Eight-year results of transtibial nonanatomic single-bundle versus double-bundle anterior cruciate ligament reconstruction: Clinical, radiologic outcomes and survivorship

Effect of Leg Dominance on Medium- to Long-Term Functional Outcomes, Quality of Life, and Revision Rates After Isolated ACL Reconstruction

Background:

The effect of leg dominance on short-term functional outcomes and return to sports after arthroscopic anterior cruciate ligament reconstruction (ACLR) has been evaluated. However, postoperative medium- to long-term recovery and revision rates are not well known.

Purpose:

To investigate whether leg dominance affects medium- to long-term clinical and functional scores and revision rates after ACLR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in this study were 235 patients (205 male and 30 female) who underwent isolated arthroscopic ACLR. Patients were divided according to the leg dominance status of their injured limb into 2 groups: dominant leg injured (120 patients) and nondominant leg injured (115 patients). Preoperative and postoperative functional outcomes and health-related quality of life (HRQoL) were evaluated using the visual analog scale for pain, Tegner activity scale, Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, 36-Item Short Form Health Survey (SF-36), and overall patient satisfaction. Moreover, the revision rates of the 2 groups were compared according to leg dominance, patient characteristics, and operative features.

Results:

The mean follow-up period was 8.0 ± 2.3 years (range, 5-13 years). A significant preoperative to postoperative improvement in range of motion and functional scores was noticed in both groups (P < .001 for all). However, the improvement was significantly higher in the dominant leg group for the Tegner (P = .001), Lysholm (P = .006), and IKDC (P < .001) scores as well as for the SF-36 domain scores for general health (P = .009), social role (P = .048), and emotional role (P = .032). Also, patient satisfaction was significantly higher in the dominant leg group (P = .007). The dominant leg group was associated with a lower revision rate compared with the nondominant leg group (5.8% vs 15.7%, respectively; P = .015).

Conclusion:

High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. However, leg dominance had a significant effect on postoperative medium- to long-term functional outcomes, HRQoL, and revision rates.

Interbundle Impingement Pressure in Individualized and Nonindividualized Double-Bundle Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

Background:

Graft impingement is one of the main concerns in double-bundle anterior cruciate ligament reconstruction (DB-ACLR). Impingement between the anteromedial (AM) and posterolateral (PL) bundles has been postulated to cause graft deterioration or rerupture, but this has not been thoroughly investigated, and the interbundle impingement pressure (IIP) has not been well researched.

Purpose:

To determine the IIP between the AM and PL bundles in the native anterior cruciate ligament (ACL) and in DB-ACLR with individualized and nonindividualized double-tunnel placement.

Study Design:

Controlled laboratory study.

Methods:

A total of 30 fresh-frozen, nonpaired, human cadaveric knees were randomly divided into 3 groups of 10 knees: native intact ACL (NI group), DB-ACLR tunnel placement using the preserved remnant procedure (individualized reconstruction) (PR group), and DB-ACLR tunnel placement using the bony landmark procedure (nonindividualized reconstruction) (BL group). Pressure sensors were inserted between the AM and PL bundles. The knee was moved passively from full extension to full flexion, and the IIP between the 2 ACL bundles was measured every 15°. Similarly, the impingement pressure was measured between the ACL and intercondylar roof and between the ACL and posterior cruciate ligament (PCL).

Results:

No significant differences were found in the maximum, mean, or minimum ACL-roof and ACL-PCL impingement pressures among the 3 groups. The IIP significantly increased when the knee joint was flexed >120° in all 3 groups (P < .001). Compared with the other 2 groups, the BL group had significantly higher maximum and mean IIP throughout the range of knee movement (P < .001) and from maximum extension to 120° of flexion (P < .001). The BL group also had significantly higher minimum IIP than the other 2 groups when knee flexion was >120° (P < .001). No significant differences were seen in maximum, minimum, or mean IIP between the NI and PR groups.

Conclusion:

The PR procedure (individualized DB-ACLR) was more consistent with the interbundle biomechanical conditions of the native ACL, whereas the BL procedure (nonindividualized DB-ACLR) had higher maximum and mean IIP. The IIP was higher than the ACL–intercondylar roof or ACL-PCL pressures, and it increased significantly when knee flexion was >120°.

Clinical Relevance:

These data suggest that surgeons can perform individualized DB-ACLR using preserved remnants for tunnel placement as impingement-free DB-ACLR.

Anatomic single- and double-bundle ACL reconstruction both restore dynamic knee function: a randomized clinical trial-part II: knee kinematics

PURPOSE

Compare side-to-side differences for knee kinematics between anatomic single-bundle (SB) and anatomic double-bundle (DB) ACLR during downhill running at 6 and 24 months post ACLR using high-accuracy dynamic stereo X-ray imaging. It was hypothesized that anatomic DB ACLR would better restore tibio-femoral kinematics compared to SB ACLR, based on comparison to the contralateral, uninjured knee.

METHODS

Active individuals between 14 and 50 years of age that presented within 12 months of injury were eligible to participate. Individuals with prior injury or surgery of either knee, greater than a grade 1 concomitant knee ligament injury, or ACL insertion sites less than 14 mm or greater than 18 mm were excluded. Subjects were randomized to undergo SB or DB ACLR with a 10 mm-wide quadriceps tendon autograft harvested with a patellar bone block and were followed for 24 months. Dynamic knee function was assessed during treadmill downhill running using a dynamic stereo X-ray tracking system at 6 and 24 months after surgery. Three-dimensional tibio-femoral kinematics were calculated and compared between limbs (ACLR and uninjured contralateral) at each time point.

RESULTS

Fifty-seven subjects were randomized (29 DB) and 2-year follow-up was attained from 51 (89.5%). No significant differences were found between SB and DB anatomic ACLR for any of the primary kinematic variables.

CONCLUSIONS

Contrary to the study hypothesis, double-bundle reconstruction did not show superior kinematic outcomes compared to the single-bundle ACLR. While neither procedure fully restored normal knee kinematics, both anatomic reconstructions were similarly effective for restoring near-normal dynamic knee function. The findings of this study indicate both SB and DB techniques can be used for patients with average size ACL insertion sites.

LEVEL OF EVIDENCE

Level I.

The Forgotten Joint Score-12 in Anterior Cruciate Ligament injuries

PURPOSE

The Forgotten Joint Score (FJS-12) is a scoring system initially created to assess post arthroplasty outcomes. It has since been used to evaluate Anterior Cruciate Ligament surgery outcomes. Our study aims to evaluate the applicability and validity of the FJS-12 in post Anterior Cruciate Ligament reconstructed patients, and to assess correlation with established Patient Reported Outcome Measure Scores in the same population.

DESIGN

Case series, level 3 evidence.

METHODS

We conducted a cross sectional study across patients who had undergone Anterior Cruciate Ligament reconstruction and carried out the FJS-12 questionnaire by phone interview. Patients who had undergone primary Anterior Cruciate Ligament reconstruction were considered for the study.

RESULTS

The average Forgotten Joint Score-12 for all 82 patients was 71.4 (±22.9), which corresponded to a normal distribution. The average Lysholm and Tegner score at the 2-year post-operative visit was 93.5 ± 9.5 and 5.8 ± 1.8 respectively and the distribution was non-normal. We noticed a large ceiling effect of 42.7% in the Lysholm scores, but only 8.4% in FJS-12. There was a weak correlation with Lysholm and a positive correlation with Tegner.

CONCLUSIONS

Forgotten Joint Score-12 seems to be a promising patient reported outcome measure that can be used in evaluating post Anterior Cruciate Ligament reconstruction outcomes. It is more discerning than traditional scores and is easy to administer thus it can used in the clinical follow-up of patients. With the scores being normally distributed, it makes for a meaningful PROMS and would allow more accurate application of parametric statistical tests.

Biomechanical comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction: a meta-analysis

BACKGROUND

Of the many issues regarding surgical techniques related to anterior cruciate ligament reconstruction (ACLR), single-bundle (SB) or double-bundle (DB) ACLR is one of the most debated topics. However, it is unclear which of the techniques yields better outcomes after ACLR for ACL injury. The purpose of this meta-analysis was to compare the benefits of SB versus DB ACLR in terms of biomechanical outcomes.

METHODS

The electronic databases MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched for relevant articles comparing the outcomes of SB-ACLR versus DB-ACLR that were published until November 2019.

RESULTS

Seventeen biomechanical studies were included. The anterior laxity measured using the anterior drawer test showed significantly better results in DB-ACLR when compared with SB-ACLR. In addition, outcomes of the anterior tibial translation test under a simulated pivot shift presented with better results at low flexion and 30° in DB-ACLR, compared with SB-ACLR. However, there were no significant biomechanical differences between the groups in internal rotation.

CONCLUSIONS

The present study demonstrated that both techniques for ACLR are associated with restoration of normal knee kinematics. DB-ACLR is superior to SB-ACLR in terms of restoration of anteroposterior stability. However, which technique yields better improvement in internal rotation laxity, and internal rotation laxity under a simulated pivot shift at a specific angle, remains unclear.

LEVEL OF EVIDENCE

This is a level II meta-analysis.