study.

RESULTS

A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees.

CONCLUSIONS

Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome.

LEVEL OF EVIDENCE

III retrospective comparative prognostic trial.

High prevalence of associated intra-articular injuries with increasing time period from anterior cruciate ligament injury to reconstruction, even in apparent copers

BACKGROUND

It still unclear whether copers may bear the same time-sensitive risk of intra-articular injury as non-copers. The objectives were to investigate the clinical characteristics of copers and non-copers that have sustained an anterior cruciate ligament (ACL) injury, and to examine and compare the intra-articular pathologies in delayed ACL reconstruction (ACLR) in copers and noncopers.

METHODS

Patients who sustained ACL injury while participating in high-performance sports and opted for non-operative treatment were enrolled in this study. Depending on the occurrence of the knee giving way, patients were classified into copers and noncopers. Clinical characteristics were compared between the two groups. Additionally, intra-articular injuries were evaluated for those who eventually underwent delayed ACLR.

RESULTS

11 of the 75 patients (14.7%) were classified as copers. No major differences were found in the clinical characteristics between groups. Following the initial non-operative treatment, 67 patients underwent delayed ACLR. When examining intra-articular abrasions at the time of surgery, non-copers who continued sports activities for 3 to 12 months exhibited a significantly higher rate of injury as opposed to their coper counterparts. However, the difference in the prevalence of intra-articular lesions between the two groups in patients who continued to play sports for at least 12 months before surgery was nominal.

CONCLUSION

The rate of copers was relatively low in patients who resumed playing high-level sports after ACL injury. Additionally, even in copers, those who continued sports activities for more than 12 months had comparably high prevalence of intra-articular injuries with noncopers.

STUDY DESIGN

Retrospective case-control study; Level of evidence, 3.

ABVENTURE-P pilot trial of physical therapy versus standard of care following ventral hernia repair: Protocol for a randomized controlled trial

Hernia disease is one of the most common reasons patients seek surgical treatment, yet nearly 1 in 4 patients seeking ventral hernia repair in the United States suffer from chronic pain, disability, and diminished physical activity. The relationships between the anterior abdominal wall, lower back, diaphragm, and pelvic floor are critical in providing function and quality of life, yet management of hernia disease has been limited to surgical restoration of anatomy without taking into consideration the functional relationships of the abdominal core. Therefore, the primary goal of this study is to evaluate the feasibility of implementing physical therapy targeted to improving stability and function in this population. A secondary goal is to estimate whether pre-operative abdominal core function predicts responsiveness to physical therapy. This study is a registry-based randomized controlled trial (NCT05142618: Pilot Trial of Abdominal Core Rehabilitation To Improve Outcomes After Ventral Hernia Repair (ABVENTURE-P)). All participants will be randomized to one of two post-operative treatment arms: standard of care plus up to 16 sessions of physical therapy, or standard of care alone. Primary timepoints include pre-operative (baseline) and ten weeks after surgery, with intermediate or secondary timepoints 30 days, 6 months, and 1 year post-operative. At each timepoint, participants will undergo functional and patient-reported outcome testing. We will also collect data on retention rate and treatment adherence. An intention to treat approach is planned for all analyses, using all participants who were randomized and have available data at the 10-week timepoint. This is a pilot and feasibility trial, hence our goals are to establish safety and initial efficacy of the PT intervention, retention and adherence to both PT and control arms, whether pre-operative abdominal core function predicts responsiveness to PT, and to collect a large enough sample to power a future definitive multi-center randomized controlled trial.

Lower Patellofemoral Joint Contact Force During Side-Step Cutting After Return-to-Sports Clearance Anterior Cruciate Ligament Reconstruction

BACKGROUND

Low patellofemoral joint (PFJ) contact force has been associated with PFJ osteoarthritis. Quadriceps force and knee flexion angles, which are typically altered after an anterior cruciate ligament reconstruction (ACLR), primarily influence PFJ contact forces. It is still inconclusive whether differences in PFJ contact forces are present during high knee flexion tasks such as side-step cutting after clearance to return to sports (RTS) after ACLR.

PURPOSE

To explore PFJ contact forces in the ACLR limb and compare them with those of the contralateral and control limbs during side-step cutting tasks after clearance to RTS.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 26 male athletes with ACLR who were previously cleared to RTS were matched with 23 healthy men serving as the control group. Three-dimensional motion capture and force plate data were collected while both groups performed anticipated side-step cutting tasks. Joint kinematics, kinetics, muscle forces, and PFJ contact forces were calculated using musculoskeletal modeling.

RESULTS

Peak PFJ force was lower in the ACLR limbs compared with the contralateral limbs (mean difference [MD], 5.89 body weight [BW]; 95% CI, 4.7-7.1 BW; P < .001) and the control limbs (MD, 4.44 BW; 95% CI, 2.1-6.8 BW; P < .001). During peak PFJ force, knee flexion angle was lower in ACLR limbs compared with the contralateral (MD, 4.88°; 95% CI, 3.0°-6.7°; P < .001) and control (MD, 6.01°; 95% CI, 2.0°-10.0°; P < .002) limbs. A lower quadriceps force compared with the contralateral (MD, 4.14 BW; 95% CI, 3.4-4.9 BW; P < .001) and control (MD, 2.83 BW; 95% CI, 1.4-4.3 BW; P < .001) limbs was also found.

CONCLUSION

Lower PFJ contact forces and a combination of quadriceps force deficits and smaller knee flexion angle were found in the ACLR compared with the contralateral and control limbs even after clearance to RTS.

CLINICAL RELEVANCE

Despite rehabilitation and subsequent clearance to RTS, differences in PFJ contact forces are present after ACLR. Current rehabilitation and RTS battery may not be effective and sensitive enough to identify and address these differences.

Predicting anterior cruciate ligament failure load with T2* relaxometry and machine learning as a prospective imaging biomarker for revision surgery

Non-invasive methods to document healing anterior cruciate ligament (ACL) structural properties could potentially identify patients at risk for revision surgery. The objective was to evaluate machine learning models to predict ACL failure load from magnetic resonance images (MRI) and to determine if those predictions were related to revision surgery incidence. It was hypothesized that the optimal model would demonstrate a lower mean absolute error (MAE) than the benchmark linear regression model, and that patients with a lower estimated failure load would have higher revision incidence 2 years post-surgery. Support vector machine, random forest, AdaBoost, XGBoost, and linear regression models were trained using MRI T2* relaxometry and ACL tensile testing data from minipigs (n = 65). The lowest MAE model was used to estimate ACL failure load for surgical patients at 9 months post-surgery (n = 46) and dichotomized into low and high score groups via Youden's J statistic to compare revision incidence. Significance was set at alpha = 0.05. The random forest model decreased the failure load MAE by 55% (Wilcoxon signed-rank test: p = 0.01) versus the benchmark. The low score group had a higher revision incidence (21% vs. 5%; Chi-square test: p = 0.09). ACL structural property estimates via MRI may provide a biomarker for clinical decision making.

Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration

BACKGROUND

Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown.

PURPOSE

To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates.

RESULTS

In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044).

CONCLUSION

Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Anterior cruciate ligament reconstruction results in better patient reported outcomes but has no advantage for activities of daily living or the subsequent development of osteoarthritis. A systematic review and meta-analysis

BACKGROUND

Surgical reconstruction of ACL injuries is a common strategy but superiority over conservative treatment has not been established. The aim was to perform a systematic review and meta-analysis comparing outcomes between operative and non-operative treatment of ACL injuries.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2021. Patient reported outcome scores and objective measures for knee stability were included. Risk of bias was assessed using the Cochrane Collaboration's tools. GRADE was used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I² statistics.

RESULTS

Twelve studies were included in the analysis. All studies had a high risk of bias and were of low quality. The pooled estimates for IKDC (p = 0.040) favored surgical treatment. There were significant differences for activities of daily living (p = 0.0001) in favor of conservative treatment. There were significant differences for knee stability (p = 0.016) in favor of surgical treatment. The risk of osteoarthritis was not significantly different between the two treatment modalities (p = 0.219). Patients undergoing surgery had a 57% higher risk of osteoarthritis.

CONCLUSION

ACL reconstruction results in a significantly more stable knee with superior clinical and functional outcomes. However, these advantages over conservative treatment were not observed for routine activities of daily living, and subjective patient perceived outcomes favor nonsurgical treatment. Surgical treatment did not reduce the risk of later developing osteoarthritis. Regardless, due to low study quality and high risk of bias, these findings must be interpreted with caution.

A comparison of preoperative scores prior to anterior cruciate ligament reconstruction with optimal preinjury scores and final scores at two-year follow up

AIMS

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

METHODS

We performed a prospective study on patients who underwent primary ACLR by a single surgeon at a single centre between October 2010 and January 2018. Preoperative preinjury scores were collected at time of first assessment after the index injury. Preoperative (pre- and post-injury), one-year, and two-year postoperative functional outcomes were assessed by using the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Score, and Tegner Activity Scale.

RESULTS

We enrolled 308 males and 263 females of mean age 27 years (19 to 46). The mean preinjury and preoperative post-injury Lysholm Knee Scores were 94 (73 to 100) and 63 (25 to 85), respectively, while the respective mean scores at one and two years postoperatively were 84 (71 to 100) and 89 (71 to 100; p < 0.001). The mean Tegner preinjury and preoperative post-injury scores were 7 (3 to 9) and 3 (0 to 6), respectively, while the respective mean scores at one and two years postoperatively were 6 (1 to 8) and 6 (1 to 9) (p < 0.001). The mean KOOS scores at preinjury versus two years postoperatively were: symptoms (96 vs 84); pain (94 vs 87); activities of daily living (97 vs 91), sports and recreation function (84 vs 71), and quality of life (82 vs 69), respectively (p < 0.001).

CONCLUSION

Functional scores improved following ACLR surgery at two years in comparison to preoperative post-injury scores. However, at two-year follow-up, the majority of patients failed to achieve their preinjury scores. The evaluation of ACLR outcomes needs to consider the preinjury scores rather than the immediate preoperative score that is usually collected.Cite this article: Bone Jt Open 2023;4(1):46-52.

Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis

BACKGROUND

To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed.

OBJECTIVE

The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR).

METHODS

Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3-6 months, 7-12 months, > 1-2 years, > 2-5 years, > 5 years).

RESULTS

Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2-25.3]; KSES: 5.0 [4.4-5.5]) compared with 3-6 months following ACLR (TSK-11: 19.6 [18.7-20.6]; KSES: 19.6 [18.6-20.6]). Meta-analysis suggests similar kinesiophobia > 3-6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only.

CONCLUSIONS

Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3-6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.

Impact of Rehabilitation on Gait Kinematic following Grade II Anterior Cruciate Ligament Injury among Wrestlers

Background

Anterior cruciate ligament (ACL) injuries are among the most common injuries in wrestling. Even though there are several studies available in the literature about the changes in gait kinematics following ACL injury and ACL reconstruction surgery, none of these studies investigated the changes in gait kinematics following nonoperative rehabilitation protocol. So, this study is aimed at investigating the changes in gait kinematic following a supervised ACL rehabilitation protocol among wrestlers following a grade II ACL injury.

Methods

Fifteen male professional wrestlers with recent grade II ACL injury with mean age: 19.93 ± 2.01 years, weight: 72.33 ± 7.46 kg, and height: 173 ± 4.95 cm volunteered for this single-arm pretest-posttest study. Kinematic parameters during walking pre- and postrehabilitation were examined by two-dimensional (2D) video graphic analysis. Paired sample t-test and Cohen's d were used to determine significant differences and effect size of segmental angle, cadence, step length, stride length, etc.

Results

Injured wrestlers after the rehabilitation program walked significantly faster and had a 10.13% higher cadence, a 10.89% faster gait velocity, a 05% greater step length, and a 4.69% longer stride length, compared with a prerehabilitation program of injured wrestlers. Furthermore, joint angles at the hip, knee, and ankle were significantly different between pre- and postrehabilitation.

Conclusion

Research findings suggest that rehabilitation programs significantly impact the gait pattern of injured wrestlers. A 19-week supervised rehabilitation protocol can increase gait velocity and related parameters in ACL injured wrestlers.

Creating Crosswalks for Knee Outcomes After ACL Reconstruction Between the KOOS and the IKDC-SKF

BACKGROUND

Anterior cruciate ligament (ACL) registries do not all use the same patient-reported outcome measures, limiting comparisons and preventing pooling of data for meta-analysis. Our objective was to create a statistical crosswalk to convert cohort and registry mean Knee Injury and Osteoarthritis Outcome Scores (KOOS) to International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores and vice versa to allow these comparisons.

METHODS

Data from 3 ACL registries were pooled (n = 14,412) and were separated into a training data set (70% of the sample) or a validation data set (30% of the sample). The KOOS and the IKDC-SKF scores were available prior to the operation and at 1, 2, and 5 or 6 years postoperatively. We used equipercentile equating methods to create crosswalks in the training data set and examined accuracy in the validation data set as well as bootstrapping analyses to assess the impact of sample size on accuracy.

RESULTS

Preliminary analyses suggested that crosswalks could be attempted: large correlations between scores on the 2 measures (r = 0.84 to 0.94), unidimensionality of scores, and subpopulation invariance were deemed sufficient. When comparing actual scores with crosswalked scores in the validation data set, negligible bias was observed at the group level; however, individual score deviations were variable. The crosswalks are successful for the group level only.

CONCLUSIONS

Our crosswalks successfully convert between the KOOS and the IKDC-SKF scores to allow for a group-level comparison of registry and other cohort data.

CLINICAL RELEVANCE

These crosswalks allow comparisons among different national ligament registries as well as other research cohorts and studies; they also allow data from different patient-reported outcome measures to be pooled for meta-analysis. These crosswalks have great potential to improve our understanding of recovery after ACL reconstruction and aid in our ongoing efforts to improve outcomes and patient satisfaction, as well as to allow the continued analysis of historical data.

Long-term Return to Sports After Anterior Cruciate Ligament Injury: Reconstruction vs No Reconstruction-A Comparison of 2 Case Series

BACKGROUND

Reconstruction is considered to provide the best opportunity for return to sports (RTS) after anterior cruciate ligament (ACL) rupture. However, recent studies report that <50% of athletes return to preinjury sporting levels and that RTS rates at 1 year after injury are the same for athletes undergoing reconstruction and nonoperative management. Long-term studies are essential to confirm these findings and guide decisions regarding surgery.

PURPOSE

First, to compare long-term sports participation after ACL reconstruction and nonreconstruction and, second, to relate RTS level to strength and stability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

Patients with ACL deficiency (n = 101) who were referred for physical therapy at the time of diagnosis were followed long term: 56 were treated surgically 2.5 years (interquartile range [IQR], 1-4) after injury and 45 were treated nonoperatively. At long-term follow-up, the reconstructed group was at 9 years (IQR, 7-11) after injury and aged 33.3 ± 6.2 years (mean ± SD, 70% male; 61% meniscal injury), and the nonreconstructed group was at 11 years (IQR, 7-14) after injury and aged 38.7 ± 8.3 years (67% male; 58% meniscal injury). Measures of objective stability, subjective stability, and quadriceps/hamstring strength were compared between groups using independent-samples t tests. Current RTS level, scored on a 6-point scale, was compared between groups using chi-square tests. Spearman rho correlated RTS with outcome measures.

RESULTS

Of the total group of patients, 96% with reconstruction and 93% without continued to play sports. In the reconstructed and nonreconstructed groups, 4% and 7% did not RTS, and 8% and 17% returned to safe sports, respectively: 13% and 12% to running, 20% and 26% to sports involving limited twisting, 12% and 24% to recreational pivoting sports, and 43% and 14% to competitive pivoting sports. The only significant difference was in return to competitive pivoting sports (P = .003). Five patients with reconstruction ruptured the contralateral ACL, and 1 ruptured his graft. Most patients treated nonoperatively modified their sports participation. Their RTS levels correlated significantly with quadriceps strength (r = 0.65; P < .001), hamstring strength (r = 0.721; P < .001), and subjective stability (r = 0.405; P = .01).

CONCLUSION

Surgically treated patients returned to competitive pivoting sports at 3 times the rate of those managed nonoperatively, confirming that reconstruction provides the best opportunity for continued participation in competitive pivoting sports. Regardless of grouping, RTS correlated with modifiable factors, including strength and stability. Higher rates of subsequent injuries observed after reconstruction may result from increased participation in competitive pivoting sports.

Comparison of Anterior Cruciate Ligament Tears Treated Nonoperatively Versus With Reconstruction: Risk of Subsequent Surgery

BACKGROUND

Anterior cruciate ligament (ACL) tears can be devastating injuries, leading to joint instability, meniscal tears, and subsequent arthritis. It is unknown whether ACL reconstruction (ACLR) alters the natural history of joint degeneration in the ACL-deficient knee compared with nonoperative treatment, and few studies have examined outcomes in middle-aged patients.

PURPOSE

The objective of this study was to compare the midterm risk of subsequent ipsilateral knee surgery in middle-aged patients after an ACL injury treated with initial conservative (nonoperative) management (CM) versus ACLR (operative management [OM]) within 6 months of the diagnosis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed an electronic database search from 2011 to 2012 for all patients aged 35 to 55 years with an initial diagnosis of magnetic resonance imaging-confirmed ACL tear. Patients who elected CM and those who underwent ACLR within 6 months of the diagnosis (OM) were identified. Index patient and clinical characteristics were collected from the health record. All patients were longitudinally observed until August 31, 2017. The primary outcome was subsequent ipsilateral knee surgeries, and secondary outcomes included contralateral knee surgeries, deep surgical-site infections, and venous thrombotic events.

RESULTS

The mean follow-up was 4.8 ± 0.6 years. The CM group included 463 patients (40.2%) and the OM group included 690 patients (59.8%). The mean ages were 43.9 ± 5.7 years and 42.7 ± 5.3 years for patients in the CM and OM groups, respectively (P < .001). Obesity and smoking were significantly more common in the CM group. During the follow-up, 180 patients (38.9%) in the CM group underwent subsequent ipsilateral knee surgery compared with 73 (10.6%) patients in the OM group (P < .001). The mean time to the first ipsilateral procedure was 0.9 ± 1.1 years in the CM and 2 ± 1.5 years in the OM group (P < .001). Delayed ipsilateral ACLRs were performed in 81 patients in the CM group (17.5%); non-ACLR ipsilateral knee surgeries were performed in 156 patients in the CM group (33.7%). Contralateral knee surgery rates were similar. In a regression model, after controlling for age, sex, the Charlson Comorbidity Index score, and smoking status, it was found that normal body mass index and CM group were risk factors for undergoing subsequent knee surgery or ipsilateral non-ACLR surgery.

CONCLUSION

Excluding delayed ACLR, subsequent ipsilateral knee surgeries were more common and occurred earlier in middle-aged patients with nonoperatively managed ACL tears compared with patients managed with reconstruction.

The top 100 most impactful articles on the anterior cruciate ligament: An altmetric analysis of online media

Objectives:

To identify the top 100 most impactful anterior cruciate ligament articles in online media as measured by the Altmetric Attention Score and compare their characteristics to the most-cited anterior cruciate ligament articles in the scientific literature.

Methods:

The Altmetric database was queried to identify all published articles pertaining to the anterior cruciate ligament. The search yielded 9445 articles, which were stratified by highest to lowest Altmetric Attention Score. The top 100 articles were included. Collected data included article type, article topic, journal name, and online mentions in news, blogs, Twitter, Facebook, Wikipedia, and other sources. The geographic origin of each article was also determined based on the institutional affiliation of the first author.

Results:

Altmetric Attention Score of the top 100 anterior cruciate ligament articles ranged from 109 to 2193 (median 172.0, interquartile range 137.5–271.5). Of the 100 articles, 65 were published in three journals: American Journal of Sports Medicine, British Journal of Sports Medicine, and Journal of Orthopaedic & Sports Physical Therapy. The most prevalent article type was original research (60%), followed by systematic review/meta-analysis (18%). The most prevalent article topic was rehabilitation and return to play after anterior cruciate ligament reconstruction (22%), followed by epidemiology/risk factors (16%), injury prevention (14%), and biomechanics of anterior cruciate ligament injuries (14%). Of the top 100 articles, 54% were American, 31% were European, and 15% were published in other countries outside of the United States and Europe.

Conclusion:

This study used Altmetric Attention Score to identify the 100 most engaged anterior cruciate ligament articles in online media. The characteristics of these articles differed substantially from the most-cited anterior cruciate ligament articles in the literature with regard to article type, article topic, geographic origin, and publication journal. These findings suggest that alternative metrics measure distinct components of anterior cruciate ligament article engagement and add an important dimension to understanding the overall impact of published research on the anterior cruciate ligament.

Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation

Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.

Current perspectives of New Zealand physiotherapists on rehabilitation and return to sport following anterior cruciate ligament reconstruction: A survey

OBJECTIVE

To investigate the clinical beliefs and practices of New Zealand physiotherapists regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online cross-sectional survey.

METHODS

A survey was adapted from a previously published survey and disseminated to New Zealand physiotherapists who were considered more likely to be involved in post-ACLR rehabilitation.

RESULTS

The number of completed surveys was 318. Most physiotherapists (85%) preferred to first consult patients within 14 days of ACLR. In the first six weeks following ACLR, 89% of physiotherapists see patients at least once per week. Between 3- and 6-months post-ACLR, 76% of physiotherapists see patients at least once a fortnight. Pre-operative rehabilitation and post-operative rehabilitation exceeding six months are considered essential or important to patient outcomes by over 95% of physiotherapists. While 63% of physiotherapists support RTS 9-12 months after ACLR, 11% permit RTS within 6-9 months of surgery. Common RTS considerations include functional capacity, movement quality during functional tasks, time from ACLR, and knee strength.

CONCLUSION

The survey revealed variability in the beliefs and practices of NZ physiotherapists regarding post-ACLR rehabilitation, and these beliefs and practices are at times inconsistent with best practice recommendations.

Joint effusion, anteroposterior stability, muscle strength and degree of patellofemoral osteoarthritis significantly impact outcome following revision ACL reconstruction

PURPOSE

Effusion, impaired muscle function and knee instability are considered as some of the most important factors effecting outcome following anterior cruciate ligament reconstruction (ACL-R) but the impact on revision ACL-R remains unclear. It was hypothesized that these factors will significantly worsen clinical outcome following revision ACL-R.

METHODS

Seventy knees (13 female and 57 male) were followed retrospectively after revision ACL-R at a mean follow-up of 47.8 ± 20.7 months. Clinical examination was based on the International Knee Documentation Evaluation Form-2000 (IKDC), Tegner activity scale. Instrumented measurement of anterior tibial translation was performed using the Rolimeter® (DJO Global, Freiburg, Germany). Bilateral circumference of the thigh was measured 10 and 20 cm proximal to the medial joint space. Cartilage was assessed according to Outerbridge classification during both primary and revision ACL-R.

RESULTS

Tegner activity scale decreased significantly from 7.8 ± 1.4 points at primary ACL-R to 7 ± 1.8 points at revision ACL-R, and 5.8 ± 1.7 points at the time of follow up (p < 0.001). Joint effusion (r = - 0.47, p < 0.01) and side to side differences in single leg hop test (r = - 0.48, p < 0.1) significantly correlated with inferior outcome. Cartilage lesions were found in 67% of the patients at the time of revision ACL-R compared to 38% at the time of primary ACL-R. According to the IKDC classification A was graded in three patients (4.3%), B in 35 (50%), C in 29 (41.4%) and D in three (4.3%). Joint effusion was measured in 35% of patients at the time of follow-up. Degeneration at the patellofemoral compartment of > grad 2 was responsible for IKDC grade C and D (p = 0.035). Instrumented anteroposterior site-to-site difference of ≥3 mm showed significant impact on clinical outcome (p < 0.019).

CONCLUSION

The study has shown that chronic effusion, quadriceps dysfunction, cartilage lesions especially at the patellofemoral compartment and side to side difference in anteroposterior stability significantly influences patient outcome after revision ACL-R. These factors require special attention when predicting patient's outcome.

LEVEL OF EVIDENCE

Level-IV, case-controlled study.

Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons

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.

Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis

PURPOSE

To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable.

RESULTS

Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use.

CONCLUSIONS

Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of RCTs.

Editorial Commentary: Timing of Anterior Cruciate Ligament Reconstruction Is Just as Important as a Correct Surgical Procedure

The timing between anterior cruciate ligament (ACL) injury and surgical treatment may determine secondary injuries and abnormal laxity. Specifically, a knee without a functioning ACL is more at risk of a future episode of instability and the development of injuries to other joint structures. Ultimately, this may result in degenerative joint disease. Associated medial or lateral meniscus, cartilage or multiligamentous lesions indicate earlier ACL reconstruction. In particular, the possibility of an effective meniscus repair is a key indicator for early surgery. Patient selection is the key to success of ACL surgery, and it is deeply linked to surgical timing. Also, in the case of athletic patients, professional or otherwise, surgery must be as performed early to allow a rapid recovery of activity.

The efficacy and safety of local infiltration analgesia vs femoral nerve block after anterior cruciate ligament reconstruction: A retrospective trial protocol

BACKGROUND

Several previous trials have attempted to compare the efficacy of femoral nerve block (FNB) and local infiltrative analgesia (LIA) for patients received anterior cruciate ligament (ACL) reconstruction, but reached inconsistent conclusions. The primary purpose of this present research was to compare the FNB and LIA in the reconstruction of ACL.

METHODS

This investigation was conducted and then reported on the basis of Strengthening the Reporting of Observational studies in the Epidemiology checklist. From our registry database, we retrospectively determined 688 patients who received the primary reconstruction of ACL from 2016 to 2019 at our academic institutions. This current retrospective cohort study was approved through the institutional review committee at our hospital. Inclusion criteria contained the primary or autograft bone-patellar tendine-bone reconstruction of ACL in the patients over 16 years of age. Patients in the LIA group underwent intraoperative infiltration at the harvested site after tendon harvest, with use of 2 mg/mL of ropivacaine 20 mL and 5 mg/mL of epinephrine, respectively. After the reconstruction of ACL, 5 Lg/mL of epinephrine, and 20 mL of ropivacaine (2 mg/mL) were injected at the site of surgical trauma. The patient in FNB group was given 40 mL of ropivacaine (2 mg/mL), and the ropivacaine was injected into femoral nerve sheath at femoral triangle level. The primary outcome was the consumption of morphine 24 h after the operation. And the secondary results involved the complications, functional results, and the scores of pain.

RESULTS

It is assumed that the efficacy of LIA in the early postoperative pain is no less than that of FNB. For our study, the major limitation is the lack of randomization. Nevertheless, these data were prospectively harvested, with high response rate of patient.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6277).

Operative and nonoperative management of anterior cruciate ligament injury: Differences in gait biomechanics at 5 years

Gait biomechanics after anterior cruciate ligament (ACL) injury are associated with functional outcomes and the development of posttraumatic knee osteoarthritis. However, biomechanical outcomes between patients treated nonoperatively compared with operatively are not well understood. The primary purpose of this study was to compare knee joint contact forces, angles, and moments during loading response of gait between individuals treated with operative compared with nonoperative management at 5 years after ACL injury. Forty athletes treated operatively and 17 athletes treated nonoperatively completed gait analysis at 5 years after ACL reconstruction or completion of nonoperative rehabilitation. Medial compartment joint contact forces were estimated using a previously validated, patient-specific electromyography-driven musculoskeletal model. Knee joint contact forces, angles, and moments were compared between the operative and nonoperative group using mixed model 2 × 2 analyses of variance. Peak medial compartment contact forces were larger in the involved limb of the nonoperative group (Op: 2.37 ± 0.47 BW, Non-Op: 3.03 ± 0.53 BW; effect size: 1.36). Peak external knee adduction moment was also larger in the involved limb of the nonoperative group (Op: 0.25 ± 0.08 Nm/kg·m, Non-Op: 0.32 ± 0.09 Nm/kg·m; effect size: 0.89). No differences in radiographic tibiofemoral osteoarthritis were present between the operative and nonoperative groups. Overall, participants treated nonoperatively walked with greater measures of medial compartment joint loading than those treated operatively, while sagittal plane group differences were not present. Statement of clinical relevance: The differences in medial knee joint loading at 5 years after operative and nonoperative management of ACL injury may have implications on the development of posttraumatic knee osteoarthritis.

Clinical and Radiographic Outcomes of Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Graft and Femoral Cortical Button Fixation at Minimum 20-Year Follow-up

BACKGROUND

The short-term outcomes of anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone or hamstring tendon (HT) graft are excellent with good clinical stability and patient-reported outcomes. Although some studies have reported the long-term outcomes of bone-patellar tendon-bone graft ACL reconstruction, few have reported the outcomes of HT graft ACL reconstruction.

PURPOSE

To assess clinical and radiographic outcomes of HT graft ACL reconstruction with femoral cortical button fixation at a minimum 20-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A prospective study was performed in which all patients undergoing isolated transtibial primary ACL reconstruction between 1994 and 1996 with HT graft and femoral cortical button fixation were assessed clinically and radiographically. Follow-up was obtained in 48 of 94 patients (51%). Median (interquartile range) age at operation was 31 years (26-39 years); median follow-up was 21 years (20-22 years); 65% were male; and 48% had meniscal injury at surgery and underwent partial meniscectomy. Graft rupture, reoperation, and contralateral injury rates were assessed; clinical stability was measured using the KT-1000 arthrometer; patient-reported outcomes were assessed (International Knee Documentation Committee [IKDC], Lysholm, Forgotten Joint Score, Tegner activity, Knee injury and Osteoarthritis Outcome Score [KOOS], Anterior Cruciate Ligament Quality of Life [ACL-QOL], EuroQol 5-Dimension 5-Level [EQ-5D-5L]); and radiographic osteoarthritis (defined as Kellgren-Lawrence grade ≥2) was assessed for the ipsilateral and the contralateral knee.

RESULTS

Graft rupture occurred in 4 patients (8%), contralateral injury in 4 patients (8%), and reoperation in 15 patients (31%), which consisted mainly of meniscal tears or hardware removal. In patients with an intact graft, excellent patient-reported outcome measures (PROMs) were noted, with a median Lysholm of 90 (78-100), subjective IKDC of 86 (72-95), and KOOS-Sports of 86 (58-100). There was low awareness of the operated knee (Forgotten Joint Score, 81 [60-96]) and good quality of life (ACL-QOL, 85 [75-94]; EQ-5D-5L, 0.87 [0.83-1.00]). Median side-to-side difference, as measured with the KT-1000 arthrometer, was 1 mm (-1 to 3 mm). Radiographic osteoarthritis was evident in 49% of ipsilateral and 10% of contralateral knees and was associated with meniscectomy at index surgery and decreased PROMs at follow-up.

CONCLUSION

Long-term outcomes of transtibial HT graft ACL reconstruction with femoral cortical button fixation are generally good with a low failure rate, low awareness of the operated knee, and good clinical stability. Radiographic osteoarthritis was evident in approximately half of the patients at 20-year follow-up and was associated with meniscectomy at index surgery and decreased PROMs at follow-up.

Anterior Cruciate Ligament Reconstruction Within 3 Weeks Does Not Increase Stiffness and Complications Compared With Delayed Reconstruction: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Injury-to-surgery time has been identified as a key point in anterior cruciate ligament (ACL) reconstruction, with early versus delayed treatment remaining a debated and controversial topic in the management of ACL tears.

PURPOSE/HYPOTHESIS

The aim was to quantitatively synthesize the best literature evidence by including only randomized controlled trials (RCTs) comparing early versus delayed ACL reconstruction, with a clear and univocal definition of cutoffs of early or delayed surgery. The hypothesis was that early treatment would lead to similar final clinical results compared with the delayed approach while providing a faster recovery without an increase in complications after ACL reconstruction.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic literature search was performed on February 12, 2019, using PubMed, Web of Science, Cochrane Library, and gray literature databases. According to previous literature, 2 analyses with different cutoffs for injury-to-surgery time (3 weeks and 10 weeks) were performed to distinguish early and delayed reconstruction. The influence of timing was analyzed through meta-analyses in terms of patient-reported outcome measures (PROMs), risk of complications, range of motion (ROM) limitation, risk of retears, and residual laxity. Risk of bias and quality of evidence were assessed following the Cochrane guidelines.

RESULTS

Eight studies (5 in 3-week cutoff analysis and 3 in 10-week cutoff analysis) were included. No differences were found in terms of PROMs, risk of complications, ROM limitation, risk of retears, and residual laxity either in the 3-week cutoff analysis or in the 10-week cutoff analysis (P > .05). The level of evidence was moderate to low for the outcomes of the 3-week cutoff analysis and low to very low for the outcomes of the 10-week cutoff analysis.

CONCLUSION

This meta-analysis did not confirm the previously advocated benefits of delaying ACL surgery to avoid the acute posttraumatic phase. In fact, RCTs demonstrated that timing of surgery after ACL tears has no influence on the final functional outcome, risk of retears, or residual instability. While no data were available about the recovery time, literature results showed that early ACL reconstruction could be performed without increasing the risk of complications.

STUDY REGISTRATION

CRD42019119319 (PROSPERO).

Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis

Objective

We compared long-term follow-up from surgical versus non-surgical treatment of ACL rupture regarding radiographic knee osteoarthritis (OA), secondary surgery, laxity and patient-reported outcome measures (PROMs).

Design

Systematic review and meta-analysis.

Data sources

Embase, MEDLINE, CINAHL and the Cochrane Library databases.

Eligibility criteria for selecting studies

Studies directly comparing the minimally invasive surgical (arthroscopy or miniarthrotomy) and non-surgical treatment of ACL rupture with at least 10 years of follow-up in adult patients were included.

Results

Five studies met the eligibility criteria. A meta-analysis revealed a higher risk of radiographic knee OA and a lower risk of secondary meniscal surgery for patients in the surgical group. The risk of graft rupture/secondary ACL revision and secondary ACL reconstruction was equal in the surgical and non-surgical groups. Knee laxity was lower among patients in the surgical group in four studies. No difference was found in the PROMs (ie, International Knee Documentation Committee, Tegner, Knee Injury and Osteoarthritis Outcome, and Lysholm scores).

Conclusion

The risk of radiographic knee OA was higher, but the risk of secondary meniscal injury was lower 10 years after surgical treatment of ACL rupture. The risk of graft rupture/secondary ACL revision or secondary reconstruction was unrelated to treatment type. The degree of knee laxity was reduced after surgical treatment in comparison with non-surgical treatment, while PROMs were similar. However, due to the methodological challenges highlighted in this systematic review, these findings must be interpreted with caution.

PROSPERO registration number

CRD42019119468

Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture

Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging. The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life. The three main treatment options for ACL rupture are (1) rehabilitation as first-line treatment (followed by ACL reconstruction (ACLR) in patients, who develop functional instability), (2) ACLR and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation. We provide practical recommendations for informing and discussing management options with patients, and describe patient-related factors associated with a worse ACL-rupture outcome. Finally, we define evidence-based rehabilitation and present phase-specific rehabilitation recommendations and criteria to inform return to sport decisions.