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Gabr A, Mancino F, Robinson J, Hage W, O'Leary S, Spalding T, Haddad FS. Satisfactory 5-year functional outcomes following primary ACL reconstructions from the UK National Ligament Registry. Knee Surg Sports Traumatol Arthrosc 2024; 32:798-810. [PMID: 38426562 DOI: 10.1002/ksa.12071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). METHODS A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 years and 5 years following the index procedure. RESULTS During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 years and 5 years postoperatively. CONCLUSION Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ayman Gabr
- West Suffolk Hospital NHS Trust, Bury St Edmunds, UK
- University College London Hospitals NHS Trust, London, UK
| | - Fabio Mancino
- University College London Hospitals NHS Trust, London, UK
| | | | | | - Sean O'Leary
- The Royal Berkshire Hospital NHS Trust, Reading, UK
| | | | - Fares S Haddad
- University College London Hospitals NHS Trust, London, UK
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Liukkonen R, Vaajala M, Mattila VM, Reito A. Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques. Bone Joint J 2023; 105-B:1140-1148. [PMID: 37907079 DOI: 10.1302/0301-620x.105b11.bjj-2023-0058.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Aims The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades. Methods The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β). Results The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)). Conclusion The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.
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Affiliation(s)
- Rasmus Liukkonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matias Vaajala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Aleksi Reito
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Haddad FS. The challenge of evaluating our surgical procedures. Bone Joint J 2023; 105-B:1133-1134. [PMID: 37907078 DOI: 10.1302/0301-620x.105b11.bjj-2023-0998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cite this article: Bone Joint J 2023;105-B(11):1133–1134.
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Affiliation(s)
- Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
- The Princess Grace Hospital, London, UK
- The NIHR Biomedical Research Centre, UCLH, London, UK
- The Bone & Joint Journal , London, UK
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Haddad FS. The power of the media. Bone Joint J 2023; 105-B:1031-1032. [PMID: 37777200 DOI: 10.1302/0301-620x.105b10.bjj-2023-0883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Abstract
The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females' greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.
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Affiliation(s)
- Fabio Mancino
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Ayman Gabr
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Ricci Plastow
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
- The Bone & Joint Journal , London, UK
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Haddad FS. Important matters that need attention. Bone Joint J 2023; 105-B:717-718. [PMID: 37391204 DOI: 10.1302/0301-620x.105b7.bjj-2023-0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
- Princess Grace Hospital, London, UK
- The Bone & Joint Journal , London, UK
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Hu M, Zhang Y, Shang G, Guo J, Xu H, Ma X, Yang X, Xiang S. Vancomycin presoak reduces infection in anterior cruciate ligament reconstruction: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:267. [PMID: 37020216 PMCID: PMC10074692 DOI: 10.1186/s12891-023-06331-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
PURPOSE To compare the effect of vancomycin presoak treatment of grafts during anterior cruciate ligament reconstruction on the incidence of postoperative infection or septic arthritis. METHODS Studies published before May 3, 2022 investigating vancomycin presoak of grafts during anterior cruciate ligament reconstruction were searched in the PubMed and Cochrane Central Register of Controlled Trials. Studies were screened, and data on the incidence of postoperative infection or septic arthritis were extracted and included in the analysis. RESULTS Thirteen studies were included for analysis after search screening, yielding a total of 31,150 participants for analysis, of whom 11,437 received graft vancomycin presoak treatment, and 19,713 did not receive treatment. Participants who received vancomycin treatment had significantly lower infection rates (0.09% versus 0.74%; OR 0.17; 95% CI 0.10, 0.30; P < 0.00001). CONCLUSION Pre-soaking of the graft with vancomycin during ACL reconstruction reduced the incidence of postoperative infection and septic arthritis.
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Affiliation(s)
- Mingwei Hu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Yifan Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Guangqian Shang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Jianjun Guo
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Hao Xu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Xue Ma
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Xue Yang
- Operation Room, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China
| | - Shuai Xiang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, No. 59, Haier Road, Laoshan District, Qingdao, Shandong, China.
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Farshidfar SS, Cadman J, Neri T, Parker D, Appleyard R, Dabirrahmani D. Towards a validated musculoskeletal knee model to estimate tibiofemoral kinematics and ligament strains: comparison of different anterolateral augmentation procedures combined with isolated ACL reconstructions. Biomed Eng Online 2023; 22:31. [PMID: 36973768 PMCID: PMC10044816 DOI: 10.1186/s12938-023-01094-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Isolated ACL reconstructions (ACLR) demonstrate limitations in restoring native knee kinematics. This study investigates the knee mechanics of ACLR plus various anterolateral augmentations using a patient-specific musculoskeletal knee model. MATERIALS AND METHODS A patient-specific knee model was developed in OpenSim using contact surfaces and ligament details derived from MRI and CT data. The contact geometry and ligament parameters were varied until the predicted knee angles for intact and ACL-sectioned models were validated against cadaveric test data for that same specimen. Musculoskeletal models of the ACLR combined with various anterolateral augmentations were then simulated. Knee angles were compared between these reconstruction models to determine which technique best matched the intact kinematics. Also, ligament strains calculated by the validated knee model were compared to those of the OpenSim model driven by experimental data. The accuracy of the results was assessed by calculating the normalised RMS error (NRMSE); an NRMSE < 30% was considered acceptable. RESULTS All rotations and translations predicted by the knee model were acceptable when compared to the cadaveric data (NRMSE < 30%), except for the anterior/posterior translation (NRMSE > 60%). Similar errors were observed between ACL strain results (NRMSE > 60%). Other ligament comparisons were acceptable. All ACLR plus anterolateral augmentation models restored kinematics toward the intact state, with ACLR plus anterolateral ligament reconstruction (ACLR + ALLR) achieving the best match and the greatest strain reduction in ACL, PCL, MCL, and DMCL. CONCLUSION The intact and ACL-sectioned models were validated against cadaveric experimental results for all rotations. It is acknowledged that the validation criteria are very lenient; further refinement is required for improved validation. The results indicate that anterolateral augmentation moves the kinematics closer to the intact knee state; combined ACLR and ALLR provide the best outcome for this specimen.
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Affiliation(s)
- Sara Sadat Farshidfar
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Joseph Cadman
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Thomas Neri
- Sydney Orthopaedic Research Institute, Sydney, Australia
- Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France
- EA 7424-Inter-University Laboratory of Human Movement Science, University Lyon-University Jean Monnet Saint Etienne, Saint Etienne, France
| | - David Parker
- Sydney Orthopaedic Research Institute, Sydney, Australia
| | - Richard Appleyard
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Danè Dabirrahmani
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
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Zakharia A, Lameire DL, Abdel Khalik H, Kay J, Uddandam A, Nagai K, Hoshino Y, de Sa D. Quadriceps tendon autograft for pediatric anterior cruciate ligament reconstruction results in promising postoperative function and rates of return to sports: A systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:3659-3672. [PMID: 35445330 DOI: 10.1007/s00167-022-06930-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the performance of the quadriceps tendon (QT) autograft in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of MEDLINE, PubMed, and EMBASE was conducted on March 1, 2021. Studies of all levels of evidence reporting outcomes and/or complications after QT autograft ACLR in pediatric patients (≤ 18 years old) were eligible for inclusion. Study demographics, patient demographics, reported outcomes, and complications were abstracted. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Descriptive statistics were presented when applicable, with data for heterogeneous outcomes presented in narrative summary fashion. RESULTS A total of 14 studies examining 596 patients (46.3% female), mean age 15.4 years, were included in this systematic review. Mean postoperative Lysholm scores ranged from 94.0 to 99.5. Mean postoperative IKDC subjective scores ranged from 75.9 to 94.0. Limb symmetry index ranged from 96.8 ± 10.4 to 100.4 ± 7.6% across multiple hop tests. Return to sports (RTS) rates ranged from 88.9 to 91.7%. Eleven studies reported postoperative complications, whereby 16 patients (4.8%) experienced contralateral complications and injuries. Forty-six patients (9.4%) experienced ipsilateral complications, including ten graft failures (2.5%) and two growth disturbances (0.6%). CONCLUSIONS QT autograft ACLR in the pediatric population retains the potential of regaining a preinjury level of knee stability, and yields promising postoperative function and rates of RTS, yielding comparable outcomes relative to HT autograft and the reference-standard BPTB ACLR that have previously been described in the literature. Moreover, use of the QT autograft is associated with low rates of postoperative complications, including graft failure and growth disturbances in this active and high-risk patient population in observational studies to date. Therefore, clinical equipoise exists to further appraise the influence of QT autograft on postoperative outcomes compared to aforementioned autograft options in a randomized control trial fashion. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Darius L Lameire
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Hassaan Abdel Khalik
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Abhilash Uddandam
- MacSports Research Program, McMaster University, Hamilton, ON, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
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Evaluation of Experimental and Clinical Efficacy on Surgical Debridement and Systemic Antibiotics Treatment for Early Knee Infection after Anterior Cruciate Ligament Reconstruction. Antimicrob Agents Chemother 2022; 66:e0011222. [PMID: 35499314 DOI: 10.1128/aac.00112-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Deep knee infection (DKI) after anterior cruciate ligament reconstruction (ACLR) is rare and challenging. The optimal treatment strategy for infection after ACLR remains controversial. This study aimed to investigate the optimal treatment for early infection after ACLR surgery. Rats with unilateral ACLR were injected with 3.0 × 105 colony forming units (CFU) of Staphylococcus aureus in the knee joint for 7 days. Next, with surgical debridement (SD) and/or 21 days of antimicrobial (systemic vancomycin and oral rifampicin [SVR]) therapy, rats were euthanatized and samples harvested. We evaluated signs of infection by general postoperative conditions, serum inflammatory markers, microbiological counting, knee radiographs, micro-computed tomography (micro-CT), histologic staining, and scanning electron microscopy (SEM). Clinically, the data from 12 patients who suffered from DKI after ACLR were analyzed retrospectively. The DKI rats treated with SVR showed better outcomes in general postoperative conditions, serum inflammatory markers, microbiological counting, biofilm on the interference screw and graft, radiographic signs of periarticular osseous destruction, and inflammatory reaction in the joint tissues than those with SD treatment, while the DKI rats with SD and SVR administration showed the best outcomes. Rats which received SD and SVR administration had their S. aureus contamination completely eradicated. All patients treated with SD & SVR or SVR alone had effectively controlled knee infections and achieved good knee function outcomes in the 6 months after treatment, but one patient developed more serious knee infections. Therefore, surgical debridement combined with systemic antibiotics treatment could effectively eliminate S. aureus contamination in the DKI rat model and in patients after ACLR without affecting knee function. Treatment with systemic antibiotics could also control early DKI, which would be especially applicable in patients who could not tolerate surgery.
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Haddad FS. A New Year and some good opportunities. Bone Joint J 2022; 104-B:1-2. [PMID: 34969268 DOI: 10.1302/0301-620x.104b1.bjj-2021-1674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Fares S Haddad
- University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK.,The Bone & Joint Journal, London, UK
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