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Leite CBG, Smith R, Lavoie-Gagne OZ, Görtz S, Lattermann C. Biologic Impact of Anterior Cruciate Ligament Injury and Reconstruction. Clin Sports Med 2024; 43:501-512. [PMID: 38811124 DOI: 10.1016/j.csm.2023.07.003] [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] [Indexed: 05/31/2024]
Abstract
Surgical intervention after anterior cruciate ligament (ACL) tears is typically required because of the limited healing capacity of the ACL. However, mechanical factors and the inflammatory response triggered by the injury and surgery can impact patient outcomes. This review explores key aspects of ACL injury and reconstruction biology, including the inflammatory response, limited spontaneous healing, secondary inflammation after reconstruction, and graft healing processes. Understanding these biologic mechanisms is crucial for developing new treatment strategies and enhancing patient well-being. By shedding light on these aspects, clinicians and researchers can work toward improving quality of life for individuals affected by ACL tears.
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Affiliation(s)
- Chilan B G Leite
- Department of Orthopaedic Surgery, Center for Cartilage Repair and Sports Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Richard Smith
- Department of Orthopaedic Surgery, Center for Cartilage Repair and Sports Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Ophelie Z Lavoie-Gagne
- Department of Orthopaedic Surgery, Center for Cartilage Repair and Sports Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Simon Görtz
- Department of Orthopaedic Surgery, Center for Cartilage Repair and Sports Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Christian Lattermann
- Department of Orthopaedic Surgery, Center for Cartilage Repair and Sports Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Sherman SL, Raji Y, Calcei JG, Sherman MF. Anterior Cruciate Ligament Repair-Here to Stay or History Repeating Itself? Clin Sports Med 2024; 43:433-448. [PMID: 38811120 DOI: 10.1016/j.csm.2023.09.001] [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] [Indexed: 05/31/2024]
Abstract
Anterior cruciate ligament (ACL) injuries continue to be a prevalent concern among athletes and individuals with an active lifestyle. Traditionally, the standard of care for ACL tears has involved surgical reconstruction using autograft or allograft. This article aims to provide an overview of the evolving landscape of primary ACL repair, examining the current evidence, surgical techniques, patient selection criteria, outcomes, and potential future directions in this field.
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Affiliation(s)
- Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway, MC 6342, Pavilion C, Redwood City, CA 94063, USA.
| | - Yazdan Raji
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway, MC 6342, Pavilion C, Redwood City, CA 94063, USA
| | - Jacob G Calcei
- University Hospitals Drusinsky Sports Medicine Institute, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Hanna House 6th Floor, Cleveland, OH 44106, USA
| | - Mark F Sherman
- Richmond University Medical Center, 2052 Richmond Road, Staten Island, NY 10306, USA
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Opoku M, Fang M, Lu W, Li Y, Xiao W. Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies. J Orthop Surg Res 2024; 19:331. [PMID: 38825707 PMCID: PMC11145936 DOI: 10.1186/s13018-024-04812-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/23/2024] [Indexed: 06/04/2024] Open
Abstract
PURPOSE To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture. METHOD We searched Pubmed, Embase, the Cochrane Library, and Web of Science databases to seek relevant studies. Clinical outcomes included failure rate, hardware removal rate, anteroposterior (AP) knee laxity, and patient-reported outcomes. In addition, subgroup analysis was carried out according to repair techniques, rupture locations, and study designs. Funnel plots were used to detect publication bias. All statistical analysis was performed using STATA (version 14.2, StataCorp). RESULTS A total of 10 articles were included in this study, comprising 5 randomized controlled trials (RCTs) and 5 cohort studies, involving a total of 549 patients. We found no statistical differences between the ACL repair and ACL reconstruction in the following outcomes: failure rate, AP knee laxity, International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome (KOOS) Score, and Tegner score. However, the ACL repair group had a higher hardware removal rate. Except for AP knee laxity results on different repair techniques, there was no statistical difference in other subgroup analyses. CONCLUSION Compared with ACL reconstruction, ACL repair shows similar results in clinical outcomes, and it is promising to be an effective alternative treatment for acute ACL rupture. Larger samples and higher-quality studies are needed to support our results and further explore the advantages of ACL repair in other aspects. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael Opoku
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mingqing Fang
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, 410083, China
| | - Wenhao Lu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yusheng Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China.
| | - Wenfeng Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China.
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Kunze KN, Pareek A, Nwachukwu BU, Ranawat AS, Pearle AD, Kelly BT, Allen AA, Williams RJ. Clinical Results of Primary Repair Versus Reconstruction of the Anterior Cruciate Ligament: A Systematic Review and Meta-analysis of Contemporary Trials. Orthop J Sports Med 2024; 12:23259671241253591. [PMID: 38867918 PMCID: PMC11168252 DOI: 10.1177/23259671241253591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 06/14/2024] Open
Abstract
Background Primary anterior cruciate ligament (ACL) repair has gained renewed interest in select centers for patients with proximal or midsubstance ACL tears. Therefore, it is important to reassess contemporary clinical outcomes of ACL repair to determine whether a clinical benefit exists over the gold standard of ACL reconstruction (ACLR). Purpose To (1) perform a meta-analysis of comparative trials to determine whether differences in clinical outcomes and adverse events exist between ACL repair versus ACLR and (2) synthesize the midterm outcomes of available trials. Study Design Systematic review; Level of evidence, 3. Methods The PubMed, OVID/Medline, and Cochrane databases were queried in August 2023 for prospective and retrospective clinical trials comparing ACL repair and ACLR. Data pertaining to tear location, surgical technique, adverse events, and clinical outcome measures were recorded. DerSimonian-Laird random-effects models were constructed to quantitatively evaluate the association between ACL repair/ACLR, adverse events, and clinical outcomes. A subanalysis of minimum 5-year outcomes was performed. Results Twelve studies (893 patients; 464 ACLR and 429 ACL repair) were included. Random-effects models demonstrated a higher relative risk (RR) of recurrent instability/clinical failure (RR = 1.64; 95% confidence interval [CI], 1.04-2.57; P = .032), revision ACLR (RR = 1.63; 95% CI, 1.03-2.59; P = .039), and hardware removal (RR = 4.94; 95% CI, 2.10-11.61; P = .0003) in patients who underwent primary ACL repair versus ACLR. The RR of reoperations and complications (knee-related) were not significantly different between groups. No significant differences were observed when comparing patient-reported outcome scores. In studies with minimum 5-year outcomes, no significant differences in adverse events or Lysholm scores were observed. Conclusion In contemporary comparative trials of ACL repair versus ACLR, the RR of clinical failure, revision surgery due to ACL rerupture, and hardware removal was greater for primary ACL repair compared with ACLR. There were no observed differences in patient-reported outcome scores, reoperations, or knee-related complications between approaches. In the limited literature reporting on minimum 5-year outcomes, significant differences in adverse events or the International Knee Documentation Committee score were not observed.
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Affiliation(s)
- Kyle N. Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Benedict U. Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Anil S. Ranawat
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D. Pearle
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T. Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Answorth A. Allen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Riley J. Williams
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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Turati M, Anghilieri FM, Gatti SD, Courvoisier A, Rigamonti L, Zatti G, Nicolaou N, Bigoni M. Arthroscopic repair of proximal anterior cruciate ligament tears in children and adolescents: A systematic review. J Child Orthop 2024; 18:249-257. [PMID: 38831852 PMCID: PMC11144375 DOI: 10.1177/18632521241244626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/17/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Anterior cruciate ligament repair techniques are of growing interest because they allow for minimally invasive surgery that avoids harvesting of the transplant, without risking growth deficiencies in young patients. The aim of this study is to summarize the published evidence about arthroscopic repair of anterior cruciate ligament proximal tears in skeletally immature patients. Methods In total, four studies were included and processed for data extraction after screening for eligibility for this systematic review: one retrospective cohort study and three retrospective case series. Altogether, the four studies included in this review included 61 skeletally immature patients with a mean age of 12.1 years diagnosed with proximal anterior cruciate ligament tear who underwent arthroscopic repair with preservation of the native ligament. The mean follow-up period was 2.8 years. Results The most relevant and objective outcome that we considered was re-rupture rate. One study reports a cumulative incidence of graft failure in the first 3 years after surgery of 48.8% while the others report a 0%, 0% and 21.5% re-rupture rate. No growth disturbances were reported in the included studies. Conclusion Despite growing interest surrounding anterior cruciate ligament repair techniques, the presence of limited quality studies in the literature means repair cannot be strongly supported at present. Some encouraging data regarding the absence of growth disturbance and functional outcomes does exist, but studies with larger samples are required. Level of evidence level IV.
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Affiliation(s)
- Marco Turati
- Orthopedic Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Paediatric Orthopedic Surgery, Hospital Couple Enfants, Grenoble Alpes University, Grenoble, France
| | | | - Simone Daniel Gatti
- Orthopedic Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurelien Courvoisier
- Transalpine Center of Pediatric Sports Medicine and Surgery, University of Milano-Bicocca - Hospital Couple Enfant, Monza (Italy), Grenoble, France
- Department of Paediatric Orthopedic Surgery, Hospital Couple Enfants, Grenoble Alpes University, Grenoble, France
| | - Luca Rigamonti
- Department of Orthopedic Surgery, Policlinico San Pietro, Ponte San Pietro, Italy
| | - Giovanni Zatti
- Orthopedic Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nicolas Nicolaou
- Sheffield Children’s Hospital and Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Marco Bigoni
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Orthopedic Surgery, Policlinico San Pietro, Ponte San Pietro, Italy
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Owens BD. Failing to Reach Significance. Am J Sports Med 2024; 52:1401-1402. [PMID: 38690619 DOI: 10.1177/03635465241247714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
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Karlin EA, McCann J, Panish BJ, Geng X, Wei L, Argintar E. Anterior Cruciate Ligament Repair Leads to Improved Patient-Reported Outcomes Compared to Anterior Cruciate Ligament Reconstruction. Cureus 2024; 16:e60693. [PMID: 38903336 PMCID: PMC11187451 DOI: 10.7759/cureus.60693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Anterior cruciate ligament (ACL) tears occur frequently in young athletes, and ligament repair and reconstruction are surgical treatments. Although there are suggested benefits for both approaches, there is a lack of direct comparisons between ACL repair and reconstruction.This study aims to compare the mid-term functional outcomes and quality of life measures between patients that have undergone ACL repair versus reconstruction. Methods A retrospective review was conducted for demographic and operative report data of patients who underwent an ACL repair or reconstruction between 2012 and 2018. Patients were contacted over the phone and underwent a Patient-Reported Outcomes Measurement Information System (PROMIS) survey evaluating pain interference, mobility, and function. Patients were excluded from the study if there was an incomplete operative note, missing contact information, or failure to answer phone calls. Results A total of 74 eligible patients were included, with n = 54 in the ACL reconstruction group (73.0%) and n = 20 in the ACL repair group (27.0%). Reconstruction patients had a PROMIS (median (IQR)) physical function score of 22.50 (16.00-59.00), as compared to repair patients' physical function score of 60.00 (21.50-60.00). There was a significant difference favoring repair (p = 0.040). In addition, ACL reconstruction patients had a significantly higher rate of additional procedures, with 63.0% of reconstruction patients receiving an additional operation as compared to 30.0% of repair patients (p = 0.017). The surgery type did not show a significant effect on physical function scores, while additional procedures remained significant in the linear regression analysis. Conclusion Although ACL repair is associated with improved physical function scores as compared to reconstruction in the univariate analysis, surgery type did not show significance when controlling for other variables. Further studies are necessary to compare patients with similar injuries to account for differences in additional procedures, but the results remain promising in assisting with patient-driven treatment decisions.
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Affiliation(s)
- Elan A Karlin
- Orthopedics, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Julia McCann
- Orthopedics, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Brian J Panish
- Orthopedics, MedStar Georgetown University Hospital, Washington, D.C., USA
| | - Xue Geng
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, D.C., USA
| | - Linlin Wei
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, D.C., USA
| | - Evan Argintar
- Orthopedics, MedStar Washington Hospital Center, Washington, D.C., USA
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Wasilczyk C. Nanosurgical and Bioengineering Treatment of Human Anterior Cruciate Ligament Tears with Ultrasound-Guided Injection of Modified Platelet-Rich Plasma Using Human Cell Memory Based on Clinical, Ultrasound, MRI, and Nanoscope Analyses: A Double-Blind Randomized Trial. J Clin Med 2024; 13:2475. [PMID: 38731004 PMCID: PMC11084372 DOI: 10.3390/jcm13092475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Anterior cruciate ligament (ACL) tears account for 40% to 50% of all ligamentous knee injuries. Most patients with ACL ruptures undergo surgical treatment. There is currently no objective, well-documented, repeatable, and standardized nonsurgical method for ACL tear treatment. This study aimed to investigate ACL outcomes in patients who underwent a novel nanosurgery and bioengineering treatment (NSBT) for an ACL tear. Methods: This was a double-blind randomized trial including 44 patients with a history of traumatic knee injury and a confirmed ACL tear. The final sample comprised 40 patients who met all the eligibility criteria. The patients were divided into two groups: the treatment group (n = 30) and the control group (n = 10). The treatment group underwent nanosurgery with an ultrasound-guided injection of modified platelet-rich plasma (PRP) using human cell memory (RP-hCM). The control group was treated with an ultrasound-guided PRP injection into the joint capsule. At baseline and post-treatment, all patients underwent both ultrasonography and magnetic resonance imaging (MRI), and the following clinical variables were assessed: the WOMAC score, the Lysholm knee score, the visual analog scale score, and knee instability. In most patients, the clinical outcome was verified using nanoscopy. Results: The median WOMAC, VAS, and LKS scores, as well as knee instability, improved significantly 12 weeks after the procedure in the treatment group (p < 0.001). We found a significantly larger improvement in the assessed parameters in the treatment group compared to the control group (p < 0.001). In the treatment group, all the patients had good and very good clinical outcomes, while 90% of the patients had a normal ACL signal in a follow-up MRI scan. In the control group, a physical examination revealed no changes in knee stability after treatment. Conclusions: This study showed that there is a significant difference in patient experience and the duration of recovery for patients with ACL tears treated with NSBT. The novel nonsurgical method was shown to be repeatable, objective, well documented, standardized, and highly effective.
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Affiliation(s)
- Cezary Wasilczyk
- Medical Department, Wasilczyk Medical Clinic, ul. Kosiarzy 37/80, 02-953 Warszawa, Poland
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Nyland J, Sirignano MN, Richards J, Krupp RJ. Regenerative Anterior Cruciate Ligament Healing in Youth and Adolescent Athletes: The Emerging Age of Recovery Science. J Funct Morphol Kinesiol 2024; 9:80. [PMID: 38804446 PMCID: PMC11130880 DOI: 10.3390/jfmk9020080] [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] [Received: 01/03/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/29/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries mainly arise from non-contact mechanisms during sport performance, with most injuries occurring among youth or adolescent-age athletes, particularly females. The growing popularity of elite-level sport training has increased the total volume, intensity and frequency of exercise and competition loading to levels that may exceed natural healing capacity. Growing evidence suggests that the prevailing mechanism that leads to non-contact ACL injury from sudden mechanical fatigue failure may be accumulated microtrauma. Given the consequences of primary ACL injury on the future health and quality of life of youth and adolescent athletes, the objective of this review is to identify key "recovery science" factors that can help prevent these injuries. Recovery science is any aspect of sports training (type, volume, intensity, frequency), nutrition, and sleep/rest or other therapeutic modalities that may prevent the accumulated microtrauma that precedes non-contact ACL injury from sudden mechanical fatigue failure. This review discusses ACL injury epidemiology, current surgical efficacy, the native ACL vascular network, regional ACL histological complexities such as the entheses and crimp patterns, extracellular matrix remodeling, the concept of causal histogenesis, exercise dosage and ligament metabolism, central nervous system reorganization post-ACL rupture, homeostasis regulation, nutrition, sleep and the autonomic nervous system. Based on this information, now may be a good time to re-think primary ACL injury prevention strategies with greater use of modified sport training, improved active recovery that includes well-planned nutrition, and healthy sleep patterns. The scientific rationale behind the efficacy of regenerative orthobiologics and concomitant therapies for primary ACL injury prevention in youth and adolescent athletes are also discussed.
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Affiliation(s)
- John Nyland
- Norton Orthopedic Institute, 9880 Angie’s Way, Suite 250, Louisville, KY 40241, USA (J.R.); (R.J.K.)
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Thompson KA, Shelton TJ, Lee CA. What's New in Sports Medicine. J Bone Joint Surg Am 2024; 106:667-673. [PMID: 38386765 DOI: 10.2106/jbjs.23.01420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Kamali A Thompson
- Department of Orthopaedic Surgery, Temple University, Philadelphia, Pennsylvania
| | | | - Cassandra A Lee
- Department of Orthopaedic Surgery, University of California at Davis Health, Sacramento, California
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Homan MD, Braaten JA, Banovetz MT, Monson JK, Kennedy NI, LaPrade RF. Principles for optimizing anterior cruciate ligament reconstruction outcomes in elite athletes: a review of current techniques. ANNALS OF JOINT 2024; 9:19. [PMID: 38694814 PMCID: PMC11061659 DOI: 10.21037/aoj-22-40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/29/2023] [Indexed: 05/04/2024]
Abstract
Anterior cruciate ligament (ACL) tears are one of the most common sport-related injuries and occur in greater than 3% of athletes in a four-year window of sports participation. Non-contact injuries are the most common mechanism for ACL injury in elite-level athletes, especially with increased valgus and external rotation of the knee when loading eccentrically in flexion. Because of the immense toll these injuries and their recovery take on athletes especially, optimal treatment has been a subject of great interest for some time. Many ACL reconstruction (ACLR) and repair techniques have been implemented and improved in the last two decades, leading to many surgical options for this type of injury. The surgical approach to high-level athletes in particular requires additional attention that may not be necessary in the general population. Important considerations for optimizing ACL treatment in high-level athletes include choosing repair vs. reconstruction, surgical techniques, choice of auto- or allograft, and associated concomitant procedures including other injuries or reinforcing techniques as well as attention to rehabilitation. Here, we discuss a range of surgical techniques from repair to reconstruction, and compare and contrast various reconstructive and reinforcing techniques as well as associated surgical pearls and pitfalls. Good outcomes for athletes suffering from ACL injury are attainable with proper treatment including the principles discussed herein.
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12
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He Y, Fan Y, Zhai L, Zhu W. Comparative efficacy and safety of different surgical approaches for the treatment of anterior cruciate ligament injury: a Bayesian network meta-analysis protocol. BMJ Open 2024; 14:e077242. [PMID: 38553073 PMCID: PMC10982744 DOI: 10.1136/bmjopen-2023-077242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/15/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) rupture can be treated surgically or non-surgically, with several surgical interventions available at present. However, the comparatively effective surgical intervention with relatively fewer side effects remains unknown. This study aims to fill in this gap by conducting a Bayesian network meta-analysis (NMA) and provide a theoretical basis for the clinical application. METHOD AND ANALYSIS We will perform a Bayesian NMA and will include randomised controlled trials (RCTs) published in English or Chinese that compare surgical intervention (ie, standard ACL reconstruction, ACL remnant-preserving reconstruction and ACL repair with suture augmentation to conservative therapy or studies that compare one surgical intervention to another for the symptom relief and function recovery of patients with ACL rupture. Primary outcome will be the proportion of patients with symptomatic and functional improvement measured by the Knee Injury and Osteoarthritis Outcome Score before and 6 months after treatment, with scores ranging from 0 (worst) to 100 (best). Secondary outcomes will be knee-specific quality of life (ACL QoL), return to activity and level of sport participation (Tegner or modified Tegner score), health-related QoL (EuroQol Group 5-Dimension 5-Level, EQ-5D-5L), resource use, intervention-related complications and patient satisfaction. We have developed search strategies for PubMed, Embase, the Cochrane Library and Web of Science, retrieving RCTs that meet the inclusion criteria from database inception to 1 December 2023. The methodological quality of the included RCTs will be assessed based on the Cochrane risk of bias table. The relative ranking probability of the best intervention will be estimated using the surface under the cumulative ranking curve. The Bayesian NMA will be conducted by using WinBUGS V.1.4.3. The Grading of Recommendations Assessment, Development and Evaluation approach will be applied to determine our confidence in an overall treatment ranking from the NMA. ETHICS AND DISSEMINATION Ethical approval for this study is not required because no private or confidential patient data will be used in this study. Findings of this study would be disseminated through the publication in a peer-reviewed medical journal. PROSPERO REGISTRATION NUMBER CRD42023437115.
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Affiliation(s)
- Yuchen He
- Department of Orthopadics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yishu Fan
- Department of Orthopadics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Central South University, Changsha, Hunan, China
| | - Longxiang Zhai
- Department of Orthopadics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Weihong Zhu
- Department of Orthopadics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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13
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Hu J, Zhang J, Zhang P, Wang J, He J, Chen P, Liang Y. Suture Bridge Technique with 5-Ethibond: A Promising Approach for Infrapatellar Pole Fracture Treatment. Orthop Rev (Pavia) 2024; 16:94275. [PMID: 38505135 PMCID: PMC10950202 DOI: 10.52965/001c.94275] [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] [Received: 07/21/2023] [Accepted: 02/18/2024] [Indexed: 03/21/2024] Open
Abstract
Purpose Infrapatellar pole fractures are challenging injuries that require appropriate treatment to ensure optimal functional outcomes. This study aimed to introduce the application of the Suture Bridge technique using the 5-Ethibond for the treatment of infrapatellar patella fracture. Methods Five cases of infrapatellar pole fracture that were treated at our institution between February 2020 and September 2021. The patients included one male and four females, with an average age of 66 years (range: 60-77 years). All patients were treated with the Suture Bridge technique using the 5-Ethibond to preserve the infrapatellar pole. Results The average operative time was 64 min (range: 50-80 min). The average blood loss during surgery was 51 mL (range: 40-60 mL). All cases demonstrated fracture healing at an average of 10 weeks (range 8-12) after surgery. The patients were followed up for an average period of 14.8 months (8-22). No wound infection or second displacement of fracture fragment was found. Full range of motion was restored in all patients within 12-14 weeks after surgery. None of the patients complained of anterior knee pain. Conclusions Based on the findings of the study, it appears that the Suture Bridge technique using 5-Ethibond is a promising and viable option for the treatment of infrapatellar pole fractures.
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Affiliation(s)
- Jinlong Hu
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Jiale Zhang
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Pei Zhang
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Jingcheng Wang
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Jinshan He
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Pengtao Chen
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
| | - Yuan Liang
- Department of Orthopedics Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Nantong West Road 98, Yangzhou, 225001, China
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14
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Chu CR, Murray MM, Maloney WJ, Hogan MV. How Research Improves Clinical Care: The Case for Orthopaedic Surgeon Research Leadership and Collaboration: AOA Critical Issues Symposium. J Bone Joint Surg Am 2024; 106:466-471. [PMID: 38117871 DOI: 10.2106/jbjs.23.00599] [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] [Indexed: 12/22/2023]
Abstract
ABSTRACT Improving the performance and impact of orthopaedic research is a critical leadership challenge. Musculoskeletal (MSK) conditions are a leading cause of disability worldwide, for which research investment and performance lags far behind the burden of disease. In the United States, MSK disorders account for the highest health care costs, have increased in incidence at the fastest rate, and exceed the combined costs of cardiovascular diseases and neoplasms. Despite the cost to society, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), with primary responsibility for MSK research, receives <1.4% of the funds allocated to the National Institutes of Health (NIH). Although orthopaedic surgeons are leading providers of MSK clinical care, the dearth of orthopaedic clinician-scientists also greatly reduces representation of MSK scientific and clinical expertise among academic and scientific leaders. The goals of this symposium were to highlight the critical need for greater prioritization and investment in orthopaedic research and to engage orthopaedic leaders in addressing these needs. Compelling stories of research success from 3 orthopaedic chairs were featured to highlight how orthopaedic surgeon leadership in bench-to-bedside research substantially advances MSK clinical care. Seminar participants also emphasized the need to improve evidence-based clinical practice for which multicenter prospective cohort and registry studies represent opportunities for broader involvement. Prioritization of orthopaedic clinician-scientist development and formation of multidisciplinary partnerships with basic and translational scientists were emphasized as critical needs to advance MSK health. It is critical for orthopaedic chairs to "be invested in" and to "invest in" the success of orthopaedic research. This investment includes developing a professional climate that values research achievement and collaboration as well as implementing strategies to support and sustain research success. Finally, orthopaedic leaders need to advocate for federal research funding to be proportional to the economic burden of disease for which MSK conditions carry the highest current and projected costs. With health-care costs accounting for nearly one-fifth of the U.S. economy, increasing the investment in orthopaedic research to reduce the prevalence, disability, and morbidity from MSK disease needs to be a top orthopaedic and national leadership priority.
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Affiliation(s)
- Constance R Chu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Martha M Murray
- Department of Orthopedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - MaCalus V Hogan
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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15
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Gao S, Wang T. Suture Anchor Technique for Bridge Enhanced Anterior Cruciate Ligament Restoration. Arthrosc Tech 2024; 13:102880. [PMID: 38584620 PMCID: PMC10995693 DOI: 10.1016/j.eats.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/02/2023] [Indexed: 04/09/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries are common in the athletic population. ACL repair with bridge enhancement is an emerging technology with promising clinical outcomes in patients with a proximal to midsubstance ACL tears. Currently, there are a variety of fixation methods described for isolated ACL repair, including suspensory and anchor techniques. This Technical Note describes a bridge enhanced ACL restoration procedure technique, using suture anchors for the femoral fixation. Advantages of this technique include more rigid fixation and avoiding need for accessory over-the-top incision. Additionally, the surgical workflow is more similar to an ACL reconstruction with intra-articular screw fixation, which may be more readily adopted by some surgeons.
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Affiliation(s)
- Sean Gao
- Department of Orthopaedic Surgery, Sports Medicine, Scripps Clinic Medical Group, La Jolla, California, U.S.A
| | - Tim Wang
- Department of Orthopaedic Surgery, Sports Medicine, Scripps Clinic Medical Group, La Jolla, California, U.S.A
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16
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Ambrosio L, Franco D, Vadalà G, Russo F, Papalia R. Anterior Cruciate Ligament Repair Augmented With Dynamic Intraligamentary Stabilization Is Equivalent to Hamstring Autograft Reconstruction at Short- and Mid-Term Follow-Up: A Systematic Review. Arthroscopy 2024:S0749-8063(23)01015-0. [PMID: 38417640 DOI: 10.1016/j.arthro.2023.12.011] [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: 08/11/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 03/01/2024]
Abstract
PURPOSE To compare clinical outcomes, knee stability and complications, failure, and revision rates after anterior cruciate ligament repair (ACLr) with dynamic intraligamentary stabilization (DIS) versus anterior cruciate ligament reconstruction (ACLR) with hamstring autograft for primary ACL ruptures at short and mid-term follow-up. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of PubMed/MEDLINE and Scopus was performed. Studies that evaluated patients undergoing ACLr with DIS or ACLR with hamstring autograft were considered for inclusion. Studies were excluded if patients were affected by concomitant meniscal, ligamentous, or chondral injuries needing surgical treatment, because of their potential confounding effect on postoperative outcomes. The Risk of Bias-2 tool was used to assess the risk of bias in the included studies. The quality of available evidence was rated according to Grading of Recommendations Assessment, Development, and Evaluation recommendations. The study protocol was registered in the PROSPERO database (ID: CRD42023394558). RESULTS Five randomized controlled trials comparing the outcomes of ACLr with DIS versus ACLR with hamstring autograft met the inclusion criteria. No major differences in terms of patient-reported outcomes (International Knee Documentation Committee subjective form, Lysholm score, Tegner activity scale, Knee injury and Osteoarthritis Outcome Score, visual analog scale satisfaction) or rates of complications, revisions, and failures were found in included studies at all time points. Repair showed greater International Knee Documentation Committee subjective form scores at 5 years in one study, whereas ACLR displayed significantly increased knee stability at 6 months and 5 years in 2 different studies, although the clinical relevance of these differences is doubtful. CONCLUSIONS The results of this study suggest that ACLr with DIS is not inferior to ACLR with hamstring autograft in terms of rates of clinical outcomes, knee stability, risk of failure, complications, and revision surgery. Therefore, ACLr with DIS may be a viable alternative to ACLR with hamstring autograft in selected patients. LEVEL OF EVIDENCE Level I, systematic review of Level I studies.
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Affiliation(s)
- Luca Ambrosio
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Domenico Franco
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Gianluca Vadalà
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | - Fabrizio Russo
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Rocco Papalia
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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17
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Ferrel JR, Conley CE, Johnson DL. Routine Use of Suture Tape Augmentation for Primary Anterior Cruciate Ligament Reconstruction Surgery Is Not Justified. Arthroscopy 2024:S0749-8063(24)00157-9. [PMID: 38417641 DOI: 10.1016/j.arthro.2024.02.022] [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: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
High rates of graft failure after primary ACLR and the need for revision ACLR continue to be a challenge. Multiple studies demonstrate graft failure rates and the need for revision ACLR in 10% to 15% of young patients participating in pivot sporting activities. There's currently a wide range of strategies to mitigate this problem being investigated, including extraarticular augmentation (with modified lateral extra-articular tenodesis or anterolateral ligament reconstruction) and intraarticular fixation (that aim for primary ACL healing or augmentation of an ACL reconstruction with suture tape). While the early data on suture tape augmentation of primary ACLR seems optimistic, it does not justify its routine use.
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Affiliation(s)
- Jason R Ferrel
- Orthopedic Surgery Sports Medicine Fellow, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284.
| | - Caitlin E Conley
- Assistant Professor, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284
| | - Darren L Johnson
- Professor of Orthopedic Surgery, Director and Chief: Sports Medicine, University of Kentucky School of Medicine, Kentucky Clinic, Dept. of Orthopaedic Surgery, 740 S. Limestone, Suite K401, Lexington, Ky. 40536-0284
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18
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Johns WL, Martinazzi BJ, Miltenberg B, Nam HH, Hammoud S. ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024:S0749-8063(24)00061-6. [PMID: 38311261 DOI: 10.1016/j.arthro.2024.01.017] [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: 08/23/2023] [Revised: 01/01/2024] [Accepted: 01/08/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery. METHODS A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index. RESULTS Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore. CONCLUSIONS Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients. CLINICAL RELEVANCE Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Brandon J Martinazzi
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A..
| | - Benjamin Miltenberg
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Hannah H Nam
- Penn State College of Medicine, Hershey, Pennsylvania, U.S.A
| | - Sommer Hammoud
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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19
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Bechis M, Rosso F, Blonna D, Rossi R, Bonasia DE. Lateral Extra-Articular Tenodesis with Indirect Femoral Fixation Using an Anterior Cruciate Ligament Reconstruction Suspensory Device. J Clin Med 2024; 13:377. [PMID: 38256513 PMCID: PMC10816928 DOI: 10.3390/jcm13020377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND The lateral extra-articular tenodesis (LET) procedure associated with anterior cruciate ligament (ACL) reconstruction can be considered in selected patients to diminish the risk of persistent rotatory instability and achieve a protective effect on the graft. Several techniques have been described in the literature to treat rotatory instability. Usually, a strip of the iliotibial band (ITB) is harvested from its middle while leaving the distal insertion, then passed underneath the lateral collateral ligament and fixed on the lateral aspect of the distal femur with various fixation methods such as staples, screws, anchors or extracortical suspensory devices. Despite their effectiveness, these fixation methods may be associated with complications such as lateral pain, over-constraint and tunnel convergence. METHODS This study presents a detailed surgical description of a new technique to perform an LET during ACL reconstruction with any type of graft fixing the ITB strip with the sutures of the ACL femoral button, comparing its pros and cons in relation to similar techniques found in the literature. CONCLUSIONS This technique represents a reproducible, easy to learn and inexpensive solution to perform a lateral extra-articular tenodesis associated with an ACL reconstruction using the high-resistance sutures of the femoral button.
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Affiliation(s)
- Marco Bechis
- AO Ordine Mauriziano Hospital, Department of Orthopedics and Traumatology, University of Torino, 10124 Turin, Italy
| | | | | | | | - Davide Edoardo Bonasia
- AO Ordine Mauriziano Hospital, Department of Orthopedics and Traumatology, University of Torino, 10124 Turin, Italy
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20
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Ren Y, Wang J, Ji J, Zhang C, Meng Q. Comparison of Clinical Outcomes Between Modern Augmented ACL Repair and Autograft ACL Reconstruction: A Systematic Review and Meta-analysis of Studies With Minimum 2-Year Follow-up. Orthop J Sports Med 2024; 12:23259671231223743. [PMID: 38282789 PMCID: PMC10812109 DOI: 10.1177/23259671231223743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Indexed: 01/30/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) reconstruction has been the gold standard for primary ACL rupture since the 1990s. In the past decade, ACL repair has received renewed attention and increased research. Purpose To compare the clinical outcomes of modern augmented ACL repair versus autograft reconstruction for ACL ruptures. Study Design Systematic review; Level of evidence, 3. Methods A search of the PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library databases was conducted for prospective or retrospective comparative studies published between January 1, 2010, and January 3, 2023, with a minimum 2-year follow-up. Two independent reviewers performed data extraction and methodological quality assessment. Sensitivity analysis was performed to maintain the stability of results. Results Nine studies were included (minimum follow-up period, 24-60 months). The total sample size was 833 patients (augmented repair group: 358 patients; autograft ACL reconstruction group: 475 patients). There were 4 randomized controlled trials (level 1), 1 prospective comparative study (level 2), 2 retrospective comparative studies (level 3), and 2 case-control studies (level 3). The augmented ACL repair group attained significantly higher Lysholm score (weighted mean difference [WMD] = 1.57; 95% confidence interval [CI], 0.14-3.01; P = .03) and hamstring strength (WMD = 36.69; 95% CI, 29.07-44.31; P < .01) but had higher rates of hardware removal (odds ratio [OR] = 6.30; 95% CI, 2.44-16.23; P = .0001), reoperation (OR = 1.87; 95% CI, 1.33-2.62; P = .0003), and failure (OR = 1.58; 95% CI, 1.03-2.43; P = .0003) compared with the autograft ACL reconstruction group. No significant differences were observed between the repair and reconstruction groups regarding postoperative International Knee Documentation Committee scores, Tegner scores, knee laxity, satisfaction, ACL revisions, complications, and reoperation rather than revision. Conclusion Augmented ACL repair was associated with higher rates of reoperation, hardware removal, and failure compared with autograft ACL reconstruction in studies with minimum 2-year follow-up data. However, augmented ACL repair had higher Lysholm scores and hamstring strength versus autograft ACL reconstruction.
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Affiliation(s)
- Yunong Ren
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
- Medical College of Qingdao University, Qingdao, Shandong, China
| | - Jia Wang
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Junjie Ji
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Chao Zhang
- Medical College of Qingdao University, Qingdao, Shandong, China
| | - Qingyang Meng
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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21
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Li LT, Sinkler MA, Adelstein JM, Voos JE, Calcei JG. ChatGPT Responses to Common Questions About Anterior Cruciate Ligament Reconstruction Are Frequently Satisfactory. Arthroscopy 2024:S0749-8063(23)01013-7. [PMID: 38171421 DOI: 10.1016/j.arthro.2023.12.009] [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: 09/24/2023] [Revised: 11/13/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE To evaluate ChatGPT responses to common questions patients have regarding anterior cruciate ligament (ACL) reconstruction. METHODS Ten frequently asked questions regarding ACL tears and ACL reconstruction were chosen from the frequently asked questions found on the websites of major institutions. These were presented to ChatGPT and responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS Four responses were satisfactory, requiring minimal clarification, 3 were satisfactory, requiring moderate clarification, 2 were unsatisfactory, and 1 was excellent, requiring no clarification. CONCLUSIONS As hypothesized, ChatGPT provided generally accurate information to common questions around ACL reconstruction. Although clarification often was needed, responses were satisfactory for providing generalized information about ACL tears and ACL reconstruction. CLINICAL RELEVANCE ChatGPT is a promising avenue for patients to learn about general background information regarding ACL reconstruction, although questions specific to any planned operation need to be addressed directly with an orthopaedic provider.
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Affiliation(s)
- Lambert T Li
- Department of Orthopaedic Surgery, University Hospitals, Case Western Reserve University, Cleveland, Ohio, U.S.A..
| | - Margaret A Sinkler
- Department of Orthopaedic Surgery, University Hospitals, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Jeremy M Adelstein
- Department of Orthopaedic Surgery, University Hospitals, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - James E Voos
- Department of Orthopaedic Surgery, University Hospitals, Case Western Reserve University, Cleveland, Ohio, U.S.A
| | - Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals, Case Western Reserve University, Cleveland, Ohio, U.S.A
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22
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Nelson PA, George T, Bowen E, Sheean AJ, Bedi A. An Update on Orthobiologics: Cautious Optimism. Am J Sports Med 2024; 52:242-257. [PMID: 38164688 DOI: 10.1177/03635465231192473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Orthobiologics are rapidly growing in use given their potential to augment healing for multiple musculoskeletal conditions. Orthobiologics consist of a variety of treatments including platelet-rich plasma and stem cells that provide conceptual appeal in providing local delivery of growth factors and inflammation modulation. The lack of standardization in nomenclature and applications within the literature has led to a paucity of high-quality evidence to support their frequent use. The purpose of this review was to describe the current landscape of orthobiologics and the most recent evidence regarding their use.
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Affiliation(s)
- Patrick A Nelson
- University of Chicago Department of Orthopedic Surgery, Chicago, Illinois, USA
| | - Tom George
- Northshore University Healthcare System, Evanston, Illinois, USA
| | - Edward Bowen
- Weill Cornell Medicine, New York City, New York, USA
| | - Andrew J Sheean
- San Antonio Military Medical Center, Department of Orthopedic Surgery, San Antonio, Texas, USA
| | - Asheesh Bedi
- Northshore University Healthcare System, Evanston, Illinois, USA
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23
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Filbay SR, Dowsett M, Chaker Jomaa M, Rooney J, Sabharwal R, Lucas P, Van Den Heever A, Kazaglis J, Merlino J, Moran M, Allwright M, Kuah DEK, Durie R, Roger G, Cross M, Cross T. Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. Br J Sports Med 2023; 57:1490-1497. [PMID: 37316199 DOI: 10.1136/bjsports-2023-106931] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP). METHODS Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7-16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman's test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0-1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2-3 (continuous but thinned/elongated or complete discontinuity)). RESULTS Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94-100) vs 94 (85-100)) and ACLQOL (89 (76-96) vs 70 (64-82)) scores, compared with ACLOAS grades 2-3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2-3. Eleven patients (14%) re-injured their ACL. CONCLUSION After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.
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Affiliation(s)
- Stephanie R Filbay
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Dowsett
- School of Medicine, Sydney Campus, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Mohammad Chaker Jomaa
- School of Public Health, University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Jane Rooney
- Lifecare Prahran Sports Medicine Centre, Melbourne, Victoria, Australia
| | | | - Phil Lucas
- PRP Diagnostic Imaging, Sydney, New South Wales, Australia
| | | | - James Kazaglis
- Stadium Sports Physiotherapy, Sydney, New South Wales, Australia
| | - Justin Merlino
- Stadium Sports Physiotherapy, Sydney, New South Wales, Australia
| | - Mick Moran
- Stadium Sports Physiotherapy, Sydney, New South Wales, Australia
| | | | - Donald E K Kuah
- New South Wales Institute of Sports, Sydney, New South Wales, Australia
| | - Ra Durie
- Sportsmed Manawatu, Palmerston North, New Zealand
| | - Greg Roger
- The University of Sydney School of Biomedical Engineering, Darlington, New South Wales, Australia
- Vestech Medical Pty Ltd, Sydney, New South Wales, Australia
| | - Mervyn Cross
- The Stadium Sports Medicine Clinic, Sydney, New South Wales, Australia
| | - Tom Cross
- The Stadium Sports Medicine Clinic, Sydney, New South Wales, Australia
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24
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Robinson JD, Williamson T, Carson T, Whelan RJ, Abelow SP, Gilmer BB. Primary anterior cruciate ligament repair: Current concepts. J ISAKOS 2023; 8:456-466. [PMID: 37633336 DOI: 10.1016/j.jisako.2023.08.008] [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] [Received: 05/08/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023]
Abstract
The renewed interest in ACL repair over the last two decades stems from advances in modern arthroscopic techniques and clinical studies that have provided evidence that the ACL can reliably heal, and patients can return to sport at a comparable rate to ACL reconstruction patients. The ability to maintain and utilize native ACL tissue, with proprioceptive capabilities, and the smaller drill tunnels needed to repair an ACL leads to an overall less invasive procedure and improved early rehabilitation. Additionally, repair avoids a variety of comorbidities associated with autograft harvest. This current concept review details modern techniques of ACL repair and their current studies, a review on the use of biologic enhancement in ACL repair, and other considerations to appropriately integrate ACL repair into the sports medicine orthopaedic surgeon's practice.
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Affiliation(s)
- John D Robinson
- Lake Tahoe Sports Medicine Fellowship, Barton Center for Orthopedics and Wellness, 2170B South Ave., South Lake Tahoe, CA 96150, USA. Correspondence:
| | - Tyler Williamson
- Lake Tahoe Sports Medicine Fellowship, Barton Center for Orthopedics and Wellness, 2170B South Ave., South Lake Tahoe, CA 96150, USA
| | - Taylor Carson
- University of Nevada, Reno School of Medicine, 1664 N Virginia St., Reno, NV 89557, USA
| | - Ryan J Whelan
- University of Nevada, Reno School of Medicine, 1664 N Virginia St., Reno, NV 89557, USA
| | - Stephen P Abelow
- Lake Tahoe Sports Medicine Fellowship, Barton Center for Orthopedics and Wellness, 2170B South Ave., South Lake Tahoe, CA 96150, USA
| | - Brian B Gilmer
- Mammoth Orthopedic Institute, Mammoth Hospital, 85 Sierra Park Rd. Mammoth Lakes, CA 93546, USA
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Duong JKH, Bolton C, Murphy GT, Fritsch BA. Anterior cruciate ligament repair versus reconstruction: A clinical, MRI and patient-reported outcome comparison. Knee 2023; 45:100-109. [PMID: 37925800 DOI: 10.1016/j.knee.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/08/2023] [Accepted: 09/19/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND There has been a resurgence in anterior cruciate ligament (ACL) repair for proximal tears using modern surgical techniques and technology. This study aims to compare ACL repair with reconstruction using MRI, clinician-measured and patient-reported outcome measures (PROMs). METHODS A post-hoc analysis was performed on prospectively collected data from 20 consecutive primary ACL repairs by the senior author. This was compared with an age and sex-matched cohort of 20 ACL reconstructions by the same surgeon using PROMs, return-to-sport (RTS) testing, and MRI signal noise quotient (SNQ). RESULTS Repairs demonstrated equivalent post-operative PROMs to reconstructions as measured by International Knee Documentation Committee subjective score (78.5 ± 17.1 vs. 83.7 ± 13.3, P = 0.333), Tegner Activity Scale (5.9 ± 1.8 vs. 6.1 ± 2.6, P = 0.646) and Lysholm score (89.8 ± 10.0 vs. 89.6 ± 10.4, P = 0.762). There was no difference in repairs and reconstructions passing quadriceps strength criteria (50% vs. 53%, P = 0.097). A greater proportion of repairs passed hamstrings strength criteria (86% vs. 60%, P = 0.023) and hamstrings-to-quadriceps ratio (71% vs. 20%, P = 0.003). There were no differences across hop and Y-balance testing. Repairs had earlier RTS assessment (8.2 ± 2.8 months vs. 10.6 ± 1.4 months, P = 0.020). On 12-month MRI, repairs demonstrated higher femoral (8.8 ± 5.7 vs. 4.6 ± 2.9, P = 0.009) and tibial SNQ (10.0 ± 5.7 vs. 4.3 ± 4.2, P = 0.001), with no mid-substance difference (12.3 ± 8.5 vs. 7.6 ± 5.2, P = 0.074). There were no graft failures. CONCLUSIONS When patient selection is optimized for proximal tears, ACL repairs demonstrate equivalent PROMs and better objective outcomes to reconstructions at an earlier timepoint. Repair tissue quality on MRI shows higher signal at tibial and femoral attachments.
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Affiliation(s)
- Julian K H Duong
- Sydney Orthopaedic Research Institute, St Leonards, Sydney, Australia.
| | - Claire Bolton
- Sydney Orthopaedic Research Institute, St Leonards, Sydney, Australia
| | - Geoffrey T Murphy
- Sydney Orthopaedic Research Institute, St Leonards, Sydney, Australia
| | - Brett A Fritsch
- Sydney Orthopaedic Research Institute, St Leonards, Sydney, Australia; Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
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Maerz T. Is synovitis inevitable after ACL injury? Osteoarthritis Cartilage 2023; 31:1531-1533. [PMID: 37597654 DOI: 10.1016/j.joca.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Affiliation(s)
- Tristan Maerz
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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Migliorini F, Vecchio G, Eschweiler J, Schneider SM, Hildebrand F, Maffulli N. Reduced knee laxity and failure rate following anterior cruciate ligament reconstruction compared with repair for acute tears: a meta-analysis. J Orthop Traumatol 2023; 24:8. [PMID: 36805839 PMCID: PMC9941413 DOI: 10.1186/s10195-023-00688-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/04/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Following anterior cruciate ligament (ACL) tears, both repair and reconstruction may be performed to restore joint biomechanics and proprioception. The present study compared joint laxity, patient-reported outcome measures (PROMs), and rate of failure following primary repair versus reconstruction for ACL ruptures. METHODS This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Google scholar, Embase, and Web of Science were accessed in September 2022. All the clinical investigations comparing repair versus reconstruction for primary ACL tears were accessed. Studies reporting data on multiple ligament injuries settings were not eligible. RESULTS Data from eight articles (708 procedures) were collected. The mean length of the follow-up was 67.3 ± 119.4 months. The mean age of the patients was 27.1 ± 5.7 years. Thirty-six percent (255 of 708 patients) were women. The mean body mass index (BMI) was 24.3 ± 1.1 kg/m2. The mean time span from injury to surgery was 36.2 ± 32.3 months. There was comparability at baseline with regards to instrumental laxity, Lachman test, International Knee Document Committee (IKDC), and Tegner Scale (P > 0.1). Similarity between ACL reconstruction and repair was found in IKDC (P = 0.2) and visual analog scale (VAS) satisfaction (P = 0.7). The repair group demonstrated greater mean laxity (P = 0.0005) and greater rate of failure (P = 0.004). CONCLUSION ACL reconstruction may yield greater joint stability and lower rate of failure compared with surgical repair. Similarity was found in PROMs. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany. .,Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Gianluca Vecchio
- grid.11780.3f0000 0004 1937 0335Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA Italy
| | - Jörg Eschweiler
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Sarah-Marie Schneider
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Frank Hildebrand
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Nicola Maffulli
- grid.11780.3f0000 0004 1937 0335Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA Italy ,grid.9757.c0000 0004 0415 6205School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Thornburrow Drive, Stoke On Trent, England ,grid.4868.20000 0001 2171 1133Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG England
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Almonroeder TG, Friedrich JO, Hyoda H, Grabowski P, Jagim A, Dobbs W, Luedke J. Inter-limb kinetic asymmetries during sit-to-stand performance persist following unilateral total knee arthroplasty: A systematic review and meta-analysis. Clin Biomech (Bristol, Avon) 2023; 110:106103. [PMID: 37774467 DOI: 10.1016/j.clinbiomech.2023.106103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/12/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Kinetic asymmetries during sit-to-stand have been consistently observed early after total knee arthroplasty; however, the longer-term outcomes are less clear. The purpose of this systematic review and meta-analysis was to analyze the results of studies examining inter-limb kinetic symmetry during sit-to-stand performance among individuals who were at least one-year post unilateral total knee arthroplasty. METHODS PubMed, SPORTDiscus, CINAHL, and Health Source databases were searched. Studies were included if they were published in a peer-reviewed journal, included subjects who had undergone unilateral total knee arthroplasty at least one-year prior, and examined vertical ground reaction forces and/or knee extension moments for the involved and uninvolved limbs during sit-to-stand performance. Data were transformed into a limb symmetry index, which expressed the ratio of the peak forces/moments for the involved limb, relative to the uninvolved limb (1.0 reflects perfect symmetry). These ratios were meta-analyzed using the ratio of means method. FINDINGS Seven studies were deemed eligible for inclusion. Ground reaction force data was pooled from seven studies and knee extension moment data was pooled from two studies. For the peak vertical ground reaction forces, the pooled limb symmetry index was 0.96 (CI95% = [0.93, 0.99]). For the peak knee extension moments, the pooled limb symmetry index was 0.91 (CI95% = [0.84, 0.98]). In both cases this reflects greater limb/knee loading for the uninvolved limb, relative to the involved limb. INTERPRETATION Asymmetries in limb/knee loading persist beyond the one-year post-operative period following total knee arthroplasty, potentially contributing to degenerative changes for the uninvolved limb.
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Affiliation(s)
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care and Department of Medicine, Temerty Faculty of Medicine, University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada; Unity Health Toronto - St. Michael's Hospital, 30 Bond St., Bond Wing, Room 4-015, Toronto, ON M5B 1W8, Canada.
| | - Haruka Hyoda
- Trine University, 1819 Carew St., Fort Wayne, IN 46805, USA.
| | - Patrick Grabowski
- University of Wisconsin-La Crosse, 1725 State St., La Crosse, WI 54601, USA.
| | - Andrew Jagim
- Mayo Clinic Health System, 700 West Ave. S., La Crosse, WI 54601, USA.
| | - Ward Dobbs
- University of Wisconsin-La Crosse, 1725 State St., La Crosse, WI 54601, USA.
| | - Joel Luedke
- Mayo Clinic Health System, 700 West Ave. S., La Crosse, WI 54601, USA.
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Anz AW, Jordan SE, Ostrander RV, Branch EA, Denney TS, Cohen A, Andrews JR. Augmentation of ACL Autograft Reconstruction With an Amnion Collagen Matrix Wrap and Bone Marrow Aspirate Concentrate: A Pilot Randomized Controlled Trial With 2-Year Follow-up. Orthop J Sports Med 2023; 11:23259671231210035. [PMID: 38021297 PMCID: PMC10656805 DOI: 10.1177/23259671231210035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background It is theorized that the lack of a synovial lining after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) contributes to slow ligamentization and possible graft failure. Whether graft maturation and incorporation can be improved with the use of a scaffold requires investigation. Purpose To evaluate the safety and efficacy of wrapping an ACL autograft with an amnion collagen matrix and injecting bone marrow aspirate concentrate (BMAC), quantify the cellular content of the BMAC samples, and assess 2-year postoperative patient-reported outcomes. Study Design Randomized controlled trial; Level of evidence, 2. Methods A total of 40 patients aged 18 to 35 years who were scheduled to undergo ACLR were enrolled in a prospective single-blinded randomized controlled trial with 2 arms based on graft type: bone-patellar tendon-bone (BTB; n = 20) or hamstring (HS; n = 20). Participants in each arm were randomized into a control group who underwent standard ACLR or an intervention group who had their grafts wrapped with an amnion collagen matrix during graft preparation, after which BMAC was injected under the wrap layers after implantation. Postoperative magnetic resonance imaging (MRI) mapping/processing yielded mean T2* relaxation time and graft volume values at 3, 6, 9, and 12 months. Participants completed the Single Assessment Numeric Evaluation Score, Knee injury and Osteoarthritis Outcome Score, and pain visual analog scale. Statistical linear mixed-effects models were used to quantify the effects over time and the differences between the control and intervention groups. Adverse events were also recorded. Results No significant differences were found at any time point between the intervention and control groups for BTB T2* (95% CI, -1.89 to 0.63; P = .31), BTB graft volume (95% CI, -606 to 876.1; P = .71), HS T2* (95% CI, -2.17 to 0.39; P = .162), or HS graft volume (95% CI, -11,141.1 to 351.5; P = .28). No significant differences were observed between the intervention and control groups of either graft type on any patient-reported outcome measure. No adverse events were reported after a 2-year follow-up. Conclusion In this pilot study, wrapping a graft with an amnion collagen matrix and injecting BMAC appeared safe. MRI T2* values and graft volume of the augmented ACL graft were not significantly different from that of controls, suggesting that the intervention did not result in improved graft maturation. Registration NCT03294759 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Adam W. Anz
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Steve E. Jordan
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Roger V. Ostrander
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Eric A. Branch
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
| | - Thomas S. Denney
- Department of Electrical and Computer Engineering, Auburn University, Auburn, Alabama, USA
| | - Achraf Cohen
- Department of Mathematics and Statistics, University of West Florida, Pensacola, Florida, USA
| | - James R. Andrews
- Department of Research, Andrews Institute Center for Regenerative Medicine, Andrews Research & Education Foundation, Gulf Breeze, Florida, USA
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Marcaccio SE, Morrissey PJ, Testa EJ, Fadale PD. Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction. JBJS Rev 2023; 11:01874474-202310000-00002. [PMID: 37812667 PMCID: PMC10558152 DOI: 10.2106/jbjs.rvw.23.00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.
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Affiliation(s)
- Stephen E. Marcaccio
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Patrick J. Morrissey
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Edward J. Testa
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D. Fadale
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Fayard JM, Foissey C, Pacoret V, Abid H, Vieira TD, Gabr A, Thaunat M. Return to Sports After ACL Augmentation With Anterolateral Reconstruction (ALR) Harvesting Gracilis Only Compared With ACL Reconstruction With ALR Harvesting Both Hamstring Tendons. Am J Sports Med 2023; 51:2918-2927. [PMID: 37548031 DOI: 10.1177/03635465231187038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) repair (ACL-Rp) is known to be a valuable alternative to ACL reconstruction (ACL-Rc) in selected indications. The majority of the ACL-Rp techniques recommend the use of a synthetic brace. The use of the gracilis allows both a biological internal brace and anterolateral ligament reconstruction (ALR). PURPOSE The primary objective was to compare the early ability to return to sports between patients who underwent ACL-Rp using a gracilis autograft as an internal brace augmentation with ALR and patients who underwent the conventional ACL-Rc with ALR technique sacrificing both the gracilis and the semitendinosus. The secondary objective was to compare the failure rate, clinical scores, and return to sports at a minimum follow-up of 2 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis was undertaken. A total of 49 patients who underwent ACL-Rp with ALR between December 2018 and May 2019 were propensity matched at a 1:1 ratio to those who underwent ACL-Rc with ALR during the same period. The decision to perform ACL-Rp with ALR was based on preoperative selection and intraoperative arthroscopic findings: proximal avulsion tear, partial ACL tear, low- to midlevel sports participation, and good tissue quality. The ability to return to sports was assessed using isokinetic tests and the Knee Santy Athletic Return to Sport test functional test at 6 months postoperatively. At the final follow-up, knee laxity parameters, return to sports, and clinical outcome (Lysholm score, Tegner Activity Scale score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Anterior Cruciate Ligament-Return to Sport after Injury score) were recorded. RESULTS The ACL-Rp group had significantly less hamstring strength deficit when compared with their counterparts who underwent ACL-Rc (0.2% vs 10.2% in concentric, P < .001; 2.5% vs 14% in eccentric, P < .001). The mean Knee Santy Athletic Return to Sport test score was significantly higher in the ACL-Rc group (69.7% ± 16.6% [range, 19%-100%] vs 61% ± 16.8% [range, 19%-100%]; P = .001). In the ACL-Rp group, 61% (30/49) of the patients were authorized to return to pivot sports versus 41% (20/49) in the ACL-Rc group (P = .04). At a mean final follow-up of 31.4 ± 3.5 months, no significant differences were demonstrated between groups with respect to clinical scores and knee laxity parameters. There was a trend for a higher failure rate in the ACL-Rp group without any significance (ACL-Rp: 6.1% [3/49] vs ACL-Rc: 0%; P = .08). CONCLUSION At 6 months after operation, harvesting only the gracilis with this ACL-Rp and augmentation with ALR technique was linked to a better early ability to return to sports compared with the ACL-Rc with ALR technique harvesting both the gracilis and semitendinosus. This technique had a limited effect on early flexion strength and provided a satisfactory rerupture rate.
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Affiliation(s)
- Jean-Marie Fayard
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Constant Foissey
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Victor Pacoret
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Hichem Abid
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ayman Gabr
- University College London Hospital, London, United Kingdom
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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D’Ambrosi R, Meena A, Arora ES, Attri M, Schäfer L, Migliorini F. Reconstruction of the anterior cruciate ligament: a historical view. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:364. [PMID: 37675316 PMCID: PMC10477645 DOI: 10.21037/atm-23-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/17/2023] [Indexed: 09/08/2023]
Abstract
Management of anterior cruciate ligament (ACL) tears has continuously evolved since its first description in approximately 170 A.D. by Claudius Galenus of Pergamum and Rome. The initial immobilization using casts was replaced by a variety of surgical and conservative approaches over the past centuries. The first successful case of ACL repair was conducted by Mayo Robson in 1885, suturing cruciate at the femoral site. In the nineteenth century, surgical techniques were focused on restoring knee kinematics and published the first ACL repair. The use of grafts for ACL reconstruction was introduced in 1917 but gained popularity in the late 1900s. The introduction of arthroscopy in the 1980s represented the greatest milestones in the development of ACL surgery, along with the refinements of indications, development of modern strategies, and improvement in rehabilitation methods. Despite the rapid development and multitude of new treatment approaches for ACL injuries in the last 20 years, autografting has remained the treatment of choice. Compared to the initial methods, arthroscopic procedures are mainly performed, and more resistant and safer fixation devices are available. This results in significantly less trauma from the surgery and more satisfactory long-term results. The most commonly used procedures are still patellar tendon or hamstring autograft. Additionally, popular, but less common, is the use of quadriceps tendon (QT) grafts and allografts. In parallel with surgical developments, biological reconstruction focusing on the preservation of ACL remnants through the use of cell culture techniques, partial reconstruction, tissue engineering, and gene therapy has gained popularity. In 2013, Claes reported the discovery of a new ligament [anterolateral ligament (ALL)] in the knee that could completely change the treatment of knee injuries. The intent of these modifications is to significantly improve the primary restriction of rotational laxity of the knee after ACL injury. Kinematic studies have demonstrated that anatomic ACL reconstruction and anterolateral reconstruction are synergistic in controlling pivot displacement. Recently, there has been an increased focus on the application of artificial intelligence and machine learning to improve predictive capability within numerous sectors of medicine, including orthopedic surgery.
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Affiliation(s)
- Riccardo D’Ambrosi
- CASCO Department, IRCCS Orthopedic Institute Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Amit Meena
- Department Orthopaedic Sports Medicine, Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Ekjot Singh Arora
- Department of Orthopedic, Fortis Escorts Heart Institute, New Delhi, India
| | - Manish Attri
- Department of Orthopedic, Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Luise Schäfer
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
- Department of Orthopedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
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Khan AU, Aziz R, Reen M, Walker W, Myers P. The First Case of Bridge-Enhanced Anterior Cruciate Ligament (ACL) Repair (BEAR) Procedure in Mississippi. Cureus 2023; 15:e44218. [PMID: 37767267 PMCID: PMC10522361 DOI: 10.7759/cureus.44218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/29/2023] Open
Abstract
In the past, surgical treatment of anterior cruciate ligament (ACL) tears has mainly involved reconstruction using allografts and autografts. The relatively new FDA-approved bridge-enhanced ACL repair (BEAR) procedure allows the body to use its innate healing properties to help repair the ACL using an absorbable protein-based implant. The procedure is currently being offered by surgeons in 44 states. This case describes the first BEAR procedure performed in the state of Mississippi. A 47-year-old female of normal BMI presented to the orthopedic clinic with a chief complaint of right knee pain. The patient stated that she felt unstable on the injured knee, and the patient had positive anterior drawer and Lachman's tests on physical examination. MRI of the knee one month after injury revealed full-thickness ACL rupture. The patient underwent arthroscopic bridge-enhanced ACL repair in the right knee 43 days after the initial injury. The patient reported positive progress in her healing process at her three-month follow-up, and MRI at the three-month follow-up showed successful repair of the patient's ACL. At six months post-operatively, the patient reported that she is still doing well, and she feels that the stability of her right knee has improved. This case highlights an early trend towards repairs instead of reconstructions in ACL injuries for candidates that meet the following requirements: within 50 days of injury and have an intact tibial stump as recommended by the implant manufacturers.
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Affiliation(s)
- Azeem U Khan
- Orthopedic Surgery, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Rida Aziz
- Orthopedic Surgery, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Michael Reen
- Orthopedic Surgery, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - William Walker
- Orthopedic Surgery, William Carey University College of Osteopathic Medicine, Hattiesburg, USA
| | - Philip Myers
- Orthopedics, Singing River Hospital, Gulfport, USA
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34
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Ellis HB, Zak TK, Jamnik A, Lind DRG, Dabis J, Losito M, Wilson P, Moatshe G. Management of Pediatric Anterior Cruciate Ligament Injuries: A Critical Analysis. JBJS Rev 2023; 11:01874474-202308000-00001. [PMID: 37535763 DOI: 10.2106/jbjs.rvw.22.00223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
» Overall evidence for the treatment of an anterior cruciate ligament (ACL) injury in a pediatric or skeletally immature patient remains lows.» An ACL reconstruction is recommended with concomitant repairable chondral and meniscus injury or with symptoms of persistent instability despite high-quality rehabilitation.» Treatment decision for pediatric ACL reconstruction should use a shared decision-making model weighing the risks and benefits of both a nonoperative vs. surgical treatment.
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Affiliation(s)
- Henry B Ellis
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | | | | | - Dane R G Lind
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Philip Wilson
- Scottish Rite for Children, Dallas, Texas
- University of Texas Southwestern, Dallas, Texas
| | - Gilbert Moatshe
- Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
- Department of Orthopedics, Oslo University Hospital, Oslo, Norway
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Han M, Singh M, Karimi D, Kim JY, Flannery SW, Ecklund K, Murray MM, Fleming BC, Gholipour A, Kiapour AM. LigaNET: A multi-modal deep learning approach to predict the risk of subsequent anterior cruciate ligament injury after surgery. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.25.23293102. [PMID: 37546855 PMCID: PMC10402234 DOI: 10.1101/2023.07.25.23293102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are a common cause of soft tissue injuries in young active individuals, leading to a significant risk of premature joint degeneration. Postoperative management of such injuries, in particular returning patients to athletic activities, is a challenge with immediate and long-term implications including the risk of subsequent injury. In this study, we present LigaNET, a multi-modal deep learning pipeline that predicts the risk of subsequent ACL injury following surgical treatment. Postoperative MRIs (n=1,762) obtained longitudinally between 3 to 24 months after ACL surgery from a cohort of 159 patients along with 11 non-imaging outcomes were used to train and test: 1) a 3D CNN to predict subsequent ACL injury from segmented ACLs, 2) a 3D CNN to predict injury from the whole MRI, 3) a logistic regression classifier predict injury from non-imaging data, and 4) a multi-modal pipeline by fusing the predictions of each classifier. The CNN using the segmented ACL achieved an accuracy of 77.6% and AUROC of 0.84, which was significantly better than the CNN using the whole knee MRI (accuracy: 66.6%, AUROC: 0.70; P<.001) and the non-imaging classifier (accuracy: 70.1%, AUROC: 0.75; P=.039). The fusion of all three classifiers resulted in highest classification performance (accuracy: 80.6%, AUROC: 0.89), which was significantly better than each individual classifier (P<.001). The developed multi-modal approach had similar performance in predicting the risk of subsequent ACL injury from any of the imaging sequences (P>.10). Our results demonstrate that a deep learning approach can achieve high performance in identifying patients at high risk of subsequent ACL injury after surgery and may be used in clinical decision making to improve postoperative management (e.g., safe return to sports) of ACL injured patients.
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Affiliation(s)
- Mo Han
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mallika Singh
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Davood Karimi
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jin-Young Kim
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 1 Hoppin St, Providence RI 02903, USA
| | - BEAR Trial Team
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 1 Hoppin St, Providence RI 02903, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
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Itthipanichpong T, Tangboonnitiwong N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Thamrongskulsiri N. Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor. Arthrosc Tech 2023; 12:e1009-e1013. [PMID: 37533897 PMCID: PMC10390709 DOI: 10.1016/j.eats.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/15/2023] [Indexed: 08/04/2023] Open
Abstract
An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.
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Affiliation(s)
- Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Napol Tangboonnitiwong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Ferretti A, Carrozzo A, Saithna A, Argento G, Annibaldi A, Latini F, Schirò A, Marzilli F, Monaco E. Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up. Am J Sports Med 2023; 51:2300-2312. [PMID: 37350021 DOI: 10.1177/03635465231178301] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse. PURPOSE/HYPOTHESIS The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score-12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure. RESULTS A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63). CONCLUSION ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).
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Affiliation(s)
- Andrea Ferretti
- Institute of Sports Medicine and Science, Italian National Olympic Committee CONI, Rome, Italy
| | - Alessandro Carrozzo
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | | | - Giuseppe Argento
- Department of Radiology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Alessandro Annibaldi
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Francesca Latini
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Antonio Schirò
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Fabio Marzilli
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Edoardo Monaco
- Department of Orthopaedic Surgery and Traumatology, AOU Sant'Andrea, La Sapienza University of Rome, Rome, Italy
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Flannery SW, Murray MM, Badger GJ, Ecklund K, Kramer DE, Fleming BC, Kiapour AM. Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery. Knee Surg Sports Traumatol Arthrosc 2023; 31:1690-1698. [PMID: 35704062 PMCID: PMC9751233 DOI: 10.1007/s00167-022-07000-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Quantitative magnetic resonance imaging (qMRI) has been used to determine the failure properties of ACL grafts and native ACL repairs and/or restorations. How these properties relate to future clinical, functional, and patient-reported outcomes remain unknown. The study objective was to investigate the relationship between non-contemporaneous qMRI measures and traditional outcome measures following Bridge-Enhanced ACL Restoration (BEAR). It was hypothesized that qMRI parameters at 6 months would be associated with clinical, functional, and/or patient-reported outcomes at 6 months, 24 months, and changes from 6 to 24 months post-surgery. METHODS Data of BEAR patients (n = 65) from a randomized control trial of BEAR versus ACL reconstruction (BEAR II Trial; NCT02664545) were utilized retrospectively for the present analysis. Images were acquired using the Constructive Interference in Steady State (CISS) sequence at 6 months post-surgery. Single-leg hop test ratios, arthrometric knee laxity values, and International Knee Documentation Committee (IKDC) subjective scores were determined at 6 and 24 months post-surgery. The associations between traditional outcomes and MRI measures of normalized signal intensity, mean cross-sectional area (CSA), volume, and estimated failure load of the healing ACL were evaluated based on bivariate correlations and multivariable regression analyses, which considered the potential effects of age, sex, and body mass index. RESULTS CSA (r = 0.44, p = 0.01), volume (r = 0.44, p = 0.01), and estimated failure load (r = 0.48, p = 0.01) at 6 months were predictive of the change in single-leg hop ratio from 6 to 24 months in bivariate analysis. CSA (βstandardized = 0.42, p = 0.01), volume (βstandardized = 0.42, p = 0.01), and estimated failure load (βstandardized = 0.48, p = 0.01) remained significant predictors when considering the demographic variables. No significant associations were observed between MRI variables and either knee laxity or IKDC when adjusting for demographic variables. Signal intensity was also not significant at any timepoint. CONCLUSION The qMRI-based measures of CSA, volume, and estimated failure load were predictive of a positive functional outcome trajectory from 6 to 24 months post-surgery. These variables measured using qMRI at 6 months post-surgery could serve as prospective markers of the functional outcome trajectory from 6 to 24 months post-surgery, aiding in rehabilitation programming and return-to-sport decisions to improve surgical outcomes and reduce the risk of reinjury. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Sean W Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M Murray
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Gary J Badger
- Department of Medical Biostatistics, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Kirsten Ecklund
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E Kramer
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M Kiapour
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
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Raja BS, Arora M, Gowda AKS, Maheshwari VK, Regmi A. Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:722-747. [PMID: 37128558 PMCID: PMC10147891 DOI: 10.1007/s43465-022-00805-2] [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] [Received: 07/04/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
Purpose The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes. Methods Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS). Results A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies. Conclusion The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.
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Affiliation(s)
- Balgovind S. Raja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Manit Arora
- Department of Orthopaedics, Fortis Hospital, Mohali, Punjab India
| | - Aditya K. S. Gowda
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vikas K. Maheshwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Van de Velde SK. Double-Bundle Anterior Cruciate Ligament Reconstruction With Primary Repair and Hamstring Autograft Augmentation. Arthrosc Tech 2023; 12:e639-e645. [PMID: 37323793 PMCID: PMC10265486 DOI: 10.1016/j.eats.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/31/2022] [Indexed: 06/17/2023] Open
Abstract
The optimal treatment of a ruptured anterior cruciate ligament (ACL) restores the patient's native anatomy and biomechanics as close to normal as possible. The purpose of this technical note is to describe an ACL reconstruction technique in which a double-bundle concept is used, wherein one bundle contains repaired ACL tissue and the second bundle contains a hamstring autograft, and each bundle is tensioned independently. Even in chronic cases, this technique allows for incorporation of the native ACL because, more often than not, there is sufficient tissue of good quality available for repair of one bundle. By augmenting the ACL repair with an autograft sized to the fit the individual anatomy, the patient's ACL tibial footprint can be closely restored to normal, and the potential benefits of tissue preservation are combined with the biomechanical strengths of an autograft double-bundle ACL reconstruction.
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Affiliation(s)
- Samuel K. Van de Velde
- Address correspondence to Samuel K. Van de Velde, M.D., M.P.H., Ph.D., Department of Orthopedic Surgery, Columbia University Irving Medical Center, 622 West 168th St., New York, NY 10032, U.S.A.
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Vandenrijt J, Callenaere S, Van der Auwera D, Michielsen J, Van Dyck P, Heusdens CHW. Posterior cruciate ligament repair seems safe with low failure rates but more high level evidence is needed: a systematic review. J Exp Orthop 2023; 10:49. [PMID: 37099086 PMCID: PMC10133428 DOI: 10.1186/s40634-023-00605-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/31/2023] [Indexed: 04/27/2023] Open
Abstract
PURPOSE To discuss recent literature on posterior cruciate ligament (PCL) repair and report on the clinical and radiological outcomes. METHODS A systematic review was conducted according to the PRISMA guidelines. In August 2022, three databases (PubMed, Scopus, and Cochrane Library) were searched for studies on PCL repair by two independent reviewers. Articles published between January 2000 and August 2022 focussing on the clinical and/or radiological outcomes, following PCL repair, were included. Patient demographic data, clinical evaluations, patient‑reported outcome measures, post-operative complications and radiological outcomes were extracted. RESULTS Nine studies met the inclusion criteria, covering 226 patients with a mean age ranging from 22.4 to 38.8 years and mean follow-up periods ranging from 14 to 78.6 months. Seven studies (77.8%) were level IV and two studies (22.2%) were level III. Arthroscopic PCL repair was performed in four studies (44.4%) while the remaining five studies (55.6%) described open PCL repair. In four studies (44.4%) additional suture augmentation was applied. Arthrofibrosis affected a combined total of 24 patients (11.7%; range 0-21.0%) making it the most common complication and the overall failure rate was 5.6%, ranging from 0 to 15.8%. Two studies (22.2%) performed post-operative MRI and confirmed PCL healing. CONCLUSION This systematic review indicates that PCL repair can be a safe procedure with an overall failure rate of 5.6%, ranging from 0% to 15.8%. However, more high quality research is necessary before widespread clinical implementation is warranted. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jasper Vandenrijt
- Orthopaedics, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Sofie Callenaere
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2610, Belgium
| | - Dries Van der Auwera
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2610, Belgium
| | - Jozef Michielsen
- Orthopaedics, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2610, Belgium
| | - Pieter Van Dyck
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2610, Belgium
- Department of Radiology, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium
| | - Christiaan H W Heusdens
- Orthopaedics, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, 2650, Belgium.
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2610, Belgium.
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Lind DRG, Patil RS, Amunategui MA, DePhillipo NN. Evolution of anterior cruciate ligament reconstruction & graft choice: a review. ANNALS OF JOINT 2023; 8:19. [PMID: 38529255 PMCID: PMC10929403 DOI: 10.21037/aoj-22-39] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/21/2023] [Indexed: 03/27/2024]
Abstract
The surgical treatment of anterior cruciate ligament (ACL) injuries dates back over 100 years from the present day [2022]. While open repair of the torn ACL was popularized in the early 1900s, the first ACL reconstructions utilized the fascia lata as a graft and other extra-articular stabilizing techniques. The first free tendon graft reported for ACL reconstructions was the quadriceps tendon (QT) in the 1930s, followed by the hamstrings tendon (HT), and then the patellar tendon. With improved understanding of the ACL anatomy and biomechanics and the invention of the arthroscope, ACL reconstruction evolved from open procedures to arthroscopic. Similarly, with the help of many surgeon-scientists who reported patient outcomes following ACL reconstruction with various techniques, graft choice evolved with the hamstrings and patellar tendon grafts becoming the dominant and preferred choice of both surgeons and patients. In present day, we see a resurgence of one of the original grafts reported, the QT, as well as primary ACL repair. Future research will result in continued advancements of ACL surgical techniques and graft harvesting, which will allow the orthopedic community (including patients and surgeons) to benefit from such innovations and advanced technologies.
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Affiliation(s)
- Dane R G Lind
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Rohan S Patil
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew A Amunategui
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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He J, Kanto R, Fayed AM, Price TM, DiNenna MA, Linde MA, Smolinski P, van Eck CF. Augmenting ACL Repair With Suture Tape Improves Knee Laxity: A Biomechanical Study. Orthop J Sports Med 2023; 11:23259671221146013. [PMID: 37138945 PMCID: PMC10150432 DOI: 10.1177/23259671221146013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/11/2022] [Indexed: 05/05/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) repair is an alternative to reconstruction; however, suture tape support may be necessary to achieve adequate outcomes. Purposes To investigate the influence of suture tape augmentation (STA) of proximal ACL repair on knee kinematics and to evaluate the effect of the 2 flexion angles of suture tape fixation. Study Design Controlled laboratory study. Methods Fourteen cadaveric knees were tested using a 6 degrees of freedom robotic testing system under anterior tibial (AT) load, simulated pivot-shift (PS) load, and internal rotation (IR) and external rotation loads. Kinematics and in situ tissue forces were evaluated. Knee states tested were (1) ACL intact, (2) ACL cut, (3) ACL repair with suture only, (4) ACL repair with STA fixed at 0° of knee flexion, and (5) ACL repair with STA fixed at 20° of knee flexion. Results ACL repair alone did not restore the intact ACL AT translation at 0°, 15°, 30°, or 60° of flexion. Adding suture tape to the repair significantly decreased AT translation at 0°, 15°, and 30° of knee flexion but not to the level of the intact ACL. With PS and IR loadings, only ACL repair with STA fixed at 20° of flexion was not significantly different from the intact state at all knee flexion angles. ACL suture repair had significantly lower in situ forces than the intact ACL with AT, PS, and IR loadings. With AT, PS, and IR loadings, adding suture tape significantly increased the in situ force in the repaired ACL at all knee flexion angles to become closer to that of the intact ACL state. Conclusion For complete proximal ACL tears, suture repair alone did not restore normal knee laxity or normal ACL in situ force. However, adding suture tape to augment the repair resulted in knee laxity closer to that of the intact ACL. STA with fixation at 20° of knee flexion was superior to fixation with the knee in full extension. Clinical Relevance The study findings suggest that ACL repair with STA fixed at 20° could be considered in the treatment of femoral sided ACL tears in the appropriate patient population.
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Affiliation(s)
- Jinshen He
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedic Surgery,
Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ryo Kanto
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aly M. Fayed
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Taylor M. Price
- Department of Mechanical and Material
Science Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael A. DiNenna
- Department of Mechanical and Material
Science Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica A. Linde
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick Smolinski
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Mechanical and Material
Science Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carola F. van Eck
- Department of Orthopaedic Surgery,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Carola F. van Eck, MD, PhD,
Sequoia Institute for Surgical Services Inc, 2300 West Sunnyside Avenue,
Visalia, CA 93277, USA (
)
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Menghini D, Kaushal SG, Flannery SW, Ecklund K, Murray MM, Fleming BC, Kiapour AM. Three-dimensional magnetic resonance imaging analysis shows sex-specific patterns in changes in anterior cruciate ligament cross-sectional area along its length. J Orthop Res 2023; 41:771-778. [PMID: 35803594 PMCID: PMC9825677 DOI: 10.1002/jor.25413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 02/04/2023]
Abstract
Smaller anterior cruciate ligament (ACL) size in females has been hypothesized to be a key contributor to a higher incidence of ACL tears in that population, as a lower cross-sectional area (CSA) directly corresponds to a larger stress on the ligament for a given load. Prior studies have used a mid-length CSA measurement to quantify ACL size. In this study, we used magnetic resonance imaging to quantify the CSA along the entire length of the intact ACL. We hypothesized that changes in the ACL CSA along its length would have different patterns in males and females. We also hypothesized that changes in ACL CSA along its length would be associated with body size or knee size with different associations in females and males. MR images of contralateral ACL-intact knees of 108 patients (62 females, 13-35 years) undergoing ACL surgery were used to measure the CSA along the ACL length, using a custom program. For both females and males, the largest CSA was located at 37%-39% of ACL length from the tibial insertion. Compared to females, males had a significantly larger CSA only within the distal 41% of the ACL (p < 0.001). ACL CSA was associated with patient height and weight in males (r > 0.3; p < 0.05), whereas it was associated with intercondylar notch width in females (r > 0.3; p < 0.05). These findings highlight the importance of standardizing the location of measurement of ACL CSA.
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Affiliation(s)
- Danilo Menghini
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Health Sciences and Technology, ETH Zurich, CH-8092 Zurich, Switzerland
| | - Shankar G. Kaushal
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Kirsten Ecklund
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
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Batista JP, Maestu R, Barbier J, Chahla J, Kunze KN. Propensity for Clinically Meaningful Improvement and Surgical Failure After Anterior Cruciate Ligament Repair. Orthop J Sports Med 2023; 11:23259671221146815. [PMID: 37065184 PMCID: PMC10102942 DOI: 10.1177/23259671221146815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 04/18/2023] Open
Abstract
Background Primary repair of the anterior cruciate ligament (ACL) confers an alternative to ACL reconstruction in appropriately selected patients. Purpose To prospectively assess survivorship and to define the clinically meaningful outcomes after ACL repair. Study Design Case series; Level of evidence, 4. Methods Included were consecutive patients with Sherman grade 1-2 tears who underwent primary ACL repair with or without suture augmentation between 2017 and 2019. Patient-reported outcomes (Lysholm, Tegner, International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score [KOOS] subscales) were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. The minimal clinically important difference (MCID) was calculated using a distribution-based method, whereas the Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were calculated using an anchor-based method. Plain radiographs and magnetic resonance imaging (MRI) were obtained at 6 months, 1 year, and 2 years postoperatively. Results A total of 120 patients were included. The overall failure rate was 11.3% at 2 years postoperatively. Changes in outcome scores required to achieve the MCID ranged between 5.1 and 14.3 at 6 months, 4.6 and 8.4 at 1 year, and 4.7 and 11.9 at 2 years postoperatively. Thresholds for PASS achievement ranged between 62.5 and 89 at 6 months, 75 and 89 at 1 year, and 78.6 and 93.2 at 2 years postoperatively. Threshold scores (absolute/change based) for achieving the SCB ranged between 82.8 and 96.4/17.7 and 40.1 at 6 months, between 94.7 and 100/23 and 45 at 1 year, and between 95.3 and 100/29.4 and 45 at 2 years. More patients achieved the MCID and PASS at 1 year compared with 6 months and 2 years. For SCB, this trend was also observed for non-KOOS outcomes, while for KOOS subdomains, more patients achieved the SCB at 2 years. High-intensity signal of the ACL repair (odds ratio [OR], 31.7 [95% CI, 1.5-73.4]; P = .030) and bone contusions on MRI (OR, 4.2 [95% CI, 1.7-25.2]; P = .041) at 1 year postoperatively were independently associated with increased risk of ACL repair failure. Conclusion The rate of clinically meaningful outcome improvement was high early after ACL repair, with the greatest proportion of patients achieving the MCID, PASS, and SCB at 1 year postoperatively. Bone contusions involving the posterolateral tibia and lateral femoral condyle as well as high repair signal intensity at 1 year postoperatively were independent predictors of failure at 2 years postoperatively.
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Affiliation(s)
| | - Rodrigo Maestu
- Centro de Tratamiento de Enfermedades
Articulares, Buenoa Aires, Argentina
| | - Jose Barbier
- Centro Artroscópico Jorge Batista SA,
Buenos Aires, Argentina
| | - Jorge Chahla
- Division of Sports Medicine, Department
of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois,
USA
| | - Kyle N. Kunze
- Department of Orthopedic Surgery,
Hospital for Special Surgery, New York, New York, USA
- Kyle N. Kunze, M.D,
Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th
Street, New York, NY 10021, USA ()
(Twitter: @kylekunzemd)
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Clinical Research Progress of Internal Brace Ligament Augmentation Technique in Knee Ligament Injury Repair and Reconstruction: A Narrative Review. J Clin Med 2023; 12:jcm12051999. [PMID: 36902785 PMCID: PMC10004357 DOI: 10.3390/jcm12051999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Knee ligament injuries are most common in sports injuries. In general, ligament repair or reconstruction is necessary to restore the stability of the knee joint and prevent secondary injuries. Despite advances in ligament repair and reconstruction techniques, a number of patients still experience re-rupture of the graft and suboptimal recovery of motor function. Since Dr. Mackay's introduction of the internal brace technique, there has been continuous research in recent years using the internal brace ligament augmentation technique for knee ligament repair or reconstruction, particularly in the repair or reconstruction of the anterior cruciate ligament. This technique focuses on increasing the strength of autologous or allograft tendon grafts through the use of braided ultra-high-molecular-weight polyethylene suture tapes to facilitate postoperative rehabilitation and avoid re-rupture or failure. The purpose of this review is to present detailed research progress in the internal brace ligament enhancement technique of knee ligament injury repair as well as the reconstruction from biomechanical and histological research and clinical studies and to comprehensively assess the value of the application of this technique.
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Weng PW, Chen CH, Lin YC, Chen KH, Yeh YY, Lai JM, Chiang CJ, Wong CC. Platelet-Rich Fibrin-Augmented Gap-Bridging Strategy in Rabbit Anterior Cruciate Ligament Repair. Am J Sports Med 2023; 51:642-655. [PMID: 36752674 DOI: 10.1177/03635465221149993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND We assessed the efficacy of a novel platelet-rich fibrin (PRF)-augmented repair strategy for promoting biological healing of an anterior cruciate ligament (ACL) midsubstance tear in a rabbit model. The biological gap-bridging effect of a PRF scaffold alone or in combination with rabbit ligamentocytes on primary ACL healing was evaluated both in vitro and in vivo. HYPOTHESIS A PRF matrix can be implanted as a provisional fibrin-platelet bridging scaffold at an ACL defect to facilitate functional healing. STUDY DESIGN Controlled laboratory study. METHODS The biological effects of PRF on primary rabbit ligamentocyte proliferation, tenogenic differentiation, migration, and tendon-specific matrix production were investigated for treatment of cells with PRF-conditioned medium (PRFM). Three-dimensional (3D) lyophilized PRF (LPRF)-cell composite was fabricated by culturing ligamentocytes on an LPRF patch for 14 days. Cell-scaffold interactions were investigated under a scanning electron microscope and through histological analysis. An ACL midsubstance tear model was established in 3 rabbit groups: a ruptured ACL was treated with isolated suture repair in group A, whereas the primary repair was augmented with LPRF and LPRF-cell composite to bridge the gap between ruptured ends of ligaments in groups B and C, respectively. Outcomes-gross appearance, magnetic resonance imaging, and histological analysis-were evaluated in postoperative weeks 8 and 12. RESULTS PRFM promoted cultured ligamentocyte proliferation, migration, and expression of tenogenic genes (type I and III collagen and tenascin). PRF was noted to upregulate cell tenogenic differentiation in terms of matrix production. In the 3D culture, viable cells formed layers at high density on the LPRF scaffold surface, with notable cell ingrowth and abundant collagenous matrix depositions. Moreover, ACL repair tissue and less articular cartilage damage were observed in knee joints in groups B and C, implying the existence of a chondroprotective phenomenon associated with PRF-augmented treatment. CONCLUSION Our PRF-augmented strategy can facilitate the formation of stable repair tissue and thus provide gap-bridging in ACL repair. CLINICAL RELEVANCE From the translational viewpoint, effective primary repair of the ACL may enable considerable advancement in therapeutic strategy for ACL injuries, particularly allowing for proprioception retention and thus improved physiological joint kinematics.
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Affiliation(s)
- Pei-Wei Weng
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hwa Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Cheng Lin
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Hao Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Biomedical Materials and Engineering, Taipei Medical University, Taipei, Taiwan
| | - Yi-Yen Yeh
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jen-Ming Lai
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Chang-Jung Chiang
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Flannery SW, Barnes DA, Costa MQ, Menghini D, Kiapour AM, Walsh EG, Kramer DE, Murray MM, Fleming BC. Automated segmentation of the healed anterior cruciate ligament from T 2 * relaxometry MRI scans. J Orthop Res 2023; 41:649-656. [PMID: 35634860 PMCID: PMC9708947 DOI: 10.1002/jor.25390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/16/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023]
Abstract
Collagen organization of the anterior cruciate ligament (ACL) can be evaluated using T2 * relaxometry. However, T2 * mapping requires manual image segmentation, which is a time-consuming process and prone to inter- and intra- segmenter variability. Automating segmentation would address these challenges. A model previously trained using Constructive Interference in Steady State (CISS) scans was applied to T2 * segmentation via transfer learning. It was hypothesized that there would be no significant differences in the model's segmentation performance between T2 * and CISS, structural measures versus ground truth manual segmentation, and reliability versus independent and retest manual segmentation. Transfer learning was conducted using 54 T2 * scans of the ACL. Segmentation performance was assessed with Dice coefficient, precision, and sensitivity, and structurally with T2 * value, volume, subvolume proportions, and cross-sectional area. Model performance relative to independent manual segmentation and repeated segmentation by the ground truth segmenter (retest) were evaluated on a random subset. Segmentation performance was analyzed with Mann-Whitney U tests, structural measures with Wilcoxon signed-rank tests, and performance relative to manual segmentation with repeated-measures analysis of variance/Tukey tests (α = 0.05). T2 * segmentation performance was not significantly different from CISS on all measures (p > 0.35). No significant differences were detected in structural measures (p > 0.50). Automatic segmentation performed as well as the retest on all segmentation measures, whereas independent segmentations were lower than retest and/or automatic segmentation (p < 0.023). Structural measures were not significantly different between segmenters. The automatic segmentation model performed as well on the T2 * sequence as on CISS and outperformed independent manual segmentation while performing as well as retest segmentation.
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Affiliation(s)
- Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Meggin Q. Costa
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Danilo Menghini
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward G. Walsh
- Department of Neuroscience, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, USA
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49
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Glasbrenner J, Raschke MJ, Kittl C, Herbst E, Peez C, Briese T, Michel P, Herbort M, Kösters C, Schliemann B. Comparable Instrumented Knee Joint Laxity and Patient-Reported Outcomes After ACL Repair: Response. Am J Sports Med 2023; 51:NP12-NP14. [PMID: 36856284 PMCID: PMC9983043 DOI: 10.1177/03635465221144035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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50
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Barnes DA, Flannery SW, Badger GJ, Yen YM, Micheli LJ, Kramer DE, Fadale PD, Hulstyn MJ, Owens BD, Murray MM, Fleming BC, Kiapour AM. Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration. Am J Sports Med 2023; 51:413-421. [PMID: 36645042 PMCID: PMC9905304 DOI: 10.1177/03635465221142323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Dominique A. Barnes
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, Larner College of
Medicine, University of Vermont, Burlington, VT, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Dennis E. Kramer
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul D. Fadale
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Michael J. Hulstyn
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Brett D. Owens
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of
Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA, USA
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