Knee laxity and functional knee outcome after contralateral ACLR are comparable to those after primary ACLR

Revision ACL reconstruction, but not bilateral ACL reconstruction, is associated with clinically relevant inferior subjective knee function compared with primary ACL reconstruction: A comparative analysis of 6831 patients

PURPOSE

To evaluate and compare the subjective knee function in patients undergoing revision and bilateral anterior cruciate ligament (ACL) reconstruction (ACLR) with those undergoing primary ACLR in a large cohort.

METHODS

Patients without concomitant ligament injuries who underwent primary, revision or bilateral ACLR at the Capio Artro Clinic, Stockholm, Sweden, between 2005 and 2018 were identified. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2 and 5 years postoperatively from the Swedish National Knee Ligament Registry. Patients who underwent revision and bilateral ACLR were compared with those who underwent primary ACLR (control group) using Student's t test.

RESULTS

A total of 6831 patients (6102 with primary ACLRs, 343 with revision ACLRs and 386 with bilateral ACLRs) were included. Preoperatively, there were significant but nonclinically relevant differences in favour of the revision ACLR group for KOOS Symptoms, Pain, Activities of Daily Living (ADL) and Sport/Rec subscale scores compared with the primary ACLR group. Postoperatively, except for the 1-year Symptoms and ADL subscales, the revision ACLR group reported significantly lower scores on all KOOS subscales than the primary ACLR group, with clinically relevant differences (>8-10 points) for the 1-, 2- and 5-year Sport/Rec and Quality of Life (QOL) subscales. The bilateral ACLR group reported significantly, but not clinically relevant, inferior scores on the 1-year Symptoms and QOL subscales and the 5-year Sport/Rec and QOL subscales compared with the primary ACLR group.

CONCLUSIONS

Revision ACLR, but not bilateral ACLR, was associated with clinically relevant inferior subjective knee function compared with primary ACLR. It is important to counsel patients regarding their future subjective knee function after repeated ACLR. Compared to primary ACLR, inferior subjective results should be expected after revision ACLR, but not after bilateral ACLR.

LEVEL OF EVIDENCE

Level III.

Knee Cartilage Change within 5 Years after Aclr Using Hamstring Tendons with Preserved Tibial-Insertion: A Prospective Randomized Controlled Study Based on Magnetic Resonance Imaging

Background: Comparing to anterior cruciate ligament reconstructions (ACLR) with free hamstring tendon (FHT), ACLR with preserved tibial-insertion hamstring tendon (HT-PTI) could ensure the blood supply of the graft and avoid graft necrosis. Yet, whether HT-PTI could protect the cartilage and clinical outcomes in mid-long period after ACLR was still unclear. Purpose: To compare the cartilage change and clinical results between the HT-PTI and FHT in 5 years after ACLR. Study design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 45 patients who underwent isolated ACLR with the autograft of hamstring tendons were enrolled and randomized into 2 groups. The study group undertook ACLR with HT-PTI, whereas the control group had FHT. At pre-operation, and 6, 12, 24, and 60 months post-operation, all cases underwent evaluation with Knee Injury and Osteoarthritis Outcome Score (KOOS), and MR examination. The knee cartilage was divided into 8 sub-regions of which the T2 value and cartilage volume on MRI were measured and documented. The data of two groups were compared and their correlations were analyzed. Results: A total of 18 patients in the HT-PTI group and 19 patients in the FHT group completed the follow-up. The KOOS scores were improved at each follow-up time point (p < 0.001), reached the most superior at 12 months and maintained until 60 months but had no significant difference between the two groups. At 60 months, the cartilage in most subregions in FHT group had higher T2 values than those of pre-operation (p < 0.05) and also higher than HT-PTI group; The cartilage volume changes (CV%) are positive at 6 months and negative from 12 to 60 months in the FHT group, while being negative at all time points in the HT-PTI group. The values of absolute CV% in most subregions in FHT group were significantly higher than those in the HT-PTI group at 6 and 60 months (p < 0.05). Conclusion: The improvement of KOOS score peaked at 12 months in all cases and had no difference between the two groups. The cartilage in the FHT group had more volume loss, earlier and wider damage than that in the HT-PTI group within 5 years. No significant correlation was found among KOOS score, CV%, and T2 value.

Comparison of Knee Function and Activity Level Between Bilateral and Unilateral ACL Reconstruction: A Matched-Group Analysis With Minimum 5-Year Follow-up

Background:

There is a lack of knowledge regarding knee function and activity level after bilateral anterior cruciate ligament reconstruction (ACLR) at midterm follow-up.

Purpose:

To compare activity level, patient-reported knee function, and quality of life in patients with bilateral ACLR and matched controls with unilateral ACLR at a minimum 5-year follow-up.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with bilateral ACLR who were aged ≤40 years and had a second ACLR performed between 2010 and 2015 were identified in the authors’ local database. Surgical data and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted. The patients were sent a letter with questionnaires including the KOOS, EuroQol 5-Dimensions (EQ-5D), and EuroQol visual analog scale (EQ-VAS) and were asked study-specific questions by telephone regarding activity level and knee function at a minimum 5-year follow-up. For every patient with bilateral ACLR, a control matched for age ±2 years, sex, year ACLR was performed, and preinjury activity level or sport at the time of injury were identified in the database.

Results:

A total of 98 patients (mean age ± SD, 33.3 ± 7.3 years) with bilateral ACLR and 98 patients with unilateral ACLR (mean age ± SD, 33.1 ± 7.7 years) were included. The mean postoperative follow-up was 7.6 ± 1.8 years (from the second ACLR) for patients with bilateral ACLR and 7.8 ± 1.7 years for patients with unilateral ACLR. Patients with bilateral ACLR reported lower scores on all KOOS subscales, the EQ-5D, and the EQ-VAS at follow-up (P < .05). There was no difference in activity level between the groups at follow-up, but patients with bilateral ACLR were less satisfied with their activity level and knee function (P < .05).

Conclusion:

Patient-reported knee function and health-related quality of life were inferior in patients with bilateral ACLR compared with patients with unilateral ACLR. Patients with bilateral ACLR cannot expect the same knee function and quality of life as patients with unilateral ACLR.

Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR

PURPOSE

To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR.

METHODS

Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005-2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR.

RESULTS

A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m², time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28-0.58; P < 0.001), time from injury to surgery ≥ 12 months (OR 0.48; 95% CI 0.30-0.75; P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04-2.34; P = 0.03).

CONCLUSION

Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR.

LEVEL OF EVIDENCE

Level III.