Same knee, different goals: patients and surgeons have different priorities related to ACL reconstruction

Reconceptualisation of sport and quality of life in young athletes following anterior cruciate ligament reconstruction: understanding the experiences behind the numbers through a prospective mixed-methods study

To explore the theory of response shift in young athletes undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) by investigating athletes' conceptualisation of quality of life (QOL) across time following ACL injury. A mixed-methods study was conducted to understand young athletes' perceived QOL through qualitative investigation of participant perspectives and quantitative self-reported QOL ratings. 20 young athletes were purposively sampled for semi-structured interviews at two timepoints: preoperatively following ACL injury, and 1 year after ACLR. During the interviews, participants also reported their QOL on a visual analogue scale from 0 to 100. Transcripts were coded by two independent researchers. Descriptive quantitative analyses of QOL ratings and thematic analysis of qualitative data were conducted to identify mechanisms of response shift. Self-reported ratings of QOL indicated a recalibration response shift. When recalled preoperative scores were used in place of actual preoperative ratings, improvement in self-reported QOL was larger (median change: 13, range -6 to 62 vs median change: 29, range 5 to 75, respectively). Postoperatively, three processes of reprioritisation related to sport were identified within 16 interviews 1 year after surgery: (1) early transition away from sport as a priority, (2) expected transition away from sport as a priority and (3) sport preserved as a priority. Athletes' perception of overall QOL was influenced by the use of various coping strategies and engagement in self-reflection. QOL does not mean the same things to athletes before and after ACLR, and conceptualisations of QOL are influenced by complex factors. True change in patient-reported outcomes cannot be validly measured if the definitions of constructs are changing. We propose the SPARQ ACL Model of Sport Prioritisation and Athlete Reconceptualisation of Quality of life following ACL injury and reconstruction to help understand these changes.

Evaluation of Outcomes After Anterior Cruciate Ligament Reconstruction: What We Know, What We Have, and What to Consider

Measurement of success following anterior cruciate ligament reconstruction (ACLR) hinges on the appropriate use of high quality and meaningful outcome measures. We identified and categorized over 100 outcome measures for ACLR using the International Classification of Functioning, Disability and Health (ICF) model. The ICF model is a useful framework to facilitate decisions about outcome selection and describe recovery following ACL injury. We outline key considerations when selecting outcome measures during study design (purpose, measurement properties, sample size, global assessment) or evaluating reported outcomes (measurement properties, sample size, magnitude/precision, clinical relevance, applicability), and discuss challenges in outcome measurement following ACLR.

Avoiding Graft Failure: Lessons Learned from the Stability Trial

The Stability Study was a multicenter, pragmatic, parallel groups, randomized clinical trial comparing hamstring tendon autograft anterior cruciate ligament reconstruction with or without the addition of lateral extra-articular tenodesis in young patients at high risk of graft failure. Having recruited 618 patients with a 5% loss to follow up, we were able to demonstrate a clinically and statistically significant reduction in clinical failure and graft rupture at 2 years postoperative. No differences in patient-reported outcomes (PROs) were demonstrated between groups; however, patients who experienced an adverse event had significantly worse PROs than those who did not.

Revision Rates After Primary ACL Reconstruction Performed Between 1969 and 2018: A Systematic Review and Metaregression Analysis

Background:

Numerous studies, including randomized controlled trials (RCTs), have been published on the optimal graft choice for primary anterior cruciate ligament (ACL) reconstruction.

Purpose:

To review existing studies to investigate whether advances in orthopaedics have affected revision rates after primary ACL reconstruction.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed database was searched from inception to December 31, 2020, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patient series, observational studies, clinical trials, and registry-based studies investigating primary ACL reconstruction were included, as were high-quality RCTs from an additional study. The minimum required follow-up time for inclusion was 1 year. The primary outcome measure was the pooled prevalence of revision ACL reconstruction. The effect of the year the surgery was performed on revision rates was evaluated with metaregression analysis. All graft types were analyzed simultaneously, and all analyses were repeated separately for each graft type.

Results:

Overall, 330 articles with 52,878 patients were included, with a median patient age of 28 years (range, 15-57 years). The primary ACL reconstructions were performed between 1969 and 2018. At a median of 2.3 years of follow-up, the overall revision rate was 3.14% (95% CI, 2.76% to 3.56%); it was 2.71% (95% CI, 2.25% to 3.27%) for hamstring autografts, 2.38% (95% CI, 1.82% to 3.11%) for bone–patellar tendon–bone (BPTB) autografts, and 5.24% (95% CI, 4.02% to 6.80%) for other graft types. For hamstring grafts, the revision rate increased over time (year of surgery), with a 0.0434 (95% CI, 0.0150 to 0.0718) increase effect in the logit-transformed scale for every additional year. There was a slight decrease in revision rates for BPTB (β = –0.0049; 95% CI, –0.0352 to 0.0254) and other graft types (β = –0.0306; 95% CI, –0.0608 to −0.0005) over time; however, confidence intervals for BPTB included the zero change.

Conclusion:

Based on this systematic review and meta-analysis, ACL reconstruction is a reliable procedure with overall low historical revision rates. BPTB autograft had the lowest revision rate and a slightly decreasing trend of failures during the past 45 years, although both BPTB and hamstring autografts are reliable graft choices.