Patient-Related Risk Factors for Contralateral Anterior Cruciate Ligament (ACL) Tear After ACL Reconstruction: An Analysis of 3707 Primary ACL Reconstructions

Association of Smokeless Tobacco Use With Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Previous studies focus on tobacco as a broad categorization of traditional smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR.

PURPOSES

To (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke tobacco.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary ACLR with a minimum 2-year follow-up were included. Smokeless tobacco users (n = 898), cigarette smokers (n= 22,062), and non-tobacco users (n= 207,462) were matched based on patient variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were used to control for confounding variables.

RESULTS

Compared with nonusers, smokeless tobacco users demonstrated an increased risk of pneumonia (odds ratio [OR], 3.36; 95% CI, 1.41-7.90), acute kidney injury (OR, 12.7; 95% CI, 3.77-52.8), and emergency department (ED) utilization (OR, 6.29; 95% CI, 3.70-10.9) within 90 days of the ACLR. Additionally, smokeless tobacco users had an increased risk of ACLR (OR, 4.75; 95% CI, 3.60-6.26) and meniscal surgery (OR, 2.89; 95% CI, 2.23-3.73) within 2 years. When compared with cigarette smokers, smokeless tobacco users showed an increased risk of pneumonia (OR, 3.25; 95% CI, 1.33-7.78), acute kidney injury (OR, 7.63; 95% CI, 2.72-22.5), and ED visits (OR, 1.55; 95% CI, 1.26-1.90) within 90 days and subsequent ACLR (OR, 4.81; 95% CI, 3.58-6.47) and meniscal surgery (OR, 3.23; 95% CI, 2.45-4.26) within 2 years.

CONCLUSION

Smokeless tobacco use was associated with an increased risk of medical complications, ED utilization, and subsequent procedures compared with nonuser controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.

Higher Unilateral Muscle Imbalance at the Contralateral Knee 6 Months after Anterior Cruciate Ligament Reconstruction

There are a considerable number of patients who, after anterior cruciate ligament reconstruction (ACL), suffer from relapses or reduced performance. Data collected from isokinetic dynamometry can provide useful information on the condition of the knee during rehabilitation. Seventy-one young sports patients with ACL reconstruction performed concentric (CON) isokinetic dynamometry (CON/CON 90°/s and CON/CON 240°/s) to assess the muscle strength of the quadriceps (Q) and hamstrings (H) in both knees at 6 months after ACL reconstruction. Limb symmetry index (LSI) and the H/Q ratio were calculated. Comparative statistical tests and multivariate regression were performed. At 90°/s, 57 patients (80.3%) had an LSI below 90% for quadriceps and 28 (60.6%) for hamstring. The number of imbalanced patients according to H/Q ratio was higher in the non-operated knee (n = 56, 78.9%) (p < 0.001). At 240°/s, 49 cases (69.1%) had LSI values above 90% for quadriceps and 37 (52.1%) for hamstrings. Regarding H/Q, imbalanced cases were higher in the non-operated limb (n = 60, 84.5%) (p < 0.001). Strength data at 6 months after ACL reconstruction and post-operative rehabilitation indicated greater unilateral (H/Q) muscle imbalance in the non-operated knee than in the operated knee. Most patients did not achieve the adequate LSI values.

Obesity-associated outcomes after ACL reconstruction: a propensity-score-matched analysis of the US Nationwide Inpatient Sample 2005-2018

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common among physically active individuals, and obesity may increase the risk of such injuries due to factors like biomechanical stress on the knee. We aimed to determine if obesity affects postoperative outcomes after ACL reconstruction.

METHODS

Data from adults aged 20 years and older with ACL injuries who underwent inpatient reconstruction from 2005 to 2018 were extracted from the United States (US) Nationwide Inpatient Sample (NIS) database. Patients were divided into two groups based on the presence of co-existing obesity, defined as a body mass index (BMI) ≥ 30 kg/m2. Propensity-score matching (PSM) was employed to balance between-group differences. Associations between obesity and concomitant meniscus injury, length of stay (LOS), post-procedural complications, and non-routine discharge were examined using univariate and multivariable logistic and linear regressions.

RESULTS

After PSM, data from 1323 patients (representing 6396 individuals in the US) were analyzed. Of these, 441 (33%) were classified as obese, while 882 (67%) were not obese. After adjustment, obesity was significantly associated with a longer LOS (adjusted beta (aBeta) = 0.32, 95% confidence interval (CI) 0.31-0.321) and an increased likelihood of non-routine discharge (adjusted OR (aOR) = 2.18, 95% CI 1.47-3.22). There were no significant associations between obesity and concomitant meniscus injury (aOR = 1.04, 95% CI 0.81-1.32) or post-procedural complications (aOR = 0.97, 95% CI 0.74-1.27).

CONCLUSIONS

In patients undergoing ACL reconstruction in the US, obesity is independently associated with a longer LOS and a higher risk of non-routine discharge. Nevertheless, obesity does not appear to be associated with concomitant meniscus injury or post-procedural complications.

Diabetes in Orthopaedic Sports Medicine Surgeries Standard Review

Diabetes mellitus has been shown to affect the outcomes of various orthopaedic procedures. Although orthopaedic sports medicine procedures tend to be less invasive and are often performed on younger and healthier patients, diabetes is associated with an increased risk of postoperative infection, readmission, and lower functional outcome scores. However, this risk may be moderated by the glycemic control of the individual patient, and patients with a low perioperative hemoglobin A1c may not confer additional risk. Further research is needed to evaluate the impact of diabetes on surgical outcomes in sports orthopaedics is needed, with the goal of evaluating mediating factors such as glycemic control in mind.

Improvements in Physical Function and Pain Interference and Changes in Mental Health Among Patients Seeking Musculoskeletal Care

Importance

Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health.

Objective

To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care.

Design, Setting, and Participants

This cohort study included adult patients treated by an orthopedic department of a tertiary care US academic medical center from June 22, 2015, to February 9, 2022. Eligible participants presented between 4 and 6 times during the study period for 1 or more musculoskeletal conditions and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit.

Exposure

PROMIS Physical Function and Pain Interference scores.

Main Outcomes and Measures

Linear mixed effects models were used to determine whether improvements in PROMIS Anxiety and PROMIS Depression scores were associated with improved PROMIS Physical Function or Pain Interference scores after controlling for age, gender, race, and PROMIS Depression (for the anxiety model) or PROMIS Anxiety (for the depression model). Clinically meaningful improvement was defined as 3.0 points or more for PROMIS Anxiety and 3.2 points or more for PROMIS Depression.

Results

Among 11 236 patients (mean [SD] age, 57 [16] years), 7218 (64.2%) were women; 120 (1.1%) were Asian, 1288 (11.5%) were Black, and 9706 (86.4%) were White. Improvements in physical function (β = -0.14; 95% CI, -0.15 to -0.13; P < .001) and pain interference (β = 0.26; 95% CI, 0.25 to 0.26; P < .001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of 21 PROMIS points or more (95% CI, 20-23 points) on Physical Function or 12 points or more (95% CI, 12-12 points) on Pain Interference would be required. Improvements in physical function (β = -0.05; 95% CI, -0.06 to -0.04; P < .001) and pain interference (β = 0.04; 95% CI, 0.04 to 0.05; P < .001) were not associated with meaningfully improved depression symptoms.

Conclusions and Relevance

In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms, and were not associated with any meaningful improvement in depression symptoms. Patients seeking musculoskeletal care clinicians providing treatment cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety.

Incidence and risk factors for revision and contralateral anterior cruciate ligament reconstruction: A population-based retrospective cohort study

There is a limited data on epidemiology of primary and recurrent anterior cruciate ligament reconstruction (ACLR) in Canada. The objectives of this study were to examine the incidence and factors associated with recurrent ACLR (revision and contralateral ACLR) in a western Canadian province of Alberta. We conducted a retrospective cohort study with an average follow up of 5.7 years. Albertans aged 10 to 60 years with a history of primary ACLR between 2010/11 to 2015/16 were included in the study. Participants were followed up until March 2019 to observe outcomes: Ipsilateral revision ACLR and contralateral ACLR. Kaplan Meir approach was used to estimate event free survival and Cox proportional hazard regression analysis was conducted to identify associated factors. Of the total participants with a history of primary ACLR on a single knee (n = 9292), n = 359, 3.9% (95% confidence interval: 3.5-4.3) underwent a revision ACLR. A similar proportion among those having primary ACLR on either knee (n = 9676), n = 344, 3.6% (95% confidence interval: 3.2-3.9) underwent a contralateral primary ACLR. Young age (<30 years) was associated with increased risk of contralateral ACLR. Similarly, young age (<30 years), having initial primary ACLR in winter and having allograft were associated with a risk of revision ACLR. Clinicians can use these findings in their clinical practice and designing rehabilitation plans as well as to educate patients about their risk for recurrent anterior cruciate ligament tear and graft failure.

Biomechanical Gender Differences in the Uninjured Extremity After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes: A Retrospective Motion Analysis Study

Introduction Subsequent anterior cruciate ligament (ACL) injury is more common in the pediatric population and encompasses graft failure and subsequent contralateral tears. Females are at a higher risk. The purpose of the present study was to compare the knee valgus angles at initial contact, knee extension moments, anterior and lateral knee joint forces, hip flexion angles, hip adduction moments, and ankle inversion during the drop vertical test in the uninjured extremity between adolescent males and females who had previously undergone an anterior cruciate ligament reconstruction (ACLR). Methods This IRB-approved retrospective chart review included patients aged 8-18 years who were seen at the five to seven month postoperatively following ACL reconstruction. A total of 168 patients met our inclusion criteria (86 girls and 82 boys.) Using three-dimensional motion capture technology (CORTEX software, Motion Analysis Corp., Rohnert Park, CA), data were collected while the subject performed the drop vertical test over floor-mounted force plates (FP-Stairs, AMTI, Watertown, MA) under the direct supervision of a pediatric physical therapist. The Wilcoxon rank sum was used, and p < 0.05 was considered statistically significant. Results Females demonstrated a larger average knee joint extension moment (0.31 vs 0.28 N*m/kg, p = 0.0408), a larger anterior knee joint force at initial contact (3.51 vs. 2.79, N/kg, p = 0.0458), larger average hip flexion angle (41.50° vs. 35.99°, p = 0.0005), a smaller maximum hip adduction moment (0.92 vs. 1.16, N*m/kg, p = 0.0497), and a smaller average ankle inversion angle (5.08° vs. 6.41°, p = 0.03231). No significant differences were found regarding knee abduction angle or lateral knee joint force. Conclusions The biomechanical profile of the contralateral extremity varies significantly between the genders after ACLR. In the uninjured extremity, females may have larger hip flexion angles, smaller hip adduction moments, larger anterior knee joint forces, larger knee extension moments, and smaller ankle inversion angles as compared to males after ACLR. These findings may explain the higher incidence of subsequent contralateral injury in female adolescent athletes. Further work is required to develop a composite score that determines at-risk athletes.

Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review

PURPOSE

The purpose of this study is to develop a comprehensive complications profile for quadriceps tendon-autograft anterior cruciate ligament reconstruction (QT ACL-R).

METHODS

A traditional and grey literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non-randomised studies and Cochrane's RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random-effects model.

RESULTS

A total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B-QT), 19 used all-soft tissue quadriceps tendon (S-QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2-58 years and an average reported follow-up time of 28.1 months (range, 6-90 months) for non-randomised studies and 34.3 months (range, 0.233-120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor-site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor-site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%.

CONCLUSIONS

QT ACL-R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL-R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices.

LEVEL OF EVIDENCE

Level IV.

REGISTRATION

This study was preregistered under PROSPERO with preregistration code CRD42022302078.

No differences found in long-term outcomes of a randomized controlled trial comparing ipsilateral versus contralateral hamstring graft in ACL reconstruction

PURPOSE

Contralateral graft harvest in primary ACL reconstruction is relatively uncommon and the long-term comparative of this approach relative to ipsilateral harvest has not been described. The purpose of this study was to evaluate ACL graft and contralateral rupture following ipsilateral or contralateral semitendinosus and gracilis (STG) graft harvest at follow-up of a minimum 10 years post-reconstruction in the treatment of a complete ACL tear.

METHODS

Patients from a previous randomized trial were evaluated. The primary outcome measures were ipsilateral and contralateral reinjury as well as the International Knee Documentation Committee (IKDC) knee assessment form, the ACL Quality of Life questionnaire (ACL-QoL) and the Tegner activity scale. Participants completed four different single-leg hop tests and concentric knee flexion and extension strength were assessed on an isokinetic dynamometer.

RESULTS

Of the original 100 patients, 50 patients (41.3 ± 9.5 years of age, 31 males, 19 females) reported on re-injury at 12.6 ± 1.4 years post-operative. Thirty-eight patients returned for full assessment and 12 responded by mail or phone survey. There were no differences between groups for graft rupture, contralateral injury, ACL-QoL score, IKDC categorization, or anterior tibial translation, though both groups experienced a reduction in the Tegner Activity Scale from their preinjury scores. There was no difference in knee flexor and extensor isokinetic concentric strength, or single leg hop test performance. Knee flexor strength limb symmetry index was reduced when measured in the supine relative to the seated position in both groups, indicating persistent deficits in knee flexor strength when measured in the supine position.

CONCLUSION

Contralateral hamstring harvest does not put patients at an increased risk of a contralateral ACL tear and long-term outcomes of ACL reconstruction do not differ based on the side of graft harvest. Contralateral STG harvest may provide a safe alternative surgical option for select patients.

LEVEL OF EVIDENCE

Level II.

Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score

PURPOSE

To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups.

METHODS

Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores.

RESULTS

A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study.

CONCLUSIONS

Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.