"Doctor, What Happens After My Anterior Cruciate Ligament Reconstruction?"

The Principles of Knee Joint Preservation: Operative Treatment Strategies

➤ Joint alignment, meniscal status, and ligament stability are codependent factors involved in knee joint preservation, and any injury or imbalance can impact the knee articular cartilage status and can result in adverse clinical outcomes.➤ Cartilage preservation procedures in the knee will not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligamentous instability.➤ Lower-extremity varus or valgus malalignment is a risk factor for the failure of an anterior cruciate ligament (ACL) reconstruction. It represents an indication for a high tibial osteotomy or distal femoral osteotomy in the setting of failed ACL reconstruction, and may even be considered in patients who have an initial ACL injury and severe malalignment.➤ An elevated posterior tibial slope increases the risk of failure of ACL reconstruction, whereas a decreased posterior tibial slope increases the risk of failure of posterior cruciate ligament reconstruction.

Tibiofemoral contact and alignment in patients with anterior cruciate ligament rupture treated nonoperatively versus reconstruction : an upright, open MRI study

AIMS

Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction. This study uses standing MRI to investigate changes in contact area, contact centroid location, and tibiofemoral alignment between ACL-injured knees and healthy controls, to examine the effect of ACL reconstruction on these parameters.

METHODS

An upright, open MRI was used to directly measure tibiofemoral contact area, centroid location, and alignment in 18 individuals with unilateral ACL rupture within the last five years. Eight participants had been treated nonoperatively and ten had ACL reconstruction performed within one year of injury. All participants were high-functioning and had returned to sport or recreational activities. Healthy contralateral knees served as controls. Participants were imaged in a standing posture with knees fully extended.

RESULTS

Participants' mean age was 28.4 years (SD 7.3), the mean time since injury was 2.7 years (SD 1.6), and the mean International Knee Documentation Subjective Knee Form score was 84.4 (SD 13.5). ACL injury was associated with a 10% increase (p = 0.001) in contact area, controlling for compartment, sex, posture, age, body mass, and time since injury. ACL injury was associated with a 5.2% more posteriorly translated medial centroid (p = 0.001), equivalent to a 2.6 mm posterior translation on a representative tibia with mean posteroanterior width of 49.4 mm. Relative to the femur, the tibiae of ACL ruptured knees were 2.3 mm more anteriorly translated (p = 0.003) and 2.6° less externally rotated (p = 0.010) than healthy controls. ACL reconstruction was not associated with an improvement in any measure.

CONCLUSION

ACL rupture was associated with an increased contact area, posteriorly translated medial centroid, anterior tibial translation, and reduced tibial external rotation in full extension. These changes were present 2.7 years post-injury regardless of ACL reconstruction status. Cite this article: Bone Joint J 2021;103-B(9):1505-1513.

A Systematic Review of Basic Science and Animal Studies on the Use of Doxycycline to Reduce the Risk of Posttraumatic Osteoarthritis After Anterior Cruciate Ligament Rupture/Transection

BACKGROUND

Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common.

PURPOSE

To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was "doxycycline cruciate ligament." Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group.

RESULTS

Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study.

CONCLUSION

Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.

Whether sutures reduce the graft laceration caused by interference screw in anterior cruciate ligament reconstruction? A biomechanical study in vitro

Background

Interference screw is commonly used for graft fixation in anterior cruciate ligament (ACL) reconstruction. However, previous studies had reported that the insertion of interference screws significantly caused graft laceration. The purposes of this study were to (1) quantitatively evaluate the graft laceration from one single insertion of PEEK interference screws; and (2) determine whether different types of sutures reduced the graft laceration after one single insertion of interference screws in ACL reconstruction.

Methods

The in-vitro ACL reconstruction model was created using porcine tibias and bovine extensor digitorum tendons of bovine hind limbs. The ends of grafts were sutured using three different sutures, including the bioabsorbable, Ethibond and ultra-high molecular weight polyethylene (UHMWPE) sutures. Poly-ether-ether-ketone (PEEK) interference screws were used for tibial fixation. This study was divided into five groups (n = 10 in each group): the non-fixed group, the non-sutured group, the absorbable suture group, the Ethibond suture group and the UHMWPE suture group. Biomechanical tests were performed using the mode of pull-to-failure loading tests at 10 mm/min. Tensile stiffness (newtons per millimeter), energy absorbed to failure (in joules) and ultimate load (newtons) were recorded for analysis.

Results

All prepared tendons and bone specimens showed similar characteristics (length, weight, and pre-tension of the tendons, tibial bone mineral density) among all groups (P > 0.05). The biomechanical tests demonstrated that PEEK interference screws significantly caused the graft laceration (P < 0.05). However, all sutures (the bioabsorbable, Ethibond and UHMWPE sutures) did not reduce the graft laceration in ACL reconstruction (P > 0.05).

Conclusions

Our biomechanical study suggested that the ultimate failure load of grafts was reduced of approximately 25 % after one single insertion of a PEEK interference screw in ACL reconstruction. Suturing the ends of the grafts using different sutures (absorbable, Ethibond and UHMWPE sutures) did not decrease the graft laceration caused by interference screws.

Conversion rates and timing to total knee arthroplasty following anterior cruciate ligament reconstruction: a US population-based study

PURPOSE

To define the rate of subsequent TKA following ACLR in a large US cohort and to identify factors that influence the risk of later undergoing TKA after ACLR.

METHODS

The California's Office of Statewide Health Planning and Development (OSHPD) database was queried from 2000 to 2014 to identify patients who underwent primary ACLR (ACL group). An age-and gender-matched cohort that underwent appendectomy was selected as the control group. The cumulative incidence of TKA was calculated and ten-year survival was investigated using Kaplan-Meier analysis with failure defined as conversion to arthroplasty. Univariate and multivariate analyses were performed to explore the risk factors for conversion to TKA following ACLR.

RESULTS

A total of 100,580 ACLR patients (mean age 34.48 years, 66.1%male) were matched to 100,545 patients from the general population. The ACL cohort had 1374 knee arthroplasty events; conversion rate was 0.71% at 2-year follow-up, 2.04% at 5-year follow-up, and 4.86% at 10-year follow-up. This conversion rate was higher than that of the control group at all time points, with an odds ratio of 3.44 (p<0.001) at 10-year follow-up. Decreasing survivorship following ACLR was observed with increasing age, female gender, and worker's compensation insurance, while increased survivorship was found in patients of Hispanic and Asian Pacific Islander racial heritage and those who underwent concomitant meniscal repair.

CONCLUSIONS

In this US statewide study, the rate of TKA after ACLR is higher than reported elsewhere, with significantly increased odds when compared to a control group. Age, gender, concomitant knee procedures and other socioeconomic factors influence the rate of conversion to TKA following ACLR.

Do Older Skiers Have Worse Outcomes After Anterior Cruciate Ligament Reconstruction Compared With Non-Skiers or Younger Skiers?

Background:

There remains a paucity of literature comparing clinical outcomes after anterior cruciate ligament reconstruction (ACLR) between skiers and non-skiers, particularly in older patient populations.

Purpose:

To compare clinical outcomes after ACLR between skiers and non-skiers, with a subanalysis based on age.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A nested cohort of 128 patients from the Multicenter Orthopaedic Outcomes Network cohort who underwent primary ACLR completed a series of patient-reported outcomes pre- and postoperatively at 2 and 6 years including the Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, and subjective International Knee Documentation Committee (IKDC) score. Data including patient sex, age at surgery, graft type, and sport participation were analyzed. Patients were stratified by participation in skiing (skiers vs non-skiers) and by age subgroup (≤29, 30-39, and ≥40 years). Student t tests and analysis of variance were used to compare mean improvement between pre- and postoperative outcomes.

Results:

A total of 44 skiers (female, 59.1%; age, 35.3 ± 11.6 years) and 84 non-skiers (female, 34.5%; age, 27.7 ± 11.3 years) were included. ACLR was performed using allograft in 36.7% (22 skiers, 25 non-skiers), autograft in 58.6% (19 skiers, 56 non-skiers), or hybrid autograft-allograft in 4.7% (3 skiers, 3 non-skiers). Although both non-skiers and skiers demonstrated improvements in outcomes from baseline to 2 and 6 years, non-skiers demonstrated significantly less overall improvement from 2 to 6 years postoperatively in KOOS Symptoms (P = .01), KOOS Pain (P = .002), and KOOS Activities of Daily Living (P = .03) subscales compared with skiers. There were 15 skiers who were 29 years or younger (34.1%), 14 skiers between 30 and 39 years (31.8%), and 15 skiers 40 years or older (34.1%). Skiers 40 years and older demonstrated significantly greater mean improvement in KOOS Symptoms (P = .02) and KOOS Quality of Life (QoL) (P = .01) subscales at 2 years and KOOS QoL (P = .01) at 6 years postoperatively compared with skiers 29 years or younger.

Conclusion:

Compared with non-skiers, skiers demonstrated significantly greater mean improvements in KOOS scores between 2 and 6 years after ACLR. In addition, skiers 40 years or older showed greater improvement in KOOS QoL compared with younger skiers. This information can be used to counsel skiers, especially those older than 40 years, as to their expected outcomes after ACLR.