Notchplasty is associated with decreased risk of anterior cruciate ligament graft revision

Notchplasty in anterior cruciate ligament reconstruction: A systematic review of clinical outcomes

Introduction

Notchplasty is an adjuvant procedure performed during Anterior Cruciate Ligament reconstruction (ACLR) with the purpose of widening the intercondylar notch of the femur. Its use is controversial due to its biomechanical influence on the knee and the potential for increased complications. The purpose of this systematic review is to evaluate the outcomes of patients who underwent ACLR with notchplasty.

Materials and methods

A systematic search of Cochrane, Embase, and Medline was conducted to identify papers evaluating clinical outcomes of patients who underwent ACLR with notchplasty. Inclusion criteria encompassed human studies with a control group, reporting clinical outcomes such as graft failure, graft rupture, range of motion values, and patient-reported outcomes.

Results

A total of 4 studies were included comprising 396 patients (129 with notchplasty, 235 without). No significant differences were reported regarding graft survivability or Lysholm score between those with notchplasty and those without. One study reported significantly reduced rates of revision surgery after ACLR with notchplasty. There were conflicting complication rates between studies regarding chronic synovitis and arthrofibrosis.

Conclusion

Patients who undergo notchplasty during primary ACLR have similar outcome scores and risk of graft failure compared to those who do not undergo notchplasty. Notchplasty patients may also be at a higher risk for loss of extension and chronic synovitis.

Morphological Risk Factors for Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures

BACKGROUND

Both tibial spine fractures (TSFs) and anterior cruciate ligament (ACL) tears result in functional loss of knee stability. Nonetheless, it remains unclear why some patients sustain ACL tears, whereas others have TSFs.

PURPOSE

To identify the common morphological risk factors for pediatric ACL tears and TSFs and to determine the morphological differences between them using multiplanar reconstruction of magnetic resonance imaging (MRI).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Age- and sex-matched participants (159 total [53 ACL tears, 53 TSFs, and 53 controls]) aged <18 years who visited a pediatric tertiary-care center for ACL tears, TSFs, or anterior knee pain from March 2009 to April 2023 were included. Each group comprised 41 male and 12 female participants. Data on demographic characteristics and estimated bone age based on the knee MRI atlas were retrospectively collected, and various knee morphological parameters were evaluated using multiplanar reconstruction of MRI. Parameters showing significant differences among the 3 groups were selected as independent variables for multivariable multinomial logistic regression analysis, with the groups as dependent variables.

RESULTS

The mean chronological age at the time of MRI was 13.2 ± 2.3 years. Height, weight, body mass index, bone age, articular medial tibial slope, and bony medial tibial slope did not differ among the groups. Articular lateral tibial slope was independently associated with the occurrence of both ACL tears (relative risk ratio [RRR], 1.42 [95% confidence interval (CI), 1.16-1.74]; P = .001) and TSFs (RRR, 1.33 [95% CI, 1.10-1.62]; P = .004). A high notch width index was a protective factor against ACL tears (RRR, 0.86 [95% CI, 0.77-0.96]; P = .006) but not against TSFs (RRR, 1.01 [95% CI, 0.91-1.12]; P = .848).

CONCLUSION

A high articular lateral tibial slope was a common risk factor for ACL tears and TSFs. Patients with ACL tears had a narrower intercondylar notch than those with TSFs and controls.

Revision Anterior Cruciate Ligament Reconstructions at an Urban Tertiary Referral Center in Western India: A Retrospective Cross-Sectional Study

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is a surgery performed to achieve knee stability and allow the knee to return to the preinjury level. There has been a significant increase in the number of primary arthroscopic ACLRs in recent years. However, the increase in primary surgeries has led to a proportional rise in revision ACLRs, primarily due to failure of the index surgery resulting from various factors.

MATERIALS AND METHODS

Hospital records from August 2020 to July 2023 were analyzed for revision ACLRs carried out at our center by a single surgeon with one year of postoperative follow-up. The patients who met the inclusion criteria and consented to participate in the study were called for clinical follow-up, and Lysholm scoring was performed to assess the functional outcome of the surgery.

RESULTS

Twenty-eight patients met the inclusion criteria, 20 of whom consented to participate in the study. The mean age of the study population was 30.5 ± 6.82 years, with 85% (n=17) being males. There was a statistically significant difference in the Lysholm scores between primary and revision surgeries, with 50% (n=10) of patients having excellent outcomes (score >90) after index surgery and only 30% (n=6) falling into that category after revision surgery. There was a significant relationship between higher Lysholm scores and return to the preinjury level of play.

CONCLUSIONS

 Revision arthroscopic ACLRs have good functional outcomes in the short and medium terms and are excellent for restoring knee stability. However, the outcomes are fair compared with those of primary arthroscopic ACLRs.

Postoperative Return to Play and the Role of Imaging

Return to play (RTP) following surgery is a complex subject at the interface of social and internal pressures experienced by the athlete, psychological readiness, and intrinsic healing of the surgically repaired structures. Although functional testing, time from surgery, clinical examination, and scoring metrics can help clarify an athlete's readiness to return to sport, imaging can allow for a more direct assessment of the structures in question. Because imaging is often included in the diagnostic work-up of pain following surgery, the radiologist must be familiar with the expected postsurgical imaging appearance, as well as the associated complications. We briefly review such findings following anterior cruciate ligament reconstruction, Achilles tendon repair, syndesmotic fixation, and ulnar collateral ligament reconstruction in the context of the athlete, highlighting issues related to RTP.

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction

PURPOSE

In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts.

METHODS

Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D).

RESULTS

The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D.

CONCLUSIONS

Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement.

LEVEL OF EVIDENCE

Level III.