ACL Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Provides Good Clinical Scores, High Levels of Satisfaction and Return to Sport, and a Low Retear Rate at 2 Years

Biomechanical and Histological Study of Retrieved LARS Synthetic Ligaments

BACKGROUND

Synthetic grafts have been used for a number of years in anterior cruciate ligament (ACL) reconstruction surgery. One of the more recent additions to the stable of synthetic ligaments is the Ligament Augmentation and Reconstruction System (LARS) ligament.

PURPOSE

To analyze the biomechanics and histology of LARS grafts retrieved due to failure of the device.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 22 LARS ligament grafts that were explanted from patients were sent for analysis. Five new, unused samples of the standard LARS ACL graft were also analyzed. Biomechanical testing was performed: ultimate tensile force, force versus displacement, and stress versus strain were recorded. Histopathological examination was performed looking for degree of fibrous tissue ingrowth as well as the presence of a foreign body reaction.

RESULTS

Of the 22 grafts retrieved, 14 were used for ACL grafts, 1 for a lateral collateral ligament graft, 2 for medial collateral ligament grafts, 4 for gluteal tendon augmentation, and 1 for a supraspinatus augmentation. A severe foreign body reaction was found in 86% of the grafts (18/22) and a mild foreign body reaction in the remaining 14% (4/22). Tissue ingrowth was minimal in the majority of ACL grafts; the other grafts showed moderate tissue ingrowth. Maximal tensile force was significantly higher for the new ACL grafts (mean ± SD, 1667 ± 845 N) compared with the retrieved grafts (897 ± 395 N; P < .05).

CONCLUSION

This study demonstrated that the vast majority of retrieved LARS artificial ligaments had a florid foreign body reaction. There was minimal tissue ingrowth in ACL grafts and moderate ingrowth in other grafts. Retrieved grafts had a decreased ultimate tensile force, which increased their risk of rupture.

CLINICAL RELEVANCE

Surgeons should be cautious in choosing to use these grafts in reconstructive surgery for patients.

Restoring Knee Flexor Strength Symmetry Requires 2 Years After ACL Reconstruction, But Does It Matter for Second ACL Injuries? A Systematic Review and Meta-analysis

BACKGROUND

It is unknown whether knee flexor strength recovers after anterior cruciate ligament (ACL) reconstruction with a hamstring tendon (HT) autograft and whether persistent knee flexor strength asymmetry is associated to a second ACL injury.

OBJECTIVE

We aimed to systematically review (1) whether knee flexor strength recovers after ACL reconstruction with HT autografts, and (2) whether it influences the association with a second ACL injury. A third aim was to summarize the methodology used to assess knee flexor strength.

DESIGN

Systematic review and meta-analysis reported according to PRISMA.

METHODS

A systematic search was performed using the Cochrane Library, Embase, Medline, PEDRo, and AMED databases from inception to December 2021 and until completion in January 2023. Human clinical trials written in English and conducted as randomized controlled trials, longitudinal cohort, cross-sectional, and case-control studies on patients with index ACL reconstructions with HT autografts harvested from the ipsilateral side were considered. Knee flexor strength was measured isokinetically in both the reconstructed and uninjured limb to enable the calculation of the limb symmetry index (LSI). The Risk of Bias Assessment Tool for Non-Randomized Studies was used to assess risk of bias for non-randomized studies and the revised Cochrane Risk of Bias tool was used for randomized controlled trials. For the meta-analysis, the LSI (mean ± standard error) for concentric knee flexor strength at angular velocities of 60°/second (s) and 180°/s preoperatively and at 3 months, 6 months, 12 months, and 24 months were pooled as weighted means with standard errors.

RESULTS

The search yielded 64 studies with a total of 8378 patients, which were included for the assessment of recovery of knee flexor strength LSI, and a total of 610 patients from four studies that investigated the association between knee flexor strength and second ACL injuries. At 1 year after ACL reconstruction, the knee flexor strength LSI had recovered to 89.0% (95% CI 87.3; 90.7%) and 88.3% (95% CI 85.5; 91.1%) for the velocities of 60°/s and 180°/s, respectively. At 2 years, the LSI was 91.7% (95% CI 90.8; 92.6%) and 91.2% (95% CI 88.1; 94.2%), for velocities of 60°/s and 180°/s, respectively. For the association between knee flexor strength and second ACL injuries, there was insufficient and contradictory data.

CONCLUSIONS

There was low to very low certainty of evidence indicating that the recovery of knee flexor strength LSI, defined as ≥ 90% of the uninjured side, takes up to 2 years after ACL reconstruction with HT autografts. Whether knee flexor strength deficits influence the association of second ACL injuries is still uncertain. There was considerable heterogeneity in the methodology used for knee flexor strength assessment, which together with the low to very low certainty of evidence, warrants further caution in the interpretation of our results.

REGISTRATION NUMBER

CRD42022286773.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact

BACKGROUND

Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA).

METHODS

Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed.

RESULTS

We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR.

CONCLUSION

SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

A comparison between physical therapy clinics with high and low rehabilitation volumes of patients with ACL reconstruction

BACKGROUND

Treatment volume can impact outcomes after surgical procedures of the knee between surgeons with high- and low-patient-volumes. However, the difference between physical therapeutic clinics with high- and low-volumes has not been widely researched. This registry study aims to investigate how patient volume affects knee function outcomes after anterior cruciate ligament (ACL) reconstruction at physical therapy (PT) clinics in terms of odds for a second ACL injury, return to pre-injury level of activity, perceived knee function, and recovery of strength and hop performance.

METHOD

Data were extracted from the Project ACL, a local rehabilitation registry. High- and low-volume clinics were defined based on the number of patients who attended different clinics. High-volume clinics were defined as those with > 100 patient registrations in Project ACL during the study period while low-volume clinics were those with ≤ 100 patient registrations. High- and low-volume clinics were compared, based on muscle function and patient-reported outcomes across 4 follow-ups, 2-, 4-, 8-, and 12 months, during the first year after ACL reconstruction, and odds of second ACL injury up to 2 years after ACL reconstruction.

RESULT

Of the 115 rehabilitation clinics included, 111 were classified as low-volume clinics and included 733 patients, and 4 as high-volume clinics which included 1221 patients. There were 31 (1.6%) second ACL injuries to the ipsilateral or contralateral side within the first 12 months and 68 (4.0%) within 2 years. No difference in the incidence of a second ACL injury, within 12 months follow-up odds ratio (OR) 0.95 [95% CI 0.46-1.97] or within 2 years follow-up OR 1.13 [95% CI 0.68-1.88], was found between high- and low-volume clinics. There were early (2 months) and non-clinically relevant differences in patient-reported outcomes (PROs) and physical activity levels early after ACL reconstruction in favor of high-volume clinics. One year after ACL reconstruction, no differences were observed between high- and low-volume clinics in terms of PROs, muscle function, and return to pre-injury level of activity.

CONCLUSION

No clinically relevant difference in the incidence of secondary ACL injuries in patients who underwent rehabilitation after ACL reconstruction at high- or low-volume physical therapist clinics was found. In addition, no clinically relevant differences in outcomes were found during the first year in terms of patient-reported outcomes, recovery of muscle function, or return to pre-injury level of activity.

Cohort study of short-term outcomes after ACL-reconstruction using autograft with internal brace reinforcement versus isolated autograft demonstrating no significant difference

Background

The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. Few studies have examined these techniques, in particular when compared to non-augmented grafts. This study assesses the short-term outcome of ACL-R using augmented and non-augmented hamstring tendon autografts.

Methods

This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes.

Results

There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82 mm versus 8.44 mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width.

Conclusion

No statistically significant difference was demonstrated in the short-term functional outcome of ACL reconstruction using an augmented or non-augmented hamstring graft. Augmented ACL-R may achieve superior graft diameters, failure rates and patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further.

Suture-tape augmentation of anterior cruciate ligament reconstruction: a prospective, randomised controlled trial (STACLR)

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction aims to restore anteroposterior and rotatory stability to the knee following ACL injury. This requires the graft to withstand the forces applied during the process of ligamentisation and the rehabilitative period. We hypothesise that the use of suture tape augmentation of single bundle ACL reconstruction (ACLR) will reduce residual knee laxity and improve patient-reported outcomes at 2-year follow-up. We will conduct a 1:1 parallel arm single-centre randomised controlled trial comparing suture tape augmented ACLR to standard ACLR technique.

METHODS

The study design will be a parallel arm 1:1 allocation ratio randomised controlled trial. Sixty-six patients aged 18 and over waitlisted for primary ACLR will be randomised. Patients requiring osteotomy and extra-articular tenodesis and who have had previous contralateral ACL rupture or repair of meniscal or cartilage pathology that modifies the post-operative rehabilitation will be excluded. The primary outcome measure will be the side-to-side difference in anterior tibial translation (measured on the GNRB arthrometer) at 24 months post-surgery. GNRB arthrometer measures will also be taken preoperatively, at 3 months and 12 months post-surgery. Secondary outcomes will include patient-reported outcome measures (PROMs) collected online, including quality of life, activity and readiness to return to sport, complication rates (return to theatre, graft failure and rates of sterile effusion), examination findings and return to sport outcomes. Participants will be seen preoperatively, at 6 weeks, 3 months, 12 months and 24 months post-surgery. Participants and those taking arthrometer measures will be blinded to allocation.

DISCUSSION

This will be the first randomised trial to investigate the effect of suture-tape augmentation of ACLR on either objective or subjective outcome measures. The use of suture-tape augmentation in ACLR has been associated with promising biomechanical and animal-level studies, exhibiting equivalent complication profiles to the standard technique, with initial non-comparative clinical studies establishing possible areas of advantage for the technique. The successful completion of this trial will allow for an improved understanding of the in situ validity of tape augmentation whilst potentially providing a further platform for surgical stabilisation of the ACL graft.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12621001162808. Universal Trial Number (UTN): U1111-1268-1487. Registered prospectively on 27 August 2021.

Good clinical scores, no evidence of excessive anterior tibial translation, a high return to sport rate and a low re-injury rate is observed following anterior cruciate ligament reconstruction using autologous hamstrings augmented with suture tape

INTRODUCTION

Augmented anterior cruciate ligament reconstruction (ACLR) techniques have been proposed to reduce the high reported re-injury rates and low rates of return to sport (RTS). This study reports clinical outcomes, RTS and re-injury rates in patients undergoing ACLR using autologous hamstrings augmented with suture tape.

MATERIALS AND METHODS

A total of 53 patients were prospectively recruited, undergoing ACLR using hamstrings with suture tape augmentation, combined with a structured rehabilitation programme. Outcomes were collected to 24 months, including patient-reported outcome measures (PROMs), KT-1000 measurements, peak isokinetic knee strength and a four hop test battery. Limb Symmetry Indices (LSIs) were calculated for performance measures, whilst RTS rates, re-tears and re-operations were presented.

RESULTS

There were no significant side-to-side differences in anterior tibial translation between the operated and non-operated knees at 6 months (p = 0.433), with no increase (p = 0.841) in side-to-side anterior tibial translation from 6 to 24 months. At 24 months, 98.0% of patients demonstrated normal (< 3 mm) or near normal (3-5 mm) side-to-side differences. LSIs for peak knee extensor torque (p < 0.0001) and the single (p = 0.001), triple (p = 0.001) and triple crossover (p < 0.0001) hop tests for distance significantly improved. All PROMs significantly improved (p < 0.0001), with 70.2% and 85.7% of patients actively participating in pivoting sports at 12 and 24 months, respectively. Three patients underwent secondary procedures for meniscal symptoms. One patient suffered an ACL re-tear (17 months), with no further ipsilateral or contralateral injuries.

CONCLUSION

ACLR with suture tape augmentation demonstrated no evidence of excessive anterior tibial translation, high-scoring PROMs, sound performance scores, a high rate of RTS and low re-injury rate.

Tourniquet Use Improves Intraoperative Parameters, Leading to Similar Postoperative Outcomes Compared With No Tourniquet Use in Anterior Cruciate Ligament Reconstruction: A Prospective, Double-Blind, Randomized Clinical Trial

PURPOSE

To examine the effect of tourniquet use in arthroscopic anterior cruciate ligament reconstruction in terms of: (1) intraoperative visualization with operative time and consumption of sterile saline, and (2) intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum creatine phosphokinase (CPK) and hemoglobin (Hb) concentrations, clinical outcomes, and graft healing.

METHODS

In this prospective randomized clinical trial, patients were assigned to tourniquet inflation (tourniquet-up) or tourniquet deflation (tourniquet-down) groups. Primary outcomes were intraoperative visualization with operative time and sterile saline consumption. Secondary outcomes were intra- and postoperative blood loss, postoperative pain, opioid consumption, swelling, serum CPK, Hb concentration, subjective and objective functional scores, and graft healing.

RESULTS

Intraoperative visualization was satisfactory in 100 of 100 cases in the tourniquet-up group and 64 of 100 cases in the tourniquet-down group (P < .05). The mean operative time was 58.4 ± 5.7 minutes in the tourniquet-up group and 72.5 ± 8.6 minutes in the tourniquet-down group (P < .05). The mean sterile saline consumption was 6.4 ± 2.5 L in the tourniquet-up group and 8.7 ± 4.6 L in the tourniquet-down group (P < .05). The respective amounts of estimated intraoperative and postoperative blood loss were 95.3 ± 25.1 mL and 240.3 ± 44.5 mL in the tourniquet-up group and 230.2 ± 22.3 mL and 75.6 ± 15.3 mL in the tourniquet-down group (P < .05). Our results showed no significant difference in postoperative pain, opioid consumption, percentage of patients using opioids, swelling, mean serum CPK and Hb levels, subjective and objective functional scores, or graft healing (P > .05) between the 2 groups.

CONCLUSIONS

Tourniquet use during anterior cruciate ligament reconstruction significantly improves intraoperative visualization, shortens operative time, and decreases intraoperative sterile saline consumption and blood loss without serious adverse events or greater complication rates based on early postoperative outcomes.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone

PURPOSE

To compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group).

METHODS

From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24 months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage.

RESULTS

A total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first two years. At the three month follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and six month follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates.

CONCLUSIONS

Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.

Massive foreign body reaction and osteolysis following primary anterior cruciate ligament reconstruction with the ligament augmentation and reconstruction system (LARS): a case report with histopathological and physicochemical analysis

BACKGROUND

Autologous hamstrings and patellar tendon have historically been considered the gold standard grafts for anterior cruciate ligament reconstruction (ACLR). In the last decades, the utilization of synthetic grafts has re-emerged due to advantageous lack of donor site morbidity and more rapid return to sport. The Ligament Augmentation and Reconstruction System (LARS) has demonstrated to be a valid and safe option for ACLR in the short term. However, recent studies have pointed out the notable frequency of associated complications, including synovitis, mechanical failure, and even chondrolysis requiring joint replacement.

CASE PRESENTATION

We report the case of a 23-year-old male who developed a serious foreign body reaction with wide osteolysis of both femoral and tibial tunnels following ACLR with LARS. During first-stage arthroscopy, we performed a debridement of the pseudocystic mass incorporating the anterior cruciate ligament (ACL) and extending towards the tunnels, which were filled with autologous anterior iliac crest bone graft chips. Histological analysis revealed the presence of chronic inflammation, fibrosis, and foreign body giant cells with synthetic fiber inclusions. Furthermore, physicochemical analysis showed signs of fiber depolymerization, increased crystallinity and formation of lipid peroxidation-derived aldehydes, which indicate mechanical aging and instability of the graft. After 8 months, revision surgery was performed and ACL revision surgery with autologous hamstrings was successfully carried out.

CONCLUSIONS

The use of the LARS grafts for ACLR should be cautiously contemplated considering the high risk of complications and early failure.

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.

Return to Sport Activities and Risk of Reinjury Following Primary Anterior Cruciate Ligament Reconstruction

This article examines the elements that affect the return to sport (RTS) and the risk and percentages of reinjury following a prior primary anterior cruciate ligament reconstruction (ACLR). The prevalence of RTS following ACLR ranges from 71% to 83%. Concerning elements affecting RTS, a limb symmetry index score of 90 or more duplicates the likelihood of RTS and triplicates it when the International Knee Documentation Committee (IKDC) score is 95 or more, irrespective of age. Other elements recognized to be preindicative of RTS at 1 year include complete rehabilitation, age ≤25, and higher IKDC scores. The prevalence of reinjury following ACLR ranges from 1.5% to 37.5% (between 9% and 29% in the majority of reports). It has been published that 1 in 5 individuals suffers reinjury to either knee, and that male individuals are more prone to reinjure following ACLR. The highest percentage of ACLR reinjury happens in younger male (<18 years), being substantially higher than in female of the same age. Passing a combination of functional tests with predetermined cut-off points utilized as RTS criteria are related diminished ACLR reinjury percentages.

Double-bundle anterior cruciate ligament reconstruction using autologous hamstrings with LARS augmentation demonstrates comparable outcomes to hamstrings alone, without evidence of synovitis or early osteoarthritis

PURPOSE

To compare the clinical and radiological outcomes in patients undergoing anterior cruciate ligament reconstruction (ACLR) with, or without, LARS augmentation.

METHODS

One-hundred and thirty-six patients that underwent double-bundle ACLR with (DB Hams/LARS, n = 67), or without (DB Hams, n = 69), LARS augmentation, were assessed clinically and with Magnetic Resonance Imaging (MRI) at a minimum of 7-years post-surgery. Patients were assessed via patient-reported outcome measures (PROMs), KT-1000 (laxity), isokinetic knee extensor and flexor strength and a 4-hop test battery. Limb symmetry indices (LSIs) were calculated. The Whole-Organ Magnetic Resonance Imaging Score (WORMS) evaluated knee status via MRI. Sport participation, secondary operations, ACL re-tears and contralateral ACL tears were reported.

RESULTS

No differences (n.s.) were observed in demographics, PROMs, KT-1000 scores or strength and hop LSIs. Normal (< 3 mm side-to-side differences) KT-1000 scores were observed in 64 (92.8%) and 59 (88.1%) of DB Hams and DB Hams/LARS patients, respectively. Comparative rates of satisfaction were reported. Knee flexor strength and hop test LSIs were all ˃95% in both groups, which was 94.2% and 96.7% for knee extensor strength in the DB Hams and DB Hams/LARS cohorts, respectively. While 53 (76.8%) and 52 (77.6%) of the DB Hams and DB Hams/LARS patients had returned to pivoting sports, 42 (60.9%) and 41 (61.2%) were participating in pivoting sports at the minimum 7-year review. No difference (n.s.) was observed in the WORMS (12.3 DB Hams, 16.7 DB Hams/LARS). Of the cohort assessed, 8 (11%) DB Hams and 11 (16%) DB Hams/LARS patients had undergone secondary surgery. In addition to one patient in each group that demonstrated ACL rupture on MRI, an additional cohort of patients were excluded from the current analysis due to prior re-tear (DB Hams n = 6, DB Hams/LARS n = 8) or contralateral ACL tear (DB Hams n = 4, DB Hams/LARS n = 4).

CONCLUSIONS

Comparable outcomes were observed after double-bundle ACLR using autologous hamstrings with, or without, LARS augmentation. Therefore, while these outcomes do not justify the additional use of synthetic augmentation given the lack of further benefit and additional cost, higher rates of graft failure, synovitis and early osteoarthritic change previously reported were not observed.

LEVEL OF EVIDENCE

III.

Outcomes After Hamstring ACL Reconstruction With Suture Tape Reinforcement in Adolescent Athletes

Background:

Previous studies have suggested that suture tape-reinforced anterior cruciate ligament (ACL) grafts may have higher ultimate failure loads without stress-shielding. In patients at high risk for graft failure, such as adolescents, the addition of suture tape could have beneficial outcomes.

Hypothesis:

Suture tape reinforcement (STR) of ACL grafts in adolescent patients would lead to fewer graft ruptures during early recovery, without hindering subjective outcomes.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective review was performed on adolescent patients with a minimum 2-year follow-up after hamstring tendon autograft ACL reconstruction; enrolled were patients from both before (n = 40) and after (n = 40) a shift in surgical technique that added STR. Both the no-STR and the STR cohorts were contacted yearly to obtain patient-reported outcome data for visual analog scale (VAS; range, 0-10) for pain score, Single Assessment Numeric Evaluation, Lysholm score, Tegner activity score, patient satisfaction score (range, 0-100), and return to previous level of sport (yes/no). The cohorts were then matched based on follow-up duration, excluding those with follow-up of <2 years and >3 years to maintain consistency in duration of follow-up. Graft failure was defined as either graft rupture or recurrent instability symptoms, and failures occurring from index procedure to the 3-year mark were recorded for calculations of failure rate.

Results:

There were no differences between cohorts in mean age [STR, 15.7 years (range, 9.5-18.7 years); no STR, 14.9 years (range, 9.3-18.8 years)], follow-up duration, laterality, or graft size. While not statistically significant, 2 (5%) patients in the STR cohort experienced graft rupture compared with 7 (17.5%) patients in the no-STR cohort. The Tegner score was significantly higher in the STR cohort (P = .017); no between-group differences were seen on the other outcome scores. A subanalysis of the STR cohort comparing small-diameter grafts (<8 mm) with grafts ≥8 mm also demonstrated no difference in outcome measures, with 1 graft failure in each cohort.

Conclusion:

Study outcomes indicated that patients treated with ACL reconstruction and STR experienced a significant improvement in Tegner scores while at the same time maintaining the other subjective outcomes.

Predictors of patient satisfaction after primary hamstring anterior cruciate ligament reconstruction

BACKGROUND

Predictors of patient satisfaction (PS) after anterior cruciate ligament (ACL) reconstruction are not well known. This study investigated predictors of PS and whether PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life after ACL reconstruction.

METHODS

Patients who underwent primary hamstring ACL reconstruction between January 2015 and December 2017 were retrospectively evaluated. An online survey was used to evaluate PS (yes = satisfied, no = unsatisfied), duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport, pre-injury level of sport participation, patient reported knee function and quality of life. Preoperative, operative and postoperative variables were collected from the medical records.

RESULTS

A total of 183 patients completed the survey at a median of 3.6 (1.5) years after ACL surgery. At final follow-up, 82% of patients were satisfied with the outcome. Preoperative (e.g. age) and operative (e.g. meniscal tear) variables were not predictors of PS (p > 0.05). Duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport and postoperative ACL injury were predictors of PS (p = 0.018, p = 0.016 and p < 0.001, respectively). Pre-injury level of sport participation was significantly higher in satisfied compared to unsatisfied patients: 44.7% (n = 67) versus 18.2% (n = 6) (p = 0.005). In addition, satisfied patients reported significantly higher patient reported knee function and quality of life compared to unsatisfied patients (p < 0.001).

CONCLUSION

This study provided data on predictors of PS after primary ACL reconstruction. Furthermore, PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Versus Hamstrings Alone: A Comparative Cohort Study

BACKGROUND

Few studies have reported the return-to-sports (RTS) rate in patients after augmentation of autologous anterior cruciate ligament reconstruction (ACLR) with the Ligament Augmentation and Reconstruction System (LARS).

PURPOSE/HYPOTHESIS

The purpose of this study was to compare postoperative outcomes in patients who underwent ACLR with single-bundle 4-strand hamstring autograft either without augmentation (HA-ACLR group) or with LARS augmentation (AUG-ACLR group). It was hypothesized that clinical outcomes and RTS rates would be better in the AUG-ACLR group at the 1-year follow-up, with similar outcomes in both cohorts by 2 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent ACLR between April 2014 and December 2017 were included in the current comparative study if they were skeletally mature and had 1- and 2-year follow-up outcomes; patients with concomitant meniscal surgery were also included. Included were 66 patients with AUG-ACLR (mean age, 26.8 years; 67% male) and 130 patients with HA-ACLR (mean age, 27.5 years; 61% male). Subjective outcome measures included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score, Lysholm scale, Tegner activity scale, and the Noyes sports activity rating scale. Objective measures included knee laxity, maximal isokinetic knee flexion and extension strength, and the results of 4 functional hop tests.

RESULTS

There were no significant differences between the study groups in age, sex distribution, body mass index, time to surgery, or number of concurrent meniscal surgeries. At the 1-year follow-up, the AUG-ACLR group had a significantly higher Tegner score (P = .001) and rates of RTS (P = .029) and return to preinjury level of sport (P = .003) compared with the HA-ACLR group. At the 2-year follow-up, there were no differences in these measures between groups. There were no between-group differences in other subjective outcomes, knee laxity, or strength and hop test results at either postoperative time point. There were also no differences in rerupture rates or other complications between the groups.

CONCLUSION

Patients with AUG-ACLR had higher 1-year postoperative Tegner scores and rates of RTS and preoperative sport level compared with the HA-ACLR group. The 2-year rerupture rate for the AUG-ACLR group was low, and no intra-articular inflammatory complications were noted.

Biomechanical analysis of three different types of fixators for anterior cruciate ligament reconstruction via finite element method: a patient-specific study

Complication rates of anterior cruciate ligament reconstruction (ACL-R) were reported to be around 15% although it is a common arthroscopic procedure with good outcomes. Breakage and migration of fixators are still possible even months after surgery. A fixator with optimum stability can minimise those two complications. Factors that affect the stability of a fixator are its configuration, material, and design. Thus, this paper aims to analyse the biomechanical effects of different types of fixators (cross-pin, interference screw, and cortical button) towards the stability of the knee joint after ACL-R. In this study, finite element modelling and analyses of a knee joint attached with double semitendinosus graft and fixators were carried out. Mimics and 3-Matic softwares were used in the development of the knee joint models. Meanwhile, the graft and fixators were designed by using SolidWorks software. Once the meshes of all models were finished in 3-Matic, simulation of the configurations was done using MSC Marc Mentat software. A 100-N anterior tibial load was applied onto the tibia to simulate the anterior drawer test. Based on the findings, cross-pin was found to have optimum stability in terms of stress and strain at the femoral fixation site for better treatment of ACL-R.

Patellar tendon versus artificial grafts in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Background

The aim of anterior cruciate ligament reconstruction (ACLR) is to restore the function of the knee joint, protect the cartilage, and reduce the occurrence of osteoarthritis. However, due to the structural limitations of the human body, it is not possible to perform ACLR with conventional sutures. To restore normal functioning of the anterior cruciate ligament (ACL), a new ligament must be reconstructed in the position of the previous ACL.

Objective

To compare autografts and synthetic grafts in terms of postoperative knee stability and function

Search methods

The protocol for this study was registered with PROSPERO (CRD42021243451). Two reviewers independently searched the PubMed, Embase, and the Cochrane Library databases from database inception though February 10, 2021. The following search method was used: ((Autograft) OR (Autologous) OR (Autotransplant)) OR Artificial Ligament AND (Anterior Cruciate Ligament Injury [MeSH Terms]) AND (Randomized controlled trial [MeSH Terms]). Methodological quality was assessed by the Cochrane risk of bias tool.

Selection criteria

We only included randomized controlled trials (level I) that compared autograft and synthetic graft interventions in participants with ACL injury. We included trials that evaluated ACLR using at least one outcome (Lachman test, pivot shift test, IKDC grades, or complications).

Results

A total of 748 studies were identified in the initial literature search, and seven studies that examined only bone-patellar tendon-bone (BPTB) grafts compared with artificial grafts met the predetermined inclusion criteria. The results showed that BPTB grafts were associated with significantly better pivot shift test and Lachman test results and better IKDC grades and lower complication rates than synthetic grafts.

Conclusions

This review indicates that for adults, BPTB grafts perform more favorably than synthetic grafts in ACLR in terms of knee stability, function, and complication. More research is needed to compare autologous tendons and allogeneic tendons with artificial ligaments, especially in elderly individuals.

Level of evidence

Level I, systematic review and meta-analysis

Test Batteries After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

There is a lack of consensus regarding test batteries for return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR).

OBJECTIVE

To report the RTS test batteries for individuals after ACLR and to examine alignment with the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC). Finally, to examine how published RTS batteries prior to the AAOS AUC (2010-2015) compared with those after publication of the AUC (2016-2020).

DATA SOURCE

A systematic search of PubMed (2010-2020).

STUDY SELECTION

Studies were included if they were published from 2010 to 2020, patients underwent primary ACLR and were tested between 6 months and 2 years postoperatively and included a minimum of 2 assessments. Studies were excluded if patients were tested outside the designated time; had undergone a revision, contralateral, or multiligament injury; included healthy participants; were level 5 evidence or the study was a systematic review. A total of 1012 articles were reviewed and 63 met the criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Information regarding the RTS batteries and patient demographics were extracted from the included articles.

RESULTS

A total of 63 studies met the inclusion and exclusion criteria (22 from 2010-2015 and 41 from 2016-2020). The most common RTS batteries included the hop test, quadriceps strength test, and patient-reported outcome measures. No study met all 7 AUC; the most common criteria met were functional skills (98.4%), followed by confidence (22.2%), then range of motion and knee stability (20.6%).

CONCLUSION

The test batteries in the current literature show high variability and a lack of essential components necessary for RTS. No study met the AUC guidelines, suggesting a disconnect between recommended guidelines and clinical practice. Test battery research has expanded over the past decade; however, standardized, clinically applicable batteries that encompass all criteria are needed.