Anterior Cruciate Ligament Reconstruction in Patients Over 40 Years Old Shows Low Failure Rates: A Systematic Review

Purpose

To review the literature reporting on complications and failure rates after primary anterior cruciate ligament reconstruction (ACLR) in patients ≥40 years.

Methods

This was a secondary analysis from a prior systematic review of the MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases on studies evaluating clinical outcomes in ACLR patients ≥40 years. Studies were included based on the following criteria: English-language studies reporting on postoperative complications and/or ACLR failure rates in patients ≥40 years. Case reports, technical notes, studies with duplicate reporting of patient cohorts, or studies using publicly available registry data were excluded. ACLR failure definitions, failure rates, graft rupture rates, revision ACLR and non-ACLR revision rates, and complication rates were recorded.

Results

Twenty-one studies were included following full-text review. Autografts were used in 89.0% of cases. Definitions for ACLR failure varied, ranging from (1) revision ACLR, (2) graft rupture, (3) clinical examination of increased knee laxity, and (4) postoperative arthrofibrosis requiring an additional surgery. The median ACLR failure rate was 5.0% (range, 0%-12.1%) among the 9 studies reporting this outcome, with only 4 of the studies providing explicit definitions of failure. The median ACLR revision surgery, graft rupture, and non-ACLR revision surgery rates were 0% (range, 0%-7.7%), 2.7% (range, 0%-9.1%), and 7.2% (range 0%-34.4%), respectively. Commonly reported complications included pain (range, 0%-14.0%), stiffness (range, 0%-12.7%), hematoma (range, 2.5%-8.8%), neurovascular (range, 0%-41.7%), and undefined (range, 0%-13.8%).

Conclusions

ACLR in patients over 40 years old shows low failure rates.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

After an anterior cruciate ligament (ACL) injury, people need secondary prevention strategies to identify osteoarthritis at its earliest stages so that interventions can be implemented to halt or slow the progression toward its long-term burden. The Osteoarthritis Action Alliance formed an interdisciplinary Secondary Prevention Task Group to develop a consensus on recommendations to provide clinicians with secondary prevention strategies that are intended to reduce the risk of osteoarthritis after a person has an ACL injury. The group achieved consensus on 15 out of 16 recommendations that address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. We hope this statement raises awareness among clinicians and researchers on the importance of taking steps to mitigate the risk of osteoarthritis after an ACL injury.

Operative Management for Anterior Cruciate Ligament Injury in Patients Over 40 Years Old Yields Increased Clinical Outcome: A Systematic Review

PURPOSE

To evaluate outcomes of anterior cruciate ligament (ACL) rupture in patients ≥40 years treated nonoperatively or with ACL reconstruction (ACLR).

METHODS

A review of MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases from inception to June 1, 2021, was performed to identify randomized controlled trials, prospective or retrospective cohorts, case controls, or case series that met the following criteria: English-language studies reporting at least one subjective and/or objective outcome measure in ACL rupture patients ≥40 years treated nonoperatively or by ACLR. No limits were placed on graft type, time-to-surgery/follow-up, or concomitant procedures. Variability in patient-reported outcome scores, including subjective IKDC score, Lysholm score, Tegner activity score, and Knee Injury and Osteoarthritis Outcome Score, was assessed to evaluate the utility of applying previously established clinically meaningful thresholds to pooled outcome data.

RESULTS

12,605 citations were identified using screening criteria. Sixty studies satisfied criteria following full-text review. As previous systematic reviews reported on earlier literature evaluating ACLR outcomes in patients ≥40 years, studies in this review were limited to include only those published in the last 10 years (40 studies). An additional 16 studies were excluded based on aims of the review not identified during initial screen. Although preoperative to postoperative population-based improvements in Lysholm score, Tegner score, and IKDC score surpassed minimal clinically important differences (MCID) in at least 50% of studies, the variability present in the pooled data may limit its application. No studies evaluated nonoperative outcomes.

CONCLUSIONS

Evidence supports operative management in patients ≥40 years, as studies generally demonstrated preoperative to postoperative improvements in clinical outcomes based on population-level changes. However, application of patient-level clinically relevant thresholds to pooled outcome data should be undertaken with caution as reporting of population-based outcome scores may not accurately reflect changes in individual patients.

LEVEL OF EVIDENCE

Systematic review, IV.

Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement

CONTEXT

The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury.

OBJECTIVE

Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps.

DESIGN

Consensus process.

SETTING

Virtual video conference calls and online voting.

PATIENTS OR OTHER PARTICIPANTS

The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds.

MAIN OUTCOME MEASURE(S)

The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation.

RESULTS

The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models.

CONCLUSIONS

This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.

High School Athletic Directors Report Poor Compliance With Concussion Reporting and Medical Clearance in Massachusetts

Purpose

To assess statewide prevalence of medical access, concussion reporting, and concussion clearance rates of high school athletic departments in Massachusetts after the implementation of state-wide concussion legislation.

Methods

A random sample of 50 athletic directors (ADs) from Massachusetts high schools with an enrollment of >150 students was selected. A 10-minute electronic survey about access to athletic trainers and physicians, and concussion reporting and clearance practices was administered. Responses were anonymous.

Results

The response rate was 80% (n = 40). In total, 90% of respondents were male. Median age and experience of respondents was 52 years old and 10 years, respectively. The median school size was 637 students, represented from all Massachusetts geographic athletic districts. ADs disclosed that on average, 12% (95% confidence interval 7%-20%) of concussions go unreported at their schools. In total, 16% of respondents reported that at least 1 in 4 of concussed athletes at their school returned to play without appropriate medical clearance, and 5% of ADs reported that not all of their coaches had undergone any form of concussion training. Overall, 55% of high schools do not have access to a full-time athletic trainer and 50% do not have a team physician; 20% have affiliations with an orthopaedic surgeon and 8% with a neurologist.

Conclusions

Despite new regulations in Massachusetts, high school ADs report concussion reporting and clearance that are less than 100%. Less than one half of all Massachusetts high schools report access to a full-time athletic trainer or formal relationship with a school physician.

Clinical Relevance

Investigating compliance with Massachusetts school athletics safety regulations could help identify a need for reform of policies designed to help schools keep student athletes safer in situations where a concussion may have occurred.

Treatment Outcomes in Septic Arthritis of the Foot and Ankle in People Who Inject Drugs

Background:

Although injection drug use (IDU) is a known risk factor for septic arthritis (SA) of the foot and ankle (F&A), disease and hospitalization outcomes are poorly characterized. We evaluated national trends, demographic characteristics, and hospitalization outcomes of SA of the F&A in people who inject drugs vs those who do not.

Methods:

Using the Nationwide Inpatient Sample, we identified all patients aged 15-64 with a principal discharge diagnosis of SA of the F&A from 2000 to 2013 and evaluated if they were related or unrelated to IDU. We assessed differences in demographic characteristics and in-hospital outcomes in these groups.

Results:

From 2000 to 2013, there were an estimated 14,198 hospitalizations for SA of the F&A in the United States, and 11% were associated with IDU (SA-IDU). Compared to SA unrelated to IDU, people with SA-IDU were significantly more likely to be younger, black, and have Medicaid or no insurance. People with SA-IDU were significantly more likely to leave against medical advice (9.7% vs 1.4%, P < .001), have a longer length of stay (9.2 vs 6.8 days, P < .001), and incur increased hospital charges ($58 628 vs $38 876, P = .005). People with SA-IDU were significantly less likely to receive an arthroscopy (1.5% vs 6.5%, P < .001) or arthrotomy (2.2% vs 11.0%, P < .001) of the foot.

Conclusion:

People with SA-IDU of the F&A had suboptimal hospitalization outcomes with greater costs. Recognizing risk factors and proactively addressing potential complications of substance use disorder in the hospital should be prioritized by the orthopedic community.

Level of Evidence:

Level III, retrospective cohort study.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners

BACKGROUND

Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running.

HYPOTHESIS

Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy.

RESULTS

A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively.

CONCLUSION

Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery.

CLINICAL RELEVANCE

Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Intramedullary cannulated headless screw fixation of a comminuted subcapital metacarpal fracture: case report

This case report describes an alternative technique for the fixation of displaced comminuted subcapital fractures of the metacarpal with limited distal bone stock. Using a cannulated headless screw as an intramedullary device placed through the articular surface, we were able to secure proximal and distal bone purchase without excessive soft tissue stripping or disruption of the fracture hematoma. This technique allows early rehabilitation, and our patient went on to uneventful healing with excellent functional results.

The effect of H-2 compatibility on pancreatic beta cell survival in the nonobese diabetic mouse

The effect of major histocompatibility (MHC) antigens on the survival of newborn pancreatic iso and allografts was assessed in the nonobese diabetic (NOD) mouse, which develops a spontaneous autoimmune diabetes. The NOD mouse (H-2Kd,Db) rejects skin allografts from CBA (H-2k) within a 12-day period, indicating normal immune function toward alloantigens. A pancreatic allograft into the NOD mouse represents a presumed first-set allogeneic response, as well as a possible second-set immune response to islets. To assess the effect of donor H-2 antigen and the influence of autoimmune disease on pancreatic graft survival, newborn pancreata from various strains of mice were transplanted into diabetic NOD mice treated with 40 mg/kg/day cyclosporine (CsA) that prevented skin allograft rejection. The grafts were then harvested at day 10 to histologically assess the graft viability. CBA pancreatic grafts, incompatible at all MHC loci, showed the least lymphocytic infiltration, and good donor beta cell survival. Furthermore, CBA newborn pancreata under appropriate conditions were able to cure or improve the diabetic condition in 3/6 NOD mice. In the graft sharing class I MHC antigens, lymphocytic infiltration was significantly increased, while the donor beta cell number clearly decreased. The intensity of the graft destruction was intermediate in C57BL/6 allografts sharing H-2Db antigen, and strongest in BALB/c allografts sharing H-2Kd and in NOD isografts. The results indicate that in diabetic NOD mice the CsA dose controlling allograft rejection is incapable of controlling antiislet immunity. This antiislet immunity appears to exert its effect in an H-2-restricted manner. These findings may have important implications for the transplantation of pancreatic tissue in treating type I diabetes in humans.