Epidemiology of Recurrent Anterior Cruciate Ligament Injuries in National Collegiate Athletic Association Sports: The Injury Surveillance Program, 2004-2014

Cutting Movement Assessment Scores during Anticipated and Unanticipated 90-Degree Sidestep Cutting Manoeuvres within Female Professional Footballers

Background: ACL injuries present a considerable burden in female football, with highest incidence being related to change of direction (COD) tasks. The aim was to identify if differences existed between an anticipated and unanticipated 90-degree cutting task using the CMAS. Methods: 11 female professional footballers completed twelve 90-degree COD tasks (6 anticipated, 6 unanticipated). Participants performed the unanticipated task in response to a moving football at the start of their acceleration. All COD tasks were filmed and assessed using the CMAS. Results: The CMAS score for the unanticipated COD task (5.53 ± 0.71) was significantly larger than for the anticipated COD task (3.55 ± 0.85, p < 0.012). Excellent intra-rater reliability was observed (ICC = 0.97) for analysis of CMAS scores. Conclusions: Female footballers in this sample demonstrated a greater CMAS score during an unanticipated COD task compared to an anticipated COD task. These athletes are therefore more likely to display ‘high-risk’ movement patterns, thus greater risk of injury. Reacting to a sporting implement, such as a moving ball, may be a contributing factor to these results. Further research into unanticipated COD tasks should be considered to determine why these differences occur and the impact of anticipation on performance.

Returning Athletes to Sports Following Anterior Cruciate Ligament Tears

PURPOSE OF REVIEW

The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population.

RECENT FINDINGS

Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.

Diagnostic Value of Lachmeter in Measuring Anterior Tibia Translation on Post-Anterior Cruciate Ligament Tear Reconstruction Compared to CT Scan

BACKGROUND: Anterior translation of the tibia (ATT) is a secondary sign of an anterior cruciate ligament (ACL) tear. With advances in technology, new tools such as the Lachmeter are expected to replace computed tomography scanning (CT scan) in measuring the ATT. AIM: This study aims to determine the diagnostic validity of the Lachmeter in measuring the ATT 6–12 months after ACL tear reconstruction. MATERIALS AND METHODS: A retrospective diagnostic test with a Lachmeter was used to measure ATT in patients 6–12 months after ACL tear reconstruction, compared with the gold standard CT scan and using a consecutive sampling technique. The optimal cutoff value of ATT was determined with Lachmeter afterwards. Statistical Package for the Social Sciences version 21.0 was used for the data analysis. RESULTS: There are 28 persons with a positive ATT (≥ 5 mm) and four people with a negative ATT (<5 mm) measured using CT scan out of 32 samples. The optimal cutoff of ATT with Lachmeter is ≥7.28 mm (Area under curve = 0.88, 95% CI, 0.67–1.00 and p = 0.004) with a sensitivity of 84.62%, specificity 83.33%, positive predictive value 95.65%, negative predictive value 55.56%, positive likelihood ratio (LR) 5.08, negative LR 0.18, and 84.38% accuracy. CONCLUSION: Lachmeter is a new tool for determining ATT that is highly efficient and easy to use. With good sensitivity and specificity values, this new tool has been proven to be very good at measuring ATT compared to CT scan as the gold standard.

Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial

PURPOSE

To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts.

METHODS

A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft.

RESULTS

Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P = .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P = .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P = .02).

CONCLUSIONS

Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point.

LEVEL OF EVIDENCE

I, randomized control trial.

A Systematic Review and Meta-Analysis of Strength Recovery Measured by Isokinetic Dynamometer Technology after Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autografts vs. Hamstring Tendon Autografts or Patellar Tendon Autografts

Background: This systematic review and meta-analysis compared the isokinetic strength of the muscular knee joint between quadriceps tendon autografts (QTAs) and hamstring tendon autografts (HTAs) or patellar tendon autografts (PTAs) after anterior cruciate ligament (ACL) reconstruction by determining the isokinetic angular velocity and follow-up time points. The functional outcomes and knee stability at the same time points were also compared using isokinetic technology. Methods: Two independent reviewers searched the Medline (via PubMed search engine), Scopus, Web of Science and Cochrane Library databases to include full text comparative studies that assessed isokinetic strength test following ACL reconstruction. The DerSimonian and Laird method was used. Results: In total, ten studies were included; seven compared studies QTAs vs. HTAs, and three compared QTAs vs. PTAs. Five studies were included in the meta-analysis. Isokinetic strength data were reported 3, 6, 12 and 24 months after ACL reconstruction. Conclusions: The QTAs showed better and significant results with knee flexion compared with HTAs, similar results to PTAs at 6 and 12 months. While HTAs showed better and significant results with knee extension at 6 months and similar results at 12 months compared to QTAs. Furthermore, a standardized isokinetic strength test must be followed to achieve a more specific conclusion and better clinical comparison among participants.

Anterior Cruciate Ligament Length in Pediatric Populations: An MRI Study

Background:

As regards anterior cruciate ligament (ACL) reconstruction (ACLR), graft diameter has been identified as a major predictor of failure in skeletally mature patients; however, this topic has not been well-studied in the higher risk pediatric population. Hamstring tendon autograft configuration can be adjusted to increase graft diameter, but tendon length must be adequate for ACLR. Historical parameters of expected tendon length have been variable, and no study has quantified pediatric ACL morphology with other osseous parameters.

Purpose:

To develop magnetic resonance imaging (MRI)–derived predictors of native ACL graft length in pediatric patients so as to enhance preoperative planning for graft preparation in this skeletally immature patient population.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

MRI scans of 110 patients were included (64 girls, 46 boys; median age, 10 years; range, 1-13 years). Patients with musculoskeletal diseases or prior knee injuries were excluded. The following measurements were taken on MRI: ACL length; sagittal and coronal ACL inclination; intercondylar notch width and inclination; and femoral condyle depth and width. Associations between these measurements and patient sex and age were investigated. Univariate linear regression and multivariable regression models were created for each radiographic ACL measure to compare R².

Results:

Female ACL length was most strongly associated with the depth of the lateral femoral condyle as viewed in the sagittal plane (R² = 0.65; P < .001). Other statistically significant covariates of interest included distal femoral condylar width, age, and coronal notch width (P < .05). For males, the ACL length was most strongly associated with the distal femoral condyle width as viewed in the coronal plane (R² = 0.70; P < .001). Other statistically significant covariates of interest for male ACL lengths were lateral femoral condyle depth, age, and coronal notch width (P < .05).

Conclusion:

In pediatric populations, femoral condylar depth/width and patient age may be valuable in assessing ACL size and determining appropriate graft dimensions and configuration for ACLRs. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in this high-risk group.

Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

PURPOSE OF REVIEW

Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.

RECENT FINDINGS

Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Preoperative MRI Assessment of Hamstring Tendons to Predict the Quadruple Hamstring Graft Diameter in Anterior Cruciate Ligament Reconstruction

Introduction

The cross-sectional area (CSA) and length of an individual's hamstring tendons are both variable, making it challenging for the operating surgeon to generate an ideal size graft during arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. If we can predict the hamstring graft diameter using MRI (a routine radiological investigation used to diagnose knee pathology), this information, if obtained before surgery rather than after the harvesting of the hamstring tendons, may influence the graft choice and allow us to successfully perform ACL reconstruction with sufficient graft diameter.

Aims

The aims of this study were to determine the reliability and accuracy of 3T MRI in predicting quadruple hamstring graft diameter for ACL reconstruction, to determine the statistical correlation between the CSA of hamstring tendons on MRI and intraoperative quadruple hamstring graft diameter, and to find out the minimum CSA of hamstring tendons (ST+GR) required for an 8 mm quadruple hamstring graft diameter.

Methods

This prospective diagnostic study included 50 patients diagnosed with complete ACL rupture. On MRI, we assessed the CSA of the semitendinosus and gracilis tendons at two levels: one at the joint line and the other at the level where the anteroposterior (AP) diameter of the medial femoral condyle is longest. The quadruple ST+GR graft was passed through 0.5 mm increments of holes in the block (Biotek (Winooski, Vermont) or Smith & Nephew, London, United Kingdom) intraoperatively, and the diameter of the hole that permitted smooth passage of the whole graft was taken as the quadruple graft diameter. The cutoff CSA required for a graft of sufficient size was calculated using simple logistic regression analysis. The correlation between CSA measurements on MRI and intraoperative quadruple hamstring graft diameter was determined using Pearson's rank correlation coefficient.

Results

The mean ST+GR CSA on MRI was 18.9 mm², the minimum CSA was 14.45 mm², and the maximum CSA was 23.8 mm². Pearson's correlation between the intraoperative quadruple hamstring graft diameter (mm) and ST+GR CSA on MRI was 0.838. The minimum ST+GR CSA required for an 8 mm quadruple hamstring graft diameter is 17.5 mm².

Conclusion

A strong statistical correlation between ST+GR CSA on MRI and intraoperative quadruple hamstring graft diameter was found (Pearson's correlation = 0.838, p-value = 0.000). Thus, MRI is a reliable radiological investigation that can be used to predict the quadruple hamstring graft diameter. This method can help orthopedic surgeons successfully perform ACL reconstruction surgery without any graft complications.  

Satisfactory patient-reported outcomes at 5 years following primary repair with suture tape augmentation for proximal anterior cruciate ligament tears

PURPOSE

An enhanced understanding of anterior cruciate ligament (ACL) healing and advancements in arthroscopic instrumentation has resulted in a renewed interest in ACL repair. Augmentation of a ligament repair with suture tape reinforces the ligament and acts as a secondary stabilizer. This study assesses the 5-year patient-reported outcomes of primary repair with suture tape augmentation for proximal ACL tears.

METHODS

Thirty-seven consecutive patients undergoing ACL repair with suture tape augmentation for an acute proximal rupture were prospectively followed up for a minimum of 5 years. Patients with midsubstance and distal ruptures, poor ACL tissue quality, retracted ACL remnants and multiligament injuries were excluded. Patient-reported outcome measures were collated using the Knee Injury and Osteoarthritis Outcomes Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12) and the Marx Activity Scale. Patients with a re-rupture were identified.

RESULTS

Three patients were lost to follow-up leaving 34 patients in the final analysis (91.9%). The mean KOOS at 5 years was 88.5 (SD 13.8) which improved significantly from 48.7 (SD 18.3) preoperatively (p < 0.01). The VAS score improved from 2.3 (SD 1.7) to 1.0 (SD 1.5) and the VR-12 score improved from 35.9 (SD 10.3) to 52.4 (SD 5.9) at 5 years (p < 0.01). However, the Marx activity scale decreased from 12.4 (SD 3.4) pre-injury to 7.3 (SD 5.2) at 5 years (p = 0.02). Six patients had a re-rupture (17.6%) and have since undergone a conventional ACL reconstruction for their revision surgery with no issues since then. These patients were found to be younger and have higher initial Marx activity scores than the rest of the cohort (p < 0.05).

CONCLUSION

Primary repair with suture tape augmentation for proximal ACL tears demonstrates satisfactory outcomes in 28 patients (82.4%) at 5-year follow-up. Six patients sustained a re-rupture and have no ongoing problems following treatment with a conventional ACL reconstruction. These patients were significantly younger and had higher initial Marx activity scores.

LEVEL OF EVIDENCE

Level IV.

Reliability and Repeatability of ACL Quick Check®: A Methodology for on Field Lower Limb Joint Kinematics and Kinetics Assessment in Sport Applications

Anterior cruciate ligament (ACL) lesion represents one of the most dramatic sport injuries. Even though clinical screenings aiming at identifying subjects at risk of injuries are gaining popularity, the use of sophisticated equipment still represents a barrier towards their widespread use. This study aimed to test both reliability and repeatability of a new methodology to assess lower limb joints kinematics and kinetics directly on field with the aid of video cameras and plantar pressure insoles. Ten athletes and one case study (post ACL surgery) were assessed in a gait laboratory, while performing double leg squats, through the simultaneous acquisition of stereophotogrammetry, force plates, commercial video cameras and plantar pressure insoles. Different sources of errors were investigated and both reliability and repeatability analysis performed. Minimum and maximum RMSE values of 0.74% (right knee joint center trajectory) and 64.51%, respectively (ankle dorsi-plantarflexion moment), were detected. Excellent to good correlation was found for the majority of the measures, even though very poor and inverse between-trials correlation was found on a restricted number of trials especially for the ankle dorsi-plantarflexion moment. These findings could be used in combination with already available screening tools in order to provide more repeatable results.

Current Concepts in Anterior Tibial Closing Wedge Osteotomies for Anterior Cruciate Ligament Deficient Knees

PURPOSE OF REVIEW

Anterior closing wedge osteotomies (ACWO) are utilized to better restore knee stability and in situ forces on anterior cruciate ligament (ACL) grafts during ACL revision reconstruction while reducing the risk of retearing and subsequent revision procedures. However, clinical outcomes following ACWO for patients undergoing ACL reconstruction remains largely limited. The purpose of this review was to provide a concise overview of the current literature on indication, techniques, and outcomes following ACWO in ACL-deficient patients undergoing primary or revision ACL reconstruction while discussing the authors' preferred technique to ACWO during a staged ACL revision reconstruction.

RECENT FINDINGS

Currently available clinical studies and case reports have demonstrated ACWO to improve knee stability and outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction with low complication rates. The ACWO provides an adjunct surgical option to decrease graft failure while improving knee stability and post-surgical outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction. Further investigations are warranted to validate currently reported outcomes following ACWO in higher-level clinical studies with longer-term follow-up.

Quadricep ACL Reconstruction Techniques and Outcomes: an Updated Scoping Review of the Quadricep Tendon

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date summary on the most recent literature examining techniques and outcomes in anterior cruciate ligament (ACL) reconstruction using quadriceps tendon (QT) which will enable surgeons to make well informed evidence-based decisions when choosing a particular graft option and technique in ACL reconstruction.

RECENT FINDINGS

Several RCTs and systematic reviews have been published recently on this topic, and overall, there were no differences found between the QT, HT, and BPTB groups in patient-reported outcomes, stability testing, or graft re-rupture rates. In terms of strength testing, the QT group did have inferior knee extensor strength on isokinetic testing when compared to the HT group, whereas the HT group had inferior knee flexor strength compared to the QT group. No differences were found on strength testing between the QT and BPTB groups. Currently, two large RCTs, the Stability2 and SQuASH trials, are ongoing examining the effectiveness of the QT vs BPTB with or without LET and QT vs HT in the pediatric population which will help shed further light on the effectiveness of the QT as a graft choice in ACL reconstruction. The findings of this scoping review demonstrate that the QT is an excellent graft option in ACL reconstruction both in the primary and revision settings, among adult and pediatric populations. This review provides surgeons with further assurance when selecting QT autograft in ACL reconstruction.

Medial-lateral hip positions predicted kinetic asymmetries during double-leg squats in collegiate athletes following anterior cruciate ligament reconstruction

ACL re-injury rates are high in collegiate athletes, and double-leg squats have been used as a functional weight-bearing exercise to strengthen the lower extremities and assess bilateral kinetic asymmetries. The primary purpose was to quantify the correlations between medial-lateral shoulder/hip positions and lateral bending angles and bilateral asymmetries in vertical ground reaction forces (VGRF) and knee extension moments during double-leg squats in collegiate athletes at two assessments following anterior cruciate ligament reconstruction (ACLR). Seventeen National Collegiate Athletic Association Division I athletes performed double-leg squats between 0 and 6 months and/or between 6 and 12 months following their ACLR while kinematic and kinetic data were collected. Medial-lateral shoulder positions strongly and significantly correlated with VGRF asymmetries at both assessments (p ≤ 0.007, r ≥ 0.68). Medial-lateral hip positions strongly and significantly correlated with VGRF asymmetries and knee moment asymmetries at both assessments (p ≤ 0.018, r ≥ 0.62). Additionally, participants demonstrated decreased VGRF asymmetries and knee moment asymmetries, more neutral shoulder and hip positions, and increased knee moments for the injured leg at the second assessment compared to the first assessment with large effect sizes (p ≤ 0.008, Cohen's d ≥ 1.06). In conclusion, medial-lateral hip positions correlated and predicted VGRF and knee moment asymmetries during double-leg squats in collegiate athletes at two assessments (0-6 and 6-12 months) following ACLR. The bilateral asymmetries support the need for an individual approach for kinetic asymmetry assessments. A commercially available camera can be utilized as a low-cost and convenient tool to monitor and potentially train bilateral kinetic symmetries during double-leg squats in patients following ACLR.

Current concepts in graft selection for anterior cruciate ligament reconstruction

Graft selection for anterior cruciate ligament reconstruction (ACLR) is important for optimizing post-operative rehabilitation, facilitating return to full sporting function and reducing the risk of complications.The most commonly used grafts for ACLR include hamstring tendon autografts, bone-patellar tendon-bone autografts, quadriceps tendon autografts, allografts and synthetic grafts.This instructional review explores the existing literature on clinical outcomes with these different graft types for ACLR and provides an evidence-based approach for graft selection in ACLR.The existing evidence on the use of extra-articular tenodesis to provide additional rotational stability during ACLR is also revisited. Cite this article: EFORT Open Rev 2021;6:808-815. DOI: 10.1302/2058-5241.6.210023.

Characterization of Rookie Season Injury and Illness and Career Longevity Among National Basketball Association Players

IMPORTANCE

There is limited research investigating injury and illness among professional basketball players during their rookie season. By improving the understanding of injury incidence and risk specific to rookie players, sports medicine clinicians may be able to further individualize injury mitigation programs that address the unique needs of rookie players.

OBJECTIVE

To compare incidence and rate ratio (RR) of injury and illness among professional National Basketball Association (NBA) players in their rookie season with veteran players and to explore the association of sustaining an injury rookie season with career longevity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used an online data repository and extracted publicly available data about NBA players between the 2007 and 2008 season to the 2018 and 2019 season. Available data for initial injury and all subsequent injuries were extracted during this time frame.

EXPOSURES

Injury and illness based on injury status during the rookie season of professional NBA players.

MAIN OUTCOMES AND MEASURES

Injury and illness incidence and RR. Association of injury during the rookie season with career longevity was assessed via Poisson regressions.

RESULTS

Of the 12 basketball seasons analyzed, 904 NBA players were included (mean [SD] age, 24.6 [3.9] years; body mass index, 24.8 [1.8]). The injury and illness incidence for rookie players was 14.28 per 1000 athlete game exposures (AGEs). Among all body regions, ankle injuries had the greatest injury incidence among players injured during their rookie season (3.17 [95% CI, 3.15-3.19] per 1000 AGEs). Rookie athletes demonstrated higher RR compared with veterans across multiple regions of the body (ankle: 1.32; 95% CI, 1.12 to 1.52; foot/toe: 1.29; 95% CI, 0.97 to 1.61; shoulder/arm/elbow: 1.43; 95% CI, 1.10 to 1.77; head/neck: 1.21; 95% CI, 0.61 to 1.81; concussions: 2.39; 95% CI, 1.89 to 2.90; illness: 1.14; 95% CI, 0.87 to 1.40), and demonstrated a higher rate of initial injuries compared with veteran players (1.41; 95% CI, 1.29 to 1.53). Players who sustained an injury rookie season demonstrated an unadjusted decrease in total seasons played (-0.4 [95% CI, -0.5 to -0.3] log years; P < .001), but this decrease was not observed within adjusted analysis (0.1 [95% CI, -0.1 to 0.2] log years; P = .36).

CONCLUSIONS AND RELEVANCE

In this study, rookie athletes demonstrated the highest injury incidence at the ankle and increased RR across multiple regions. These findings may reflect differences in preseason conditioning or load variables impacting rookie athletes and warrant further investigation. Future research is needed to determine the association of cumulative injury burden vs a singular injury event on career longevity.

A comparison of kinematic demands placed on the knee and hip during two ACL return-to-sport screening maneuvers and an agility test

OBJECTIVES

This study's purpose was to compare the kinematic demands placed on the knee and the hip during various biomechanical tests.

DESIGN

Retrospective cross-sectional design.

SETTING

A university research laboratory.

PARTICIPANTS

The study sample consisted of 70 NCAA Division I female athletes.

MAIN OUTCOME MEASURES

During the performance of three test maneuvers, a drop vertical jump (DVJ), single leg cross over hop (COH) and modified T-test (AT), the hip and knee joint angles at maximum knee valgus were obtained from marker displacement data collected using a 20-camera motion analysis system. A linear mixed model was used to compare the effect of test on joint angle.

RESULTS

A significant difference (p < 0.001) in the frontal and sagittal plane position of the knee and hip was noted between the DVJ, COH, and AT tests at maximum knee valgus.

CONCLUSIONS

The DVJ, COH, and AT maneuvers do not appear to place the same kinematic stress on the knee, supporting the need for the development of return to sport tests that mimic on field demands.

High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study

Background

Studies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce.

Aim

To investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR.

Study design

Prospective cohort study.

Setting

Men’s professional football.

Methods

118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury.

Results

Median follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR.

Conclusions

Almost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.

Physeal-sparing posteromedial portal approach reduced distance between guide pin and neurovascular structures

PURPOSE

To compare a femoral physeal sparing anterior cruciate ligament (ACL) reconstruction technique utilizing a posteromedial portal to traditional transphyseal techniques with regards to anatomic tunnel positioning and proximity to important neurovascular structures.

METHODS

Eight cadaveric knees were obtained for the study. Femoral tunnel guide pins were placed utilizing four different techniques: accessory anterior medial portal, posteromedial portal, trans-tibial, and figure-4 methods. The knees were then dissected and the following measurements taken: distance of each pin to the saphenous and peroneal nerve, popliteus tendon, neurovascular bundle, femoral ACL footprint and articular cartilage, and the angle of the guide pin entering the lateral femoral condyle. Fluoroscopic imaging was taken to determine the disruption of the physeal scar.

RESULTS

Posteromedial portal guide pin was significantly closer to the neurovascular bundle, popliteal tendon and saphenous nerve when compared to the other 3 techniques, but was further from the peroneal nerve. It also had the smallest distance from the anatomic footprint of the ACL, and the largest angle to the lateral femoral condyle. The posteromedial portal guide pin had similar distance from the articular cartilage as the accessory anterior medial portal and figure-4 guide pin, with the trans-tibial guide pin being the farthest. The posteromedial portal guide pin failed to disrupt the physeal scar in all specimens, while the other three techniques consistently violated the physeal scar.

CONCLUSION

The posteromedial portal technique offers an appropriate method for anatomic ACL reconstruction while protecting the distal femoral physis from injury. Care needs to be taken with this technique as it comes in closer proximity to some of the important neurovascular structures. This study indicates that posteromedial portal technique is a less technically challenging approach for physeal-sparing ACL repair with special attention required for the protection of neurovascular bundle from potential injury.

The Challenges of Treating Female Soccer Players With ACL Injuries: Hamstring Versus Bone-Patellar Tendon-Bone Autograft

Background:

Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear.

Purpose/Hypothesis:

To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort.

Study Design:

Case series; Level of evidence, 4.

Methods:

We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport.

Results:

Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection.

Conclusion:

Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up

PURPOSE

The anterior cruciate ligament (ACL) tear is one of the most common sports injuries of the knee, and the arthroscopic reconstruction is the gold standard. Nevertheless, controversies about the surgical techniques and the type of graft still exist. Allografts have been considered by many surgeons as valid alternative to autografts. The aim of this study was to assess the effectiveness of allografts compared to autografts at approximately 10 years of follow-up, investigating the level of physical activity currently performed by patients of each group.

METHODS

Ninety-four patients, divided into two groups (allografts and autografts), have been retrospectively studied. The two groups did not significantly differ in preoperative sport activity level, age (mean 40.70 years for autografts and 41.23 for allografts) and characteristics. Allograft group received a fresh-frozen graft from the musculoskeletal tissues bank. Evaluations were made using the International Knee Documentation Committee (IKDC) and Lysholm score; every patient was interviewed for complications.

RESULTS

The mean follow-up time was approximately 10 years for both groups, with a minimum of 8 years. There were no statistically significant differences between the two groups. Average IKDC scores were 75.21 (SD 15.36) and 80.69 (SD 13.65) for the allograft and autograft groups, respectively. The mean Lysholm score was 87.57 (SD 9.43) for the allografts and 89.10 (SD 8.33) for the autografts. No major complications linked to the allograft tissue arose.

CONCLUSION

Both groups achieved almost the same functional outcomes at an average 10 years of follow-up, indicating fresh-frozen allografts as a reasonable alternative for ACL reconstruction.

LEVEL OF EVIDENCE

IV, Retrospective case-control study.

Relationship between pre- and post-operative isokinetic strength after ACL reconstruction using hamstring autograft

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are of major concern in sports. As mostly young and active individuals are affected there is an emphasis on the rapid and safe return to sports (RTS). Strengthening the ventral and dorsal thigh muscles is a prerequisite for a successful RTS after ACL reconstruction (ACLR), as persistent muscle weakness may increase the incidence for secondary injuries and impair performance. Aiming to increase evidence on the importance of preoperative muscle strength and the coaching of patients, the purpose of this study is to compare thigh muscle strength pre- and post-operatively after ACLR.

METHODS

We performed a retrospective analysis of 80 patients with primary, isolated ACLR using a four-stranded hamstring autograft. We performed bilateral isokinetic concentric strength measurement (60°/s) before and six months after ACLR. Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q ratio) and the corresponding limb symmetry indices (LSI). Pearson correlations were calculated for pre- and post-surgical values.

RESULTS

The operated as well as the unaffected leg increased maximal knee extension (+ 18% ± 7% p < 0.05; + 11% ± 5% p < 0.05) and flexion torque (+ 9% ± 5% p < 0.05, + 10% ± 6% p < 0.05) throughout the 6 months of rehabilitation. The H/Q ratio remained unaffected (- 2% ± 3% p = 0.93; - 4% ± 4% p = 0.27). LSI of knee extension strength increased significantly (6% ± 3% p < 0.05), while flexion strength remained unaffected (+ 2% ± 4% p = 0.27). Positive correlations underline the interrelationship between the strength pre- and post-surgery for the knee extension (r = 0.788 p < 0.05) and knee flexion strength (r = 0.637 p < 0.05) after ACLR.

CONCLUSIONS

Preoperative leg extension and flexion strength normalized to body mass are strongly correlated to postoperative strength performance after ACLR. Therefore, pre-operative quadriceps and hamstring muscle strength deficits may have a significant negative impact on functional performance following ACLR. This emphasizes the need for intensive preoperative screening and subsequent treatment to achieve the best possible preoperative leg strength before ACLR.

TRIAL REGISTRATION

DRKS00020210 .

Epidemiology of Anterior Cruciate Ligament Injury on Natural Grass Versus Artificial Turf in Soccer: 10-Year Data From the National Collegiate Athletic Association Injury Surveillance System

Background:

Anterior cruciate ligament (ACL) injury is prevalent among National Collegiate Athletic Association (NCAA) soccer players. Controversy remains regarding the effect of the surface type on the rate of ACL injury in soccer players, considering differences in sex, type of athletic exposure, and level of competition.

Hypothesis:

Natural grass surfaces would be associated with decreased ACL injury rate in NCAA soccer players. Sex, type of athletic exposure (match vs practice), and level of competition (Division I-III) would affect the relationship between playing surface and ACL injury rates.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using the NCAA Injury Surveillance System (ISS) database, we calculated the incidence rate of ACL injury in men and women from 2004-2005 through 2013-2014 seasons. The incidence was normalized against athletic exposure (AE). Additional data collected were sex, athletic activity at time of injury (match vs practice), and level of competition (NCAA division) to stratify the analysis. Statistical comparisons were made by calculating incidence rate ratios (IRR). Statistical significance was set at an alpha of .05.

Results:

There were 30,831,779 weighted AEs during the study period. The overall injury rate was 1.12 ACL injuries per 10,000 AEs (95% CI, 1.08-1.16). Women comprised 57% of the match data (10,261 games) and 55% of practice data (26,664 practices). The overall injury rate was significantly higher on natural grass (1.16/10,000 AEs; 95% CI, 1.12-1.20) compared with artificial turf (0.92/10,000 AEs [95% CI, 0.84-1.01]; IRR, 1.26 [95% CI, 1.14-1.38]) (P < .0001). This relationship was demonstrated consistently across all subanalyses, including stratification by NCAA division and sex. The injury rate on natural grass (0.52/10,000 AEs; 95% CI, 1.11-1.26) was significantly greater than the injury incidence during practice on artificial turf (0.06/10,000 AEs; 95% CI, 0.043-0.096). Players were 8.67 times more likely to sustain an ACL injury during practice on natural grass compared with practice on artificial turf (95% CI, 5.43-12.13; P < .0001). No significant difference was found in injury rates between matches played on grass versus turf (IRR, 0.93; 95% CI, 0.84-1.03; P = .15).

Conclusion:

NCAA soccer players who practice on natural grass have increased risk of ACL injury compared with the risk of those practicing on an artificial surface, regardless of sex or NCAA division of play. No difference in risk of ACL injury between playing surfaces was detected during matches. Further research is necessary to examine the effect of multiple factors when evaluating the effect of the surface type on the risk of ACL injury in soccer players.

FRAMEWORK FOR OPTIMIZING ACL REHABILITATION UTILIZING A GLOBAL SYSTEMS APPROACH

Knee injuries such as ACL tears commonly occur and there is a high re-injury rate after primary ACL reconstruction with figures estimated at 25%-33%. Clinicians often use hip strengthening as a key component of knee rehabilitation. Evidence suggests that adopting a "regional" or "proximal" approach to rehabilitation can increase hip strength, but motor control often remains unchanged, particularly during more complex tasks such as running and jumping. It has been previously suggested that the current approach to "regional/proximal" rehabilitation is too basic and is constrained by a reductionist philosophy. This clinical commentary provides the clinician a framework for optimizing knee rehabilitation, underpinned by a more global approach. Although this approach remains hip-focused, it can be easily adapted to modify exercise complexity and key loading variables (speed, direction, flight), which will help the clinician to better replicate the sport specific demands on the knee.

LEVEL OF EVIDENCE

5.

Influence of poor preparation and sleep deficit on injury incidence in amateur small field football of both gender

INTRODUCTION

Amateur small-field football tournaments are rather common worldwide. Adequate preparation is essential for injury prevention. The consequences of insufficient injury preparation at this level are still unclear. This study investigates the factors influencing injuries in this football population.

MATERIALS AND METHODS

In 2017, medical students participating in a national amateur football tournament were analysed in a prospective cohort study. Injury incidence, injury pattern and factors influencing injuries were investigated according to the statement on data collection and injury definition of Fuller et al. (Br J Sports Med 40:193-201, 2006). Preparation for the tournament was assessed for both sexes by means of hours of sleep, alcohol consumption, training level and warm-up performance.

LEVEL OF EVIDENCE

II.

RESULTS

Of 694 amateur football players (423 men and 271 women) with a mean age of 23 years (SD 2.5), 321 (21.1%) injuries happened during the tournament. 60% of injuries affected the lower extremity. The most common types of traumatic injury were skin abrasions (40.0%) and muscle strains (23.3%). The injury incidence of male players during match exposure was 469 per 1000 h football and significantly higher than in female players 313 (p = 0.025). One potential reason for the higher injury rate of male players as measure for inadequate preparation was significantly higher alcohol consumption the evening before the tournament (p < 0.001) and the after-effects on match day (p < 0.001). Additionally, male players reported less and inadequate sleep the night before the tournament (p < 0.007) and a lower warm-up rate before the matches compared to female players (p < 0.001).

CONCLUSIONS

Small-field tournaments in football have a high injury incidence. Male players have a higher injury incidence than female players and show additionally a lack of sleep and alcohol consumption the night before the tournament and poor warm-up performance on match day. Adequate preparation for a football tournament is the key factor for preventing injuries, also in recreational football.

Trends in Recurrent Anterior Cruciate Ligament Injuries Differ From New Anterior Cruciate Ligament Injuries in College and High School Sports: 2009-2010 Through 2016-2017

Background:

Knee injuries are common and result in extended time missed from sports participation. Little is known regarding the comparative characteristics of recurrent versus first-time anterior cruciate ligament (ACL) injuries sustained during athletic events and how they are influenced by sex, sports participation level, and game-time features.

Purpose:

To evaluate the characteristics (sex, sports level, and game timing [ie, early vs late in the game]) of recurrent ACL injury in National Collegiate Athletic Association (NCAA) and high school athletes compared with first-time ACL injury.

Study Design:

Descriptive epidemiology study.

Methods:

Athletic trainers reported ACL injury occurrences and characteristics for collegiate athletes during the 2009-2010 through 2016-2017 academic years and for high school athletes during the 2011-2012 through 2013-2014 academic years. Logistic regression was used to estimate odds ratios (ORs) and 95% CIs for recurrent versus first-time ACL injury. The number of ACL injuries, proportions, and ORs were calculated by sex, competition level, and time in game played. Results were also classified according to injury mechanism: noncontact, overuse, or surface contact.

Results:

A total of 705 ACL injuries were reported, including 644 first-time injures and 61 recurrent injuries. When restricting to noncontact ACL injuries, 416 were reported (373 first-time injuries and 43 recurrent injuries). The odds of a recurrent versus new ACL injury in NCAA student-athletes were 4.6 times that of high school student-athletes (95% CI, 1.41-15.24; P = .01). When restricting to noncontact ACL injuries, the odds of a recurrent versus new ACL injury during postseason and preseason were 4.5 and 2.8 times that during the regular season, respectively. Athletes in limited-contact and noncontact sports had greater odds of a recurrent versus new ACL injury compared with athletes playing football and other contact and collision sports. There was no significant difference in the odds of a recurrent ACL injury by sex or time in game.

Conclusion:

Based on the current study, the odds of recurrent ACL injuries are associated with the level of competition but not associated with sex or timing of game play. Determinants of reinjury after primary ACL reconstruction will help advance care for young injured athletes who continue to participate in competitive sports.

Failure risks in anatomic single-bundle anterior cruciate ligament reconstruction via the outside-in tunnel technique using a hamstring autograft

Purpose

To retrospectively evaluate the failure risk factors in anatomic single-bundle anterior cruciate ligament (ACL) reconstruction via outside-in tunnel technique using a hamstring autograft, and investigate the relationship between each risk factor.

Methods

The patients who underwent the ACL reconstruction with a minimum 1-year follow-up were included. We divided the patients into two groups - those who experienced graft failure (the failure group) and those who did not experience graft failure (the no failure group) - and compared their age, height, weight, sports activity level, graft size, and muscle strength. We defined graft failure as patients who underwent revision ACL reconstruction or had a second injurious ACL episode and those with a graft grade of C or D based on the International Knee Documentation Committee score.

Results

The study included 232 patients (101 male, 131 female; mean age at operation was 26.1 ± 11.9 years). The failure rate was 11.6% (failure group: 27 patients; no failure group: 205 patients). The patients in the failure group were younger and had higher sports activity level than those in the no failure group. (p < 0.001 and p < 0.001, respectively). Patient body weight in the failure group was lower than that in the no failure group (p = 0.047). Regarding the graft size of the tibial side, the failure group had smaller graft sizes than the no failure group (p = 0.030). With respect to muscle strength, quadriceps strength 6 months after surgery in the failure group was stronger than that in the no failure group (p = 0.001). In addition, the hamstring/quadriceps strength (H/Q) ratios 3 and 6 months after surgery were lower in the failure group than that in the no failure group (p = 0.041 and p = 0.001, respectively). There was an association between the age and the body weight, between the body weight and the graft size of the tibial side, and between lower age and high sports activity. Moreover, the high quadriceps strength at 6 months and the low H/Q ratio at 3 months were related to the low H/Q ratio at 6 months.

Conclusion

Young age, high activity sports level, low body weight, small graft diameter of the tibial side, high quadriceps strength at 6 months, and low H/Q ratio at 3 and 6 months can be failure risk factors in anatomic single-bundle ACL reconstruction via the outside-in tunnel technique using a hamstring autograft.

Revision ACL reconstruction using quadriceps or hamstring autografts leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level

PURPOSE

Due to the increased importance of revision ACL reconstruction, this study aims to evaluate the outcome 4 years after the surgery, compare two revision strategies and identify factors that influence the results.

METHODS

Seventy-nine patients who received a revision ACL reconstruction were retrospectively evaluated. All patients were assessed with an average follow-up of 4.4 years (range 3.3-5.5 years). The results of patients treated with a quadriceps autograft were compared with those treated with a hamstring autograft.

RESULTS

Ninety-seven percent of patients had a KT-1000 side-to-side difference of ≤ 5 mm (mean 1.7 ± 2.0 mm). Pivot-shift test was absent or minor in 95%. In the SLTH-test, 70% of patients reached 90% of the contralateral side. The mean Lysholm score on follow-up was 83 ± 12 (56% excellent/good). The mean IKDC 2000 subjective evaluation score was 81 ± 14 (58% normal/almost normal). The median Tegner activity score was 6 (range 3-10), a median of 2 levels worse than before the first injury. Return to sport rate was 89% but only 34% of patients reached their pre-injury sport level. Most common cause for this reduction was fear of another injury. Three patients suffered a re-rupture. Patients with a hamstring autograft performed pivoting sports more often, but had worse pivot-shift results compared to those with a quadriceps autograft. No significant influence was seen for other parameters. Young, male patients with a high activity level and no chondral damage had the best results.

CONCLUSION

Through revision ACL reconstruction, the goal of stabilizing the knee can be achieved in the majority of patients. However, a good function and a high activity level are significantly less common in these patients. The main reason for this is fear of a renewed ACL-injury. Both quadriceps and hamstring autografts were able to achieve a good outcome. Young, male, patients with a normal BMI, a high activity level and without cartilage damage seem to benefit the most from revision ACL surgery. The discrepancy between the good laxity restoration and the lower activity rate should therefore be a main point in clinical counseling when deciding for or against revision ACL-Reconstruction.

LEVEL OF EVIDENCE

III.

[Progress of sterilization and preservation methods for allografts in anterior cruciate ligament reconstruction]

OBJECTIVE

To review the current status and progress of sterilization and preservation for allograft in anterior cruciate ligament reconstruction.

METHODS

The related literature about the sterilization and preservation of allografts in anterior cruciate ligament reconstruction was extensively reviewed and summarized.

RESULTS

There are many sterilization methods for allografts, the most commonly used method is γ-ray irradiation, but the optimal irradiation dose is still unclear. Electron beam irradiation is also available, but excessive dose is harmful to graft shaping. A combined sterilization method combining physics and chemistry methods is still being explored. Cryopreservation is the most commonly used method of preservation. In order to reduce the influence of crystals, the principle of "slow cooling and rapid rewarming" should be adhered to as far as possible.

CONCLUSION

The processing methods of allograft can affect the effectiveness of anterior cruciate ligament reconstruction. The clinical doctors should consider the sterilization and preservation methods in practice.

Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts

BACKGROUND

Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential.

PURPOSE

(1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo).

STUDY DESIGN

Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3.

METHODS

A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes.

RESULTS

No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores (P < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS-Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON (P = .011).

CONCLUSION

Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR.

REGISTRATION

NCT01773317 (ClinicalTrials.gov identifier).

Combined Anatomic Anterior Cruciate and Anterolateral Ligament Reconstruction With Quadriceps Tendon Autograft and Gracilis Allograft Through a Single Femoral Tunnel

Despite technical advances in anterior cruciate ligament (ACL) reconstruction surgery, there remains a need to improve postoperative outcomes with respect to graft failure rates. Recently, it has been shown that combined ACL-anterolateral ligament (ALL) reconstruction (using a graft composed of a tripled semitendinosus and single-strand gracilis tendon) is associated with a significant reduction in graft rupture rates compared with isolated ACL reconstruction. It is recognized that the hamstring tendons are not always available (revision scenario) or are not always the primary ACL graft choice. Some surgeons prefer to use quadriceps tendon ACL grafts because of the suggestion that these grafts may be associated with equal or better functional scores. However, if surgeons wish to try to reduce the risk of graft failure by performing an ALL reconstruction, either a combined reconstruction or the use of an independent ALL graft, with a separate femoral socket, could be considered. The disadvantage of an independently performed extra-articular procedure is the risk of femoral socket collision with the femoral ACL tunnel. This Technical Note therefore describes the use of a combined ACL-ALL reconstruction using quadriceps tendon autograft (ACL graft), gracilis allograft (ALL graft), and a single femoral tunnel.

Neuromuscular Control of Vertical Jumps in Female Adolescents

BACKGROUND

Poor landing mechanics are considered deficits in neuromuscular control and risk factors for lower extremity injury. The Landing Error Scoring System (LESS) has been used to assess the neuromuscular control of landing mechanics for the first landing in a drop vertical jump (DVJ) task. However, the second DVJ landing may provide different results, warranting assessment.

HYPOTHESES

(1) LESS scores will differ between first and second DVJ landings across all female participants with (2) greater intraparticipant variability among the second landing compared with the first landing scores.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 13 gymnasts and 31 softball players (N = 44) performed 3 DVJ trials. The mean ± SD age of 44 female athletes was 16.46 ± 2.59 years. The LESS was scored using 2-dimensional video of each trial.

RESULTS

There was a significant difference between the first and second DVJ landings (P < 0.01). All participants demonstrated higher LESS scores (worse landing mechanics) during the second DVJ landing (10.10 ± 2.25) than the first landing (6.97 ± 2.72).

CONCLUSION

The initial landing in a DVJ has been the focus of neuromuscular control studies using the LESS. This study found worse neuromuscular control during the second DVJ landing, which highlights the importance of evaluating landing mechanics beyond the initial landing.

CLINICAL RELEVANCE

LESS analysis of both DVJ landings might improve neuromuscular control screening in female athletes and augment lower extremity and anterior cruciate ligament injury prevention programs.

Injury epidemiology and risk factors in competitive artistic gymnasts: a systematic review

Background

Artistic gymnastics is reported to have some of the highest injury rates in sports, which limits participation and often involves considerable medical expenses.

Purpose

To critically appraise the epidemiological literature on injury patterns and risk factors in competitive artistic gymnastics.

Study design

Systematic review.

Methods

Six databases were searched for articles that investigated injuries in competitive artistic gymnasts. Injury incidence, prevalence and risk factor data were extracted, alongside information on injury location, type, severity, nature and mechanism of injury. Quality and level of evidence were assessed using a modified Downs and Black quality index checklist and the Oxford Centre for Evidence-based Medicine guidelines.

Results

The search identified 894 articles, with 22 eligible for inclusion. Descriptive analysis showed that injury incidence and prevalence varied from 0.3 to 3.6 injuries per gymnast (female=0.3–3.6, male=0.7) and 2.0–2.3 (female=2.0–2.3, male=2.0), respectively. Male gymnasts sustained mostly upper limb injuries, while female gymnast reported lower limb injuries. Floor was associated with the greatest number of injuries for both male and female gymnasts. Higher competitive level and exposure to competition were risk factors for gymnastics injury: age, body mass, body size, training duration and life stress were significant associated factors.

Conclusion

Injury incidence and prevalence results are substantial among artistic gymnasts of all competitive levels. Gymnasts who train at highly competitive levels and are exposed to competition environments are a greater risk of injury. Future researchers should implement consistent reporting methods.

Young age and high BMI are predictors of early revision surgery after primary anterior cruciate ligament reconstruction: a cohort study from the Swedish and Norwegian knee ligament registries based on 30,747 patients

PURPOSE

To analyse patient-related risk factors for 2-year ACL revision after primary reconstruction. The hypothesis was that younger athletes would have a higher incidence of an early ACL revision.

METHODS

This prospective cohort study was based on data from the Norwegian and Swedish National Knee Ligament Registries and included patients who underwent primary ACL reconstruction from 2004 to 2014. The primary end-point was the 2-year incidence of ACL revision. The impact of activity at the time of injury, patient sex, age, height, weight, BMI, and tobacco usage on the incidence of early ACL revision were described by relative risks (RR) with 95% confidence intervals (CI).

RESULTS

A total of 58,692 patients were evaluated for eligibility and 30,591 patients were included in the study. The mean incidence of ACL revision within 2 years was 2.82% (95% CI 2.64-3.02%). Young age (13-19) was associated with an increased risk of early ACL revision (males RR = 1.54 [95% CI 1.27-1.86] p < 0.001 and females RR = 1.58 [95% CI 1.28-1.96] p < 0.001). Females over 1 SD in weight ran an increased risk of early ACL revision (RR = 1.82, [95% CI 1.15-2.88] p = 0.0099). Individuals with a BMI of over 25 ran an increased risk of early ACL revision (males: RR = 1.78, [95% CI 1.38-2.30] p < 0.001 and females: RR = 1.84, [95% CI 1.29-2.63] p = 0.008).

CONCLUSION

Young age, a BMI over 25, and overweight females were risk factors for an early ACL revision.

LEVEL OF EVIDENCE

II.

Cellular Complexity at the Interface: Challenges in Enthesis Tissue Engineering

The complex heterogeneous cellular environment found in tendon-to-bone interface makes this structure a challenge for interface tissue engineering. Orthopedic surgeons still face some problems associated with the formation of fibrotic tissue or re-tear occurring after surgical re-attachment of tendons to the bony insertion or the application of grafts. Unfortunately, an understanding of the cellular component of enthesis lags far behind of other well-known musculoskeletal interfaces, which blocks the development of new treatment options for the healing and regeneration of this multifaceted junction. In this chapter, the main characteristics of tendon and bone cell populations are introduced, followed by a brief description of the interfacial cellular niche, highlighting molecular mechanisms governing tendon-to-bone attachment and mineralization. Finally, we describe and critically assess some challenges faced concerning the use of cell-based strategies in tendon-to-bone healing and regeneration.