Effect of patient age on morphology of anterior cruciate ligament grafts at second-look arthroscopy

Preserving Knee Health and Delivering Specialized Care for Active Older Athletes

CONTEXT

Athletes differ from recreational exercisers in many characteristics and often require tailored treatments uniquely adapted to their situations and requirements. This practice is highlighted in young and middle-aged high-performance athletes. However, with advancing age and declining physical performance, age often outweighs athleticism, discounting the existing distinctions. This review focuses on physiological age-related processes in active older athletes and common knee conditions and elucidates the differences in preventing and treating knee injuries from the active adult population.

EVIDENCE ACQUISITION

Nonsystematic review with critical appraisal of existing literature.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Nonsteroidal anti-inflammatory drugs may interfere with the muscle hypertrophy mechanism in older athletes and it may be beneficial to adapt to other pharmacological interventions for knee osteoarthritis (OA). Arthroplasty is not typically compatible with high level sports activities; anterior cruciate ligament reconstruction surgery in the older athlete may be an effective option to improve function and enable return to sport, especially in the absence of OA. Chronic degenerative meniscal injuries can usually be treated conservatively, regardless of subjective mechanical symptoms. Acute traumatic meniscal tears in nonarthritic knees that cause effusions or reproducible mechanical symptoms may yet be considered for repair at any age. Conservative options are more dominant for patella tendinopathy, where platelet-rich plasma may be more effective than the classic extracorporeal shockwave therapy.

CONCLUSION

With the increase of the active older athletic population, prevention and injury treatment strategies must be balanced and tailored to their individual needs. Older athletes have various goals and demands in their respective sports, necessitating distinct prevention and treatment strategies.Strength of Recommendation Taxonomy (SORT):B.

Effect of Remnant Continuity on Postoperative Outcomes After Remnant Tensioning Anterior Cruciate Ligament Reconstruction in Respect to Clinical, Radiological, and Second-Look Arthroscopic Criteria

Background

Remnant tensioning (RT) anterior cruciate ligament (ACL) reconstruction has been reported to have excellent postoperative outcomes for femoral-side tears. However, the influence of remnant continuity (RC) on the postoperative results after RT ACL reconstruction remains unclear.

Purpose

To investigate the effects of RC on the postoperative clinical, radiological, and second-look arthroscopic outcomes after RT ACL reconstruction for femoral-side ACL tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

This study included 94 patients who underwent RT ACL reconstruction using the hamstring tendon for femoral-side ACL tears between 2015 and 2020. The patients were divided into 2 groups according to the continuity of the remnant tissue: RC (n = 50) and remnant discontinuity (RD) (n = 44). Stability tests, including the Lachman and pivot-shift tests, side-to-side difference on Telos stress radiographs and KT-2000 arthrometer, patient-reported outcome measurements (PROMs), and graft status on postoperative magnetic resonance imaging (MRI) and second-look arthroscopy were evaluated.

Results

Results of all stability tests and PROMs significantly improved postoperatively. The mean follow-up periods were 35.3 and 36.8 months in the RC and RD group, respectively. The 2 groups showed no statistically significant differences in stability outcomes or PROMs. Furthermore, the RC and RD groups showed comparable postoperative graft status on postoperative MRI and second-look arthroscopy.

Conclusion

RT ACL reconstruction for RD between the femoral insertion site and ACL tissue showed comparable postoperative outcomes, including stability test, PROMs, postoperative MRI, and second-look arthroscopic data, to surgery for RC in femoral-side tears.

Articular Cartilage Damage in the Patellofemoral Compartment at ACL Reconstruction Predicts Poor Postoperative Subjective Outcomes in Patients Age 40 and Older

The purpose of this study was to investigate factors that influence clinical outcomes after anterior cruciate ligament (ACL) reconstruction in patients aged ≥40 years. We studied 264 patients aged ≥40 and 154 patients aged ≤20 years who underwent ACL reconstruction at several surgical centers. A logistic regression analysis was conducted to identify factors that influenced the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 1 year post-ACL reconstruction. In the older patient group, cartilage damage in the patellofemoral compartment at surgery was a significant risk factor for poor postoperative KOOS subscores (pain, activities of daily living [ADL], sports, and quality of life [QOL]). Articular cartilage damage in the lateral compartment also significantly influenced one of the postoperative KOOS subscores (symptoms). In the younger patient group, articular cartilage damage in any compartments did not influence the postoperative KOOS subscores; only two preoperative KOOS subscores (symptoms and QOL) significantly influenced their postoperative KOOS subscores. We concluded that the articular cartilage damage in the patellofemoral compartment at ACL reconstruction predicts poor KOOS subscores at the 1-year follow-up in patients aged ≥40 years. STUDY DESIGN:  Cohort study (Prevalence); Level of evidence, 2.

Anterior Cruciate Ligament Reconstruction in Patients Over 40 Years Old Shows Low Failure Rates: A Systematic Review

Purpose

To review the literature reporting on complications and failure rates after primary anterior cruciate ligament reconstruction (ACLR) in patients ≥40 years.

Methods

This was a secondary analysis from a prior systematic review of the MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases on studies evaluating clinical outcomes in ACLR patients ≥40 years. Studies were included based on the following criteria: English-language studies reporting on postoperative complications and/or ACLR failure rates in patients ≥40 years. Case reports, technical notes, studies with duplicate reporting of patient cohorts, or studies using publicly available registry data were excluded. ACLR failure definitions, failure rates, graft rupture rates, revision ACLR and non-ACLR revision rates, and complication rates were recorded.

Results

Twenty-one studies were included following full-text review. Autografts were used in 89.0% of cases. Definitions for ACLR failure varied, ranging from (1) revision ACLR, (2) graft rupture, (3) clinical examination of increased knee laxity, and (4) postoperative arthrofibrosis requiring an additional surgery. The median ACLR failure rate was 5.0% (range, 0%-12.1%) among the 9 studies reporting this outcome, with only 4 of the studies providing explicit definitions of failure. The median ACLR revision surgery, graft rupture, and non-ACLR revision surgery rates were 0% (range, 0%-7.7%), 2.7% (range, 0%-9.1%), and 7.2% (range 0%-34.4%), respectively. Commonly reported complications included pain (range, 0%-14.0%), stiffness (range, 0%-12.7%), hematoma (range, 2.5%-8.8%), neurovascular (range, 0%-41.7%), and undefined (range, 0%-13.8%).

Conclusions

ACLR in patients over 40 years old shows low failure rates.

Level of Evidence

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

Effects of higher femoral tunnels on clinical outcomes, MRI, and second-look findings in double-bundle anterior cruciate ligament reconstruction with a minimal 5-year follow-up

BACKGROUND

To perform anatomical anterior cruciate ligament reconstruction (ACLR), tunnels should be placed relatively higher in the femoral anterior cruciate ligament (ACL) footprint based on the findings of direct and indirect femoral insertion. But the clinical results of higher femoral tunnels (HFT) in double-bundle ACLR (DB-ACLR) remain unclear. The purpose was to investigate the clinical results of HFT and lower femoral tunnels (LFT) in DB-ACLR.

METHODS

From September 2014 to February 2016, 83 patients who underwent DB-ACLR and met the inclusion and exclusion criteria were divided into HFT-ACLR (group 1, n = 37) and LFT-ACLR (group 2, n = 46) according to the position of femoral tunnels. Preoperatively and at the final follow-up, clinical scores were evaluated with International Knee Documentation Committee (IKDC), Tegner activity, and Lysholm score. The stability of the knee was evaluated with KT-2000, Lachman test, and pivot-shift test. Cartilage degeneration grades of the International Cartilage Repair Society (ICRS) were evaluated on magnetic resonance imaging (MRI). Graft tension, continuity, and synovialization were evaluated by second-look arthroscopy. Return-to-sports was assessed at the final follow-up.

RESULTS

Significantly better improvement were found for KT-2000, Lachman test, and pivot-shift test postoperatively in group 1 ( P >0.05). Posterolateral bundles (PL) showed significantly better results in second-look arthroscopy regarding graft tension, continuity, and synovialization ( P <0.05), but not in anteromedial bundles in group 1. At the final follow-up, cartilage worsening was observed in groups 1 and 2, but it did not reach a stastistically significant difference ( P >0.05). No statistically significant differences were found in IKDC subjective score, Tegner activity, and Lysholm score between the two groups. Higher return-to-sports rate was found in group 1 with 86.8% (32/37) vs. 65.2% (30/46) in group 2 ( P = 0.027).

CONCLUSION

The HFT-ACLR group showed better stability results, better PL, and higher return-to-sports rate compared to the LFT-ACLR group.

Double-bundle anterior cruciate ligament reconstruction in patients aged 60 years and older

Background

This study aimed to examine the clinical outcomes of double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in patients aged ≥60 years.

Methods

Anatomical DB-ACL reconstruction using hamstring tendon autografts was performed in 13 patients aged ≥60 years at our institution between June 2012 and May 2018. The patients included seven men and six women, and the mean age at surgery was 65.0 years (range, 60-73 years). The mean time from injury to surgery was 80.5 months (range, 1-480 months), and the mean follow-up time was 26.2 months (range, 24-42 months). All patients were assessed based on physical examination findings, clinical scores, Kellgren-Lawrence grades preoperatively and at the final postoperative follow-up, intraoperative meniscal or chondral lesions, and perioperative complications. Status of returning to sports for all patients was assessed at the final follow-up.

Results

The mean side-to-side differences by arthrometer improved from 4.3 mm (range, 2-8 mm) to 0.9 mm (range, 0-2 mm), and the positive pivot-shift test decreased from 100% to 8%. The mean extensor muscle strength was 93.3% (range, 74-116%) postoperatively. The mean Lysholm score improved from 71.1 (range, 27-85) to 95.2 (range, 89-100). Ten of the 13 patients (77%) returned to their pre-injury level of sports performance, and one patient (8%) returned to sports with less intensity. Intraoperatively, meniscal tears were observed in 10 patients (77%), and chondral lesions >grade 2 were observed in 11 (85%). One patient developed perioperative complications. At the final follow-up, the Kellgren-Lawrence grade worsened in only one patient. No re-injury or infection was observed, and revision surgery was not required for any patients.

Conclusions

Anatomical DB-ACL reconstruction could provide satisfactory clinical outcomes and knee function restoration in patients aged ≥60 years.

Level of evidence

A retrospective study, case series (IV).

Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial

PURPOSE

To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial.

METHODS

From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups.

RESULTS

Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups.

CONCLUSIONS

The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented with Ligament Augmentation and Reconstruction Systems (LARS) or Synthetic Meshwork of LARS Compared with Four-Strand Hamstring Tendon Grafts Alone, a Prospective, Randomized Clinical Study with 2- to 8-Year Follow-Up

Purpose

To compare the long-term outcomes of anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft alone (hamstring group) or with synthetics (Ligament Augmentation and Reconstruction System, LARS group) or synthetic meshwork of LARS (meshwork group).

Methods

Patients who underwent ACL reconstruction using four-strand hamstring tendon grafts (hamstring group), autologous hamstrings augmented with the LARS (LARS group), or synthetic meshwork of LARS (meshwork group) were selected in this prospective randomized clinical study. Patient-reported outcome measures (PROMs) were obtained preoperatively; at 6, 12, and 18 months postoperatively; and at final follow-up between 3 and 8 years. Second-look arthroscopic findings were used to evaluate graft morphology based on graft tension, graft tear, and synovial coverage.

Results

A total of 141 consecutive patients underwent ACL reconstruction, 47 patients in each group, and 21 patients were lost to follow-up during the study period. At the 6-month follow-up, the IKDC scores and Lysholm scores were significantly better in the LARS group (P < 0.05). At the 6- and 12-month follow-ups, the KOS-ADLS, KOOS-activities of daily living and quality of life, NSARS scores, GRC scores, Tegner scores, and ACL-RSI scores were significantly better in the LARS group (P < 0.05). For the LARS group, hamstring group, and meshwork group, the cumulative failure rates were 8.5%, 12.8%, and 4.3%, respectively. Malposition of the femoral tunnel was significantly associated with cumulative failure (P < 0.05). There was no difference between the groups in other outcomes at any other time, including radiographic and arthroscopic outcomes.

Conclusions

ACL reconstruction using autologous hamstring augmented with LARS resulted in significantly better clinical scores with a faster return to sports and comparative side-to-side differences in graft laxity by 6 and 12 months follow-up. Despite these findings, no statistically significant differences were seen among the three patient groups in terms of objective outcomes and clinical scores at the 18-month, 3-year and 8-year follow-ups. Additionally, a malpositioned femoral tunnel was associated with graft failure.

Operative Management for Anterior Cruciate Ligament Injury in Patients Over 40 Years Old Yields Increased Clinical Outcome: A Systematic Review

PURPOSE

To evaluate outcomes of anterior cruciate ligament (ACL) rupture in patients ≥40 years treated nonoperatively or with ACL reconstruction (ACLR).

METHODS

A review of MEDLINE, CINAHL, SportDiscus, Embase, Web of Science, and Cochrane databases from inception to June 1, 2021, was performed to identify randomized controlled trials, prospective or retrospective cohorts, case controls, or case series that met the following criteria: English-language studies reporting at least one subjective and/or objective outcome measure in ACL rupture patients ≥40 years treated nonoperatively or by ACLR. No limits were placed on graft type, time-to-surgery/follow-up, or concomitant procedures. Variability in patient-reported outcome scores, including subjective IKDC score, Lysholm score, Tegner activity score, and Knee Injury and Osteoarthritis Outcome Score, was assessed to evaluate the utility of applying previously established clinically meaningful thresholds to pooled outcome data.

RESULTS

12,605 citations were identified using screening criteria. Sixty studies satisfied criteria following full-text review. As previous systematic reviews reported on earlier literature evaluating ACLR outcomes in patients ≥40 years, studies in this review were limited to include only those published in the last 10 years (40 studies). An additional 16 studies were excluded based on aims of the review not identified during initial screen. Although preoperative to postoperative population-based improvements in Lysholm score, Tegner score, and IKDC score surpassed minimal clinically important differences (MCID) in at least 50% of studies, the variability present in the pooled data may limit its application. No studies evaluated nonoperative outcomes.

CONCLUSIONS

Evidence supports operative management in patients ≥40 years, as studies generally demonstrated preoperative to postoperative improvements in clinical outcomes based on population-level changes. However, application of patient-level clinically relevant thresholds to pooled outcome data should be undertaken with caution as reporting of population-based outcome scores may not accurately reflect changes in individual patients.

LEVEL OF EVIDENCE

Systematic review, IV.

Clinical and arthroscopic outcomes of single-bundle anterior cruciate ligament reconstruction using autologous hamstrings augmented with ligament augmentation and reconstruction systems compared with four-strand hamstring tendon grafts alone

PURPOSE

To compare the clinical, radiological, and second-look arthroscopic outcomes in patients who underwent anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (hamstring group) either without augmentation or with ligament augmentation and reconstruction system (LARS) augmentation (LARS augmentation group).

METHODS

From January 2018 to December 2019, patients who underwent ACL reconstruction were included. Patient-reported outcome measures (PROMs) were undertaken pre-operatively and at three, six, 12, and 24 months post-operatively. Arthroscopic evaluation was performed focusing on the morphology of the graft based on graft tension, graft tear, and synovial coverage.

RESULTS

A total of 178 consecutive patients received single-bundle ACL reconstruction, 89 patients in each group, and 20 patients were lost to follow-up in the first two years. At the three month follow-up, the LARS augmentation group had significantly higher Lysholm scores, IKDC scores, and KOS-ADLS scores than the hamstring group (P < 0.001). At the three, six and 12-month follow-ups, there were significantly higher Tegner scores and ACL-RSI scores in the LARS augmentation group than in the hamstring group (P < 0.05). At the three and six month follow-ups, the LARS augmentation group had significantly higher rates of return to sports and return to sports at their preinjury level (P < 0.05). There were no between-group differences in other outcomes, including arthroscopic outcomes, graft signal intensity, post-operative complications or rerupture rates.

CONCLUSIONS

Autologous hamstring augmented with the LARS augmentation technique provides good and realistic clinical and functional results during the early post-operative period with high levels of satisfaction of patients, including participation in sports and physical activity, and high rates of return to sports at the preinjury level, without any apparent complications compared with hamstring ACL reconstruction alone. No increases in complication, reinjury rates, or increased lateral laxity were observed at the 12-month or 24-month follow-up.

Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups

BACKGROUND

Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood.

HYPOTHESES

The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups.

RESULTS

The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes.

CONCLUSION

Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.

Second-look arthroscopy after double-bundle posterior cruciate ligament reconstruction: Effect of patient age

Purpose

Second-look arthroscopy is invasive but still one of the most useful postoperative evaluation methods since graft morphology including graft tension, graft tear, and synovial coverage can be directly evaluated. However, only a few studies have evaluated transplanted posterior cruciate ligament (PCL) grafts. This study aimed to clarify the PCL graft morphology and chondral damages at second-look arthroscopy after double-bundle PCL reconstruction (PCLR) and to investigate the effects of patient age on these arthroscopic findings.

Methods

This study retrospectively included 26 patients who underwent second-look arthroscopy at the time of hardware removal 14 months after double-bundle PCLR for isolated PCL injury from January 2007 to December 2020. The patients were divided into two groups: group A, 39 years or younger (n = 14); and group B, 40 years or older (n = 12). At second-look arthroscopy, the grafts were evaluated based on tension (taut, graft tension as tense as a normal PCL; lax, graft tension looser than a normal PCL, unclassified, completely torn graft), tear (one or more tendon strands torn), and synovial coverage (good, synovial coverage greater than 80% around the graft; fair, synovial coverage greater than 50%; and poor, synovial coverage less than 50%). The chondral damages were evaluated using the Outerbridge classification system. Radiographic posterior tibial translation with gravity sag view as well as clinical outcomes were also evaluated.

Results

Anterolateral (AL) graft tension was lax in 8% of the patients, whereas posteromedial (PM) graft tension was lax or unclassified in 24% (p = 0.043). Graft tear was observed only in the PM graft of 19% patients (p = 0.022). Synovial coverage of AL grafts was good or fair in all cases, whereas that of PM grafts was poor in 28% cases (p < 0.001). Regarding the effect of patient age, the synovial coverage of PM grafts was significantly poorer in group B (p = 0.033), but no statistical difference in graft tension or tear was found. The chondral damages were significantly advanced in group B (p ≤ 0.01), except for the trochlear groove and lateral femoral condyle. No patients had residual subjective posterior instability, knee swelling, or loss of extension exceeding 5° or flexion exceeding 10°. All patients had improved from grade II or III preoperatively to grade I or grade II in the posterior drawer test. The posterior tibial translation significantly improved from 10.0 ± 3.6 mm preoperatively to 3.6 ± 2.1 mm at second-look arthroscopy. No significant differences in the postoperative clinical outcomes were observed between the two groups.

Conclusion

The morphology of the PM grafts at second-look arthroscopy after double-bundle PCLR was poorer than that of the AL grafts. Patient age negatively affected the postoperative graft synovial coverage and chondral status but did not affect the clinical outcomes.

•

Second-look arthroscopy is a direct evaluation of the transplanted graft.

•

There are very few studies of second-look arthroscopy of transplanted PCL grafts.

•

Arthroscopic findings in the PM graft were inferior to those in the AL graft.

•

Poorer synovial coverage in the PM graft was observed in the patients ≥40 years.

Outcomes of human umbilical cord blood-derived mesenchymal stem cells in enhancing tendon-graft healing in anterior cruciate ligament reconstruction: an exploratory study

Background

The study investigated whether allogeneic human umbilical cord blood-derived MSCs (hUCB-MSCs) could be safely used without treatment-related adverse events, reducing tunnel enlargement, and improve clinical results in human anterior cruciate ligament (ACL) reconstruction.

Methods

Thirty patients were enrolled consecutively. They were divided into three groups by randomization. In the negative control group, ACL reconstruction surgery without additional treatment was performed. In the experimental group, a hUCB-MSC and hyaluronic acid mixture was applied to the tendon-bone interface of the femoral tunnels during ACL reconstruction surgery. In the positive control group, only hyaluronic acid was applied. Finally, 27 patients were analyzed after the exclusion of three patients. The incidence of treatment-related adverse events, clinical outcomes, including second-look arthroscopic findings, and the amount of tunnel enlargement, were evaluated.

Results

There were no treatment-related adverse events in the treatment groups. Tunnel enlargement in the experimental group (579.74 ± 389.85 mm³) was not significantly different from those in the negative (641.97 ± 455.84 mm³) and positive control (421.96 ± 274.83 mm³) groups (p = 0.6468). There were no significant differences between the groups in clinical outcomes such as KT-2000 measurement (p = 0.793), pivot shift test (p = 0.9245), International Knee Documentation Committee subjective score (p = 0.9195), Tegner activity level (p = 0.9927), and second-look arthroscopic findings (synovial coverage of the graft, p = 0.7984; condition of the graft, p = 0.8402).

Conclusions

Allogeneic hUCB-MSCs were used safely for ACL reconstruction without treatment-related adverse event in a 2-year follow-up. However, our study did not suggest any evidence to show clinical advantage such as the prevention of tunnel enlargement postoperatively and a decrease in knee laxity or improvement of clinical outcomes.

Trial registration

CRIS, Registration Number: KCT0000917. Registered on 12 November 2013; https://cris.nih.go.kr/cris/index.jsp

Anterior Cruciate Ligament Injuries in the Older Athlete

CONTEXT

Older adults are remaining active longer and continuing during later stages of life to participate in sports and activities that involve pivoting on 1 foot. The rate of anterior cruciate ligament (ACL) tears is increasing in people older than 40 years of age, which has caused a concomitant increase in the rate of surgical reconstruction.

EVIDENCE ACQUISITION

We searched the PubMed database for articles published in English between January 1980 and January 2018 using the terms anterior cruciate ligament injury, ACL injury, ACL tear, anterior cruciate ligament reconstruction, ACLR, older, older athlete, and elderly.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Nonoperative treatment with activity modification and physical therapy may be an appropriate option for nonathletes older than 40 years of age with physically low-demand lifestyles. For patients with injuries that are unresponsive to nonoperative treatment or athletes participating in physically demanding activities, ACL reconstruction can improve function and facilitate return to sports. When evaluating whether a patient is a candidate for surgery, numerous variables should be considered, such as timing, graft choice, and postoperative rehabilitation.

CONCLUSION

Outcomes of ACL reconstruction in older athletes are similar to those of younger patients. To date, published evidence is inadequate to determine the long-term effects of nonoperative and operative treatment as well as the role of ACL reconstruction in the development of osteoarthritis in the older athlete.

Remnant-Tensioning Single-Bundle Anterior Cruciate Ligament Reconstruction Provides Comparable Stability to and Better Graft Vascularity Than Double-Bundle Anterior Cruciate Ligament Reconstruction in Acute or Subacute Injury: A Prospective Randomized Controlled Study Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging

PURPOSE

To compare the clinical, second-look arthroscopic, magnetic resonance imaging (MRI), and dynamic-contrast-enhanced MRI (DCE-MRI) findings between remnant-tensioning single-bundle (RT-SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR).

METHODS

Sixty-seven patients with acute or subacute anterior cruciate ligament (ACL) injury were randomized to undergo RT-SB or DB ACLR. Twenty-six patients in the RT-SB group and 28 in the DB group were evaluated using stability tests (Lachman test, pivot-shift test, and KT-2000 arthrometer) and multiple clinical scores. One year postoperatively, all 54 patients underwent MRI for evaluation of graft continuity and graft signal/noise quotient and DCE-MRI for the calculation of normalized area under the curve (nAUC) as a marker of graft vascularity. Among them, 41 patients underwent second-look arthroscopy for the evaluation of graft continuity, graft tension, and synovialization. The results were compared between the 2 groups.

RESULTS

At the minimum 2-year follow-up (28.7 ± 6.4 months), the stability tests, clinical scores, second-look arthroscopic findings, and MRI findings were not significantly different between the groups. However, the mean nAUC values on DCE-MRI for the ACL graft were significantly higher in the RT-SB group than those in the DB group in all 3 zones (nAUC_proximal, P = .005; nAUC_middle, P = .021; nAUC_distal, P = .027; and nAUC_average, P = .008).

CONCLUSION

For acute or subacute ACL injury, the RT-SB ACLR showed an outcome comparable to that of DB ACLR in terms of knee stability, clinical scores, MRI findings, and second-look arthroscopic findings. Moreover, RT-SB ACLR showed better graft vascularity 1 year postoperatively than DB ACLR using DCE-MRI.

LEVEL OF EVIDENCE

II, prospective randomized controlled trial.

An Autograft for Anterior Cruciate Ligament Reconstruction Results in Better Biomechanical Performance and Tendon-Bone Incorporation Than Does a Hybrid Graft in a Rat Model

BACKGROUND

The biomechanical and tendon-bone incorporation properties of allograft-augmented hybrid grafts for anterior cruciate ligament (ACL) reconstruction compared with traditional autografts are unknown.

HYPOTHESIS

Using an autograft for ACL reconstruction yields better results on biomechanical testing, radiographic analysis, and histological evaluation versus using a hybrid graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 66 adult male Sprague Dawley rats underwent unilateral ACL reconstruction with an autograft (AT group; n = 33) or a hybrid graft (HB group; n = 33). The grafts used in both groups were harvested from the peroneus longus tendon and were fixed by suturing to the surrounding periosteum. Samples were harvested for biomechanical testing, micro-computed tomography (CT), and histological evaluation at 4, 8, and 12 weeks postoperatively. Bone tunnels on the femoral and tibial sides were divided into 3 subregions: intra-articular (IA), midtunnel (MT), and extra-articular (EA). A cylinder-like volume of interest in the bone tunnel and a tubular-like volume of interest around the bone tunnel were used to evaluate new bone formation and bone remodeling, respectively, via micro-CT.

RESULTS

In the AT group, there were significantly higher failure loads and stiffness at 8 weeks (failure load: 3.04 ± 0.40 vs 2.09 ± 0.54 N, respectively; P = .006) (stiffness: 3.43 ± 0.56 vs 1.75 ± 0.52 N/mm, respectively; P < .001) and 12 weeks (failure load: 9.10 ± 1.13 vs 7.14 ± 0.94 N, respectively; P = .008) (stiffness: 4.45 ± 0.75 vs 3.36 ± 0.29 N/mm, respectively; P = .008) than in the HB group. With regard to new bone formation in the bone tunnel, in the AT group, the bone volume/total volume (BV/TV) was significantly higher than in the HB group on the tibial side at 8 weeks (IA: 22.21 ± 4.98 vs 5.16 ± 3.98, respectively; P < .001) (EA: 19.66 ± 7.19 vs 10.85 ± 2.16, respectively; P = .030) and 12 weeks (IA: 30.50 ± 5.04 vs 17.11 ± 7.31, respectively; P = .010) (MT: 21.15 ± 2.58 vs 15.55 ± 4.48, respectively; P = .041) (EA: 20.75 ± 3.87 vs 10.64 ± 3.94, respectively; P = .003). With regard to bone remodeling around the tunnel, the BV/TV was also significantly higher on the tibial side at 8 weeks (MT: 33.17 ± 8.05 vs 15.21 ± 7.60, respectively; P = .007) (EA: 25.19 ± 6.38 vs 13.94 ± 7.10, respectively; P = .030) and 12 weeks (IA: 69.46 ± 4.45 vs 47.80 ± 6.16, respectively; P < .001) (MT: 33.15 ± 3.88 vs 13.76 ± 4.07, respectively; P < .001) in the AT group than in the HB group. Sharpey-like fibers had formed at 8 weeks in the AT group. A large number of fibroblasts withdrew at 12 weeks. In the AT group, the width of the interface was significantly narrower at 4 weeks (85.86 ± 17.49 vs 182.97 ± 14.35 μm, respectively; P < .001), 8 weeks (58.86 ± 10.99 vs 90.15 ± 11.53 μm, respectively; P = .002), and 12 weeks (42.70 ± 7.96 vs 67.29 ± 6.55 μm, respectively; P = .001) than in the HB group.

CONCLUSION

Using an autograft for ACL reconstruction may result in improved biomechanical properties and tendon-bone incorporation compared with a hybrid graft.

CLINICAL RELEVANCE

Augmenting small autografts with allograft tissue may result in decreased biomechanical performance and worse tendon-bone incorporation, increasing the risk of graft failure.

Comparable clinical and functional outcomes after anterior cruciate ligament reconstruction over and under 40 years of age

PURPOSE

The aim of the present meta-analysis was to update the literature on the outcomes and complications of ACL reconstruction in patients aged 40 years and older. It has been hypothesized that patients older than 40 years of age may have comparable clinical outcomes to those of younger patients.

METHODS

A systematic review of articles from 1996 to 2018 was completed using Pubmed, Medline, Cochrane Reviews, and Google Scholar databases using the keyword terms "anterior cruciate ligament reconstruction" and "middle-aged OR elderly OR over 40 OR age factors." Functional and clinical outcomes (International Knee Documentation Committee, Lysholm and Tegner score and KT-1000 arthrometer), complication and graft failure rate were evaluated.

RESULTS

Eleven articles met inclusion criteria. In total, 306 middle-aged patients and 566 younger patients were included in this study. The mean age of patients > 40 was 49 ± 7 (range 40-75) years with a mean follow-up of 25 ± 9 months (range 12-68). The mean age of younger patients was 26 ± 2.7 (range 15-39) years with a mean post-operative follow-up of 26.7 ± 11.5 months (range 3-64). The results were slightly higher (but no significantly different) towards the younger group in terms of objective IKDC (P = n.s.), Lysholm (P = n.s.) and Tegner (P = n.s.) scores and knee laxity assessment (P = n.s.). Complication rate (P = n.s.) and graft failure (P = n.s.) were low even in this cohort.

CONCLUSIONS

The present meta-analysis shows that patients older than 40 years achieve comparable clinical outcomes to those of younger patients following primary ACL reconstruction. This evidence may push the surgeons toward a more aggressive approach in this specific cohort of patients.

LEVEL OF EVIDENCE

III.

Clinical and Functional Outcomes of Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendon in Patients Aged 50 Years or Older

PURPOSE

To assess the clinical and functional outcomes, including the return to sports and the progression of arthritis, in patients aged 50 years or older after anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective series of patients aged 50 years or older with ACL rupture who received ACL reconstruction surgery with autologous hamstring tendon was examined. Preoperative and postoperative functional outcomes were evaluated with the International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score. Associated injuries, postoperative complications, and the rate of return to preinjury sports were documented. A paired t test and the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical evaluation.

RESULTS

A total of 67 patients with a mean age of 56.6 years were enrolled. The mean follow-up time was 30.2 months. Clinical improvement in the IKDC score (from 41.4 preoperatively to 88.9 postoperatively), Lysholm score (from 49.8 to 86.1), and Tegner activity score (from 2.7 to 4.4) was noted. Regarding clinically relevant values of the MCID, all patients (100%) showed a ΔLysholm score exceeding 8.9; 66 of 67 patients (98.5%) revealed a ΔIKDC score exceeding 16.7; and 47 of 67 patients (70.1%) showed a ΔTegner activity score of more than 1. For the PASS, none of the patients had an IKDC score over 75.9 preoperatively whereas 60 patients (89.5%) had a score exceeding 75.9 postoperatively. Associated lesions included meniscal injuries (73.1%) and osteochondral lesions (89.6%). Of the patients, 36 (53.7%) returned to preinjury sports and 18 (22.9%) returned to sports with less intensity. No major complication, rerupture, or deterioration of arthritis was noted.

CONCLUSIONS

Patients aged 50 years or older receiving ACL reconstruction achieved significant improvements in IKDC, Lysholm, and Tegner scores. All patients reached the MCID for the ΔLysholm score; 98.5%, for the ΔIKDC score; and 70.1%, for the ΔTegner activity score. None of the patients reached the PASS for the preoperative IKDC value, whereas 89.5% reached the PASS postoperatively. Among patients aged 50 years or older, 53.7% returned to preinjury sports and 26.9% returned to sports with lower intensity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Clinical outcomes and second-look arthroscopic findings of anterior cruciate ligament reconstruction with autograft, hybrid graft, and allograft

Background

There is no consensus as to the choice of grafts for primary anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the clinical and second-look arthroscopic outcomes after ACL reconstruction by use of autograft, hybrid graft, and γ-irradiated allograft.

Methods

Ninety-seven patients who underwent second-look arthroscopy after ACL reconstruction with autografts (28 patients, hamstring autograft), hybrid grafts (32 patients, hamstring autograft augmented with γ-irradiated tibialis anterior tendon allograft), or γ-irradiated allografts (37 patients, tibialis anterior tendons) were included in this study. The clinical outcomes were compared by using Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity score, and the side-to-side differences of KT-1000 measurement. Second-look arthroscopic findings were compared in terms of synovial coverage and graft tension.

Results

There were no statistical significances among the three groups in Lysholm score, IKDC score, or Tegner activity score (P > 0.05). The KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group than in the autograft or hybrid graft groups (P = 0.006, and P = 0.013, respectively). Two patients in the autograft group, 2 patients in the hybrid graft group and 4 patients in the allograft group were evaluated as graft failure on second-look arthroscopy. The synovial coverage was superior in the autograft group than that in the hybrid graft group or the allograft group (P = 0.013 and P = 0.010, respectively), and was comparable between the hybrid graft group and allograft group (P = 0.876). With regard to graft tension, the autograft group and hybrid group were comparable (P = 0.883) but showed better results than the allograft group (P = 0.011 and P = 0.007, respectively).

Conclusion

The hamstring autografts and hybrid grafts used for ACL reconstruction produced equal efficacy but provided better knee stability than allografts. In addition, the hamstring autografts showed better synovial coverage than the other two graft types.

Age over 50 years is not a contraindication for anterior cruciate ligament reconstruction

PURPOSE

To report clinical and functional results of ACL reconstruction in patients over 50 years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients.

METHODS

A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50 years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score.

RESULTS

A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6 years (50-75 years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2 mm (0.2-2.7 mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren-Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64 months.

CONCLUSION

ACL reconstruction in patients older than 50 years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients.

LEVEL OF EVIDENCE

IV.

Evaluation parameters of graft maturation on second-look arthroscopy following anterior cruciate ligament reconstruction: a systematic review

Purpose

The purpose of this systematic review was to investigate and summarize the evaluation methods of graft maturation on second-look arthroscopy following anterior cruciate ligament (ACL) reconstruction.

Methods

A literature search was performed on articles before December 2017 to identify the literature that has evaluated graft maturation on second-look arthroscopy following ACL reconstruction. Only studies using human grafts, evaluating graft maturation with two or more gross findings were included. Study design, grafts, surgical techniques, follow-up period, evaluation parameters, and categories were compiled.

Results

Twenty-eight studies were included in this study. All studies evaluated graft maturation with two or more of the following three findings: graft integrity, tension, and synovial coverage. Two to four categories were used for evaluating each parameter, but the criteria for classification were slightly different for each study. Several studies reported neo-vascularization of grafts and the total maturation score by summing up the scores assigned to each evaluation parameter. Three studies reported that there was no correlation between second-look findings and patient-reported outcomes.

Conclusions

Graft integrity, tension, and synovial coverage were the most frequently evaluated for graft maturation on second-look arthroscopy. However, there is no uniform criterion for evaluation. Therefore, development of a valid, uinform criterion is required.

Level of evidence

Level IV, systematic review of level I–IV investigations.

Comparison of Modified Transtibial and Anteromedial Portal Techniques in Anatomic Single-Bundle ACL Reconstruction

The purpose of this study was to compare the clinical, 3-dimensional computed tomography, magnetic resonance imaging, and second-look arthroscopic findings of the modified transtibial technique with those of the anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction (SB-ACLR). Among patients who underwent SB-ACLR from February 2012 to May 2014, 95 patients with a minimum of 36 months of follow-up were included in this retrospective study. Forty-five patients underwent a reconstruction using the modified transtibial technique. Fifty patients underwent a reconstruction using the anteromedial portal technique. Clinical scores and stabilities were recorded preoperatively and at final follow-up. All patients had postoperative computed tomography and the computed tomography parameters, including tunnel position and graft obliquity, evaluated. Additionally, postoperative magnetic resonance imaging and second-look arthroscopy were performed. On the basis of the functional and stability outcomes, all of the patients showed significant improvement after SB-ACLR, with no significant differences existing between the 2 groups (P>.05). Tunnel position and obliquity were not significantly different between the 2 groups (P>.05). There were no statistically significant differences between the 2 groups regarding the magnetic resonance imaging and second-look arthroscopy findings (P>.05). The tunnel characteristics and clinical results of the 2 techniques were comparable. Given the several advantages of the modified transtibial technique, including its simplicity and patients' greater activity level, it is suitable for anatomic SB-ACLR. [Orthopedics. 2019; 42(2):83-89.].

Management of Anterior Cruciate Ligament Injuries in Adults Aged >40 Years

Management of anterior cruciate ligament (ACL) injuries in adults aged >40 years has received increased attention in the literature because of an increase in the functional demands of aging athletes. Multiple structural and biomechanical age-dependent changes exist in the ACL, for example, fewer mesenchymal stem cells, decreased healing potential, decreased structural organization, decreased stiffness, and a decreased load to failure with age. As in younger patients, ACL insufficiency can predispose an older patient to the same risks of recurrent instability, meniscal and chondral injury, and osteoarthritis. The role of nonsurgical versus surgical management in these patients remains controversial. Lower-demand patients may be able to cope with ACL deficiency. Higher-demand patients may have functional instability, and the limited studies available suggest good functional outcomes with surgical reconstruction of the ACL in this population.

A Comparison of Results after Anterior Cruciate Ligament Reconstruction in over 40 and under 40 Years of Age: A Meta-Analysis

Purpose

Anterior cruciate ligament (ACL) injury is one of the most common injuries that occur in the knee, and ACL reconstruction (ACLR) is commonly performed for preventing aggravation of degenerative changes and restoring of knee stability in young, athletic patients. This metaanalysis has a purpose of evaluating the clinical and arthrometrical outcomes of ACLR in a group of middle age patients (40 years and older) and comparing with patients under 40 years of age.

Methods

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and SCOPUS electronic databases were searched for relevant articles comparing the outcomes of ACLR between younger and older than 40 years of age until December 2016. Data searching, extraction, analysis, and quality assessment were performed based on the Cochrane Collaboration guidelines. Clinical outcomes were evaluated and compared between groups. The results were presented as mean difference for continuous outcomes with 95% confidence intervals whereas risk ratio for binary outcomes.

Results

Seven studies were included in the meta-analysis. Based on International Knee Documentation Committee classification, side-to-side difference, Tegner activity score, Lysholm knee score, there were no significant clinical and mechanical differences between the groups.

Conclusions

This meta-analysis confirmed that after ACLR, middle age (>40 years) and young age (<40 years) patients did not present with significant difference in clinical and arthrometric results.

Comparison of Clinical Results, Second-Look Arthroscopic Findings, and MRI Findings Between the Transportal and Outside-In Techniques for Double-Bundle Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Trial With a Minimum 2-Year Follow-up

BACKGROUND

Although image analysis has shown that the outside-in (OI) technique is associated with different femoral tunnel geometry than the transportal (TP) technique in anatomic anterior cruciate ligament (ACL) reconstruction, it is not known whether clinical results differ between the 2 techniques.

PURPOSE

To compare clinical results, second-look arthroscopic findings, and magnetic resonance imaging (MRI) findings between the TP and OI techniques in anatomic double-bundle (DB) ACL reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

From November 2010 to March 2013, 128 patients were enrolled in this study and were randomly assigned to either the TP group (64 patients) or the OI group (64 patients), and DB ACL reconstructions were performed. At the minimum 2-year follow-up (34.9 ± 10.9 months), 111 patients (86.7%) were evaluated with multiple clinical scores and stability tests (KT-2000 arthrometer, Lachman test, and pivot-shift test). Ninety-three knees were evaluated for graft continuity, graft tension, and synovialization by use of second-look arthroscopy. Seventy-eight knees were evaluated on MRI for graft continuity, femoral graft tunnel healing, and graft signal/noise quotient (SNQ). The primary outcome was KT-2000 arthrometer results. Results were compared between the TP and OI groups.

RESULTS

No significant differences were found between the 2 groups in terms of KT-2000 arthrometer results, which was the primary outcome, and other clinical results, with the exception of the postoperative functional test of International Knee Documentation Committee (IKDC) objective score. The ratio of grade A and B on the postoperative functional test of IKDC objective score was significantly larger for the OI group (51/58) than the TP group (36/53) ( P = .005). The second-look arthroscopic findings were not significantly different between the 2 groups in either bundle ( P > .05). In addition, MRI findings did not differ significantly between the 2 groups ( P > .05).

CONCLUSION

With the exception of the functional test of IKDC objective score, we found that clinical results, second-look arthroscopic findings, and MRI findings did not differ significantly between the OI and TP techniques for anatomic ACL reconstruction, although femoral tunnel geometries differed significantly between the 2 techniques.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 2: Radiographic Predictors of Early Graft Failure

BACKGROUND

Accumulating evidence suggests that long-term anterior cruciate ligament (ACL) deficiency can give rise to an abnormal tibiofemoral relationship and subsequent intra-articular lesions. However, the effects of chronic ACL deficiency (ACLD) on early graft failure after anatomic reconstruction remain unclear.

HYPOTHESIS

We hypothesized that patients with long-term ACLD lasting more than 5 years would have a greater rate of early graft failure due to insufficient intraoperative reduction of the tibia and that the preoperative and immediately postoperative abnormal tibiofemoral relationship in the sagittal plane, such as anterior tibial subluxation (ATS), would correlate with the graft status on postoperative magnetic resonance imaging (MRI).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 358 patients who had undergone anatomic ACL reconstruction with hamstring grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken in all patients to evaluate the tibiofemoral relationship, specifically with regard to ATS, space for the ACL (sACL), and extension angle. All patients underwent MRI at 6 months to reveal graft status. Groups with a high rate of graft failure were further analyzed to compare demographic and radiographic factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors.

RESULTS

Graft failure without trauma was observed in 4 (1.8%), 0 (0%), 1 (3.7%), 3 (9.7%), and 8 patients (17.7%) in groups 1, 2, 3, 4, and 5, respectively. Of the 76 patients in groups 4 and 5, significant differences were noted between the failure and intact subgroups in preoperative ATS (4.9 vs 2.4 mm, respectively; P < .01), side-to-side differences in sACL (sACL-SSD) (4.7 vs 1.9 mm, respectively; P < .01), extension deficit (4.4° vs 1.3°, respectively; P < .01), and chondral lesions (P = .02), while postoperative ATS and sACL-SSD showed no differences. Multivariate logistic regression analysis revealed that of these factors, preoperative sACL-SSD could be a risk factor for early graft failure (odds ratio, 3.2; 95% CI, 1.37-7.46).

CONCLUSION

Early graft failure at 6 months increased in patients with ACLD longer than 2 years. In this population, preoperative sACL-SSD was the most significant risk factor for early graft failure on MRI. However, immediately postoperative radiographic measurements had no effect on graft failure rates.

Acute ACL reconstruction in patients over 40 years of age

PURPOSE

The purpose of this study is to compare the clinical outcome of ACL reconstructions in patients older than 40 years of age to younger subjects. It has been hypothesized that patients older than 40 years of age achieve comparable clinical outcomes following acute ACL reconstruction using a hamstring tendon autograft than younger patients.

METHODS

Patients with an isolated ACL tear without any concomitant injuries and subsequent ACL reconstruction within 48 h from injury were included in this prospective study. According to patients' age, subjects were assigned to two groups: (A) 18-40 years and (B) 40-60 years. Functional outcomes, pain, post-operative radiographs and return to sports were recorded and analysed. The follow-up period was 24 months.

RESULTS

A total of 59 patients were included in the study. Group A consisted of 39 patients (14 women, 25 men; median 27 years), group B of 20 patients (12 women, 8 men; median 45 years) respectively. At final follow-up, the Lysholm score showed no significant difference between group A (median 90; range 68-100) and group B (median 94.5; range 63-100) (n.s.). The final Tegner score showed a significant difference between group A (median 6; range 2-9) and group B (median 5.5; range 3-8) (p < 0.05). The mean VAS pain score was 1.3 (range 0-6) in group A and 1 (range 0-7) in group B, respectively (n.s.). Both groups returned to their pre-injury activity level and did not significantly change their activity in respect of pivoting sports and sports frequency at final follow-up (n.s.). According to the IKDC score, all except one of the patients in group A and all patients in group B had a normal or nearly normal final outcome (n.s.).

CONCLUSION

Patients older than 40 years of age achieve comparable clinical outcomes following acute ACL reconstruction using a hamstring tendon autograft than younger patients.

LEVEL OF EVIDENCE

Cohort study, Level III.

High Variability in Outcome Reporting Patterns in High-Impact ACL Literature

BACKGROUND

ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction.

METHODS

All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study.

RESULTS

Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively).

CONCLUSIONS

Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.

Clinical outcomes of second-look arthroscopic evaluation after anterior cruciate ligament augmentation

We report the clinical outcome and findings at second-look arthroscopy of 216 patients (mean age 25 years (11 to 58)) who underwent anterior cruciate ligament (ACL) reconstruction or augmentation. There were 73 single-bundle ACL augmentations (44 female, 29 male), 82 double-bundle ACL reconstructions (35 female, 47 male), and 61 single-bundle ACL reconstructions (34 female, 27 male).

In 94 of the 216 patients, proprioceptive function of the knee was evaluated before and 12 months after surgery using the threshold to detect passive motion test.

Second-look arthroscopy showed significantly better synovial coverage of the graft in the augmentation group (good: 60 (82%), fair: 10 (14%), poor: 3 (4%)) than in the other groups (p = 0.039). The mean side-to-side difference measured with a KT-2000 arthrometer was 0.4 mm (-3.3 to 2.9) in the augmentation group, 0.9 mm (-3.2 to 3.5) in the double-bundle group, and 1.3 mm (-2.7 to 3.9) in the single-bundle group: the result differed significantly between the augmentation and single-bundle groups (p = 0 .013). No significant difference in the Lysholm score or pivot-shift test was seen between the three groups (p = 0.09 and 0.65, respectively). In patients with good synovial coverage, three of the four measurements used revealed significant improvement in proprioceptive function (p = 0.177, 0.020, 0.034, and 0.026).

We conclude that ACL augmentation is a reasonable treatment option for patients with favourable ACL remnants.

Cite this article: Bone Joint J 2014;96-B:1325–32

The mature athlete: aging tendon and ligament

CONTEXT

Aging changes the biology, healing capacity, and biomechanical function of tendons and ligaments and results in common clinical pathologies that present to orthopedic surgeons, primary care physicians, physical therapists, and athletic trainers. A better understanding of the age-related changes in these connective tissues will allow better patient care.

EVIDENCE ACQUISITION

The PubMed database was searched in December 2012 for English-language articles pertaining to age-related changes in tendons and ligaments.

LEVEL OF EVIDENCE

Level 5.

RESULTS

The mature athlete faces challenges associated with age-dependent changes in the rotator cuff, Achilles tendon, lateral humeral epicondylar tendons, quadriceps tendon, and patellar tendon. The anterior cruciate ligament and the medial collateral ligament are the most studied intra-articular and extra-articular ligaments, and both are associated with age-dependent changes.

CONCLUSION

Tendons and ligaments are highly arranged connective tissue structures that maintain joint motion and joint stability. These structures are subject to vascular and compositional changes with increasing age that alter their mechanotransduction, biology, healing capacity, and biomechanical function. Emerging research into the etiology of age-dependent changes will provide further information to help combat the age-related clinical complications associated with the injuries that occur to tendons and ligaments.

ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies

BACKGROUND

Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.

PURPOSE

To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).

STUDY DESIGN

Systematic review.

METHODS

A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at critically analyzing ACL outcome studies and used to examine each study design.

RESULTS

Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in the review. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.

CONCLUSION

Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes.

The importance of tibial tunnel placement in anatomic double-bundle anterior cruciate ligament reconstruction

PURPOSE

The purposes of this study were to measure the anterior edge of the tibial tunnel after anatomic anterior cruciate ligament (ACL) reconstruction on lateral radiographs and to determine whether the difference in tibial tunnel placement affects postoperative outcomes.

METHODS

For 60 patients who underwent anatomic double-bundle ACL reconstruction with semitendinosus tendon, we evaluated the side-to-side difference in anterior tibial translation on stress radiographs, as well as rotational stability by the pivot-shift test, 2 years after surgery. Loss of extension (LOE) was evaluated on lateral radiographs of both knees in full extension, and graft integrity was assessed during second-look arthroscopy 1 to 2 years after surgery. On true lateral radiographs, we measured the anterior placement percentage of the tibial tunnel using the method described by Amis and Jakob. The cutoff value was set at 25% of the mean value of the anterior edge of the ACL that Amis and Jakob reported, and patients were divided into 2 groups (27 in the anterior group and 33 in the posterior group). Postoperative clinical results were compared between the groups.

RESULTS

The mean anterior placement percentage was 26.0% ± 4.1%. The postoperative mean side-to-side difference was 1.4 ± 2.7 mm for the anterior group and 3.0 ± 2.7 mm for the posterior group, a significant difference (P < .05). The positive ratio of the pivot-shift test was not significantly different between groups (P > .05). Mean LOE in the anterior and posterior groups was 0.9° ± 3.0° and -0.8° ± 4.0°, respectively; the difference was not significant (P > .05). Five of 27 knees in the anterior group and 5 of 33 knees in the posterior group had superficial graft laceration or elongation, which was not significantly different (P > .05).

CONCLUSIONS

Anterior placement of the tibial tunnel in anatomic double-bundle ACL reconstruction leads to better anterior knee stability than posterior placement does. Anterior tibial tunnel placement inside the footprint did not increase the incidence of LOE and graft failure.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Second-look arthroscopic findings and clinical results after polyethylene terephthalate augmented anterior cruciate ligament reconstruction

PURPOSE

Based on the revival of artificial ligaments containing polyethylene terephthalate, this study aimed to evaluate objective intra-articular findings within scheduled second-look arthroscopy, patient-reported clinical outcome and stability after isolated augmented ACL reconstruction with polyethylene terephthalate (Trevira®) augmented patella-bone-tendon-bone graft.

METHODS

In a retrospective analysis of our institutional database, we found 126 patients with polyethylene terephthalate (Trevira®) augmented ACL reconstruction. All these patients underwent standardised second-look arthroscopic evaluation when removal of the augmentation became necessary. These second-look arthroscopic analyses focused on graft integration and remodelling in line with the polyethylene terephthalate augmentation. Arthroscopic re-examination comprised a graft evaluation including a structural and functional classification according to the Marburger Arthroscopy Score (MAS). Additional clinical evaluation was performed via the IKDC score and the scores of Tegner and Lysholm. Instrumental anterior laxity testing was carried out with a KT-1000™ arthrometer. Furthermore, a correlation analysis between the clinical parameters, the instrumental stability assessment and the corresponding arthroscopic graft condition was performed.

RESULTS

The arthroscopic evaluation showed rupture of 87 (69 %) of 126 augmentation devices. In 27 (31 %) of these 87 cases, synovial reactions were found particularly in the anterior compartment. An intact synthetic augmentation with signs of graft integration with intact synovial coating was only found in 30 %. Evaluation according to the MAS showed good to excellent structural and functional characteristics in 88 % of patients. Presence of a type III graft (MAS) was found in an additional 11 %. A rudimentary (type IV) graft was only detected once. Eighty-five percent of patients were graded A or B according to IKDC score. The Lysholm score was 92.4 ± 4.8. Correlation analysis demonstrated a significant relationship between clinical outcome according to the IKDC score (p<0.05), instrumental stability performance according to the KT-1000™ assessment (p<0.05) and the corresponding arthroscopic graft evaluation according to the MAS.

CONCLUSION

Graft integration and remodelling has complex and multi-factorial origins, particularly with artificial augmentation. Correlation analysis showed a significant relation between clinical condition, instrumental stability performance and arthroscopic graft constitution. The release of polyethylene terephthalate fibres caused inflammation of synovial tissue of the knee. Characteristic sub-clinical graft changes of structural, morphological and functional qualities of the inserted graft appear on second-look arthroscopy despite good clinical results.

Triple-bundle ACL grafts evaluated by second-look arthroscopy

PURPOSE

The purpose of this study was to evaluate the morphology of transplanted triple-bundle anterior cruciate ligament (ACL) grafts by second-look arthroscopy.

METHODS

The subjects were 41 patients with a mean age of 25.5 ± 8.5 years who underwent second-look arthroscopy at between 6 and 22 months after the anatomical triple-bundle ACL reconstruction using semitendinosus tendon autograft. Lachman test was negative in 38 knees and mildly positive with a firm endpoint in 3 knees. Arthroscopic evaluation of grafts was performed for the anteromedial graft (AM), the intermediate graft (IM), and the posterolateral graft (PL), focusing on tension and graft damage.

RESULTS

All grafts showed "fan-out" shape approaching the tibial attachment, which looked closer to the natural ACL compared to the double-bundle grafts. As to graft tension, 93% of AM, 90% of IM, and 88% of PL grafts were evaluated as taut, respectively. As to graft damage, there was no apparent rupture in the AM and IM grafts, while complete or substantial rupture was observed in 10% of PL grafts around the femoral tunnel aperture. The incidence of graft rupture in PL grafts was significantly greater than those in the AM and IM grafts. As to synovial coverage, 76% of AM, 78% of IM, and 59% of PL grafts were evaluated as "Good," while 41% of PL grafts were not fully covered with synovium. All of the synovial defects were observed around the femoral tunnel aperture.

CONCLUSION

The morphology of the triple-bundle grafts resembled that of the natural ACL, while complete or substantial rupture was observed in 10% of the PL grafts.

LEVEL OF EVIDENCE

Study of case series with no comparison group, Level IV.

Outcomes and second-look arthroscopic evaluation after double-bundle anterior cruciate ligament reconstruction with use of a single tibial tunnel

BACKGROUND

The correlation between graft appearance and clinical outcome after double-bundle anterior cruciate ligament (ACL) reconstruction is a major concern. In this study, the graft appearance was assessed with use of second-look arthroscopy and was correlated with the clinical outcome. Overall clinical outcomes after double-bundle ACL reconstruction with use of a single tibial tunnel were analyzed.

METHODS

Thirty-seven knees that underwent second-look arthroscopy after double-bundle ACL reconstruction and sixty-two knees that underwent double-bundle ACL reconstruction without subsequent second-look arthroscopy were included in this retrospective study. The ninety-nine patients enrolled were followed for thirty-five months (range, twenty-four to fifty-eight months), and the mean duration from ACL reconstruction to second-look arthroscopy was twenty-five months (range, twelve to thirty-six months). Graft thickness, apparent graft tension, and synovial coverage were graded during second-look arthroscopy. Correlations were sought between graft appearance and Lysholm knee scores, International Knee Documentation Committee (IKDC) grades, anterior laxity, and pivot-shift test results.

RESULTS

Postoperatively, ninety-four (94.9%) of the ninety-nine knees had an IKDC rating of B or higher, mean anterior laxity was 1.29 mm (range, 0 to 6 mm), and ninety-two knees (92.9%) had a negative pivot-shift result. With regard to graft thickness and tension, anteromedial bundles were graded as A in twenty-eight (75.7%) of the thirty-seven second-look knees and as B in nine knees (24.3%). Posterolateral bundles were graded as A in twenty-five knees (67.6%), B in six knees (16.2%), and C in six knees (16.2%). With regard to synovial coverage, anteromedial bundles were graded as C in only two knees (5.4%) and posterolateral bundles were graded as C in six knees (16.2%). No correlation was found between graft appearance and clinical outcome.

CONCLUSIONS

In the present study, we observed that clinical outcomes were as satisfactory with a single tibial tunnel as with two tibial tunnels. However, more tears and poorer synovial coverage were observed for posterolateral than for anteromedial bundles during second-look arthroscopy. No significant correlation was found between graft appearance and clinical outcome.