Results from the Swedish national anterior cruciate ligament register

Double-bundle anterior cruciate ligament reconstruction is superior to single-bundle reconstruction in terms of revision frequency: a study of 22,460 patients from the Swedish National Knee Ligament Register

PURPOSE

Studies comparing single- and double-bundle anterior cruciate ligament (ACL) reconstructions often include a combined analysis of anatomic and non-anatomic techniques. The purpose of this study was to compare the revision rates between single- and double-bundle ACL reconstructions in the Swedish National Knee Ligament Register with regard to surgical variables as determined by the anatomic ACL reconstruction scoring checklist (AARSC).

METHODS

Patients from the Swedish National Knee Ligament Register who underwent either single- or double-bundle ACL reconstruction with hamstring tendon autograft during the period 2007-2014 were included. The follow-up period started with primary ACL reconstruction, and the outcome measure was set as revision surgery. An online questionnaire based on the items of the AARSC was used to determine the surgical technique implemented in the single-bundle procedures. These were organized into subgroups based on surgical variables, and the revision rates were compared with the double-bundle ACL reconstruction. Hazard ratios (HR) with 95% confidence interval (CI) was calculated and adjusted for confounders by Cox regression.

RESULTS

A total of 22,460 patients were included in the study, of which 21,846 were single-bundle and 614 were double-bundle ACL reconstruction. Double-bundle ACL reconstruction had a revision frequency of 2.0% (n = 12) and single-bundle 3.2% (n = 689). Single-bundle reconstruction had an increased risk of revision surgery compared with double-bundle [adjusted HR 1.98 (95% CI 1.12-3.51), p = 0.019]. The subgroup analysis showed a significantly increased risk of revision surgery in patients undergoing single-bundle with anatomic technique using transportal drilling [adjusted HR 2.51 (95% CI 1.39-4.54), p = 0.002] compared with double-bundle ACL reconstruction. Utilizing a more complete anatomic technique according to the AARSC lowered the hazard rate considerably when transportal drilling was performed but still resulted in significantly increased risk of revision surgery compared with double-bundle ACL reconstruction [adjusted HR 1.87 (95% CI 1.04-3.38), p = 0.037].

CONCLUSIONS

Double-bundle ACL reconstruction is associated with a lower risk of revision surgery than single-bundle ACL reconstruction. Single-bundle procedures performed using transportal femoral drilling technique had significantly higher risk of revision surgery compared with double-bundle. However, a reference reconstruction with transportal drilling defined as a more complete anatomic reconstruction reduces the risk of revision surgery considerably.

LEVEL OF EVIDENCE

III.

A Review of Databases Used in Orthopaedic Surgery Research and an Analysis of Database Use in Arthroscopy: The Journal of Arthroscopic and Related Surgery

PURPOSE

The purpose of this study was to evaluate how database use has changed over time in Arthroscopy: The Journal of Arthroscopic and Related Surgery and to inform readers about available databases used in orthopaedic literature.

METHODS

An extensive literature search was conducted to identify databases used in Arthroscopy and other orthopaedic literature. All articles published in Arthroscopy between January 1, 2006, and December 31, 2015, were reviewed. A database was defined as a national, widely available set of individual patient encounters, applicable to multiple patient populations, used in orthopaedic research in a peer-reviewed journal, not restricted by encounter setting or visit duration, and with information available in English.

RESULTS

Databases used in Arthroscopy included PearlDiver, the American College of Surgeons National Surgical Quality Improvement Program, the Danish Common Orthopaedic Database, the Swedish National Knee Ligament Register, the Hospital Episodes Statistics database, and the National Inpatient Sample. Database use increased significantly from 4 articles in 2013 to 11 articles in 2015 (P = .012), with no database use between January 1, 2006, and December 31, 2012.

CONCLUSIONS

Database use increased significantly between January 1, 2006, and December 31, 2015, in Arthroscopy.

LEVEL OF EVIDENCE

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

Prediction of length and diameter of hamstring tendon autografts for knee ligament surgery in Caucasians

PURPOSE

Prediction of hamstring tendon autograft size facilitates preoperative planning of knee ligament surgery and may reduce the need for allografts in complex knee reconstructions. The aim of this study was to analyse whether length and diameter of hamstring tendon autografts can be predicted preoperatively with anthropometric parameters and patient characteristics.

METHODS

In this observational study, 725 consecutive Caucasian patients scheduled for ACL reconstruction were included. Preoperatively gender, age, height and weight were recorded. After harvest, tendon lengths of both gracilis and semitendinosus tendons were measured. Diameter of the final four-strand hamstring autograft was recorded. Relationship between length and diameter of tendon grafts and different anthropometric parameters were assed by linear and logistic regression analyses.

RESULTS

Mean lengths of the semitendinosus and gracilis tendon autografts were 28.9 ± 3.1 and 27.7 ± 3.0 cm, respectively. Length of the gracilis and semitendinosus grafts was independently related to patient height. Female gender was correlated with smaller graft diameter. One in nine female patients had a diameter <8 mm. The ratio in men was 1 in 36.

CONCLUSION

Hamstring autograft length and size can be predicted in Caucasians. Length of the gracilis and semitendinosus tendons was related to patient height. Smaller graft diameter was related to female gender.

LEVEL OF EVIDENCE

II.

Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature.

PURPOSE

To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non-active-duty beneficiaries.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure-related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort.

RESULTS

The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non-active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest.

CONCLUSION

In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

The effect of smoking on ACL reconstruction: a systematic review

OBJECTIVE

Anterior cruciate ligament reconstruction (ACLR) depends on proper healing of the graft or bone plug at the cellular level. The effect of cigarette smoke on ACLR was not commonly reported until recently. The primary purpose of this review was to determine if smoking has a negative effect on subjective or objective outcome scores after ACLR. The secondary purpose was to identify any increased risk of complications, infection, ACL re-tear, or revision procedures.

METHODS

A systematic literature review of the MEDLINE, SCOPUS and PubMed databases was performed to identify all studies that compared outcomes of ACLR surgery between smokers and nonsmokers. The frequency-weighted mean was calculated for outcome measures that were similar across several studies.

RESULTS

Seventeen studies were identified that met inclusion criteria for patients undergoing ACLR (mean age, 26.8 years) with a mean follow-up of 37 months. Smokers had significantly worse subjective outcome measures and worse side-to-side difference in anterior translation compared to non-smokers (2.68 mm vs 1.89 mm, respectively). In 2 studies, smokers were found to have a significantly higher risk of developing an infection and VTE (venous thromboembolism) post-operatively. The evidence for the effect of smoking on risk for subsequent re-tear is mixed. No study reported a higher rate of development of radiographic knee osteoarthritis among smokers compared to nonsmokers.

CONCLUSIONS

Cigarette smoke is associated with significantly worse clinical outcome scores, an increase in anterior translation, and increased complication rates after ACL reconstruction. These findings may help orthopaedic surgeons better inform their patients about the potential negative effects of smoking on the outcomes of ACL reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Defining Thresholds for the Patient Acceptable Symptom State for the IKDC Subjective Knee Form and KOOS for Patients Who Underwent ACL Reconstruction

BACKGROUND

A clinically meaningful change in patient-reported outcome (PRO) may not be associated with an acceptable state that corresponds to "feeling well," also known as the patient acceptable symptom state (PASS). The PASS thresholds for the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS) have not been determined for individuals after anterior cruciate ligament (ACL) reconstruction.

PURPOSE

To determine the PASS thresholds for the IKDC-SKF and KOOS in individuals at 1 to 5 years after ACL reconstruction.

STUDY DESIGN

Cohort study (diagnosis): Level of evidence, 2.

METHODS

Individuals 1 to 5 years after primary ACL reconstruction completed a survey that included the IKDC-SKF and KOOS. All subjects assessed satisfaction with their current state by answering the question, "Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?"

RESULTS

A total of 251 participants (mean age ± SD, 26.1 ± 9.9 years) completed the survey at an average of 3.4 ± 1.3 years after ACL reconstruction. Of these, 223 (89.2%) individuals indicated that they were in an acceptable symptom state (PASS-Y). Analysis of the receiver operating characteristic curve revealed that the IKDC-SKF and each of the KOOS subscales (pain, symptoms, activities of daily living [ADL], sport and recreation [sport/rec], and quality of life [QoL]) were significantly better identifiers of PASS than chance as indicated by the significance of the area under the curves. The PASS threshold (sensitivity, specificity) was 75.9 (0.83, 0.96) for the IKDC-SKF, 88.9 (0.82, 0.81) for the KOOS pain, 57.1 (0.78, 0.67) for the KOOS symptoms, 100.0 (0.70, 0.89) for the KOOS ADL, 75.0 (0.87, 0.88) for the KOOS sport/rec, and 62.5 (0.82, 0.85) for the KOOS QoL. In addition, the difference between PASS-Y and PASS-N was statistically significant (P < .001) for all PROs.

CONCLUSION

To our knowledge, this is the first study to identify the PASS thresholds for the IKDC-SKF and the KOOS subscales for individuals 1 to 5 years after ACL reconstruction. By identifying threshold values for the PASS, this study provides additional information to facilitate interpretation of the IKDC-SKF and KOOS in daily practice and clinical research related to ACL reconstruction.

Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL are disastrous outcomes after successful ACL reconstruction (ACLR), rehabilitation, and return to activity. Studies reporting ACL reinjury rates in younger active populations are emerging in the literature, but these data have not yet been comprehensively synthesized.

PURPOSE

To provide a current review of the literature to evaluate age and activity level as the primary risk factors in reinjury after ACLR.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was conducted via searches in PubMed (1966 to July 2015) and EBSCO host (CINAHL, Medline, SPORTDiscus [1987 to July 2015]). After the search and consultation with experts and rating of study quality, 19 articles met inclusion for review and aggregation. Population demographic data and total reinjury (ipsilateral and contralateral) rate data were recorded from each individual study and combined using random-effects meta-analyses. Separate meta-analyses were conducted for the total population data as well as the following subsets: young age, return to sport, and young age + return to sport.

RESULTS

Overall, the total second ACL reinjury rate was 15%, with an ipsilateral reinjury rate of 7% and contralateral injury rate of 8%. The secondary ACL injury rate (ipsilateral + contralateral) for patients younger than 25 years was 21%. The secondary ACL injury rate for athletes who return to a sport was also 20%. Combining these risk factors, athletes younger than 25 years who return to sport have a secondary ACL injury rate of 23%.

CONCLUSION

This systematic review and meta-analysis demonstrates that younger age and a return to high level of activity are salient factors associated with secondary ACL injury. These combined data indicate that nearly 1 in 4 young athletic patients who sustain an ACL injury and return to high-risk sport will go on to sustain another ACL injury at some point in their career, and they will likely sustain it early in the return-to-play period. The high rate of secondary injury in young athletes who return to sport after ACLR equates to a 30 to 40 times greater risk of an ACL injury compared with uninjured adolescents. These data indicate that activity modification, improved rehabilitation and return-to-play guidelines, and the use of integrative neuromuscular training may help athletes more safely reintegrate into sport and reduce second injury in this at-risk population.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

BACKGROUND

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction.

RESULTS

At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes.

CONCLUSION

Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels.

REGISTRATION

NCT00625885.

Comparison of patient-reported outcomes among those who chose ACL reconstruction or non-surgical treatment

The aim of our study was to cross-sectionally compare patient-reported knee function outcomes between people who chose non-surgical treatment for ACL injury and those who chose ACL reconstruction. We extracted Knee Injury and Osteoarthritis Outcome Score (KOOS) and EuroQoL-5D data entered into the Swedish National ACL Registry by patients with a non-surgically treated ACL injury within 180 days of injury (n = 306), 1 (n = 350), 2 (n = 358), and 5 years (n = 114) after injury. These data were compared cross-sectionally to data collected pre-operatively (n = 306) and at 1 (n = 350), 2 (n = 358), and 5 years (n = 114) post-operatively from age- and gender-matched groups of patients with primary ACL reconstruction. At the 1 and 2 year comparisons, patients who chose surgical treatment reported superior quality of life and function in sports (1 year mean difference 12.4 and 13.2 points, respectively; 2 year mean difference 4.5 and 6.9 points, respectively) compared to those who chose non-surgical treatment. Patients who chose ACL reconstruction reported superior outcomes for knee symptoms and function, and in knee-specific and health-related quality of life, compared to patients who chose non-surgical treatment.

Epidemiology of soccer players traumatic injuries during the 2015 America Cup

AIM

to provide an overview of the traumatic injuries sustained by players in the 2015 America Cup.

MATERIAL AND METHODS

we collected the medical reports on all the matches held during the 2015 America Cup, in Chile, in 2015. Twelve American teams took part in the championship, consisted of 26 matches with a total of 276 players. The physician for each team sent a request form of the traumatic injuries sustained, including the time at which the injury was produced, the location and diagnosis, its severity and the circumstances (contact injury, sanction, treatment required).

RESULTS

the mean number of minutes played was 233 (SD: 147) (5-570) minutes. An injury occurred every 58 minutes, which means that there were 17.25 injuries per 1,000 minutes of match time. We found 44 injuries in 30 players. There were 14 non-contact injuries, and 30 contact injuries, of which 13 were declared fouls and resulted in cards being given. Five teams had one injured player, two had 2, two had 4, and one had 25 injuries. The most frequent injuries were those to the lower limbs. The muscles strains happened in the second part of the second half of the match, the ACL rupture at the end of the first half, and the other sprains and strains in the second half. The contusions occurred at all times throughout the match, although they seemed to be concentrated towards the end of the first half, while the cases of tendinitis were caused in the first part of the second half.

CONCLUSION

football injuries are very common, and even though serious injuries are rare, it is increasingly necessary to set protocols for action which ensure good medical attention at all levels to address the problems that arise, both during training and in competitions, and to be prepared to treat serious injuries if these occur.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction

The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.].

Smoking increases the risk of early meniscus repair failure

PURPOSE

The goal of this study is to determine whether patients who smoke cigarettes at the time of surgery are at significantly increased risk of early meniscus repair failure relative to non-smokers.

METHODS

Retrospective chart review identified 64 current smokers within a series of 444 consecutive patients who underwent meniscus repair during a 7 years period. Fifty-two of these 64 smokers were available for follow-up and were matched by age, sex, and ACL status with non-smokers from the same cohort. Records of these 104 patients with a total of 120 meniscus repairs were reviewed to identify meniscus repair failure (defined as repeat surgery on the index meniscus) during the median 13-month (range: 3-79 months) follow-up period.

RESULTS

The smoking and non-smoking groups were similar in age, sex, ACL status, BMI, meniscus repair technique, and meniscus involved. Meniscus repair failure occurred in 19 of the 112 menisci in 104 patients, for an overall failure risk of 17 %. Of the 19 failures, 14 occurred in 79 repaired medial menisci (18 % failure risk) and 5 occurred in 33 repaired lateral menisci (15 % failure risk). Meniscus repair failure occurred in significantly more smokers (15 failures in 56 menisci in 52 patients -27 % failure risk) than non-smokers (4 failures in 56 menisci in 52 patients -7 % failure risk) (p = 0.0076).

CONCLUSIONS

Smoking is associated with significantly increased risk of early meniscus repair failure as defined by the incidence of repeat surgery on the index meniscus.

LEVEL OF EVIDENCE

III.

Current status of ACL reconstruction in Germany

INTRODUCTION

Reconstruction of the anterior cruciate ligament (ACL) is characterized by a variety of possibilities concerning its implementation. Different choices for grafts, fixation methods and tunnel positioning, as well as diverse technical tools are available and have clinical significance. Besides specific pre- and post-operative procedures, different indications for surgery and further surgeon-/clinic-related factors add variability to the treatment. In response to the lack of descriptive statistics about the implementation of these factors and the increasing numbers of ACL reconstructions this study has been conducted to display the current state of the treatment for ACL tears throughout Germany.

MATERIALS AND METHODS

709 clinics with surgical and orthopedic departments were provided an online-questionnaire that surveyed their statistical records (e.g. annually implemented operations, number of surgeons, duration of operations), implemented techniques (e.g. choice of grafts, construction of drilling tunnel, tibial/femoral fixation) and personal assessment (e.g. frequency/cause of graft failure, frequency/handling of infection). The response rate was 22 % (n = 155). Based on the statistical records a specialized group within the respondents was identified, enabling a cross-comparison between high- and low-volume surgeons.

RESULTS

On average, the German orthopedic surgeons in the clinics surveyed annually performs 35 ACL reconstructions, with each operation lasting an average of 67 min. After subdividing the data with references to annually performed surgeries into high- and low-volume-surgeons, differences and common features between the subgroups become apparent. Differences between high- and low-volume-surgeons, respectively, show shorter duration of both ACL reconstructions (55 vs. 71 min) and revision ACL reconstructions (75 vs. 90 min), higher membership rates in professional associations (83 vs. 38 % have at least one membership), more frequent implementation of stability examinations (47 vs. 21 %) and different frequencies of femoral drilling techniques (using the anterolateral portal in 71 vs. 54 %). With reference to evaluating operation dates, choosing grafts and assessing reasons for graft failure both groups share commonalities, as well as regarding the predominant use of monofixation for femoral fixation (88 % of the participants-mainly with endobutton in 38 % and transfixation pin in 27 %) and for tibial fixation (81 % of the participants-mainly with bioabsorbable screw in 60 %).

CONCLUSIONS

The treatment of ACL tears in the group of German clinics studied is characterized by a variety of surgical possibilities. This condition might reflect the entirety of clinics reconstructing ACL in Germany. For the first time, a descriptive statistical survey was implemented to display this variety and to provide insight into the current status quo. Within the entirety of surgeons implementing ACL reconstruction a specialized subgroup with a particular expertise seems to exist.

Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter

BACKGROUND

There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation.

METHODS

Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA).

RESULTS

Subjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961.

CONCLUSIONS

The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block.

CLINICAL RELEVANCE

Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.

Predictors for additional anterior cruciate ligament reconstruction: data from the Swedish national ACL register

PURPOSE

To identify predictors for additional anterior cruciate ligament (ACL) reconstruction.

METHODS

Patients from the Swedish national ACL register who underwent ACL reconstruction between January 2005 and February 2013 (follow-up duration 6-104 months) were included. Cox regression analyses included the following independent variables regarding primary injury: age, sex, time between injury and primary ACL reconstruction, activity at primary injury, concomitant injuries, injury side, graft type, and pre-surgery KOOS and EQ-5D scores.

RESULTS

Among ACL reconstruction procedures, 93% involved hamstring tendon (HT) autografts. Graft type did not predict additional ACL reconstruction. Final regression models only included patients with HT autograft (n = 20,824). Of these, 702 had revision and 591 contralateral ACL reconstructions. The 5-year post-operative rates of revision and contralateral ACL reconstruction were 4.3 and 3.8%, respectively. Significant predictors for additional ACL reconstruction were age (fourfold increased rate for <16-year-old patients vs. >35-year-old patients), time between injury and primary surgery (two to threefold increased rate for ACL reconstruction within 0-90 days vs. >365 days), and playing football at primary injury.

CONCLUSION

This study identified younger age, having ACL reconstruction early after the primary injury, and incurring the primary injury while playing football as the main predictors for revision and contralateral ACL reconstruction. This suggests that the rate of additional ACL reconstruction is increased in a selected group of young patients aiming to return to strenuous sports after primary surgery and should be taken into consideration when discussing primary ACL reconstruction, return to sports, and during post-surgery rehabilitation.

LEVEL OF EVIDENCE

II.

Prevention and rehabilitation of paediatric anterior cruciate ligament injuries

PURPOSE

To review the current knowledge on anterior cruciate ligament (ACL) injury prevention and ACL rehabilitation in individuals who have not yet reached musculoskeletal maturity.

METHODS

This is a narrative review based on a targeted and systematic literature search for paediatric ACL injury risk factors, injury prevention and rehabilitation.

RESULTS

The search strategies resulted in 119 hits on risk factor studies, 57 hits on prevention and 37 hits on rehabilitation. Modifiable risk factors for ACL injury are largely unknown in the paediatric population. ACL injury prevention using neuromuscular training is highly successful in the adolescent population, and existing injury prevention programmes are cost-effective. The efficacy of ACL injury prevention programmes in children is, however, investigated to a markedly lesser degree. Paediatric ACL injury rehabilitation is poorly described, although supervised active rehabilitation progressed through phases with functional milestones is generally encouraged.

CONCLUSION

Although limited, current evidence supports implementation of injury prevention programmes in female football players from the age of 12. Supervised active rehabilitation where progression is guided by functional milestones is also advocated. Future identification of modifiable risk factors is needed to design prevention programmes for younger children. There is a need for international multicentre studies on treatment algorithms and rehabilitation to increase knowledge on the short- and long-term outcomes following existing algorithms.

STUDY DESIGN

Narrative review, level III.

The ESSKA paediatric anterior cruciate ligament monitoring initiative

PURPOSE

To survey and describe the treatment of paediatric anterior cruciate ligament (ACL) injuries performed by orthopaedic surgeons affiliated with the European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

METHODS

A closed e-survey was submitted to all registered members and affiliates of ESSKA in July 2013. All recipients were invited to participate in the survey by answering 34 questions online. The list of potential respondents was extracted from the ESSKA office database.

RESULTS

Invitation was sent to 2236 ESSKA members and affiliates, and received 491 (22%) unique responses. Among the respondents, 445 (91%) were orthopaedic surgeons, with 354 (72%) stating that they were involved in treatment of paediatric ACL injuries. The main findings were that there are substantial differences with regard to preferred treatment algorithms, surgical techniques and long-term follow-up procedures. The summed estimate of skeletally immature children with ACL injury seen by the responders in 2012 was minimum 1923 individuals, and a minimum of 102 clinically relevant post-operative growth disturbances were registered.

CONCLUSION

The present survey documents that the incidences of paediatric ACL injuries and idiopathic growth disturbances may be higher than previously estimated. Treatment algorithms and surgical techniques are highly diverse, and consensus could not be identified. It is worrying that only half the surgeons reported to follow-up children until skeletal maturity after surgical treatment. The results of this survey highlight the importance of international multicentre studies on paediatric ACL treatment and the development of an outcome registry to enable prospective data collections.

LEVEL OF EVIDENCE

IV.

Minimally Invasive Anterior Semitendinosus Harvest: A Technique to Decrease Saphenous Nerve Injury

Hamstring tendon harvest, especially semitendinosus harvest, has been widely used in anterior cruciate ligament reconstruction for many years. However, donor site morbidity has been described regarding the infrapatellar branch of the saphenous nerve. Minimally invasive anterior semitendinosus harvest is a simple, safe, reproducible, and elegant technique. A 2-cm vertical incision above the pes anserinus is performed 2 cm medial to the tibial anterior tubercle. The fascia superficialis is opened with a horizontal incision, and the gracilis is isolated using a retractor. The semitendinosus is grabbed with a probe, and the vincula are hooked one by one. The tendon is harvested with a closed stripper. The expansions are cut, and the tendon is detached from the bone with part of the periosteum.

Epidemiology of injuries sustained by players during the 16th Under-17 South American Soccer Championship

OBJECTIVE

We performed an epidemiological study of the traumatic injuries during the XVI South American U-17 Football Championship, 2015.

MATERIAL AND METHODS

Observational surveys submitted by the 10 teams medical services of 220 players. Thirty-five games were held and 116 goals (3.31 per game) were recorded.

RESULTS

103 lesions, ie, 2.94 per game or 32.7 injuries per 1,000 min were recorded. Fifty-six were from direct contact and 66 requiring treatment. 36% of the injuries were punished by fault and 26% of the injuries also saw card. Injuries were most common in the ankle (15 cases), Achilles tendon (14 cases) and thigh (14 cases), followed by trauma to the knee and foot (7 cases each), face and the lumbar region (6 cases each), being rare in the upper extremity.

CONCLUSION

Injuries during Soccer World Cup are difficult to predict and prevent, but serious injuries are rare. Is necessary to establish protocols that get adequate health care at all levels to solve problems produce, both in training and during the competition, and be prepared to solve the serious problems that may arise.

Quality of Life Following ACL Reconstruction: Baseline Predictors of Patient-Reported Outcomes

The study by Dunn et al., "Baseline Predictors of Health-Related Quality of Life after Anterior Cruciate Ligament Reconstruction: A longitudinal analysis of a multicenter cohort at two and six years," evaluates patient factors that are predictive of outcomes following anterior cruciate ligament reconstruction. The current review critically analyzes the findings of this study in light of the current body of literature on the subject and assesses its contribution to the development of evidence-based guidelines. The authors' primary endpoint, the Short Form-36 (SF-36), is used ubiquitously in health care research and allows their results to be compared across different disease states and studies. Despite its widespread use, the SF-36 has been shown to be sensitive to outcomes following anterior cruciate ligament reconstruction. The authors' use of generic health-related quality of life outcome as a primary endpoint represents an important contribution to the field, and their findings allow for improved preoperative counseling by identifying baseline patient factors that predict outcomes following anterior cruciate ligament reconstruction. Furthermore, by deriving utilities from SF-36 scores, the authors are able to assess the value of anterior cruciate ligament reconstruction as compared to other medical and surgical procedures.

The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis

BACKGROUND

One of the well-studied epidemiological phenomena of anterior cruciate ligament (ACL) injuries is the 2- to 9-fold increase in the relative risk of ACL rupture in female athletes compared with male athletes. However, the influence of patient sex on the outcome after ACL reconstruction remains unclear, with some authors reporting inferior outcomes in females and others noting no significant difference.

PURPOSE

To provide a comprehensive systematic review and meta-analysis to examine the possible association between patient sex and the subjective and objective outcomes after ACL reconstruction.

METHODS

This study was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported clinical outcomes after ACL reconstruction in males and females independently were included in the review. A quantitative random-effects meta-analysis was performed to compare outcomes between sexes. For outcomes with considerable heterogeneity, meta-regression was used to identify potential moderators. Articles were evaluated qualitatively when quantitative data were not reported.

RESULTS

A total of 135 publications were included in the review. Females had inferior outcomes in instrumented laxity (standardized mean difference [SMD], 0.24; 95% CI, 0.11-0.37), revision rate (relative risk [RR], 1.15; 95% CI, 1.02-1.28), Lysholm score (SMD, -0.33; 95% CI, -0.55 to -0.11), Tegner activity scale (SMD, -0.37; 95% CI, -0.49 to -0.24), and incidence of not returning to sports (RR, 1.12; 95% CI, 1.04-1.21), all of which were statistically significant. Other outcomes were comparable between sexes, including anterior drawer test, Lachman test, pivot-shift test, timed single-legged hop test, single-legged hop test, quadriceps testing, hamstring testing, extension loss, flexion loss, development of cyclops lesion, and International Knee Documentation Committee (IKDC) knee examination score. Females and males were equally likely to develop anterior knee pain and osteoarthritis after ACL reconstruction. The graft rupture and graft failure rates did not differ significantly between sexes.

CONCLUSION

There were comparable or inferior results for females compared with males in all outcomes analyzed. No statistically significant sex difference was identified in most of the objective parameters. However, subjective and functional outcomes, including Lysholm score, Tegner activity scale, and ability to return to sports, have been shown to be poorer in females.

Predictors of contralateral anterior cruciate ligament reconstruction: a cohort study of 9061 patients with 5-year follow-up

BACKGROUND

Identifying predictors of contralateral anterior cruciate ligament (ACL) reconstruction is important to focus preventive strategies and related research on high-risk groups.

PURPOSE

To investigate predictors of contralateral ACL reconstruction in patients who have already undergone a primary ipsilateral reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This study was based on data from the Swedish National Knee Ligament Register from January 1, 2005, to December 31, 2013. Patients aged 13 to 59 years who underwent primary ipsilateral (index) ACL reconstruction with hamstring tendon or bone-patellar tendon-bone autografts were included. Follow-up started on date of index ACL reconstruction and ended either with primary contralateral ACL reconstruction, after 5 years of follow-up, or on December 31, 2013, whichever occurred first. The investigated variables were patient sex, age at index reconstruction, activity at the time of index injury, timing of surgery, graft selection, graft harvest site, and meniscal and chondral injury. The study end point was primary contralateral ACL reconstruction. Relative risks (RRs) and 95% CIs were calculated and adjusted for confounding factors using multivariate statistics.

RESULTS

A total of 9061 participants were included (n = 5196 males [57.3%] and 3865 females [42.7%]), of which 270 participants (3.0%) underwent primary contralateral ACL reconstruction during the 5-year follow-up. There was no difference in contralateral reconstruction rates between males and females (3.0% vs 2.9%, P = .695). Age <20 years significantly increased the risk of contralateral reconstruction (males: RR = 2.4 [95% CI, 1.7-3.4] and females: RR = 2.9 [95% CI, 1.9-4.5]; P < .001). Among female patients undergoing reconstruction using autograft hamstring, harvest of a contralateral hamstring tendon significantly increased this risk (RR = 3.4 [95% CI, 1.4-7.9]; P = .006).

CONCLUSION

In both male and female participants, age <20 years predicted an almost 3 times higher 5-year risk of contralateral ACL reconstruction. Among female participants undergoing reconstruction with autograft hamstring, a contralateral harvest predicted a more than 3 times higher 5-year risk of contralateral ACL reconstruction. Patient sex, activity at the time of index injury, graft selection, meniscal injury, and chondral injury were not predictors of contralateral ACL reconstruction.

Current state of anterior cruciate ligament registers

PURPOSE

The purpose of this work was to report the main characteristics and results of all active anterior cruciate ligament (ACL) reconstruction registers along with the differences between them.

METHODS

We systematically searched on Google and Medline via PubMed to identify ACL registers. National or regional registers were included if they were active and took into account ACL reconstructions. The main results and characteristics, namely the number of inclusions, exhaustivity, data collection methods and results dissemination methods were determined. The collected information was then submitted to each register for validation.

RESULTS

Four registers (3 national, 1 regional) were identified that routinely included every ACL reconstruction procedure. Register data were collected either through dedicated websites or on paper forms. All the registers used the same two outcome measures, namely the revision rate and a subjective patient score (KOOS score). Register results were made available through scientific publications or annual reports. The main differences between registers were in the graft choice and presence of associated meniscus and cartilage injuries.

CONCLUSIONS

Although there are only a few ACL reconstruction-specific registers, their scientific contribution is undeniable thanks to the quality of the collected data and the organization and collaboration between registers. Their impact on health care and science should grow in the future.

Computer-assisted surgery for knee ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults.

SEARCH METHODS

For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI).

MAIN RESULTS

The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.

AUTHORS' CONCLUSIONS

From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.

Computer-assisted surgery for knee ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults.

SEARCH METHODS

For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI).

MAIN RESULTS

The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.

AUTHORS' CONCLUSIONS

From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.