Timing of Anterior Cruciate Ligament Reconstruction and Relationship With Meniscal Tears: A Systematic Review and Meta-analysis

Characterization of bone marrow edema patterns among patients with Segond fracture in the setting of acute anterior cruciate ligament injury: A comparative MRI study

PURPOSE

The purpose of this study is to investigate the anatomic distribution of bone marrow edema on MRI among patients who sustained a Segond fracture compared to those with an isolated ACL tear.

METHODS

A retrospective cohort study was performed of patients aged 18-40 years old who presented with an acute isolated ACL tear between January 2012 and May 2022. Two blinded readers reviewed all knee MRIs to assess bone marrow edema using the Whole-Organ Magnetic Resonance Imaging Score and the area of each sub-compartment was scored.

RESULTS

There were 522 patients in the final analysis, of which 28 patients (5.4%) were identified to have a Segond fracture. The Segond group demonstrated significantly greater rates of WORMS grades 2 and 3 in the central lateral femoral condyle, as well as the anterior, central, and posterior lateral tibial plateau. Furthermore, the Segond group demonstrated significantly greater rates of WORMS grades 2 and 3 in the central medial femoral condyle and the anterior medial tibial plateau. Bone edema at the central lateral femoral condyle (R = 0.034, p = 0.019) and central tibial plateau (R = 0.093, p = 0.033) were significantly correlated with lateral meniscus tears, while the edema in the posterior medial femoral condyle was correlated with medial meniscus tears (R = 0.127, p = 0.004).

CONCLUSION

Patients who present with ACL tear and a concomitant Segond fracture demonstrate significantly more extensive bone marrow edema in both the medial and lateral compartments of the knee compared to patients with an isolated ACL tear.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction

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.

Timing of Anterior Cruciate Ligament Surgery

This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.

Associations of patient characteristics, rate of torque development, voluntary activation of quadriceps with quadriceps strength, and knee function before anterior cruciate ligament reconstruction

Good preoperative knee function (KF) and quadriceps strength (QS) relate to good prognoses after anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate the associations between patient characteristics, rate of torque development (RTD), voluntary activation (VA) of the quadriceps against preoperative KF and QS. A cross-sectional study was conducted. Forty patients with a primary, unilateral ACL injury who had finished the preoperative rehabilitation and scheduled for an ACLR were included. KF was evaluated using the International Knee Documentation Committee score. QS was measured by maximal voluntary isometric contractions. RTD was divided into the early (RTD0-50) and the late (RTD100-200) phases. Quadriceps VA was measured using the superimposed burst technique. Our results showed that patients with poor preoperative KF    had more deficits in RTD0-50 (P = 0.025), higher BMI(P = 0.043), and more meniscus injuries (MI) (P = 0.001) than those with good KF. Patients with asymmetrical QS   showed lower BMI (P = 0.020) and shorter time from injury (TFI) (P = 0.027) than those with symmetrical QS. Additionally, a higher pre-injury Tegner score combined with greater RTD100-200 contributed to greater QS on the injured limb (R2 = 0.357, P = 0.001). To conclude, BMI, TFI, concomitant MI, pre-injury physical activity level, and quadriceps RTD are related to QS and KF before ACLR.

Current views on preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia: An online-based cross-sectional survey

Preoperative rehabilitation is an important stage to both physically and mentally prepare patients for anterior cruciate ligament reconstruction (ACLR) and postoperative rehabilitation. This study aimed to investigate the current preoperative rehabilitation practice after anterior cruciate ligament injury among licensed physical therapists in Saudi Arabia. This was an online-based cross-sectional survey. A total of 114 physical therapists completed the survey. The survey consisted of 16 mandatory questions about management strategies, prescribed exercises, patients' physical and psychological concerns, and discussions about nonoperative management. The majority of the respondents used the following preoperative interventions: education (89.5%), closed kinetic chain exercises (66.7%), stretches (63.2%), open kinetic chain exercises (61.4%), proprioceptive exercises (59.6%), cold (56.1%), and activity modification advice (52.6%). More than half of the respondents would recommend patients awaiting ACLR to complete the exercises 2 to 4 times weekly (56.1%) for up to 8 weeks (80.7%) before ACLR. The respondents (73.7%) reported that patients awaiting ACLR did not receive preoperative rehabilitation due to 2 primary factors: the orthopedic team did not refer patients to rehabilitation specialists, and there was a lack of awareness about preoperative rehabilitation. Most therapists (86%) would discuss conservative management if a patient returned to their preinjury level of function before surgery. The surveyed physical therapists reported using various interventions and preoperative rehabilitation lengths with patients awaiting ACLR. The majority of the therapists indicated that patients awaiting ACLR did not receive preoperative rehabilitation. Future studies are needed to establish a consensus on the optimal preoperative rehabilitation program.

Changes in passive hamstring stiffness after primary anterior cruciate ligament reconstruction: A prospective study with comparison of healthy controls

BACKGROUND

The mechanical properties of knee flexors muscles contribute to reducing anterior cruciate ligament loading. This case-control study evaluated the passive knee flexors stiffness after primary anterior cruciate ligament reconstruction with comparison of healthy controls.

METHODS

After anterior cruciate ligament reconstruction, 88 participants (24.5 [8.6] years, 56,8% males) had two isokinetic tests at 4 and 8 postoperative months with measurement of the passive resistive torque of knee flexors and extensors/flexors strength. In the control group, 44 participants (24.5 [4.3] years, 56,8% males) had one visit with the same procedures. Passive knee flexors stiffness was calculated as the slope of the passive torque-angle curve on the last 10° of knee extension (Nm/°). We investigated the impact of timing and type of surgery (autograft and combined meniscus repair) and persistent knee extension deficits on knee flexors stiffness.

FINDINGS

At 4 and 8 postoperative months, passive knee flexors stiffness was lower on the operated limb than on the non-operated limb (P < 0.001) but both limbs had significant lower values than controls (P < 0.001). Stiffness was positively correlated with knee flexors strength (P < 0.010), and knee flexors stiffness at 4 months was lower in individuals who underwent surgery <6 months from injury (P = 0.040). Knee extension deficit or the type of surgery did not have a significant influence on knee flexors stiffness.

INTERPRETATION

Similarly to neuromuscular factors that are traditionally altered after anterior cruciate ligament reconstruction, evaluating passive knee flexors stiffness changes over time could provide supplementary insights into postoperative muscle recovery.

Diagnostic performance of modern computed tomography in cruciate ligament injury detection: A comprehensive study

BACKGROUND

This study aimed to evaluate the clinical utility of modern single and dual-energy computed tomography (CT) for assessing the integrity of the cruciate ligaments in patients that sustained acute trauma.

METHODS

Patients who underwent single- or dual-energy CT followed by 3 Tesla magnetic resonance imaging (MRI) or knee joint arthroscopy between 01/2016 and 12/2022 were included in this retrospective, monocentric study. Three radiologists specialized in musculoskeletal imaging independently evaluated all CT images for the presence of injury to the cruciate ligaments. An MRI consensus reading of two experienced readers and arthroscopy provided the reference standard. Diagnostic accuracy parameters and area under the receiver operator characteristic curve (AUC) were the primary metrics for diagnostic performance.

RESULTS

CT images of 204 patients (median age, 49 years; IQR 36 - 64; 113 males) were evaluated. Dual-energy CT yielded significantly higher diagnostic accuracy and AUC for the detection of injury to the anterior (94% [240/255] vs 75% [266/357] and 0.89 vs 0.66) and posterior cruciate ligaments (95% [243/255] vs 87% [311/357] and 0.90 vs 0.61) compared to single-energy CT (all parameters, p <.005). Diagnostic confidence and image quality were significantly higher in dual-energy CT compared to single-energy CT (all parameters, p <.005).

CONCLUSIONS

Modern dual-energy CT is readily available and can serve as a screening tool for detecting or excluding cruciate ligament injuries in patients with acute trauma. Accurate diagnosis of cruciate ligament injuries is crucial to prevent adverse outcomes, including delayed treatment, chronic instability, or long-term functional limitations.

Bilateral impairments of quadriceps neuromuscular function occur early after anterior cruciate ligament injury

The study aimed to investigate the impairments in quadriceps neuromuscular function, including strength, rate of torque development (RTD) and activation failure (QAF) early after an ACL injury. A cross-sectional study was conducted. Thirty physically active patients with a primary ACL injury within three months, aged 18 to 40 years old, and who were scheduled for ACL reconstruction were included. Thirty matched healthy controls were also recruited. All the outcomes were measured on an isokinetic dynamometer with knee flexion at 45°. Quadriceps strength was measured by maximal voluntary isometric contractions (MVIC). Early (RTD0-50) and late (RTD100-200) phases of RTD were retrieved from the MVIC test from 0 to 50 ms and 100-200 ms, respectively. QAF was quantified by the central activation ratio (CAR) measured by superimposed burst technique. The results of Mann-Whitney U test showed that compared with the healthy limbs, the injured limbs of the ACL group showed lower quadriceps strength (P < 0.001), RTD0-50 (P < 0.001) and RTD100-200 (P < 0.001); the uninjured limbs showed lower quadriceps strength (P = 0.009), RTD0-50 (P = 0.006) as well as greater QAF (P = 0.010). To conclude, bilateral quadriceps suffered from neuromuscular impairments early after an ACL injury.

IL-6 induces periostin production in human ACL remnants: a possible mechanism causing post-traumatic osteoarthritis

OBJECTIVE

Perostin (POSTN) and IL-6 consistently elevated after ACL injury, and ACL has been proposed as the major source of POSTN. However, there is a lack of evidence whether IL-6 induces ACL remnants to produce POSTN. This study aimed to investigate the effect of IL-6 on POSTN production in ACL fibroblasts, which may help us understand more about the mechanism of PTOA after ACL injury and ACL reconstruction.

METHODS

ACL remnants were harvested from 27 patients undergoing ACL reconstruction. Quantitative real-time polymerase chain reaction (PCR) was performed to examine the POSTN gene expression of ACL fibroblasts after treatment of different concentrations of IL-6. The POSTN protein production of ACL fibroblasts was determined using western blot analysis. The blockers of possible signaling pathways, including PI3K/Akt, Ras/MAPK, and JAK/STAT pathways, were added to test whether the effect of IL-6 on ACL fibroblast could be attenuated. ACL fibroblast and chondrocyte co-culture was carried out to determine the influence of ACL and IL-6 on chondrocytes.

RESULTS

Quantitative real-time PCR showed that IL-6 time-dependently and dose-dependently increased POSTN gene expression of ACL fibroblast. Western blot analysis also revealed that IL-6 dose-dependently induced POSTN protein production. Regarding the chronicity of ACL injury, the POSTN protein production was comparable between ACL remnants which were derived within 3 months of injury and at least 6 months after injury. PI3K/Akt blockers could attenuate the effect of IL-6 on ACL remnants, whereas Ras/MAPK and JAK/STAT did not decrease POSTN production. The coexistence of ACL and IL-6 induced more MMP-13 and ADAMTS-4 by chondrocytes.

CONCLUSIONS

IL-6 induced ACL remnants to produce POSTN. This effect could be attenuated by the PI3K/Akt blocker. Coexistence of IL-6 and ACL remnants may accelerate post-traumatic arthritis.

Efficacy and safety of early versus delayed reconstruction for anterior cruciate ligament injuries: A systematic review and meta-analysis

OBJECTIVE

To critically evaluate the efficacy and safety of early versus delayed anterior cruciate ligament reconstruction (ACLR) for anterior cruciate ligament (ACL) injuries based on the different cut-off values of the timing of operation.

METHODS

PubMed, Medline, Embase, Cochrane library, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang Digital Periodical database were searched from inception to November 2022 without language restrictions. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing early ACLR with delayed ACLR for ACL injuries were included.

RESULTS

Twenty-four studies (10 RCTs and 14 CSs) were included. According to the information from included studies, 3 weeks, 4 weeks, 6 weeks, 6 months, and 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR. When 4 weeks were considered as the cut-off value, early ACLR could significantly improve Lysholm score, IKDC score and VAS score at 6 and 12 months postoperatively and decrease the incidence of adverse events compared with delayed ACLR (P < 0.05). However, no statistically significant difference in positive rate of Lachman test and incidence of meniscus injuries and chondral lesions between the two groups when 3 weeks, 6 weeks, 6 months or 12 months after ACL injuries were considered as the cut-off values of early and delayed ACLR (P > 0.05).

CONCLUSION

The present study suggests that early ACLR, especially conducted within 3-4 weeks after ACL injuries, may be more effective for improving knee function and relieving pain compared with delayed ACLR. More high-quality RCTs are warranted.

Navigating ACL Injuries Amid the COVID-19 Pandemic: A Retrospective Analysis

Introduction In the United Kingdom, musculoskeletal injuries represent a substantial proportion of primary care appointments, and within this category, acute knee injuries are prominent in accident and emergency department cases. Notably, diagnosing anterior cruciate ligament (ACL) injuries is a recognized challenge, often leading to extended diagnostic delays. The COVID-19 pandemic has significantly affected the management of musculoskeletal disorders, driven by reduced surgical capacities, creating a backlog of patients awaiting necessary surgical interventions. Delayed ACL reconstruction poses risks of prolonged knee instability and secondary injuries. To address these concerns, this study evaluates the impact of COVID-19 on the timeline from ACL injury diagnosis to MRI and surgical intervention, with a specific focus on an internal acute knee clinic pathway designed to expedite the evaluation, diagnosis, and management of soft tissue knee injuries. Methods In this cross-sectional study, we retrospectively reviewed all the patients who underwent primary ACL reconstruction from January 2019 to November 2022 in a district general teaching hospital (DGH). Besides demographic data of the patients, we recorded the dates of injury, primary presentation, first knee specialist review, knee MRI, and ACL reconstruction surgery, as well as the injury-to-surgery, injury-to-MRI, and MRI-to-surgery periods. Patients were divided based on the date of operation to pre- and post-COVID, and outcomes were compared to see the possible effects of COVID-19. Data were analyzed using a quantitative and qualitative test with a P < 0.05 significance level. Results Our cohort included 97 patients, and the mean age of patients was 30.6 years (17-53 years). The median time of injury-to-MRI was 46.5 days during the pre-COVID period, which decreased to 44 days in the post-COVID period (P = 0.596). The median time of injury-to-surgery was 287.5 days during the pre-COVID period, which increased to 289 days in the post-COVID period (P = 0.019). The median MRI-to-surgery duration was 200 days during the pre-COVID period, which increased to 225 days in the post-COVID period (P = 0.006). Around 35% of patients had an MRI prior to getting evaluated by a specialist. Conclusion The COVID-19 pandemic had a significant impact on the management of ACL injuries, with delays in elective knee clinics and surgery potentially leading to delays in the diagnosis and management of such injuries. However, our study showed that the delay from ACL injury to subsequent surgery actually reduced post-pandemic due to hospital-based acute knee pathway, which is particularly important in the context of associated meniscal injury that can worsen while patients wait for surgery.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear

PURPOSE

The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender.

METHODS

Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%).

RESULTS

Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001).

CONCLUSION

Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury.

LEVEL OF EVIDENCE

Level III.

Meniscal injuries in skeletally immature children with tibial eminence fractures. Systematic review of literature

PURPOSE

Although the mechanisms of injury are similar to ACL rupture in adults, publications dealing with meniscal lesions resulting from fractures of the intercondylar eminence in children are much rarer. The main objective was to measure the frequency of meniscal lesions associated with tibial eminence fractures in children. The second question was to determine whether there is any available evidence on association between meniscal tears diagnostic method, and frequencies of total lesions, total meniscal lesions, and total entrapments.

METHODS

A comprehensive literature search was performed using PubMed and Scopus. Articles were eligible for inclusion if they reported data on intercondylar tibial fracture, or tibial spine fracture, or tibial eminence fracture, or intercondylar eminence fracture. Article selection was performed in accordance with the PRISMA guidelines.

RESULTS

In total, 789 studies were identified by the literature search. At the end of the process, 26 studies were included in the final review. This systematic review identified 18.1% rate of meniscal tears and 20.1% rate of meniscal or IML entrapments during intercondylar eminence fractures. Proportion of total entrapments was significantly different between groups (17.8% in the arthroscopy group vs. 6.2% in the MRI group; p < .0001). Also, we found 20.9% of total associated lesions in the arthroscopy group vs. 26.1% in the MRI group (p = .06).

CONCLUSION

Although incidence of meniscal injuries in children tibial eminence fractures is lower than that in adults ACL rupture, pediatric meniscal tears and entrapments need to be systematically searched. MRI does not appear to provide additional information about the entrapment risk if arthroscopy treatment is performed. However, pretreatment MRI provides important informations about concomitant injuries, such as meniscal tears, and should be mandatory if orthopaedic treatment is retained. MRI modalities have yet to be specified to improve the diagnosis of soft tissues entrapments.

STUDY DESIGN

Systematic review of the literature REGISTRATION: PROSPERO N° CRD42021258384.

Diagnostic value of DECT-based colored collagen maps for the assessment of cruciate ligaments in patients with acute trauma

OBJECTIVES

The purpose of this study was to evaluate the diagnostic accuracy of third-generation dual-source dual-energy CT (DECT) color-coded collagen reconstructions for the assessment of the cruciate ligaments compared to standard grayscale image reconstruction.

METHODS

Patients who underwent third-generation dual-source DECT followed by either 3-T MRI or arthroscopy of the knee joint within 14 days between January 2016 and December 2021 were included in this retrospective study. Five radiologists independently evaluated conventional grayscale DECT for the presence of injury to the cruciate ligaments; after 4 weeks, readers re-evaluated the examinations using grayscale images and color-coded collagen reconstructions. A reference standard for MRI was provided by a consensus reading of two experienced readers and arthroscopy. Sensitivity and specificity were the primary metrics of diagnostic performance.

RESULTS

Eighty-five patients (mean age, 44 years ± 16; 50 male) with injury to the ACL or PCL (n = 31) were ultimately included. Color-coded collagen reconstructions significantly increased overall sensitivity (94/105 [90%] vs. 67/105 [64%]), specificity (248/320 [78%] vs. 215/320 [67%]), PPV (94/166 [57%] vs. 67/162 [39%]), NPV (248/259 [96%] vs. 215/253 [85%]), and accuracy (342/425 [81%] vs. 282/425 [66%]) for the detection of injury to the anterior cruciate ligament (all parameters, p < .001). For injury to the posterior cruciate ligament, diagnostic accuracy increased for complete tears (p < .001). Color-coded collagen reconstructions achieved superior diagnostic confidence, image quality, and noise scores compared to grayscale CT (all parameters, p < .001) and showed good agreement with MRI examinations.

CONCLUSIONS

DECT-derived color-coded collagen reconstructions yield substantially higher diagnostic accuracy and confidence for assessing the integrity of the cruciate ligaments compared to standard grayscale CT in patients with acute trauma.

KEY POINTS

• Color-coded collagen reconstructions derived from dual-energy CT yield substantially higher diagnostic accuracy and confidence for the assessment of the cruciate ligaments compared to standard grayscale CT in patients with acute trauma. • Color-coded collagen reconstructions demonstrate good agreement with MRI for the assessment cruciate ligament injury. • Dual-energy CT may serve as a readily available screening approach for patients with acute trauma to the knee when injury to the cruciate ligaments is suspected.

Is Preferred Language Other Than English Associated With Delayed Surgery After ACL Injury in Children and Adolescents?

BACKGROUND

Previous studies have investigated the impact of social determinants of health, such as the type of healthcare insurance and household income, on children and adolescents with ACL tears. However, despite the increasing incidence of ACL injury in young patients and a substantial proportion of families who may prefer languages other than English, the relationship between language and clinical care remains unclear.

QUESTIONS/PURPOSES

To investigate the relationship between language and the care of children and adolescents with ACL tears, we asked: (1) Is a preferred language other than English (PLOE) associated with a delay between ACL injury and surgery? (2) Is a PLOE associated with a greater odds of a patient experiencing a meniscal tear and undergoing a meniscectomy than in those who prefer English?

METHODS

We treated 591 patients surgically for ACL injuries between 2011 and 2021. Of those, we considered patients aged 18 years or younger who underwent primary ACL reconstruction for this retrospective, comparative study. Five percent (31 of 591) of patients were excluded because the date of injury was not clearly documented, 2% (11 of 591) were revision reconstructions, and 1% (6 of 591) underwent procedures that were intentionally delayed or staged, leaving 92% (543 of 591) for analysis. The mean age was 16 ± 2 years, and 51% (276 of 543) of patients were boys. The family's preferred language was noted, as were demographic data, time between injury and surgery, and intraoperative findings. A language other than English was preferred by 21% (113 of 543) of patients. Of these, 94% (106 of 113) preferred Spanish. In a univariate analysis, we used independent-samples t-tests, Mann-Whitney U-tests, and Fisher exact tests, as appropriate. Purposeful-entry multivariable regression analyses were used to determine whether PLOE was associated with increased time to surgery, concomitant meniscus injury, or performance of meniscectomy while adjusting for confounding variables. Variables were included in multivariable models if they met the threshold for statistical significance in univariate testing (p < 0.05).

RESULTS

The median time between injury and ACL reconstruction was shorter in families who preferred English compared with those with a PLOE (69 days [IQR 80] versus 103 days [IQR 107)]; p < 0.001). After controlling for potentially confounding variables like insurance and age, we found that patients whose families had a PLOE had greater odds of undergoing surgery more than 60 days after injury (OR 2.2 [95% CI 1.3 to 3.8]; p = 0.005) and more than 90 days after injury (OR 1.8 [95% CI 1.1 to 2.8]; p = 0.02). After controlling for insurance, age, and other factors, PLOE was not associated with surgical delay beyond 180 days, concomitant meniscal tears, or performance of meniscectomy.

CONCLUSION

In this study of children and adolescents undergoing primary ACL reconstruction, patients whose families prefer a language other than English experienced a longer delay between injury and surgery. In areas with a large proportion of families with a PLOE, partnerships with primary care clinicians, emergency departments, schools, athletic teams, and community organizations may improve efficiency in the care of children with ACL injuries. Clinicians proficient in other languages, reliable interpreter services, and translated references and resources may also be impactful. Our results suggest a need for further research on the experiences, needs, and long-term outcomes of these patients, as well as the association of preferred language with results after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic study.

ACL stump and ACL femoral landmarks are equally reliable in ACL reconstruction for assisting ACL femoral tunnel positioning

PURPOSE

This study aimed to comparatively evaluate the accuracy of femoral tunnel positioning after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction performed with the remnant preservation (RP) technique versus the non-remnant preservation (NRP) technique.

METHODS

A retrospective review of 145 patients who underwent ACL reconstruction from May 2020 to May 2022 were performed in this single-surgeon study. A total of 120 patients met the inclusion criteria and were allocated into two groups according to the surgical technique (i.e. RP group and NRP group). The relative location of the femoral tunnel in the lateral condyle was evaluated as a percentage using a standardized grid system on the three-dimensional computed tomography (3D-CT) image. The accuracy and precision of the RP group were assessed based on published anatomical data in direct comparison with the NRP group.

RESULTS

According to the surgical procedure, 57 of the 120 patients included were allocated into the RP group, and 63 into the NRP group. Significant differences were observed between the two groups in terms of tunnel position (posterior-to-distal (PD): 28.4 ± 5.4% (RP) vs. 31.8 ± 5.3% (NRP); P = 0.01), (anterior-to-posterior (AP): 32.6 ± 7.7% (RP) vs. 38.8 ± 7.7% (NRP); P = 0.00), while no significant differences were found in terms of the accuracy (8.6% (RP) vs. 8.9% (NRP); n.s) and precision (4.4% (RP) vs. 5.6% (NRP); n.s) of femoral tunnel positioning between the two groups.

CONCLUSIONS

From this single-surgeon study, it was concluded that there were no differences in the creation of ACL femoral tunnel between the RP technique and the non-remnant preserving technique. Meanwhile, the RP technique would not sacrifice the ideal position of the femoral tunnel and is able to retain the possible benefits of the ACL stump.

LEVEL OF EVIDENCE

Level III.

Delayed ACL reconstruction increases rates of concomitant procedures and risk of subsequent surgery

PURPOSE

To utilise a large cross-sectional database to analyse the effects of time duration between diagnosis of anterior cruciate ligament (ACL) tear and ACL reconstruction (ACLR) on concomitant procedures performed and subsequent surgery within 2 years.

METHODS

An analysis from 2015 to 2018 was performed using the Mariner PearlDiver Patient Records Database. Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-10) codes identified patients with a diagnosis of ACL tear who underwent subsequent ACLR. Patients were stratified in biweekly and bimonthly increments based on the time duration between initial diagnosis of ACL tear and surgical treatment. Chi-squared analysis was used to compare categorical variables, and trend analysis was performed with Cochran-Armitage independence testing.

RESULTS

Of 11,867 patients who underwent ACLR, 76.1% underwent surgery within 2 months of injury diagnosis. Patients aged 10-19 were most likely to undergo surgery within 2 months of injury diagnosis (83.5%, P < 0.0001). As duration from injury diagnosis to ACLR increased from < 2 months to > 6 months, rates of concomitant meniscectomy increased from 9.1% to 20.5% (P < 0.0001). The overall 2-year subsequent surgery rate was 5.3%. The incidence of revision ACLR was highest for patients who underwent surgery > 6 months after diagnosis (P < 0.0001), whilst the incidence of ipsilateral lysis of adhesions and manipulation under anaesthesia (MUA) was highest for patients who underwent surgery < 2 months after diagnosis (P < 0.0001). ACLR at 6-8 weeks after diagnosis demonstrated the lowest risk for concomitant procedures as well as 2-year subsequent surgery.

CONCLUSION

The majority of patients undergo ACL reconstruction within 2 months of initial ACL tear diagnosis. Delayed surgery greater than 6 months after the diagnosis of an ACL rupture leads to increased need for concomitant meniscectomy as well as higher risk for revision ACLR within 2 years, but immediate surgery may increase risk for knee arthrofibrosis.

LEVEL OF EVIDENCE

IV.

Optimal Timing of Anterior Cruciate Ligament Reconstruction in Patients With Anterior Cruciate Ligament Tear: A Systematic Review and Meta-analysis

IMPORTANCE

The timing of surgery has been regarded as a key factor in anterior cruciate ligament reconstruction (ACLR), and early vs delayed ACLR remains a controversial topic.

OBJECTIVE

To synthesize up-to-date published data from randomized clinical trials (RCTs) comparing early vs elective delayed ACLR for patients with ACL deficiency, in terms of clinical outcomes and complications.

DATA SOURCES

The PubMed, Cochrane Library, and Web of Science databases were systematically searched until September 9, 2022.

STUDY SELECTION

All published RCTs comparing clinical and functional outcomes and complications associated with early ACLR vs elective delayed ACLR.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted relevant data and assessed the methodological quality following the PRISMA guidelines.

MAIN OUTCOMES AND MEASURES

Due to the clinical heterogeneity, the random-effects model was preferred. The primary outcomes were functional outcomes and complications. The Mantel-Haenszel test was used to evaluate dichotomous variables and the inverse variance method was used to assess continuous variables.

RESULTS

This meta-analysis included 972 participants in 11 RCTs stratified by follow-up duration. The following factors did not differ between early and delayed ACLR: operative time (mean difference, 4.97; 95% CI, -0.68 to 10.61; P = .08), retear (OR, 1.52; 95% CI, 0.52-4.43; P = .44), and infection (OR, 3.80; 95% CI, 0.77-18.79; P = .10). There were also no differences between groups in range of motion, knee laxity, International Knee Documentation Committee (IKDC rating scale), and Tegner score. IKDC score (mean difference, 2.77; 95% CI, 1.89-3.66; P < .001), and Lysholm score at 2-year follow-up (mean difference, 2.61; 95% CI, 0.74-4.48; P = .006) significantly differed between early and delayed ACLR. In addition, the timing of surgery was redefined in the included RCTs and subgroup analyses were performed, which validated the robustness of the principal results.

CONCLUSION AND RELEVANCE

This systematic review and meta-analysis found that early ACLR was not superior to delayed ACLR in terms of most factors analyzed, except for IKDC and Lysholm scores. This information should be available to patients with ACL deficiency and clinicians as part of the shared decision-making process of treatment selection.

Relationship Between Timing of Anterior Cruciate Ligament Reconstruction and Chondral Injuries: A Systematic Review and Meta-analysis

BACKGROUND

After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear.

PURPOSE

To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis.

STUDY DESIGN

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

METHODS

Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged >16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model.

RESULTS

After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs >3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003).

CONCLUSION

Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage.

REGISTRATION

CRD42016032846 (PROSPERO).

Acute and subacute anterior cruciate ligament reconstructions are associated with a higher risk of revision and reoperation

PURPOSE

(1) Report concomitant cartilage and meniscal injury at the time of anterior cruciate ligament reconstruction (ACLR), (2) evaluate the risk of aseptic revision ACLR during follow-up, and (3) evaluate the risk of aseptic ipsilateral reoperation during follow-up.

METHODS

Using a United States integrated healthcare system's ACLR registry, patients who underwent primary isolated ACLR were identified (2010-2018). Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision, with a secondary outcome evaluating ipsilateral aseptic reoperation. Outcomes were evaluated by time from injury to ACLR: acute (< 3 weeks), subacute (3 weeks-3 months), delayed (3-9 months), and chronic (≥ 9 months).

RESULTS

The final sample included 270 acute (< 3 weeks), 5971 subacute (3 weeks-3 months), 5959 delayed (3-9 months), and 3595 chronic (≥ 9 months) ACLR. Medial meniscus [55.4% (1990/3595 chronic) vs 38.9% (105/270 acute)] and chondral injuries [40.0% (1437/3595 chronic) vs 24.8% (67/270 acute)] at the time of ACLR were more common in the chronic versus acute groups. The crude 6-year revision rate was 12.9% for acute ACLR, 7.0% for subacute, 5.1% for delayed, and 4.4% for chronic ACLR; reoperation rates a 6-year follow-up was 15.0% for acute ACLR, 9.6% for subacute, 6.4% for delayed, and 8.1% for chronic ACLR. After adjustment for covariates, acute and subacute ACLR had higher risks for aseptic revision (acute HR 1.70, 95% CI 1.07-2.72, p = 0.026; subacute HR 1.25, 95% CI 1.01-1.55, p = 0.040) and aseptic reoperation (acute HR 2.04, 95% CI 1.43-2.91, p < 0.001; subacute HR 1.31, 95% CI 1.11-1.54, p = 0.002) when compared to chronic ACLR.

CONCLUSIONS

In this cohort study, while more meniscal and chondral injuries were reported for ACLR performed ≥ 9 months after the date of injury, a lower risk of revision and reoperation was observed following chronic ACLR relative to patients undergoing surgery in acute or subacute fashions.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19

CONTEXT

The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004-2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19.

OBJECTIVE

Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period.

DESIGN

Retrospective cohort study.

SETTING

This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016-June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic.

PATIENTS OR OTHER PARTICIPANTS

Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified.

MAIN OUTCOME MEASURE(S)

Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses.

RESULTS

A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant.

CONCLUSIONS

Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

The influence of gluteal muscle strength deficits on dynamic knee valgus: a scoping review

Anterior cruciate ligament (ACL) injuries are caused by both contact and non-contact injuries. However, it can be claimed that non-contact ones account approximately for 70% of all cases. Thus, several authors have emphasized the role of reduction of muscle strength as a modifiable risk factor referred to non-contact ACL injury, with the latter being targeted by specific training interventions.The present paper wants to review the available literature specifically on the relationship between dynamic knee valgus, gluteal muscles (GM) strength, apart from the potential correlation regarding ACL injury.After a research based on MEDLINE via PubMed, Google scholar, and Web of Science, a total of 29 articles were collected and thus included.Additionally, this review highlights the crucial role of gluteal muscles in maintaining a correct knee position in the coronal plane during different exercises, namely walking, running, jumping and landing.

Prevalence and Incidence of Chondral and Meniscal Lesions in Patients Undergoing Primary and Subsequent Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 213 Patients From the SANTI Group

BACKGROUND

Previous studies have shown a higher prevalence of meniscal and chondral lesions at the time of revision anterior cruciate ligament reconstruction (R-ACLR) compared with primary ACLR procedures. However, studies that follow the development of meniscal and chondral status through primary and subsequent R-ACLR are scarce.

PURPOSE

To compare the prevalence of meniscal and chondral injuries in patients undergoing primary ACLR and subsequent R-ACLR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent ACLR and subsequently needed R-ACLR between January 2009 and February 2018 in a single center were included. A retrospective analysis of prospectively collected data was conducted.

RESULTS

A total of 213 patients were included, with a mean follow-up of 59.7 months. The mean age was 22 years at primary ACLR and 26.1 years at the time of revision. The proportion of meniscal tears was higher at the time of R-ACLR compared with the time of primary reconstruction (70.0% vs 44.6%, respectively; P < .001). Similarly, the prevalence of chondral lesions was significantly higher at the time of revision versus the primary reconstruction (15.5% vs 7.0%, respectively; P = .003).

CONCLUSION

R-ACLR is associated with a higher rate of concomitant meniscal and chondral lesions than primary ACLR.