Females Have Earlier Muscle Strength and Functional Recovery After Bridge-Enhanced Anterior Cruciate Ligament Repair

Indications, Techniques, and Outcomes of Bridge-Enhanced ACL Restoration (BEAR)

PURPOSE OF REVIEW

The current landscape of treating anterior cruciate ligament (ACL) tears is rapidly evolving with the advent of the bridge-enhanced ACL restoration (BEAR). BEAR is a novel approach to restore the ACL in lieu of conventional reconstruction. BEAR has recently been approved for post-market use by all orthopaedic surgeons for midsubstance or proximal ACL tears. This article provides a review of the indications and outcomes of BEAR, graduating from the Trial 1 stage to the post-market stage, current operative techniques, and the postoperative rehabilitation protocol for BEAR.

RECENT FINDINGS

Current research demonstrates similar postoperative patient-reported outcome measures and functional outcomes following BEAR compared to ACL reconstruction in clinical trials. Combining all three BEAR trials, there was an aggregate re-tear rate of 15%. Our post-market published BEAR data shows non-inferior short-term postoperative PROMs and functional outcomes as well as zero re-tears. The early- and mid-term results of BEAR show that it is a potential alternative to ACLR for specific patient groups.

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.

Bioactive and Bioinductive Implants Are Increasingly Used in Orthopaedic Sports Medicine but Adequately Controlled Studies Are Needed: A Scoping Review

PURPOSE

To describe the currently available literature reporting clinical outcomes for bioactive and bioinductive implants in sports medicine.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 4 databases was completed to identify eligible studies. Inclusion criteria were studies using bioactive or bioinductive implants in human clinical studies for sports medicine procedures. Data were extracted and reported in narrative form, along with study characteristics.

RESULTS

In total, 145 studies were included involving 6,043 patients. The majority of included studies were level IV evidence (65.5%), and only 36 included a control group (24.8%). Bioactive materials are defined as any materials that stimulate an advantageous response from the body upon implantation, whereas bioinductive materials provide a favorable environment for a biological response initiated by the host. Bioactivity can speed healing and improve clinical outcome by improving vascularization, osteointegration, osteoinduction, tendon healing, and soft-tissue regeneration or inducing immunosuppression or preventing infection. The most common implants reported were for knee (67.6%, primarily cartilage [most commonly osteochondral defects], anterior cruciate ligament, and meniscus), shoulder (16.6%, primarily rotator cuff), or ankle (11.7%, primarily Achilles repair). The most common type of implant was synthetic (44.1%), followed by autograft (30.3%), xenograft (16.6%), and allograft (9.0%). In total, 69% of implants were standalone treatments and 31% were augmentation.

CONCLUSIONS

The existing bioactive and bioinductive implant literature in sports medicine is largely composed of small, low-level-of-evidence studies lacking a control group.

CLINICAL RELEVANCE

Before bioactive implants can be adapted as a new standard of care, larger, comparative clinical outcome studies with long-term follow-up are essential.

Female Athletes Are Underrepresented in Anterior Cruciate Ligament Reconstruction Rehabilitation Studies: A Systematic Review

PURPOSE

To systematically review the representation of female athletes in the current primary literature available on rehabilitation after anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic review was conducted using PubMed to provide a comprehensive analysis of female representation in ACLR postoperative rehabilitation protocols. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. Studies were analyzed based on nine factors: study population, athletic caliber, menstrual status, research theme, journal impact factor, sample size of male and female participants, time to return to sport, and graft failure rate. Population categories included males-only, females-only, mixed-sex, and male vs. female comparisons. Athletic caliber had 6 tiers. Menstrual status was categorized as natural, hormonal contraception, irregularities, mixed, or unclassified. Research themes were health-focused, performance-focused, or combined. Study impact was assessed via journal impact factor.

RESULTS

Thirty-three studies were included. Females comprised 3031/6798 (44.6%) of ACLR participants. No female-only studies were found; male-only studies accounted for 3 of 33 (9%), mixed-sex for 25 of 33 (69.7%), male versus female subanalysis for 3 of 33 (9%), and male versus female features for 2 of 33 (6%). No studies investigated outcomes for the highest athletic levels. Menstrual status was not considered. No studies focused on performance outcomes; 25 of 33 (69.7%) had a health research focus. Female athletes were under-represented in studies evaluating return to sport timeline and graft failure rate.

CONCLUSIONS

Female athletes face a 2 to 8 times greater risk of ACL injury but are under-represented in ACLR postop rehabilitation studies, with only 44.6% participation compared with 55.4% for male athletes. In 9 studies, female athletes comprised 30% or less of participants. Even studies including female athletes at near-equal rates failed to address menstrual status or sex hormones on injury and rehabilitation.

LEVEL OF EVIDENCE

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

Examining the Relationship and the Gender Differences between Re-Injury Worry, Confidence, and Attention after a Sport Musculoskeletal Injury

Introduction: A sport injury is an unfortunate event that can significantly impact the injured athletes' psychology. There have been no studies examining gender differences in the psychological state after a sport-related musculoskeletal injury. Τhe aims of the current study were to (a) investigate the relationship between re-injury worry levels, confidence, and attention in the injured athletes who followed a rehabilitation program in order to return to competition, and (b) compare differences in these psychological factors between male and female athletes. Methods: A cross-sectional research design was used. A total of 60 athletes (30 men and 30 women) volunteered to participate, aged 25.50 ± 5.25 years old, all of whom had experienced a musculoskeletal injury within the past year. Three validated questionnaires, i.e., the Causes of Re-Injury Worry Questionnaire, the Sport Confidence Questionnaire of Rehabilitated Athletes Returning to Competition, and the Attention Questionnaire of Rehabilitated Athletes Returning to Competition, were completed by the participants on their first competitive game after their rehabilitation program. Results: All of the athletes experienced average levels of re-injury worry due to their opponents' ability and distraction attention, and high levels of confidence and functional attention. Many factors from the questionnaires were correlated with each other. Men experienced lower levels of re-injury worry due to rehabilitation compared to the women athletes (U = 329.00, p < 0.05), and women exhibited higher "Re-injury Worry due to Opponent's Ability" compared to the men athletes (U = 292.00, p < 0.01). Conclusions: A strong relationship was found between re-injury worry, confidence, and attention, with few gender differences. Since there is no previous research examining re-injury worry, confidence, and attention between men and women, future research with larger and more homogeneous samples is needed to confirm the present results.

A Preliminary Study of Post-Market Bridge-Enhanced ACL Restoration (BEAR) Suggests Non-Inferior Short-Term Outcomes and Low Complications

Background

To improve outcomes following anterior cruciate ligament (ACL) reconstruction, bridge-enhanced ACL restoration (BEAR) was introduced. Bridge-enhanced ACL restoration uses a collagen-based implant saturated with infused autologous blood to bridge the torn proximal and distal ACL fibers.

Purpose

We sought to analyze the short-term complications, clinical outcomes, and patient-reported outcome measures (PROMs) in patients undergoing BEAR outside of the initial clinical trials.

Methods

We conducted a retrospective cohort study of all skeletally mature patients who had a midsubstance or proximal ACL tear treated with BEAR by 2 surgeons at a single institution and had a minimum follow-up of 6 weeks. A total of 58 patients were included (average age was 38 years, average time from injury to surgery was 45 days). Data on demographic factors, functional outcomes, and complications were collected from electronic medical records. Patient-reported outcome measures and a descriptive return-to-activity survey were analyzed utilizing paired t-tests and Wilcoxon signed-rank tests.

Results

All 58 patients demonstrated a grade of 1A on the Lachman test at 6 weeks postoperatively. At 6 months postoperatively, the mean active flexion was 135° ± 5°, and all patients achieved 0° extension. Although not all patients completed PROM questionnaires, among those who did we observed a significant increase in PROMs between preoperative and postoperative measurements; more than half achieved the minimal clinically important difference in all PROMs, and 26 patients (87%) had a 1-level decrease in function. There were no cases of retear or instability. Three patients (5%) had postoperative arthrofibrosis.

Conclusion

Early results of this preliminary post-market approval study suggest that BEAR may provide a safe and non-inferior approach to ACL reconstruction in selected patients. Studies are needed to investigate the long-term outcomes of this novel technique.

No sign of weakness: a systematic review and meta-analysis of hip and calf muscle strength after anterior cruciate ligament injury

OBJECTIVE

We aimed to determine hip and lower-leg muscle strength in people after ACL injury compared with an uninjured control group (between people) and the uninjured contralateral limb (between limbs).

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL and SportDiscus to 28 February 2023.

ELIGIBILITY CRITERIA

Primary ACL injury with mean age 18-40 years at time of injury. Studies had to measure hip and/or lower-leg muscle strength quantitatively (eg, dynamometer) and report muscle strength for the ACL-injured limb compared with: (i) an uninjured control group and/or (ii) the uninjured contralateral limb. Risk of bias was assessed according to Cochrane Collaboration domains.

RESULTS

Twenty-eight studies were included (n=23 measured strength ≤12 months post-ACL reconstruction). Most examined hip abduction (16 studies), hip extension (12 studies) and hip external rotation (7 studies) strength. We found no meaningful difference in muscle strength between people or between limbs for hip abduction, extension, internal rotation, flexion or ankle plantarflexion, dorsiflexion (estimates ranged from -9% to +9% of comparator). The only non-zero differences identified were in hip adduction (24% stronger on ACL limb (95% CI 8% to 42%)) and hip external rotation strength (12% deficit on ACL limb (95% CI 6% to 18%)) compared with uninjured controls at follow-ups >12 months, however both results stemmed from only two studies. Certainty of evidence was very low for all outcomes and comparisons, and drawn primarily from the first year post-ACL reconstruction.

CONCLUSION

Our results do not show widespread or substantial muscle weakness of the hip and lower-leg muscles after ACL injury, contrasting deficits of 10%-20% commonly reported for knee extensors and flexors. As it is unclear if deficits in hip and lower-leg muscle strength resolve with appropriate rehabilitation or no postinjury or postoperative weakness occurs, individualised assessment should guide training of hip and lower-leg strength following ACL injury.

PROSPERO REGISTRATION NUMBER

CRD42020216793.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy

INTRODUCTION

Counseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients' normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy.

METHODS

Children ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category.

RESULTS

Among 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis.

CONCLUSIONS

This study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction

» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.

Dimensions of the anterior cruciate ligament and thickness of the distal femoral growth plate in children: a MRI-based study

BACKGROUND

When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height.

OBJECTIVES

We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty.

METHODS

We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18 years (mean age: 14.9 ± 2.6 years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured.

RESULTS

Mean ACL length increased linearly up to the age of 12 years in females and 14 years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13 years (38.18 mm) in females and at 15 to < 16 years (39.38 mm) in males. Mean ACL width increased up to the age of 12 years in girls and 13 years in boys. After the age of 12 years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12 years in girls and 14 years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12 years and 12 to < 13 years in girls and between the age intervals of 13 to < 14 years and 14 to < 15 years in boys.

CONCLUSIONS

ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures.

LEVEL OF EVIDENCE

III-retrospective cohort study.

Optimizing outcomes of ACL surgery-Is autograft reconstruction the only reasonable option?

Anterior cruciate ligament (ACL) injuries occur at a high frequency in the United States with approximately 400,000 ACL reconstructions being performed each year. While ACL reconstruction is our current gold standard of treatment, it does not restore joint motion, or prevent the premature development of posttraumatic osteoarthritis (PTOA) in many patients. Thus, new treatments for an ACL injury, which are less invasive and minimize patient morbidity, including cartilage damage, are highly desirable. We have used a tissue-engineered approach to stimulate ligament healing, to improve upon current treatment options. In this review, we describe and discuss our work moving a tissue engineering strategy from the concept to bench, preclinical, clinical trials and ultimately FDA 510(k) de Novo approval, providing clinicians and patients with a viable alternative to ACL reconstruction.