Twenty-Year Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Prospectively Collected Data

Imaging and Surgical Procedures After Surface-Related Collegiate Football Injuries on Artificial Turf Versus Natural Grass: Prevalence and Trends Over 15 Seasons

Background

Few longitudinal studies exist comparing medical procedures after football injuries on artificial and natural grass surfaces.

Purpose/Hypothesis

The purpose of this study was to specifically compare imaging and surgical procedures after surface-related collegiate football injuries on artificial turf versus natural grass. It was hypothesized that there would be no difference in the incidence of imaging and surgical procedures, combined medical procedures, or combined substantial and severe injuries over time between these surfaces.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 39 universities across all Football Bowl Subdivision conferences were evaluated over 15 seasons (2006-2020). Playing surfaces evaluated were either a heavyweight artificial turf infill system (≥9.0 lb infill/ft2) or natural grass. Outcomes of interest included medical procedures across injury category, primary injury type, injury location, and specific procedures. Data involved multivariate analyses of variance (MANOVA) and Wilks λ criteria using general linear model procedures and were expressed as medical procedure incidence rates (IRs) per 10-game season.

Results

Overall, 2224 games were documented: 1106 (49.7%) on artificial turf and 1118 (50.3%) on natural grass. Of the 9137 total injuries reported, 4010 (44%) were surface-related cases. MANOVA indicated significant main effects between surfaces according to imaging procedure (F 2,1738 = 4.718; P = .009), surgical procedure (F 1,539 = 5.974; P = .003), and medical diagnosis (F 2,456 = 2.643; P = .040). Post hoc analyses indicated significantly lower (P < .05) incidences on artificial turf versus natural grass, respectively, for the following outcomes: imaging procedures ordered after player-to-surface impact trauma (IR [95% CI], 1.5 [1.3-1.8] vs 2.1 [1.9-2.4]), shoe-to-surface trauma during physical contact (4.4 [4.1-4.7] vs 5.2 [4.9-5.5]), foot injuries (0.6 [0.5-0.7] vs 1.1 [0.9-1.2]), ligament sprains/tears (4.6 [4.3-4.9] vs 5.3 [5.0-5.6]), muscle strains/tears (0.2 [0.2-0.3] vs 0.7 [0.6-0.9]), surgeries performed after shoe-to-surface trauma during physical contact (1.1 [0.9-1.3] vs 1.6 [1.4-1.8]), lower body surgeries (1.8 [1.6-2.0] vs 2.3 [2.1-2.6]), and surgeries involving ligament tears (1.0 [0.9-1.2] vs 1.5 [1.3-1.7]), as well as fewer diagnoses of syndesmosis sprains/tears (0.7 [0.5-0.8] vs 1.0 [0.8-1.2]) and Lisfranc trauma (0.3 [0.2-0.4] vs 0.5 [0.4-0.7]). Trends over the 15 seasons indicated a significant rise in combined medical procedures (P = .005) and combined substantial and severe injuries (P = .0007) irrespective of surface.

Conclusion

Results indicated that collegiate football competition on heavyweight artificial turf resulted in lower incidences of imaging and surgical procedures and medical diagnoses compared with natural grass.

Evaluation of Outcomes After Anterior Cruciate Ligament Reconstruction: What We Know, What We Have, and What to Consider

Measurement of success following anterior cruciate ligament reconstruction (ACLR) hinges on the appropriate use of high quality and meaningful outcome measures. We identified and categorized over 100 outcome measures for ACLR using the International Classification of Functioning, Disability and Health (ICF) model. The ICF model is a useful framework to facilitate decisions about outcome selection and describe recovery following ACL injury. We outline key considerations when selecting outcome measures during study design (purpose, measurement properties, sample size, global assessment) or evaluating reported outcomes (measurement properties, sample size, magnitude/precision, clinical relevance, applicability), and discuss challenges in outcome measurement following ACLR.

Four-year comparative analysis of return to sport and psychological recovery following ACL revision: Artificial ligament vs. anterior tibial tendon allograft

Background

Research on return to sport and psychological recovery in anterior cruciate ligament (ACL) revision remains scarce. The clinical efficacy of artificial ligament in ACL revision requires further exploration. Our objectives were (1) to compare the midterm clinical outcomes of artificial ligament versus allogenic tendon graft in ACL revision and (2) to analyze the effects of employing artificial ligament on return to sport and psychological recovery in ACL revision.

Methods

This cohort study included the cases receiving ACL revision from 2014 to 2021 in Sports Medicine Department of Huashan Hospital. The grafts used were Ligament Advanced Reinforcement System (LARS) and ATT allograft. We recorded patients' baseline data. The final follow-up assessment included subjective scales, physical examination, and return to sport status. We recorded the rates and timings of return to sport. Subjective scales included the 2000 International Knee Documentation Committee (IKDC) subjective score, Lysholm Knee Scaling Score (LKSS), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity score, Marx activity rating score, and Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI). Anterior knee stability was assessed using the KT-1000 arthrometer.

Results

Fifty cases (LARS group: 27; ATT group: 23) enrolled and 45 (LARS group: 23; ATT group: 22) completed evaluations with a median follow-up period of 49 months. At recent follow-up, LARS group outperformed in knee stability (1.0 ± 1.9 mm vs. 2.6 ± 3.0 mm, P = 0.039), confidence (86.7 ± 12.4 vs. 69.4 ± 18.6, P < 0.001), emotion (82.7 ± 11.3 vs. 70.7 ± 16.2, P < 0.001), KOOS knee function (78.7 ± 8.8 vs. 69.5 ± 11.0, P = 0.003), quality of life (79.1 ± 16.1 vs. 66.4 ± 19.5, P = 0.014), Tegner score (6.3 ± 1.9 vs. 5.2 ± 2.1, P < 0.001), and Marx activity score (10.7 ± 3.7 vs. 7.9 ± 4.0, P = 0.012). The LARS group had significantly higher return rates: recreational (91.3 % vs. 63.6 %, P = 0.026), knee cutting and pivoting (87.0 % vs. 59.1 %, P = 0.035), competitive (78.3 % vs. 45.5 %, P = 0.023), and pre-injury (56.5 % vs. 27.3 %, P = 0.047). For return timings, the LARS group was earlier at recreational (11.2 ± 3.9 vs. 27.8 ± 9.0 weeks, P < 0.001), knee cutting and pivoting (17.2 ± 5.8 vs. 35.6 ± 13.8 weeks, P < 0.001), competitive (24.8 ± 16.2 vs. 53.2 ± 22.0 weeks, P < 0.001), and pre-injury levels (32.8 ± 11.0 vs. 72.8 ± 16.9 weeks, P < 0.001).

Conclusion

In ACL revision, using LARS demonstrated improved joint stability and functionality compared to using allogenic ATT four years postoperative. Patients accepting the LARS procedure exhibited higher rates and earlier timings of return to various levels of sport, indicating enhanced confidence and emotional resilience.

The translational potential of this article

In ACL revision, the choice of artificial ligament to shorten recovery time, thereby enabling patients to return to sport more quickly and effectively, is thought-provoking. The research value extends beyond mere graft selection, guiding future clinical trials and studies. This research enhances our understanding of the application value of artificial ligament in ACL revision, emphasizing the importance of psychological recovery and updating our perceptions of return to sport levels post-revision. It stimulates exploration into personalized rehabilitation programs and treatment strategies, aiming to optimize clinical outcomes and meet the real-world needs of patients with failed ACL reconstruction.

Hyperbaric oxygen therapy enhances graft healing and mechanical properties after anterior cruciate ligament reconstruction: An experimental study in rabbits

Hyperbaric oxygen therapy (HBOT) has proven successful in wound healing. However, its potential effects on anterior cruciate ligament (ACL) injuries remain uncertain. This study aimed to investigate the impact of HBOT on graft healing following ACL reconstruction in rabbits. Male New Zealand rabbits underwent ACL reconstruction and were randomly divided into two groups: the HBOT group and the ambient air group. The HBOT group received 100% oxygen at 2.5 atmospheres absolute for 2 h daily for 5 consecutive days, starting from the first day after surgery. The ambient air group was maintained in normal room air throughout the entire period. After 12 weeks following the surgery, animals were euthanized, and their knees were harvested for analysis. The HBOT group demonstrated superior graft maturation and integration in comparison to the ambient air group, as evidenced by lower graft signal intensity on magnetic resonance imaging, decreased femoral and tibial tunnel size, and higher bone mineral density values on high-resolution peripheral quantitative computed tomography scans. Additionally, biomechanical testing indicated that the HBOT group had greater load to failure and stiffness values than the ambient air group. In conclusion, the adjuvant use of HBOT improved ACL graft maturation and integration, reduced tunnel widening, and enhanced the biomechanical properties of the graft. These results may provide important insights into the potential clinical application of HBOT as a therapeutic intervention to enhance graft healing after ACL reconstruction, paving the way for further research in this area.

Eighteen-year outcome of anterior cruciate ligament reconstruction with patellar tendon or hamstring autograft

PURPOSE

To evaluate patient reported outcomes and radiographic arthritic changes of transtibial anterior cruciate ligament reconstruction (ACLR) with either bone-patellar tendon-bone (BPTB) or hamstrings (HS) auto-grafts at a minimum of 15-year follow-up.

METHODS

Ninety-four patients (51 of the HS group, 43 of BPTB group) who were operated between the years 2000 to 2005 in two tertiary referral hospitals were contacted and invited to a retrospective evaluation. The interview included subjective outcomes using the Lysholm knee scoring questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Tegner activity level scale, Visual Analogue Scale (VAS) for pain and patients' satisfaction scale. Knee examination included measurements of motion and stability. Knee radiographs were evaluated for osteoarthritic changes according to the Kellgren-Lawrence (KL) score.

RESULTS

The average evaluation time from surgery was 18.6 years. Subjectively, there was no significant difference between groups except for a better post-operative level of activity and satisfaction in the HS group. Objectively, there was no significant difference between groups in knee stability and range of motion. Most patients had grade KL ≤ 1 radiographic osteoarthritits changes and there was no significant difference between groups. Recurrent complete tear of the reconstructed graft occurred in 3 patients of each group. In both groups 84% had no further surgery while the indications for further surgery were mostly a meniscal tear or tibial hardware removal.

CONCLUSIONS

Very long-term outcomes and clinical stability of transtibial HS or BPTB graft ACL reconstruction are good with low rate of graft failure and radiographic osteoarthritis.

A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature

Purpose

The aim of the present systematic review was to quantitatively synthesize the best literature evidence regarding osteoarthritis developing after anterior cruciate ligament reconstruction (ACLR), including only studies with a follow-up duration of at least 20 years.

Material and Methods

A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on four electronic databases (PubMed, Scopus, EMBASE and Cochrane Library). The outcome measures extracted from the studies were failure rate, subsequent knee surgery on the same knee, radiographic development of osteoarthritis measured with Kellgren-Lawrence, International Knee Documentation Committee (IKDC) radiographic score and Ahlbäck classification. The health of both the ACLR knee and the contralateral knee was compared.

Results

A total of 1552 patients were included in the study, of which 1290 (83.11%) were operated on using a patellar tendon graft, 190 (12.24%) with hamstrings, 27 (1.73%) with an iliotibial band and 45 (2.89%) with patellar tendon plus a ligament augmentation device (LAD). The mean age at the time of surgery was 25.18 ± 1.91 years, and the mean follow-up time was 23.34 ± 2.56 years. Analysing IDKC Score at final follow-up, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 33.2% (324/976) of the patients showed a moderate to severe degree (Grade C or D) of osteoarthritis, while for Kellgren-Lawrence, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 28.9% (196/678) of the patients showed a moderate to severe degree (Grade III or IV) of osteoarthritis. In total, 1552 patients were registered, 155 reruptures (9.98%) and a total of 300 (19.3%) new surgeries, of which 228 meniscectomy (14.69%), 21 (1.35%) knee arthroplasty and 17 (1.09%) hardware removal were recorded.

Conclusions

ACL reconstruction appears to result in mild osteoarthritis in the long term in most of the patients and only less than 33.2% develop a moderate to severe degree of knee OA according to IKDC radiographic score. A slight degree of osteoarthritis appears to be present in ACLR knees compared with contralateral healthy knees.

Level of Evidence

Level IV.

Bilateral movement asymmetries exist in recreational athletes during a 45° sidestep cut post-anterior cruciate ligament reconstruction

Individuals post-ACL reconstruction (ACLR) are at elevated risk for ACL re-injury. While several studies have examined biomechanical asymmetries post-ACLR during landing, less is known about asymmetries during a sidestep cut. Therefore, the purpose of this study was to compare sagittal and frontal plane biomechanics at the hip and knee during a 45° sidestep cut in post-ACLR participants and healthy controls. Nineteen athletes post-ACLR and nineteen healthy controls performed a bilateral 45° sidestep cut while three-dimensional kinematics and kinetics were measured. Sagittal and frontal plane kinematics and kinetics were examined at the hip and knee during stance phase. A linear mixed model compared biomechanical differences between the limbs of ACLR and healthy control participants (α = 0.05). In the post-ACLR group, peak hip extension, peak knee flexion, sagittal hip and knee excursion, and the peak knee extensor moment were significantly lower in the ACLR surgical limb compared to the non-surgical limb (p < 0.05). The peak knee flexion angle and peak knee extensor moment were also lower in the ACLR surgical limb compared to the matched control limb (p < 0.05). In summary, post-ACLR participants exhibited altered sagittal plane movement in their surgical limb that was not demonstrated in the non-surgical limb or in control participants, which may suggest avoidance, or reduced utilization of the ACLR limb.

Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Using a Calcium Phosphate-Hybridized Tendon Graft with More than an Average of 5 Years of Follow-Up: A Follow-Up Study of a Randomized Controlled Trial

Calcium phosphate (CaP)-hybridized tendon grafting using an alternate soaking process improves tendon-to-bone healing in anterior cruciate ligament (ACL) reconstructions. This study aimed to compare bone tunnel enlargement, knee osteoarthritis, and clinical results between CaP-hybridized tendon grafting and conventional grafting in anatomical single-bundle ACL reconstruction. This study was a follow-up of a randomized controlled trial. Between July 2011 and December 2015, 90 patients underwent unilateral anatomical single-bundle ACL reconstructions and were randomly assigned to the CaP-hybridized tendon grafting (CaP group, n = 45; age, 27.1 [14-54] years; sex, 21 males and 24 females) or conventional grafting (control group, n = 45; age, 22.9 [13-58] years; sex, 26 males and 19 females). The randomization was performed according to the days of the week when the patients first visited the outpatient. The CaP-hybridized tendon grafting was created intraoperatively. The tendon grafts were soaked in a calcium solution for 30 s. After that, the tendon grafts were soaked in a NaHPO4 solution for 30 s. This soaking cycle between the calcium solution and the NaHPO4 solution was repeated 10 times. The bone tunnel enlargement, osteoarthritis grade, clinical score, and sports level were evaluated in patients who could be followed up for >3 years (CaP group, n = 20, average follow-up period 6.0 [5.1-6.9] years; control group, n = 15, average follow-up period 5.6 [4.3-6.9] years). Clinical scores, sports levels, and osteoarthritis grades were analyzed using a generalized linear mixed model (GLMM) based on repeated measurement data from preoperative and final observations, with time, group, sex, age, and BMI as fixed effects and the effect of individual differences as variable effects. In addition, bone-tunnel enlargements were analyzed using generalized linear models (GLM) with group, sex, age, and BMI as the main effects. Compared with the control group, the CaP group exhibited significantly reduced bone-tunnel enlargement on the femoral side (anteroposterior diameter; CaP group, 7.9% [-1.1-16.8] vs. control group, 29.2% [17.9-40.5], p = 0.004, MCID 16.05, proximal-distal diameter; CaP group, 7.9% [-1.9-17.8] vs. control group, 22.8% [10.9-34.7], p = 0.062, MCID 15.00). The osteoarthritis grades progressed in both groups (p < 0.001). The clinical scores and sports levels were not significantly different between the groups. This study suggests that the calcium phosphate-hybridized tendon graft reduces femoral bone-tunnel enlargement after anatomical single-bundle anterior cruciate ligament reconstruction in an average >5-year follow-up period. A longer follow-up period is necessary to reveal the clinical effects of the calcium phosphate-hybridized tendon grafts in anterior cruciate ligament reconstruction.

Long-term Quality of Life in Patients After ACL Reconstruction With Concomitant Meniscal Injury Treatment: Patient-Reported Outcomes at Minimum 10-Year Follow-up

Background

Long-term studies of patients after anterior cruciate ligament (ACL) reconstruction with or without concomitant meniscal tear treatment are limited.

Purposes

To (1) report postoperative outcomes after anatomic ACL reconstruction with a hamstring autograft, (2) investigate how concomitant treatment of meniscal injury could affect these outcomes, and (3) evaluate the association between quality of life and activity levels at a minimum 10-year follow-up.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients treated with a unilateral, anatomic ACL reconstruction between 2005 and 2011 were investigated. The following patient-reported outcome measures (PROMs) were reported for the overall sample as well as a subsample of patients with meniscal injury: International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm knee score, Tegner activity scale, 5-level EQ-5D (EQ-5D-5L), and patient satisfaction. Sex, age, body mass index (BMI), and meniscal injury treatment (meniscectomy vs meniscal repair) were examined as patient-specific risk factors regarding long-term activity and quality of life.

Results

Overall, 106 patients, 90 men (85%) and 16 women (15%), were enrolled in the study, with a mean follow-up of 13.2 years. The ACL retear rate was 2.8%. The mean scores were 80.6 ± 16.7 (IKDC-SKF), 87.4 ± 15.0 (KOOS), 90.5 ± 11.5 (Lysholm), 5.6 ± 1.9 (Tegner), and 91.8 ± 14.5 (EQ-5D-5L). The majority (90.6%) of patients considered their knee state satisfactory during follow-up. When compared with patients who underwent meniscal repair, patients who underwent meniscectomy had statistically significantly lower scores on all PROMs except for the Tegner and EQ-5D-5L (P < .05 for all). The mean difference between the 2 groups was ≥7 points on all PROM scores. Patient sex, age, and BMI did not affect PROM scores. There was a statistically significant, strong positive correlation between quality of life and activity.

Conclusion

Patients had few or no symptoms and considered their knee state satisfactory 13.2 years after anatomic ACL reconstruction. Patients with concomitant meniscal tears having undergone meniscal repair had improved PROMs compared with those treated with meniscectomy. Finally, participation in activities of daily living and sports was interrelated with quality of life and was not affected by patient age, sex, or BMI.