Patients Forget About Their Operated Knee More Following Arthroscopic Primary Repair of the Anterior Cruciate Ligament Than Following Reconstruction

Repair with suture tape augmentation vs. reconstruction for ACL tears: A systematic review and meta-analysis

Background and aims

Interest in repairing ruptured anterior cruciate ligaments (ACL) has resurged, with suture tape augmentation (internal brace, ACL-IB) emerging as a prominent technique. However, the efficacy of ACL-IB compared to ACL reconstruction (ACL-R) remains unclear. We conducted a meta-analysis to address this gap.

Methods

Adhering to PRISMA guidelines, a search to PubMed, EMBASE and Cochrane Central for studies comparing ACL-IB to ACL-R was performed. The main endpoints were patient-reported outcomes (PROs) and failure rate. Muscle and joint function and surgery time were also assessed. Statistical analysis was performed by Review Manager 5.1.7.

Results

Nine studies comprising 1049 patients were included; 381 (36.3 %) underwent ACL-IB. Hamstring autografts were used for ACL-R in 421 patients (63.0 %). Most studies (6 of 8) reported follow-up longer than two years. The failure rate was higher in the ACL-IB group (risk ratio 3.62; 95 % CI 1.16 to 11.33; p = 0.03; I2: 52 %). No significant difference was found between groups for PROs, except KOOS Symptoms, which was significantly improved with ACL-IB (mean difference 2.49; 95 % CI 0.05 to 4.92; p = 0.05; I2: 0 %). ACL-IB resulted in stronger hamstrings (mean difference 11.99 %; 95 % CI 4.47 %-19.51 %; p = 0.002; I2: 73 %). No significant difference was found in anterior tibial translation and quadriceps strength.

Conclusions

ACL-IB had a higher failure rate compared to ACL-R. However, ACL-IB showed better hamstring strength and KOOS symptom score. No significant differences were seen in other PROs, time to return to sports, or quadriceps strength.

Arthroscopic Anterior Cruciate Ligament Primary Repair With Suture Combined With Femoral Double Bone Tunnel Suspension Fixation

Anterior cruciate ligament (ACL) injury is a common orthopaedic sports injury. Arthroscopic anterior cruciate ligament reconstruction (ACLR) is the gold standard for treatment. In recent years, with the popularization and precision of arthroscopic techniques, as well as the discovery that acute ACL rupture has the potential to heal itself, arthroscopic ACL primary repair has become an alternative surgical treatment. This Technical Note describes an arthroscopic ACL primary repair with suture combined with femoral double bone tunnel suspension fixation. It tightens the tendon-bone contact, increases the contact area, and strengthens the fixation, all of which contribute to better tendon-bone healing. Thus, this can be used as a surgical method for ACL repair.

Anterior cruciate ligament primary repair revision rates are increased in skeletally mature patients under the age of 21 compared to reconstruction, while adults (>21 years) show no significant difference: A systematic review and meta-analysis

PURPOSE

To evaluate the impact of age as a risk factor on the revision rates of anterior cruciate ligament (ACL) primary repair (ACLPR), dynamic intraligamentary stabilization (DIS) and bridge-enhanced ACL restoration (BEAR) compared to ACL reconstruction (ACLR).

METHODS

A systematic literature search was performed for comparative studies comparing outcomes for ACLPR, DIS or BEAR to ACLR. A random-effects meta-analysis was performed to assess nondifferentiated and age-differentiated (skeletally mature patients ≤21 and >21 years) ACL revision and reoperation risk, as well as results for subjective outcomes. Methodological study quality was assessed using the Risk of Bias Tool 2.0c and Methodological Index for Nonrandomized Studies tools.

RESULTS

A total of 12 studies (n = 1277) were included. ACLR demonstrated a lower nonage-stratified revision risk at 2 years versus ACLPR, DIS and BEAR, but a similar revision risk at 5 years when compared to DIS. However, an age-stratified analysis demonstrated a significantly increased ACLPR revision risk as compared to ACLR in skeletally mature patients ≤21 years of age (risk ratios [RR], 6.33; 95% confidence interval [CI], 1.18-33.87, p = 0.03), while adults (>21 years) showed no significant difference between groups (RR, 1.48; 95% CI, 0.25-8.91, n.s.). Furthermore, DIS reoperation rates were significantly higher than respective ACLR rates (RR, 2.22; 95% CI, 1.35-3.65, p = 0.002), whereas BEAR (RR, 1.07; 95% CI, 0.41-2.75, n.s.) and ACLPR (RR, 0.81; 95% CI, 0.21-3.09, n.s.) showed no differences. IKDC scores were equivalent for all techniques. However, ACLPR exhibited significantly better FJS (mean difference, 11.93; 95% CI, 6.36-17.51, p < 0.0001) and Knee injury and Osteoarthritis Outcome Score Symptoms (mean difference, 3.01; 95% CI, 0.42-5.60, p = 0.02), along with a lower Tegner activity reduction.

CONCLUSIONS

ACLPR in skeletally mature patients ≤21 years of age is associated with up to a six-fold risk increase for ACL revision surgery compared to ACLR; however, adults (>21 years) present no significant difference. Based on the current data, age emerges as a crucial risk factor and should be considered when deciding on the appropriate treatment option in proximal ACL tears.

LEVEL OF EVIDENCE

Level III.

Arthroscopic Primary Repair of Proximally Based Anterior Cruciate Ligament Tear With Augmentation and All-Epiphyseal Fixation

Arthroscopic anterior cruciate ligament (ACL) reconstruction has been the gold standard of care for ACL injuries for many years. Recently, there has been growing literature and interest in arthroscopic primary ACL repair in select patients with predominantly proximally based ACL tears. This Technical Note demonstrates a surgical technique that offers an efficient minimally invasive and physeal-sparing anatomic ACL repair with all-inside internal brace augmentation that in the short term has offered good results for our patients.

Anterior Cruciate Ligament Repair With Suture Tape Augmentation of Proximal Tears and Early Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Result in Comparable Clinical Outcomes With Anterior Cruciate Ligament Reconstruction at 2-Year Follow-Up

PURPOSE

To compare the postoperative side-to-side laxity and short-term clinical outcomes of patients who received primary anterior cruciate ligament (ACL) repair with suture tape augmentation, acute anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation performed within 8 weeks of injury (ACLRacute), or ACLR beyond 8 weeks of injury.

METHODS

After institutional review board approval was obtained, 100 patients were enrolled in this prospective trial: 34 primary ACL repair with suture tape augmentation, 33 ACLRs performed within 8 weeks of injury (ACLRacute), and 33 ACLRs. Patients were allocated to ACL repair if a proximal avulsion was present with good tissue quality (Sherman type 1), confirmed by intraoperative diagnostic arthroscopy. Preoperative side-to-side anteroposterior knee laxity was assessed with KT-1000 arthrometer, and patient-reported outcomes (PROs) including the visual analog scale, Marx activity scale, Veterans RAND 12-item health survey (VR-12 physical & mental), Single Assessment Numeric Evaluation, Knee Injury and Osteoarthritis Outcome Score survey subscales, and range of motion were collected. These objective and subjective measures were repeated at regular intervals postoperatively through 2 years. Minimal clinically important difference calculations were performed assessing postoperative PRO changes at 2 years compared with preoperative.

RESULTS

The average time from injury to surgery was 5.03 ± 1.2 weeks for the ACL repair group, 5.09 ± 0.74 weeks for the ACLRacute, and 43.22 ± 33.5 weeks for the ACLR group. Postoperatively, the KT-1000 side-to-side laxity difference for 30 lbs was determined to be 0.1 ± 0.37 (95% confidence interval [CI] -0.7 to 0.8) for ACL repair versus ACLR (P < .0001), -0.8 ± 0.35 (95% CI -1.5 to -0.1) for ACLRacute versus ACLR (P < .0001), and 0.8 ± 0.40 (95% CI 0.0-1.6) for ACL repair versus ACLRacute (P < .0001). The data reveal ACL repair and ACLRacute are noninferior to ACLR at 2-year follow-up. The postoperative difference from baseline for all PROs demonstrated improvement for all PROs. Magnetic resonance imaging at 1 year revealed tissue healing for the 3 ACL injury treatment groups.

CONCLUSIONS

Patients who underwent ACL repair of proximal tears with suture tape augmentation or ACL reconstruction within 8 weeks from injury resulted in noninferior side-to-side knee laxity, comparable PROs, and similar range of motion at 2-year follow-up compared with ACLR.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies

PURPOSE

To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture.

METHOD

We searched Pubmed, Embase, the Cochrane Library, and Web of Science databases to seek relevant studies. Clinical outcomes included failure rate, hardware removal rate, anteroposterior (AP) knee laxity, and patient-reported outcomes. In addition, subgroup analysis was carried out according to repair techniques, rupture locations, and study designs. Funnel plots were used to detect publication bias. All statistical analysis was performed using STATA (version 14.2, StataCorp).

RESULTS

A total of 10 articles were included in this study, comprising 5 randomized controlled trials (RCTs) and 5 cohort studies, involving a total of 549 patients. We found no statistical differences between the ACL repair and ACL reconstruction in the following outcomes: failure rate, AP knee laxity, International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome (KOOS) Score, and Tegner score. However, the ACL repair group had a higher hardware removal rate. Except for AP knee laxity results on different repair techniques, there was no statistical difference in other subgroup analyses.

CONCLUSION

Compared with ACL reconstruction, ACL repair shows similar results in clinical outcomes, and it is promising to be an effective alternative treatment for acute ACL rupture. Larger samples and higher-quality studies are needed to support our results and further explore the advantages of ACL repair in other aspects.

LEVEL OF EVIDENCE

Level III.

Clinical Results of Primary Repair Versus Reconstruction of the Anterior Cruciate Ligament: A Systematic Review and Meta-analysis of Contemporary Trials

Background

Primary anterior cruciate ligament (ACL) repair has gained renewed interest in select centers for patients with proximal or midsubstance ACL tears. Therefore, it is important to reassess contemporary clinical outcomes of ACL repair to determine whether a clinical benefit exists over the gold standard of ACL reconstruction (ACLR).

Purpose

To (1) perform a meta-analysis of comparative trials to determine whether differences in clinical outcomes and adverse events exist between ACL repair versus ACLR and (2) synthesize the midterm outcomes of available trials.

Study Design

Systematic review; Level of evidence, 3.

Methods

The PubMed, OVID/Medline, and Cochrane databases were queried in August 2023 for prospective and retrospective clinical trials comparing ACL repair and ACLR. Data pertaining to tear location, surgical technique, adverse events, and clinical outcome measures were recorded. DerSimonian-Laird random-effects models were constructed to quantitatively evaluate the association between ACL repair/ACLR, adverse events, and clinical outcomes. A subanalysis of minimum 5-year outcomes was performed.

Results

Twelve studies (893 patients; 464 ACLR and 429 ACL repair) were included. Random-effects models demonstrated a higher relative risk (RR) of recurrent instability/clinical failure (RR = 1.64; 95% confidence interval [CI], 1.04-2.57; P = .032), revision ACLR (RR = 1.63; 95% CI, 1.03-2.59; P = .039), and hardware removal (RR = 4.94; 95% CI, 2.10-11.61; P = .0003) in patients who underwent primary ACL repair versus ACLR. The RR of reoperations and complications (knee-related) were not significantly different between groups. No significant differences were observed when comparing patient-reported outcome scores. In studies with minimum 5-year outcomes, no significant differences in adverse events or Lysholm scores were observed.

Conclusion

In contemporary comparative trials of ACL repair versus ACLR, the RR of clinical failure, revision surgery due to ACL rerupture, and hardware removal was greater for primary ACL repair compared with ACLR. There were no observed differences in patient-reported outcome scores, reoperations, or knee-related complications between approaches. In the limited literature reporting on minimum 5-year outcomes, significant differences in adverse events or the International Knee Documentation Committee score were not observed.

Anterior Cruciate Ligament Repair Leads to Improved Patient-Reported Outcomes Compared to Anterior Cruciate Ligament Reconstruction

Introduction Anterior cruciate ligament (ACL) tears occur frequently in young athletes, and ligament repair and reconstruction are surgical treatments. Although there are suggested benefits for both approaches, there is a lack of direct comparisons between ACL repair and reconstruction.This study aims to compare the mid-term functional outcomes and quality of life measures between patients that have undergone ACL repair versus reconstruction. Methods A retrospective review was conducted for demographic and operative report data of patients who underwent an ACL repair or reconstruction between 2012 and 2018. Patients were contacted over the phone and underwent a Patient-Reported Outcomes Measurement Information System (PROMIS) survey evaluating pain interference, mobility, and function. Patients were excluded from the study if there was an incomplete operative note, missing contact information, or failure to answer phone calls. Results A total of 74 eligible patients were included, with n = 54 in the ACL reconstruction group (73.0%) and n = 20 in the ACL repair group (27.0%). Reconstruction patients had a PROMIS (median (IQR)) physical function score of 22.50 (16.00-59.00), as compared to repair patients' physical function score of 60.00 (21.50-60.00). There was a significant difference favoring repair (p = 0.040). In addition, ACL reconstruction patients had a significantly higher rate of additional procedures, with 63.0% of reconstruction patients receiving an additional operation as compared to 30.0% of repair patients (p = 0.017). The surgery type did not show a significant effect on physical function scores, while additional procedures remained significant in the linear regression analysis. Conclusion Although ACL repair is associated with improved physical function scores as compared to reconstruction in the univariate analysis, surgery type did not show significance when controlling for other variables. Further studies are necessary to compare patients with similar injuries to account for differences in additional procedures, but the results remain promising in assisting with patient-driven treatment decisions.

Proprioception After Primary Repair of the Anterior Cruciate Ligament

BACKGROUND

Primary repair of the anterior cruciate ligament (ACL) has some potential advantages over the reconstruction technique, which include but are not limited to better knee sensation due to preservation of the natural ACL tissue in patients compared with tendon graft. Proprioception is impaired after ACL injuries and the sense of the joint position is lost.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare arthroscopic ACL primary repair and ACL reconstruction techniques clinically and functionally and analyze the differences in proprioception. It was hypothesized that primary repair would restore knee joint proprioception more successfully because the original tissue of the ACL is preserved.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 63 patients (34 underwent reconstruction and 29 underwent primary repair between 2017 and 2020) and 33 healthy controls, as well as the healthy knees of the operated groups, were evaluated between 24 and 48 months (mean, 29 months) postoperatively. Patients with proximal femoral avulsion tears and stump quality suitable for repair underwent primary repair, and those with tears outside these criteria underwent reconstruction using hamstring tendon autograft. Proprioception was evaluated using the active joint position sensation method during weightbearing, with a digital inclinometer used to measure differences between the target and achieved flexion angles of 15°, 30°, and 60°.

RESULTS

At 15° of knee flexion, the deviation angles for the healthy knee of the reconstruction and primary repair groups were significantly smaller than those of the control group (P < .001), but there was no statistically significant difference between the groups in terms of deviation angle at 30° and 60° of flexion. The deviation angle of the operated knees was statistically significantly larger in the reconstruction group than in the primary repair group at all angles. The deviation angles at 15°, 30°, and 60° were 2.83°, 2.66°, and 2.66° in the reconstruction group and 1.00°, 1.00°, and 1.33° in the primary repair group, respectively (P < .001). There was no statistically significant difference between the reconstruction and primary repair groups in terms of clinical scores.

CONCLUSION

Primary ACL repair can preserve proprioception in a well-selected patient group. In short-term follow-up, primary repair of the ACL in patients with proximal femoral avulsion tears and stump quality suitable for repair appears to be proprioceptively protective. Future studies are needed to clarify the long-term consequences of primary repair on proprioception in a larger population.

Suture-Augmented Anterior Cruciate Ligament Repair for Proximal Avulsion or High-Grade Partial Tears Shows Similar Side-to-Side Difference and No Clinical Differences at Two Years Versus Conventional Anterior Cruciate Ligament Reconstruction for Mid-Substance Tears or Poor Anterior Cruciate Ligament Tissue Quality

PURPOSE

To compare objective and subjective clinical outcomes between suture-augmented anterior cruciate ligament (ACL) repair (SAACLR) and conventional ACL reconstruction (CACLR) with minimum 2-year follow-up.

METHODS

In this nonrandomized, prospective study, 30 patients underwent SAACLR for proximal ACL avulsion or high-grade partial ACL tear (Sherman grade 1 or 2) and 30 patients underwent CACLR for proximal one-third/distal two-thirds junction tears and mid-substance tears (Sherman grade 3 or 4) tear types by 1 surgeon between 2018 and 2020. Failure was defined as ACL reinjury. Outcome measures were KT-1000 for side-to-side knee laxity evaluation, Visual Analog Scale for pain, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Severity Score (KOOS), Tegner Activity Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, and Single Assessment Numeric Evaluation. Minimal clinically important difference (MCID) was calculated for IKDC and KOOS subscores.

RESULTS

Three failures (10%) occurred in the SAACLR group, with no failures in the CACLR group (P = .24). A total of 23 (85%) SAACLR patients and 27 (90%) CACLR patients had patient-reported outcomes and physical examination at minimum 2 years. Two-year KT-1000 testing with 20 lbs showed less than 1 mm side-to-side difference between the groups. No significant differences in the percentage of patients meeting the MCID were found between the SAACLR and CACLR groups at 2 years: IKDC, 10.81 (82%) versus 10.54 (93%) (P = .48); KOOS Pain, 11.55 (73%) versus 10.58 (78%) (P = .94); KOOS Symptoms, 8.15 (77%) versus 10.32 (74%) (P = 1.0); KOOS Activities of Daily Living, 12.19 (59%) versus 12.28 (70%) (P = .60); 18.99 (71%) versus 16.77 (86%) (P = .42). Significantly higher IKDC scores were observed with SAACLR versus CACLR at 3 months (P = .01) and 6 months (P = .02), and significantly higher Lysholm scale, Tegner Activity Scale, and all KOOS subscale scores were observed at 6 months.

CONCLUSIONS

At 2 years after surgery, KT-1000 testing showed less than 1 mm side-to-side difference and no differences were observed between the groups in the percentage of patients who met or exceeded the MCID. Significantly higher early patient-reported outcome scores were found with SAACLR versus CACLR. The rerupture rate between the groups was not significantly different.

LEVEL OF EVIDENCE

Level II, Prospective cohort study.

Graft Reorientation and Lateral Extra-articular Tenodesis in Revision Surgery for Persistent Rotational Instability of a Verticalized Anterior Cruciate Ligament Graft

Persistent rotational instability after anterior cruciate ligament reconstruction is a relatively common postoperative complication, typically associated with graft verticalization due to improper femoral tunnel placement, especially with classic transtibial femoral tunnel techniques. This article describes a technique designed to reorient a verticalized anterior cruciate ligament graft at its femoral insertion to a more anatomic position in the coronal and sagittal planes, aiming to restore knee stability without the need for a complete revision operation. Additionally, a lateral extra-articular tenodesis with fascia lata is added to reinforce rotational stability.

Primary anterior cruciate ligament repair: Current concepts

The renewed interest in ACL repair over the last two decades stems from advances in modern arthroscopic techniques and clinical studies that have provided evidence that the ACL can reliably heal, and patients can return to sport at a comparable rate to ACL reconstruction patients. The ability to maintain and utilize native ACL tissue, with proprioceptive capabilities, and the smaller drill tunnels needed to repair an ACL leads to an overall less invasive procedure and improved early rehabilitation. Additionally, repair avoids a variety of comorbidities associated with autograft harvest. This current concept review details modern techniques of ACL repair and their current studies, a review on the use of biologic enhancement in ACL repair, and other considerations to appropriately integrate ACL repair into the sports medicine orthopaedic surgeon's practice.

Reduced knee laxity and failure rate following anterior cruciate ligament reconstruction compared with repair for acute tears: a meta-analysis

BACKGROUND

Following anterior cruciate ligament (ACL) tears, both repair and reconstruction may be performed to restore joint biomechanics and proprioception. The present study compared joint laxity, patient-reported outcome measures (PROMs), and rate of failure following primary repair versus reconstruction for ACL ruptures.

METHODS

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Google scholar, Embase, and Web of Science were accessed in September 2022. All the clinical investigations comparing repair versus reconstruction for primary ACL tears were accessed. Studies reporting data on multiple ligament injuries settings were not eligible.

RESULTS

Data from eight articles (708 procedures) were collected. The mean length of the follow-up was 67.3 ± 119.4 months. The mean age of the patients was 27.1 ± 5.7 years. Thirty-six percent (255 of 708 patients) were women. The mean body mass index (BMI) was 24.3 ± 1.1 kg/m². The mean time span from injury to surgery was 36.2 ± 32.3 months. There was comparability at baseline with regards to instrumental laxity, Lachman test, International Knee Document Committee (IKDC), and Tegner Scale (P > 0.1). Similarity between ACL reconstruction and repair was found in IKDC (P = 0.2) and visual analog scale (VAS) satisfaction (P = 0.7). The repair group demonstrated greater mean laxity (P = 0.0005) and greater rate of failure (P = 0.004).

CONCLUSION

ACL reconstruction may yield greater joint stability and lower rate of failure compared with surgical repair. Similarity was found in PROMs.

LEVEL OF EVIDENCE

III.

Favorable Patient-Reported, Clinical, and Functional Outcomes 2 Years After ACL Repair and InternalBrace Augmentation Compared With ACL Reconstruction and Healthy Controls

BACKGROUND

Recently, interest in anterior cruciate ligament (ACL) preservation and repair after proximal ACL tears has been resurrected. Although good clinical outcomes have been reported in the literature with adequate patient selection, to date detailed scientific evidence for the functional benefit of primary ACL repair with ligament augmentation is scarce.

PURPOSE

To compare patient-reported, clinical, and functional outcomes in patients 2 years after ACL repair and InternalBrace augmentation (ACL-IB) with age- and sex-matched patients 2 years after ACL reconstruction (ACL-R) and with matched healthy controls.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In total, 29 patients 2 years after ACL-IB, 27 sex- and age- matched patients 2 years after ACL-R (hamstring autografts), and 29 matched healthy controls were included. Patient-reported outcomes were assessed using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, EQ-5D-5L, Tegner Activity Scale, and Anterior Cruciate Ligament Return to Sports after Injury scale. Surgery time was recorded. For clinical outcomes, range of motion and thigh and shank circumference were measured, and passive anterior translation was determined using the Rolimeter. Isokinetic muscle strength was measured using a Biodex dynamometer. The limb symmetry index (operated/contralateral or nondominant/dominant × 100), side-to-side differences (operated - contralateral, nondominant - dominant), and hamstring-quadriceps ratios were calculated for functional parameters. Failure and reoperation rates were not compared.

RESULTS

Two years after surgery, patients treated with ACL-IB showed good to excellent patient-reported outcomes comparable with those of patients after ACL-R. Surgery time, including concomitant surgeries, was significantly shorter in the ACL-IB group (mean, 81 minutes) compared with the ACL-R group (mean, 97 minutes) (P = .024). Isokinetic muscle strength was comparable between patient groups without significant differences in extensor and flexor strength or in hamstring-quadriceps ratios.

CONCLUSION

These results suggest that ACL-IB achieves comparable patient-reported, clinical, and functional outcomes with ACL-R at 2 years postoperatively and, after careful patient selection, should be considered as a valuable early treatment alternative for proximal ACL tears.

REGISTRATION

NCT04429165 (ClinicalTrials.gov identifier).

Functional leg performance 2 years after ACL surgery: a comparison between InternalBrace™-augmented repair versus reconstruction versus healthy controls

BACKGROUND

While clinical and patient-reported outcomes have been investigated in patients after InternalBrace™-augmented anterior cruciate ligament repair (ACL-IB), less is known regarding restoration of functional performance. We aimed to determine differences in functional performance within and between patients 2 years after ACL-IB, patients 2 years after ACL reconstruction (ACL-R), and healthy controls.

MATERIALS AND METHODS

A total of 29 ACL-IB, 27 ACL-R (hamstring autograft), and 29 controls performed single-leg hop (maximum forward distance hop, SLH; side hop > 40 cm in 30 s, SH), proprioception (knee joint position sense at 30° and 60° flexion), and dynamic postural balance (Y Balance) tests. Differences were calculated within groups (side-to-side difference) and between the involved leg of patients and the non-dominant leg of controls, and were evaluated to predefined statistical (P < 0.05), clinically relevant, and methodological (smallest detectable change) thresholds. The number of exceeded thresholds represented no (0), small (1), moderate (2), or strong (3) differences. In addition, the relative number of participants achieving leg symmetry (≥ 90%) and normal performance (≥ 90% of the average performance of the non-dominant leg of controls) were compared between groups (chi-squared tests, P < 0.05).

RESULTS

We observed no-to-moderate leg differences within ACL-IB (moderate difference in hops) and within ACL-R (moderate difference in knee proprioception), no leg differences between patient groups, no-to-small leg differences between ACL-IB and controls, and no leg differences between ACL-R and controls in functional performance. However, two patients in ACL-IB and ACL-R, respectively, passed the hop pretest only with their uninvolved leg, and fewer patients after ACL-IB and ACL-R than controls reached a leg symmetry and normal leg performance of controls in SLH (P < 0.001).

CONCLUSIONS

Functional performance seems to be comparable 2 years postoperatively between ACL-IB and ACL-R for a specific subgroup of patients (i.e., proximal ACL tears, moderate activity level). However, the presumed advantage of comparable functional outcome with preserved knee structures after augmented ACL repair compared with ACL-R, and the tendency of both patient groups toward leg asymmetry and compromised single-leg hop performance in the involved legs, warrants further investigation. Level of Evidence Level III, case-control study. Trial registration clinicaltrials.gov, NCT04429165 (12/09/2020). Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04429165 .

Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament

Background

Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans.

Purpose

To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks.

Study Design

Cohort study; Level of evidence, 2.

Methods

All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test.

Results

Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block.

Conclusion

The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review

PURPOSE

To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures.

METHODS

Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.).

RESULTS

Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS.

CONCLUSIONS

The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Stabilization and Gap Formation of Adjustable Versus Fixed Primary ACL Repair With Internal Brace: An in Vitro Full-Construct Biomechanical Cadaveric Study

Background

A knotless, tensionable primary anterior cruciate ligament (ACL) repair system preloaded with an internal brace has been released. Currently, there is no biomechanical data on the stabilization and gap formation behavior of the adjustable system when compared with fixed repairs in human ACL tissue.

Hypothesis

That knotless adjustable suture repair with an internal brace would provide overall higher construct stability and greater load share on the ACL with less gap formation compared with fixed repair.

Study Design

Controlled laboratory study.

Methods

Human cadaveric knees were utilized for internal braced ACL repair constructs (each group n = 16). Two fixed groups consisting of a single-cinch loop (SCL), cortical button (SCL group), and knotless suture-anchor (anchor group) were compared with an SCL-adjustable loop device (SCL-ALD) group. Testing was performed at 4 different peak loads (50, 150, 250, 350 N) over 4000 cycles at 0.75 Hz including suture repair preconditioning (10 cycles at 0.5 Hz) for SCL-ALD. Specimens were ultimately pulled to failure with a cut internal brace. The final loading situation of the construct and ACL repair with gap formation and ultimate strength were evaluated.

Results

Peak elongation at various peak loads showed a significantly higher (P < .001) stabilization of SCL-ALD when compared with both fixed groups. There was a significantly higher (P < .001) load share of SCL-ALD, especially at lower loads (48% of 50 N), and the gap formation remained restricted up to 250 N. With only a little load share on the fixed constructs (<6%) at lower loads (50, 150 N), gap formation in these groups started at a load of 150 N, leading to significantly higher gaps (P < .001). The ultimate failure load for SCL-ALD and anchor groups was significantly increased (P < .001) as compared with SCL. The stiffness of SCL-ALD (62.9 ± 10.6 N/mm) was significantly increased (P < .001).

Conclusion

Internal braced knotless adjustable fixation for ACL repair with preconditioning of the suture repaired ligament increased the overall stabilization with higher load share on the ACL and restricted gap formation (<0.5 mm up to 350 N) compared with fixed suture repair. All internal braced repairs restored stability according to native ACL function.

Clinical Relevance

Adjustable ACL repair improved the mechanical characteristics and reduced gap formation, but the overall clinical significance on healing remains unclear.

Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor

An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.

Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up

BACKGROUND

Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse.

PURPOSE/HYPOTHESIS

The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score-12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure.

RESULTS

A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63).

CONCLUSION

ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).

Cortical suspensory button fixation has superior biomechanical properties to knotless anchor suture in anterior cruciate ligament repair: a biomechanical study

The purpose of our biomechanical study was to assess load-to-failure, stiffness, gap formation following cyclic loading, and the failure mechanism for anterior cruciate ligament (ACL) repair comparing the cortical suspensory button and knotless anchor suture. Eight Thiel's embalmed paired cadaveric knees from four cadavers were dissected. The specimens were assigned to undergo ACL repair either with cortical suspensory button or with knotless anchor suture. The Instron machine replicates cyclic loading and then determines the gap formation. Traction was applied until failure. The load-to-failure, stiffness, and modes of failure in both groups were recorded. The load-to-failure, stiffness, and gap formation were compared between the two groups using the student's t-test. The mean load-to-failure in the cortical suspensory button group was significantly higher than the knotless anchor suture group (212.96 ± 54.57 vs 44.57 ± 20.80, p value < 0.01). No statistically significant difference was found regarding gap formation following cyclic loading and stiffness between the cortical suspensory button group and the knotless anchor suture group. This biomechanical study showed a higher load-to-failure for the ACL repair with cortical suspensory button compared to ACL repair with knotless anchor suture, while no statistically significant difference was found regarding the gap formation following cyclic loading and the stiffness. The load-to-failure in both cortical suspensory button and knotless anchor suture are below regular daily activity load. Thus, an internal brace or external support is recommended during rehabilitation.

Propensity for Clinically Meaningful Improvement and Surgical Failure After Anterior Cruciate Ligament Repair

Background

Primary repair of the anterior cruciate ligament (ACL) confers an alternative to ACL reconstruction in appropriately selected patients.

Purpose

To prospectively assess survivorship and to define the clinically meaningful outcomes after ACL repair.

Study Design

Case series; Level of evidence, 4.

Methods

Included were consecutive patients with Sherman grade 1-2 tears who underwent primary ACL repair with or without suture augmentation between 2017 and 2019. Patient-reported outcomes (Lysholm, Tegner, International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score [KOOS] subscales) were collected preoperatively and at 6 months, 1 year, and 2 years postoperatively. The minimal clinically important difference (MCID) was calculated using a distribution-based method, whereas the Patient Acceptable Symptom State (PASS) and substantial clinical benefit (SCB) were calculated using an anchor-based method. Plain radiographs and magnetic resonance imaging (MRI) were obtained at 6 months, 1 year, and 2 years postoperatively.

Results

A total of 120 patients were included. The overall failure rate was 11.3% at 2 years postoperatively. Changes in outcome scores required to achieve the MCID ranged between 5.1 and 14.3 at 6 months, 4.6 and 8.4 at 1 year, and 4.7 and 11.9 at 2 years postoperatively. Thresholds for PASS achievement ranged between 62.5 and 89 at 6 months, 75 and 89 at 1 year, and 78.6 and 93.2 at 2 years postoperatively. Threshold scores (absolute/change based) for achieving the SCB ranged between 82.8 and 96.4/17.7 and 40.1 at 6 months, between 94.7 and 100/23 and 45 at 1 year, and between 95.3 and 100/29.4 and 45 at 2 years. More patients achieved the MCID and PASS at 1 year compared with 6 months and 2 years. For SCB, this trend was also observed for non-KOOS outcomes, while for KOOS subdomains, more patients achieved the SCB at 2 years. High-intensity signal of the ACL repair (odds ratio [OR], 31.7 [95% CI, 1.5-73.4]; P = .030) and bone contusions on MRI (OR, 4.2 [95% CI, 1.7-25.2]; P = .041) at 1 year postoperatively were independently associated with increased risk of ACL repair failure.

Conclusion

The rate of clinically meaningful outcome improvement was high early after ACL repair, with the greatest proportion of patients achieving the MCID, PASS, and SCB at 1 year postoperatively. Bone contusions involving the posterolateral tibia and lateral femoral condyle as well as high repair signal intensity at 1 year postoperatively were independent predictors of failure at 2 years postoperatively.

Failure Rates After Anterior Cruciate Ligament Repair With Suture Tape Augmentation in an Active-Duty Military Population

Background

Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair.

Purpose/Hypothesis

The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels.

Study Design

Case series; Level of evidence, 2.

Methods

Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated.

Results

Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group (P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure.

Conclusion

Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.

Arthroscopic biological internal bracing with remnant repair for subacute ACL femoral avulsions

Arthroscopic anterior cruciate ligament (ACL) reconstruction predictably restores sagittal plane knee stability, however its inability to replicate a complex fan-shaped ligament of multiple fascicles, along with deficient restoration of normal rotational knee kinematics, results in failure to reverse a high risk for premature post-traumatic osteoarthritis. Although arthroscopic repair for acute ACL femoral avulsions is proposed to counter these deficiencies, the risk of early failure following non-healing, along with lack of convincing evidence of efficacy has impeded its universal acceptance. Moreover, since ACL repair needs to be performed in the acute phase following injury, it has an increased risk of developing arthrofibrosis, besides precluding any possibility to achieve natural healing of an ACL avulsion with non-operative treatment. The technique of biological internal bracing with remnant repair incorporates the advantages of both reconstruction and repair, and is indicated for patients with persistent ACL deficiency in the subacute phase (6-12 weeks) following an ACL femoral avulsion. This operation essentially involves two steps. The step of biological internal bracing is similar to a conventional ACL reconstruction using a small diameter hamstring graft that is targeted to the centre of the anteromedial ACL bundle on the femur, whereas the tibial socket is located posteriorly within the ACL tibial footprint so as to preserve the anterior fan-shaped morphology of the ACL tibial insertion. The second step involves repairing the remnant ACL tibial stump using one of three techniques. Although technically more complex than an ACL reconstruction, this novel technique provides native anatomy restoration with potential biomechanical and functional advantages, and should be considered for unhealed subacute ACL avulsion injuries.

Rare Fracture Knee Dislocation Treated with Ligament Repair and Novel Arcuate Fracture Repair Technique: A Case Report

CASE

A 57-year-old man presented with a left knee dislocation after a motor vehicle collision. Clinical and imaging evaluation demonstrated disruption of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), anterolateral ligament (ALL), and posterolateral corner (PLC). The patient underwent acute, single-stage arthroscopic primary ACL and PCL repair, with arcuate fracture fixation using a novel technique. At 4 years postoperatively, he continues to do well subjectively with minimal clinical laxity.

CONCLUSION

Acute, single-stage arthroscopic primary ligamentous repair is a viable option for high-grade multiligamentous knee dislocations and may be combined with our novel technique for arcuate fracture fixation.

LEVEL OF EVIDENCE

Level IV, Case Report.

Promising functional outcomes following anterior cruciate ligament repair with suture augmentation

PURPOSE

There has been a renewed interest in the repair of the torn anterior cruciate ligament (ACL). Purpose of this study was to evaluate the functional outcome of arthroscopic ACL repair with additional suture augmentation (SA), hypothesizing that isolated ACL ruptures would yield superior patient-reported outcome measures (PROMs) compared to those with concomitant meniscal and/or ligamentous injuries.

METHODS

This is a retrospective analysis of 93 consecutive patients (67 female, median age 42 years) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 for an acute traumatic ACL tear confirmed by magnetic resonance imaging (MRI). Patients with pre- or intraoperative mid-substance or distal ACL tears and/or poor tissue quality of the ACL remnant were not considered for ACL repair but were scheduled for an ACL reconstruction with a tendon autograft. In patients who underwent ACL repair with SA, the SA construct was proximally stabilized with a flip-button and distally with a suture anchor. Surgery was preferably performed on the day of injury and all surgeries were performed by the same surgeon. Postoperative rehabilitation included partial weight-bearing (20 kg) for 6 weeks and immobilization in a brace limited at 90-degrees of knee flexion for 4 weeks. Patient-reported outcome measures (PROMs) were determined using International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Score (LS), Tegner Activity Score (TS) and Forgotten Joint Score (FJS). Knee-laxity was assessed using the KT-1000 arthrometer (Med Metrics Corp. Inc., San Diego, USA).

RESULTS

Nine patients underwent revision surgery for a traumatic re-tear (four patients) and chronic instability (five patients) and were excluded from further functional analysis. Functional results of 77 patients (54 female) with a median age of 44 years (IQR 33-51) on the day of surgery were available for follow-up after a median time of 35 months (IQR 33-44). Concomitant injuries were observed in 66 Patients (86%), meniscal injuries in 43 patients (55%) and ligamentous injuries in 50 patients (65%). Median interval from injury to surgery was 1 day (IQR 0-1) with 81% (62/77) of patients being treated within 24 h of injury. The median IKDC was 92 (IQR 86-99), the median LS was 95 (IQR 86-100), the median pre-traumatic TS was 7 (IQR 6-7), the median post-traumatic TS was 6 (IQR 5-7) with a non-significant median difference (TS_Diff) of 0 (IQR 0-1). The median FJS was 95 (IQR 78-98). KT-1000 measurements were available in 34 of 77 patients with a median postoperative laxity compared to the uninjured side of 1 mm (IQR 0-2). Interval from injury to surgery, patients' age, body mass index (BMI), knee laxity and concomitant ligamentous or meniscal injuries had no statistically significant impact on postoperative PROMs (n.s.).

CONCLUSION

Following arthroscopic ACL repair with SA good-to-excellent functional results were observed. However, a failure rate of 10% cannot be neglected and warrants further attention. Concomitant injuries to the meniscus and/or collateral ligaments do not seem to be associated with inferior PROMs.

LEVEL OF EVIDENCE

Level IV.

The Minimal Clinically Important Difference, Patient Acceptable Symptom State, and Clinical Outcomes of Anterior Cruciate Ligament Repair Versus Reconstruction: A Matched-Pair Analysis From the SANTI Study Group

BACKGROUND

There has been increasing interest in anterior cruciate ligament (ACL) repair because of theoretical advantages over ACL reconstruction; however, the contemporary literature has failed to provide high-quality evidence to demonstrate these advantages.

PURPOSE

To compare the clinical and functional outcomes of ACL repair versus ACL reconstruction at a minimum follow-up of 2 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent ACL repair were propensity matched (based on demographics, time between injury and surgery, knee laxity parameters, presence of meniscal lesions, preoperative activity level, and sport participation), in a 1:1 ratio, to those who underwent ACL reconstruction during the same period. Isokinetic testing was used to evaluate strength deficits at 6 months postoperatively. Knee laxity parameters were evaluated at 12 months. Complications, return to sport, and patient-reported outcome scores were recorded at final follow-up.

RESULTS

In total, 75 matched pairs (150 patients) were evaluated. The repair group had significantly better mean hamstring muscle strength at 6 months compared with the reconstruction group (1.7% ± 12.2% vs -10.0% ± 12.8%, respectively; P < .0001). At a mean final follow-up of 30.0 ± 4.8 months, the repair group had a significantly better mean Forgotten Joint Score-12 (FJS-12) score compared with the reconstruction group (82.0 ± 15.1 vs 74.2 ± 21.7, respectively; P = .017). Noninferiority criteria were met for ACL repair, compared with ACL reconstruction, with respect to the subjective International Knee Documentation Committee score (86.8 ± 9.0 vs 86.7 ± 10.1, respectively; P < .0001) and side-to-side anteroposterior laxity difference (1.1 ± 1.4 vs 0.6 ± 1.0 mm, respectively; P < .0001). No significant differences were found for other functional outcomes or the pivot-shift grade. There were no significant differences in the rate of return to the preinjury level of sport (repair group: 74.7%; reconstruction group: 60.0%; P = .078). A significant difference was observed regarding the occurrence of ACL reruptures (repair group: 5.3%; reconstruction group: 0.0%; P = .045). Patients who experienced a failure of ACL repair were significantly younger than those who did not (26.8 vs 40.7 years, respectively; P = .013). There was no significant difference in rupture rates between the repair and reconstruction groups when only patients aged >21 years were considered (2.9% vs 0.0%, respectively; P = .157). The minimal clinically important difference and Patient Acceptable Symptom State (PASS) thresholds were defined for the ACL repair group. A significantly greater proportion of patients in the repair group achieved the PASS for the FJS-12 compared with their counterparts in the reconstruction group (77.3% vs 60.0%, respectively; P = .034).

CONCLUSION

ACL repair was associated with some advantages over ACL reconstruction including superior hamstring muscle strength at 6 months and significantly better FJS-12 scores. However, the failure rate was significantly higher after ACL repair, and younger patients were particularly at risk.

Bilateral simultaneous anterior cruciate ligament tears treated with single staged simultaneous primary repair: A case report

Introduction and importance

Simultaneous bilateral anterior cruciate ligament (ACL) injuries are a rare injury pattern within the literature. There is not a consensus optimal management of this injury. Bilateral primary ACL repair in a single stage surgery provides knee stability with a minimally morbid surgery in a single rehabilitation period. This case report offers another option for surgeons to consider in the treatment of this rare injury.

Case presentation

A 45-year-old female skier presented with simultaneous bilateral isolated proximal anterior cruciate ligament injuries. MRI demonstrated bilateral proximal ACL tear patterns which were amenable to primary ACL repair. The patient subsequently underwent acute single-staged arthroscopic primary ACL repair with suture augmentation of both knees. She attained rehabilitation milestones and was fully cleared to return to sporting activities one year post-operatively. Two years post-operatively the patient continues to do well with excellent clinical outcomes.

Clinical discussion

The other treatment modalities reported in the literature were single staged and two staged ACL reconstruction with either autograft or allograft. While single staged procedures are more time and cost efficient, the primary concern is that simultaneous rehabilitation of bilateral ACL reconstructions may lead to severe quadriceps deconditioning. Primary ACL repair poses a potential solution as a minimally morbid surgery with faster rehabilitation from surgery.

Conclusion

Due to the limited invasiveness and morbidity of ACL primary repair with suture augmentation, simultaneous primary repair surgery could be an excellent treatment option for this rare patient population, saving time and cost while providing appropriate knee stability.

Level of evidence

Level IV, Case Report.

•

Single-stage bilateral ACL repair is a viable treatment option in a patient with simultaneous bilateral ACL injuries

•

ACL repair might be an excellent treatment option for this population due to its minimally morbid nature.

•

Simultaneous bilateral ACL repair allows for early return to ambulation and range of motion

Primary repair with suture augmentation for proximal anterior cruciate ligament tears: A systematic review with meta-analysis

PURPOSE

To assess the outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears with suture augmentation in the literature.

METHODS

A systematic search was performed using PubMed, EMBASE, and Cochrane for studies reporting on outcomes of primary repair of proximal ACL tears with suture augmentation between 2015 and 2021. Primary outcomes included failure and reoperation rates, whereas secondary outcomes consisted of functional outcomes. Proportion meta-analysis was performed to assess the overall incidence of failure rates. Outcomes of adults and adolescent were reported separately.

RESULTS

Thirteen studies with 418 patients were included in this study (mean age 32 years, mean follow-up 2.0 years, 49% male). There were no randomized studies and overall grade of recommendation was weak. Overall failure rate for primary repair with suture augmentation was 8% (95% CI 3.9-14.4), but this was higher for younger patients (17%; 95% CI 2.5-63.9) than for older patients (6%; 95% CI 3.8-8.9). The risk for additional reoperations, complications, or hardware removal was low (all <2%), while functional outcomes were good to excellent (all >80% of maximum score).

CONCLUSION

Current literature shows that primary repair with suture augmentation is a reliable treatment option for proximal ACL tears with a failure rate of 8% and good functional outcome scores at short-term follow-up. Although functional outcomes were good irrespective of age, failure rates were higher in young patients (17% vs 6%, respectively). There is a need for high-quality comparative studies with large group of patients to compare these outcomes with ACL reconstruction.

Primary Repair versus Reconstruction in Patients with Bilateral Anterior Cruciate Ligament Injuries: What Do Patients Prefer?

Purpose. The purpose is to evaluate knee preference and functional outcomes of patients with primary anterior cruciate ligament (ACL) repair in one knee and ACL reconstruction in the contralateral side. Methods. All patients who underwent both procedures were retrospectively reviewed at minimum two-year follow-up. Patients were asked to complete questionnaires regarding their operated knees’ preferences during rehabilitation, daily activities, sports activities, and overall function. Furthermore, the Subjective International Knee Documentation Committee, Forgotten Joint Score-12, and Anterior Cruciate Ligament-Return to Sport after Injury were completed. Results. Twenty-one patients were included. All patients underwent ACL reconstruction first, which was displayed at younger age at surgery (24 vs. 33 years, $p=0.010$ ) and longer follow-up (10.2 vs. 2.3 years, $p<0.001$ ), respectively. Thirty-three percent preferred the repaired knee, 11% the reconstructed knee, and 56% had no preference; however, 78% indicated that their repaired knee was less painful during rehabilitation and 83% reported earlier range of motion (ROM) return following repair, which was similar for both knees in 17%. Eighty-three percent of patients indicated better function and progression during rehabilitation with their repaired knee and 11% with their reconstructed knees. No statistical differences were found in patient-reported outcomes between both procedures (all $p>0.4$ ). Objective laxity assessment showed mean side-to-side difference of 0.6 mm between both sides in favor of the reconstructed knee. Conclusion. This study showed that ACL repair and ACL reconstruction lead to similar functional outcomes. However, patients undergoing both procedures may have less pain, earlier ROM return, and faster rehabilitation progression following primary repair.

Arthroscopic Anterior Cruciate Ligament Repair Versus Autograft Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of Comparative Studies

Purpose

To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) repair and autograft ACL reconstruction for ACL ruptures.

Methods

PubMed, EMBASE, Scopus, Web of Science and The Cochrane Library were searched for relevant studies from 1 January 1990 to 21 March 2022. Two evaluators independently screened the literature, extracted data and assessed the methodological quality of the enrolled studies. Meta-analysis was conducted using RevMan 5.4 software.

Results

Ten studies with mean follow-up periods from 12 to 36 months were included. For 638 patients with ACL ruptures, arthroscopic ACL repair showed statistically comparable outcomes of failure (p = 0.18), complications (p = 0.29), reoperation other than revision (p = 0.78), Lysholm score (p = 0.78), Tegner score (p = 0.70), and satisfaction (p = 0.45) when compared with autograft ACL reconstruction. A significantly higher rate of hardware removal (p = 0.0008) but greater International Knee Documentation Committee (IKDC) score (p = 0.009) were found in the ACL repair group. The heterogeneity of the side-to-side difference of anterior tibial translation (ΔATT) was high (I 2 = 80%). After the sensitivity analysis, the I 2 decreased dramatically (I 2 = 32%), and the knees with ACL repair showed significantly greater ΔATT (P = 0.04).

Conclusion

For proximal ACL ruptures, arthroscopic ACL repair showed similar clinical outcomes, and even better functional performance when compared to autograft ACL reconstruction. ACL repair has a higher rate of hardware removal, and might be related to greater asymptomatic knee laxity. More high-quality prospective trials are needed to confirm our findings.

Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair

CONTEXT

Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods.

EVIDENCE ACQUISITION

A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear.

CONCLUSION

More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients.

STRENGTH OF RECOMMENDATION TAXONOMY (SORT)

C.

Good Validity and High Internal Consistency of the Forgotten Joint Score-12 in Patients After Medial Opening Wedge High Tibial Osteotomy

BACKGROUND

The Forgotten Joint Score-12 (FJS-12) was originally developed to assess awareness of an artificial joint. Medial opening wedge high tibial osteotomy (MOWHTO), an alternative surgical method of knee replacement, is a joint-preservation surgery; therefore, joint awareness should be used to evaluate its clinical results. However, FJS-12 has not been validated as a tool to evaluate the postoperative results of MOWHTO. This study aimed to validate FJS-12 in MOWHTO.

METHODS

Patients with bilateral knee surgery, previous knee surgery, flexion contracture >15°, varus alignment >20°, and patients without plate removal surgery were excluded. Finally, 71 knees of 71 patients were analyzed, with a mean follow-up of 34.5 months. The FJS-12 score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained, and the floor and ceiling effect of each score was investigated. Cronbach's α was calculated to determine the internal consistency of FJS-12. Spearman's correlation coefficients between FJS-12 and KOOS were calculated to assess convergent validity.

RESULTS

There were ceiling effects in 3 KOOS subscales (symptoms [25.4%], pain [15.5%], and activities of daily living [25.4%]) but not in FJS-12 (8.5%). No floor effect was noted in any patient-reported outcome measures. The total Cronbach's α was 0.9457 in FJS-12. FJS-12 showed moderate-to-strong positive correlations with all KOOS subscales (r = 0.64-0.72).

CONCLUSION

FJS-12 showed a lower ceiling effect than KOOS and high internal consistency and convergent validity in patients following MOWHTO. With its low ceiling effect, FJS-12 was found to be useful for evaluating patients following MOWHTO.

Prediction of improvement after anterior cruciate ligament reconstruction

Objective

The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not.

Methods

We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS₄).

Results

The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5–13.3).

Conclusions

Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR.

Level of evidence

Case-control study. Level of evidence 3.

Reliable Internal Consistency and Adequate Validity of the Forgotten Joint Score-12 after Primary Anterior Cruciate Ligament Repair

Purpose

To validate the Forgotten Joint Score-12 (FJS-12) as a subjective outcome metric for patients undergoing arthroscopic primary anterior cruciate ligament (ACL) repair.

Methods

In this retrospective study, all patients undergoing primary ACL repair for complete isolated proximal tears between 2008 and 2018 were eligible for inclusion. Patients were contacted and asked to complete the FJS-12, Lysholm Knee Score, modified Cincinnati score, Single Assessment Numeric Evaluation (SANE), Subjective International Knee Documentation Committee (IKDC), and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale at a minimum of 1 year of follow-up. Internal consistency, convergent validity, and ceiling effects were analyzed.

Results

Ninety-six patients could be included (62%), with a mean FJS-12 score of 86.9 ± 14.0 (range, 31.3-100). The FJS-12 showed reliable internal consistency (Cronbach’s alpha = 0.89). Construct validity was moderate to strong (r = 0. 621-0.702). Ceiling effect for the FJS-12 was 21.9%, which was lower than for the Lysholm (44.6%), modified Cincinnati (45.1%), equal to the IKDC subjective (21.9%), and SANE score (22.0%) but higher compared to the ACL-RSI (12.8%). Furthermore, internal consistency for the other scores was also good to excellent (range Cronbach’s alpha = 0.627-0.953).

Conclusion

The FJS-12 shows high internal consistency and construct validity after primary ACL repair. Furthermore, this metric showed equal or less ceiling effect than most other scores, although still notable. This study suggests that the FJS-12 is an easy and validated outcome metric to evaluate subjective primary repair outcomes.

Level of Evidence

Level III, diagnostic study.

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears With Suture Augmentation

Background

Historically, the midterm outcomes of open anterior cruciate ligament (ACL) repair were rather disappointing, and ACL reconstruction subsequently became the surgical standard for ACL injuries. Recent studies, however, have shown that there might be a role for arthroscopic primary repair in appropriately selected patients with proximal ACL tears.

Indications

Due to more prominent blood supply in the proximal ligament region, ACL repair should only be performed in patients with proximal tears and good-to-excellent tissue quality. Although all patients are potential candidates, this procedure is preferably performed acutely and in adult patients.

Technique Description

First, it is identified whether a proximal tear with good tissue quality is present. Then, both ACL bundles are sutured individually from distal to proximal using a Bunnell-type pattern and a self-retrieving suture passer. The posterolateral bundle is then reattached first in anatomical fashion, using a 4.75-mm vented biocomposite suture anchor. Next, the suture anchor of the anteromedial bundle is preloaded with an internal suture tape augmentation. After anchor deployment, the suture tape augmentation is channeled through a small 2.5-mm tibial tunnel in the anterior third of the tibial ACL footprint. Finally, the suture augmentation is tensioned near full extension and fixed to the tibia's anteromedial cortex using single suture anchor fixation.

Results

Recently, we have published a series of the first 113 consecutive repair patients with minimum 2-year follow-up, of which 60 received additional suture augmentation. In this cohort, the overall failure rate was 13%, which was similar to 3 other studies on modern-day ACL repair (range: 5%-15%). Subgroup analysis showed that the failure rate was much higher in patients ≤21 years (38%) but low in patients >21 years (0%). Finally, it has been shown that there is an earlier return of knee motion, complications are rare, and there is less joint awareness after ACL repair as compared with ACL reconstruction.

Conclusion

Selective, modern-day, arthroscopic primary ACL repair with suture augmentation seems to be a good alternative to ACL reconstruction in carefully selected patients, which include patients with proximal tears and good tissue quality and aged ≥22 years.

Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial

Background

For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking.

Methods

This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up.

Discussion

Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores.

Trial registration

Registered at Netherlands Trial Register (NL9072) on 25th of November 2020.

Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears

PURPOSE

To assess failure rates and patient-reported outcomes measures following arthroscopic primary anterior cruciate ligament (ACL) repair of proximal tears in different age groups.

METHODS

Between 2008 and 2017, the first 113 consecutive patients treated with repair were retrospectively reviewed at minimum of 2 years. Patients were stratified into 3 age groups: ≤21, 22-35, and >35 years. Primary outcomes were ipsilateral reinjury or reoperation, and contralateral injury rates, and secondary outcomes consisted of Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, International Knee Documentation Committee subjective, pain, and satisfaction scores. Group differences were compared using χ² tests and Mann-Whitney U tests.

RESULTS

Follow-up was obtained in 113 patients (100%). Median age was 35 years (interquartile range [IQR] 23-43) and median follow-up was 2.2 years (IQR 2.0-2.8). Overall, ACL reinjury occurred in 13 patients (11.5%), reoperation in 7 patients (6.2%), complications in 2 patients (1.8%) and contralateral ACL injury in 4 patients (3.5%). Overall, median Lysholm was 95 (IQR 89-100) and International Knee Documentation Committee subjective 92 (IQR 84-99). Treatment failure was significantly greater in the youngest age group (37.0%) as compared with the middle and older groups (4.2% and 3.2%, both P < .005). No significant differences were seen in reoperation, complication, or contralateral injury rates between groups (all P > .2), nor in patient-reported outcomes measures between the groups (all P > .1).

CONCLUSIONS

The failure rate of primary repair of proximal ACL tears is high in patients aged 21 or younger (37.0%), and this should be taken into account when discussing repair in this patient group. In patients older than 21, repair may be an excellent treatment with low failure (3.5%) and complication rates (1.2%) and good subjective scores.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up

PURPOSE

To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation.

METHODS

Patients with a proximal tear of the ACL who underwent primary ACL repair with a minimum 2-year follow-up were included. The exclusion criteria included multiligamentous knee injuries, midsubstance tears, tibial avulsion fractures, and distal tears. Demographic characteristics, injury pattern, concomitant injury pattern, and patient-reported outcome measures were recorded. Patients were evaluated at a minimum 2-year follow-up for clinical success, defined as stability not requiring revision ACL reconstruction, and for patient-reported outcome measurements. Failure was defined as the need for revision surgery.

RESULTS

The mean follow-up period was 2.8 ± 0.9 years. Thirty-five patients met the inclusion criteria, with an average age of 32.2 ± 7.2 years, and 2-year follow-up was obtained for 29 of these patients. Revision surgery was required in 2 of the 29 patients (6.9%); successful treatment was achieved in the remaining 93.1%. The Single Assessment Numeric Evaluation score and Knee Injury and Osteoarthritis Outcome Score for the 27 successfully treated patients were recorded, with 70.4% having Single Assessment Numeric Evaluation scores of 80 or greater.

CONCLUSIONS

This case series shows that primary surgical repair of proximal ACL tears using suture tape augmentation results in a low rate of revision surgery.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Acute and delayed anterior cruciate ligament repair results in similar short to mid-term outcomes

BACKGROUND

To assess whether primary repair of proximal ACL tears in the delayed setting leads to similar clinical and functional outcomes as compared to ACL repair in the acute setting.

METHODS

All patients with proximal tears with good tissue quality treated in the acute (≤3 weeks post-injury) and delayed setting (>3 months post-injury) were retrospectively reviewed at minimum 2-year follow-up. Ipsilateral reinjury or reoperation and contralateral injury rates were recorded. Functional outcomes were evaluated using the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation, International Knee Documentation Committee subjective, Forgotten Joint Score-12, Anterior Cruciate Ligament-Return to Sport after Injury scale, and satisfaction scores. Finally, time to return to work, time to discontinue brace-usage, time to running, and time to return to sports were reviewed. Group differences were compared using chi-square tests and Mann-Whitney U tests.

RESULTS

Sixty-nine patients were included, of which 34 (49%) were treated acutely and 35 (51%) in the delayed setting. Besides time from injury to surgery, patient demographics were similar between groups (all p > 0.1). There were three reinjuries (9%) in the acute group and four in the delayed (11%; p > 0.999). Reoperation, complication, and contralateral injury rates were similar between groups (all p > 0.1), while functional outcomes were also comparable (all p > 0.05).

CONCLUSION

This study found that acute and delayed primary ACL repair results in similar clinical and functional outcomes at short to mid-term follow-up. Therefore, the most important factors for repair surgery success seem to be tissue quality and tissue length, rather than acuity of the surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

A comparison of postoperative pain between anterior cruciate ligament reconstruction and repair

PURPOSE

To determine if patients who underwent ACL repair experienced less short-term postoperative pain versus patients who underwent ACL reconstruction.

METHODS

Electronic charts were retrospectively reviewed of patients who underwent ACL surgery from November 2014 through April 2019 by a single surgeon. Patients were divided into two groups based on whether they underwent ACL repair or ACL reconstruction. A two-tailed equal variance t-test was used to evaluate visual analog scale (VAS) pain scores at the first postoperative visit. A chi-squared test of independence was used to evaluate narcotic prescription refills at the first postoperative visit.

RESULTS

36 ACL repair patients and 71 ACL reconstruction patients were included. The mean visual analog scale (VAS) pain score at the first postoperative visit (12.9 ± 3.7 days post-op) for ACL repair patients (2.81 ± 1.79) was significantly lower (p = .004) compared to ACL reconstruction patients (4.07 ± 2.26). The number of narcotic prescription refills at the first postoperative visit was significantly lower (p = .027, ARR = 21.4%, NNT = 4.67) in the ACL repair group (7 of 36, 19.4%) compared to the ACL reconstruction group (29 of 71, 40.8%).

CONCLUSION

Patients who underwent ACL repair experienced less short-term postoperative pain and were prescribed fewer narcotics compared to patients who underwent ACL reconstruction.

Knotless Primary Anterior Cruciate Ligament Repair with Adjustable Loop Device and Internal Brace Augmentation

With the recent resurgence of primary anterior cruciate ligament repair, it is important to strive for optimal patient outcomes. This knotless primary repair procedure takes advantage of the use of an adjustable loop device, which allows for intraoperative retensioning by the surgeon. This technical advancement combined with augmentation with an internal brace could potentially minimize gap formation at the repair site, thereby increasing repair stability and ultimate outcome.

Large variation in indications, preferred surgical technique and rehabilitation protocol for primary anterior cruciate ligament repair: a survey among ESSKA members

PURPOSE

To assess current surgical preferences and practice patterns regarding primary anterior cruciate ligament (ACL) repair among European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members.

METHODS

A web-based survey was designed, including questions regarding indications for primary repair, outcomes of primary repair, and rehabilitation protocols. An invitation for study participation was sent by email to all ESSKA e-mail contacts. Descriptive statistics were performed.

RESULTS

A total of 169 surgeons responded to the survey (7% response rate of active members). Lack of supporting scientific evidence is the main reason for not using repair as a surgical treatment (63%). Most important indications were proximal avulsion tears (84%), younger age (49%), and older age (34%). Among those currently utilizing repair as a treatment option, transosseous tunnel fixation repair (34%) and repair with internal brace using transosseous tunnel fixation (32%) were the most preferred techniques. Eleven percent indicated dynamic intraligamentary stabilization as their preferred technique. A similar rate of progression for rehabilitation for repair and reconstruction techniques was noted among respondents.

CONCLUSION

This practice survey shows that the majority of surgeons indicated the main reason for not incorporating primary repair in their current practices was a lack of supporting scientific evidence. Among those holding favourable attitudes and beliefs, most surgeons indicated patients with proximal tears, younger-aged, and older-aged patients might be eligible for repair. Prospective studies with higher levels of evidence are warranted to establish guidelines for repair, including indications, optimal surgical technique, and rehabilitation protocols.

LEVEL OF EVIDENCE

V (expert opinion).

Return to sports following arthroscopic primary repair of the anterior cruciate ligament in the adult population

BACKGROUND

To assess return to sport (RTS) rates and evaluate the timeline of rehabilitation milestones following arthroscopic primary anterior cruciate ligament (ACL) repair.

METHODS

A retrospective review of all patients treated with primary repair between 2008 and 2018 was conducted. All adult patients with preoperative Tegner of ≥6 and minimum follow-up of two years were included. Patients were seen in clinic or contacted to complete the postoperative Tegner, and report their time to return to work, time to running, and time to RTS. Additionally, they were asked to complete the ACL-Return to Sport After Injury (ACL-RSI). Outcomes were compared using Mann-Whitney U tests and chi-square tests.

RESULTS

Sixty patients treated with repair were included, of which 85% returned to any sports, 70% returned to knee-strenuous sports, and 60% returned to preinjury level. Patients returned to work in seven days (IQR five to 14 days), running in 90 days (IQR 57-120 days), and sports in 180 days (IQR 116-270 days). Overall, ACL-RSI score was 80.0 (IQR 53.0-95.0). Higher return to preinjury rates was found in patients with older age and lower fear of reinjury (all p < .05).

CONCLUSION

Following primary ACL repair, 70% of adult patients returned to knee-strenuous sports and 60% to preinjury levels by 180 days postoperatively. Positive predictors for return to preinjury levels included older age and low fear of reinjury.

LEVEL OF EVIDENCE

Retrospective Case-Series, level IV.

Editorial Commentary: The Forgotten Joint Score-Don't Compare Apples to Oranges

Patient outcomes have become focused on satisfaction with the end result. It is now appreciated that objective measurements are not the sole criterion for a successful surgical procedure. With the transition to evaluating patient-reported outcome measures, additional scoring techniques are being used to determine the best method for defining surgical success. The Forgotten Joint Score asks the simple question, "Are you aware of the joint that had surgery?" Essentially, does the patient have any sense that there has been surgery on the limb or joint? Although it has been validated as a reliable testing technique in specific surgical procedures, it has not been validated as a method of comparing 2 dissimilar surgical procedures. One must be selective and careful when using scoring methods. There are no data or validation to support the use of patient perception of the joint on surgical procedures that are divergent in their approach. Patient-reported outcomes such as the Forgotten Joint Score should not be used to compare procedures that are dissimilar in technique.